M

]oumol of Hospital infection (200 I) 48 (Supplement A): S40-S46

doi: IO. I053/jhin.200 I .0977, available online at http://wwwidealibrary.com on ImE bl”

Compliance with hand disinfection and its

impact on hospital-acquired infections
D. Pittet
Infection Control Programme, University of Geneva Hospitals, I2 I I Geneva 14, Switzerland

Summary: Hand hygiene prevents cross-infection in hospitals, but adherence to guidelines is poor among
healthcare workers. Although some interventions to improve compliance have been successful, none had
achieved lasting improvement until very recently. Reasons for non-compliance with recommendations occur
at individual, group and institutional levels. The complexity of the process of behavioural change would
suggest that the application of multimodal, multidisciplinary strategies are necessary. Both easy access to
hand hygiene in a timely fashion and skin protection appear necessary prerequisites for satisfactory hand
hygiene behaviour. Alcohol-based hand-rub may be superior to traditional handwashing as it requires less
time, acts faster, irritates hands less often, and recently proved significantly to contribute to sustained
improvement in compliance associated with decreased infection rates. This paper reviews barriers to appro-
priate hand hygiene and describes the results of the first successful experience of sustained hand hygiene
promotion and its effectiveness on hospital-acquired infection.
0 200 I The Hospital Infection Society

Keywords: Hand hygiene; handwashing; hand-rub; alcohol-based hand disinfection; epidemiology; hospital-acquired
infections; MRSA; healthcare workers.

Introduction leaflets, workshops and lectures, and performance

feedback on hand hygiene compliance rates, have
Hand hygiene is the simplest and most effective mea-
been associated with, at best, transient improve-
sure for preventing hospital-acquired infections.‘,*
ment.3,6,14-16 No single intervention has consis-
Studies have repeatedly documented that the impor-
tently sustained improved compliance with hand
tance of hand hygiene is not sufficiently recognised
hygiene in HCWs’ infection control practices.”
by health care workers (HCWS)~ and adherence
This paper reviews factors that may explain the
with recommended practices is unacceptably 10w.~-‘~
lack of adherence by healthcare personnel to hand
Average compliance with hand hygiene recommen-
hygiene procedures, suggests strategies for success-
dations is usually estimated as below 50%; it varies
ful promotion, and reports the first example of sus-
between different hospital wards, among professional
tained improvement in hospitals and its impact on
categories of HCWs and according to working
infection rates.
conditions.
Promotion of hand hygiene is considered a
major challenge by infection control experts.3v”-‘3 Barriers to appropriate hand hygiene practice
In-service education, distribution of information
A large number of barriers to appropriate hand
hygiene have been reported in the literature.9,‘7-22
The main reasons reported by HCWs for the lack
Author for correspondence: Didier Pittet, Professor of
of adherence with hand hygiene recommendations
Medicine, Director, Infection Control Programme, 24, rue
Micheli-du-Crest, University of Geneva Hospitals (HUG),
include: skin irritation by hand hygiene agents,
1211 Geneva 14, Switzerland. inaccessibility of hand hygiene supplies, interfer-
Fax: +41-22-372-3987; E-mail: didier.pittet@hcuge.ch ence with HCW-patient relationship, patient needs

