Hand hygiene is described by many health care workers as the single most important tool in preventing the spread of health care-associated infections between patients.
According to WHO, there are few definitive data on the patient-care activities that are most likely to transmit bacteria to health care worker (HCW) hands, but there have been several studies that identified many possibilities. Although bacteria have been found on HCW hands after activities such as wound care, intravascular catheter care, respiratory tract care and handling patient secretions as expected, bacteria also have been found on HCW hands after so-called “clean” contact, such as taking a patient’s pulse, temperature or blood pressure.
Organisms found on HCW hands after such patient contact range from Klebsiella spp., Staphylococcus aureus, Clostridium difficile, MRSA and gram-negative bacteria. However, direct patient contact is not the only way HCW hands can be contaminated. HCWs can acquire bacteria on their hands by touching contaminated surfaces in the patient environment and simply by touching a contaminated chart at the nurses’ station, according to the literature.
Washing hands before and after patient contact seems like a simple solution to prevent the spread of bacteria between patients. Most hospitals have hand hygiene policies in place that guide their employees to do just that. But it is not as simple as it seems.
Michael Edmond, MD, MPH, said that
HCWs need to be “hardwired” to perform
hand hygiene on a subconscious level.
Photo courtesy of Jones A, VCU
“When we look at all of the things that we can do to prevent infections in the hospital, one of the most important things about hand hygiene is that it works for so many different types of organisms, and you get a lot of bang for the buck,” Michael Edmond, MD, MPH, the Richard P. Wenzel professor of internal medicine in the division of infectious diseases at Virginia Commonwealth University, told Infectious Disease News. “The issue is that you have to practice it at a high level of compliance for it to work. There are so many opportunities for hand hygiene, and it is difficult to get to a level of compliance where we’re able to make changes to infection rates.”
According to new CDC data, approximately one in 25 patients acquires a health care-associated infection (HAI) during their hospital care, adding up to about 722,000 infections a year. Of these, 75,000 patients die of their infections. CDC Director Thomas Frieden, MD, MPH, said even the most advanced health care will not work if clinicians neglect basic practices such as hand hygiene.
For the second story in a two-part series on infection control in hospitals, Infectious Disease News spoke with several experts, including hospital epidemiologists, to discuss the importance of hand hygiene and reasons behind the variability in hand hygiene compliance.
In the mid-1800s, the concept of hand hygiene was first introduced by a Hungarian physician named Ignaz P. Semmelweis, who found that when physicians washed their hands before delivering babies, it prevented deaths in postpartum women, according to Connie Price, MD, associate professor of medicine at the University of Colorado Denver. Although Semmelweis was initially ridiculed for this suggestion, eventually it was recognized that he was correct.
“After centuries of knowledge, it is now known that Semmelweis was right, and that hand-washing is an effective way to prevent HAIs,” Price, also chief of infectious diseases at Denver Health Medical Center, told Infectious Disease News. “All of the technologies we have, all of the other intricate tools we use to prevent HAIs can easily be nullified if HCWs don’t wash their hands.”
Since Semmelweis’ observation, there have been many studies to confirm the role that HCW hands play in transmission of pathogens in the health care setting. Various organizations, including the CDC and WHO, have published guidelines on appropriate hand hygiene practices for HCWs.
The five moments of hand hygiene outlined by WHO are: Before patient contact; before aseptic task; after bodily fluid exposure; after patient contact; and after contact with patient surroundings.
Despite these guidelines, as well as the Joint Commission requiring some type of monitoring or quality assessment protocols for hand hygiene in hospitals, compliance rates for appropriate hand hygiene are far from where they should be.
“There are multiple papers that show adherence to hand hygiene, according to the WHO guidelines, is usually around 50% to 60%,” Elaine Larson, PhD, RN, Anna C. Maxwell professor of nursing research and associate dean for research at Columbia University School of Nursing, told Infectious Disease News. “It has begun to change, slowly, since WHO published its new guidelines in 2009, but it takes a long and sustained effort, and a multifaceted intervention to change behavior that is already ingrained.”
Lack of compliance
The subpar compliance with hand hygiene practices is unintentional, according to the experts.
“There is a great awareness about hand hygiene among HCWs,” Emily Landon, MD, assistant professor in the section of infectious diseases at The University of Chicago department of medicine and medical director of antimicrobial stewardship and infection control at the University of Chicago Medical Center, told Infectious Disease News. “Everyone knows the importance of hand hygiene, and everyone wants to perform hand hygiene.”
