A multicentre survey of hand hygiene practice in intensive care units

Results of an Infection Control Survey in Ultrasound Departments and Recommended Guidelines

Prevention of disease transmission by cross infection is very important in the hospital environment to protect both staff and patients.

At the present time most hospitals have stringent infection control policies which are largely geared toward the wards, critical care units and the operating theatres but there does not appear to be specific guidelines for ultrasound departments. Considering the contact nature of the ultrasound examination and the large number of tests that are performed in most hospitals annually it was felt that this was an area that needed to be addressed. One must be aware not only of protection of patients and staff but also of care in the cleaning of expensive equipment.

We undertook a national survey of the larger general ultrasound departments, vascular and cardiac laboratories to establish current practices and to assess whether these are adequate. We also contacted a number of ultrasound companies and requested cleaning specifications for their equipment.

The full results of the survey, the biological effectiveness of different cleaning techniques and their compatibility with ultrasound transducers will be discussed. Finally, recommendations regarding safe effective cleaning procedures and sensible infection control precautions in ultrasound departments will be made.

Health Care Workers’ Hand Decontamination Practices

The primary purpose of this quasi-experimental research is to observe health care workers’ compliance with hand-hygiene guidelines during patient care in an intensive care unit in Ireland before (pretest) and after (posttest) implementation of a multifaceted hand-hygiene program. Health care workers’ attitudes, beliefs, and knowledge in relation to compliance with handwashing guidelines were also investigated. A convenience sample of nurses, doctors, physiotherapists, and care assistants ( n = 73 observational participants, n = 62 questionnaire respondents) was used. Data ( N = 314 observations, 62 questionnaires) were analyzed descriptively and cross-tabulated using chi-square (Pearson’s) and Mann-Whitney statistical tests. Results revealed that a significant shift (32%) occurred in health care workers’ compliance with handwashing guidelines (pretest 51%, posttest 83%, p < .001) following the interventional hand-hygiene program. Significant changes were also found in relation to health care workers’ attitudes, beliefs, and knowledge ( p < .05).

Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care

Objectives.

To assess the prevalence and correlates of compliance and noncompliance with hand hygiene guidelines in hospital care.

Design.

A systematic review of studies published before January 1, 2009, on observed or self-reported compliance rates.

Methods.

Articles on empirical studies written in English and conducted on general patient populations in industrialized countries were included. The results were grouped by type of healthcare worker before and after patient contact. Correlates contributing to compliance were grouped and listed.

Results.

We included 96 empirical studies, the majority (n= 65) in intensive care units. In general, the study methods were not very robust and often ill reported. We found an overall median compliance rate of 40%. Unadjusted compliance rates were lower in intensive care units (30%–40%) than in other settings (50%–60%), lower among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact. The majority of the time, the situations that were associated with a lower compliance rate were those with a high activity level and/or those in which a physician was involved. The majority of the time, the situations that were associated with a higher compliance rate were those having to do with dirty tasks, the introduction of alcohol-based hand rub or gel, performance feedback, and accessibility of materials. A minority of studies (n= 12) have investigated the behavioral determinants of hand hygiene, of which only 7 report the use of a theoretical framework with inconclusive results.

Conclusions.

Noncompliance with hand hygiene guidelines is a universal problem, which calls for standardized measures for research and monitoring. Theoretical models from the behavioral sciences should be used internationally and should be adapted to better explain the complexities of hand hygiene.

Survey of Knowledge, Beliefs, and Practices of Neonatal Intensive Care Unit Healthcare Workers Regarding Nosocomial Infections, Central Venous Catheter Care, and Hand Hygiene

Objective:

To assess the knowledge, beliefs, and practices of neonatal intensive care unit (NICU) healthcare workers (HCWs).

Design:

Self-administered survey.

Setting:

A 55-bed NICU.

Participants:

NICU HCWs (N = 215).

Results:

The response rate was 68%. Ninety-two percent knew central venous catheters (CVCs) should be capped, clamped, or connected to running fluids at all times. Ninety-five percent knew when to change gloves. Thirty-one percent knew the recommended duration for handwashing. Most HCWs believed sterile technique in CVC care (96%), gloves (91%), and handwashing (99%) prevent nosocomial infection (NI). Sixty-seven percent used sterile barriers to insert CVCs, 76% reported wearing gloves, 81% reported routine handwashing, 35% knew that bacterial hand counts are higher with rings, 30% knew that long fingernails are associated with higher gram-negative bacterial hand contamination, and 35% knew that artificial fingernails are associated with higher gram-negative bacterial hand contamination. Most (93%) believed HCWs can affect outcomes of patients with NIs. Fewer believed rings (40%), artificial fingernails (61%), and long fingernails (48%) play a role in NIs, or that policies concerning number of rings (50%), cutting fingernails (35%), or prohibiting artificial fingernails (47%) would prevent NIs. Sixty-one percent of HCWs regularly wore at least one ring to work, 56% wore their fingernails shorter than the fingertip, and 8% wore artificial fingernails.

Conclusions:

A disconnect existed between CVC knowledge and beliefs and practice. HCWs did not know the relationship between bacterial hand counts and rings and fingernails, and did not believe rings or long or artificial fingernails increased the risk of NIs.

Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance

BACKGROUND

Hospitals and infection prevention specialists have attempted to achieve high levels of compliance with hand hygiene protocols for many decades. Despite these efforts, measured performance is disappointingly low.

METHODS

The Joint Commission Center for Transforming Healthcare convened teams of experts in performance improvement and infectious disease from eight hospitals for its hand hygiene quality improvement project, which was conducted from December 2008 through September 2010. Together, they used Lean, Six Sigma, and change management methods to measure the magnitude of hand hygiene noncompliance, assess specific causes of hand hygiene failures, develop and test interventions targeted to specific causes, and sustain improved levels of performance.

RESULTS

At baseline, hand hygiene compliance averaged 47.5% across all eight hospitals. Initial data revealed 41 different causes of hand hygiene noncompliance, which were condensed into 24 groups of causes. Key causes varied greatly among the hospitals. Each hospital developed and implemented specific interventions targeted to its most important causes of hand hygiene noncompliance. The improvements were associated with a 70.5% increase in compliance across the eight hospitals from 47.5% to 81.0% ( p < .001), a level of performance that was sustained for 11 months through the end of the project period.

