Since the age of Ignaz Semmelweiss, healthcare practitioners have been admonished to cleanse their hands before coming in contact with patients. While common sense dictated hand hygiene for decades, it wasn’t until 1981 that the Centers for Disease Control and Prevention (CDC) issued the industry’s first evidence-based hand hygiene guideline, according to Larson et al. (2007). Because of fiscal restraints, CDC stopped issuing guidelines in the mid-1980s, but the Association for Professionals in Infection Control and Applied Epidemiology (APIC) stepped in and in 1988 it issued its first hand hygiene guideline (later revised in 1995). When the Healthcare Infection Control Practices Advisory Committee (HICPAC) was created in 1992, it started producing industry guidance, and in 2002 it released an updated hand hygiene guideline that “required major departures from traditional clinical practice,” according to Larson et al. (2007).
These researchers have observed that despite a wide dissemination of national evidence-based practice guidelines, their impact on patient outcomes often go unmeasured. Through surveys and site visits, the researchers measured healthcare-acquired infection (HAI) rates at 40 U.S. hospitals one year before and after publication of the CDC’s hand hygiene guideline and used direct observation of hand hygiene compliance. Larson et al. (2007) report: “All study hospitals had changed their policies and procedures and provided products in compliance with Guideline recommendations; 89.8 percent of 1359 staff members surveyed anonymously reported that they were familiar with the guideline. However, in 44.2 percent of the hospitals, there was no evidence of a multidisciplinary program to improve compliance. Hand hygiene rates remained low (average of 56.6 percent). Rates of central line-associated bloodstream infections were significantly lower in hospitals with higher rates of hand hygiene. No impact of guideline implementation or hand hygiene compliance on other HAI rates was identified.” They surmised further, “Wide dissemination of this guideline was not sufficient to change practice. Only some hospitals had initiated multidisciplinary programs; practice change is unlikely without such multidisciplinary efforts and explicit administrative support.”
If the guideline is not being followed, does it explain the traditionally low compliance rates in U.S. hospitals? Johnston and Bryce (2009) observe, “Studies performed during the last decade have documented reductions in the rates of MRSA and vancomycin-resistant enterococci in hospitals that introduced alcohol-based, waterless hand antiseptics, usually in the context of a general campaign promoting hand hygiene as the cornerstone of safe patient care. Although these and other studies reported improved compliance with hand hygiene, at best compliance improved to 66 percent of opportunities for hand hygiene in one study [Pittet et al., 2000] and 48 percent in another.” [Bischoff et al., 2000]
Perhaps one of the reasons why hand hygiene compliance is so difficult is because compliance itself differs so greatly among different types of healthcare professionals. For instance, Pittet et al., (2000) demonstrated that physicians were the least compliant with handwashing, being performed in just 30 percent of hand-hygiene opportunities.