Hand Hygiene: Importance, Compliance, and Strategies for Prevention of Healthcare-Associated Infections

This article discusses the importance of hand hygiene in preventing healthcare-associated infections (HCAIs) and the lack of compliance among healthcare providers. It provides strategies to improve compliance and emphasizes the role of hand hygiene in reducing the risk of HCAIs and improving patient outcomes.

HAND HYGIENE
Introduction:
Health care associated infections (HCAI) also known as nosocomial infections are the
infections which the patient acquires in health care settings (Gould, Moralejo, Drey,
Chudleigh and Taljaard,2017; "The burden of health care-associated infection worldwide",
2019; Haque, Sartelli, McKimm and Baker,2018; Kingston, O’Connell and Dunne,2016).
WHO report states that worldwide millions of patients suffer from HCAIs with the
prevalence in developed countries being 3.5 to 12% (Dettenkofer et al.,2016). This results in
adverse patient outcome such as increased mortality, morbidity, lengthened hospital stay,
long term disability, psychological stress, flourishing of antibiotic resistant micro- organisms,
increased health care cost for the patient and burden on the health care system ("The burden
of health care-associated infection worldwide",2019; Kingston et al.,2016). Cross
contamination of the pathogenic organisms between the patients and health care providers
result in HCAI. The WHO guidelines for prevention and control of HCAIs include execution
of standard protocols such as hand hygiene. It also suggests surveillance and reporting at
national and international levels ("The burden of health care-associated infection worldwide",
2019). The WHO guidelines suggest implementation of hand hygiene as the most important
and effective strategy to prevent and control HCAIs. It is a very simple, low cost but effective
method to reduce the risk of HCAIs. A 5 moment hand hygiene protocol is recommended by
WHO for improved efficiency. The procedure of hand hygiene including the duration,
method of hand rub and amount of sanitizer used is also crucial for effectively removing the
micro- organisms from the surface of the hands of the healthcare providers. However, there is
a lack of compliance to hand hygiene practice amongst healthcare workers. Strategies such as
training and education are important to ensure compliance for hand hygiene for prevention
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and control of HCAI leading to well- being of the patient (Doronina, Jones, Martello, Biron
and Lavoie- Tremblay,2017).
Mechanism of spread of infections in healthcare environment:
The commonest route of spread of HCAIs is by direct contact particularly the hands
of the healthcare providers. Cross contamination between patients and healthcare workers
results in HCAIs. Some of the other modes of spread of HCAIs are interventions such as
intravascular catheterization, urinary catheterization and endotracheal intubation. The
presence of the micro-organisms on hospital floors, door knobs, taps, working surfaces can
spread to patients causing HCAIs. Contaminated hospital waste such as surgical waste is
another reservoir of the micro-organisms increasing the risk of HCAIs (Haque et al.,2018).
Some of the common risk factors for HCAI are depicted in figure 1 (Presterl, Schahawi,
Lusignani, Paula and Reilly,2018).
Fig 1: Health care associated infections and risk factors (Persterl et al., 2018)
Strategies to reduce and prevent the occurrence of HCAI:
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WHO guidelines have recommended strategies for reduction and prevention of
HCAIs. These include the following ("The burden of health care-associated infection
worldwide", 2019; Dettenkofer et al., 2016):
 Identification of determinants of HCAI
 Reporting and surveillance at local and national level
 Provision of components of infection control such as decolonisation, disinfection and
antiseptics
 Implementation of standard protocols such as hand hygiene procedures
 Ensuring staff compliance by providing staff education and improving responsibility
 Encouraging research to improve surveillance
 Conducting research to involve patients in control and prevention of HCAI
Importance and method of hand hygiene in prevention and control of HCAI:
Hand hygiene is regarded as the most effective method for prevention and control of
HCAIs. The principle behind it is that hand hygiene can effectively halt the chain of infection
thereby lowering the risk of HCAI (Gould, Creedon, Jeanes, Drey, Chudleigh and Moralejo,
2017). Hand hygiene removes the micro-organisms mechanically from the hands of the
healthcare workers thereby preventing spread of the micro-organisms to the patients or the
surroundings. This mechanical removal can be achieved by the following methods:
 Washing the hands with soap and water and drying
 Use of aqueous antiseptic such as chlorhexidine gluconate
 Use of alcohol based hand rubs.
Amongst the above methods of hand hygiene, alcohol based hand rubs are more
convenient, require less amount of time to be effective and have a higher rate of anti-
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microbial activity (Gould, Taljaard et al.,2017). Therefore, handrubbing with alcohol based
hand rubs is commonly used in healthcare facilities.
To attain effective hand hygiene, the proper technique and procedure should be used
(Sickbert-Bennett, DiBiase, Willis, Wolak, Weber and Rutala, 2016). The amount of product
used either soap or alcohol based hand rub should be sufficient enough to cover the entire
hand surface. Approximately 2 to 3 ml of alcohol based hand rub can be used to achieve
adequate hand hygiene. The duration of rubbing is also important and generally 30 sec
rubbing is adequate to remove the micro-organisms from the surface of the hands (Chraiti and
Widmer, 2017). The WHO guidelines for technique of hand hygiene is illustrated in fig 2.
