A Question of Compliance for Hand Hygiene

Selected Acute Illnesses

A Question of Compliance for Hand Hygiene

March 14, 2005

A Question of Compliance for Hand Hygiene

Is there a problem with compliance related to hand hygiene in acute care clinical settings? The importance of cleanliness related to good health dates back to Nightingale (Nightingale, 1969). Proper hand hygiene is the most important factor to prevent cross contamination of microorganisms and thus communicable diseases (college of Nurses of Ontario, 2004). Yet hand washing is done less than fifty percent of the time between patients as found in most studies from the past twenty years (McGuckin, 2003). Health care workers willingly admit to neglecting hand hygiene.

Nurses often neglect to use appropriate hand hygiene between patients and prior to drawing up medications as observed in various clinical settings. With the implementation of alcohol based cleansers there has been an small increase in compliance however there is a reluctance to accept alcohol based cleansers as a substitute for hand washing (Girou, 2002). There are many factors that contribute to this non-compliance. There are also many interventions appropriate to promoting compliance. With an increase in hand hygiene compliance cross transmission of microorganisms will be prevented, consequently the number of communicable diseases will be decreased.

The accepted way to effectively wash hands includes the use of warm water and soap. Start by wetting both hands then with one to three millilitres of soap and start scrubbing. Scrub both hands, wrists and under finger nails for a minimum of ten seconds preferably longer. The soap dissolves oil and breaks the germs’ connection to the skin so they can be rinsed off with the soapsuds. Rinse off the suds one hand at a time and dry with disposable towels or a hand dryer. Use a paper towel to turn off the taps as to not contaminate your clean hands. A more detailed procedure is found on the Canadian Centre for Occupational Health and Safety (CCOHS) website. With hand washing the nurse must go to a sink and stay there to complete hand hygiene. This fact proves to be the main problem with compliance as nurses have hectic work schedules that do not always have the time and readily available washing area.

Hand hygiene using alcohol based cleansers is much less time consuming. With the alcohol based cleanser there is only one step. Rub the cleanser between both hands covering all surfaces until the alcohol evaporates completely. Alcohol based cleansers are fast acting and significantly reduce the number of micro organisms (Centres for Disease Control Prevention, 2004). There is no need to remain stationary while cleansing with the alcohol-based solution therefore nurses can perform hand hygiene while on their way to their next patient. The only indication against using alcohol-based cleansers is when hands are visibly soiled. Washing with soap and water is the only way to properly clean when hands are visibly soiled.

To wash hands effectively time, knowledge, supplies and care is needed. Nurses do not always have the time and therefore alcohol-based cleansers have been made available. As a new knowledge and practise there is a reluctance to accept the alcohol-based cleansers as a substitute for hand washing. “There is a reluctance to accept handrubbing as a substitute for hand washing, even among some infection control practitioners” (Girou, 2002). A survey indicated that the lack of confidence in the alcohol based cleansers efficacy was the main concern among health care professionals. The results of a randomized clinical trial by Girou discovered that hand rubbing with an alcohol based cleanser was more effective in reducing bacterial contamination of health care workers’ hands than hand washing. This knowledge is important to convey to nurses to help increase the confidence in alcohol based cleansers.

Using either method of hand hygiene repeatedly, as nurses do, tends to irritate and cause skin dryness. With the use of alcohol-based cleansers, use of hand lotions is recommended to minimize skin irritation and dryness (Ontario Ministry of Health and Long-term care, 2004). Since hand washing tends to dry skin more than alcohol cleansers the importance of skin integrity is clear for both methods. When selecting hand lotions it is important to consider one that will not compromise glove efficacy (Wilson, 2004). With skin irritation the use of gloves will help to avoid getting bacteria into damaged areas of skin. However the use of gloves is not a substitute for hand hygiene nor is hand hygiene a substitute for the use of gloves (CCOHS, 2004). The knowledge of the importance of hand hygiene is fundamental as is healthy skin. A combination of hand washing, the use of alcohol based cleansers, the use of gloves and moisturizing lotions must be used to maintain hand hygiene in the clinical setting.

In summary hand hygiene compliance is decreased for the following contributing factors. Hand washing is time consuming, requiring the nurse to stand stationary at a sink. Hand washing also requires warm running water, soap and paper towels which are not always readily available. The knowledge deficit related to alcohol based cleanser efficacy. Skin irritation and dryness due to repeated washing and or hand rubbing with alcohol based cleansers. All of these issues have various solutions for increasing compliance of hand hygiene in the clinical setting.