CONCLUSION

Lean, Six Sigma, and change management tools were used to identify specific causes of hand hygiene noncompliance at individual hospitals and target specific interventions to remedy the most important causes. This approach allowed each hospital to customize its improvement efforts by focusing on the causes most prevalent at its own facility. Such a targeted approach may be more effective, efficient, and sustainable than "one-size-fits-all" strategies.

Compliance of healthcare workers with hand hygiene practices in neonatal and pediatric intensive care units: overt observation

Background. The objective of this study was to assess the compliance of hand hygiene (HH) of healthcare workers (HCWs) in the neonatal and pediatric intensive care unit in a tertiary university hospital in Istanbul. Methods. An observational study was conducted on the compliance of HH for the five World Health Organization (WHO) indications. HCWs were observed during routine patient care in day shift. The authors also measured the technique of HH through hand washing or hand hygiene with alcohol-based disinfectant. Results. A total of 704 HH opportunities were identified during the observation period. Overall compliance was 37.0% (261/704). Compliance differed by role: nurses (41.4%) and doctors (31.9%) [P = 0.02, OR: 1.504, CI 95%: 1.058-2.137]. HCWs were more likely to use soap and water (63.6%) compared to waterless-alcohol-based hand hygiene (36.3%) [P < 0.05]. Conclusion. Adherence to hand hygiene practice and use of alcohol-based disinfectant was found to be very low. Effective education programs that improve adherence to hand hygiene and use of disinfectants may be helpful to increase compliance.

A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections

BACKGROUND

Although hand hygiene (HH) is key to reducing health care-associated infections, it is well documented that health care worker (HCW) adherence to appropriate HH protocols is relatively low.

METHODS

This was a collaborative quality improvement project with multiple interventions conducted in a 570-bed academic hospital in Columbia, MO between April 2006 and September 2012. A multimodal action plan to improve HH adherence among all HCWs was developed, addressing 4 key areas: staff education, staff accountability, hand sanitizer product selection and accessibility, and organizational culture. HH adherence and central line-associated bloodstream infection (CLABSI) rates were monitored as outcome measures.

RESULTS

The overall HH adherence rate increased from 58% in April 2006 to 98% in September 2012. The adherence rates increased among all hospital units and among all HCW categories; in September 2012, HH adherence was 96% for physicians, 99% for nursing staff, and 99% for food services staff. CLABSI rates decreased over the same period, from 4.08 per 1000 device-days to 0.42 per 1000 device-days.

CONCLUSIONS

This multifactorial quality improvement project resulted in an institution-wide increase in HH adherence and a significant decrease in CLABSIs.

Infection control in the intensive care unit

Nosocomial infections are common in many hospital departments, but particularly so on the intensive care unit, where they affect some 20 to 30% of patients. While early diagnosis and appropriate treatment are, of course, important, perhaps the greatest challenge is in the application of techniques to limit the development of such infections. This review will briefly discuss some of the background pathophysiology and epidemiology of nosocomial infection, and then focus on general and infection-specific preventative strategies individually and as part of broader infection-control programs with infection surveillance.

Physician 'defiance' towards hand hygiene compliance: Is there a theory-practice-ethics gap?

BACKGROUND

The theory-practice gap has always existed [1,2]. This gap is often cited as a culmination of theory being idealistic and impractical, even if practical and beneficial, is often ignored. Most of the evidence relating to the non-integration of theory and practice assumes that environmental factors are responsible and will affect learning and practice outcomes, hence the gap. Therefore, the author believes that to 'bridge the gap' between theory and practice, an additional dimension is required: ethics. A moral duty and obligation ensuring theory and practice integrate. In order to effectively implement new practices, one must deem these practices as worthy and relevant to their role as healthcare providers (HCP). Hence, this introduces a new concept which the author refers to as the theory-practice-ethics gap. This theory-practice-ethics gap must be considered when reviewing some of the unacceptable outcomes in healthcare practice [3]. The literature suggests that there is a crisis of ethics where theory and practice integrate, and healthcare providers are failing to fulfill our duty as patient advocates.

HYPOTHESIS

Physician hand hygiene practices and compliance at King Abdulaziz Cardiac Centre (KACC) are consistent with those of other physicians in the global healthcare arena. That is one of noncompliance to King Abdulaziz Medical City (KAMC) organizational expectations and the World Health Organization (WHO) requirements?

METHODS

An observational study was conducted on the compliance of cardiac surgeons, cardiologists and nurses in the authors' cardiac center from January 2010 to December 2011. The hand hygiene (HH) compliance elements that were evaluated pertained to the WHO's five moments of HH recommendations. The data was obtained through direct observation by KAMC infection prevention and control practitioners.

RESULTS

Physician hand hygiene compliance at KACC was consistently less than 60%, with nurses regularly encouraging physicians to be diligent with hand hygiene practices in the clinical area.

CONCLUSION

Hand hygiene compliance will not improve unless evidence-based recommendations are adopted and endorsed by all healthcare professionals and providers.

Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections

BACKGROUND

Hand hygiene is the single most important intervention to combat infections in any health care setting. However, adherence to hand hygiene practice remains low among health care workers.

OBJECTIVES

Our objective was to assess compliance with hand hygiene over time utilizing a multifaceted approach to hand hygiene. In addition, we assessed the rate of device-associated infections.

METHODS

This is a descriptive time series study with a multitude of interventions from October 2006 to December 2011 set in a 350-bed community hospital in Saudi Arabia. We utilized a multimodal program to promote hand hygiene activities. We also calculated device-associated infection rates as outcome measures.

