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

Health Science Students' Perceptions of Hand Hygiene Education and Practice in a South African University: Introducing the University Hand Hygiene Improvement Model

Hand hygiene serves as a critical preventative measure against the spread of acquired infections in healthcare facilities and is an integral component of patient safety programs. While healthcare students in training are typically introduced to the principles underlying hand hygiene, the translation of this understanding into practice is often lacking, and compliance has remained low. This study aimed to evaluate health science students' in biomedical sciences, chiropractic and emergency medical care, environmental health, complementary medicine, medical imaging and radiation sciences, nursing, optometry, podiatry, and sports and movement studies perceptions regarding hand hygiene education (knowledge and attitude) and practice at a university in South Africa. Consenting students were asked to complete an online questionnaire that tested their knowledge, practices, and skills in handwashing. The ANOVA analysis results suggested significant differences in hand hygiene scores across departments and years of study. The multiple regression analyses confirmed these findings, suggesting that the department of study significantly influenced all aspects of hand hygiene, while the year of study affected hand hygiene skills, and age group influenced hand hygiene practices. Based on these findings, a conceptual model, the University Hand Hygiene Improvement Model (UHHIM), was proposed to enhance the teaching and learning of hand hygiene at the university level. The model underscores the necessity of targeted education, continuous monitoring, and feedback, and the pivotal roles of hand hygiene facilitators and student participation in enhancing hand hygiene behaviors.

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.

Systematic review on factors influencing the effectiveness of alcohol-based hand rubbing in healthcare

BACKGROUND

The effectiveness of hand rubbing with alcohol-based handrub (ABHR) is impacted by several factors. To investigate these, World Health Organization (WHO) commissioned a systematic review.

AIM

To evaluate the impact of ABHR volume, application time, rubbing friction and hand size on microbiological load reduction, hand surface coverage or drying time.

METHODS

Medline, CINAHL, Web of Science and ScienceDirect databases were searched for healthcare or laboratory-based primary studies, published in English, (1980- February 2021), investigating the impact of ABHR volume, application time, rubbing friction or hand size on bacterial load reduction, hand coverage or drying time. Two reviewers independently performed data extraction and quality assessment. The results are presented narratively.

FINDINGS

Twenty studies were included in the review. Categories included: ABHR volume, application time and rubbing friction. Sub-categories: bacterial load reduction, hand size, drying time or hand surface coverage. All used experimental or quasi-experimental designs. Findings showed as ABHR volume increased, bacterial load reduced, and drying times increased. Furthermore, one study showed that the application of sprayed ABHR without hand rubbing resulted in significantly lower bacterial load reduction than poured or sprayed ABHR with hand rubbing (- 0.70; 95%CI: - 1.13 to - 0.28). Evidence was heterogeneous in application time, volume, technique, and product. All studies were assessed as high risk of bias.

CONCLUSIONS

There is insufficient evidence to change WHO recommendation of a palmful of ABHR in a cupped hand applied for 20-30 s or manufacturer-recommended volume applied for about 20 s (Centers for Disease Control and Prevention). Future hand hygiene research should standardise volume, application time, and consider hand size.

What is new with hand hygiene?

PURPOSE OF REVIEW

Healthcare-associated infections (HAIs) challenge healthcare systems worldwide. As healthcare workers' hands are considered the main vector for transmission of pathogens, effective hand hygiene is the single most important action to prevent HAIs. We sought to highlight new developments and advances in hand hygiene.

RECENT FINDINGS

Hand hygiene compliance averages at 38%. A sustained increase of compliance with a subsequent decrease of HAIs may be achieved by national, systematic and rigorous education, and auditing programs. Periodically deployed self-operating hand hygiene surveillance systems coupled with personalized reminders could facilitate such efforts. Alcohol-based hand-rub (ABHR) solutions remain the hand hygiene gold standard, but are modified in texture and composition to better meet healthcare workers' preferences. Modifications of the hand hygiene procedure have been proposed targeting both time and technique of hand rub application. Reducing rub-time from 30 to 15 s and simplifying the technique to consist of three rather than six steps yielded encouraging results in terms of microbiological efficacy and higher compliance.

