Literature Review

Coignard B, Grandbastien B, Berrouane Y, et al. Handwashing quality: Impact of a special program. Infect Control Hosp Epidemiol 1998; 19:510-513.

Hand washing is considered the most effective way to prevent transmission of nosocomial infections, yet studies show health care workers have low compliance with basic hand washing (BHW). Few studies on handwashing technique are available, so researchers at the University Hospital of Lille (5,700 HCWs) in France implemented an educational campaign on BHW technique to identify failed steps in the BHW procedure and focus education on them.

The infection control staff and a network of HCWs defined a 13-step protocol for a proper BHW as follows:

1. Wear short sleeves or roll up long sleeves before washing.

2. Keep fingernails cut short.

3. Do not wear jewelry or a watch.

4. Let water run for a few seconds.

5. Wet hands and wrists with water.

6. Take one dose of soap.

7. Take soap using elbow or forearm.

8. Rub hands and wrists.

9. Rinse hands and wrists.

10. Dry hands with paper towels.

11. Dry hands and wrists gently without rubbing.

12. Use paper towels to turn off hand faucet.

13. Avoid touching wastebasket when discarding towels.

In addition, 175 collective training sessions were conducted, supplemented by individual technique demonstrations, hospital newsletter articles, and posters.

Researchers conducted a before/after audit. A BHW was considered proper if all steps were performed correctly. Frequency, duration, and appropriateness of BHW were not evaluated. Data were collected anonymously in a two-step random sampling of physicians, registered nurses and midwives, nurses’ aides, and housekeeping staff. Each surveyor observed two or three HCWs, following them during routine activities. HCWs did not know which hand washing was evaluated. The analysis was based on 426 observations for the first audit and 392 for the second.

Results showed that steps one and two had a high success proportion, more than 90%. Steps three, four, six, seven, and 11 rarely were performed properly in the first audit. A subsequent training program emphasized those five steps. The success proportion of steps three through 13 increased significantly in the second audit. The five steps on which the program focused had relative increases between 31% and 72% in the success proportion. In the first audit, the success of step one was associated with the success of step five.

The proportion of proper BHW increased from 4.2% in the first audit to 18.6% in the second. In both audits, the proportion of proper BHW did not differ significantly between medical or surgical units, physicians or nonphysicians, daytime or nighttime, and before or after patient care.

However, the proportion of proper BHW was higher among HCWs who held their present position for less than a year. HCWs also tended to perform better BHW if they had been in practice for less than a year.

While the proportion of each step performed properly and the proportion of proper BHW both improved after the intervention, steps poorly performed in the first audit remained quality breakpoints in the second audit.

Previous studies have shown that physicians comply with hand washing recommendations less than nurses, but this study did not find such a difference. Overall results showed the difficulty of obtaining good BHW quality. The time required to perform hand washing may explain low compliance, and briefer alcoholic hand disinfection has been proposed in another study.

"Results of this study suggest that alternative protocols also should be simpler," researchers conclude.