Hand Hygiene, It Is More Than Washing Our Hands

Did you know that the concept of hand hygiene started in 1847 when the father of hand hygiene, Ignaz Semmelweis, implemented mandatory hand washing, which dramatically decreased the deaths in a maternity ward in Vienna? A few years later, during the Crimean War, Florence Nightingale also started a hand-washing campaign. It was more than a century later, in the 1980s, when the Centers for Disease Control and Prevention (CDC) created the first national hygiene guidelines. Since then, hand washing and other forms of hand hygiene practices are recognized as important ways to prevent infection in the hospital and are considered a cost-effective tool to improve patient outcomes.

Hand Hygiene Practices: Use of Alcohol-Based Hand Sanitizer (ABHS) and Hand Washing With Soap and Water: The Good and the Bad

1. The Good
   1. More effective in reducing viable bacterial and viral count on the hands compared with hand washing with soap and water
   2. Takes less time compared with hand washing with soap and water
   3. Produces less hand irritation compared with soap and water
   4. An online CDC article, "Show Me the Science,"mentioned that ABHSs do not contribute to antibiotic resistance.
2. The Bad
   1. Not applicable in all situations, such as in the case of C. diff, where hand washing with soap and water is warranted to remove spores
   2. FDA warns that vapors from ABHS can have adverse effects. Therefore, it is recommended to apply ABHS in a well-ventilated area.
   3. Adverse effects of frequent and increased use of ABHSs are related to accidental ingestion, dermal absorption and suicidal ingestion based on a study conducted in 2020.
   4. Another research study published in 2022 revealed that ethanol exposure causes contact dermatitis, skin irritation and eye irritation. Prolonged use of ABHS containing isopropyl alcohol may lead to poisoning.

Recent Guideline Update and Practice Recommendation

The Society for Healthcare Epidemiology of America (SHEA) in collaboration with Infectious Diseases Society of America (IDSA), Association for Professionals in Infection Control and Epidemiology (APIC), American Hospital Association and The Joint Commission, recently published SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 Update, which provides recommendations and implementation strategies on hand hygiene to prevent healthcare-associated infections (HAIs). Following are some of the updates:

1. Perform Hand Hygiene - Hand hygiene must be performed at the correct moments and the correct way:
   1. 5 moments
   2. How to hand wash or use ABHS
2. Promoting the Maintenance of Healthy Hand Skin and Fingernails
   1. Maintain short, natural fingernails that should not extend past the fingertips.
   2. In high risk areas (ICU, perioperative) clinicians should not wear artificial fingernail extenders.
   3. Fingernail polish and gel shellac are prohibited for those who scrub and interact with the sterile field during surgical procedures.
3. ABHS Use
   1. Use ABHS with ingredients that enhance efficacy against organisms (with at least 60% alcohol).
   2. ABHS dispensers must be accessible.
   3. Maintain the minimum threshold for dispensers to ensure appropriate supplies are accessible.
4. Appropriate Glove Use
   1. Provide accessible facility-approved hand moisturizer compatible with antiseptics and gloves.
   2. Cotton glove liners should be available for healthcare workers (HCWs) who have adverse reactions such as contact dermatitis or similar.
   3. Use gloves for all contact with patients and the environment per standard and isolation precautions.
   4. Avoid contamination during doffing.
   5. Double gloving is not recommended, except in certain cases.
5. Environmental Contamination Reduction
   1. Use EPA-registered hospital disinfectant for cleaning hand-washing sinks, faucets and drains.
   2. Patient care supplies and medications should not be kept on countertops or mobile surfaces within 3 feet (1 meter) of the sinks.
   3. Hot air dryers are not recommended in patient care areas.
6. Monitoring Adherence to Hand Hygiene and Providing Meaningful Feedback

Ways to Monitor Adherence to Hand Hygiene

Following are some tips on how to implement and monitor compliance with hand hygiene practices:

1. Direct observation
   1. Overt - the gold standard
   2. Covert - performance baseline and evaluation of technique
2. Electronic hand hygiene monitoring system - real-time feedback and reminders; provides trends in hand hygiene performance
3. Remote video observation
4. Indirect measures - product usage
5. Audits of accessibility and functionality of supplies
6. Role modeling
7. Just-in-time education
8. Feedback and incentives
9. Behavioral nudges - visual cues such as posters and signs

