A review of hand-washing techniques in primary care and community settings

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.

Assessment of the effect of hand dryers used in shopping malls on hand hygiene

BACKGROUND

Hand drying is one of the most important factors affect hand hygiene. This study was conducted to investigate the effect of hand dryers used in the restrooms located on the food court floors in shopping malls in Turkey on hand hygiene.

METHODS

Hands were washed for at least 20 seconds by following hygienic hand washing procedures of the World Health Organization. Swab samples were taken from the wet hands after hand washing, then from the dry hands, which were dried under the hand dryers and from the air blowing part of the hand dryers. Samples were cultured on agar plates that were directly exposed to the air-blowing part of the hand dryers.

RESULTS

It was found that total coliform bacteria were 0.000 colony-forming unit (CFU)/petri in wet and dried hand, 3.437 CFU/petri in blown air and 5.250 CFU/petri in swab samples. Staphylococcus aureus was found to be 0.125, 64.125, 26.375, and 388.750 CFU/petri, respectively. Total bacteria count was found to be 0.687, 48.750, 35.625, and 595.000 CFU/petri, respectively. S. aureus and the total bacterial load were higher in the blower outlet of the hand dryers than washed hand, blown air and dried hand (P < .05). The bacteria count in the unfiltered hand dryers was higher than that in the filtered hand dryers (P < .05).

CONCLUSIONS

Using hand dryers would negatively affect hand hygiene even if hands were washed following hygienic hand washing procedures.

Microbiological Assessment of the Different Hand Drying Methods and Washroom Environment Cross-Contamination

Proper hand drying is a fundamental part of the hand hygiene process looking at optimizing the elimination of potentially pathogenic microbes. This research compared the effectiveness of three different hand drying methods—paper towels, the use of warm air dryers in stationary hands position, and the use of air drying while hand rubbing—and their potential for cross-contamination of other users and the surrounding environment. One hundred sixty samples were collected from finger pads and palms, before and after drying. The outlet of the air dryers, air current emitted from the air dryers, and washroom environment air were also tested. The study reported that paper towels were more successful in eliminating bacteria and lead to less contamination to the washroom environment compared to the air dryers. The average number of bacteria obtained from volunteers using hand air dryer while hand rubbing was significantly higher than drying with air dryer while holding hands stationary. Plates exposed to the turned-off dryer for 5 minutes gave an average of only 25 colonies/plate, while plates exposed to the air outlet of the turned-on warm air dryers provided 292 colonies/plate. Placing Petri dishes at least one meter away from the dryer in the washroom for 30 minutes gave 72.5 colonies/plate. The current research also documented frequent contamination of public washroom environments and showed dissemination of potential pathogens, including Escherichia coli (E. coli), Klebsiella species, Bacillus cereus (B. cereus), Staphylococcus aureus (S. aureus), and coagulase-negative Staphylococci. Over 70.0% of Staphylococci were resistant to at least three antibiotics and 50.0% revealed coresistance to at least four antibiotics including penicillin, erythromycin, clindamycin, and co-trimoxazole. The method of hand drying may serve as a risk factor of cross-contamination from users to the environment and subsequent users and as reservoirs of drug-resistant bacteria in public washrooms.

Feasibility, Utility, and Limitations of a Rapid Community Behavioral Diagnosis for Social Distancing During the 2020 Coronavirus Pandemic

PURPOSE

To evaluate the feasibility, utility, and limitations of a rapid community behavioral diagnosis (RCBD) for social distancing behaviors to prevent coronavirus transmission during a global coronavirus pandemic.

DESIGN

Using social media for recruitment, we partnered with a local community task force to administer a brief online survey.

SETTING

Residential urban community.

SAMPLE

Eighty-four community members, the majority of whom were white, female, college educated completed the survey.

MEASURES

Theory of planned behavior constructs: behavioral intentions, attitudes, perceived norms, and perceived behavioral control for 3 social distancing behaviors: maintaining a 6-foot distance, avoiding places people congregate, and staying home as much as possible.

