Hand hygiene compliance

World Health Organization (2009) highlighted that the magnitude of HCAI burden worldwide which should be emphasized as an important issue and it is overly underestimated. According to Allegranz and Pittet (2009), the hospital-wide studies and long-term follow up reports showed that there is a temporal association between improved hand hygiene practice and reduced infection rates. In their review paper, therefore, they spotlighted that hand hygiene is the leading measure to prevent transmission of HCAI and antimicrobial resistant.They also found out that optimal level of hand hygiene compliance among health care providers is low in most of the setting. It is to promote hand hygiene through multimodal interventions which appeared to be the most suitable strategy to behavioural change. Allegranz and Pittet (2009) also noted that introduction of alcohol-based hand rubs and continuous educational programmes are key factors to challenge barriers to hand hygiene compliance.

Larson, Quiros and Lin (2007) conducted a study to evaluate compliance with CDC hand hygiene guidelines and compare the rates of HCAI before and after guidelines recommendations. They designed pre-and post-guidelines implementation site visits and surveys in 40 US hospitals, using direct observation of hand hygiene compliance and guideline implementation score. Their study results showed that hand hygiene compliance rate remained low and there is no impact of guidelines implementation on HAI rates.

They found out that there was no evidence of multidisciplinary programs to improve practice of hand hygiene. Larson, Quiros and Lin (2007), therefore, concluded that wide dissemination of guidelines is not a sufficient intervention to promote hand hygiene unless multidisciplinary programs are initiated in hospital setting.

In twenty-four-hour observational study on compliance of hand hygiene in hospitals conducted by Randle, Arthur and Vaughan (2010), the rates of hand hygiene compliance among nurses and allied health professionals were improved, and the rates are still low among doctors and ancillary workers. They found out that compliance for head hygiene was high before performing procedures with asepsis techniques, after body fluid exposure and after contact with patients. However, the rate of compliance was low before contact with the patients and after contact with surrounding objects, which indicated that hospital staffs’ concerns to wash hand before contact with patient is poor and necessary to improve. Randle, Arthur and Vaughan (2010) concluded that hand hygiene is influential and cost effective to reduce HCAI rates, and implementation of numerous strategies have impact on hand hygiene compliance.

Mathai et al (2011) stated that HCAI prevention programs are more widely implemented compare to specific hand hygiene promotion. They reflected the recommendation of WHO that hand hygiene is to be encouraged in health care setting as quality indicator. They noted that there has been 59% of current active initiatives at national and sub national level incorporating hand hygiene in measurement for quality of care. There are more initiatives requires to incorporate hand hygiene compliance as quality indicator, and to implement multiple strategies in health care setting all over the world.

Critical analysis on the issue for poor hand hygiene practice is important to find out the barriers or factors affecting these poor practices, and solutions to combat the problems of health care related infections. In review of scientific data related to hand hygiene, perceived barriers to adherence with hand hygiene practice are skin irritation caused by hand hygiene agents, inaccessible hand hygiene supplies, interference with staff-patient relationships, patient needs perceived as a priority over hand hygiene, wearing of gloves, forgetfulness, lack of knowledge about guidelines, insufficient time for hand hygiene, high workload and understaffing, and the lack of scientific information showing a definitive impact of improved hand hygiene on increasing nosocromial infection rates (World Health Organization, 2009).

World Health Organization ( 2009) also reported additional perceived barriers to recommended hang hygiene practice which includes; lack of active participation in hand hygiene promotion at individual level, lack of institutional priority for hand hygiene, lack of administrative sanction for non-compliers and rewarding of compliers, lack of knowledge, lack of role model from colleagues and superiors and disagreement with recommendations. This comprehensive report gives the insight that it is a need to remove these barriers to promote hand hygiene practice among staff, and that nurse leaders and managers must be role model in practicing hand hygiene according to the established guidelines.

According to Centre for Disease Control and Prevention (2002), education is a cornerstone for improvement with hand hygiene practices, and it is recommended to be addressed by educational programs include with; 1)scientific information for the definitive impact of improved hand hygiene on healthcare associated infection and resistant organism transmission rates; 2) awareness of guidelines for hand hygiene and indications for hand hygiene; 3) knowledge concerning the low average adherence rate to hand hygiene by the majority of hospital staff; and 4) knowledge concerning the appropriateness, efficacy, and understanding of the use of hand-hygiene and skin-care–protection agents. Informed knowledge creates awareness of their problematic behaviours among staff and directs them to change behaviour towards compliance to hand hygiene practice.

Report from World Health Organization (2009) included with determinants or self-reported factors for good adherence to hand hygiene, which are peer behaviour, perceived expectation from colleague, being perceived as role model, perception that hand hygiene is easy to perform, perceived risk of infection, beliefs in performing hand hygiene and participation in previous hand hygiene campaign. Therefore, Center for Disease Control and Prevention (2002) recommended that Interventions to promote hand hygiene in hospital need to consider various factors including intentions, attitude towards the behavior, perceived social norm, perceived behavioral control, perceived risk factors, hand hygiene practices, perceived role model, perceived role model and motivation.

From these points, the author realized that extrinsic motivators such as rewards and punishments, having easy access to sinks and hand rub and regular auditing are not enough to promote hand hygiene practice among staff. The management team needs to consider about internal motivators such as giving opportunity to take part in hand hygiene initiative, giving some responsibilities on hand hygiene promotion program and being empowered nurses as future leader to hold perceived role model for the younger generation.

References:

Centers for Disease Control and Prevention (2002) Guidelines for Hand Hygiene In Health-Care Settings, Morbidity and Mortality Weekly Report: Recommendations and reports, V. 5, No. RR-16.

 Larson, E. L., Quiros, D., and Lin, S. X. (2007) “Dissemination of the CDC’s Hand Hygiene  Guideline and impact on infection rates,” American Journal of Infection Control, 35(10), 666-675.

 Mathai, E. (2011) “Promotion hand hygiene in healthcare through national/subnational campains,” Journal of Hospital Infection, 77(4), pp. 294-298.

 Randle, Arthur and Vaughan (2010) “Twenty-four-hour observational study on hospital hand hygiene compliance,” Journal of Hospital Infection,76(3), 252-255.

World Health Organization (2009) WHO Guidelines on Hand Hygiene in Health Care, First Global Patient Safety Challenge Clean Care is Safer Care, Geneva.