See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/6892702

Hand hygiene compliance in healthcare workers

Article in Journal of Hospital Infection · December 2006

DOI: 10.1016/j.jhin.2006.06.008 · Source: PubMed

CITATIONS READS

106 1,925

3 authors, including:

Jules Storr

81 PUBLICATIONS 1,320 CITATIONS

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Lead author, WHO Guidelines on Core Components of Infection Prevention and Control Programmes at the National and Acute Health Care Facility Level View project

Implementation View project

All content following this page was uploaded by Jules Storr on 10 November 2017.

The user has requested enhancement of the downloaded file.

Journal of Hospital Infection (2006) 64, 205e209

www.elsevierhealth.com/journals/jhin

REVIEW

Hand hygiene compliance in healthcare workers

J. Randle*, M. Clarke, J. Storr

Queens Medical Centre, Nottingham, UK

Available online 8 August 2006

KEYWORDS Summary The ‘clean-your-hands’ campaign has now been introduced

Hand hygiene; Clean- into hospitals in England but it was initially piloted in six acute trusts.
your-hands campaign; The campaign was multi-modal and aimed to improve hand hygiene compli-
Compliance
ance. This review reports the findings from one of the trusts involved in the
pilot. The campaign consisted of a toolkit that included placing alcohol
hand rub beside patients, along with posters and supporting marketing ma-
terials. A guide to implementation and a strategy aimed at increasing pa-
tient information and empowerment was also initiated. In order to assess
the success of the campaign, audits of hand hygiene in healthcare workers
were conducted over a six-month period. Additionally, data were obtained
from staff surveys, patient surveys, usage levels of alcohol hand rub and
interviews with the on-site lead. The local campaign indicated that a multi-
modal campaign induced a marked increase in hand hygiene compliance
(from 32% to 63%), with 74% of staff reporting increased compliance
throughout the campaign. Usage of alcohol hand rub increased by 184%.
The majority of patients indicated that the public should be actively
involved in helping healthcare staff to improve their hand hygiene.
ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights
reserved.

Hand hygiene compliance after improved compliance with hand hygiene.1e8

Although hand hygiene is the single most efficient
Hand hygiene is considered to be the most effec- preventive measure, compliance with hand hy-
tive strategy to combat hospital-associated infec- giene remains low.3,9e11 Factors associated with
tion, with a reduction in infection rates reported poor compliance include heavy workloads, per-
forming activities with cross-transmission, glove
use and involvement in technical specialities.12,13
* Corresponding author. Address: Faculty of Medicine and Lack of compliance with hand hygiene appears to
Health Sciences, Queens Medical Centre, University of Notting-
ham, Rm B59a, Nottingham NG7 2UH, UK. Tel.: þ44 115
be part of a larger picture, where many staff
8230899. have generally poor compliance with good infec-
E-mail address: Jacqueline.Randle@nottingham.ac.uk tion control practices.14,15
0195-6701/$ - see front matter ª 2006 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.jhin.2006.06.008
206 J. Randle et al.

