Simplifying the WHO 'how to hand rub' technique: three steps are as effective as six-results from an experimental randomized crossover trial

Clinical Effectiveness of a 3-Step Versus a 6-Step Hand Hygiene Technique: A Randomized Controlled Cross-over Study

BACKGROUND

The aim of this study is to assess the clinical effectiveness of the 3-step hand hygiene (HH) technique (3-HT) compared with the 6-step HH technique (6-HT; World Health Organization 6-step technique) using an alcohol-based hand rub.

METHODS

A randomized controlled crossover trial was conducted from November to December 2023 in 10 wards of a tertiary A-level hospital according to CONSORT guidelines. The 240 healthcare workers (HCWs) were randomly divided into the 3-HT intervention group or the 6-HT control group. The trial was conducted in 2 stages, and the effectiveness of each indicator in the 2 groups was compared after a washout period of 2 weeks.

RESULTS

Compared with the 6-HT, the 3-HT has demonstrated significant superiority in all indicators of HH compliance as well as the accuracy rate of HH practices. The total HH median times for the 3-HT and 6-HT were 16.00 (interquartile range, 15.00-20.00) and 32.50 (30.00-40.00) seconds, respectively (P < .05). The reduction factors for bacterial colony-forming unit counts did not differ and the colony-forming unit counts were not significantly different. Bacillus, Staphylococcus, and Micrococcus were detected before and after the use of hand rubs. HCWs preferred the 3-HT over the 6-HT. There were no significant difference in healthcare-associated infections rate between the 2 techniques.

CONCLUSIONS

The 3-HT was significantly superior to the 6-HT in terms of the HH eligibility rate, compliance, and HH time. The safety and feasibility of the 3-HT were verified by assessing microorganism count.

Hand hygiene compliance in a Brazilian COVID-19 unit: the impact of moments and contact precautions

BACKGROUND

Healthcare-associated infections are among the most common complications during hospitalization. These infections increase morbidity and mortality and they increase length of hospital stay and the cost of healthcare. The aims of our study were to monitor hand hygiene (HH) compliance, HH technique quality and factors related to HH practice among health professionals in a COVID-19 Intensive Care Unit (ICU).

METHODS

An observational, prospective study. Between September and December 2021, we observed 69 healthcare professionals in an eight-bed ICU for patients with COVID-19 in midwestern Brazil. We used the WHO observation form to collect data. The dependent variable was HH compliance and independent variables were professional category, sex, HH quality (3-step technique for at least 15 s), number of HH opportunities observed, observation shift and inappropriate glove use.

RESULTS

We observed 1185 HH opportunities. The overall compliance rate was 26.4%, but only 6.5% were performed with the correct 3-step technique for the minimum time. HH compliance was considerably lower for moments "before" tasks (6.7%; 95% CI 4.8%, 9.2%) compared with moments "after" tasks (43.8%; 95% CI 39.9%, 47.8%). The logistic model found that inappropriate glove use, night shift and physicians (p < 0.001) were associated with low HH compliance. The infrastructure analysis found that the unit had an insufficient number of alcohol-based handrub (ABHR) dispensers at the point of care and that the mechanism for activating them was poorly designed.

CONCLUSIONS

HH compliance was very low. Inappropriate glove use was associated with low compliance and the unit's infrastructure did not support good HH practice. The fact that healthcare professionals were more likely to do HH after tasks, suggests that they use HH to protect themselves rather than the patients. Adequate infrastructure and ongoing health education with a focus on HH while caring for patients in contact precautions are essential for improving HH compliance and patient safety.

Current issues in hand hygiene

BACKGROUND

Multiple aspects of hand hygiene have changed in recent years.

METHODS

A PubMed search was conducted to identify recent articles about hand hygiene.