Fig 2: WHO guidelines for hand hygiene procedure (Hand hygiene WHO leaflet, 2019)
WHO guidelines for hand hygiene:
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In 2009, WHO published guidelines for execution and evaluation of hand hygiene practice in
healthcare facilities. According to these guidelines, the following efforts need to be
implemented for hand hygiene programmes: (Gould, Taljaard, et al.,2017)
 Alcohol based hand rubs should be available with the health care provider
 Training and education of the health care workers regarding necessity and proper use
of hand hygiene techniques
 Feedback to be obtained regarding consistent use of hand hygiene practices
 Regular reminders for the use of hand hygiene
 Support from the administration for effective implementation of hand hygiene
Hand hygiene 5 moments:
The WHO recommended a 5 moment approach (fig 3) for effective hand hygiene to reduce
the incidence of HCAI. The principle of this guideline is to prevent cross contamination of
infection between the patient and the health care provider and also prevent the entry of the
patient’s own micro-organisms into his body during certain procedures (Hand hygiene WHO
leaflet, 2019). According to this guideline, hand hygiene should be adopted by healthcare
providers at 5 distinct moments during the course of patient care. These 5 moments are as
follows: ("My 5 Moments for Hand Hygiene", 2019)
1) Before touching a patient
2) Before performing procedures with clean/aseptic precautions
3) After exposure or contact with body fluids, non intact skin, wound dressings etc.
4) After touching a patient, and
5) After touching patient surroundings or inanimate objects around the patient.
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Fig 3: WHO guidelines: 5 moments for hand hygiene ("My 5 Moments for Hand Hygiene",
2019)
Lack of Compliance:
It has been reported that there is a lack of compliance to adhere to hand hygiene
practice amongst healthcare providers. There are several reasons for poor compliance which
include improper education and training, time constraints, low staffing, scarcity and
inaccessibility to hand dispensers, concerns of effect of the sanitizers on the skin, poor role
models and adherence to wrong procedures (Presterl, et al.2018). Hand hygiene compliance
can be measured by observation or proxy indicators of compliance such as measurement by
automated devices. Simple devices dispense a fixed amount of the product and the number of
times the device is used is recorded. Sophisticated sensors are also available which are
attached to the body and linked to a computer to record whether the hands have been cleaned
(Gould, Taljaard, et al.,2017).
Strategies to ensure hand hygiene compliance among healthcare providers:
Various strategies have been recommended to improve the compliance to hand
hygiene techniques among healthcare providers. Multimodal interventions which involve
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several components are suggested for improving compliance. (Gould, Taljaard et al., 2017).
Some of the recommendations are as follows: (Gould, Taljaard et al., 2017; Presterl, et al.,
2018)
 Education and training of the healthcare staff regarding appropriate and optimal hand
hygiene procedures. Continuous training and hand hygiene campaigns in the form of
posters, advertising campaigns, promotional materials etc. are important to improve
compliance
 Administrative support to provide easy accessibility to alcohol based hand rubs at the
point of contact with the patient. Portable bottles are good alternatives in case of non-
availability of dispensers
 Regular feedback and audit of the medical staff regarding use of hand hygiene
techniques. Direct observation is crucial for monitoring compliance.
 Accountability by physicians to adhere to hand hygiene practices helps to improve
compliance because physicians are the role models for other health care workers. The
need for cumulative effort by all the healthcare staff members to recall and help each
other regarding the 5 moment hand hygiene technique needs to be emphasized
through training
 Health care environment modifications such as use of alcohol based hand rub,
substitution of liquid hand rub with a gel, changes related to gloves, modification in
the work setting to make the hand hygiene products more easily accessible and
increase their availability
 Leadership and administrative support to implement strategies locally to attend to the
issues which contribute to lower compliance.
Conclusion:
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HCAIs are a global healthcare issue which has adverse effects on patient mortality
and morbidity and also are a burden on the healthcare system. Several studies have
established that hand hygiene is the most effective intervention to prevent and control HCAI.
WHO has published guidelines for hand hygiene in 2009, regarding the necessity and
techniques of efficient hand hygiene in the prevention of HCAI. It recommends a multimodal
strategy such as education and training, observation and feedback and administrative support
to achieve effective hand hygiene. The 5 moment hand hygiene is promoted by WHO.
Alcohol based hand rubs are the most effective products to remove the micro-organisms
present on the skin of the healthcare workers. Lack of compliance is a major constraint for
effective hand hygiene. Several strategies have been recommended by WHO to improve
compliance. These include regular training and education, advertising campaigns using
posters etc., observation and feedback. These approaches have a positive impact on the
compliance of hand hygiene thereby promoting well being of the patient and reducing the
healthcare expenditure.
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