16.1. Hand hygiene practices among health-care workers

Understanding hand hygiene practices among HCWs is essential in planning interventions in health care. In observational studies conducted in hospitals, HCWs cleaned their hands on average from 5 to as many as 42 times per shift and 1.7–15.2 times per hour (Table I.16.1). ^{79,137,217–219,262,264,611,613,623,624,647–655} The average frequency of hand hygiene episodes fluctuates with the method used for monitoring (see Part III, Section 1.1) and the setting where the observations were conducted; it ranges from 0.7 to 30 episodes per hour (Table I.16.1). On the other hand, the average number of opportunities for hand hygiene per HCW varies markedly between hospital wards; nurses in paediatric wards, for example, had an average of eight opportunities for hand hygiene per hour of patient care, compared with an average of 30 for nurses in ICUs.^334,656 In some acute clinical situations, the patient is cared for by several HCWs at the same time and, on average, as many as 82 hand hygiene opportunities per patient per hour of care have been observed at post-anaesthesia care unit admission.⁶⁵² The number of opportunities for hand hygiene depends largely on the process of care provided: revision of protocols for patient care may reduce unnecessary contacts and, consequently, hand hygiene opportunities.⁶⁵⁷

Table I.16.1

Frequency of hand hygiene actions among health-care workers.

In 11 observational studies, the duration of hand cleansing episodes by HCWs ranged on average from as short as 6.6 seconds to 30 seconds. In 10 of these studies, the hand hygiene technique monitored was handwashing,^{79,124,135,213–216,218,572,611} while handrubbing was monitored in one study.⁴⁵⁷. In addition to washing their hands for very short time periods, HCWs often failed to cover all surfaces of their hands and fingers.^611,658 In summary, the number of hand hygiene opportunities per hour of care may be very high and, even if the hand hygiene compliance is high too, the applied technique may be inadequate.

16.2. Observed adherence to hand cleansing

Adherence of HCWs to recommended hand hygiene procedures has been reported with very variable figures, in some cases unacceptably poor, with mean baseline rates ranging from 5% to 89%, representing an overall average of 38.7% (Table I.16.2).^{60,140,215,216,334,335,485,486,492,493,496,497,613,633,637,648–651,654,655,657,659–711} It should be pointed out that the methods for defining adherence (or non-adherence) and the methods for conducting observations varied considerably in the reported studies, and many articles did not include detailed information about the methods and criteria used. Some studies assessed compliance with hand hygiene concerning the same patient,^{60,334,648,652,666,667,683,685–687} and an increasing number have recently evaluated hand hygiene compliance after contact with the patient environment.^{60,334,648,652,654,657,670,682,683,686,687,691,698,700–702,704,707–709,711,712}

Table I.16.2

Hand hygiene adherence by health-care workers (1981–June 2008).

A number of investigators reported improved adherence after implementing various interventions, but most studies had short follow-up periods and did not establish if improvements were of long duration. Few studies reported sustained improvement as a consequence of the long-running implementation of programmes aimed at promoting optimal adherence to hand hygiene policies.^{60,494,657,713–719}

16.3. Factors affecting adherence

Factors that may influence hand hygiene include risk factors for non-adherence identified in epidemiological studies and reasons reported by HCWs for lack of adherence to hand hygiene recommendations.

Risk factors for poor adherence to hand hygiene have been determined objectively in several observational studies or interventions to improve adherence.^{608,656,663,666,720–725} Among these, being a doctor or a nursing assistant, rather than a nurse, was consistently associated with reduced adherence. In addition, compliance with hand cleansing may vary among doctors from different specialities.³³⁵ Table I.16.3 lists the major factors identified in observational studies of hand hygiene behaviour in health care.

Table I.16.3

Factors influencing adherence to hand hygiene practices.

In a landmark study,⁶⁵⁶ the investigators identified hospitalwide predictors of poor adherence to recommended hand hygiene measures during routine patient care. Predicting variables included professional category, hospital ward, time of day/week, and type and intensity of patient care, defined as the number of opportunities for hand hygiene per hour of patient care. In 2834 observed opportunities for hand hygiene, average adherence was 48%. In multivariate analysis, non-adherence was the lowest among nurses compared with other HCWs and during weekends. Non-adherence was higher in ICUs compared with internal medicine, during procedures that carried a high risk of bacterial contamination, and when intensity of patient care was high. In other words, the higher the demand for hand hygiene, the lower the adherence. The lowest adherence rate (36%) was found in ICUs, where indications for hand hygiene were typically more frequent (on average, 22 opportunities per patient-hour). The highest adherence rate (59%) was observed in paediatrics, where the average intensity of patient care was lower than elsewhere (on average, eight opportunities per patient-hour). The results of this study suggested that full adherence to previous guidelines was unrealistic and that easy access to hand hygiene at the point of patient care, i.e. in particular through alcohol-based handrubbing, could help improve adherence,^615,656,720 Three recent publications evaluating the implementation of the CDC hand hygiene guidelines⁵⁸ in the USA tend to concur with these results and considerations.^726–728 Various other studies have confirmed an inverse relation between intensity of patient care and adherence to hand hygiene.^{60,334,335,493,649,652,653,656,689,729,730}

Perceived barriers to adherence with hand hygiene practice recommendations include skin irritation caused by hand hygiene agents, inaccessible hand hygiene supplies, interference with HCW–patient relationships, patient needs perceived as a priority over hand hygiene, wearing of gloves, forgetfulness, lack of knowledge of guidelines, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information showing a definitive impact of improved hand hygiene on HCAI rates.^{608,656,663,666,722–725,729,731,732} Some of the perceived barriers to adherence with hand hygiene guidelines have been assessed or quantified in observational studies.^{608,663,666,720,722–724} Table I.16.3 lists the most frequently reported reasons that are possibly, or effectively, associated with poor adherence. Some of these barriers are discussed in Part I, Section 14 (i.e. skin irritation, no easy access to hand hygiene supplies), and in Part I, Section 23.1 (i.e. impact of use of gloves on hand hygiene practices).

Lack of knowledge of guidelines for hand hygiene, lack of recognition of hand hygiene opportunities during patient care, and lack of awareness of the risk of cross-transmission of pathogens are barriers to good hand hygiene practices. Furthermore, some HCWs believed that they washed their hands when necessary even when observations indicated that they did not.^{218,220,666,667,676,733}

Additional perceived barriers to hand hygiene behaviour are listed in Table I.16.3. These are relevant not only on the institutional level, but also to particular HCWs or HCW groups.