RESULTS

The COVID-19 pandemic caused temporary changes in hand hygiene compliance rates and shortages of alcohol-based hand sanitizers (ABHSs), and in marketing of some products that were ineffective or unsafe. Fortunately, ABHSs are effective against SARS-CoV-2 and other emerging pathogens including Candida auris and mpox. Proper placement, maintenance, and design of ABHS dispensers have gained additional attention. Current evidence suggests that if an adequate volume of ABHS has been applied to hands, personnel must rub their hands together for at least 15 seconds before hands feel dry (dry time), which is the primary driver of antimicrobial efficacy. Accordingly, practical methods of monitoring hand hygiene technique are needed. Direct observation of hand hygiene compliance remains a challenge in many healthcare facilities, generating increased interest in automated hand hygiene monitoring systems (AHHMSs). However, several barriers have hindered widespread adoption of AHHMSs. AHHMSs must be implemented as part of a multimodal improvement program to successfully improve hand hygiene performance rates.

CONCLUSIONS

Remaining gaps in our understanding of hand hygiene warrant continued research into factors impacting hand hygiene practices.

Comparing the effectiveness of hand hygiene techniques in reducing the microbial load and covering hand surfaces in healthcare workers: Updated systematic review

BACKGROUND

This review, commissioned by the World Health Organization (WHO), examined the effectiveness of the WHO 6-step hand hygiene (HH) technique in reducing microbial load on hands and covering hand surfaces, and compared its effectiveness to other techniques.

METHODS

Medline, CINAHL, ProQuest, Web of Science, Mednar, and Google Scholar were searched for primary studies, published in English (1978-February 2021), evaluating the microbiological effectiveness or hand surface coverage of HH techniques in healthcare workers. Reviewers independently performed quality assessment using Cochrane tools. The protocol for the narrative review was registered (PROSPERO 2021: CRD42021236138).

RESULTS

Nine studies were included. Evidence demonstrated that the WHO technique reduced microbial load on hands. One study found the WHO technique more effective than the 3-step technique (P = .02), while another found no difference between these 2 techniques (P = .08). An adapted 3-step technique was more effective than the WHO technique in laboratory settings (P = .021), but not in clinical practice (P = .629). One study demonstrated that an adapted 6-step technique was more effective than the WHO technique (P = .001). Evidence was heterogeneous in application time, product, and volume. All studies were high risk of bias.

CONCLUSIONS

Eight studies found that the WHO 6-step technique reduced microbial load on healthcare workers' hands; but the studies were heterogeneous and further research is required to identify the most effective, yet feasible technique.

Evaluation of the Efficiency of Hand Hygiene Technique with Hydroalcoholic Solution by Image Color Summarize

Background and Objectives: The HH (hand hygiene) technique is relatively simple. Even so, in practice there are still non-conformities regarding this aspect. Lack of knowledge or lack of compliance can be reasons for non-adherence with HH techniques. In this context, the purpose of this study was to follow the realization of the hand-washing technique with hydroalcoholic solution, applied before and after receiving the HH recommendations. Materials and Methods: A descriptive, cross-sectional study was conducted from May 2022 to June 2022. Students from a second year dental medicine class teaching in French 2021/22 “Grigore T. Popa” University of Medicine and Pharmacy in Iasi were included in the study. The approval of the ethics commission was received: No. 184/05.05.2022. The study was conducted in two stages. In the first stage, HH was performed without any recommendation. In the second stage, the antiseptic hand rubbing technique was presented following the WHO recommendations. The fluorescent Fluo-Add solution, Wood lamp for dermatology (4 × 5.5 W ultraviolet tubes with a wavelength of 360 nm), and photo camera were used. Subjects performed their HH movement before and after receiving instructions according to WHO. Images were initially taken from the backhand and palm and were finally analyzed with Image Color Summarizer. The data were analyzed by the Mann–Whitney U Test, t-test paired samples using IBM-SPSS version 26 (IBM, Armonk, NY, USA), and p ≤ 0.05 was considered statistically significant. Results: After analyzing the images, there were 70 subjects, 45.7% (32) female and 54.33% (38) male. Final average covered area of backhand was 60.89% (±17.17), 28.84:86.11, compared to 52.07% (±17.04), 9:85.23. Final average covered area for palm was 69.91% (±13.5), 31.61:93.41 compared to 59.74% (±16.64), 26.13:92.72. No statistical significance was obtained by gender. Conclusions: The study showed an improvement in hand hygiene technique without highlighting gender differences.

