Updated WHO Guidelines Support Multi-Modal Approach to Hand Hygiene Compliance


Hand hygiene compliance is recognized as “one of the most important ways to reduce the transmission of pathogens in healthcare settings”1 and by inference, reduces the occurrence or healthcare-associated infections (HAIs). Although the Centers for Disease Control and Prevention (CDC) has publicized that proper hand hygiene is the single most effective method for preventing these infections, every year 2 million patients contract HAIs in the U.S. alone and approximately 99,000 die from them. Although significant effort and emphasis has been placed on hand hygiene compliance in the U.S. and abroad, rates are estimated to be 30 percent to 50 percent on average at most facilities. Healthcare providers are facing increased challenges as new requirements around mandatory reporting and Centers for Medicare and Medicaid Services (CMS) non-reimbursement of certain healthcare-acquired conditions puts pressure on providers to implement more robust infection prevention programs to improve patient safety.

Few people outside of the infection control world realize that HAIs are the fourth leading cause of death in the U.S., but awareness is growing as media coverage of methicillin-resistant Staphylococcus aureus (MRSA) infections continues and legislation calling for MRSA screening is being put in place. It is only a matter of time before hospitals will be asked to begin reporting on hand hygiene compliance in addition to other quality metrics. In fact, such a program of reporting hand hygiene compliance rates is being called for now in the U.K. by the Scotland National Health Service.

Studies have shown that improved hand hygiene compliance in hospitals has financial benefits in addition to improved patient safety through lower incidence of HAIs. According to data from the Pennsylvania Health Care Cost Containment Council, the average hospital charge is $31,389, while a patient with an HAI is nearly six times the cost at $185,260.2 As hospitals look to further increase hand hygiene compliance, they must take into consideration the various guidelines set forth by regulatory and advisory bodies with their specific requirements and differences. The World Health Organization (WHO) and Joint Commission (JC) recommendations focus on reducing the risk of HAIs, and encouraging patients’ active involvement in their own care. The CDC’s recommendations focus more on educating healthcare workers around improving and monitoring hand hygiene practices. The WHO has also implemented a campaign to educate healthcare workers on “Five Moments for Hand Hygiene:”3

1. Before patient contact

2. Before aseptic tasks

3. After body fluid exposure risk

4. After patient contact

5. After contact with patient surroundings

The focus here is to help clarify when healthcare workers should perform hand hygiene. The simplicity of the language, the alignment with work process flow, and the applicability to a wide variety of settings make this simple tool valuable to any program to improve hand hygiene compliance.

When comparing the CDC and WHO guidelines, both call out direct observation as well as indirect monitoring, in which the hospitals can monitor product usage and use these measurements as a surrogate in order to determine compliance rates throughout the hospital.

Some hospitals have implemented such product measurement systems with good success. For example, Good Samaritan Hospital in Baltimore takes a multi-modal approach to its hand hygiene compliance program, including patient empowerment (“It’s OK to Ask”), staff education, direct observation, and product volume measurement means of encouraging and measuring compliance. As subscribers to Ecolab’s Hand Hygiene Compliance Monitoring Program, Good Samaritan is provided a monthly analysis of its compliance rates through McGuckin Methods International, Inc., an independent consulting group.

As presented in a poster at this year’s meeting of the Society for Healthcare Epidemiologists of America (SHEA), Good Samaritan Hospital began using the Ecolab patient empowerment program, “It’s OK to Ask,” in May 2008. One month later, the product volume measurement (PVM) compliance average was 70 percent; the direct observation (DO) average was 96 percent. After six months, the compliance average as measured by product volume was 77 percent, while direct observation compliance average was 97 percent. In that period, compliance increased by 7 percent as measured by product volume use and 1 percent as observed handwashing. The small difference between the direct observation rates may be attributable to the Hawthorne effect which this method is subject to if workers are aware of the observers’ presence. The improvement as measured by the product volume method is significant and is not subject to the same bias. The different methods of measurement complement each other, offering a more complete picture of hand hygiene compliance.

The benefits of product volume measurement as compared to direct observation are that it serves as a good way to spot potential issues; for example, units at higher levels (70 percent to 80 percent PVM, compared to baseline rates of about 40 percent) may not require direct observation because the behavior supporting infection prevention has already been established. However, units coming in at 20 percent to 30 percent PVM can be looked at more closely to identify issues, provide additional training, or make other changes in order to address the situation.

Another component of the updated WHO hand hygiene guidelines is the use of patient empowerment programs as a means to encourage proper hand hygiene. Using patient empowerment programs, in which hospitals educate patient and visitors on the importance of hand hygiene, helps encourage the patient and their families to get involved in their care. Many patients and family members at first find it daunting to ask a healthcare provider whether they have sanitized their hands, and need to be assured that “It’s OK to Ask.” When supported by administration and staff role models, these programs can serve as the catalyst for change at a hospital. In fact, patient empowerment programs have been shown to improve hand hygiene compliance significantly and sustain that improvement over months, according to studies.4-5

In addition to empowering patients to ask if their healthcare providers have washed or sanitized their hands, patients should also be encouraged to commend their healthcare providers when they catch them “doing something right” and use it as an opportunity to provide positive reinforcement for proper hand hygiene. To help educate patients on the importance of hand hygiene, hospitals can create their own materials such as brochures, posters, signs and stickers, or use materials developed by suppliers.

Another area of emphasis with the WHO guidelines is the importance of dispenser placement, with an emphasis on placing hand sanitizers at the point of patient care. This is critical, as hands can easily become re-contaminated by touching surfaces within the patient care area or indeed the patient, even if the healthcare worker did clean their hands upon entering the room. Mounting wall dispensers with the patient room, or use of dispensing systems that can easily attach to beds, IV poles and other areas within close proximity to the patient, such as the Ecolab FlexMount™ Dispenser, makes it easier for staff to sanitize their hands before contact with the patient and supports the WHO guidelines’ Five Moments for Hand Hygiene. With the increase in public concern about HAIs public education campaigns such as the one being undertaken by the WHO on the topic, there is an outstanding opportunity for the health care community to use this heightened awareness to help bring hand hygiene compliance from the (overall) unacceptably low levels that it has been stalled at for decades, to levels where it can be eliminated as a contributing factor to avoidable HAIs. The future of hand hygiene in healthcare must include healthcare providers, visitors, and patients all supporting the vision of the WHO’s “Five Moments for Hand Hygiene” by washing their hands or using hand sanitizers at the appropriate times, and pushing ever closer to zero preventable infections.

Cheryl Littau is a senior scientist for skin care innovation at Ecolab Healthcare. She holds a PhD in surfactant chemistry and can be reached at cheryl.littau@ecolab.com.


1. Joint Commission 2009 Monograph, Measuring Hand Hygiene Adherence: Overcoming the Challenges.

2. http://www.pennpirg.org/in-the-news/health-care/health-care/new-report-sheds-sobering-light-on-hospital-infections

3. WHO Guidelines on Hand Hygiene in Health Care (advanced draft).

4. McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control, 32:235-8, 2004.

5. McGuckin M, Waterman R, Storr J, Bowler I, Ashby M. Evaluation of patient empowering hand hygiene programme in UK. J Hosp Infect, 48: 222-227, 2001.

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