Edmond said one potential reason for low compliance is that the target is invisible: HCWs do not realize they are carrying pathogens on their hands because they cannot see them. Another reason is they can not link their contact with a patient, when pathogens may be transmitted from their contaminated hands, to an infection that may result days or even months later.
In addition, the risk to the HCWs from not performing hand hygiene is low, Edmond said. It is unlikely that they will get an infection if they do not wash their hands. The risk for infecting a patient from one episode of noncompliance with hand hygiene practices is small. However, the patient bears the cumulative risk of all episodes of noncompliance, and there are a lot of issues regarding the perception of patient risk.
Another possible excuse for lack of compliance is the cost of time for HCWs.
“The number of hand hygiene opportunities is almost immeasurable in any given hospital,” Edmond said. “In the end, the hand hygiene is an altruistic behavior on the part of the HCWs because the person who bears the burden of doing it doesn’t really reap the benefit of it. The benefit accrues to the patient.”
Many studies have shown that the principal reason HCWs do not wash their hands enough is because they are too busy, or there are not enough hand rub dispensers available, Landon said, adding that she does not think this is the problem.
“HCWs are very often overwhelmed by thinking of other things, particularly the status of their patients, and they never develop a habit of hand hygiene,” Landon said. “If hand hygiene was something you needed to remember before each patient, it would be a huge flub. It’s something that needs to be done as a habit, without even thinking about it. The problem is that it’s difficult to create that habit or enforce it among HCWs.”
Edmond agreed and said the main problem associated with a lack of hand hygiene compliance is that humans are not naturally “hardwired” to perform hand hygiene in the absence of sensing a substance on their hands.
He compared it with the use of seatbelts: Most people do not even think about putting the seatbelt on when they get into a car. They do it on a subconscious level, and they are usually not even aware they put it on.
“That’s where we need to be with hand hygiene, hardwired so that we do it without even thinking about it,” Edmond said. “When a behavior is hardwired like that, you can always sense when you didn’t do it because you start to feel uncomfortable. It’s a long process to get to that point.”
Larson said for some HCWs, it is ingrained, and they do perform hand hygiene almost exactly according to the WHO’s “Five Moments for Hand Hygiene,” which is currently the standard hand hygiene guideline used by most health care facilities. However, for some, adoption of these guidelines means rethinking current habits.
“Some people require external motivation more than others, meaning more feedback and/or incentives,” Larson said. “There are those who are already good at hand hygiene who could be recruited as ‘champions’ of the unit. With this positive deviance, you can slowly change the culture to make good hand hygiene the expectation.”
The gold standard in monitoring hand hygiene compliance is direct observation, Landon said, usually by infection control practitioners or a dedicated person such as the nursing manager of a group. But the reliability of this method to measure true, actual compliance with hand hygiene is questionable.
Hand hygiene compliance increases dramatically when these observers, who are usually well known to the staff, are circulating in the unit, Landon said. Then compliance rates decline when those people are no longer around.
In one study, Landon and colleagues hired a new student for hand hygiene observation in the same unit that a well-known practitioner had recently observed.
“We found that the practitioner observed close to 70% compliance with hand hygiene and the student observed close to 30% compliance,” Landon said. “The bottom line is that there is a big discrepancy between what is observed by a brand new observer and by someone well known to the unit.”
It is the classic Hawthorne effect, Edmond said. People change their behavior when they know they are being watched. In addition, another pitfall of direct observation is that it is difficult to observe a significant fraction of the total number of hand hygiene opportunities, he said, which in any given hospital on any given day is huge.
Nonetheless, direct observation still has a benefit.
“It does remind people to wash their hands, and over time, this reinforcement has an impact on the number of people who do hand hygiene,” Edmond said.
Price also said any type of feedback is one of the most tried and true methods to make sure HCWs are practicing hand hygiene. Many HCWs do not realize when they are making any errors.
“These people believe hand hygiene is important and they think that they’re complying,” Price said. “In reality, they miss a lot of opportunities, and seeing that data and receiving that feedback is important. This can be done with direct observation, and there are also automated technologies to measure compliance.”
Research is underway to identify more objective and reliable methods to measure hand hygiene compliance. There are many potential systems to accomplish this, each with their own benefits and drawbacks.
One method for this is to have HCWs wear a wristband or badge that gives reminders to do hand hygiene. The HCW would receive a printout of their individual compliance rate in real time. An individualized method such as this would be the “holy grail,” Landon said, because it provides individual feedback. However, in a recent study of a badge system utilizing radiofrequency identification (RFID) tracking, the researchers found that the accuracy for identifying hand hygiene events in a real-life clinical setting was only 52.4%, missing nearly half of the potential events.