RESULTS

Over the study, the overall hand hygiene compliance rate increased from a baseline of 38% in second quarter 2006 to 65% in 2010 and then to 85% in 2011 (P < .001). The compliance rates increased among all professions and different hospital units. The compliance rates were 87% for physicians, 89% for nursing staff, and 93% for nutritionist. The rate of health care-associated methicillin-resistant Staphylococcus aureus per 1,000 patient-days decreased from 0.42 in 2006 to 0.08 in 2011. Ventilator-associated infection rates decreased from 6.12 to 0.78, central line-associated bloodstream infections rates decreased from 8.23 to 4.8, and catheter-associated urinary tract infection rates decreased from 7.08 to 3.5.

CONCLUSION

This intervention used a multitude of interventions and resulted in an institution-wide increase and sustained improvement in compliance rates.

Determinants of hand hygiene noncompliance in intensive care units

BACKGROUND

Hand hygiene (HH) is single most effective preventive measure for health care-associated infection, but compliance rates remain low. This study estimated HH compliance among health care workers (HCWs) and examined factors associated with noncompliance.

METHODS

An observational study design was carried out in 5 intensive care units (ICUs) at the University Hospital in Riyadh, Saudi Arabia. Among 242 HCWs, a total of 3,940 HH opportunities were observed by 6 trained medical interns and students. The World Health Organization's "Five Moments for Hand Hygiene" procedure was used as a basis for the observations.

RESULTS

The overall observed noncompliance rate was 58%. The factors associated with noncompliance were HCW job title (physicians, odds ratio [OR], 2.8; 95% confidence interval [CI], 1.8-4.2; allied health professionals, OR, 2.9, 95% CI, 1.9-4.6); working the a.m. shift (OR, 1.5; 95% CI, 1.3-1.8), working in a pediatric ICU (OR, 1.8; 95% CI, 1.5-2.2), and performance of HH before patient contact (OR, 4.5; 95% CI, 2.6-7.8).

CONCLUSIONS

Overall HH noncompliance was high in ICUs of this hospital. The demanding ICU work setting was an important factor associated with noncompliance. HH compliance was highest among therapists and technicians because of fewer patient interactions and thus fewer HH noncompliance opportunities per person. Further studies on the relationship between work environment demands and HH compliance rates are needed.

Improving hand hygiene compliance in healthcare settings using behavior change theories: reflections

BACKGROUND

Although hand hygiene is the most effective method for preventing healthcare-associated infections, hand hygiene practice falls short in many healthcare facilities. The compliance rate is mostly linked to system design and easily accessible hand hygiene products. System change, healthcare worker motivation, and complex behavioral considerations seem to play a significant role.

SUMMARY

This article discusses the application of behavioral theories in hand hygiene promotion in a theoretical manner. The program relies on the transtheoretical model (TTM) of health behavior change, John Keller's (ARCS) Model of Motivational Design, and the theory of planned behavior (TPB). Thus, the program links attitudes and behavior to hand hygiene promotion.

CONCLUSIONS

The TTM of health behavior change helps to tailor interventions to predict and motivate individual movement across the pathway to change. A program could be based on this theory with multiple intercalations with John Keller's ARCS and the TPB. Such a program could be strengthened by linking attitudes and behavior to promote hand hygiene. The program could utilize different strategies such as organization cultural change that may increase the attention as well as fostering the movement in the ARCS stages. In addition, modeling TPB by creating peer pressure, ability to overcome obstacles, and increasing knowledge of the role of hand hygiene may lead to the desired outcome. The understanding and application of behavior change theories may result in an effective program to improve awareness and raise intention and thus may increase the potential for success of hand hygiene promotion programs.

Outbreaks where food workers have been implicated in the spread of foodborne disease. Part 11. Use of antiseptics and sanitizers in community settings and issues of hand hygiene compliance in health care and food industries

Hand washing with soap is a practice that has long been recognized as a major barrier to the spread of disease in food production, preparation, and service and in health care settings, including hospitals, child care centers, and elder care facilities. Many of these settings present multiple opportunities for spread of pathogens within at-risk populations, and extra vigilance must be applied. Unfortunately, hand hygiene is not always carried out effectively, and both enteric and respiratory diseases are easily spread in these environments. Where water is limited or frequent hand hygiene is required on a daily basis, such as for many patients in hospitals and astronauts in space travel, instant sanitizers or sanitary wipes are thought to be an effective way of preventing contamination and spread of organisms among coworkers and others. Most concerns regarding compliance are associated with the health care field, but the food industry also must be considered. Specific reasons for not washing hands at appropriate times are laziness, time pressure, inadequate facilities and supplies, lack of accountability, and lack of involvement by companies, managers, and workers in supporting proper hand washing. To facilitate improvements in hand hygiene, measurement of compliant and noncompliant actions is necessary before implementing any procedural changes. Training alone is not sufficient for long-lasting improvement. Multiactivity strategies also must include modification of the organization culture to encourage safe hygienic practices, motivation of employees willing to use peer pressure on noncompliant coworkers, a reward and/or penalty system, and an operational design that facilitates regular hand hygiene.

Hand washing among school children in Bogotá, Colombia

OBJECTIVES

We assessed hand-washing behaviors and intentions among school children in Bogotá, Colombia, to help identify and overcome barriers to proper hygiene practices.

METHODS

Data on hand-washing behavior and intentions and individual and contextual factors were collected from 2042 sixth- through eighth-grade students in 25 schools in Bogotá via anonymous questionnaires. A member of the school administration or teaching staff completed a questionnaire about the school environment. Site inspections of bathroom facilities were conducted.

RESULTS

Only 33.6% of the sample reported always or very often washing hands with soap and clean water before eating and after using the toilet. About 7% of students reported regular access to soap and clean water at school. A high level of perceived control was the strongest predictor of positive hand-washing intentions (adjusted odds ratio [AOR]=6.0; 95% confidence interval [CI]=4.8, 7.5). Students with proper hand-washing behavior were less likely to report previous-month gastrointestinal symptoms (OR=0.8; 95% CI=0.6, 0.9) or previous-year school absenteeism (OR=0.7; 95% CI=0.6, 0.9).

CONCLUSIONS

Scarcity of adequate facilities in most schools in Bogotá prevents children from adopting proper hygienic behavior and thwarts health promotion efforts. The current renovation program of public schools in Bogotá provides a unique opportunity to meet the challenges of providing a supportive environment for adoption of healthy behaviors.

