Improving compliance with hand hygiene practices
Introduction
Healthcare-associated infections (HCAIs) continue to be a challenge, and the costs to healthcare systems and patients in financial and human terms creates a burden (WHO 2011). Compliance with hand hygienepractices is considered to be the most effective strategy to prevent HCAIs (Allegranzi et al 2010, Erasmus et al 2010, Kirkland et al 2012, Azim and McLaws 2014).
However, even with this knowledge, compliance with hand hygiene practices by healthcare workers remains patchy, with an overall median compliance rate of 40% (Erasmus et al 2010). Using knowledge from the discipline of human factors, the focus of this module is to understand factors that lead to hand hygiene policy and protocol violations by healthcare workers.
Healthcare-associated infections (HCAIs) continue to be a challenge, and the costs to healthcare systems and patients in financial and human terms creates a burden (WHO 2011). Compliance with hand hygienepractices is considered to be the most effective strategy to prevent HCAIs (Allegranzi et al 2010, Erasmus et al 2010, Kirkland et al 2012, Azim and McLaws 2014).
However, even with this knowledge, compliance with hand hygiene practices by healthcare workers remains patchy, with an overall median compliance rate of 40% (Erasmus et al 2010). Using knowledge from the discipline of human factors, the focus of this module is to understand factors that lead to hand hygiene policy and protocol violations by healthcare workers.
Background
In the 1840s Ignaz Semmelweis demonstrated that when medical students and staff washed their hands before attending to women giving birth, the rate of mortality from infections was reduced from 13-18% to 2% (Best and Neuhauser 2004). Florence Nightingale also recognised the importance of handwashing in the prevention of infection in the mid-1800s (Nightingale 1859, Lim 2010). These clinicians experienced derision, disbelief and resistance to the implementation of hand hygiene regimens. However, science has validated their claims by demonstrating the presence of pathogens and the crucial role of handwashing in preventing the spread of the micro-organisms that lead to HCAIs (Allegranzi et al 2011).
Complete time out activity 1
List the reasons you think might contribute to low hand hygiene compliance rates. Ask your colleagues what reasons they think contribute to non-compliance with hand hygiene requirements.
Once completed your time out activity is saved and stored in "My Modules”.
In the 1840s Ignaz Semmelweis demonstrated that when medical students and staff washed their hands before attending to women giving birth, the rate of mortality from infections was reduced from 13-18% to 2% (Best and Neuhauser 2004). Florence Nightingale also recognised the importance of handwashing in the prevention of infection in the mid-1800s (Nightingale 1859, Lim 2010). These clinicians experienced derision, disbelief and resistance to the implementation of hand hygiene regimens. However, science has validated their claims by demonstrating the presence of pathogens and the crucial role of handwashing in preventing the spread of the micro-organisms that lead to HCAIs (Allegranzi et al 2011).
Complete time out activity 1
List the reasons you think might contribute to low hand hygiene compliance rates. Ask your colleagues what reasons they think contribute to non-compliance with hand hygiene requirements.
Once completed your time out activity is saved and stored in "My Modules”.
SAVE LIVES: Clean Your Hands campaign
The SAVE LIVES: Clean Your Hands campaign (WHO 2009a) galvanised commitment from many countries to improve hand hygiene practices in healthcare settings. As part of the campaign, WHO developed hand hygiene improvement strategies targeting organisational systems and the behaviour of healthcare workers.
Strategies of the campaign included (WHO 2009b):
- The introduction of hand hygiene products.
- An increase in the number, and strategic placement, of sinks, soap and handrub dispensers.
- Education programmes.
- Reminders and prompts such as posters.
- A focus on organisational safety.
While this has had an effect on increasing compliance with hand hygiene practices and a decrease in HCAIs in some organisations, overall compliance rates remain low (Erasmus et al 2010, Filion et al 2011, Stewardson and Pittet 2012, WHO 2013).
The SAVE LIVES: Clean Your Hands campaign (WHO 2009a) galvanised commitment from many countries to improve hand hygiene practices in healthcare settings. As part of the campaign, WHO developed hand hygiene improvement strategies targeting organisational systems and the behaviour of healthcare workers.
Strategies of the campaign included (WHO 2009b):
- The introduction of hand hygiene products.
- An increase in the number, and strategic placement, of sinks, soap and handrub dispensers.
- Education programmes.
- Reminders and prompts such as posters.
- A focus on organisational safety.
While this has had an effect on increasing compliance with hand hygiene practices and a decrease in HCAIs in some organisations, overall compliance rates remain low (Erasmus et al 2010, Filion et al 2011, Stewardson and Pittet 2012, WHO 2013).
Techniques for effective hand hygiene
The SAVE LIVES campaign identified principles required for effective hand hygiene, including the five moments in clinical care for hand hygiene (Box 1), and the most effective technique for cleansing using both handrub and soap and water. Handrub and handwashing techniques are the very similar. The differences are the duration of the procedure, the initial application of the product, and the requirement to dry hands if handwashing rather than air-drying them when handrub is used. The techniques involve (WHO 2009c):
- Applying product to cupped hand for handrub or wetting hands with water and applying soap to cover all hand surfaces for handwashing.
- Rubbing hands palm to palm.
- Rubbing right hand over left dorsum with interlaced fingers and vice versa.
- Rubbing palm to palm with interlaced fingers.
- Rubbing backs of fingers to opposing palms with fingers interlocked.
- Rotational rubbing of left thumb clasped in right palm and vice versa.
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.
- Performing the handrub technique for 20-30 seconds and the handwashing technique for 40-60 seconds.
- When using handrub, hand hygiene is complete once hands are dry.
- When handwashing, hand hygiene is complete after hands are rinsed, dried with a paper towel, and the towel is used to turn off the tap.
