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Hand Hygiene Training

Published: 01st Jul 2013 in AMH Magazine

Early hand hygiene practises were initially derived in the Middle East, with the Phoenicians of modern day Lebanon having invented soap around 2,600 years ago. In Roman times, hygiene traditions were embodied in Hygeia, the mythic goddess of good health, cleanliness and sanitation. Practises of the ancient world were learned through observing the consequences of failure to execute necessary hygiene steps, including effective hand washing.

In the earliest medical texts from ancient Egypt, inner and outer body cleanliness was highly prized. Maintaining clean fingernails and washing hands several times a day was seen as an essential measure to prevent the spread of infection.

Hand hygiene was considered so important that it was ordered in the Qu’ran (5:7) around 1,400 years ago.

HAI rates

The benefits of hand hygiene have been known for thousands of years, yet preventable illnesses and deaths from infectious diseases remain unacceptably high. The World Health Organization (WHO) states that 32% of deaths each year - that’s 400 million years of healthy human lives - are caused by infectious diseases. The prevalence of healthcare associated infections (HAIs) varies from between 5% to 11% in developed countries and from 5% to 19% in the developing world.

The social burden of HAIs is estimated to be many hundreds of thousands of lives, costing hundreds of billions of dollars worldwide annually. These preventable infections are attributed to:

• Patients being immune-compromised
• Patients or the hospital environment being a source of infectious disease
• Patients or healthcare workers (HCWs) spreading infections via the hands

Cost efficient prevention

Various authors have presented the cost effectiveness of training and infection preventive programmes focused on hand hygiene compliance to reduce overall medical costs resulting from HAIs. Preventive strategies executed in healthcare facilities have provided sometimes greater than nine-fold returns on investment47. While hand hygiene is considered the single most effective means of preventing the spread of HAIs, average compliance - carried out when necessary for prevention - is only considered to be 40% to 50%. 

Many approaches have attempted to raise compliance rates, but until now no ideal solution has presented itself.

Compliance training

A wide variety of different training programmes have been studied in an effort to improve compliance. Often these studies show no improvement or low level improvement. 

In many instances campaign results may appear initially effective and encouraging, only for workers to then rapidly revert back to old habits. The problem is that campaigns are, by definition, short in duration - once the campaign is over it is back to business as usual. This gets in the way of meaningful progress as hand hygiene training is quickly unlearned.

Studies are beginning to show that compliance for its own sake doesn’t deliver anywhere near the same punch as compliance that targets a reduction in infection rates. It stands to reason that hand hygiene is not an end in itself but a means to an end, so we really need to focus on the end goal and consider hand hygiene as just one of several tools to get there.

No single strategy has consistently been shown to sustain improved compliance with hand hygiene protocols.

Over a period of time researchers identified three common components to programmes that yielded improved compliance: education, motivation and changes or improvements to facilities. It was also realised that successful interventions must target reasons for non compliance.

This predicated the introduction of alcohol and non alcohol based hand sanitisers when they were introduced in 2002.

We performed a study to determine which training approaches should be utilised to increase compliance and decrease infection rates. A meta-analysis was undertaken to identify published reports on infection control programmes where hand hygiene improvement was a key part of the study and infection rates were decreased in the process. Forty clinical studies were identified, as listed in the references, where on average a 48% reduction in infection rates was obtained via multimodal hand hygiene compliance programmes.

Compliance programmes were in the categories of:

• Respiratory tract infections
• Overall Intensive Care Unit (ICU) infections
• Hospital wide infections
• Urinary tract infections
• Surgical site infections
• Blood stream infections
• Vancomycin resistant enterococci (VRE) or Methicillin- resistant Staphylococcus aureus (MRSA) infections
• Central line associated blood stream infections
• Gastrointestinal tract infections

In addition to the specific compliance interventions listed here, the healthcare facility infection control programme officers in charge must:

• Keep setting lower infection rate goals
• Fully investigate each failure and learn from it
• Hold everyone accountable
• Celebrate programme successes

In essence this is a formula for continuous process improvement. In looking at dozens of multifaceted infection control programmes with strong hand hygiene components that result in the lowering of infection rates, the following list of interventions in the areas of education, motivation and facilities improvement are seen to be utilised.

