Hand hygiene in health care: 20 years of ongoing advances and perspectives (2021)

Author: Lotfinejad N, Peters A, Tartari E, Fankhauser-Rodriguez C, Pires D, Pittet D.

Healthcare associated infections (HCAI) are preventable adverse events that can cause morbidity and mortality in hospital patients. The most common method of transmission of HCAIs is through the contaminated hands of health-care workers. This article covers the advances over the last 20 years highlighting the widespread use of alcohol hand rubs and the World Health Organisation’s (WHO) multimodal behaviour change strategy. The WHO strategy includes system change as a prerequisite for behaviour change, education, monitoring and performance feedback, reminders in the workplace, and an institutional safety climate. Here are some of the key points from the paper:

• HCAIs are estimated to be in the range of 3·5–12% in high-income countries and 5·7–19·1% in low-income and middle-income countries
• The average hand hygiene compliance rate is reported as 40% in high-income countries and less than 20% in low-income countries
• Hand hygiene with alcohol-based hand rub is the most effective HCAI preventive strategy
• The first guideline to support the use of alcohol-based hand rub as the preferred hand hygiene method unless hands were visibly soiled or contact with spore forming organisms was in 2002 by the Centres for Disease Control and Prevention (CDC)
• The use alcohol-based hand rub rather than use of soap and water for hand hygiene has led to a faster and more efficient hand cleaning method.
• Alcohol hand rubs are the most potent at concentrations between 60% and 80%.
• Alcohol hand rubs should always be available at the point of care
• The efficacy is associated with the type of alcohol, concentration, contact time, used volume, and whether it is used on wet skin, which decreases its efficacy
• The use of alcohol-based hand rub was proved effective against the SARS-CoV-2 virus
• One of the major barriers to hand hygiene compliance has been time constraint but changing from use of soap and water to the use of an alcohol hand rub for hand hygiene significantly reduced time from over 1 minute to 20-30 seconds
• One study reported that hand rubbing for 15 second with an alcohol handrub was not inferior to 30 seconds to reduce the bacterial load on hands
• Gloves should not be used as a substitute for hand hygiene
• Misuse of gloves can give a false sense of security and may also contribute to the transmission of pathogenic organisms
• Alcohol hand rubs have been shown to be much less damaging to skin than handwashing with soap and water
• Health-care workers need appropriate education with hand hygiene. Compliance was found to be higher among nurses when audio-visual media, such as videos was used compared to traditional teaching methods
• The WHO ‘5 Moments for Hand Hygiene’ approach was designed to highlight hand hygiene indications to provide understanding, training, and monitoring
• The use of validated monitoring tools to measure compliance with evaluation and performance feedback should be used
• Direct observation monitoring allows details such as the technique and misuse of gloves but can be time consuming and result in the Hawthorne effect
• Studies have indicated that doctors tend to be less compliant with hand hygiene than nurses
• Electronic monitoring enables precise and continuous evaluation without being affected by the Hawthorne effect and saves on time taken for manual observations
• Technique is vitally important for effective hand hygiene
• Fingertips can be heavily contaminated so the WHO advocate that rubbing fingertips should be the first step in hand hygiene
• Role modelling by senior staff and leaders who actively participate in hand hygiene should set an example
• Reminders in the workplace can prevent forgetfulness and promote hand hygiene
• National and local hand hygiene campaigns have been shown to be beneficial in raising awareness of the importance of hand hygiene
• Institutional safety climate should be supported with active participation of leaders and the raising awareness of individuals to improve their practice