ANALYSIS

Path analyses were conducted to understand significant determinants of intentions for each behavior to guide the development of locally tailored health promotion messages.

RESULTS

The RCBD was implemented, and results were communicated to the community within 1 week. Intentions were high across the 3 behaviors but lowest for staying home as much as possible. Younger participants had lower intentions of maintaining a 6-foot distance than older participants. For each behavior, specific recommendations for health promotion messaging emerged based on how attitudes, norms, and perceived behavioral control related to intentions.

CONCLUSION

In a situation where local community action is paramount for reducing coronavirus transmission, this RCBD process is feasible and useful for informing local health promotion.

Failure to place evidence at the centre of quality improvement remains a major barrier for advances in quality improvement

Mondoux and Shojania (M&S) issued a critique of our call to unify all disciplines of relevance for quality improvement (QI). They do not challenge the need for alignment of different fields that have played roles in the QI space. They selected to focus their critique on our views that ultimately the discipline of QI should be based on the principles of evidence-based medicine (EBM) and decision sciences. In our response, we reaffirm our calls to help achieve needed alignment and integration of all disciplines of importance to QI through "a unifying framework for improving health care" with EBM and decision sciences at helm. Challenging the importance of placing QI on solid empirical basis is misguided: As QI is all about measuring and consequently improving clinical care, acting on reliable evidence must remain its "cornerstone". Apparent differences in our views appears to be due to our focus on what care should be delivered, while M&S concentrate on how that care should be delivered. The former is the domain of a narrowly defined EBM, while the latter is the realm of improvement/implementation science-which, we argue, should also be evidence-based. QI initiatives are fundamentally local activities, and regulators would be most helpful if they require each institution to provide an annual plan of its top QI activities not included in the existing mandated list of performance measures. Finally, we addressed a number of specific QI initiatives highlighted by M&S-use of opioids, handwashing, venous-thromboembolism prophylaxis, hip replacement, and perioperative beta-blockers-to show that they would have been carried differently if they were based on the principles of EBM. Thus, the failure to place evidence at the centre remains a major barrier for advances in QI.

Deposition of Bacteria and Bacterial Spores by Bathroom Hot-Air Hand Dryers

Hot-air hand dryers in multiple men's and women's bathrooms in three basic science research areas in an academic health center were screened for their deposition on plates of (i) total bacteria, some of which were identified, and (ii) a kanamycin-resistant Bacillus subtilis strain, PS533, spores of which are produced in large amounts in one basic science research laboratory. Plates exposed to hand dryer air for 30 s averaged 18 to 60 colonies/plate; but interior hand dryer nozzle surfaces had minimal bacterial levels, plates exposed to bathroom air for 2 min with hand dryers off averaged ≤1 colony, and plates exposed to bathroom air moved by a small fan for 20 min had averages of 15 and 12 colonies/plate in two buildings tested. Retrofitting hand dryers with HEPA filters reduced bacterial deposition by hand dryers ∼4-fold, and potential human pathogens were recovered from plates exposed to hand dryer air whether or not a HEPA filter was present and from bathroom air moved by a small fan. Spore-forming colonies, identified as B. subtilis PS533, averaged ∼2.5 to 5% of bacteria deposited by hand dryers throughout the basic research areas examined regardless of distance from the spore-forming laboratory, and these were almost certainly deposited as spores. Comparable results were obtained when bathroom air was sampled for spores. These results indicate that many kinds of bacteria, including potential pathogens and spores, can be deposited on hands exposed to bathroom hand dryers and that spores could be dispersed throughout buildings and deposited on hands by hand dryers.IMPORTANCE While there is evidence that bathroom hand dryers can disperse bacteria from hands or deposit bacteria on surfaces, including recently washed hands, there is less information on (i) the organisms dispersed by hand dryers, (ii) whether hand dryers provide a reservoir of bacteria or simply blow large amounts of bacterially contaminated air, and (iii) whether bacterial spores are deposited on surfaces by hand dryers. Consequently, this study has implications for the control of opportunistic bacterial pathogens and spores in public environments including health care settings. Within a large building, potentially pathogenic bacteria, including bacterial spores, may travel between rooms, and subsequent bacterial/spore deposition by hand dryers is a possible mechanism for spread of infectious bacteria, including spores of potential pathogens if present.

