Assessment of the appropriateness of hand surface coverage for health care workers according to World Health Organization hand hygiene guidelines

Updates and future directions regarding hand hygiene in the healthcare setting: insights from the 3rd ICPIC alcohol-based handrub (ABHR) task force

Healthcare-associated infections (HAIs) and antimicrobial resistance (AMR) pose threats to global health. Effective hand hygiene is essential for preventing HAIs and the spread of AMR in healthcare. We aimed to highlight the recent progress and future directions in hand hygiene and alcohol-based handrub (ABHR) use in the healthcare setting. In September 2023, 42 experts in infection prevention and control (IPC) convened at the 3rd International Conference on Prevention and Infection Control (ICPIC) ABHR Taskforce in Geneva, Switzerland. The purpose of this meeting was to provide a synthesis of recent evidence and formulate a research agenda on four critical areas for the implementation of effective hand hygiene practices: (1) ABHR formulations and hand rubbing techniques, (2) low-resource settings and local production of ABHR, (3) hand hygiene monitoring and technological innovations, and (4) hand hygiene standards and guidelines.

Hand hygiene compliance in a Brazilian COVID-19 unit: the impact of moments and contact precautions

BACKGROUND

Healthcare-associated infections are among the most common complications during hospitalization. These infections increase morbidity and mortality and they increase length of hospital stay and the cost of healthcare. The aims of our study were to monitor hand hygiene (HH) compliance, HH technique quality and factors related to HH practice among health professionals in a COVID-19 Intensive Care Unit (ICU).

METHODS

An observational, prospective study. Between September and December 2021, we observed 69 healthcare professionals in an eight-bed ICU for patients with COVID-19 in midwestern Brazil. We used the WHO observation form to collect data. The dependent variable was HH compliance and independent variables were professional category, sex, HH quality (3-step technique for at least 15 s), number of HH opportunities observed, observation shift and inappropriate glove use.

RESULTS

We observed 1185 HH opportunities. The overall compliance rate was 26.4%, but only 6.5% were performed with the correct 3-step technique for the minimum time. HH compliance was considerably lower for moments "before" tasks (6.7%; 95% CI 4.8%, 9.2%) compared with moments "after" tasks (43.8%; 95% CI 39.9%, 47.8%). The logistic model found that inappropriate glove use, night shift and physicians (p < 0.001) were associated with low HH compliance. The infrastructure analysis found that the unit had an insufficient number of alcohol-based handrub (ABHR) dispensers at the point of care and that the mechanism for activating them was poorly designed.

CONCLUSIONS

HH compliance was very low. Inappropriate glove use was associated with low compliance and the unit's infrastructure did not support good HH practice. The fact that healthcare professionals were more likely to do HH after tasks, suggests that they use HH to protect themselves rather than the patients. Adequate infrastructure and ongoing health education with a focus on HH while caring for patients in contact precautions are essential for improving HH compliance and patient safety.

Healthcare Personnel Hand Hygiene Compliance: Are We There Yet?

Purpose of Review

Poor hand hygiene is well documented as a factor in healthcare-associated infections and excellent rates of hand hygiene remains elusive.

Recent Findings

There is increased use of universal or increased gloving to minimize hand contamination, but its use does not replace hand hygiene opportunities. There is significant interest in electronic hand hygiene monitoring systems, but they are not without their unique issues. Behavioral psychology remains a significant factor in motivating hand hygiene behaviors; even in COVID-19, hand hygiene rates initially improved but trended down back to baseline while still dealing with the pandemic.

Summary

More emphasis should be placed on the how to properly perform hand hygiene and why it is so important, as well as the role of gloves, is needed. Continued investment and awareness of their status as role models from both system leadership and senior healthcare providers are needed.

SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update

The purpose of this document is to highlight practical recommendations to assist acute-care hospitals in prioritization and implementation of strategies to prevent healthcare-associated infections through hand hygiene. This document updates the Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals through Hand Hygiene, published in 2014. This expert guidance document is sponsored by the Society for Healthcare Epidemiology (SHEA). It is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America, the Association for Professionals in Infection Control and Epidemiology, the American Hospital Association, and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise.

