Strategies to Boost Hand Hygiene Compliance

ICT asked invited clinical experts to discuss best-practice strategies that address hand hygiene compliance.

At the top of any qualified infection control agenda is the practice of proper hand hygiene. The Centers for Disease Control and Prevention (CDC) asserts that clean hands are the single most important factor in preventing the spread of dangerous healthcare-associated infections (HAIs) in healthcare settings. It is critical that infection control policies for hand hygiene are monitored for compliance regularly, as recent studies have illustrated a reduction in patient infection rates when hand hygiene protocols are correctly followed.

All hand hygiene policies should begin with the use of an alcohol-based rub before and after any resident contact, dealing with bodily fluids or any soiled materials, removing gloves and changing bedding or linens. This measure is imperative for preventing the spread of germs between residents via the medical staff. The CDC also recommends that staff should wash hands thoroughly with soap and water whenever any visible debris is present or when dealing with outbreaks caused by spore-forming bacteria such as Clostridium difficile.

Providing visitors, residents, and staff convenient access to a hand sanitizer is crucial to ensuring compliance. Facilities should encourage its guests and residents to practice proper hand hygiene frequently as part of their daily routine. Key times include before and after meals and activities and following the sharing of any hand-held items. Hand hygiene stations and additional supplies should be readily available at key locations throughout the facility including all entrances to the facility (for easy visitor access) and outside of all restrooms and resident rooms. In addition, special attention should be given to residents with mobility issues to provide sanitizing dispensers in easily accessible locations. Touchless dispensing systems also provide added protection against the inadvertent transmission of germs.

A comprehensive education program is also an important element of any hand hygiene policy. Hospital administrators should provide their staff with annual training courses to ensure that they are being kept apprised with the most current trends and best practices. Additionally, new staff should be required to take part in hand hygiene protocol training immediately following their hiring.

Lastly, it is critical that medical staff comply with policies surrounding the use of facility-approved and supplied hand lotions. It has been proven that certain types of lotions contain properties that make some medicated soaps less effective and can cause deterioration in latex gloves. Additionally, lotions can become contaminated with bacteria if refilled improperly. Therefore, it is imperative that staff only use approved products, as well as allow the proper refilling of lotion dispensers to avoid spreading germs in their facility.

-- Wava Truscott PhD, MBA, director of medical sciences and education for Kimberly-Clark Health Care

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In recent years, hand hygiene in the healthcare setting has generated a lot of attention. Reputable organizations such as the Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) and the Association of periOperative Registered Nurses (AORN) have all developed recommendations for best practices related to achieving proper hand hygiene. However, in my experience as an OR nurse, one area that deserves more attention is surgical scrubbing.

As I experienced firsthand in the OR, current surgical scrubbing techniques are not driven solely by guidelines set forth by organizations or individual institutions. Other factors weigh in when deciding which products to use, how they are used and how often. Three of these factors are education, habit and preference.

Education on the guidelines can indeed be helpful in understanding recommendations for surgical hand scrubbing. However, I find that many of the current guidelines leave room for interpretation, which can cause confusion. For instance, the OR staff may not realize that it is in accordance with guidelines for a waterless surgical hand scrub to be used as the first scrub of the day. In fact, an alcohol-based, waterless surgical hand scrub can potentially make it easier for the OR staff to scrub their hands quickly, with minimal effort or skin irritation. Modern alcohol-based surgical hand scrubs contain skin conditioners (emollients) that help prevent the drying effects of alcohol.

When it comes to selecting which alcohol-based surgical hand scrub to use many healthcare professionals default to habit, using traditional time-consuming methods. New waterless formulations on the market provide rapid and persistent activity against hand flora without the long scrub and dry time or sticky residue. Additionally, waterless surgical hand scrubs can be dispensed from a convenient motion-activated dispenser, which may make it easier and faster for OR staff to scrub in and comply with recommended practices.

In addition, product preference and staff input play a role in the selection of surgical hand scrubs, as they can impact compliance. Studies show an average compliance rate of 40 percent, and that poor compliance can be due to multiple factors, including perceived lack of time and irritation or dryness caused by the antiseptic. No one wants to use a scrub that doesnt dry quickly or leaves a sticky residue, which can make putting on gloves difficult. This is why I recommend an alcohol-based, waterless surgical scrub that dries quickly, feels soft, smooth and conditioning on the hands, and leaves no sticky or tacky feel. Understanding the factors that impact surgical hand scrubbing and the product solutions available can result in best practice hand hygiene for your OR.

Reference: CDC. Morbidity and Mortality Weekly Report: Guideline for Hand Hygiene in Health-Care Settings. October 25, 2002, Vol. 51, No. RR-16.

-- Valerie Gramlich, RN, former OR nurse and director, and clinical operations consultant for CareFusion Corporation

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Healthcare providers have understood the importance of hand hygiene since 1847, when Ignaz Semmelweis proved the connection between handwashing and the reduction of deaths from puerperal fever. Its importance is without question; yet 164 years later hand hygiene compliance remains a huge issue.

According to the Centers for Disease Control and Prevention (CDC), healthcare-associated infections (HAIs) are a leading cause of death in the U.S., killing about 100,000 people a year and infecting about 2 million. Proper hand hygiene practices play a significant role in preventing many of these infections.

Within the Greenville Hospital System, our hand hygiene compliance was at 53 percent before and after patient care. This is quite typical when you look at compliance rates across the country. Our challenge was to rapidly increase our compliance as the cornerstone of our efforts to prevent HAIs. We set a three-year goal to achieve 90 percent compliance.

To accomplish this, we needed an accurate method to measure compliance that would allow us to have a positive impact on unit behavior, track all five essential hand hygiene "moments" or opportunities as identified by the WHO and provide real-time analysis that we could immediately act on even in the event of an outbreak.

Ideally, we wanted to move to an electronic method to give us the greatest impact. While electronic systems exist that track compliance in real-time, they dont track against the gold standard WHO guidelines, are cost-prohibitive and have a "big brother feel" that could alienate our staff.

As a research-driven organization, our first step was creating an evidence-based model for measuring compliance based on the WHO "Five Moments of Hand Hygiene." To do so, one of my colleagues, Connie Steed, MSN, RN, CIC, along with Elaine Larson, RN, PhD, FAAN, of Columbia University School of Nursing, and Paul Alper of Deb Worldwide Healthcare and others, conducted the "Hospital Hand Hygiene Opportunities: Where and When (HOW2)? The HOW2 Benchmark Study," which was published in the February 2011 issue of the American Journal of Infection Control.

The study was designed to determine the average number of hand hygiene opportunities per patient day on different types of units; in different hospital types. We then worked with Deb to assist in the development and field testing of a group monitoring system that electronically monitors, tracks and reports compliance rates in real-time, based on the WHO guidelines. Through an innovative dashboard, we now have data, which combined with the benchmarks developed in the HOW2 Study, allows us to calculate compliance in real-time and feed this information back to our units.

Our approach is "measure share act." This is groundbreaking for our infection preventionists, who are now able to analyze the real-life scenarios that contribute to missed opportunities and immediately implement action.

Our focus on hand hygiene has led us to a new innovation and tools that allow us to create a sustainable safety culture within our hospitals, address compliance concerns as they occur and track against the WHO guidelines. We like to think that Semmelweiss would be proud.

-- Thomas Diller, MD, MMM, CPE, vice president of quality and patient safety at Greenville Hospital System University Medical Center in South Carolina