Pittet et al.’s work has been fundamental in Three sets of observations were taken at the
changing hand hygiene compliance rates, with start, middle and end of the six-month period. In
the implementation of a multi-modal campaign total, each pilot ward was observed on 28 occasions
resulting in a sustained increase in compliance.12 for 20 min (i.e. 56 20-min observation periods). In
Observational surveys of compliance with hand those periods, a total of 493 ‘care activities’ were
hygiene were conducted before and during imple- observed in which hand hygiene should have taken
mentation of a hand hygiene campaign, and per- place. It is important to emphasize that all ward ac-
formance feedback was provided to healthcare tivity was observed from the vantage point taken,
workers (HCWs). Healthcare-associated infection rather than observing a single individual. Frequen-
rates, attack rates of meticillin-resistant Staphylo- cies of scores were used with ‘0’ being scored for
coccus aureus (MRSA) cross-transmission and con- a hand hygiene opportunity (i.e. ‘O’ for opportu-
sumption of hand rub were measured. Across the nity) and ‘1’ being scored for an observation of
three years, hand compliance rose from 48% to hand hygiene actually taking place. Hand hygiene
66% (P < 0.001), alcohol-based hand disinfection practice was assessed against local trust policy,
increased three-fold (P < 0.001), and healthcare- which is based on national guidance. Opportunities
associated infection and MRSA transmission rates for hand hygiene were stratified into three cate-
decreased (P < 0.05). The findings from this longi- gories: high, medium and low risk. After comple-
tudinal research study along with practice infor- tion of the observation period, feedback was
mation from the Oxford Radcliffe Hospitals provided to the ward manager and senior nurse. Af-
National Health Service (NHS) Trust and University ter the six-month pilot period, the campaign was
Hospitals Lewisham underpinned the ‘clean-your- implemented across the entire trust.
hands’ campaign.16,17 Product usage (NPAH) was also monitored, with
baseline information being collected prior to the
launch of the campaign and again at the start and
The ‘clean-your-hands’ campaign end of the campaign. The assumption was made
that product usage was a consequence of cleaning
Six acute trusts in England were involved in the hands rather than it being used for any other
large ‘clean-your-hands’ campaign co-ordinated activity.
by the National Patient Safety Agency. Each trust A survey was sent to all HCWs (N ¼ 127) on the
identified two wards on which the multi-modal pilot wards and also to a convenience sample of
campaign was implemented and evaluated. The patients and their carers (N ¼ 43). The survey con-
wards were selected by the campaign manager and sisted of closed questions, but respondents were
the local on-site lead to ensure that the project invited to write additional comments that were an-
was tested in a range of settings. At a local level, alysed thematically by the project manager. Both
the initiative was performance managed by a local surveys asked questions about HCWs’ compliance
working group accountable to the hospital infec- with hand hygiene, perceptions about the cam-
tion control committee. paign, and user involvement. The staff survey
A multi-modal campaign consisting of previously was distributed two months after the campaign
successful strategies was used in order to increase started (Phase 1) and again six months from the
compliance.12,16,17 These included the introduc- start (Phase 2) to all staff on the pilot wards.
tion of near-patient alcohol hand rubs (NPAHs) The staff survey had a response rate of 45% in
and a series of posters and supporting marketing Phase 1 and 38% in Phase 2, with an overall re-
materials such as aprons and badges, aimed at sponse rate of 42%. The same sample was targeted
patients, carers and staff. The campaign also in both phases, without turnover or movement of
provided patients with leaflets that encouraged staff. There was no noticeable difference in the
them to ask staff about cleaning their hands. mix of staff responding to the surveys. Respon-
An observational survey of HCWs’ compliance dents were predominantly medical and nursing
with hand hygiene was undertaken using a pre- staff (86%), and the majority (57%) had been work-
viously validated tool, widely used for hand hy- ing in their current role for more than five years.
giene audits in the UK.17 This tool was part of the The on-site lead was interviewed in order to
campaign toolkit and the campaign project man- gain practical insight into the local implementa-
ager trained all pilot site teams in its use. Locally, tion of the campaign, and to learn lessons in order
observations were conducted by the on-site lead or to inform the national roll-out. A semi-structured
a nominated infection control nurse who had been interview guide was used to elicit answers around
trained in the use of the tool, which helped to the implementation strategy. The project manager
increase the reliability of observation reporting. conducted all interviews towards the end of the
Hand hygiene compliance in healthcare workers 207