The application of normative documents for determination of biocidal activity of disinfectants and antiseptics dedicated for medical area: a narrative review

Disinfectants and antiseptics are important weapons to reduce the number of microorganisms and thus to limit the number of infections. Different methods of antimicrobial activity testing, often not standardised, without appropriate controls and not validated are applied. To address these issues, several European Standards (EN) have been developed, describing the test methods to determine whether chemical disinfectants or antiseptic products have appropriate bactericidal, sporicidal, mycobactericidal or tuberculocidal activity; fungicidal or yeasticidal activity; or virucidal activity. In this narrative review, the 17 EN concerning evaluation of the above-mentioned antimicrobial activity of preparations dedicated to the medical area are briefly reviewed, together with recent publications on this topic. Suspension and carrier tests have been performed in clean and dirty conditions simulating the medical area. In addition, a wide range of applications of these standards has been presented in the research of biocides for hand antisepsis, surfaces disinfection, including airborne disinfection as well as medical device and medical textile disinfection. The role of normative documents in the investigation of antimicrobial activity of disinfectants and antiseptics to limit infections has been underestimated. This narrative review aims to persuade researchers to conduct antimicrobial activity testing in line with validated EN and highlights an existing gap in ongoing research. It also aims to raise awareness of the wide range of biocidal activity tests with standardised methods in medical area. We also pay attention to the recently developed European Pharmacopoeia monography concerning the testing of bactericidal and fungicidal activity of antiseptics classified as medicinal products.

Hand Hygiene, an Update

Hand hygiene by health care personnel is an important measure for preventing health care-associated infections, but adherence rates and technique remain suboptimal. Alcohol-based hand rubs are the preferred method of hand hygiene in most clinical scenarios, are more effective and better tolerated than handwashing, and their use has facilitated improved adherence rates. Obtaining accurate estimates of hand hygiene adherence rates using direct observations of personnel is challenging. Combining automated hand hygiene monitoring systems with direct observations is a promising strategy, and is likely to yield the best estimates of adherence. Greater attention to hand hygiene technique is needed.

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

Health-care-associated infections are the most prevalent adverse events of hospital care, posing a substantial threat to patient safety and burden on society. Hand hygiene with alcohol-based hand rub is the most effective preventive strategy to reduce health-care-associated infections. Over the past two decades, various interventions have been introduced and studied to improve hand hygiene compliance among health-care workers. The global implementation of the WHO multimodal hand hygiene improvement strategy and constant efforts to replace the use of soap and water with alcohol-based hand rub have led to a faster and more efficient hand cleaning method. These strategies have strongly contributed to the success of behaviour change and a subsequent decrease in health-care-associated infections and cross-transmission of multidrug-resistant organisms worldwide. The WHO multimodal behaviour change strategy requires a series of elements including system change as a prerequisite for behaviour, change, education, monitoring and performance feedback, reminders in the workplace, and an institutional safety climate. Successful adoption of the promotion strategy requires adaptation to available resources and sociocultural contexts. This Review focuses on the major advances and challenges in hand hygiene research and practices in the past 20 years and sets out various ways forward for improving this lifesaving action.

What is new with hand hygiene?

PURPOSE OF REVIEW

Healthcare-associated infections (HAIs) challenge healthcare systems worldwide. As healthcare workers' hands are considered the main vector for transmission of pathogens, effective hand hygiene is the single most important action to prevent HAIs. We sought to highlight new developments and advances in hand hygiene.

