Dangel, Marc

Schuhmacher, Heinz

Sepulcri, Daniel

Tschudin-Sutter, Sarah

Widmer, Andreas F.

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r e s e a r ch b r i e f sCompliance with the World HealthOrganization Hand Hygiene Technique:A Prospective Observational StudyStudies on compliance with hand hygiene technique commonlyfocus on observations regarding adherence of healthcare workersto the 5 moments outlined by the World Health Organization(WHO) guidelines.1 These guidelines also provide guidance onthe proper technique for the use of hand rub, consisting of6 steps to ensure the complete coverage of the hands. Severalstudies have provided strong evidence for increased bacterialkilling using this technique,2–5 but compliance with all 6 stepshas not been evaluated. Therefore, we aimed to assesscompliance of healthcare workers with the recommended handhygiene technique.This prospective observational study was performed at theUniversity Hospital Basel, a tertiary academic medical care centerin Switzerland that admits >32,000 patients annually. Duringdefined study periods from 2010 to 2013, hand hygiene observa-tions were conducted on 15 different wards: 5 medical and 5surgical wards, as well as 2 wards belonging to the emergencydepartment, 2 wards belonging to the intensive care units, and thebone marrow transplant unit. The study was approved by theinstitutional review board as part of the quality assurance program.All hand hygiene observations were performed by 3 trainedresearchers over 520 hours of direct observation of perfor-mance of hand hygiene techniques at the 5 moments of handhygiene. The 5 moments of hand hygiene as outlined by theWHO1 are (1) before touching a patient, (2) after touching apatient, (3) after touching patient surroundings, (4) after bodyfluid exposure risk, and (5) before clean/aseptic procedure”).The individual steps of the hand hygiene technique as outlinedby the WHO are (1) rubbing hands palm to palm, (2) palm topalm with fingers interlaced, (3) right palm over left dorsumwith interlaced fingers and vice versa, (4) back of fingers toopposing palms with fingers interlocked, (5) rotational rub-bing of left thumb clasped in right palm and vice versa, and(6) rotational rubbing backwards and forwards with claspedfingers of right hand in left palm and vice versa).1,6Furthermore, information regarding age, profession, andduration of employment at our institution was recorded. Agewas categorized as <26 years, 26–35 years, 36–45 years, 46–55years, and>55 years. Duration of employment was categorizedas 0–5 years, 6–10 years, 11–20 years, and >20 years.The primary outcome was compliance with all 6 steps of thehand hygiene technique. The χ2 test was used for comparisonsof proportions, and odds ratios (ORs) were calculated usingunivariable logistic regression models and Stata statisticalsoftware, version 12.0 (Stata Corp, College Station, Texas).Two-sided P values < .05 were considered significant.Overall, 2,662 hand hygiene opportunities were observed,mostly among nurses (65.3%, 1,737 of 2,662), followed bydoctors (21.7%, 579 of 2,662) and other healthcare workers(13.0%, 346 of 2,662). The most common indication was“after touching a patient” (41.9%, 1,114 of 2,662), followed by“before touching a patient” (31.9%, 848 of 2,662), “aftertouching patient surroundings” (11.0%, 292 of 2,662), “afterbody fluid exposure risk” (9.0%, 240 of 2,662), and “ beforeclean of aseptic procedure” (6.3%, 168 of 2,662).compliance with hand hygieneindicationsHand hygiene was performed in 93.2% of all opportunities(2,480 of 2,662). Compliance rates were highest in the inten-sive care units (100%, 193 of 193), followed by the emergencydepartment (94.8%, 255 of 269), the medical wards (94.0%,1,225 of 1,303), and the surgical wards (90.0%, 807 of 897)(P< .001). No differences regarding compliance in respect toprofession were identified (nurses 93.6%, 1,626 of 1,737,doctors 91.5%, 530 of 579, others 93.6%, 324 of 346).compliance with hand hygiene techniqueCompliance with all 6 steps of hand hygiene technique was8.5%, the majority of healthcare workers adhered to steps2 and 3 (Table). Profession was not associated with compliancewith hand hygiene technique (nurses 9.0%, 156 of 1,737,doctors 6.9%, 40 of 579, others 9.0%, 31 of 346, P= .288).Healthcare workers ≤ 25 years of age showed higher com-pliance with the correct technique than older age groups (OR,0.84; 95% CI, 0.74–0.97; P= .016), and compliance with all6 steps decreased with increasing duration of employment atour institution (OR, 0.68; 95% CI, 0.54–0.87; P= .002).No differences in compliance with hand hygiene indicationsor technique were detected over the study period (data notshown).While compliance with hand hygiene indications was highat our institution, proper technique for use of alcohol-basedhand rub was performed in <10% of all hand hygieneopportunities. Younger healthcare workers and thoseemployed at our institution for shorter time periods weremore likely to adhere to all 6 hand hygiene steps. This obser-vation is concerning, as