Bacteriological Aspects of Hand Washing: A Key for Health Promotion and Infections Control

The aim of this review is to show the historical aspects of hands washing for healthy life and explains how can reduce the transmission of community-acquired infectious agents by healthcare workers and patients. This review article is prepared based on available database. The key words used were hands washing, risk assessment, hands hygiene, bacterial flora, contamination, infection, nosocomial, tap water, sanitizer, bacterial resistance, hands bacterial flora, washing methods, antiseptics, healthcare workers, healthcare personnel, from PubMed, ScienceDirect, Embase, Scopus, Web of Sciences, and Google Scholar. Data were descriptively analyzed. The insistence on hand washing has a history of 1400 years. The research results indicate that the bacteria released from the female washed hands in wet and dry condition was lower than from the male's hands with a significance level (3 CFU vs. 8 CFU; confidence interval 95%, P ≤ 0.001). The valuable results of the study indicated that released amount of bacterial flora from wet hands is more than 10 times in compared to dry hands. In addition, established monitoring systems for washing hands before and after patient's manipulation as well as after toilet were dominant indices to prevent the transfer of infectious agents to the patients. Increasing awareness and belief of the healthcare workers have shown an important role by about 30% reduction in the transfection. Hand washing could reduce the episodes of transmission of infectious agents in both community and healthcare settings. However, hand washing is an important key factor to prevent transmission of infectious agents to patients. There is no standard method for measuring compliance. Thus, permanent monitoring of hand washing to reduce the transmission of infections is crucial. Finally, the personnel must believe that hand washing is an inevitable approach to infection control.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Handwashing with soap and national handwashing projects in Korea: focus on the National Handwashing Survey, 2006-2014

OBJECTIVES:

Handwashing is the most fundamental way to prevent the spread of infectious diseases. Correct handwashing can prevent 50 to 70% of water-infections and foodborne-infections. We report the results of a fact-finding study on general handwashing attitude and practice in the Republic of Korea by analyzing habits and awareness among adults and students (grades 4 to 12) based on the 2006 to 2014 National Handwashing Surveys and observational surveys.

METHODS:

The awareness survey was performed by telephone interviews with adults and students in 16 municipalities and provinces sampled by quota for region, sex and age. The observational survey was performed in subway, railway, and other public restrooms in seven municipalities selected through systematic sampling.

RESULTS:

Adults and students washed their hands with soap/sanitizer an average of 6.6 and 5.2 times daily, respectively, in 2014, an increase and decrease compared to 2006 (4.8) and 2013 (6.8). Their average daily handwashing frequency in 2014, 9.8 and 8.3, was higher than in 2006 (7.6), but lower than in 2013 (10.3).The percentage of participants handwashing with soap after using the restroom (29.5%) has been increasing since 2009, but remain slower than in other countries (42% to 49%). The percentages of participants handwashing with water in 2014, 2013, and 2011 were 57.5%, 72.6%, and 71.4%, respectively.

CONCLUSIONS:

Handwashing with soap is an important national public health issue, and national projects promoting it should be given high priority. Research support is necessary to provide scientific evidence of the importance of handwashing with soap and to develop and implement evidence-based policies.

Strategies to prevent healthcare-associated infections through hand hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

Infection control link nurse program: an interdisciplinary approach in targeting health care-acquired infection

BACKGROUND

We describe a successful interdisciplinary liaison program that effectively reduced health care-acquired (HCA), methicillin-resistant Staphylococcus aureus (MRSA) in a university hospital setting.

METHODS

Baseline was from January 2006 to March 2008, and intervention period was April 2008 to September 2009. Staff nurses were trained to be liaisons (link nurses) to infection prevention (IP) personnel with clearly defined goals assigned and with ongoing monthly education. HCA-MRSA incidence per 1,000 patient-days (PD) was compared between baseline and intervention period along with total and non-HCA-MRSA, HCA and non-HCA-MRSA bacteremia, and hand soap/sanitizer usage. Hand hygiene compliance was assessed.