RECENT FINDINGS

Hand hygiene compliance averages at 38%. A sustained increase of compliance with a subsequent decrease of HAIs may be achieved by national, systematic and rigorous education, and auditing programs. Periodically deployed self-operating hand hygiene surveillance systems coupled with personalized reminders could facilitate such efforts. Alcohol-based hand-rub (ABHR) solutions remain the hand hygiene gold standard, but are modified in texture and composition to better meet healthcare workers' preferences. Modifications of the hand hygiene procedure have been proposed targeting both time and technique of hand rub application. Reducing rub-time from 30 to 15 s and simplifying the technique to consist of three rather than six steps yielded encouraging results in terms of microbiological efficacy and higher compliance.

SUMMARY

Implementation and promotion of compliance are the major concerns of today's research on hand hygiene. Developments towards better surveillance and systematic education, improved ABHR formulation and streamlining of hand hygiene actions are paving the way ahead.

Bactericidal efficacy of two modified WHO-recommended alcohol-based hand rubs using two types of rub-in techniques for 15 s

We evaluated the bactericidal efficacy of two modified WHO-recommended alcohol-based hand rubs (3 mL) after a 15-s rubbing period using two different rub-in techniques (three vs six steps). The formulation based on 80% w/w ethanol and 0.5% v/v glycerol (modified WHO I) showed a mean log₁₀-reduction of 3.63 ± 0.87 (six steps) and 3.80 ± 0.71 (three steps) which was inferior to the reference treatment (4.27 ± 0.98; six steps). The efficacy of the formulation based on 75% w/w isopropanol and 0.5% v/v glycerol (modified WHO II) was not inferior to the reference treatment for either rub-in technique.

A two-component intervention to improve hand hygiene practices and promote alcohol-based hand rub use among people who inject drugs: a mixed-methods evaluation

Background

Inconsistent hand hygiene puts people who inject drugs (PWID) at high risk of infectious diseases, in particular skin and soft tissue infections. In healthcare settings, handwashing with alcohol-based hand rubs (ABRH) is recommended before aseptic procedures including intravenous injections. We aimed to evaluate the acceptability, safety and preliminary efficacy of an intervention combining ABHR provision and educational training for PWID.

Methods

A mixed-methods design was used including a pre-post quantitative study and a qualitative study. Participants were active PWID recruited in 4 harm reduction programmes of France and followed up for 6 weeks. After baseline assessment, participants received a face-to-face educational intervention. ABHR was then provided throughout the study period. Quantitative data were collected through questionnaires at baseline, and weeks 2 (W2) and 6 (W6) post-intervention. Qualitative data were collected through focus groups with participants who completed the 6-week study.

Results

Among the 59 participants included, 48 (81%) and 43 (73%) attended W2 and W6 visits, respectively. ABHR acceptability was high and adoption rates were 50% (W2) and 61% (W6). Only a minority of participants reported adverse skin reactions (ranging from 2 to 6%). Preliminary efficacy of the intervention was shown through increased hand hygiene frequency (multivariable linear mixed model: coef. W2 = 0.58, p = 0.002; coef. W6 = 0.61, p = 0.002) and fewer self-reported injecting-related infections (multivariable logistic mixed model: AOR W6 = 0.23, p = 0.021). Two focus groups were conducted with 10 participants and showed that young PWID and those living in unstable housing benefited most from the intervention.

Conclusions

ABHR for hand hygiene prior to injection are acceptable to and safe for PWID, particularly those living in unstable housing. The intervention’s educational component was crucial to ensure adoption of safe practices. We also provide preliminary evidence of the intervention’s efficacy through increased hand hygiene frequency and a reduced risk of infection.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-05895-1.

Effect of Wearing a Novel Electronic Wearable Device on Hand Hygiene Compliance Among Health Care Workers: A Stepped-Wedge Cluster Randomized Clinical Trial

Importance

Hand hygiene (HH) is essential to prevent hospital-acquired infections.

Objective

To determine whether providing real-time feedback on a simplified HH action improves compliance with the World Health Organization's "5 Moments" and the quality of the HH action.

Design, Setting, and Participants

This open-label, cluster randomized, stepped-wedge clinical trial was conducted between June 1, 2017, and January 6, 2018 (with a follow-up in March 2018), in a geriatric hospital of the University of Geneva Hospitals, Switzerland. All 12 wards and 97 of 306 eligible health care workers (HCWs) volunteered to wear a novel electronic wearable device that delivered real-time feedback on duration of hand rubbing and application of a hand-sized customized volume of alcohol-based handrub (ABHR).

