Abstract & Commentary

Hand Hygiene Exemplars: Lead the Followers

By Leslie A. Hoffman, RN, PhD, Department of Acute/Tertiary Care, School of Nursing, University of Pittsburgh, is Associate Editor for Critical Care Alert.

Synopsis: Hand hygiene was more likely to be performed when the first person entering the room or the attending physician (regardless of order) performed hand hygiene.

Source: Haessler S, et al. Getting doctors to clean their hands: Lead the followers. BMJ Qual Saf 2012;21:499-502.

In this study, a research assistant who was already embedded in patient care teams to observe the process of care during bedside rounds was recruited to document hand hygiene compliance by nine internal medicine teams over a 3-month period. The teams consisted of one attending, one post-graduate year 3 (PGY-3) resident, two PGY-1 residents, one medical student, and one pharmacy student. The research assistant recorded order of entry and exit from the room, training level, and adherence to hand hygiene using a data collection tool encrypted to maintain secrecy.

During the study, there were 718 observed hand hygiene opportunities when the team entered patient rooms and 744 opportunities when leaving the room. Overall, hand hygiene compliance was 52% before entering and 70% before leaving the room. Compliance by training level ranged from 47%-67% before entering and 64%-87% on leaving (P < 0.001). Simply being first, second, or last did not impact the likelihood of performing hand hygiene. However, if the first person entering or leaving the room performed hand hygiene, compliance of the other team members increased significantly (P = 0.002). If the attending physician performed hand hygiene on entering the room, overall team member compliance also increased significantly (P < 0.001). This observation held regardless of who entered or left the room first. Mean compliance was 74% if the attending physician performed hand hygiene compared to 51% if not done (P = 0.016).


Adherence to good hand hygiene is considered essential for infection protection. With the emergence of highly resistant organisms, rigid adherence to this simple practice becomes even more important. However, it is well known that compliance remains poor, despite multiple attempts to change this outcome. Findings of this study are especially intriguing because they suggest that a simple, no-cost intervention can improve hand hygiene compliance, i.e., role modeling and peer pressure. In this study, hand hygiene compliance was significantly improved when the attending physician performed this routine on entering and exiting the patient's room and, as well, when the first person to enter or exit the room performed this step.

Interestingly, hand hygiene compliance was greater on exiting the patient's room than when entering. The authors attributed this finding to "self protection" and questioned whether this finding implied that "self protection" may be a stronger driver of behavior than patient protection. In more than half of the patient encounters in this study, the attending physician was the first person to enter the room, suggesting that if senior clinicians made hand hygiene an integral part of bedside teaching, they need to do little more than perform the task themselves to motivate others to follow their example. This study was conducted on general medical wards, rather than in an ICU; however, there would appear to be no reason why the same findings would be expected in critical care settings.