SUMMARY

Implementation and promotion of compliance are the major concerns of today's research on hand hygiene. Developments towards better surveillance and systematic education, improved ABHR formulation and streamlining of hand hygiene actions are paving the way ahead.

Simplifying the World Health Organization Protocol: 3 Steps Versus 6 Steps for Performance of Hand Hygiene in a Cluster-randomized Trial

BACKGROUND

In an experimental setting, a simplified, 3-step hand hygiene technique for applying alcohol-based hand rub was non inferior in terms of reduction of bacterial counts, as compared to the conventional World Health Organization 6-step technique. We therefore compared compliance and microbiological efficacy between both hand hygiene techniques in routine clinical practice.

METHODS

We performed a cluster-randomized trial from October-November 2015 at the University Hospital Basel, Switzerland: a tertiary, academic care center (ISRCTN45923734). We randomly assigned 12 wards to either the 3-step technique or the conventional 6-step technique of hand rubbing. The primary endpoints were compliance with the assigned technique and reduction of bacterial counts on the hands of health-care workers.

RESULTS

Overall, 2923 hand hygiene indications were observed, and compliance was 70.7% (2066/2923). Compliance with technique and indications was 51.7% (595/1151) and 75.9% (1151/1516) on wards assigned to the 3-step technique, respectively, as compared to 12.7% (116/915) and 65.0% (915/1407) on wards assigned to the 6-step technique (P < .001). The reduction factor (RF) of bacterial colony counts did not differ between techniques (median RF 0.97 log10 colony-forming units [CFU] [interquartile range 0.39-1.59] for the 3-step technique vs median RF 1.04 log10 CFU [interquartile range 0.49-1.52] for the 6-step technique; P = .629).

CONCLUSIONS

In a clinical setting, the simpler hand hygiene technique, consisting of 3 steps, resulted in higher compliance with both hand hygiene indications and technique, as compared to the 6 steps. As the results of the microbiological analyses exclude inferiority, the conventional 6 steps could be safely replaced by a simpler hand hygiene technique.

CLINICAL TRIALS REGISTRATION

ISRCTN45923734.

Hand Hygiene Teaching Strategies among Nursing Staff: A Systematic Review

Background: Patient safety is a priority of any healthcare system, and one of the most effective measures is hand hygiene. For this, it is important that health staff have correct adherence and perform the technique properly. Otherwise, the incidence of nosocomial infections can increase, with consequent complications. The aim here was to analyze hand hygiene training and the effectiveness of different methods and educational strategies among nurses and whether they maintained correct adherence over time. Methods: A systematic review was conducted in the sources CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Lilacs (Latin American and Caribbean Health Sciences Literature), ProQuest (Proquest Health and Medical Complete), Medline, SciELO (Scientific Electronic Library Online), and Scopus. The search equation with Medical Subject Headings (MeSH) descriptors was “Nurs* AND (handwashing OR hand hygiene) AND clinical trial”. The review was performed following the recommendations of the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Results: n = 17 clinical trials were included, with a total of 5747 nurses and nursing students. Strategies such as reminder sounds, practical simulations, videos, and audiovisual media improved handwashing compliance. Adherence overtime increased by up to 60%. The greatest effectiveness was related to the use of povidone–iodine, which reduced colony formation compared Hand hygiene teaching strategies among nursing staff: a systematic review to soap. Conclusions: The strategies that go beyond teaching techniques such as lectures may be more effective at increasing hand hygiene compliance. Combined approaches to learning/instruction improve user satisfaction by enabling self-management, flexibility, and repetition.