noncompliance with the propertechnique for using hand rub may result in failure to cover allskin surfaces and, hence, insufficient bacterial killing.3,7These results mirror findings from a previous study revealingthat repeated training programs on the proper hand hygienetechnique should be offered throughout professional life toensure greater degrees of reduction of bacterial densities.8infection control & hospital epidemiology april 2015, vol. 36, no. 4https:/www.cambridge.org/core/terms. https://doi.org/10.1017/ice.2014.82Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 13:52:16, subject to the Cambridge Core terms of use, available atImportant limitations of our study include lack of standar-dization of types of care before performance of direct obser-vation as well as an absence of measures to avert a Hawthorneobservation effect.9 The latter limitation possibly explains thehigh compliance rate with hand hygiene indications observedat our institution while underscoring the low compliance ratewith the hand hygiene technique.In conclusion, compliance with hand hygiene does notnecessarily correlate with proper WHO-recommended techni-que. The decline of compliance with increasing age of healthcareworkers and duration of employment point to the high level oftraining needed to ensure performance of all 6 steps of the handhygiene technique. Surveillance programs focusing on adherenceof healthcare workers to hand hygiene indications may over-estimate the efficacy of such interventions.acknowledgmentsFinancial support: No commercial funding was received for the study.Potential conflicts of interest:No author has any conflict of interest relevant tothis article and no financial interest in this manuscript.Sarah Tschudin-Sutter, MD, MSc;1Daniel Sepulcri;1Marc Dangel, MPH;1Heinz Schuhmacher, RN;1Andreas F. Widmer, MD, MSc1Affiliation: Division of Infectious Diseases and Hospital Epidemiology,University Hospital Basel, Basel, Switzerland.Address correspondence to Dr. Andreas F. Widmer, Division of InfectiousDiseases and Hospital Epidemiology, University Hospital Basel, Petersgraben 4,CH-4031 Basel, Switzerland (Andreas.Widmer@uhbs.ch).Previous presentation of the data: The abstract was presented at the 24thEuropean Congress of Clinical Microbiology and Infectious Diseases, Barcelona,Spain 2014 and at the Meeting of the Swiss Society for Infectious Diseases, Aarau,Switzerland 2014.Received: September 28, 2014; Accepted: December 2, 2014; electronicallypublished January 20, 2015Infect Control Hosp Epidemiol 2015;36(4):482–483© 2015 by The Society for Healthcare Epidemiology of America. All rightsreserved. 0899-823X/2015/3604-0019. DOI: 10.1017/ice.2014.82references1. World Health Organization. WHO guidelines on hand hygiene inhealth care, first global patient safety challenge: clean care is safercare. Geneva, Switzerland: World Health Organization, 2009.2. Carabin H, Gyorkos TW, Soto JC, Joseph L, Payment P, Collet JP.Effectiveness of a training program in reducing infections in tod-dlers attending day care centers. Epidemiology 1999;10:219–227.3. Widmer AE, Dangel M. Alcohol-based handrub: evaluation of tech-nique and microbiological efficacy with international infection con-trol professionals. Infect Control Hosp Epidemiol 2004;25:207–209.4. Kramer A, Rudolph P, Kampf G, Pittet D. Limited efficacy ofalcohol-based hand gels. Lancet 2002;359:1489–1490.5. Ayliffe GA, Babb JR, Quoraishi AH. A test for ‘hygienic’ handdisinfection. J Clin Pathol 1978;31:923–928.6. European standard EN 1500. Chemical disinfectants and anti-septics. Hygienic handrub. Test method and requirements.Brussels: European Committee for Standardization, 1997.7. Widmer AF, Conzelmann M, Tomic M, Frei R, Stranden AM.Introducing alcohol-based hand rub for hand hygiene: the criticalneed for training. Infect Control Hosp Epidemiol 2007;28:50–54.8. Tschudin Sutter S, Frei R, Dangel M, Widmer AF. Effect ofteaching recommended World Health Organization techniqueon the use of alcohol-based hand rub by medical students. InfectControl Hosp Epidemiol 2010;31:1194–1195.9. Eckmanns T, Bessert J, Behnke M, Gastmeier P, Ruden H. Com-pliance with antiseptic hand rub use in intensive care units: theHawthorne effect. Infect Control Hosp Epidemiol 2006;27:931–934.table 1. Compliance with the World Health Organization HandHygiene TechniqueHand HygieneOpportunities (N= 2,662)n %Cumulative compliance withnumber of stepsCompliance with 6 of 6 steps 227 8.5Compliance with 5 of 6 steps 263 9.9Compliance with 4 of 6 steps 477 17.9Compliance with 3 of 6 steps 765 28.7Compliance with 2 of 6 steps 573 21.5Compliance with 1 of 6 steps 175 6.6Compliance with 0 of 6 steps 182 6.8Compliance with specific steps2,450 92.02,226 83.61,301 48.9572 21.51,132 42.5520 19.5research briefs 483https:/www.cambridge.org/core/terms. https://doi.org/10.1017/ice.2014.82Downloaded from https:/www.cambridge.org/core. University of Basel Library, on 30 May 2017 at 13:52:16, subject to the Cambridge Core terms of use, available at

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