campaign. Interviews were taped and data were Comments relating to patient involvement were
analysed thematically by the project manager and broadly supportive, with some caution relating to
verified by the on-site lead. how this is introduced.
The multi-centre research and ethics commit- All but one respondent in the patient survey had
tee granted permission for the evaluation part of witnessed healthcare staff cleaning their hands in
the campaign to proceed. All staff on the pilot the last 24 h. Forty patients and carers thought
wards were informed by mail about the upcoming that the public should be involved in helping staff
study and that they were eligible for inclusion. to improve their hand hygiene, and over half of
Anonymity was guaranteed for all participants. them stated that they would ask staff if they had
The observation of hand hygiene compliance was cleaned their hands. When asked if they had ever
used as part of the trust’s audit, so ethical asked staff to clean their hands, there were 16 re-
approval was not required for this aspect of the spondents. Patients felt that if they did ask, it
evaluation. would require courage, might cause offence and
Following the success of the pilot, the campaign may impact negatively on the care they received.
was rolled out across the trust. To assess the Thirty-five respondents found the posters, aprons,
longer-term impact of the campaign, further com- stickers and leaflets useful. Findings indicated that
pliance audits were undertaken on an additional the campaign resulted in patients generally feeling
eight wards that were chosen at random. more confident in their care as they witnessed
staff cleaning their hands, and they felt that focus
was also on the general cleanliness of the ward and
Evaluating the campaign hospital environment.
Data obtained from the on-site lead found that
For the pilot wards, the rate of compliance in- the framework for implementation was helpful and
creased from 32% at the start of the six-month the major issue for success of the campaign was the
study period to 41% mid way and 63% at the end. NPAH. Training needs of staff were considered to
Over the six months, NPAH usage increased by be crucial to hand hygiene compliance, and prep-
184%. This increase in product usage was sup- aration of staff to receive questions from patients
ported by staff responses in the survey question- was considered important as patients need to know
naire, with over 70% of nurses and 60% of doctors when and how hand hygiene should occur. It was
agreeing that the presence of NPAH encouraged felt locally that key staff members who are re-
them to clean their hands. sponsible for product replacement and sustaining
Responses to questions in the staff survey the campaign were vital. Similarly, support from
showed that staff felt the campaign posters were influential individuals in the organization, such as
highly visible during the campaign (97% in Phase 1 the chief executive and the director of nursing, was
and 99% in Phase 2) and made staff think about important for the campaign’s success.
their hand hygiene (76% in Phase 1 and 84% in After the successful pilot and implementation
Phase 2), with staff reporting that they cleaned across the trust, further observational studies
their hands more frequently (74% in Phase 1 and were completed six months into the campaign on
74% in Phase 2). Sixty-four percent of registered 10 wards including the pilot wards. The additional
nurses and healthcare assistants (HCAs) reported data from the 10 wards showed overall compliance
being asked about their hand hygiene. In Phase 1, rates similar to those reported by Pittet et al. at
31% had been asked about their hand hygiene by this stage of a multi-modal campaign (50%).12
patients, with this increasing to 39% in Phase 2. When combining all ward results, hand hygiene
Nearly all (97%) of the staff who had been asked was noted to have occurred 458 times out of 924
about their hand hygiene felt comfortable with opportunities. Individual ward results illustrated
this type of patient questioning. Whilst the corre- a wide range of compliance (29e66%). The two
lation between self-reporting of hand hygiene and highest results were from wards used in the pilot,
observed behaviour tends to be inaccurate due to which are now two years into the campaign. Addi-
overestimation by staff who over report, in this tional compliance data were further broken down
instance, the self-reported compliance figures into different staff groups. These were: (1) nurses
were broadly in line with those from the observa- including students (49%); (2) medics including
tions of actual behaviour.18 students (26%); (3) HCAs (64%); and (4) others,
Findings from the staff survey indicated that i.e. physiotherapists, occupational therapists,
staff were positive about the campaign. Some staff phlebotomists, dieticians, etc. (46%). Performance
expressed dissatisfaction with the quality of the feedback was seen as essential, especially on
NPAH in that it left a residue and was sticky. under-performing wards.
208 J. Randle et al.

