Hand Hygiene Adherence in the Operating Theater: Data From the Netherlands

Infection Control TodayInfection Control Today, December 2022, (Vol. 26, No. 10)
Volume 26
Issue 10

The study's investigators noted that adequate hand hygiene in the OT by nonsterile health care workers and surgeons is vital to prevent post-operative wound infections.

A surgeon performing hand hygiene.

A surgeon performing hand hygiene.

(Adobe stock)

Findings from a prospective observational study1 on health care workers’ adherence to a novel hand hygiene protocol in the operating theater (OT) were published recently in The Journal of Hospital Infection.

According to Manon D. van Dijk, Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Centre Rotterdam, the Netherlands, and colleagues, this uniform way of observing hand hygiene adherence (HHA) in the OT enables evaluation of the effectiveness of interventions in the OT and facilitates friendly competition. In the Rotterdam-Rijnmond region, the HHA rate in the OT was below 50% and needed to be addressed in teaching hospitals and among physicians.

Because the Netherlands does not have protocols or observations tools in the OT, witnessing nonsterile health care workers (HCWs) perform HHA proved difficult, and a protocol needed to be created.

“Furthermore, regardless of the department or health care setting, hand hygiene observations are often performed by using the 5 moments of hand hygiene as stated by the World Health Organization (WHO),” the investigators wrote in the study. “These 5 moments are the golden standard and are in general easy to apply on clinical wards where there is a clear distinction between the patient zone and the health care zone. The patient zone includes everything that is attached to the patient or belongs to a specific patient, while everything that is not patient specific is referred to as health care zone. Health care workers should apply hand hygiene when changing from patient zone to health care zone, and vice versa.”

The study included 9 hospitals in the Rotterdam-Rijnmond region. Because these hospitals did not have specific hand hygiene protocols for nonsterile HCWs in the OT, the investigators created one with the hospitals’ input. Once the protocol was agreed upon, an observation tool was developed and tested. Using the tool, investigators calculated HHA rates by type of hospital and HCW.

The Protocol Contained 3 Sections:

Written general hand hygiene rules

Written hand hygiene rules specifically for anesthesia and surgery

Visual representation of the OT, divided into 4 hand hygiene areas.

Generally, hand hygiene should be performed when moving from one area to another. Across all hospitals, an average HHA rate of 48.0% (95% CI, 45.2%-61.2%) was observed in OTs. The academic teaching hospital received the lowest score at 23.1% (95% CI, 0.0%-45.8%), and the 2 specialized hospitals scored highest at 64.0% (95% CI, 30.6%-89.8%) and 76.7% (95% CI, 62.8%-84.5%). Interestingly, the average HHA scores from anesthesiologists were the lowest,31.6%, (95% CI, 19.2%-62.4%), whereas OT assistants scored the highest, at 57.4% (95% CI, 50.1%-78.2%).

“Nonetheless, adequate hand hygiene in the OT by nonsterile HCW and surgeons (performing nonsterile actions) is of utmost importance to prevent postoperative wound infections. Considering patients undergoing surgery are vulnerable to infection, exposure to infection risks in the OT should be kept as low as possible,” the authors wrote.

Some strengths of this study included the following: enabling uniform hand hygiene observations from one hospital to another, specifically designed for nonsterile HCW in the OT. This information will help infection preventionists to know which departments need extra assistance. The authors also mention that comparisons between hospitals could lead to friendly competition on which has the higher HHA rate. Competition also increases the rate of HHA in each hospital’s OT. Also, as many HCWs work in more than 1 facility, if the protocols were consistent among all the facilities, then the HCWs’ HHA could remain high because the infection prevention and control policies are the same, and they do not have to remember different policies.

Some limitations of this study included the implementation of COVID-19 infection prevention protocols. Also, because of COVID-19, 3 hospitals were not included in the final study, which did not allow for as many observations of HHA. Finally, because all the observations were only performed in 1 region of 1 country, more testing is needed to assess whether these protocols would function the same way in other countries and in other styles of OTs.

“However,” the investigators noted, “[because] almost all observations in the OT nowadays are still performed by using the 5 moments of hand hygiene of the WHO, we think that our protocol and observation tool could be a valuable addition to the existing literature.”


1. Dijk MD van, Breejen MCMW den, Vermeeren JMJJ, Berg S van den, Beeck EF van, Vos MC. Compliance to a novel hand hygiene protocol tailored to non-sterile health care workers in the operating theatre. Journal of Hospital Infection. 2022;0(0). doi:10.1016/j.jhin.2022.10.009

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