The following outlines five main interventions beneficial to promoting hand hygiene compliance in the clinical setting. Address restricted time issues with emphasis on using alcohol-based products. Convenient placement of alcohol based cleanser dispensers. Include educational interventions such as newsletters, videos, and classes. Frequent reminders including but not limited to posters, signs, and patients reminding staff. Personal, peer, and non-personalized performance feedback regarding hand hygiene practice given frequently. Finally, providing suitable hand lotions within the work environment. All of these interventions have been supported with studies performed in various different clinical settings all with positive results.

Studies have shown an increase in hand hygiene compliance with the use of alcohol-based cleansers. Most importantly further research has also proven this increased compliance to be maintained with the use of alcohol-based cleansers (Beyea, 2003). The introduction of alcohol-based cleansers addressed the ‘not enough time’ issue regarding hand hygiene. Alcohol based cleansers are convenient, rapid acting and less contact time is required. Nurses do not need to stand at a sink; they can sanitize their hands and walk at the same time. In addition there is a greater reduction in bacterial contamination of hands than conventional hand washing (Girou et al, 2002). Implementation of alcohol based cleansers within the acute care clinical setting is an overall effective approach to increasing hand hygiene compliance.

Knowledge is power. By increasing and reinforcing the knowledge base an increased compliance may be obtained. A hand hygiene intervention done by the University of Geneva using “emorational” education resulted in a twenty percent increase in compliance over a period of four years (Pittet, et al, 2000). This intervention consisted of many components such as the use of a multidisciplinary team to promote hand hygiene within the facility. Providing short on-going educational sessions for staff regarding various aspects of hand hygiene such as the efficacy of alcohol-based cleansers, acceptable hand hygiene techniques, the safe removal of gloves avoiding contamination, the risks of transmission, and the costs of health care associated infections. Making the information sessions fun and interactive by involving the staff in poster development. All of these educational elements support and reinforce hand hygiene on an on going basis. With the inclusion of frequent reminders and feedback both verbal and written the compliance is reinforced further. With positive reminders nurses are encouraged by peers and patients to properly sanitize their hands. Feedback regarding noscomial infection and rates of transmission are also encouraging. Decreasing numbers of Methicillin-resistant Staphylococcus Aureus (MRSA) were reported with the intervention implemented by the University of Geneva (Pittet, et al, 2000). This positive result reinforces the importance of increased compliance.

Have hand lotions available for nurses within the clinical setting. More importantly choose an alcohol-based product that has moisturizers and emollients already. Studies have shown that skin integrity has in fact improved with the use of such alcohol-based products (Wilson, 2004). Skin irritation and dryness is counteracted with the addition of moisturizers and emollients in the alcohol based cleansers. Traditional hand washing dissolves the oils in your hands to separate the bacteria and wash them down the drain apposed to alcohol based cleansers that kill the bacteria. With the loss of the natural oils, hands tend to become irritated and the use of lotions is beneficial to maintain skin health.

Using all of the above interventions simultaneously addressing the issues of compliance is most effective. “Performance is mainly influenced by external stimuli, and can be changed by feedback, incentives, modelling, and external reinforcement” (Grol, and Grimshaw, 2003). The most effective strategy was found to be multifaceted interventions, the combination of various teaching and reinforcing techniques (Girou, et al, 2002). Implementing programs within facilities to enhance the knowledge base and stimulate nurses to sanitize their hands regularly is within reach. With implementation evaluation must follow to complete the intervention (Pittet, et al, 2000). Evaluating an intervention that is implemented helps to reaffirm and maintain sustainable outcomes.

In acute care clinical settings nurses are strained with heavy workloads. This fact complicates certain interventions such as teaching sessions that would require time. Starting a program is the biggest step, getting a multidisciplinary team motivated. From a nurses perspective most interventions would be realistic to achieve. With a focus on increased use of alcohol-based cleansers nurses can optimize their time and ensure to perform hand hygiene appropriately. Most importantly the placement of alcohol based cleansers throughout the facility. Convenient location of hand sanitizers including every bedside and at every door is crucial to increasing compliance. Posting information sheets or posters in nursing stations and other convenient locations on the floor would increase knowledge base and encourage hand hygiene. Positive feedback and reinforcement on an ongoing basis is also important.

Increased compliance of hand hygiene in acute care clinical settings is the overall preferred outcome. Thus resulting in the prevention of cross transmission of micro organisms and communicable diseases. This is theoretically and realistically possible with the use of multifaceted interventions, continuous monitoring and re-evaluations. Positive results have been achieved with the use of multifaceted on-going interventions.



References

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College of Nurses of Ontario. (2004, June). Practice Standard: Infection Prevention and Control. Retrieved November 7, 2004, from http://www.cno.org/docs/prac/41002_infection.pdf

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