Current issues in hand hygiene

Although substantial improvements in hand hygiene practices have occurred in recent years, many health care facilities continue to encounter challenges in achieving and maintaining high levels of hand hygiene compliance. Issues of current interest include the optimum dose of alcohol-based handrub (ABHR) that should be applied, the impact of hand size and alcohol-based handrub dry times have on efficacy, and ideal hand hygiene technique. There is a need to determine which additional promotional activities can augment improvements in hand hygiene that are achieved by implementing the multimodal improvement strategy recommended by the World Health Organization. Monitoring hand hygiene performance and providing personnel with feedback on their performance are essential elements of successful improvement programs. Further research is needed to establish the most effective methods of providing feedback. Additional studies are needed to optimize strategies for performing direct observation of hand hygiene compliance, and to determine the role of supplementing direct observations using automated monitoring systems.

Critical evaluation of mechanism responsible for biomass abatement during electrochemical coagulation (EC) process: A critical review

This is a first review paper that delineates fundamental disinfection mechanism undergoes during the simple electrochemical coagulation (EC) process. The elucidation of detailed mechanistic phenomenon of EC process involved would help to enhance the disinfection efficiency. In this context, the biomass (bacteria, virus and algae) abatement mechanism by EC is critically reviewed and rationalized based on the experimental demonstration performed from the recent decade. Whereas, the effect of most significant abiotic operating parameters, dissolved contents and bacteria cell wall composition on biomass reduction are explored in detail. From these analyses, physical removal and chemical inactivation routes are identified for bacteria abatement mechanism during the EC process using sacrificial electrodes. Which includes (i) enmeshment of microbial contaminants by EC flocs, (ii) sweeping flocculation is preferentially for destabilization of negatively charged biomass, and (iii) inactivation/attenuation of micro-organism cell walls by electrochemically induced reactive oxygen species (ROS) or direct interaction of electric field. Perhaps, the overall abatement mechanism attributes due to the aforementioned phenomenon endures independently and/or synergistically during the EC process. Nonetheless, to obtain better understanding of virus and algae abatement mechanism, we require more experimental investigation on algae and virus removal. Eventually, more intensive research efforts on biomass attenuation by EC are most important to reinforce this claim.

Antibacterial efficacy of handrubbing for 15 versus 30 seconds: EN 1500-based randomized experimental study with different loads of Staphylococcus aureus and Escherichia coli

OBJECTIVES

Compliance with the World Health Organization 'how to handrub' action is suboptimal. Simplifying the hand-hygiene action may improve practice. However, it is crucial to preserve antibacterial efficacy. We tested the non-inferiority of 15 versus 30 seconds handrubbing for Staphylococcus aureus and Escherichia coli contamination at different loads, using hand-size customized alcohol-based handrub (ABHR) volumes.

METHODS

In an EN1500-based study, 18 health-care workers (HCWs) with extensive experience in hand hygiene rubbed hands with a hand-size customized volume of isopropanol 60% v/v. They repeated the following sequence: hand contamination (E. coli or S. aureus; broth containing 10⁸ or 10⁶ CFU/mL); baseline fingertips sampling; handrubbing (15 or 30 seconds); re-sampling. The main outcome was log₁₀ CFU corrected reduction factor (cRF) on HCWs' hands, applying a generalized linear mixed model with a random intercept for subject.

RESULTS

The median cRF was 2.1 log₁₀ (interquartile range 1.50-3.10). After fitting the model, cRF was significantly higher for S. aureus compared with E. coli but there was no significant effect for duration of handrubbing or contamination fluid concentration. Fifteen seconds of handrubbing was non-inferior to 30 (-0.06 log₁₀, 95% CI -0.34 to 0.22; EN1500 0.60 log₁₀ non-inferiority margin). This was confirmed in all pre-specified subgroups.

CONCLUSION

Among experienced HCWs using a hand-size customized volume of ABHR, handrubbing for 15 seconds was non-inferior to 30 seconds in reducing bacterial load, irrespective of type of bacteria or contamination fluid concentration. This provides further support for a shorter, 15-seconds, hand-hygiene action.