0 195-670 l/O I IOAOS40 + 07 $35.00/O 0 200 I The Hospital Infection Society

Impact ofhandrub on hospital-acquired infections s41

perceived as a priority, wearing of gloves, forgetful- exclude the possible negative effect of newly intro-
ness, the lack of knowledge of guidelines, insuffi- duced devices.24
cient time for hand hygiene, high workload and In a large epidemiological survey of hand
understaffing, and the lack of scientific information hygiene practices,’ we identified predictors of non-
showing a definitive impact of improved hand compliance during routine patient care hospital-
hygiene on hospital-acquired infection rates. wide. Predictor variables included professional
Some of the perceived barriers for the lack of category, hospital ward, time of day/week, and type
adherence with hand hygiene guidelines have been and intensity of patient care, defined as the number
assessed, or even quantified, in observational- of opportunities for hand hygiene per hour of
studies.3F9,‘2,‘7-23 Table I lists the mast frequently patient care. In 2834 observed opportunities for
reported reasons which are possibly, or demonstrably, hand hygiene, average compliance was 48%. In
associated with poor compliance. Some are discussed multivariate analysis, non-compliance was lowest
below. among nurses compared with other HCWs, and
Access to hand hygiene supplies, whether sink, during weekends (OR 0.6, CI,, 0.4-0.8). It was
soap, medicated detergent, or non-aqueous alcohol- higher in critical care units (compared with internal
based hand-rub solution, is self-explanatory. Asking medicine, OR 2.0, CI,, 1.3-3.1) during procedures
busy HCWs to leave the patient bed in order to which carry a high risk of bacterial contamination
reach a wash-basin or a hand antisepsis solution (OR 1.8, CIs5 1.4-2.4), and when the intensity of
opens the door for non-compliance with hand patient care was high (compared with O-20 oppor-
hygiene recommendations.9,23 Engineering controls tunities: 21-40 opportunities, OR 1.3, CI,, 1.0-17;
could facilitate compliance, but careful monitoring 41-60 opportunities, or 2.1, CIss 1.5-2.9; >60
of hand hygiene behaviour should be conducted to opportunities, or 2.1, C195 1.3-3.5). In other words,
compliance with handwashing worsened when the
Table I Barriers end risk factors fir the lock of adherence with hand demand for hand cleansing was high; on average,
hygiene compliance decreased by 5% ( f 2%) per 10 oppor-
tunities per hour when the intensity of patient care
Barriers
exceeded 10 opportunities per hour. Similarly, the
Hand hygiene agents cause irritation and dryness lowest compliance rate (36%) was found in intensive
Sinks are inconveniently located; shortage of sinks
care units where indications for hand hygiene were
Lack of soap, paper, towels
Often too busy/insufficient time
typically more frequent (on average, 20 opportuni-
Understaffing/overcrowding ties per patient-hour). The highest compliance rate
Patient needs take priority (59%) was observed in paediatrics where the aver-
Hand hygiene interferes with healthcare age activity index was lower than elsewhere (on
worker-patient relationship
Low risk of acquiring infection from patients
Wearing of gloves/beliefs that glove use substitutes for
hand hygiene
Lack of knowledge of guidelines/protocols
Not thinking about it/forgetfulness Paediatrics
l
No role model from colleagues or superior(s) --.. Internal
-... . medicine
Scepticism about the effectiveness of hand hygiene
--..--._
Disagreement with the recommendations
Lack of awareness of definitive impact of improved hand hygiene l
-..T Surgery
Gynaecology ---.+
on hospital-acquired infection rates
obstetrics --._ . Critical
Observed risk factors i --._ .-care I
Physician status (rather than a nurse) -0
Nursing assistant status (rather than a nurse)
Male gender 8 12 16 20
Working in critical care Opportunities for hand hygiene per patient-hour of cart
Working during the week (rather than during the week-end)
Wearing gowns I gloves
Figure I Relationship between opportunities for hand hygiene and
Automated sink
compliance across hospital wards, University of Geneva Hospitals,
Activities with high risk of cross-transmission
1994. Average compliance is indicated for handwashing and hand dis-
High number of opportunities for hand hygiene per hour of
infection. The size of the symbol is proportional to the number of
patient care
opportunities observed in the different wards. (From Reference 9.)
S42 D. Pittet

average, eight opportunities per patient-hour). As Table II Hand hygiene compliance and type ofnursing care

shown in Figure 1, the higher the average number Number Compliance

Patient care activity
of opportunities for hand hygiene per hour of of opportunities (%I
patient care, the lower the compliance. This study for hand hygiene
confirmed modest levels of compliance with hand
After patient contact 1049 (37%) 48
hygiene in a teaching insitution and showed that
Between dirty/clean site 98 (3.4%) II
compliance varied by hospital ward and by type of After contact with IO9 (3.8%) 63
HCW, thus suggesting that targetted educational body fluid
programmes may be useful. The results of this study Before iv care* 202 (7. I %) 39
also suggested that full compliance with current After iv care* 206 (7.3%) 49