The success of the ‘clean-your-hands’ ruled out. Those conducting the observational
campaign component, however, did not believe this to be
a significant factor.
It has already been established that a multi-modal
campaign can produce a sustained improvement in
hand hygiene compliance, with reduced rates of References
nosocomial infections and MRSA transmission.12
The results from this local campaign and the wider 1. Rosenthal V, McCormick R, Guzman S, Villamayeor C,
‘clean-your-hands’ campaign supported the first Orellano P. Effect of education and performance feedback
premise, with hand hygiene compliance being im- on handwashing: the benefit of administrative support in
proved and sustained over a period of time. How- Argentinean hospitals. Am J Infect Control 2003;31:85e92.
2. Department of Health. Winning ways: working together to
ever, for hand hygiene improvements to have an reduce healthcare associated infection in England. London:
impact upon the reduction of infection, it is neces- Department of Health; 2003.
sary to achieve a sustained improvement over 3. Huggonet S, Perneger T, Pittet D. Alcohol-based handrub
a longitudinal period and it is acknowledged that improves compliance with hand hygiene in intensive care
this study was not designed to illustrate this. A units. Arch Intern Med 2002;162:1037e1043.
4. Department of Health. A matron’s charter: an action plan
four-year project funded by the Patient Safety for cleaner hospitals. London: Department of Health; 2004.
Research Programme of the Department of Health 5. Doebbeling B, Stanley G, Sheetz C, et al. Comparative effi-
will address this over the long term. cacy of alternative hand-washing agents in reducing noso-
In the local evaluation of the campaign, HCAs comial infections in intensive care units. N Engl J Med
showed the highest rates of observed compliance. 1992;327:88e93.
6. Webster J, Faoagali J, Cartwright D. Elimination of
However, there are inconsistencies when trying to methicillin-resistant Staphylococcus aureus from a neonatal
determine which healthcare group is most compli- intensive care unit after hand washing with triclosan.
ant in hand hygiene.19,20 Responses from the staff J Paediatr Child Health 1994;30:59e64.
survey indicated that some complained that the 7. Zafar A, Butler R, Reese D, Gaydos L, Mennonna P. Use of
NPAH was not new.21,22 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of
methicillin-resistant Staphylococcus aureus in a neonatal
Patients were targeted and encouraged to nursery. Am J Infect Control 1995;23:200e208.
participate by the use of posters and aprons with 8. Shahid N, Greenough W, Samadi A, Huq M, Rahman N. Hand
the slogan, ‘it’s okay to ask’. Patient involvement washing with soap reduces diarrhoea and spread of bacte-
in the NHS is a relatively new concept in terms of rial pathogens in a Bangladesh village. J Diarrhoeal Dis
NHS policy; however, patient empowerment, in- Res 1996;14:85e89.
9. Pittet D, Mourouga P, Perneger T. Compliance handwashing
volvement and participation characterize the new in a teaching hospital. Ann Intern Med 1999;130:126e130.
NHS.23 A small-scale study indicated that patient 10. Boyce J. It is time for action: improving hand hygiene in
involvement in hand hygiene is a complex issue hospitals. Ann Intern Med 1999;130:153e155.
and that hand hygiene is ultimately the responsi- 11. Pittet D. Improving adherence to hand hygiene practice:
bility of the HCW.23 a multidisciplinary approach. Emerg Infect Dis 2001;7:
234e240.
12. Pittet D, Huggonet S, Harbarth S, et al. Effectiveness of
a hospital-wide programme to improve compliance with
hand hygiene. Lancet 2000;356:1307e1312.
Conclusion 13. Boyce J, Pittet D. Guideline for hand hygiene in health-care
settings. Recommendations of the Healthcare Infection
The evidence from this local campaign supports Control Practices Advisory Committee and the HICPAC/
previous work which indicates that it is the multi- SHEA/APIC/IDSA Hand Hygiene Task Force. Geneva: Society
for Healthcare Epidemiology of America/Association for
modal nature of strategies that is crucial to Professionals in Infection Control/Infectious Diseases Soci-
success in increasing hand hygiene compliance, ety of America; 2002.
both in the short and the long term.12 It was con- 14. Roberts L, Bolton P, Asman S. Compliance of hand washing
sidered that the interplay of all related facets of practices: theory versus practice. Aust Health Rev 1998;
the campaign resulted in a change in the way 21:238e244.
15. Karabey S, Ay P, Derbentli S, Nakipoglu Y, Esen F. Hand-
that staff perceived the practice of hand hygiene washing frequencies in an intensive care unit. J Hosp Infect
from low priority to a core element of daily prac- 2002;50:36e41.
tice that could be achieved easily. This local cam- 16. Pittet D. Improving compliance with hand hygiene in hospi-
paign was small scale, but other pilot sites found tals. Infect Control Hosp Epidemiol 2000;21:381e386.
the same trends. It is impossible to estimate the 17. Pittet D, Boyce J. Hand hygiene and patient care: pursuing
the Semmelweis legacy. Lancet Infect Dis 2001;9e20.
relative efficacy of the different components of 18. O’Boyle C, Henly S, Larson E. Understanding adherence to
the intervention, and a Hawthorne effect to ex- hand hygiene recommendations: the theory of planned
plain the improvements in compliance cannot be behaviour. Am J Infect Control 2001;29:352e360.
 Hand hygiene compliance in healthcare workers 209

19. Sharir R, Teitler N, Lavi L, et al. High-level hand washing knowledge, attitudes, and behaviour in Italy. J Hosp Infect
compliance in a community teaching hospital: a challenge 2002;51:226e232.
that can be met! J Hosp Infect 2001;49:55e58. 22. Winnefeld M, Richard M, Drancourt M, Grobb J. Skin toler-
20. Pittet D, Simon A, Hugonnet S, Pessoa-Silva C, Sauvan V, ance and effectiveness of two hand decontamination proce-
Perneger T. Hand hygiene among physicians: perfor- dures in everyday hospital use. Br J Dermatol 2000;143:
mance, beliefs and perceptions. Ann Intern Med 2004; 546e550.
141:1e8. 23. Duncanson VA, Pearson LS. A study of the factors affecting
21. Noble C, Montuori P, Diaco E, Villari P. Healthcare personnel the likelihood of patients participating in a campaign to im-
and hand decontamination in intensive care units: prove staff hand hygiene. Br J Infect Control 2005;6:26e30.

View publication stats