Spanning the Gap Between Infection Reductions and Current Hand Hygiene Practices

There are hospitals all across the country claiming 90 percent or better hand hygiene compliance yet cannot document the correlating infection rate reductions. Capturing the connection is not a simple task; however, with the expectation of cutting infection rates from one third to one half, wouldn’t the effect of such great compliance show up somewhere on the radar? Aren’t significant infection rate reductions the point of our improvement efforts?

A root cause of the gap between infection rate reductions and current U.S. healthcare hand hygiene practices is found in the U.S. working translation of the 2002 Centers for Disease Control and Prevention (CDC) hand hygiene guidelines. In practice, contact with the patient environment is virtually ignored as an indication for hand hygiene. The result is a failure to achieve the infection rate reductions one would expect based on the studies at the foundation of the guidelines.

A hand hygiene compliance percentage of 90 or better in the U.S. is more than likely the measure of how often providers sanitize their hands coming and going from a patient room. The measures are taken by observers who cannot see through walls or curtains and into the critical, immediate patient environment.

Infection prevention and control professionals and clinicians, by practical necessity, have translated the indications for hand hygiene recommended by the CDC guidelines into little more than coming and going from patient rooms. The act of coming or going from a patient room in itself is not a recommended indication for hand hygiene, as defined by the CDC guidelines. It is, however, an excellent practice, as it is well aligned with actual indications and anything that reminds us to sanitize is a good thing. Touching an IV pole, monitor, bedrail, chair, etc. in the immediate patient environment is a recommended indication yet is mostly absent in both message and practice.

The fact is, providers have not had true point-of-care access to alcohol sanitizers and therefore do not respond to indications that are logistically improbable. The recommendation for point-of-care access to hand hygiene agents has been translated into wallmount dispensers situated near the patient room entrance and out of the direct patient-care workflow for providers. The CDC guidelines point to studies that show hand-transmitted infection rates are highest during the busiest times.1 When patient-care duties are most demanding, how can a nurse respond to every hand hygiene opportunity in the patient environment when the wall-mount dispenser is many steps away?

Much of the CDC guidelines is based on the working model developed by Didier Pittet, MD, and his Geneva University Hospital hand hygiene team. Their pioneering studies demonstrated that improving hand hygiene compliance from 48 percent to 70 percent can cut infection rates in half.2 But their 67 percent does not correspond to the 90 percent touted by many U.S. hospitals. Pittet measures opportunities within the patient environment. Many of their wards have no walls. Their observation measures are more complete. Providers on those units all carry and continuously use pocket bottles, some using belt clips designed by Pittet’s team.

A study abstract out of Dartmouth-Hitchcock Medical Center presented at this year’s National Patient Safety Foundation reveals how contact with the immediate patient environment as an indication for hand hygiene plays a key role in infection rate improvements. The study focused on the anesthesiology workspace in the operating room. In the test phase, body-worn personal hand sanitizer devices were worn and used an average of four times an hour as measured by time-stamp electronic circuits inside the dispensers: “Contamination of intravenous tubing occurred in 32.8 percent of cases in the control group as compared to 7.5 percent in the treatment group...patients in the treatment (device) group were 5.3 times less likely to have contaminated intravenous tubing as compared to the control group.” The study first serves to point out the need for more study in regard to the hand hygiene practices in the OR. But there are much farther-reaching ramifications.

The study demonstrates limiting hand sanitation to coming and going from a patient room is not enough and ignores the greatest opportunities for improvements. If contact with the immediate patient environment results in vectoring of pathogens in the OR, is that same practice any safer in an ICU or med-surg patient room? Colonies of potentially life-threatening pathogens within the immediate patient environment can be found in an ICU by culturing surfaces such as monitors, bedrails and IV poles. If contact with these surfaces is not followed by hand hygiene, cannot they be transmitted to the patient in so many ways?

Providers are not served by mixed messages and, the fact is, contact with the patient environment an indication for hand hygiene. It is clearly stated in the guidelines but is shrouded in working practice. The 2002 CDC guidelines were an excellent start to the process of facing the problem of medical hand hygiene head-on. Clearly there is much yet to be done. The discipline must evolve until it is clear and fully functional for providers.

We cannot give up on this critical indication for hand hygiene, difficult as it may seam to uphold. Yes, the problem of medical hand hygiene compliance has a consistent history of confounding solutions. We know given the current systems in place, clinicians neither have the technology, culture, or the clear message that contact with the patient environment is a working indication for hand hygiene. We know given the current system, getting all providers to just sanitize their hands coming and going from a patient room, is a more realistic goal to achieve. Despite many claims of high compliance, we have seen everyone struggle with hand hygiene and fail to either achieve or sustain significant infection rate reductions. But given the depth of this challenge, complacency is the only enemy.

The patient environment as a working indication for hand hygiene does not have to be abandoned. Collectively, we are innovating a solution to this challenge. New technologies are available and being developed. We can make it easy for clinicians. New ways are being created to help providers reinvent their hand hygiene to use new tools in ways that were never possible before. A paradigm shift is underway that is transforming hand hygiene into an advanced clinical skill. It is in the process of being the finest example of a “complex adaptive system” that everyone works together to sustain.3 The current patient safety renaissance brings with it the kind of human factor engineering and no-blame culture that will catapult medical hand hygiene into its destiny as an advanced clinical skill.

Claims of 90 percent or better compliance may sound great, but if the opportunity to improve infection rates is not realized, it is little more than an empty promise. Expanding working hand hygiene indications in a climate of transparency and an overwhelming drive to “do no harm” is the next logical phase in the evolution of U.S. medical hand hygiene.


1. Boyce JM and Pittet D. Guideline for hand hygiene in health-care settings. Morbidity and Mortality Weekly Report, Oct. 25 2002, Vol. 51, No. RR-16. Page 6.

2. Dix K. CDC’s endorsement of alcohol hand rubs launches new era in hand hygiene. Infection Control Today. Dec. 2002. Page 5.

3. Murphy D, Carrico R, Warye K. Building the infection prevention system of tomorrow: Proceedings of the 2007 APIC Futures Summit. Am J Infect Control. 2008;36:232-40.