The Institute for Healthcare Improvement in its How-to Guide: Improving Hand Hygiene recommends a multidimensional approach (i.e., introduction of alcohol-based hand rub, and educational and behavioral initiatives) to improve compliance with hand hygiene guidelines in healthcare settings.41 The science supporting a multidimensional hand hygiene program (glove use is included in this strategy because proper glove use is inextricably linked to effective hand hygiene) is sufficiently established to be considered a standard and consist of four components (Table 5). While these four components of best practices individually improve hand hygiene compliance, when applied together they are substantially more effective.
Table 5. Multidimensional approach to improve compliance with hand hygiene guidelines
|1. HCWs demonstrate knowledge|
Predicated on educational exposure, HCWs understand the rationale for hand hygiene:
Types of patient care activities that result in hand contamination
Relative advantages and disadvantages of handwashing and the use of alcohol-based hand rubs at the point of care
Important role that contaminated hands play in transmission of healthcare-associated pathogens, including multidrug-resistant pathogens
Morbidity and mortality caused by healthcare-associated infections
|2. HCWs demonstrate competence|
Predicated on exposure to live demonstrations, video-presentations, and/or fluorescent dye-based training methods, HCWs perform appropriate hand hygiene:
Correct technique for handwashing, hand antisepsis, and surgical hand antisepsis
Application of an appropriate volume of alcohol-based hand rub or soap that must be used if hand hygiene is to be effective
|3. Institution enables staff||Predicated on institutional commitment to good hand hygiene practices by HCWs:
Alcohol-based hand rub and gloves of various sizes readily available to HCWs near the point of use
Alcohol-based hand rub dispensers available in locations that are compliant with local and federal fire safety regulations
Established protocol with responsibility assigned for checking alcohol-based hand rub dispensers and glove boxes on a regular basis to ensure that (a) dispersers and glove boxes are not empty, (b) dispersers that are operational, and (c) dispensers that provide the correct amount of the product
Evaluated the design and function of dispensers before selecting a product for use since poorly functioning dispensers may adversely affect hand hygiene compliance rates
|4. Institution verifies competency and provides feed back|
Predicated on an established program to monitor that hand hygiene is performed and gloves are used appropriately by HCWs as recommended by the CDC:
Routinely using alcohol-based hand rub when hands are not visibly soiled
Washing hands with plain or antimicrobial soap and water when hands are visibly dirty or contaminated with proteinaceous material or with blood and other potentially infectious material
Wearing of gloves when contact with blood or other potentially infectious material (all body fluids, excretions, secretions [except sweat]), mucous membranes, and nonintact skin could occur
Recently, a novel strategy of video surveillance of hand hygiene coupled with real-time compliance feedback has been reported.42 The study was conducted in a 17-bed intensive care unit. Cameras were placed with views of every sink and hand sanitizer dispenser to record hand hygiene of HCW. Sensors in the doorways identified when an individual entered/exited. When video auditors observed a HCW performing hand hygiene upon entering/exiting, they assigned a pass; if not, a fail was assigned.
Hand hygiene was measured during a 16-week period without feedback and a 91-week period with feedback. During a 16-week pre-feedback period, hand hygiene rates were less than 10%. In the 16-week post-feedback period compliance improved to 81.6% and, subsequently, was maintained through 75 weeks at 87.9%. While quality of hand hygiene and healthcare-associated infection data were not presented, this approach for improving to improve compliance merits consideration.