Comparison of two alcohol hand rubbing techniques regarding hand surface coverage among hospital workers: a quasi-randomized controlled trial

BACKGROUND

The adapted 6-step without interlock (A6Sw/oI) hand rub technique, commonly practiced in Japan, adds the "wrist" but omits the "interlock" step compared to the WHO 6-step technique (WHO6S). The first objective of this study was to assess the differences of the two techniques regarding surface coverage. The second objective was to analyze the coverage differences between hand sizes.

METHODS

Hospital workers went under stratified quasi-randomization by glove size. The overall mean coverage, and the coverage of the sections of the hands were evaluated by fluorescent dye-based coverage assessment using a digital device with artificial intelligence technology.

RESULTS

Total of 427 workers were randomly allocated to WHO6S (N = 215) or the A6Sw/oI (N = 212). The overall mean dorsum coverage by WHO6S and A6Sw/oI was 90.6% versus 88.4% (p < 0.01), and the percentage of the participants with insufficient coverage of the backs of the four fingers ranged from 0.0-7.4% versus 28.2-51.4% (p < 0.001). Dorsum coverage varied largely between hand size for both techniques, and significant differences were found between small and large hands.

CONCLUSION

The WHO6S was superior to the locally adapted technique regarding hand surface coverage. Hand size should be considered when assessing coverage differences between procedures. No trial registrations or fundings.

Comparing the effectiveness of hand hygiene techniques in reducing the microbial load and covering hand surfaces in healthcare workers: Updated systematic review

BACKGROUND

This review, commissioned by the World Health Organization (WHO), examined the effectiveness of the WHO 6-step hand hygiene (HH) technique in reducing microbial load on hands and covering hand surfaces, and compared its effectiveness to other techniques.

METHODS

Medline, CINAHL, ProQuest, Web of Science, Mednar, and Google Scholar were searched for primary studies, published in English (1978-February 2021), evaluating the microbiological effectiveness or hand surface coverage of HH techniques in healthcare workers. Reviewers independently performed quality assessment using Cochrane tools. The protocol for the narrative review was registered (PROSPERO 2021: CRD42021236138).

RESULTS

Nine studies were included. Evidence demonstrated that the WHO technique reduced microbial load on hands. One study found the WHO technique more effective than the 3-step technique (P = .02), while another found no difference between these 2 techniques (P = .08). An adapted 3-step technique was more effective than the WHO technique in laboratory settings (P = .021), but not in clinical practice (P = .629). One study demonstrated that an adapted 6-step technique was more effective than the WHO technique (P = .001). Evidence was heterogeneous in application time, product, and volume. All studies were high risk of bias.

CONCLUSIONS

Eight studies found that the WHO 6-step technique reduced microbial load on healthcare workers' hands; but the studies were heterogeneous and further research is required to identify the most effective, yet feasible technique.

Evaluation of the Efficiency of Hand Hygiene Technique with Hydroalcoholic Solution by Image Color Summarize

Background and Objectives: The HH (hand hygiene) technique is relatively simple. Even so, in practice there are still non-conformities regarding this aspect. Lack of knowledge or lack of compliance can be reasons for non-adherence with HH techniques. In this context, the purpose of this study was to follow the realization of the hand-washing technique with hydroalcoholic solution, applied before and after receiving the HH recommendations. Materials and Methods: A descriptive, cross-sectional study was conducted from May 2022 to June 2022. Students from a second year dental medicine class teaching in French 2021/22 “Grigore T. Popa” University of Medicine and Pharmacy in Iasi were included in the study. The approval of the ethics commission was received: No. 184/05.05.2022. The study was conducted in two stages. In the first stage, HH was performed without any recommendation. In the second stage, the antiseptic hand rubbing technique was presented following the WHO recommendations. The fluorescent Fluo-Add solution, Wood lamp for dermatology (4 × 5.5 W ultraviolet tubes with a wavelength of 360 nm), and photo camera were used. Subjects performed their HH movement before and after receiving instructions according to WHO. Images were initially taken from the backhand and palm and were finally analyzed with Image Color Summarizer. The data were analyzed by the Mann–Whitney U Test, t-test paired samples using IBM-SPSS version 26 (IBM, Armonk, NY, USA), and p ≤ 0.05 was considered statistically significant. Results: After analyzing the images, there were 70 subjects, 45.7% (32) female and 54.33% (38) male. Final average covered area of backhand was 60.89% (±17.17), 28.84:86.11, compared to 52.07% (±17.04), 9:85.23. Final average covered area for palm was 69.91% (±13.5), 31.61:93.41 compared to 59.74% (±16.64), 26.13:92.72. No statistical significance was obtained by gender. Conclusions: The study showed an improvement in hand hygiene technique without highlighting gender differences.