Educational interventions

There are many educational interventions that will contribute to increasing hand hygiene compliance, including:

• Memos and letters about programme objectives
• Visitor hand hygiene instructions
• Competency testing
• Reminder signs and posters
• Scheduled hand hygiene, such as the five moment approach

In addition, in service lectures and tutorials can be excellent educational interventions. These can include:

• Self study modules
• Educational instruction and outside readings
• Demonstrations with marker bacteria or UV gel
• Movies and videos
• Refresher sessions
• New employee instruction
• Motivational interventions

One form of motivational intervention is to provide strong administrative support; for example, by posting statements of policy change or procedural review. As outlined below, feedback and supervision should also be provided, such as through the use of rewards and sanctions, the monitoring of hand hygiene and the surveillance of infection rates and types by ward.

Hand hygiene can be monitored through:

• Monitoring or observation alone
• Verbal reminders
• Secret or overt observation with verbal or posted feedback
• Enlisting patients in providing direct feedback

Surveillance of infection rates and types by ward can be carried out using:

• Epidemiologic information posted or provided in letters or memos
• Interventions targeting continuous lowering of rates

Another excellent motivational intervention is social marketing focused on educational, motivational and facility interventions; for example, the enlistment or active participation of an entire team, through the use of questionnaires and posting of positive and negative results. Another social marketing tool is to perform a root cause analysis (RCA).

An RCA can be performed using:

• RCA based corrective action targeting reasons for non compliance Iteration to ensure continuous process improvement
• Duration at the event horizon, i.e. as long as adverse events continue to occur

Facilities interventions

Facilities and medical practice interventions include implementing ward and infection best practises; screening and cohorting; using gowns and gloves when indicated; and improving garbage, human waste and infectious material disposal. It is also important to make hand hygiene possible, easy and convenient.

Methods of improving hand hygiene accessibility include:

• Surveying and evaluating hand hygiene status, as informed by team participation and RCA
• Improving the patient:sink ratio
• Installing automatic sinks
• Using new soap and sanitiser dispensers; for example, distributing soap and sanitiser samples and selecting single handed personal hand sanitiser dispensers that drive compliance

Environmental inspections and surveys are another form of facilities intervention. These include:

• Environmental cultures for indicator microorganisms
• Posted culture results
• Environmental cleaning and disinfection

Education and motivation

Hand hygiene is the simplest and most effective method of reducing HAIs. Thanks to Ignaz Semmelweis, we have known this for more than 150 years. It appears that hand hygiene compliance is not a simple matter of education; if it were, then those with the highest education would have the highest compliance rates. Interestingly, Figure 1 shows that there is in fact an inverse relationship between years of education and hand hygiene compliance.

Hand hygiene is thought of as boringly simple - certainly not rocket science. It is precisely this attitude of familiarity and dismissiveness that, at least in part, undermines compliance. Perhaps those with higher education have more on their minds, or more distractions?

In examining consumer behavioural surveys regarding hand hygiene behaviours when preparing food in 80% to 100% of participants it was found that an educational background provides the basic knowledge that leads to the decision to clean hands.

Virtually all consumers, healthcare professionals included, have the requisite knowledge to implement hand hygiene, although some review and training wouldn’t hurt.

The survey seen in Figure 2 shows attitudes and beliefs supporting hand hygiene are very positive, between 95% and 100%. This shows that people really want to do the right thing and wash their hands when demanded by the situation. Intent to wash hands was also fairly high and despite slipping slightly to the 55% to 85% level this is still very encouraging.

When the same people were asked to self report hand hygiene events in which they had recently participated, a slight drop to the 60% to 80% range was seen. When these same people were observed, compliance was seen to be only in the 25% range. When it comes to training, neither education nor attitude seems to drive improvement in compliance.

Systems' approach 

In order to have a positive impact on HAI rates, one needs to take a systems’ approach. Risks in these systems are seen to reside with those persons who, as a result of their work load: 

• Have the highest levels of hand contamination
• Touch patients most often
• Wash or sanitise their hands least frequently

Monitoring processes and particularly video monitoring and various radio frequency badges are now available to track compliance of HCWs within a facility. The problem is that staff can become alienated by negative feedback, whereas positive feedback is a preferred method of behaviour modification.

While the above training interventions show how complex hand hygiene training can become, simpler methods are also available that incorporate a few of the traditional training components combined with process changes. The best approaches addressing poor compliance are those that create a flow in which the HCW is pulled through the process.

This is achieved through the use of well perceived hand hygiene products and supplies aimed at compliance. 

Dispensers modifying behaviours

Behaviour modification is harder than initially considered and as such, other approaches to achieving optimum compliance are needed. Creating new behaviours around hand hygiene devices is one such approach. This involves using a new device or process change as a ‘teachable moment’. 

Where possible, to reduce cross contamination and to aid in taking control of the process, hands free or automatic faucet, soap, paper towel dispensers and hand sanitiser dispensers can be introduced. Despite removing some control from the participant, this actually empowers them in a designed process format.