RESULTS

A reduction in MRSA rates was as follows in intervention period compared with baseline: HCA-MRSA decreased by 28% from 0.92 to 0.67 cases per 1,000 PD (incidence rate ratio, 0.72; 95% confidence interval: 0.62-0.83, P < .001), and HCA-MRSA bacteremia rate was reduced by 41% from 0.18 to 0.10 per 1,000 PD (incidence rate ratio, 0.59; 95% confidence interval: 0.42-0.84, P = .003). Total MRSA rate and MRSA bacteremia rate also showed significant reduction with nonsignificant reductions in overall non-HCA-MRSA and non-HCA-MRSA bacteremia. Hand soap/sanitizer usage and compliance with hand hygiene also increased significantly during IP.

CONCLUSION

Link nurse program effectively reduced HCA-MRSA. Goal-defined metrics with ongoing re-education for the nurses by IP personnel helped drive these results.

Knowledge of and Adherence to Hygiene Guidelines among Medical Students in Austria

Background. Adherence to hygiene guidelines is of utmost importance for healthcare professionals. The aim of this study was to evaluate the knowledge on and the adherence to hygiene guidelines among medical students in Austria. Additionally, a possible difference between female and male students was investigated. Methods. An open paper-based survey among third-year medical students at the Medical University of Graz was conducted. The questionnaire consisted of 20 single-choice questions covering compliance with basic hygiene standards, self-rated knowledge of hygiene guidelines, and satisfaction with current hygiene education, equipment, and quality standards. Results. Of 192 medical students, 70% judged their knowledge of hygiene standards as "excellent" or "good"; however, only 49% reported adherence to hygiene guidelines and only 43% performed hygienic hand disinfection according to WHO guidelines. Of the respondents, 79% voted for a mandatory course on hygiene standards in medical education. No significant gender differences were observed. Conclusion. While the knowledge on hygiene guidelines appears to be good among medical students, adherence is limited and requires improvement. The need for an optimum education in hygiene is high.

Investigating Jordanian nurses' handwashing beliefs, attitudes, and compliance

BACKGROUND

Low rates of handwashing compliance among nurses are still reported in literature. Handwashing beliefs and attitudes were found to correlate and predict handwashing practices. However, such an important field is not fully explored in Jordan.

OBJECTIVES

This study aims at exploring Jordanian nurses' handwashing beliefs, attitudes, and compliance and examining the predictors of their handwashing compliance.

METHODS

A cross-sectional multicenter survey design was used to collect data from registered nurses and nursing assistants (N = 198) who were providing care to patients in governmental hospitals in Jordan. Data collection took place over 3 months during the period of February 2011 to April 2011 using the Handwashing Assessment Inventory.

RESULTS

Participants' mean score of handwashing compliance was 74.29%. They showed positive attitudes but seemed to lack knowledge concerning handwashing. Analysis revealed a 5-predictor model, which accounted for 37.5% of the variance in nurses' handwashing compliance. Nurses' beliefs relatively had the highest prediction effects (β = .309, P < .01), followed by skin assessment (β = .290, P < .01).

CONCLUSION

Jordanian nurses reported moderate handwashing compliance and were found to lack knowledge concerning handwashing protocols, for which education programs are recommended. This study raised the awareness regarding the importance of complying with handwashing protocols.

The hygienic efficacy of different hand-drying methods: a review of the evidence

The transmission of bacteria is more likely to occur from wet skin than from dry skin; therefore, the proper drying of hands after washing should be an integral part of the hand hygiene process in health care. This article systematically reviews the research on the hygienic efficacy of different hand-drying methods. A literature search was conducted in April 2011 using the electronic databases PubMed, Scopus, and Web of Science. Search terms used were hand dryer and hand drying. The search was limited to articles published in English from January 1970 through March 2011. Twelve studies were included in the review. Hand-drying effectiveness includes the speed of drying, degree of dryness, effective removal of bacteria, and prevention of cross-contamination. This review found little agreement regarding the relative effectiveness of electric air dryers. However, most studies suggest that paper towels can dry hands efficiently, remove bacteria effectively, and cause less contamination of the washroom environment. From a hygiene viewpoint, paper towels are superior to electric air dryers. Paper towels should be recommended in locations where hygiene is paramount, such as hospitals and clinics.