Interventions

This study had 3 sequential periods: baseline (no device), transition (device monitoring without feedback), and intervention (device monitoring and feedback). The start of the transition period was randomly allocated based on a computer-generated block randomization.

Main Outcomes and Measures

The primary outcome was HH compliance, according to the direct observation method during intervention as compared with baseline. Secondary outcomes included the volume of ABHR and duration of hand rubbing measured by the device during intervention as compared with transition.

Results

All wards and respective HCWs were evenly assigned to group 1 (26 participants), 2 (22 participants), 3 (25 participants), or 4 (24 participants). Twelve HCWs did not fully complete the intervention but were included in the analysis. During 759 observation sessions, 6878 HH opportunities were observed. HH compliance at intervention (62.9%; 95% CI, 61.1%-64.7%) was lower than at baseline (66.6%; 95% CI, 64.8%-68.4%). After adjusting for covariates, HH compliance was not different between periods (odds ratio, 1.03; 95% CI, 0.75-1.42; P = .85). Days since study onset (OR, 0.997; 95% CI, 0.994-0.998; P < .001), older age (OR, 0.97; 95% CI, 0.95-0.99; P = .015), and workload (OR, 0.29; 95% CI, 0.20-0.41; P < .001) were independently associated with reduced HH compliance. The median (interquartile range) volume of ABHR and duration of hand rubbing in transition and intervention increased from 1.12 (0.76-1.68) mL to 1.71 (1.01-2.76) mL and from 6.5 (4.5-10.5) seconds to 8 (4.5-15.5) seconds, respectively. There were no serious adverse events.

Conclusions and Relevance

The use of this device did not change HH compliance, but increased the duration of hand rubbing and volume of ABHR used by HCWs.

Trial Registration

isrctn.org Identifier: ISRCTN25430066.

Impact of mhealth messages and environmental cues on hand hygiene practice among healthcare workers in the greater Kampala metropolitan area, Uganda: study protocol for a cluster randomized trial

Background

Hand hygiene (HH) among healthcare workers (HCWs) is critical for infection prevention and control (IPC) in healthcare facilities (HCFs). Nonetheless, it remains a challenge in HCFs, largely due to lack of high-impact and efficacious interventions. Environmental cues and mobile phone health messaging (mhealth) have the potential to improve HH compliance among HCWs, however, these remain under-studied. Our study will determine the impact of mhealth hygiene messages and environmental cues on HH practice among HCWs in the Greater Kampala Metropolitan Area (GKMA).

Methods

The study is a cluster-randomized trial, which will be guided by the behaviour centred design model and theory for behaviour change. During the formative phase, we shall conduct 30 key informants’ interviews and 30 semi-structured interviews to explore the barriers and facilitators to HCWs’ HH practice. Besides, observations of HH facilities in 100 HCFs will be conducted. Findings from the formative phase will guide the intervention design during a stakeholders’ insight workshop.

The intervention will be implemented for a period of 4 months in 30 HCFs, with a sample of 450 HCWs who work in maternity and children’s wards. HCFs in the control arm will receive innovatively designed HH facilities and supplies. HCWs in the intervention arm, in addition to the HH facilities and supplies, will receive environmental cues and mhealth messages. The main outcome will be the proportion of utilized HH opportunities out of the 9000 HH opportunities to be observed. The secondary outcome will be E. coli concentration levels in 100mls of hand rinsates from HCWs, an indicator of recent fecal contamination and HH failure. We shall run multivariable logistic regression under the generalized estimating equations (GEE) framework to account for the dependence of HH on the intervention.

Discussion

The study will provide critical findings on barriers and facilitators to HH practice among HCWs, and the impact of environmental cues and mhealth messages on HCWs’ HH practice.

Trial registration

ISRCTN Registry with number ISRCTN98148144. The trial was registered on 23/11/2020.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06082-3.

