Lending a (Clean) Hand: Improving Hand-hygiene Practices

Abstract & Commentary

By Ruth Kleinpell, PhD, RN, Director, Center for Clinical Research and Scholarship, Rush University Medical Center; Professor, Rush University College of Nursing, Chicago Dr. Kleinpell reports no financial relationship to this field of study. This article originally appeared in the February 2010 issue of Critical Care Alert. It was edited by David J. Pierson, MD and peer reviewed by William Thompson, MD. Dr. Pierson is Professor, Pulmonary and Critical Care Medicine, Harborview Medical Center, University of Washington, Seattle, and Dr. Thompson is Staff Pulmonologist, VA Medical Center; Associate Professor of Medicine, University of Washington; they report no financial relationships relevant to this field of study.

Synopsis: When ICU practitioners worked under senior clinicians who modeled good hand-hygiene practices, their own behavior with respect to hand hygiene improved.

Source: Schneider J, et al. Hand hygiene adherence is influenced by the behavior of role models. Pediatr Crit Care Med. 2009;10:360-363.

Infection prevention is a priority area of focus for critical-care units worldwide. As hospital-acquired infections remain the most common cause of preventable morbidity and mortality, efforts to improve hand-hygiene compliance have great significance for improving health care outcomes for hospitalized patients.

This prospective, observational study examined the impact of hand-hygiene adherence of two critical-care fellows and four nurse orientees in a pediatric and cardiac intensive care unit of a tertiary care children's hospital who were paired with physician and nurse preceptors who maintained strict hand-hygiene adherence. The results revealed that hand-hygiene adherence improved from a baseline of 22% of 222 hand-hygiene opportunities prior to introduction of a senior supervising clinician who modeled this behavior to 56% of 234 opportunities after the supervising clinician was introduced. The study results indicate that hand-hygiene practices of senior practitioners have an impact on the hand-hygiene compliance of other health care team members.

Commentary

It is well established that one of the most important measures for preventing the spread of pathogens is effective hand washing.1 Hand-hygiene measures are an essential component of preventing health care-associated infections. Normal human skin is colonized by bacteria, including both resident flora and microorganisms that reside under the superficial cells of the stratum corneum, and transient flora, which colonize the superficial layers of the skin. Handwashing or hand antisepsis is effective at reducing the transmission of health care-associated pathogens, as well as the incidence of health care-associated infections.2 A number of studies have demonstrated the impact of hand hygiene on health care-associated infection rates or the reduction in cross transmission of antimicrobial resistant pathogens.3-5 As a result, a number of evidence-based guidelines have been published addressing effective hand hygiene.1,3,6 In addition, several organizational initiatives have focused on promoting best practices for hand hygiene to improve infection-prevention measures, including the Institute for Healthcare Improvement,7 the Hand Hygiene Resource Center,8 and ongoing campaigns such as the World Health Organization's "Save Lives: Clean Your Hands" initiative, which has designated May 5, 2010, as a global day call to action for hand hygiene to health care workers worldwide.2

As the transmission of health care-associated pathogens has been attributed most often to the contaminated hands of health care personnel,7 focusing on improving hand-hygiene compliance rates is beneficial in targeting the prevention of health care-associated infections. The study by Schneider et al demonstrated a significant improvement in hand-hygiene adherence based on the role modeling of proper hand-hygiene practices by senior practitioners. This study adds to the body of literature that has focused on improving the hand-hygiene behaviors of health care workers. Yet, as a single-site study involving a small sample size of health care practitioners, the generalizability of the results is limited. Other studies have demonstrated the benefit of multidisciplinary hospital-wide educational programs, easy access to hand-rub solutions, dispensing systems, and the impact of hospital redesign on hand-hygiene compliance rates.9-12 Yet the impact of interventions on sustaining the rates of adherence to hand-hygiene measures has been limited.3 As hand-hygiene practices involve a complex interaction of factors, additional research on the impact of role modeling to improve hand-hygiene compliance is indicated to focus on further improving a culture of patient safety and proper hand hygiene in critical care.

References

1. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Healthcare Settings — 2002. Available at: www.cdc.gov/Handhygiene/. Accessed Dec. 15, 2009.

2. World Health Organization Guidelines on Hand Hygiene in Healthcare. Available at: http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Accessed Dec. 20, 2009.

3. Boyce, JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002;23:S3-S40.

4. Larson E. A causal link between handwashing and risk of infection? Examination of the evidence. Infect Control Hosp Epidemiol 1988;9:28-36.

5. Larson EL. Skin hygiene and infection prevention: More of the same or different approaches? Clin Infect Dis 1999;29:1287-1294.

6. Healthcare Infection Control Practices Advisory Committee and Hand-Hygiene Task Force, Society for Healthcare Epidemiology of America, Association for Professionals in Infection Control and Epidemiology, & Infection Diseases Society of America. Guideline for hand hygiene in healthcare settings. J Am Coll Surg 2004;198:121-127.

7. Institute for Healthcare Improvement. How-to Guide: Improving Hand Hygiene. Available at: www.shea-online.org/Assets/files/IHI_Hand_Hygiene.pdf. Accessed Jan. 4, 2010.

8. Hand Hygiene Resource Center. Available at: www.handhygiene.org/. Accessed Jan. 4, 2010.

9. Pittet D, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000;356:1307-1312.

10. Bischoff WE, et al. Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160:1017-1021.

11. Larson EL, et al. Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: Comparison of use of 2 dispenser systems. Am J Crit Care 2005;14:304-311.

12. Lankford MG, et al. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis 2003;9:217-223.