Three successful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible?

BACKGROUND

Hand hygiene (HH) compliance by health care workers has been universally disappointing. Two major programs (Washington and Geneva) have demonstrated interventions that induce sustained improvement. The introduction of alcohol-based hand rub (AHR) together with education also has been reported to improve compliance.

METHODS

These interventions were replicated concurrently for 2 years in selected wards of an 800-bed university teaching hospital, with compliance assessed only within, not between, programs.

RESULTS

No significant improvement in HH compliance was observed after the introduction of AHR (incidence rate ratio [IRR] = 1.11; 95% confidence interval [CI] = 0.93 to 1.33; P = .238) or substitution of AHR for a similar product (IRR = 1.10; 95% CI = 0.91 to 1.32; P = .328) with concomitant education. The Washington program achieved a 48% (IRR = 1.48, 95% CI = 1.20 to 1.81; P < .001) improvement in compliance, sustained over 2 years. The Geneva program failed to induce a significant increase in HH compliance in 3 wards, but achieved a 56% (IRR = 1.56; 95% CI = 1.29 to 1.89; P < .001) improvement over the already high HH rate in 1 ward (infectious disease unit).

CONCLUSIONS

The Washington program demonstrated effectiveness in achieving sustained improved HH compliance, whereas the effect of the Geneva program was limited in those wards without strong medical leadership. Introduction of AHR without an associated behavioral modification program proved ineffective.

Strategies for prevention of RSV nosocomial infection

OBJECTIVE

To review the literature on respiratory syncytial virus (RSV) as a cause of nosocomial infections (NI) on neonatal intensive care units (NICUs) and pediatric wards, and the effectiveness of various containment strategies.

STUDY DESIGN

We conducted a literature review to define characteristics of RSV NI, and to evaluate the relative effectiveness of various infection containment programs, including the use of palivizumab on the reported incidence of RSV NI on NICUs and pediatric wards.

RESULT

Highly variable rates of RSV NI have not significantly changed since RSV was first identified. The evaluation of the effectiveness of containment strategies has relied on before/after study designs. Focus on rapid patient diagnosis, compliance of acceptable handwashing techniques and cohorting of patients and staff appears to form the backbone of most prevention and containment programs. When these or other measures have failed, the administration of palivizumab has been useful in halting the spread of RSV NI in children.

CONCLUSION

RSV NI continues to be prevalent in the NICU despite adoption of infection control programs. Preventive measures should be employed to lower the risk of RSV NI and, if identified, appropriate containment strategies should be rapidly implemented.

Effect of education on hand hygiene beliefs and practices: a 5-year program

To evaluate infection control and hand hygiene understanding at 3 public hospitals, we surveyed 4,345 healthcare workers (HCWs) 3 times during a 5-year infection control intervention. The preference for the use of alcohol hand rub for hand hygiene increased dramatically; in nurses, it increased from 14% to 34%; in physicians, 4.3% to 51%; and in allied HCWs, 12% to 44%. Study year, infection control interactive education-session attendance, infection control knowledge, and being a physician or allied HCW independently predicted a preference for alcohol hand rub.

Why healthcare workers don't wash their hands: a behavioral explanation

OBJECTIVE

To elucidate behavioral determinants of handwashing among nurses.

DESIGN

Statistical modeling using the Theory of Planned Behavior and relevant components to handwashing behavior by nurses that were derived from focus-group discussions and literature review.

SETTING

The community and 3 tertiary care hospitals.

PARTICIPANTS

Children aged 9-10 years, mothers, and nurses.

RESULTS

Responses from 754 nurses were analyzed using backward linear regression for handwashing intention. We reasoned that handwashing results in 2 distinct behavioral practices--inherent handwashing and elective handwashing--with our model explaining 64% and 76%, respectively, of the variance in behavioral intention. Translation of community handwashing behavior to healthcare settings is the predominant driver of all handwashing, both inherent (weighted beta =2.92) and elective (weighted beta =4.1). Intended elective in-hospital handwashing behavior is further significantly predicted by nurses' beliefs in the benefits of the activity (weighted beta =3.12), peer pressure of senior physicians (weighted beta =3.0) and administrators (weighted beta =2.2), and role modeling (weighted beta =3.0) but only to a minimal extent by reduction in effort (weighted beta =1.13). Inherent community behavior (weighted beta =2.92), attitudes (weighted beta =0.84), and peer behavior (weighted beta =1.08) were strongly predictive of inherent handwashing intent.

CONCLUSIONS

A small increase in handwashing adherence may be seen after implementing the use of alcoholic hand rubs, to decrease the effort required to wash hands. However, the facilitation of compliance is not simply related to effort but is highly dependent on altering behavioral perceptions. Thus, introduction of hand rub alone without an associated behavioral modification program is unlikely to induce a sustained increase in hand hygiene compliance.

Improving adherence to hand hygiene among health care workers

Increased adherence to hand hygiene is widely acknowledged to be the most important way of reducing infections in health care facilities. Despite evidence of benefit, adherence to hand hygiene among health care professionals remains low. Several behavioral and organizational theories have been proposed to explain this. As a whole, the success of interventions to improve adherence to hand hygiene among health care professionals has been limited. Recent data suggest that a multifaceted intervention, including the use of feedback, education, the introduction of alcohol-based hand wash, and visual reminders, may increase adherence to hand-hygiene recommendations. Although the "active ingredient" of such an intervention is unknown, there is evidence that the use of feedback may be the key to increasing adherence. In this article, we review the theoretical basis for interventions and provide an overview of the evidence for interventions. Coherent and methodologically sound research is required to better understand the factors contributing to hand-hygiene behavior among health care professionals.

Hygienemaßnahmen auf Intensivstationen

BACKGROUND

Aim of this study was to determine to what extent evidence-based infection control recommendations are applied in German intensive care units (ICUs).

METHODS

A questionnaire concerning handling of tubes, central vascular catheters (CVC), urinary tract catheters and methicillin-resistant Staphylococcus aureus (MRSA) positive patients was sent to 230 participants of the German Nosocomial Infection Surveillance System (KISS).