Electronic Hand Hygiene Quality and Duration Monitoring in Pre-School Children: A Feasibility Study

BACKGROUND

Hand hygiene is regarded as the most important measure to prevent spread of infectious diseases. The aim of this study was to assess the feasibility of a prototype application in an electronic device in educating, stimulating and monitoring hand hygiene quality in young children.

METHOD

A pre-school was provided with an interactive hand hygiene application for two months. The device features an online administrator dashboard for data collection and for monitoring the children's hand washing steps and duration. A good hand washing is defined as hand washing which comprise all of the steps outlined in the World Health Organization (WHO) guidelines.

RESULTS

The prototype managed to capture 6882 hand wash performed with an average of 20.85 seconds per hand wash. Washing hands palm to palm was the most frequent (79.9%) step performed, whereas scrubbing fingernails and wrists were the least (56%) steps performed.

CONCLUSIONS

The device is a good prototype to educate, stimulate and monitor good hand hygiene practices. However, other measures should be undertaken to ensure sustainability of the practices.

Improving the communication of hand hygiene procedures: Controlled observation, redesign, and randomized group comparisons

OBJECTIVE

To assess the clarity and efficacy of the World Health Organization (WHO) hand-rub diagram, develop a modified version, and compare the 2 diagrams.

DESIGN

Randomized group design preceded by controlled observation and iterative product redesigns.

SETTING

The Cognitive Ergonomics Lab in the School of Psychology at the Georgia Institute of Technology.

PARTICIPANTS

We included participants who were unfamiliar with the WHO hand-rub diagram (convenience sampling) to ensure that performance was based on the diagram and not, for example, on prior experience.

METHODS

We iterated through the steps of a human factors design procedure: (1) Participants simulated hand hygiene using ultraviolet (UV) absorbent lotion and a hand-rub technique diagram (ie, WHO or a redesign). (2) Coverage, confusion judgments, and behavioral videos informed potentially improved diagrams. And (3) the redesigned diagrams were compared with the WHO version in a randomized group design. Coverage was assessed across 72 hand areas from multiple UV photographs.

RESULTS

The WHO diagram led to multiple omissions in hand-surface coverage, including inadequate coverage by up to 75% of participants for the ulnar edge. The redesigns improved coverage significantly overall and often substantially.

CONCLUSIONS

Human factors modification to the WHO diagram reduced inadequate coverage for naïve users. Implementation of an improved diagram should help in the prevention of healthcare-associated infections.

Interventions to improve healthcare workers' hand hygiene compliance: A systematic review of systematic reviews

OBJECTIVE

To synthesize the existing evidence base of systematic reviews of interventions to improve healthcare worker (HCW) hand hygiene compliance (HHC).

METHODS

PRISMA guidelines were followed, and 10 information sources were searched in September 2017, with no limits to language or date of publication, and papers were screened against inclusion criteria for relevance. Data were extracted and risk of bias was assessed.

RESULTS

Overall, 19 systematic reviews (n=20 articles) were included. Only 1 article had a low risk of bias. Moreover, 15 systematic reviews showed positive effects of interventions on HCW HHC, whereas 3 reviews evaluating monitoring technology did not. Findings regarding whether multimodal rather than single interventions are preferable were inconclusive. Targeting social influence, attitude, self-efficacy, and intention were associated with greater effectiveness. No clear link emerged between how educational interventions were delivered and effectiveness.

CONCLUSIONS

This is the first systematic review of systematic reviews of interventions to improve HCW HHC. The evidence is sufficient to recommend the implementation of interventions to improve HCW HHC (except for monitoring technology), but it is insufficient to make specific recommendations regarding the content or how the content should be delivered. Future research should rigorously apply behavior change theory, and recommendations should be clearly described with respect to intervention content and how it is delivered. Such recommendations should be tested for longer terms using stronger study designs with clearly defined outcomes.