Another tool being evaluated is a counter that tracks how many times a soap or hand sanitizer dispenser is used. Larson said a group monitoring system such as this is more in line with what is trying to be accomplished: creating an entire culture of patient safety so that everyone feels responsible.
“We want to get away from the ‘shame and blame’ idea and move on to the idea that people just want to do the right thing,” Larson said. “We have to set up a system so that it is easier to do the right thing than to do the wrong thing.”
These systems are still investigational, however, and one of the drawbacks is that they require new technological platforms.
“There are many ways the technology can be used, and it can be effective, but a lot of work still needs to be done on these new electronic methods,” Edmond said. “The bottom line is that we don’t have a great, easy, inexpensive way to measure hand hygiene right now.”
Monitoring hand hygiene is only the first step. Policies also must be in place to hold people accountable for the hand hygiene.
“A hospital needs to have policies that support hand hygiene and make sure the administrators back the initiative,” Price said. “They need to say that it’s a priority and that it’s a policy and that jobs are at risk if the policy is broken.”
The Joint Commission recommends an approach that includes direct observation by different observers on a rotating basis, Landon said. The approach also includes an accountability piece: If hand hygiene has not improved, the offender receives warnings and undergoes other reinforcements such as online classes or discussions with an infection control committee member to encourage them to wash their hands. The system also utilizes a human resources disciplinary system: After enough warnings, people can lose their jobs for not washing their hands.
Price said the Agency for Healthcare Research and Quality and the CDC have produced materials to incorporate infection prevention into medical education, and many HCWs are required to regularly retake an infection control test module that incorporates in-depth information on hand hygiene.
“Hand hygiene is more important than ever with the rising threat of multidrug-resistant organisms,” Price said. “Antibiotic stewardship programs are powerful, but they’re not going to be effective if you don’t have good, solid infection control like hand hygiene.”
Although hand hygiene has long been a part of medical curricula, it does not always become ingrained into practitioners as it should. In a recent study, Landon and colleagues found that first- and second-year medical students believe that hand hygiene is extremely important and always do it, but not third- and fourth-year students.
“Once they actually start practicing, they see others not perform hand hygiene as often as they should and they decide it’s not as important as they thought,” Landon said. “Educational curricula do not go far in forming a habit. There needs to be a culture of reinforcement in which if you don’t wash your hands, someone is going to tell you.”
Most hospitals have installed dispensers of hand sanitizer throughout the units to make it easier for HCWs to clean their hands. Larson said this is important because hand sanitizer works faster and is better for most things.
Although these dispensers have not necessarily increased the frequency of hand hygiene, Larson said, their implementation has increased the number of times hand sanitizer is used compared with soap.
“I naively thought that having this easy-to-use product so accessible would take care of the hand hygiene compliance,” Larson said. “It’s a facilitator of hand hygiene, and it’s an important barrier if it’s not available. It’s necessary, but it’s not enough.”
Any hand hygiene program will need to have a long-term benefit, Landon said. Many have a definite short-term effect at changing behaviors, such as signs on doors that remind HCWs about hand hygiene. But after a certain amount of time, behavior reverts to old patterns because the signs are no longer new.
But one of the best ways to get someone to change their behavior is to subtly encourage them, Edmond said: getting someone to do something without forcing them to do it.
“The longer I do infection control, the more I think infection control is a behavioral science,” Edmond said. “It’s about getting people to do these certain things that we need them to do, and to get that to happen, we need to remove all the barriers to get them to do the right thing. If we can do things that nudge them to do hand hygiene, then we’ve accomplished our goal.” — by Emily Shafer
Limper H. Infect Control Hosp Epidemiol. 2013;34:1102-1105.
Magill S. N Engl J Med. 2014;370:1198-1208.
Pineles L. Am J Infect Control. 2014;42:144-147.
WHO. WHO Guidelines on Hand Hygiene. Available at: whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed March 27, 2014.
For more information:
Michael Edmond, MD, MPH, can be reached at: VCU Medical Center, Box 980019, Richmond, VA, 23298-0019; email: firstname.lastname@example.org.
Emily Landon, MD, did not respond to requests for contact information.
Elaine Larson, PhD, RN, can be reached at: Columbia University, 617 W. 168th St. Room 330, New York, NY 10032; email: email@example.com.
Connie Price, MD, can be reached at: Connie.firstname.lastname@example.org.
Disclosures: Edmond, Landon, Larson and Price report no relevant disclosures.
What is the most important tool for infection control in hospitals: hand hygiene or environmental disinfection?
Hand hygiene is the most important tool.
