Preventing Infection

Hand hygiene: How standardised processes increase compliance

Hand hygiene is widely recognised as the single most effective means of reducing healthcare-associated infections (HAI), such as surgical site infections (SSI). Implementing standardised hand disinfection processes in healthcare facilities and maintaining high compliance among healthcare professionals are needed to protect staff and patients from infections.

Children are taught that hand-washing is important. However, proper hand disinfection remains difficult for many adults – even for healthcare professionals. What might seem like a simple solution to prevent the spread of bacteria is nonetheless hugely effective. Hand hygiene has an enormous impact on patient safety and infection control in healthcare facilities. The hands of healthcare workers can be contaminated through direct patient contact of course, but also by touching contaminated surfaces at the point of care in the patient environment or by touching a contaminated infusion bottle, for example. A study by Clack et al. found that on average, contact takes place every 4.2 seconds during patient care and treatment – and every two minutes, even contact that carries the risk of infection. If healthcare workers do not sufficiently follow hand hygiene procedures, microbes such as , Staphylococcus, Clostridium or even multiresistant bacteria can be transmitted to the patients, who can develop World Health Organization, 30 per cent of HAIs could be prevented with effective infection prevention and control measures. Hand hygiene is a core component and a key step of these interventions1. Many investigations have shown that improvements in hand hygiene compliance can significantly reduce the incidence of HAI2 . Even the most technologically advanced or computer-assisted surgeries would not offer any advantages for the patients if they end up with complications from surgical site infections. Based on evidence from its investigations, the WHO published guidelines on hand hygiene in health care specifically for healthcare workers in 2009. Since then, the organisation has launched several campaigns to promote awareness and improve the understanding of the importance of hand hygiene1. Beginning in January 2019, the WHO has been conducting a survey on Infection Prevention and Control and Hand Hygiene to collect new data on the actual situation and improve future efforts3 – which shows that work is still needed.

Multimodal hand hygiene strategies – one aim

For hand hygiene measures to be effective, high levels of compliance are needed. Even if healthcare workers are aware of the importance of hand hygiene, it often takes long and sustained efforts to change their behaviour. Because people cannot see the bacteria on their hands, they often neglect to disinfect them. Multiple studies show that adherence to the WHO guidelines on hand hygiene is usually around 50 to 60 per cent4. One effective tool for improving compliance is to adopt multimodal strategies5, which integrate several interventions to achieve a positive behavioural change and make hand hygiene as natural as putting on a seatbelt in the car. When ten years ago, the WHO first published its guidelines on hand hygiene in health care1, they defined the five key moments for such multimodal approaches. “My 5 Moments for Hand Hygiene” represent a highly effective way to synchronise and standardise complex working processes to support healthcare workers in performing hand hygiene. One key factor is changing the system to ensure that healthcare facilities have the infrastructure, for example, enough visually attracting disinfectant dispensers needed in key locations to perform hand hygiene. Easy access to disinfectants* promotes an efficient multi-barrier system in a hospital. In fact, the availability of hand hygiene dispensers at the point of care ensures access, and makes hand hygiene easier, resulting in increasing compliance6. Yet to change behaviour and create new habits, training and education are also mandatory.

How do you know that measures to increase hand hygiene compliance really work? To identify the effects of new practices, monitoring and regular evaluations should be part of the strategy. Reminders in the workplace, such as posters and pocket leaflets, are effective tools for improving compliance. Additionally, the institutional climate is crucial for maintaining motivation and upholding high standards. Senior staff members act as role models for younger healthcare workers and should demonstrate the five moments for hand hygiene. In this context, national policies are required for supporting improvements in healthcare facilities.

