Can climate’ change solve hand washing bane?

Alcohol hand gels gain favor in Europe

Changing a hospital’s "organizational climate" by calling on the clout of top administrators may prove more effective at improving hand washing compliance than the myriad failed efforts that try to enact change from the "the bottom up," reported Elaine Larson, RN, PhD, professor of pharmaceutical and therapeutic research at Columbia University School of Nursing in New York City.

Larson previewed her findings from a study, which has been submitted for publication, at the recent annual meeting of the Society for Health care Epidemiology of America in San Francisco. Noting that the medical literature is rife with hand washing improvement efforts that either failed initially or saw compliance quickly revert to former levels, Larson said the new approach shows some promise in the long-running battle to get health care workers to decontaminate their hands between patients. The idea was to change a hospital’s organizational culture for the purpose of increasing the frequency of hand washing and reducing nosocomial infections. The study used a framework for changing organizational climate that made hand washing a priority of top administration.

"In this study, our clients were not the individual nurses and physicians on the wards," Larson told SHEA attendees. "It was the board of directors, the medical director, the administrators of the hospital — flowing from the top down rather than from the bottom up."

A hand washing competency was developed, and hospital staff on all units were required to complete a demonstration that they knew how to wash their hands properly as part of their performance appraisal.

"Now, it sounds pretty silly, but people took it very seriously, and they couldn’t continue to work unless they had passed this competency," she said. "All new hires received a letter from the CEO and medical director welcoming them, telling them that this was the hospital that did the hand washing — this is what we were known for, this is what we believe in."

The 300-bed hospital was compared with a similarly sized facility in the same city with comparable infection control staff. The intervention was conducted over some six months, and then the researchers did a follow-up evaluation six months later. The hypothesis was that hand washing compliance would not jump, but would gradually increase to a higher level that would be sustained. Indeed, follow-up indicated that the baseline level of hand washing compliance had tripled in the intervention hospital based on data collected from 500,000 hand washes recorded by undetectable counting mechanisms on soap dispensers. Moreover, infection rates with MRSA and VRE also declined after the intervention. Interestingly, the change occurred without feedback to workers or other follow-up interventions, she explained.

"At follow-up, after we stopped doing anything, the [new climate] had taken it over," she said. "We weren’t doing anything. We just came back and counted hand washes."

Hand washing studies have found rates of compliance after touching patients generally in the range of 20% to 40%. Efforts to change hand washing behavior through motivational and educational posters may show an immediate improve ment in hand washing but actually very little sustained effect. Similarly, engineering devices like automated sinks and paper towel dispensers may fail to sustain improved compliance, perhaps partially because some health care workers resent "losing control over their hand washing behavior," Larson noted. However, bringing in an administrative component has demonstrated efficacy in behavioral studies in other areas besides infection control, she noted.

"You see the theme here . . . get to the leaders, don’t try to work on all the individuals in the units; achieve agreement with the leadership group; implement changes administratively; do an educational blitz after deciding what’s going to work; and then ride out the reactions because people will be unhappy," she said. Eventually, a shift may occur from an individual focus on changing behavior to an organizational focus, she added.

"Do I value hand washing?’ That’s individual," she said. "Is our unit committed to reducing infections with hand hygiene practices?’ That’s organizational. We need to move ourselves from individual valuing to organizational valuing."

Looking at another aspect of hand washing at the same SHEA session, another clinician noted that even if health care workers comply, they may only wash hands briefly. Reviewing 10 studies that addressed duration of washes, John Boyce, MD, noted that six of them found that workers washed hands for less than 10 seconds. Most laboratory evaluations of soap and detergent products call for 30 seconds or one minute of hand washing time in their protocols, he added.

"I think this is an important point that has not been addressed," said Boyce, hospital epidemiologist at the Miriam Hospital in Providence, RI. ". . . Based on my cursory review of the literature, at this point I don’t know what the efficacy is of soap and detergent preparations under the actual conditions they are used by health care workers."

An alcohol gel alternative

Acceptability of the products may be a factor in use and duration of use, and Boyce said concerns about skin damage may be hindering wider acceptance of alcohol-based products by health care workers in the United States. In a study presented at SHEA, Boyce and colleagues conducted a prospective, randomized trial to determine the frequency of skin irritation and dryness associated with alcohol hand gel vs. standard soap and water hand washing.1 The study followed 29 nurses on three wards. Skin irritation and dryness were evaluated using self-assessment by study participants, visual assessment by a study nurse, and estimation of epidermal water content (to determine dryness) by using electrical capacitance measurements. Nurses were randomized to use one of the two regimens for two weeks; then after a two-week rest period, each nurse switched to the alternate regimen for two weeks. Nurses were instructed not to use hand lotion during trial periods.

"When nurses used standard soap and water hand washing during their ward activities, their hands became progressively drier during the two-week period," Boyce told SHEA attendees. "In contrast, when they were using the alcohol-gel regimen, their hands did not become dry, and in fact there was a slight improvement. This small study suggests that alcohol gel regimens that contain emollients actually do not result in more irritation and dryness, and may be tolerated better than a lot of the soaps and detergents."

The practice of using alcohol-based hygienic hand rubs has largely replaced hand washing as the standard of care in Northern Europe, added Andreas Widmer, MD, MS, a clinician at the University Hospital in Basel, Switzerland. Speaking at the same SHEA session on hand washing, Widmer said his hospital is using hand disinfection rather than hand washing more than 90% of the time that hand washing is indicated and hands are not visibly soiled. An alcohol dispenser is available between all beds, at each nurse’s desk, and two at each ICU bed, he said. A database of 4,500 workers has not identified a single case of documented allergy to the commercial alcohol compound in use. Studies indicate that hand disinfection is much more effective in killing bacteria and most viruses than hand washing with a medicated soap, he noted.2,3

However, there are no sound epidemiological data demonstrating that a certain level of killing is needed to have an impact on the incidence of nosocomial infection. Regardless, studies indicate that hand disinfection by alcohol can be done in about one-quarter of the time it takes to achieve the same results by hand washing.4,5 In addition, sinks are expensive and cannot be installed at necessary locations as easily as disinfectant dispensers, he added.


1. Boyce JM, Keliher S, Korber S. Hand disinfection with an alcoholic gel causes less skin irritation and dryness of nurses’ hands than soap and water handwashing. Abstract 78. Presented at the Conference of the Society for Healthcare Epidemiology of America. San Francisco; April 18-20, 1999.

2. Bellamy K, Alcock R, Babb JR, et al. A test for the assessment of "hygienic" hand disinfection using rotavirus. J Hosp Infect 1993; 24:201-210.

3. Rotter ML, Koller W, Wewalka G, et al. Evaluation of procedures for hygienic hand-disinfection: controlled parallel experiments on the Vienna test model. J Hyg 1986; 96:27-37.

4. Widmer AF. Infection control and prevention strategies in the ICU. Intensive Care Med 1994; 20 Suppl 4:S7-11.

5. Voss A, Widmer AF. No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol 1997; 18:205-208. n