Safe removal of gloves from contact precautions: The role of hand hygiene

BACKGROUND

Routine hand hygiene effectively removes methicillin-resistant Staphylococcus aureus (MRSA) and/or vancomycin resistant Enterococcus (VRE) from the ungloved hands of healthcare workers (HCWs) who are caring for patients under contact precautions, when exposure to bodily fluids is not expected.

METHODS

HCWs' ungloved hands were cultured after hand hygiene with alcohol-based hand rub (ABHR) or soap-and-water wash after routine clinical care of patients known to be colonized or infected with MRSA or VRE.

RESULTS

Two hundred forty samples from 40 HCWs were tested and found to be culture negative for either MRSA or VRE after contact with patients when 3 pumps of ABHR (0/80) or plain soap-and-water wash (0/80) were used. No VRE was observed in any of the 120 samples collected. Two plates (2/40) grew 1 colony-forming unit of MRSA after 2 pumps of ABHR. Two HCWs with positive plates were cultured negative on retesting.

CONCLUSION

We showed that appropriate hand hygiene was effective in removing MRSA and VRE even when gloves were not used for routine clinical care, despite contact with patients known to be colonized with MRSA or VRE. A modified approach to glove use for dry contact with patients on contact precautions might improve patient safety within healthcare settings.

A systematic review to evaluate the evidence base for the World Health Organization's adopted hand hygiene technique for reducing the microbial load on the hands of healthcare workers

BACKGROUND

Effective hand hygiene prevents healthcare-associated infections. This systematic review evaluates the evidence for the World Health Organization's (WHO) technique in reducing the microbial load on the hands of healthcare workers (HCWs).

METHODS

This study was conducted in accordance with Joanna Briggs Protocol 531. Index and free-text terms for technique, HCW, and microbial load were searched in CINAHL, Medline, Web of Science, Mednar, Proquest, and Google Scholar. Inclusion criteria were articles in English that evaluated the WHO 6-step hand hygiene technique for healthcare staff. Two reviewers independently performed quality assessment and data extraction.

RESULTS

All 7 studies found that the WHO technique reduced bacterial load on HCW hands, but the strongest evidence came from 3 randomized controlled trials, which reported conflicting evidence. One study found no difference in the effectiveness of the WHO 6-step technique compared to the Centers for Disease Control and Prevention's 3-step technique (P = .08); another study found the WHO 6-step technique to be more effective (P = .02); and the third study found that a modified 3-step technique was more effective than the 6-step technique (P = .021).

CONCLUSIONS

This review provides evidence of the effectiveness of the WHO technique but does not identify the most effective hand hygiene technique. Questions to be addressed by further research are identified. Meanwhile, current practices should continue.

Knowledge, Attitude, and Performance of Nurses toward Hand Hygiene in Hospitals

INTRODUCTION

The proper hand hygiene is one of the foremost techniques to reduce Nosocomial infections. The hand hygiene is deemed as the simplest method for control of Nosocomial infections if it is done properly it may prevent from a lot of costs and fatalities. Due to constant relationship with patients, nurses play paramount role in proper execution of hand hygiene among clinical personnel. The current study was carried out in order to analyze knowledge, attitude, and performance of nurses regarding hand hygiene.

MATERIALS & METHODOLOGY

A cross-sectional study was conducted on 200 (of 240) nurses from three hospitals in Kerman city at east of Iran in 2015. The standardized questionnaire was the tool for data collection. These data entered in SPSS (V.22). The frequency and percentage of frequency in descriptive statistics was employed for data analysis. The confidence interval was considered as 95%.

RESULTS

The results showed that the majority of participants were male173 (86.5%), had BA degree 161 (80.5%) and were married 155 (70.5%). Most of nurses 77 (38.5%) had working experience (5-10years). The majority of nurses had good knowledge 149 (74.5%), positive attitude 141 (70.5%) and good performance 175 (87.5%).

DISCUSSION & CONCLUSION

The nurses are good level in terms of knowledge, attitude, and performance but improvement of their knowledge and knowledge seems to be more necessary by holding educational classes and courses in cases where they have less knowledge.

A Pragmatic Randomized Controlled Trial of 6-Step vs 3-Step Hand Hygiene Technique in Acute Hospital Care in the United Kingdom

OBJECTIVE

To evaluate the microbiologic effectiveness of the World Health Organization’s 6-step and the Centers for Disease Control and Prevention’s 3-step hand hygiene techniques using alcohol-based handrub.