Cluster randomized trial to evaluate the effect of a multimodal hand hygiene improvement strategy in primary care

OBJECTIVE

To evaluate the effectiveness of a multimodal intervention in primary care health professionals for improved compliance with hand hygiene practice, based on the World Health Organization's 5 Moments for Health Hygiene.

DESIGN

Cluster randomized trial, parallel 2-group study (intervention and control).

SETTING

Primary healthcare centers in Madrid, Spain.

PARTICIPANTS

Eleven healthcare centers with 198 healthcare workers (general practitioners, nurses, pediatricians, auxiliary nurses, midwives, odontostomatologists, and dental hygienists). Methods. The multimodal hand hygiene improvement strategy consisted of training of healthcare workers by teaching sessions, implementation of hydroalcoholic solutions, and installation of reminder posters. The hand hygiene compliance level was evaluated by observation during regular care activities in the office visit setting, at the baseline moment, and 6 months after the intervention, all by a single external observer.

RESULTS

The overall baseline compliance level was 8.1% (95% confidence interval [CI], 6.2-10.1), and the healthcare workers of the intervention group increased their hand hygiene compliance level by 21.6% (95% CI, 13.83-28.48) compared with the control group.

CONCLUSIONS

This study has demonstrated that hand hygiene compliance in primary healthcare workers can be improved with a multimodal hand hygiene improvement strategy.

Hand hygiene: back to the basics of infection control

Health care associated infections are drawing increasing attention from patients, insurers, governments and regulatory bodies. This is not only because of the magnitude of the problem in terms of the associated morbidity, mortality and cost of treatment, but also due to the growing recognition that most of these are preventable. The medical community is witnessing in tandem unprecedented advancements in the understanding of pathophysiology of infectious diseases and the global spread of multi-drug resistant infections in health care set-ups. These factors, compounded by the paucity of availability of new antimicrobials have necessitated a re-look into the role of basic practices of infection prevention in modern day health care. There is now undisputed evidence that strict adherence to hand hygiene reduces the risk of cross-transmission of infections. With "Clean Care is Safer Care" as a prime agenda of the global initiative of WHO on patient safety programmes, it is time for developing countries to formulate the much-needed policies for implementation of basic infection prevention practices in health care set-ups. This review focuses on one of the simplest, low cost but least accepted from infection prevention: hand hygiene.

Hand disinfectant practice: the impact of an education intervention

The primary hypothesis of this study was that a lecture on basic hygiene routines could be associated with an increase in the use of disinfectant for hand hygiene. A secondary hypothesis was that the lecture could positively affect the staff's knowledge of and attitudes toward basic hygiene routines.A quasi-experimental design including one ward of the department of orthopedics in a Swedish university hospital was adopted.During the pre-intervention test period the consumption of hand disinfectant was measured for 30 days and a questionnaire was distributed to all staff. The hospital hygiene nurse subsequently provided a lecture on basic hygiene routines to all employees on the ward. During the post-intervention test period the hand disinfectant consumption was measured for another 30 days, and the questionnaire was distributed once again. A follow-up measurement was performed 9 months after the intervention.After the lecture on hygiene routines, the consumption of hand disinfectant increased by 93%. Nine months after the intervention, the consumption was still 21% higher than before the intervention. The result of the questionnaire showed that the employees considered themselves applying the disinfectant more thoroughly after the intervention. Some employees changed their perspective on basic hygiene routines after the lecture and stopped using watches and private clothes at work.Our findings suggest that a single education session, a hygiene lecture, could be a simple and cost-effective method to increase the use of hand disinfectant, thereby reducing the number of nosocomial infections on the wards.