Using an ultraviolet cabinet improves compliance with the World Health Organization's hand hygiene recommendations by undergraduate medical students: a randomized controlled trial

BACKGROUND

Appropriate hand hygiene (HH) is key to reducing healthcare-acquired infections. The World Health Organization (WHO) recommends education and training to improve HH knowledge and compliance. Physicians are ranked among the worst of all healthcare workers for compliant handrubbing with its origin probably being the failure to learn this essential behavior during undergraduate medical studies. This study evaluated if the use of Ultraviolet-cabinets (UVc) for fluorescent-alcohol-based handrubs (AHR) during an undergraduate medical student training improved the compliance rate to the WHO hand hygiene recommendations (completeness of AHR application and HH opportunities).

METHODS

This randomized trial compared a HH training with personal feedback (using UVc) to a control group. The first year, the students (2nd degree) were convened by groups (clusters) of 6-9 for a demonstration of the correct execution of WHO procedure. Randomization by cluster was done prior HH training. In the control group, the students hand rubbed under visual supervision of a tutor. In the intervention group after the same visual supervision, completeness of fluorescent-AHR hand application was recorded under UVc and was shown to the student. The intervention group had free access to the UVc until complete application. HH practices were included in simulation sessions for the both groups. One year after (3rd degree), all the students were asked to hand rub with fluorescent-AHR. A tutor (blinded to the study group) assessed the completeness of hand application under UVc and the compliance with the WHO opportunities. Complete application of AHR was defined as fluorescence for all the surfaces of hands and wrists.

RESULTS

242 students participated (140 in the intervention group and 102 in the control group). One year after the initial training, the rate of complete application of AHR was doubled in the intervention group (60.0% vs. 30.4%, p < 0.001). In a multivariate analysis which included gender, additional HH or UVc training, surgical traineeship and regular use of AHR, the hazard ratio for the intervention was 3.84 (95%CI: 2.09-7.06). The compliance with the HH WHO's opportunities was increased in the intervention group (58.1% vs. 42.4%, p < 0.018).

CONCLUSION

Using UVc for undergraduate medical students education to hand hygiene improves their technique and compliance with WHO recommendations.

Are three antiseptic paints needed for safe preparation of the surgical field? A prospective cohort study with 239 patients

Background

Preoperative skin antisepsis is an essential component of safe surgery. However, it is unclear how many antiseptic paints are needed to eliminate bacteria prior to incision. This study compared microbial skin counts after two and three antiseptic paints.

Methods

We conducted a prospective cohort study in non-emergency patients receiving a cardiac/abdominal surgery with standardized, preoperative skin antisepsis consisting of an alcoholic compound and either povidone iodine (PI) or chlorhexidine (CHX). We obtained three skin swabs from the participant’s thorax/abdomen using a sterile template with a 25 cm² window: After collection of the first swab prior to skin antisepsis, and once the second and third application of PI/CHX had dried out, we obtained a second and third swab, respectively. Our primary outcome was the reduction in microbial skin counts after two and three paints of PI/CHX.

Results

Among the 239 enrolled patients, there was no significant difference in the reduction of mean square root-transformed microbial skin counts with three versus two paints (P = 0.2). But distributions of colony forming units (CFUs) decreased from paint 2 to 3 in a predefined analysis (P = 0.002). There was strong evidence of an increased proportion of patients with zero CFU after paint 3 versus paint 2 (P = 0.003). We did not identify risk factors for insufficient reduction of microbial skin counts after two paints, defined as the detection of > 5 CFUs and/or ≥ 1 pathogens.

Conclusions

In non-emergency surgical patients, three antiseptic paints may be superior to two paints in reducing microbial skin colonization prior to surgery.

Simplifying the World Health Organization Protocol: 3 Steps Versus 6 Steps for Performance of Hand Hygiene in a Cluster-randomized Trial

BACKGROUND

In an experimental setting, a simplified, 3-step hand hygiene technique for applying alcohol-based hand rub was non inferior in terms of reduction of bacterial counts, as compared to the conventional World Health Organization 6-step technique. We therefore compared compliance and microbiological efficacy between both hand hygiene techniques in routine clinical practice.