Thanks to hands free hygiene technologies, in a few effortless waves of the hand HCWs can very cleanly go through the full hand hygiene process. These automatic devices have been shown to increase compliance in almost every setting
in which they have been employed.

Another approach amounting to empowerment of HCWs is to arm them with their own personal hand hygiene device.

Recently several different personal hand sanitiser dispensers have become available, which allow the application of alcohol or non alcohol gel hand antiseptic to be used on the go.

Worn on the person and clipped to the pocket or belt, these dispensers provide single hand application, invoking what in athletics is termed as muscle memory.

This introduces habitual drivers, which lead to increased hand hygiene compliance. While not taking the place of hand washing, constant use of antiseptic hand gel by HCWs and patients on parts of the hand often missed such as fingertips will drive opportunistic pathogen hand counts down, thereby lowering cross infection risks.

An empty hand sanitiser unit turned in by the HCW at end of their shift provides compliance monitoring, making it simple, cost effective and non-embarrassing for both the facility and the HCW. These sanitiser devices worn by workers have the major advantage of proximity. Unlike the sanitiser dispenser mounted outside the patient’s room, just inside the doorway
or next to the sink, they are constantly within reach of the HCW. No matter what they are doing or where they are, hand sanitiser is always within reach.

Dispensers placed within reach of patients, e.g. on a bed rail or table, would significantly reduce chances that patients will self contaminate wounds or the immediate environment, which is a known pathogen reservoir enabling cross contamination.

Compliance increase

It has been widely advocated that HCWs need to achieve 100% hand hygiene compliance to significantly reduce the spread of HAIs, but the facts indicate that even an increase of between 10% and 20% could have a significant impact. 

It doesn’t take much of a compliance increase to reduce infection rates because these rates are driven by those HCWs who contact patients most frequently and who, for various reasons, wash or sanitise their hands least frequently.

These are HCWs with the lowest rates of hand hygiene compliance and those at ground zero where transmission of infection occurs. By making hygiene exceptionally easy in these situations, the most significant impact is not in increasing average compliance, but more importantly in bringing up the lowest levels of compliance where the greatest risk of transmission exists with habitual non compliers. This is where hand hygiene is most needed. 

Concluding concerns 

One training issue that may come up in the Arab world is the decision of which type of hand sanitiser product to use for infection control purposes. In the United Kingdom, town councils, schools and businesses use alcohol based gels to reduce the spread of the common cold and flu virus,but some Muslims have voiced objections because the Qu’ran forbids the use of alcohol. To accommodate these individuals, some council chiefs issued non alcohol gels. 

The Muslim Council of Britain, however, stated that people should follow medical advice and use the alcohol based hand sanitisers, pointing out that Islamic teachings allow Muslims to use alcohol for medicinal purposes. External application of synthetic alcohol gel is considered permissible within the remit of infection control because it is not an intoxicant, and the alcohol used in the gels is synthetic, i.e. not derived from fermented fruit.

The Muslim Council of Britain also stated that confusion in this respect may be avoided if references to and labelling of alcohol gel bottles emphasised the disinfection properties rather than its alcohol content. Use of the term ‘Ethanol’ to describe the contents was to be encouraged.

To think that something as fundamentally basic as good hand hygiene could effortlessly save countless lives makes the consequently linked diseases and deaths all the more poignant. As a healthcare worker, practising poor hand hygiene can be paramount to signing a patient’s death warrant.

We must all work together to control the spread of healthcare acquired infections, and with a combination of motivational, educational and facilities based training interventions in force, HAIs will soon have nowhere to hide.


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Published: 01st Jul 2013 in AMH Magazine


Barry Michaels

Barry Michaels has more than 40 years of experience in the field of infectious disease investigation, control and prevention.

His research work has involved a wide variety of viral, bacterial, fungal and protozoan pathogens focused on antimicrobial intervention strategies.

Michaels began his microbiology career with the study of viral and tumour inhibitory substances at the Variety Children’s Research Foundation in Miami, Florida, obtaining his degree in Microbiology from the University of Miami. After 14 years as a microbiologist, product safety and development manager for Georgia Pacific Corporation, he founded the B. Michaels Group Inc.

This consultant group is active in areas of product safety, product development, regulatory affairs and microbiology related to personal hygiene, surface sanitation and glove use in food, healthcare and various other occupational fields where hygiene and improved skin care are important.

Dubbed the ‘Guru of Hand Hygiene’, Michaels has been widely cited in the popular press as well as being published on the subjects of skincare and infection control in hundreds of articles, abstracts, book chapters and blog posts.

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