Hand hygiene is one of the most effective means of reducing healthcare associated infection (HCAI). However, compliance by healthcare workers (HCWs) with recommended hand hygiene frequencies and techniques has been reported as suboptimal.^1;2 Time constraints, skin integrity, physical resources and absence of role models have been identified as barriers to compliance.³ Improved compliance has been reported following education,² introduction of alcohol gels/rubs,⁴ observation and feedback,⁵ and local promotion activities.

Adherence of HCWs to hand hygiene guidelines has been measured by direct observation, indirect measurements (e.g., alcohol gel/rub, soap and paper towel usage) and self reporting of practice.⁶ The World Health Organisation (WHO) recommends direct observation as the gold standard.⁷

The advantages of direct observation are:

• Assessment of compliance rates in different groups of HCWs⁸
• Assessment of HCW behaviour (e.g., when and where HCWs are more likely to wash their hands⁹)
• Assessment of hand hygiene technique^10;11

Disadvantages of direct observation are:

• Labour intensive and time consuming¹²
• Requirement for trained observers¹³
• Influence of the “Hawthorne effect” on results^14;15
• Objectivity of the observer¹³
• Using results to compare internally or externally when the
inter rater reliability has not been assessed¹⁴

Irish national hand hygiene guidelines were published in 2005 and while some healthcare facilities (HCF) are currently measuring staff compliance using the hand hygiene observation audit tool adapted from these guidelines,¹⁵ other facilities are using a range of different tools. In addition data on alcohol hand gel/rub usage in acute hospitals in available at www.hpsc.ie

The Health Protection Surveillance Centre (HPSC) in conjunction with the Infection Prevention Society (IPS) have devoloped a hand hygiene observation audit tool and a standard operating procedure (SOP) to improve consistency in hand hygiene observation audits in all acute HCFs. The tool has been piloted and has been approved by the national Strategy for Antimicrobial Resistence in Ireland (SARI) commitee. The SOP is here.

Compliance with hand hygiene is measured by noting a hand hygiene opportunity (HHO) and observing if the HCW performed a hand hygiene episode in response to that opportunity. The WHO “5 moments for hand hygiene” are used to define what is an opportunity.¹⁶ A hand hygiene episode is defined as hand washing with soap and water or using an alcohol gel/rub. Compliance is defined as the total observed hand hygiene episodes divided by the HHO multiplied by 100 and expressed as a percentage.

Compliance = observed hand hygiene episodes x 100 = % compliance
                          hand hygiene opportunities (HHO)

Acute healthcare facilities (HCF) are advised to undertake hand hygiene observational audits biannually. A local action plan to address compliance rates <75% should be put in place in each HCF. This target (75%) should be viewed as the start of a process which will see it increase year on year. The overall aim of this process is to achieve 100% compliance.

Sheila Donlon and Fidelma Fitzpatrick, HPSC

References

(1) Creedon SA. Hand hygiene compliance: exploring variations in practice between hospitals. Nurs Times 2008 Dec 9;104(49):32-5.
(2) Creedon SA. Healthcare workers' hand decontamination practices: compliance with recommended guidelines. J Adv Nurs 2005 Aug;51(3):208-16.
(3) Barrett R, Randle J. Hand hygiene practices: nursing students' perceptions. J Clin Nurs 2008 Jul;17(14):1851-7.
(4) Zerr DM, Allpress AL, Heath J, Bornemann R, Bennett E. Decreasing hospital-associated rotavirus infection: a multidisciplinary hand hygiene campaign in a children's hospital. Pediatr Infect Dis J 2005 May;24(5):397-403.
(5) Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000 Oct 14;356(9238):1307-12.
(6) Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007 May;66(1):6-14.
(7) World Heath Organisation. WHO guidelines on hand hygiene in health care (advanced draft). 2006. Ref Type: Generic

(8) Sladek RM, Bond MJ, Phillips PA. Why don't doctors wash their hands? A correlational study of thinking styles and hand hygiene. Am J Infect Control 2008 Aug;36(6):399-406.
(9) Wendt C, Knautz D, von BH. Differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers. Infect Control Hosp Epidemiol 2004 Mar;25(3):203-6.
(10) MacDonald DJ, McKillop EC, Trotter S, Gray A, Jr. Improving hand-washing performance - a crossover study of hand-washing in the orthopaedic department. Ann R Coll Surg Engl 2006 May;88(3):289-91.
(11) MacDonald DJ, McKillop EC, Trotter S, Gray AJ. One plunge or two?--hand disinfection with alcohol gel. Int J Qual Health Care 2006 Apr;18(2):120-2.
(12) Boyce JM. Hand hygiene compliance monitoring: current perspectives from the USA. J Hosp Infect 2008 Oct;70 Suppl 1:2-7.
(13) Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 2002 Dec;23(12 Suppl):S3-40.
(14) Kohli E, Ptak J, Smith R, Taylor E, Talbot EA, Kirkland KB. Variability in the Hawthorne Effect With Regard to Hand Hygiene Performance in High- and Low-Performing Inpatient Care Units. Infect Control Hosp Epidemiol 2009 Jan 27.
(15) SARI Infection Control Sub-committee. Guidelines for Hand Hygiene in Irish Health Care Settings. 2005.
(16) WHO Guidelines on Hand Hygiene in Health Care. World Health Organisation . 2009.