Challenges With Hand Hygiene Compliance

According to the World Health Organization website, approximately 70% of HCWs do not routinely practice hand hygiene. While it is essential to improve hand hygiene compliance among HCWs, they face several challenges in achieving this goal. Following are some common challenges:

1. Time constraints - HCWs are often very busy and may not have time to perform hand hygiene during an extreme emergency
2. Skin irritation - Skin irritation or skin problems may discourage compliance with hand hygiene practices
3. Lack of resources - lack of supplies, not enough resources, lack of ABHS availability
4. Noncompliance with the guidelines or insufficient knowledge - could be due to lack of understanding the importance of hand hygiene, because they do not perceive any immediate risks to themselves or their patients, or they don't know correct hand hygiene indications and techniques
5. Lack of institutional commitment to promote and support hygiene
6. Cultural and behavioral factors - Culture and behavior also play a significant role in hand hygiene compliance. Some HCWs may not prioritize hand hygiene for cultural or behavioral reasons.
7. Situational awareness - An organization that used the LEAN methodology to look into hand hygiene compliance found that some of the reasons for low compliance include distraction and not directly touching the patient (not needing to wash)

Strategies to Increase Compliance With Hand Hygiene Practices

Increasing hand hygiene compliance among HCWs is essential to prevent HAIs. Following are some strategies that can be effective in promoting hand hygiene compliance:

1. Educate and train
   1. Back to the basics training and just-in-time education (targeted coaching)
   2. Ensuring that everyone understands when and how to perform hand hygiene (hand washing or use of ABHS)
   3. Using a visual tool for training: Make learning fun
   4. Implementing visual cues: Sometimes posters and signs may end up on a wall where no one reads them, so make those visual cues interesting
   5. The 200% method: We did this at my previous hospital. It means before you enter a patient's room, if there are two of you, you should remind your colleague to perform hand hygiene - 200% - you watch out for each other.
2. Make it a habit
   1. If you make it a habit to perform gel in and gel out, or wash in and wash out, then it will be an automatic part of your routine.
3. Ensure your preceptors are up to speed and compliant. They will be teaching new hires and if a new hire or a new graduate nurse sees the preceptor doing it, it will become a habit. I remember when I was new at one organization, my preceptor had a 100% hand hygiene compliance and it seemed that when I looked at the rest of the ICU team, they were doing the same. It is great to see everyone diligently performing hand hygiene before entering the patient's room even if all they need to do is answer a question.
4. Ensure ABHS dispensers, soap, water and sinks are accessible.
5. Make your team a part of the initiatives. Encouraging HCWs to take ownership of hand hygiene initiatives and involving them increases their commitment, which may help increase hand hygiene compliance.
6. Audits and reporting results
   1. The important part of audits is bringing back the results to the unit council and providing incentives and recognition to those units who are improving and garnering high compliance scores.
   2. Relate the score to the number of HAIs in the unit to show how meaningful the results are. At an organization where I used to work, every month, Infection Prevention would send out the hand hygiene compliance data by unit and role. It became like a contest where each role wanted to be at the top of the list.

The auditing process should not only focus on compliance with hand hygiene practices but also include the following:

• Does the patient's room have an easily accessible soap/ABHS dispenser that is working properly?
• Are there enough supplies of gloves of various sizes that are easily accessible?
• Is the sink working properly, including the temperature of the water?
• Is the paper towel dispenser equipped with paper, and is it working properly? Is it easily accessible?
• Any visual reminders or cues? For example, I used to work at a hospital where the ABHS was covered with disposable plastic with a sign not to use it but instead hand wash with soap and water. This process was specific for our patients with C. diff. It was a great reminder. You will not make a mistake using the ABHS, because it is covered and a visual cue reminds you.
• Are staff members aware of the recent results of the compliance rate for their unit?

Although we know that good hand hygiene practices are one of the basic and easiest skills to learn and the most cost-effective way to prevent HAIs, improved compliance rates are still a challenge. Just like scrubbing the hub attached to the patient's IV access port prior to medication administration, which is also a basic skill, compliance is a concern. I know you are going to ask me this question: Would you delay providing care to perform hand hygiene or scrub the hub before administering an IV push of epi during an extreme emergency? I will leave that question for you to answer. You know what is best for your patient.

I would like to end this blog by saying that annually on May 5, a global campaign to "Save Lives: Clean Your Hands" during World Hand Hygiene Day is celebrated and led by the World Health Organization.

Let's join our clean hands to support this campaign globally not only May 5 but every day where hand hygiene is warranted.