RESULTS

Nasal intubation is routinely performed in 9% of ICUs, all recommended measures for CVC insertion were obeyed by 43% of ICUs and one-third of ICUs conduct regular screening of urine in catheterized patients. Urinary tract catheters are replaced at defined time intervals in 37% of ICUs. MRSA positive patients are not isolated in 5% of ICUs. MRSA screening on admission is not performed for high risk patients in 16% of ICUs.

CONCLUSIONS

There are still many German ICUs in which evidence-based recommendations are not implemented. Training of staff is necessary to improve quality of patient care.

Compliance and efficacy of hand rubbing during in-hospital practice

OBJECTIVE

To compare alcohol-based hand rubbing with hand washing using antimicrobial soap regarding antimicrobial efficacy and compliance with routine practice in hospital and intensive care units.

SUBJECTS AND METHODS

From February to June 2003, 35 nurses were randomly selected from a nursing staff of 141 and divided into two groups: hand rubbing and hand washing groups. Hand cultures were obtained before and after health care procedures. The nurses were observed on days 1, 7 and 14 of the study, in order to determine compliance and efficacy of the hand hygiene methods.

RESULTS

A total of 368 routine patient care activities were observed during the study period. Hand rubbing with alcohol-based solutions significantly reduced the bacterial contamination of the hands of the nurses more than hand washing with an antimicrobial soap (54 and 27%, respectively; p < 0.01). Compliance was also better in the hand rubbing group than in the hand washing group (72.5 and 15.4%, respectively; p < 0.001). Compliance with hand rubbing was markedly lower among the nurses who had experience of more than 3 years in hospital practice. Both hand rubbing and hand washing compliance were poorer among nurses working in intensive care units than among nurses working in the other hospital wards. Generally, after taking off gloves, nurses preferred hand washing to hand rubbing.

CONCLUSION

These data indicate that alcohol-based hand rubbing reduces mean bacterial counts on the hands of nurses more effectively than hand washing with antimicrobial soaps, and compliance rates with hand rubbing were also higher than with hand washing. Nevertheless, the compliance with hand rubbing was markedly lower in more experienced nurses.

Hand hygiene: an evidence-based review for surgeons

This review of the literature discusses the scientific evidence behind using different hand hygiene agents on the surgical ward, and in theatre for preoperative disinfection. It considers the mechanism of action of the agents and their effectiveness against different pathogens, as well as possible future agents, and how they are tested. It addresses problems such as the poor compliance with hand hygiene guidelines by healthcare workers (especially doctors) and investigates what can be done to improve compliance. Finally, it demonstrates the reduction in hospital acquired infection (HAI) rate that can be achieved by improving hand hygiene compliance, and shows that the savings associated with this easily outweigh the cost.

Healthcare workers' hand decontamination practices: compliance with recommended guidelines

AIM

This paper reports a study of healthcare workers' handwashing/hand hygiene practices from a behavioural perspective.

BACKGROUND

Hospital acquired infection poses a very real and serious threat to all who are admitted to hospital. Pathogens are readily transmitted on healthcare workers' hands, and hand hygiene substantially reduces this transmission. Evidence-based guidelines for healthcare workers' hand hygiene practices exist, but compliance with these is internationally low.

METHODS

A quasi-experimental design with a convenient sample was used. The Predisposing, Reinforcing, Enabling Constructs in Educational Diagnosis and Evaluation Health Education Theory was used as the theoretical framework, and the data were collected in 2001. Healthcare workers' handwashing practices (observation of behaviour, n = 314) and their predisposition (attitudes, beliefs and knowledge) towards compliance with hand hygiene guidelines (questionnaire, n = 62) were studied. Nurses, doctors, physiotherapists and care assistants involved in direct patient care in the study unit participated in the study. The interventional hand hygiene programme aimed to predispose healthcare workers to adopt hand hygiene behaviour (poster campaign and educational handout), reinforce (feedback on pretest results) and enable the behaviour (provision of an alcohol hand rub beside each patients bedside).

RESULTS

Implementation of the multifaceted interventional behavioural hand hygiene programme resulted in an overall improvement in compliance with hand hygiene guidelines (51-83%, P < 0.001). Furthermore, healthcare workers believed that their skin condition improved (P < 0.001). An increase in knowledge about handwashing guidelines was also found.

CONCLUSIONS

In order to be effective, efforts to improve compliance with handwashing guidelines must be multifaceted. Alcohol hand rubs (with emollients) need to be provided at each patient's bedside. Issues surrounding healthcare workers' skin irritation need to be addressed urgently.

Infection Control in Intensive Care Units

For patients in intensive care units, the development of an infection is associated with an increase in morbidity, mortality, and cost. These infections are largely preventable through the implementation of infection control programs. Infection control programs must focus on 3 general strategies: (1) prevention of health care-associated infections, (2) containment of pathogens that pose a health risk and/or are resistant to routine antibiotics, and (3) development of strategies to limit the emergence of resistant microorganisms through optimal and appropriate antimicrobial utilization. The purpose of this article is to review these 3 general strategies.

Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit

This study involved observation of hand-hygiene behaviour and evaluation of the effect of alcohol-based hand disinfection and handwashing with plain liquid soap on microbial flora. The study was performed in a combined medical and surgical intensive care unit. We demonstrated a crude compliance of hand hygiene of 50.4%, which was only performed adequately in 20.8% of cases. Of this group, handwashing and hand-disinfection procedures were performed properly 34.0% and 71.6% of the time, respectively. Hand samples for bacteriological examinations with the glove juice method demonstrated that whilst handwashing was sensitive to the way in which hand hygiene was performed, alcohol-based hand disinfection was less sensitive to such performance. Our study demonstrated that alcohol-based hand disinfection is a robust hand-hygiene method with many advantages in a practical setting. It is very feasible for use in hospital wards.

Reducing the Risk of Health Care–Associated Infections by Complying with CDC Hand Hygiene Guidelines

BACKGROUND

The Joint Commission on Accreditation of Healthcare Organizations has made the reduction of health care-associated infections one of its National Patient Safety Goals for 2005.

