Gould EDIT 16/5/08 10:08 am Page 63
Hand Hygiene Compliance
chlorhexidine or trisclosan. Alcohol-based products acquire substantivity Others have been pitched at specific groups and have taken place in a limited
when combined with chlorhexidine, but otherwise their rapid effectiveness number of clinical settings.
6,13,35,37,39–41
Therefore, the extent to which the same
is short-lived. type of intervention would be successful in other countries or other types of
healthcare settings is unknown.
In Switzerland, alcohol hand-rubs containing chlorhexidine are reported to
have contributed to increased hand hygiene compliance among nurses and In addition to their lack of external validity, most interventions to encourage
domestic staff, although not doctors, and to have reduced overall levels of hand hygiene compliance suffer due to the absence of a conceptual
HCAI and MRSA.
4
In the UK, alcohol hand-rubs that do not contain framework to underpin the intervention. This is apparent in their lack of clarity
chlorhexidine appear to have had some success in increasing hand hygiene concerning what the intervention is intended to achieve. While the authors
compliance, although their impact on HCAI remains equivocal.
33
The usually describe the intervention as ‘educational’ or use the term ‘education’
preliminary findings of this study are at odds with the reports of a recent interchangeably with ‘training,’ many accounts appear to bear the hallmarks
comprehensive review of the international literature,
34
which could find no of training rather than genuine education, ignoring important differences
conclusive evidence that alcohol-based products either have any impact on between the two activities and their different purposes. Education is intended
hand hygiene compliance or reduce levels of HCAI, because clinical trials are to promote intellectual curiosity and to encourage personal, professional, and
poorly designed. academic development, all factors that have been recognized as necessary
ingredients in successful attempts to achieve sustainable change in health
Alcohols have excellent bactericidal activity against most Gram-negative and service practice and performance.
42
Training is an altogether more pedestrian
Gram-positive bacteria, but no effect on spores and some types of viruses, endeavor focusing on the promotion of a limited repertoire of activities.
42
It
notably enteroviruses. Therefore, the need for conventional washing and can promote the discipline necessary to perform a restricted set of required
drying to remove spores from the hands by detergent effect must be behaviors, but will not encourage the development necessary to underpin
emphasized to health workers. Attempts to increase compliance must not successful and enduring changes in practice and performance.
42
rely entirely on the use of alcohol-based products. Their increasing
popularity may be at the expense of traditional washing and drying, and
may be contributing to the increase in cases of Clostridium difficile currently Failure to distinguish between the
being reported by the UK Healthcare Commission. Lack of detergent effect
related, but different, processes of
also means that alcohol-based products are unsuitable when hands are
heavily contaminated.
30
To encourage compliance the formulation must education and training may help to
incorporate an emollient, because alcohol de-fats skin and would otherwise
account for the disappointing outcomes
promote dryness and soreness, both of which are disincentives to the
necessarily frequent, repeated use. Alcohol-based products are considered of interventions intended to increase
to offer the greatest benefit at times of heavy workload when health
hand hygiene compliance.
workers move quickly between different patients and different activities,
without time to use a sink.
14,23
Failure to distinguish between the related, but different, processes
Education and Training to Increase of education and training may help to account for the disappointing
Hand Hygiene Compliance outcomes of interventions intended to increase hand hygiene compliance.
A number of educational and training strategies have been employed to The Swiss initiative
4
and all those it has stimulated, such as the
increase hand hygiene compliance. Most have been work-based rather than CleanYourHandsCampaign in England and Wales,
32
have more in common
classroom-based and many have incorporated practical demonstrations.
35,36
with training than education because of their heavy reliance on audit with
In numerous initiatives, hand hygiene performance has been audited. performance feedback to fuel behavior change. Compared with education,
Feedback of the results has been disseminated to constantly remind health training is inexpensive and is much less resource-intensive, but its impact is
workers about the need for hand hygiene.
4,29,37,38
likely to be short-lived and influenced by staff turnover and shortages
because health workers are coached to undertake a repetitive set of
In Switzerland, this approach has formed the basis of a much-publicized activities rather than to think creatively in novel situations. Thus, any
initiative where continuous audit with performance feedback is considered to learning that has taken place is unlikely to be transferable beyond the
be one of the most important ingredients of success.
4
However, a recent immediate situation to which it is applied. More subject to decay than
systematic review
1
concluded that at present there is little evidence to suggest genuine education, training may well be less cost-effective in the longer
that existing educational/training initiatives intended to promote hand term because it will require frequent updating.
hygiene compliance have been successful. Most have been restricted to a few
weeks or months and explore only the frequency of hand hygiene, not its The Role of the Organization in Hand Hygiene Compliance
quality or its impact on HCAI rates. A major drawback of these Increasing attention is being paid to the role of the organization operating
so-called educational initiatives is that they have taken place in many different within the hospital or healthcare facility concerning hand hygiene
countries with different systems of healthcare, and because the teaching is compliance.
1,43
The need for strong leadership in all matters pertaining to
often poorly described in journal articles it is not always easy to determine the infection prevention has been acknowledged in policy documents in the
precise nature and content of the intervention. Some campaigns, such as the UK.
9
Moreover, there is emerging evidence that where health workers
one in Switzerland,
4,36
have been targeted at all health workers in the hospital. receive robust support from their infection control team and when
US INFECTIOUS DISEASE 63
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