Strategies to Improve Hand Hygiene Practices

The Institute for Healthcare Improvement in its How-to Guide: Improving Hand Hygiene recommends a multidimensional approach (e.g., introduction of alcohol-based handrub, and educational and behavioral initiatives) to improve compliance with hand hygiene guidelines in healthcare settings.38 The science supporting a multidimensional approach to hand hygiene is sufficiently established to be considered the standard and consist of four components (Table 5).1,3,5,6

Table 5. Multidimensional approach to improve compliance with hand hygiene guidelines.
1. HCP demonstrate knowledgePredicated on educational exposure, HCP 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 handrubs at the point of care
  • Important role that contaminated hands play in transmission of healthcare-associated pathogens, including multidrug-resistant organisms
  • Morbidity and mortality caused by HAIs
2. HCP demonstrate competencePredicated on exposure to live demonstrations, video-presentations, and/or fluorescent dye-based training methods, HCP perform appropriate hand hygiene:
  • Correct technique for handwashing, hand antisepsis, and surgical hand antisepsis
  • Application of an appropriate volume of alcohol-based handrub, or a plain or antiseptic soap
3. Institution enables staffPredicated on institutional commitment to good hand hygiene practices:
  • Alcohol-based handrub and gloves of various sizes are readily available to HCP 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 are operational, and (c) containers dispense 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 of HCP and provides feed backPredicated on an established program to monitor that hand hygiene is performed and gloves are used appropriately by HCP as recommended by the CDC:
  • Routinely using alcohol-based handrub 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 gloves when contact with blood or OPIM (all body fluids, excretions, secretions [except sweat]), mucous membranes, and nonintact skin could occur

A novel strategy of video surveillance of hand hygiene coupled with real-time compliance feedback has been reported.39 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 HCP. Sensors in the doorways identified when an individual entered/exited. Video auditors observed HCP performing hand hygiene upon entering and exiting a room and assigned a pass or fail grade.

Hand hygiene was measured during a 16-week period without feedback and a 91-week period with feedback. During the 16-week pre-feedback period, hand hygiene rates were less than 10%. In the first 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 HAI-data were not presented, this approach to improve compliance merits consideration.

The Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care published by the CDC in 2016 includes an Infection Prevention Checklist for Dental Settings: Basic Expectations for Safe Care.6 Section I.5 of the checklist relates to institutional hand hygiene policies and practices, while Section II.1 is an evaluation tool to monitor the compliance of oral HCP with hand hygiene practices that fulfill expectations for dental healthcare settings (Box A).

Box A. Hand hygiene compliance: checklist for oral healthcare settings.
Institutional Compliance with Policies and Practices and Direct-Observation-based Hand Hygiene-related Competency of Oral HCP

Name of oral HCP evaluated

Name of observer

Date of observation
Elements to be assessedCompliance/CompetencyNotes/areas for improvement
Supplies necessary for adherence to hand hygiene for routine dental procedures (e.g., soap, water, paper towels, alcohol-based hand rub) are readily accessible to oral HCP□ Y  □ N 
If surgical procedures* are performed, appropriate supplies are available for surgical hand antisepsis (e.g., antimicrobial soap, alcohol-based hand scrub with persistent activity)□ Y  □ N 
Oral HCP are trained regarding appropriate indications for hand hygiene including handwashing, hand antisepsis, and surgical hand antisepsis#□ Y  □ N 
Appropriate hand hygiene# is performed correctly when hands are visibly soiled□ Y  □ N 
Appropriate hand hygiene# is performed correctly after barehanded touching of instruments, equipment, materials and other objects likely to be contaminated by blood, saliva, or respiratory secretions□ Y  □ N 
Appropriate hand hygiene# is performed correctly before and after treating each patient□ Y  □ N 
Appropriate hand hygiene# is performed correctly before putting on gloves□ Y  □ N 
Appropriate hand hygiene# is performed correctly immediately after removing gloves□ Y  □ N 
Surgical hand antisepsis is performed correctly before putting on sterile surgeon’s gloves for all surgical procedures*□ Y  □ N 
*Examples of surgical procedures include biopsy, periodontal surgery, apical surgery, implant surgery, and surgical extractions of teeth.
#When hands are visibly soiled or contaminated with blood and other potentially infectious material (OPIM), oral HCP must perform hand hygiene with either a non-antimicrobial or an antimicrobial soap and water. Otherwise, the preferred method of hand hygiene in clinical situations is with an alcohol-based handrub. When performing surgical procedures oral HCP must perform surgical hand antisepsis.

Adapted from: Centers for Disease Control and Prevention. Summary of Infection Prevention Practices in Dental Settings: Basic Expectations for Safe Care. 2016.