DESIGN

A parallel group randomized controlled trial.

SETTING

An acute care inner-city teaching hospital (Glasgow).

PARTICIPANTS

Doctors (n=42) and nurses (n=78) undertaking direct patient care.

INTERVENTION

Random 1:1 allocation of the 6-step (n=60) or the 3-step (n=60) technique.

RESULTS

The 6-step technique was microbiologically more effective at reducing the median log10 bacterial count. The 6-step technique reduced the count from 3.28 CFU/mL (95% CI, 3.11–3.38 CFU/mL) to 2.58 CFU/mL (2.08–2.93 CFU/mL), whereas the 3-step reduced it from 3.08 CFU/mL (2.977–3.27 CFU/mL) to 2.88 CFU/mL (−2.58 to 3.15 CFU/mL) (P=.02). However, the 6-step technique did not increase the total hand coverage area (98.8% vs 99.0%, P=.15) and required 15% (95% CI, 6%-24%) more time (42.50 seconds vs 35.0 seconds, P=.002). Total hand coverage was not related to the reduction in bacterial count.

CONCLUSIONS

Two techniques for hand hygiene using alcohol-based handrub are promoted in international guidance, the 6-step by the World Health Organization and 3-step by the Centers for Disease Control and Prevention. The study provides the first evidence in a randomized controlled trial that the 6-step technique is superior, thus these international guidance documents should consider this evidence, as should healthcare organizations using the 3-step technique in practice.

Infect Control Hosp Epidemiol 2016;37:661–666

Assessment of hand hygiene techniques using the World Health Organization's six steps

The quality of hand hygiene was evaluated via direct observation for compliance with the six recommended World Health Organization steps. A total of 2497 HH opportunities, of which 1573 (63.0%) were hand rubs, were monitored over a five month period. Compliance was higher in nurses compared with physicians and auxiliaries and in steps 1 and 2 for hand rubs as well as the first three steps of hand washing, with lower rates after these steps. Rubbing of the thumbs and fingertips achieved the lowest rates of compliance in both HH types. A combination of the five recommended moments and six steps and staff education is recommended to improve the quality of hand hygiene.

Current perspectives on the dynamics of antibiotic resistance in different reservoirs

Antibiotic resistance consists of a dynamic web. In this review, we describe the path by which different antibiotic residues and antibiotic resistance genes disseminate among relevant reservoirs (human, animal, and environmental settings), evaluating how these events contribute to the current scenario of antibiotic resistance. The relationship between the spread of resistance and the contribution of different genetic elements and events is revisited, exploring examples of the processes by which successful mobile resistance genes spread across different niches. The importance of classic and next generation molecular approaches, as well as action plans and policies which might aid in the fight against antibiotic resistance, are also reviewed.

Nurses' knowledge regarding hand hygiene and its individual and organizational predictors

INTRODUCTION

Based on recommendations from World Health Organization, hand hygiene is the most important way to control the hospital infections. Due to the critical role of nurses in patient care, they should have essential and updated information regarding hand hygiene. So this study aims at determining the knowledge of hand hygiene and its individual and organizational predictors among nurses in neonatal units.

METHODS

This descriptive and cross-sectional study was conducted in neonatal units in the hospitals affiliated to Tabriz University of Medical Sciences. The participants surveyed in this study were 150 nurses who were invited by census sampling method. A researcher prepared questionnaire that investigated the knowledge of participants about hand hygiene and was used after approving its validity and reliability. The quantitative analysis of this study used Statistical Package for Social Sciences SPSS version 13 by descriptive statistics and pearson correlation test, independent samples t-test, One-way ANOVA. For multivariable explanation of nurses' knowledge based on independent variables multiple linear regressions was used.

RESULTS

Most of participants have an acceptable level of knowledge regarding hand hygiene. The highest score was for infection control domain and the lowest score was for definition of hand hygiene domain. Multivariable analysis showed that work experience and history of previous training were the most important predictors of participants' knowledge about hand hygiene.

CONCLUSION

It is recommended that infection control committees should revise their educational methods and give more emphasis on update guidelines regarding hand hygiene. Also, more experienced nurses should be employed in neonatal units.