guidelines may be unrealistic9,‘2,23 and that faci- Before wound care 59 (2. I %) 52
After wound care 67* (2.3%) 58
litated access to hand hygiene could help improve
compliance. Before respiratory care 37 (I .3%) 18
After respiratory care 39* (I .4%) 46
Wearing of gloves may represent a barrier for
Before urinary care IO (0.4%) 33
compliance with hand hygiene. Non-compliance has
After urinary care I4* (0.8%) 43
been identified among glove users in at least two
Drug preparation 726 (26%) 51
studies.8a25 It is important to recognise that hand
Housekeeping activities 2 I8 (7.7%) 52
hygiene is required regardless of whether gloves are Total 2834 ( 100%) 48
used or changed. Failure to remove gloves after
patient contact or between dirty and clean body site *iv care indicates injection through or dressing of intravenous/
arterial catheter.
care on the same patient must be regarded as non-
#Since we could not always determine whether hands were
compliance with hand hygiene recommendations.’
washed just before the observation began, only those opportuni-
Furthermore, Doebbeling and colleagues26 concluded ties for which hand hygiene could be determined were reported,
from experimental conditions that closely mim- and thus a different number of observations are presented for
micked clinical practice that it may not be prudent to opportunities before and after a staff-patient interaction.
(Adapted with permission.9)
wash and reuse gloves between patient contact and
handwashing or disinfection should be strongly
encouraged after glove removal. The authors cul- institutional priority accorded to hand hygiene,
tured the organisms used for artificial contamina- administrative sanctions for non-complier(s) or
tion from 4% to 100% of the gloves and observed rewarding of compliers, and even the lack of an insti-
counts between 0 and 104.7 on the hands after glove tutional safety climate. 29 These parameters are linked
removal. not only to the institution but also to the HCW’s
Lack of knowledge of guidelines for hand own particular group. In this case, it would be neces-
hygiene, recognition of hand hygiene opportunities sary to implement a systems change to secure an
during patient care, and awareness of the risk of improvement in HCW hand hygiene practice.29
microbial pathogens cross-transmission constitute
barriers to hand hygiene compliance. Table II shows
The choice of hand hygiene agent
the relationship between hand hygiene opportuni-
ties during patient care activities and average com- In 1847, Ignaz Semmelweis observed that normal
pliance;’ as shown, compliance averaged only 11% handwashing did not always prevent the spread of
between dirty and clean site care in the same fatal infection’ and recommended hand disinfection
patient. Furthermore, and as recognised by others,’ in a solution of chlorinated water before each vagi-
HCWs tend to be more often compliant with hand nal examination. It is important to recall that hand
hygiene after than before patient care. In addition, disinfection is significantly more efficient than
some HCWs believed that they washed their hands standard handwashing with soap and water or water
when necessary even when observations indicated alone,2a30 particularly when contamination is
they did not. 15,21,27*28All the above- described para- heavy. 30-33 Importantly, frequent standard hand-
meters need to be addressed in HCWs’ education. washing may result in minimal reduction or even an
Additional reasons perceived as possible barriers increase in bacterial yield over baseline counts of
to hand hygiene behaviour include the lack of active clean hands.’ 3,34
participation in hand hygiene promotion at individual Because alcohols have excellent activity and the
or institutional levels, a role model for hand hygiene, most rapid bactericidal action of all antiseptics,
Impact of hondrob on hospital-acquired infections s43