Hand hygiene is the leading infection prevention measure. It has to be performed according to appropriate indications for cleaning hands at the point of care during the patient care process, which are defined by the WHO’s Five Moments for Hand Hygiene: before patient contact, before aseptic procedure, after exposure to body fluid regardless of wearing gloves, after patient contact, and after contact with the patient’s environment, regardless of patient contact.
The reason the last moment is included was to take into account the role of the environment and its potential for infecting patients. When a patient is in a bed or anywhere else in the environment, he is surrounded by materials that can be contaminated with patient flora. The Five Moments for Hand Hygiene include the concept of a patient zone, the area around the patient is where the patient is actually spreading the bacteria. When a HCW enters a patient zone and is touching either the patient or the environment, he or she has to clean his/her hands afterwards.
Hand hygiene is the most important procedure, even to prevent spread bacteria from the environment of the patient to the patient himself. Patients primarily acquire bacteria through HCW hands that are contaminated by the environment. It is always contaminated with good or bad bacteria. Even if you clean the environment really well, it will not be completely clean or sterile, and you will always have to clean your hands, despite the fact that the environment is as clean as possible.
In addition, the environment is often highly contaminated, and sometimes you never see an infection that is due to the environment. If you clean the environment very well, and if HCWs touch the environment and forget to clean their hands, then you may see an advantage to cleaning the environment well. If you have HCWs that are 100% compliant with hand hygiene, however, then I doubt you’ll see any advantage of cleaning the environment. However, 100% compliance with hand hygiene is very rare. Compliance is always a problem and we are not really able to record and monitor compliance the way it should be done.
It is important for the environment to be cleaned, but the most important measure to actually prevent spread and transmission of bacteria, from the environment to the patient, is hand hygiene. It’s clear that by improving hand hygiene, you are decreasing infections. There have been more than 50 papers published in the past several years regarding hand hygiene. In 2012, there was more than one paper a month demonstrating the value of improving hand hygiene using the WHO model to improve hand hygiene, clearly demonstrating that hand hygiene has been well associated with decreasing infection. In the case of environmental disinfection, there have only a few papers that have demonstrated that improving environmental control would decrease infection. It’s more difficult to prove, and when these studies are done, you can’t assume that hand hygiene is good.
Didier Pittet, MD, is the director of Infection Control Programme and WHO Collaborating Centre on Patient Safety at University of Geneva Hospitals, Switzerland. Disclosure: Pittet reports no relevant financial disclosures.
Environmental disinfection plays a more important role.
The aspect of environmental decontamination is one that’s really been emerging over the last several years. During this time, there’s no question that there’s more emphasis being placed on the environment as an important part of how we keep patients safe when they’re in the hospital. When it comes to comparing hand hygiene and the environment, the major advantage the environment has is data — that is, environmental decontamination can be considered an "evidence-based practice." In contrast, there really are very little data to demonstrate hand hygiene decreases rates of health care–associated infections. The WHO guidelines have 1200 different references and only 16 (1.5%) are really references that demonstrate hand hygiene does anything. Most of those 16 reference summarize before-after studies, outbreaks and/or describe multi-modal interventions. So while we all believe hand hygiene to be important, there’s really very little evidence to support it. The issue with the environment is carving out, among all the infections and transmissions that occur, how many of them are specifically related to the environment? There are data to say that we know this happens, the question is how much? I don’t know that really anybody has an answer to that.
When you go to the data on environmental decontamination, the environment is clearly a source from which patients acquire bad bugs. We’ve got data that transmission can occur from the environment to the patient. We also know it can move from the environment to HCWs to the patient. We also know that improved cleaning and disinfection of the environment, typically accomplished by improved education and feedback of environmental service employees, reduces the transmission of multi-drug resistant organisms and infections. Some of the newer interventions are these "no-touch solutions" — UV light, hydrogen peroxide vapor, and self-disinfecting surfaces like copper. There are ample data that show if you put these solutions in place you can reduce the amount of organisms on environmental surfaces. These data that shows proof of principle: we can find these bugs, use a strategy, and then there will be fewer of these bugs to contaminate patients and HCWs.
Like hand hygiene, we have data from outbreak settings that demonstrate that improved environmental decontamination decreases infection. But really, that’s where the data for hand hygiene stops, whereas the data for environmental disinfection keep going. Recently published, controlled trials demonstrate that improved environmental cleaning decreases acquisition and infection from these organisms, even in endemic settings. Environmental decontamination has clearly emerged as an important, evidence-based strategy to improve patient safety.
Deverick Anderson, MD, MPH, is associate professor of medicine, Duke University. Disclosure: Anderson reports no relevant financial disclosures.