METHODS

We performed a cluster-randomized trial from October-November 2015 at the University Hospital Basel, Switzerland: a tertiary, academic care center (ISRCTN45923734). We randomly assigned 12 wards to either the 3-step technique or the conventional 6-step technique of hand rubbing. The primary endpoints were compliance with the assigned technique and reduction of bacterial counts on the hands of health-care workers.

RESULTS

Overall, 2923 hand hygiene indications were observed, and compliance was 70.7% (2066/2923). Compliance with technique and indications was 51.7% (595/1151) and 75.9% (1151/1516) on wards assigned to the 3-step technique, respectively, as compared to 12.7% (116/915) and 65.0% (915/1407) on wards assigned to the 6-step technique (P < .001). The reduction factor (RF) of bacterial colony counts did not differ between techniques (median RF 0.97 log10 colony-forming units [CFU] [interquartile range 0.39-1.59] for the 3-step technique vs median RF 1.04 log10 CFU [interquartile range 0.49-1.52] for the 6-step technique; P = .629).

CONCLUSIONS

In a clinical setting, the simpler hand hygiene technique, consisting of 3 steps, resulted in higher compliance with both hand hygiene indications and technique, as compared to the 6 steps. As the results of the microbiological analyses exclude inferiority, the conventional 6 steps could be safely replaced by a simpler hand hygiene technique.

CLINICAL TRIALS REGISTRATION

ISRCTN45923734.

Acceptability and tolerability of alcohol-based hand hygiene products for elderly residents in long-term care: a crossover study

Background

Hand hygiene is a critical component of infection control. Much of the focus on improving hand hygiene in healthcare settings has been directed towards healthcare worker compliance but its importance for patients, including those in long-term care facilities (LTCFs), is increasingly being recognised. Alcohol-based hand rub (ABHR) can lead to improved compliance. We aimed to determine acceptability and tolerability of two ABHRs for hand hygiene of elderly LTCF residents using a modified version of the WHO protocol.

Methods

Thirty six elderly LTCF residents participated in this crossover study. A modified and translated (Chinese) version of the WHO protocol for evaluation of two or more ABHRs was used to determine product acceptability and tolerability for one gel (bottle with reclosable cap) and one foam (pump). During the 3-day testing period, participants were provided with their own portable bottle of ABHR. A research nurse objectively assessed the skin integrity of the hands at baseline and throughout the study. Skin moisture content was determined using a Scalar Moisture Checker Probe (Science Technology Resources, Ca, USA). Participants rated ABHR tolerability and acceptability using the WHO checklist at the end of each test period.

Results

Both products passed the WHO criteria for acceptability and tolerability. The foam (86%) scored higher than the gel (51%) for ease of use possibly because some participants found the cap of the gel bottle difficult to open due to finger stiffness. No evidence of damage to skin integrity was observed. Overall, skin moisture content had improved by the end of the study. Residents preferred either of the test products to the liquid formulation currently in use by the LTCF.

Conclusions

Overall, the elderly were willing to use ABHR for hand hygiene. Both products were well tolerated and preferred over the usual product provided by the LTCF. However, forgetfulness and difficulty rubbing the product over the hands due to finger stiffness posed a challenge for some residents. This could be overcome by using healthcare worker-assisted hand hygiene at specified times each day and prompts to serve as reminders to perform hand hygiene.

Hand hygiene in low- and middle-income countries

A panel of experts was convened by the International Society for Infectious Diseases (ISID) to overview evidence based strategies to reduce the transmission of pathogens via the hands of healthcare workers and the subsequent incidence of hospital acquired infections with a focus on implementing these strategies in low- and middle-income countries. Existing data suggests that hospital patients in low- and middle-income countries are exposed to rates of healthcare associated infections at least 2-fold higher than in high income countries. In addition to the universal challenges to the implementation of effective hand hygiene strategies, hospitals in low- and middle-income countries face a range of unique barriers, including overcrowding and securing a reliable and sustainable supply of alcohol-based handrub. The WHO Multimodal Hand Hygiene Improvement Strategy and its associated resources represent an evidence-based framework for developing a locally-adapted implementation plan for hand hygiene promotion.