CASE STUDY

A 57-year-old man who underwent coronary artery bypass graft surgery was discharged from the hospital without any complications. During his routine follow-up surgery clinic visit two weeks later, his sternal wound was found to be infected. Wound and blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). IMPLEMENTING SOLUTIONS: Health care workers at Barnes-Jewish Hospital (BJH), St. Louis, attended a mandatory educational session that reviewed hand hygiene guidelines and the hospital policy related to hand hygiene and infection control. In addition, posters and flyers were posted. An increase in the use of alcohol hand rubs was found. In a later effort, a multidisciplinary hand hygiene campaign was launched at one of the BJC community hospitals. All physicians were sent hand hygiene materials and supplies, and signs were posted in key areas such as the hospital cafeteria. After a six-month period, the compliance rate increased from 35% to 53%.

CONCLUSION

Hospital-related infections will never be completely eradicated, but many can be prevented.

Hand washing and hand disinfection: more than your mother taught you

Hand washing is considered the single most important intervention for prevention of nosocomial infections in patients and health care workers. Unfortunately, compliance with standard protocols for hand hygiene in the health care environment, and especially within intensive care areas such as operating rooms and post-anesthesia care units, has been generally poor. In this article, we consider the current standards for hand hygiene as they pertain to the practice of anesthesiology. We discuss the consequences of poor compliance with hand washing practices for patient and health care provider safety. And we describe modern innovations in hand washing procedures and products that improve the opportunities for anesthesiologists to employ safe hand hygiene.

Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs

The etiology of nosocomial infections, the frequency of contaminated hands with the different nosocomial pathogens, and the role of health care workers' hands during outbreaks suggest that a hand hygiene preparation should at least have activity against bacteria, yeasts, and coated viruses. The importance of efficacy in choosing the right hand hygiene product is reflected in the new Centers for Disease Control and Prevention guideline on hand hygiene (J. M. Boyce and D. Pittet, Morb. Mortal. Wkly. Rep. 51:1-45, 2002). The best antimicrobial efficacy can be achieved with ethanol (60 to 85%), isopropanol (60 to 80%), and n-propanol (60 to 80%). The activity is broad and immediate. Ethanol at high concentrations (e.g., 95%) is the most effective treatment against naked viruses, whereas n-propanol seems to be more effective against the resident bacterial flora. The combination of alcohols may have a synergistic effect. The antimicrobial efficacy of chlorhexidine (2 to 4%) and triclosan (1 to 2%) is both lower and slower. Additionally, both agents have a risk of bacterial resistance, which is higher for chlorhexidine than triclosan. Their activity is often supported by the mechanical removal of pathogens during hand washing. Taking the antimicrobial efficacy and the mechanical removal together, they are still less effective than the alcohols. Plain soap and water has the lowest efficacy of all. In the new Centers for Disease Control and Prevention guideline, promotion of alcohol-based hand rubs containing various emollients instead of irritating soaps and detergents is one strategy to reduce skin damage, dryness, and irritation. Irritant contact dermatitis is highest with preparations containing 4% chlorhexidine gluconate, less frequent with nonantimicrobial soaps and preparations containing lower concentrations of chlorhexidine gluconate, and lowest with well-formulated alcohol-based hand rubs containing emollients and other skin conditioners. Too few published data from comparative trials are available to reliably rank triclosan. Personnel should be reminded that it is neither necessary nor recommended to routinely wash hands after each application of an alcohol-based hand rub. Long-lasting improvement of compliance with hand hygiene protocols can be successful if an effective and accessible alcohol-based hand rub with a proven dermal tolerance and an excellent user acceptability is supplied, accompanied by education of health care workers and promotion of the use of the product.

Standard precautions and post exposure prophylaxis for preventing infections

In health care set up, risk of acquiring infection by both patients and health care worker (HCW) from each other is fairly high. Despite progress, hospital acquired infections (HAI) are a problem in both developed and developing countries and are an important cause of death. Many different microbes cause HAI in both patients and HCW; these include various commensals, pathogenic bacteria, viruses, parasites, and fungi. Among these HIV, hepatitis B, and hepatitis C are of major significance to HCW. 'Standard precautions' have now replaced the term 'universal precautions', and are designed to reduce the risk of transmission of microorganisms in health care set-up from both recognized and unrecognized sources. Ultimate aim is to reduce the risk of disease transmission in the healthcare setting, both to the patient and the provider, and thus reduce morbidity. This applies to all patients, regardless of their diagnosis and expands the coverage of universal precautions by recognizing that any body fluid may contain contagious and harmful microorganisms. This article reviews the standard precautions and discusses current guidelines on post exposure prophylaxis (PEP).

Differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers

BACKGROUND

The Fulkerson scale lists 15 typical clinical activities ranked according to their risk of hand contamination.

OBJECTIVE

To investigate how often healthcare workers (HCWs) apply antiseptic handrubs after each of the specified activities ranked in the Fulkerson scale.

DESIGN

Observational study.

SETTING

University Hospital of Heidelberg, a 1,600-bed teaching hospital.

METHODS

Using a structured protocol, 41 observers recorded whether HCWs rubbed their hands in 1 of 15 given situations.

RESULTS

Handrubs were used in 1,115 (52.2%) of 2,138 observations. Comparatively high rates of handrub use were observed after contact with sterile materials (39.6%) and after contact with excretions (90% to 97%). Nurses used handrubs significantly more frequently than did physicians after contact with the inanimate environment, but physicians applied handrubs significantly more frequently after contact with body secretions.

CONCLUSIONS

This study showed better compliance with hand hygiene than that reported by many previous studies, but compliance was still inadequate and varied significantly by type of HCW, type of activity, and location in the hospital.

Hand hygiene: promoting compliance among nurses and health workers

Around 10% of hospital patients acquire a healthcare-associated infection and it has been estimated that around one-third of these could be prevented. This article discusses the causal link between hand hygiene and infection and the reasons why healthcare workers (HCW) fail to comply with hand-hygiene policies. The action of hand hygiene is discussed in terms of the removal of transient micro-organisms and the agents used. Reasons for non-compliance and some measures for achieving compliance, such as education and patient empowerment, are discussed alongside the difficulties that these present. In order to move forward, it is suggested that the problem has to be managed through cultural change, making it easier for HCWs to comply by improving hand-cleansing facilities and materials and providing feedback to personnel on local infection rates so that high-priority areas can be targeted. This may be facilitated by locally based action research.