they are the preferred agents for hygienic hand-rub, limitations of these studies, most reports showed a
so-called ‘non-aqueous’ hand disinfection. In addi- temporal relationship between improved hand
tion, there is no doubt that alcohols are much more hygiene practices and reduced infection rates.
convenient for hygienic hand-rub than aqueous Similarly, the beneficial effects of hand hygiene pro-
solutions, given their excellent spreading quality motion on the risk of cross-transmission have been
and rapid evaporation. At equal concentrations, reported in surveys conducted in schools or day care
n-propanol is the most effective alcohol of those centres,42d5 as well as in a community setting.46d8
commonly used, and ethanol the least.30 Alcohol- We recently reported the results of a successful
based hand-rubs are well suited for hygienic hand hospital-wide hand hygiene promotion campaign,
disinfection for the following reasons: (1) optimal with a special emphasis on hand disinfection, that
anti-microbial spectrum (active against all bacteria, resulted in sustained improvement in compliance
most clinically important viruses, yeast and fungi); associated with a significant reduction in hospital-
(2) no wash basin is necessary for their use and acquired infections and methicillin-resistant Stuphy-
they can be made easily available at the bedside; lococcus aureus (MRSA) cross-transmission rates
(3) application does not cause microbial contamina- over a four-year period. ‘9 The overall compliance
tion of HCW’s uniform; (4) fast-acting. After with hand hygiene during routine patient care was
extensive reduction following hand disinfection monitored before and during implementation of the
with an alcohol preparation, it takes the resident hand hygiene campaign. Seven hospital-wide obser-
skin flora several hours to become completely vational surveys were conducted biannually from
restored.30 Since alcohol alone does not have any December 1994 to December 1997. Hand hygiene
lasting effect, another compound with antiseptic promotion strategy involved the use of colour
activity is sometimes added to the hand disinfection posters which emphasised the importance of hand-
solution to obtain a prolonged effect. The main cleansing, particularly hand disinfection, and hand
antiseptics have been recently extensively reviewed hygiene performance feedback. The posters were
by Rotter. 3o It is important to note that antiseptic displayed in strategic areas within the institution
hand-rub has no effect on soil. called ‘Talking Walls’. Compliance improved pro-
Soaps and detergents are damaging when gressively from 48% in 1994 to 66% in 1997
applied to skin on a regular basis.13 It is important, (P<O.OOl, Figure 2). Although recourse to hand-
however, that HCWs are better informed about the washing with soap and water remained constant,
possible effects of hand hygiene agents. Lack of frequency of non-aequeous hand disinfection sub-
knowledge and education on this topic is a key bar- stantially increased over the study period
rier to motivation. In particular, it is extremely (P<O.OOl). During the same period, overall hospi-
important to recall that: (1) alcohol-based formula- tal-acquired infection decreased (prevalence of 16.9%
tions for hand disinfection (whether isopropyl, in 1994 to 9.9% in 1998; P=O.O4) as well as MRSA
ethyl, or n-propanol, at 60-90X v/v) are less irritant transmission rates (from 2.16 to 0.93 episodes per
on skin than any antiseptic or non-antiseptic deter- 10000 patient-days; P<O.OOl; Figure 3). Individual
gents; (2) alcohols with the addition of appropriate bottles of hand-rub solution were distributed in
emollients are at least as well tolerated and effica- large numbers to all wards, and custom-made hold-
cious as detergents; (3) emollients of HCWs’ hand ers were mounted on all beds to facilitate access to
skin are recommended and may even be protective hand disinfection. HCWs were also encouraged to
against cross-infection by keeping the resident skin carry a bottle in their pocket and, in 1996, a newly-
flora intact; and (4) hand lotions help to protect designed flat (instead of round) bottle was made
skin and may reduce microbial shedding. A more available to further facilitate pocket carriage. The
detailed description of the topic was recently pro- consumption of alcohol-based hand-rub solution
posed by LarsonI and discussed by Boyce.35,38 increased from 3.5 to 15.4 litres per 1000 patient-
days between 1993 and 1998 (P<O.OOl, Figure 4).
The hand hygiene promotion campaign at the
Impact of improved hand hygiene University of Geneva Hospitals produced a sus-
The results of several quasi-experimental hospital- tained improvement in compliance with hand
based studies of the impact of hand hygiene on hygiene, coinciding with a reduction of hospital-
the risk of hospital-acquired infection were pub- acquired infections and MRSA transmission.” The
lished between 1977 and 1995.7,‘“,37-41 Despite the intervention particularly targetted three of the major
 D. Pittet

n Hand disinfection
90
LJ Handwashing
8 80

E 70

1996 1997 1998

1 2 3 4 5 6 7
Consecutive surveys
Figure 4 Use of alcohol-based hand-rub solution for
disinfection, University of Geneva Hospitals, 1993-1998. Prior to
Figure 2 Hand hygiene compliance trend during seven consecutive 1996. pocket bottles were round and contained 100 ml of hand-rub
hospital-wide surveys, University of Geneva Hospitals, 1994-l 997. solution. In 1996, flat 75-ml bottles were made available to further
Compliance is indicated separately for ( q ) handwashing and ( n ) facilitate pocket carriage. We observed a substantial improvement in
hand disinfection. (Adapted with permission.‘) hand hygiene compliance both before and after the introduction of
the 75ml bottles. Healthcare workers continued to use the IOO-ml
bottles for several months.

18 The promotion of bedside, antiseptic hand-rubs

0.6 c f
16 largely contributed to the increase in compliance.
The contributing factors to the success of the pro-

I
14
motion campaign were: the multimodal and multi-
12 disciplinary approach; including communication and
educational tools; reminders in the work environ-
10
ment; active participation and feedback at both indi-
vidual and organisational levels, and the involvement
of institutional leaders.29B49 Furthermore, special
care was taken to ensure that HCWs identified
closely with the institution’s goals by being directly
involved in the promotional campaign. For example,
the most visible components, i.e., the posters, pre-
1994 1995 1996 1997 1998 pared by the artist during interactive sessions with
personnel, carried the name of the ward which had
Figure 3 Trends in prevalence of hospital-acquired infections and proposed the message. This study represents the
annual attack rate of MRSA transmission, 1993-I 998, University of first reported experience of a sustained improve-
Geneva Hospitals. (Adapted with permission!9 )
ment in hand hygiene compliance.