Current issues in hand hygiene

Although substantial improvements in hand hygiene practices have occurred in recent years, many health care facilities continue to encounter challenges in achieving and maintaining high levels of hand hygiene compliance. Issues of current interest include the optimum dose of alcohol-based handrub (ABHR) that should be applied, the impact of hand size and alcohol-based handrub dry times have on efficacy, and ideal hand hygiene technique. There is a need to determine which additional promotional activities can augment improvements in hand hygiene that are achieved by implementing the multimodal improvement strategy recommended by the World Health Organization. Monitoring hand hygiene performance and providing personnel with feedback on their performance are essential elements of successful improvement programs. Further research is needed to establish the most effective methods of providing feedback. Additional studies are needed to optimize strategies for performing direct observation of hand hygiene compliance, and to determine the role of supplementing direct observations using automated monitoring systems.

A systematic review to evaluate the evidence base for the World Health Organization's adopted hand hygiene technique for reducing the microbial load on the hands of healthcare workers

BACKGROUND

Effective hand hygiene prevents healthcare-associated infections. This systematic review evaluates the evidence for the World Health Organization's (WHO) technique in reducing the microbial load on the hands of healthcare workers (HCWs).

METHODS

This study was conducted in accordance with Joanna Briggs Protocol 531. Index and free-text terms for technique, HCW, and microbial load were searched in CINAHL, Medline, Web of Science, Mednar, Proquest, and Google Scholar. Inclusion criteria were articles in English that evaluated the WHO 6-step hand hygiene technique for healthcare staff. Two reviewers independently performed quality assessment and data extraction.

RESULTS

All 7 studies found that the WHO technique reduced bacterial load on HCW hands, but the strongest evidence came from 3 randomized controlled trials, which reported conflicting evidence. One study found no difference in the effectiveness of the WHO 6-step technique compared to the Centers for Disease Control and Prevention's 3-step technique (P = .08); another study found the WHO 6-step technique to be more effective (P = .02); and the third study found that a modified 3-step technique was more effective than the 6-step technique (P = .021).

CONCLUSIONS

This review provides evidence of the effectiveness of the WHO technique but does not identify the most effective hand hygiene technique. Questions to be addressed by further research are identified. Meanwhile, current practices should continue.

Hand hygiene: Attitudes and practices of nurses, a comparison between 2007 and 2015

BACKGROUND

Hand hygiene reduces health care-associated infections significantly. However, international evidence suggests that practices are suboptimal. The objective of this study was to compare and contrast hand hygiene attitudes and practices and alcohol-based handrub (ABHR) use among nurses between 2007 and 2015.

METHODS

In 2007, a random sample of nurses in a large teaching hospital was invited to complete a postal survey using a validated questionnaire. In 2015, the study was replicated among all nurses employed in a university hospital group, including the setting of the original study. Data were analyzed quantitatively and qualitatively using appropriate software.

RESULTS

Attitudes to hand hygiene were positive and >90% of respondents' self-reported compliance before and after patient contact. However, 13% fewer in 2015 (42%) reported using ABHR >90% of the time compared with in 2007 (55%). Of nurses with <2 years' experience, 90% reported using ABHR >50% of the time compared with 73% of nurses with 2-5 years' experience. Barriers to ABHR improved, but remained high (skin sensitivity: 2007: 23%, 2015: 17%; skin damage: 2007: 18%, 2015: 13%; poor user acceptability and tolerance: 2007 and 2015: 25%).

CONCLUSIONS

Use of positive role models, the adoption of a positive social and cultural norm within the organization, and the provision of continuing professional development opportunities may prove useful strategies in harnessing good practice among graduate nurses and in preventing negative socialization from occurring.