Motivation is important…

Several studies have tested the effectiveness of standardised processes in preventing HAI. In 2008, a new approach to hand hygiene was introduced at the Memorial Sloan-Kettering Cancer Centre in New York. Small interdisciplinary teams were created with the aim of designing and implementing new workflows for the everyday practice of hand hygiene based on the WHO’s “5 Moments” guidelines. The project started with the teams beginning to discuss the current barriers to hand hygiene success. In the next step, it was up to them to set their own goals for hand hygiene compliance. Using the WHO guidelines, these interdisciplinary teams diagrammed detailed workflows for several of their most common patient care tasks. This way, the general guidelines were “translated” into their individual working environment. Wherever hand hygiene was indicated, the workflow was marked with a number corresponding to one or more of the WHO’s five moments (before touching a patient, before aseptic procedures, after body fluid exposure, after touching a patient, and after touching patient surroundings). Compliance that had been 60 to 70 per cent increased to 97 per cent by the end of the study period – and was then maintained (Son C et al, 20117). According to several worldwide reports, a key step in maintaining such high levels of compliance is keeping healthcare workers motivated. The combination of education, goal setting and feedback has proven to be successful in encouraging healthcare workers to follow the guidelines (Chatfield SL et al, 20178). Positive incentives can help to change the culture and make life-saving hand hygiene the standard.

But the combination is key!

However, sometimes structural changes, education and awareness are not sufficient for getting healthcare workers to adhere to hand hygiene procedures. Monitoring and evaluation practices are therefore needed to increase compliance9. Direct observation and direct on-site coaching by trained auditors are the gold standard here. Electronic systems can also be combined with observation to collect valuable data and to provide additional information. Patients can be integrated in the feedback loop and made active participants in hand hygiene procedures, too. For example, a new campaign in the US encourages patients and their visitors to ask doctors and nurses whether they have cleaned their hands.

Along with changing processes, improving hygiene product formulations can also represent an additional compliance trigger. One way to accomplish this is to minimise residual antiseptic active ingredients10 that pose risks for human health and environment. For hygienic hand disinfection, residual substances in alcoholic hand disinfectants are no longer recommended. Study findings now also show no benefits of residual active ingredients for surgical hand disinfection. Hand hygiene agents should be well accepted, well tolerated, and should not have negative influences on skin health11. The proper selection of ingredients is the key to providing products that encourage hand hygiene compliance.12

A lot of factors influence hand hygiene compliance. As a result, there cannot be just one solution to the problem. This is why multimodal strategies and various approaches, such as the WHO First Global Patient Safety Challenge “Clean Care is Safer Care” are effective measures for promoting and improving hand hygiene standards and practices. Each measure helps to make the simple act of reaching for the dispenser a natural instinctive action – like putting on a seatbelt.

Further Information

  1. WHO Guidelines on Hand Hygiene in Health Care, WHO
  2. Evidence of hand hygiene as the building block for infection prevention and control, WHO Global Infection Prevention and Control Unit
  3. WHO Global Survey on Infection Prevention and Control (IPC) and Hand Hygiene 2019, WHO
  4. Link noch nicht final, Thomas van Lengerke et al., Deutsches Ärtzeblatt International
  5. Guidelines on Core Components of Infection Prevention and Control Programmes, WHO
  6. Provision and consumption of alcohol-based hand rubs in European hospitals, Hansen S. et al, Clinical microbiology and infection
  7. Practically speaking: Rethinking hand hygiene improvement programs in health care settings, Son C et al., American Journal of Infection Control
  8. Hand hygiene among healthcare workers: A qualitative meta summary using the GRADE-CERQual process, Chatfield SL et al., Journal of Infection Prevention
  9. Electronic monitoring in combination with direct observation as a means to significantly improve hand hygiene compliance, John M Boyce, American Journal of Infection Control
  10. Händehygiene in Einrichtungen des Gesundheitswesens, Empfehlung der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO) beim Robert Koch-Institut (RKI)
  11. Lack of antimicrobial efficacy of mecetronium etilsulfate in propanol-based hand rubs for surgical hand disinfection, G Kampf, Journal of hospital infection
  12. Guide to Local Production: WHO-recommended Handrub Formulations, WHO



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