Conclusion
reasons for non-compliance by facilitating hand
hygiene through easy access to hand disinfection and The practice of hand hygiene is considered ‘a modest
through repeated reminders using the ‘Talking measure with big effects.“’ In 1997, a Handwashing
Walls’ campaign (for further details about the Liaison Group was created in the UK, the mission
strategy and the posters used, see www.hopisafe.ch). of which is ‘to modify the behaviour of HCWs to
Impact ofhondrub on hospitoCocquired infections S45

produce sustained improvement in hand hygiene 6. Graham M. Frequency and duration of handwashing
guidelines and so improve the quality of patient in an intensive care unit. Am J Infect Control 1990;
18: 77-81.
care. ‘jl Both easy access to hand hygiene in a timely
7. Doebbeling BN, Stanley GL, Sheetz CT et al.
fashion and the availability, free of charge, of skin Comparative efficacy of alternative hand-washing
care lotion, appear to be necessary prerequisites for agents in reducing nosocomial infections in intensive
appropriate hand hygiene behaviour. In particular, in care units. N Engl J Med 1992; 327: 88-93.
high demand situations, such as in most critical care 8. Thompson BL, Dwyer DM, Ussery XT, Deman S,
Vacek P, Schwartz B. Handwashing and glove use in
units, in high stress working conditions and at times
a long-term care facility. Infect Control Hasp Epi-
of overcrowding or understaffing, hand-rub with an demiol 1997; 18: 97-103.
alcohol-based solution appears the only alternative 9. Pittet D, Mourouga P, Perneger TV and the mem-
to maintain and possibly facilitate reasonable compli- bers of the Infection Control Program. Compliance
ance. Alcohol-based hand-rub, compared with tradi- with handwashing in a teaching hospital. Ann Intern
Med 1999; 130: 126-130.
tional handwashing with unmedicated soap and
10. Larson EL, CIC 1992-1993 and 1994 APIC Guide-
water or medicated hand antiseptic agents, may be lines Committee. APIC guideline for handwashing
superior because it requires less time,23 acts faster3a and hand antisepsis in health care settings. Am ‘j
and irritates less often hands;13a3’ furthermore it was Infect Control 1995; 23: 251-269.
used in the only programme that reported a sus- 11. Goldmann D, Larson E. Hand-washing and nosoco-
mial infections. N Engl J Med 1992; 327: 120-I 22.
tained improvement in hand hygiene compliance
12. Boyce JM. It is time for action: improving hand
associated with decreased infection rates.“” hygiene in hospitals. Ann Intern Med 1999; 130:
The availability of alcohol-based hand disinfection 153-155.
appears, however, insufficient to achieve sustained 13. Larson E. Skin hygiene and infection prevention:
improvement with hand hygiene practicess2-” more of the same or different approaches? Clin
Infect Dis 1999; 29: 1287-1294.
Strategies to improve compliance with hand
14. Donowitz L. Handwashing technique in a pediatric
hygiene practices should be multimodal and multi- intensive care unit. Am J Dis Child 1987; 141:
disciplinary29,55 and easy access to fast-acting hand 683-685.
hygiene agents should be viewed as the main tool of 15. Simmons B, Bryant J, Neiman K, Spencer L,
the strategy. Arheart K. The role of handwashing in prevention of
endemic intensive care unit infections. Infect Control
Hosp Epidemiol 1990; 11: 589-594.
16. Tibballs J. Teaching hospital medical staff to hand-
Acknowledgements wash. MedJ Aust 1996; 164: 395-398.
17. Larson E, Kretzer EK. Compliance with handwash-
We thank members of the Infection Control
ing and barrier precautions. J Hasp Infect 1995; 30:
Programme at the University of Geneva Hospitals 88-106.
who have been involved in research and institu- 18. Conly JM, Hill S, Ross J, Lertzman J, Louie T.
tional projects related to hand hygiene compliance Handwashing practices in an intensive care unit: the
and promotion since 1993. The author is indebted effects of an educational program ad its relationship
to infection rates. Am J Infect Control 1989; 17:
to Rosemary Sudan for editorial assistance.
330-339.
19. Sproat LJ, Inglis TJ. A multicentre survey of hand
hygiene practice in intensive care units. J Hasp Infect
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