The SAVE LIVES campaign identified principles required for effective hand hygiene, including the five moments in clinical care for hand hygiene (Box 1), and the most effective technique for cleansing using both handrub and soap and water. Handrub and handwashing techniques are the very similar. The differences are the duration of the procedure, the initial application of the product, and the requirement to dry hands if handwashing rather than air-drying them when handrub is used. The techniques involve (WHO 2009c):
- Applying product to cupped hand for handrub or wetting hands with water and applying soap to cover all hand surfaces for handwashing.
- Rubbing hands palm to palm.
- Rubbing right hand over left dorsum with interlaced fingers and vice versa.
- Rubbing palm to palm with interlaced fingers.
- Rubbing backs of fingers to opposing palms with fingers interlocked.
- Rotational rubbing of left thumb clasped in right palm and vice versa.
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.
- Performing the handrub technique for 20-30 seconds and the handwashing technique for 40-60 seconds.
- When using handrub, hand hygiene is complete once hands are dry.
- When handwashing, hand hygiene is complete after hands are rinsed, dried with a paper towel, and the towel is used to turn off the tap.
Box 1. The five moments in clinical care requiring hand hygiene
- Before touching a patient, such as helping them to move or holding the patient’s hand.
- Before a clean or aseptic procedure, such as performing wound dressings or personal hygiene tasks.
- After risk of exposure to body fluid, such as when changing a urinary catheter or obtaining blood samples.
- After touching a patient, such as helping them to move or holding their hand.
- After touching patient surroundings, such as linen, patient monitoring equipment or tray table.
(World Health Organization 2009a, 2009b)
Complete time out activity 2
Review the essential elements for hand cleansing and access the diagrams at tinyurl.com/8xykftt. Using this information, review your technique for hand hygiene. Identify changes that you need to make to improve your hand hygiene practice.
Once completed your time out activity is saved and stored in "My Modules”.
- Before touching a patient, such as helping them to move or holding the patient’s hand.
- Before a clean or aseptic procedure, such as performing wound dressings or personal hygiene tasks.
- After risk of exposure to body fluid, such as when changing a urinary catheter or obtaining blood samples.
- After touching a patient, such as helping them to move or holding their hand.
- After touching patient surroundings, such as linen, patient monitoring equipment or tray table.
(World Health Organization 2009a, 2009b)
Complete time out activity 2
Review the essential elements for hand cleansing and access the diagrams at tinyurl.com/8xykftt. Using this information, review your technique for hand hygiene. Identify changes that you need to make to improve your hand hygiene practice.
Once completed your time out activity is saved and stored in "My Modules”.
Factors related to compliance with hand hygiene practices
Many studies have investigated the reasons for poor compliance with hand hygiene practices (Erasmus et al 2010). Factors implicated include (Gluyas and Morrison 2013):
- Lack of time.
- Workload pressures.
- Lack of knowledge.
- Poor role modelling by other healthcare professionals.
- Lack of organisational support.
These factors are common in the organisational systems and working environment in which healthcare workers cognitively process and make decisions about actions and tasks. The discipline of human factors promotes understanding of the effect of these factors on the cognitive processes and decision making by healthcare workers at the point of care.
Many studies have investigated the reasons for poor compliance with hand hygiene practices (Erasmus et al 2010). Factors implicated include (Gluyas and Morrison 2013):
- Lack of time.
- Workload pressures.
- Lack of knowledge.
- Poor role modelling by other healthcare professionals.
- Lack of organisational support.
These factors are common in the organisational systems and working environment in which healthcare workers cognitively process and make decisions about actions and tasks. The discipline of human factors promotes understanding of the effect of these factors on the cognitive processes and decision making by healthcare workers at the point of care.
Learning points
- Compliance with hand hygiene practices is considered to be the most effective strategy to prevent HCAIs.
- Science has validated the presence of pathogens and the crucial role of handwashing in preventing the spread of the microorganisms that lead to HCAIs.
- Hand hygiene strategies recommended by the SAVE LIVES: Clean Your Hands campaign include: the introduction of hand hygiene products; an increase in the number and strategic placement, of sinks, soap and handrub dispensers; education programmes; reminders and prompts such as posters; and a focus on organisational safety.
- The technique of effective hand hygiene involves a series of activities: applying product to cupped hand for handrub or wetting hands with water and applying soap to cover all hand surfaces for handwashing; rubbing and rotational rubbing techniques; performing handrub for 20-30 seconds and handwashing for 40-60 seconds.
- Compliance with hand hygiene practices is considered to be the most effective strategy to prevent HCAIs.
- Science has validated the presence of pathogens and the crucial role of handwashing in preventing the spread of the microorganisms that lead to HCAIs.
- Hand hygiene strategies recommended by the SAVE LIVES: Clean Your Hands campaign include: the introduction of hand hygiene products; an increase in the number and strategic placement, of sinks, soap and handrub dispensers; education programmes; reminders and prompts such as posters; and a focus on organisational safety.
- The technique of effective hand hygiene involves a series of activities: applying product to cupped hand for handrub or wetting hands with water and applying soap to cover all hand surfaces for handwashing; rubbing and rotational rubbing techniques; performing handrub for 20-30 seconds and handwashing for 40-60 seconds.
This module aims to inform nurses and other healthcare professionals, using a human factors perspective, about factors that lead to policy and protocol violations associated with poor compliance with hand hygiene practices.
Intended learning outcomes
After reading this module and completing the time out activities you should be able to:
- Describe the principal elements involved in hand hygiene practices in healthcare settings.
- Identify the cognitive processes that can lead to errors.
- Identify the different types of violations involved in hand hygiene errors.
- Apply knowledge of hand hygiene to the work environment.
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