Nosocomial infections in adult intensive-care units

Nosocomial infections affect about 30% of patients in intensive-care units and are associated with substantial morbidity and mortality. Several risk factors have been identified, including the use of catheters and other invasive equipment, and certain groups of patients-eg, those with trauma or burns-are recognised as being more susceptible to nosocomial infection than others. Awareness of these factors and adherence to simple preventive measures, such as adequate hand hygiene, can limit the burden of disease. Management of nosocomial infection relies on adequate and appropriate antibiotic therapy, which should be selected after discussion with infectious-disease specialists and adapted as microbiological data become available.

Factors associated with hand hygiene practices in two neonatal intensive care units

OBJECTIVE

To determine whether hand hygiene practices differ between levels of contact with neonates; to characterize the hand hygiene practices of different types of personnel; and to compare hand hygiene practices in neonatal intensive care units (NICUs) using different products.

METHODS

Research assistants observed staff hand hygiene practices during 38 sessions in two NICUs. Patient touches were categorized as touching within the neonates' environment but only outside the Isolette (Level 1), touching within the Isolette but not the neonate directly (Level 2) or directly touching the neonate (Level 3). Hand hygiene practices for each touch were categorized into five groups: cleaned hands and new gloves; uncleaned hands and new gloves; used gloves; clean hands and no gloves; uncleaned hands and no gloves.

RESULTS

Research assistants observed 1472 touches. On average each neonate or his or her immediate environment was touched 78 times per shift. Nurses (P = 0.001), attending physicians (P = 0.02) and physicians-in-training (P = 0.03) were more likely to use appropriate practices during Level 3 touches, but only 22.8% of all touches were with cleaned and/or newly gloved hands. The mean number of direct touches by staff members with cleaned hands was greater in the NICU using an alcohol-based hand rub than in the NICU using antimicrobial soap (P < 0.01).

CONCLUSIONS

Hand hygiene was suboptimal in this high risk setting; administrative action and improved products may be needed to assure acceptable practice. In this study use of an alcohol-based product was associated with significantly improved hand hygiene and should be encouraged, as recommended in the new CDC hand hygiene guideline.

Handwashing compliance depends on professional status

BACKGROUND

Nosocomial infections can be transmitted from microorganisms on the hands of health care workers to patients. Handwashing (HW) has a proven benefit in preventing transmission of infection, yet compliance with handwashing, especially in intensive care units, ranges between 28% and 74%.

METHODS

To determine if HW behavior varies as a function of health care professional status and patient interaction, we conducted an observational study of a surgical intermediate care unit in a large university teaching hospital. HW compliance was observed among all health care workers (HCW): physicians (MD; N = 46), nurses (RN; N = 295), and nursing support personnel (NSP; N = 93). Over an 8-week period, unidentified, trained observers documented all HCW interactions in 1-h random blocks. HW opportunities were classified into low and high risk of pathogen acquisition and transmission.

RESULTS

A total of 493 HW opportunities were observed, of which 434 involved MD, RN, and NSP. Two hundred and sixty-one low-risk (MD 35, RN 171, NSP 55) and 173 (MD 11, RN 124, NSP 38) high-risk interactions were observed. Overall HW rates were low (44%). Significant differences existed among HCW, with MDs being the least likely to wash (15% versus RN 50%, NSP 37%, p < 0.01). In adjusting for high-risk situations, MDs (odds ratio [OR] 5.58, 95% CI 2.49-12.54; NSP, OR 1.73, 95% CI 1.13-2.64; RN, OR 0.98, 95% CI 0.77-1.23) were significantly less likely to perform HW when compared to RNs. Nursing groups were significantly less likely to wash in low-risk versus high-risk situations (MD 9.2% versus 17.1%; RN 69.4% versus 39.6%; NSP 85% versus 23.3%), suggesting individual discrimination of the importance of HW. Although nurses were less likely to wash in high-risk situations compared to NSP, the overall number of opportunities was greater, suggesting that improvement in HW to the level of NSP could have a major impact on infection transmission.

CONCLUSION

Significant opportunities exist for quality improvement, novel educational strategies, and assessment of reasons why MDs and, to a lesser extent, RNs fail to follow simple HW practices.

Hand antisepsis: evaluation of a sprayer system for alcohol distribution

OBJECTIVE

To evaluate the usefulness of a new alcohol sprayer by comparing it with an individual bottle of alcohol. Patterns of use and perceptions among healthcare personnel were compared for the two products.

DESIGN

Observational study recording the volume of alcohol used and the compliance rate (frequency of hand antisepsis per number of opportunities), and a survey of healthcare workers' perceptions of the different hand hygiene strategies.

SETTING

A 20-bed medical unit in a public hospital in Marseille, France.

PARTICIPANTS

Healthcare workers of an infectious disease unit

INTERVENTIONS

Hand hygiene alcohol systems (sprayer vs individual bottle, 70% ethyl alcohol).

RESULTS

The sprayer was used more frequently than the individual bottle (12.6 vs 9.7 hand washes per day). With the sprayer system, compliance was 91% for physicians, 28% for nurses, and 8% for housekeeping personnel. Alcohol hand antisepsis was preferred to washing hands with soap and water in low-risk situations such as simple entrance into a room (91% vs 36%; P < 10(-6)) or simple contact with a patient (69% vs 40; P < .005). The sprayer system was considered easier to use (95%), more hygienic (90%), and faster (92%), with a better tolerance than the individual bottle.

CONCLUSION

The new alcohol sprayer should improve rapid hand antisepsis.

Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

The Guideline for Hand Hygiene in Health-Care Settings provides health-care workers (HCWs) with a review of data regarding handwashing and hand antisepsis in health-care settings. In addition, it provides specific recommendations to promote improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in health-care settings. This report reviews studies published since the 1985 CDC guideline (Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control 1986;7:231-43) and the 1995 APIC guideline (Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 1995;23:251-69) were issued and provides an in-depth review of hand-hygiene practices of HCWs, levels of adherence of personnel to recommended handwashing practices, and factors adversely affecting adherence. New studies of the in vivo efficacy of alcohol-based hand rubs and the low incidence of dermatitis associated with their use are reviewed. Recent studies demonstrating the value of multidisciplinary hand-hygiene promotion programs and the potential role of alcohol-based hand rubs in improving hand-hygiene practices are summarized. Recommendations concerning related issues (e.g., the use of surgical hand antiseptics, hand lotions or creams, and wearing of artificial fingernails) are also included.

Healthcare personnel and hand decontamination in intensive care units: knowledge, attitudes, and behaviour in Italy

The purpose of this study was to evaluate knowledge, attitudes, and behaviour regarding hand decontamination in personnel of intensive care units (ICUs) in Italy. All ICU physicians and nurses in 19 and five randomly selected hospitals in Campania and Calabria (Italy) were mailed a questionnaire focusing on demographics and practice characteristics; knowledge about prevention of hospital acquired infection; attitudes and behaviour with respect to hand decontamination; and use of gloves. A total of 413 questionnaires were returned giving a response rate of 66.6%. Overall, 53.2% agreed with the correct responses on knowledge related to infection control, and this knowledge was significantly higher in neonatal and medicine-surgery wards and in larger ICUs. A positive attitude was reported by the large majority who agreed that hand decontamination reduces the risk of infection in patients (96.8%) and personnel (86.2%), and the positive attitude was significantly higher among older and female personnel and in those with a higher level of knowledge. Only 60% always decontaminate hands at the start of a shift, and 72.5% before and after a patient contact. Higher compliance is reported for invasive manoeuvres, such as urinary catheters (96.5%) and intravenous lines (77.1%). Routine hand decontamination between each patient was significantly higher in females, and in neonatal and medicine-surgery ICUs. Our results suggest that interventions should not only be focused on predisposing factors (knowledge), but also on enabling (facilitating) and reinforcing (gratifying) factors.

Overview of catheter-related infections with special emphasis on prevention based on educational programs

Intra-vascular access is an unavoidable tool in sophisticated modern medical practice, and catheter-related infection remains a leading cause of nosocomial infections, particularly in intensive care units where it is associated with significant patient morbidity, mortality, and additional hospital costs. The incidence of catheter-related bloodstream infection ranges from 2 to 14 episodes per 1000 catheter-days. On average, microbiologically documented, device-related bloodstream infections complicate the use of a central venous line in three to five per 100 cases. But this represents only the visible part of the iceberg and most episodes of clinical sepsis are nowadays considered to be catheter-related. We briefly review the pathophysiology of these infections, highlighting the importance of the skin insertion site and the intravenous line hub as principal sources of colonization and infection. Principles of therapy are briefly addressed. A large proportion of these infections are preventable and this has been the objective of creating precise guidelines. It was recently suggested that the situation may evolve with the introduction of antibiotic/antiseptic-coated devices, whose impact on the epidemiology of antibiotic resistance remains to be determined. Recently, educational programs and/or a global preventive strategy based on the strict application of specific preventive measures and careful control of all factors associated with infection proved to be even more effective than coated devices in reducing rates of infection. Practical aspects regarding educational approaches will help clinicians to adapt and incorporate educational programs into clinical practice.

Nonantibibiotic measures for the prevention of Gram-positive infections

While Gram-negative bacteria remain a leading cause of nosocomial infections such as ventilator-associated pneumonia and catheter-associated urinary tract infections, Gram-positive cocci are now responsible for a large majority of surgical site and bloodstream infections. A shift has occurred during the last decade and multidrug-resistant micro-organisms have become predominant in most referral centers. Severe infections with Gram-positive micro-organisms such as methicillin-resistant Staphylococcus aureus, coagulase-negative staphylococci, vancomycin-resistant enterococci, penicillin-resistant Streptococcus pneumoniae and, more recently, glycopeptide intermediate S. aureus are now regularly reported to be associated with increased morbidity and represent a true health problem in many institutions. The importance of nonantimicrobial measures to prevent infections and further spread is reviewed in this paper. New evidence of the effectiveness of basic infection control measures that have been regarded of little importance during the last two decades by the exponential progress of technologically sophisticated medicine, is discussed.

Infection control in the ICU

Nosocomial infections (NIs) now concern 5 to 15% of hospitalized patients and can lead to complications in 25 to 33% of those patients admitted to ICUs. The most common causes are pneumonia related to mechanical ventilation, intra-abdominal infections following trauma or surgery, and bacteremia derived from intravascular devices. This overview is targeted at ICU physicians to convince them that the principles of infection control in the ICU are based on simple concepts and that the application of preventive strategies should not be viewed as an administrative or constraining control of their activity but, rather, as basic measures that are easy to implement at the bedside. A detailed knowledge of the epidemiology, based on adequate surveillance methodologies, is necessary to understand the pathophysiology and the rationale of preventive strategies that have been demonstrated to be effective. The principles of general preventive measures such as the implementation of standard and isolation precautions, and the control of antibiotic use are reviewed. Specific practical measures, targeted at the practical prevention and control of ventilator-associated pneumonia, sinusitis, and bloodstream, urinary tract, and surgical site infections are detailed. Recent data strongly confirm that these strategies may only be effective over prolonged periods if they can be integrated into the behavior of all staff members who are involved in patient care. Accordingly, infection control measures are to be viewed as a priority and have to be integrated fully into the continuous process of improvement of the quality of care.

Compliance with hand disinfection and its impact on hospital-acquired infections

Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among healthcare workers. Although some interventions to improve compliance have been successful, none had achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur at individual, group and institutional levels. The complexity of the process of behavioural change would suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained improvement in compliance associated with decreased infection rates. This paper reviews barriers to appropriate hand hygiene and describes the results of the first successful experience of sustained hand hygiene promotion and its effectiveness on hospital-acquired infection.