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Compliance with hand hygiene in emergency medical services: an international observational study
  1. Heidi Storm Vikke1,2,
  2. Svend Vittinghus2,
  3. Matthias Giebner3,
  4. Hans Jørn Kolmos1,4,
  5. Karen Smith5,6,7,
  6. Maaret Castrén8,
  7. Veronica Lindström9,10
  1. 1 Department of Clinical Research, University of Southern Denmark, Odense, Denmark
  2. 2 Medical Office, Falck Danmark A/S, Kolding, Denmark
  3. 3 A & E Department, Sygehus Soenderjylland, Aabenraa, Denmark
  4. 4 Department of Clinical Microbiology, Odense University Hospital, Odense, Denmark
  5. 5 Centre fro Research and Evaluation, Ambulance Victoria, Melbourne, Victoria, Australia
  6. 6 Department of Community Emergency Health and Paramedic Practice, Monash University, Melbourne, Victoria, Australia
  7. 7 Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
  8. 8 Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki University, Helsinki, Finland
  9. 9 Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
  10. 10 SamordnareAkademisk ambulans SLL, Academic EMS, Stockholm, Sweden
  1. Correspondence to Dr Heidi Storm Vikke, Department of Clinical Research, University of Southern Denmark, Odense 5230, Denmark; hevi{at}, hevi{at}


Introduction Healthcare-associated infection caused by insufficient hygiene is associated with mortality, economic burden, and suffering for the patient. Emergency medical service (EMS) providers encounter many patients in different surroundings and are thus at risk of posing a source of microbial transmission. Hand hygiene (HH), a proven infection control intervention, has rarely been studied in the EMS.

Methods A multicentre prospective observational study was conducted from December 2016 to May 2017 in ambulance services from Finland, Sweden, Australia and Denmark. Two observers recorded the following parameters: HH compliance according to WHO guidelines (before patient contact, before clean/aseptic procedures, after risk of body fluids, after patient contact and after contact with patient surroundings). Glove use and basic parameters such as nails, hair and use of jewellery were also recorded.

Results Sixty hours of observation occurred in each country, for a total of 87 patient encounters. In total, there were 1344 indications for HH. Use of hand rub or hand wash was observed: before patient contact, 3%; before clean/aseptic procedures, 2%; after the risk of body fluids, 8%; after patient contact, 29%; and after contact with patient-related surroundings, 38%. Gloves were worn in 54% of all HH indications. Adherence to short or up done hair, short, clean nails without polish and no jewellery was 99%, 84% and 62%, respectively. HH compliance was associated with wearing gloves (OR 45; 95% CI 10.8 to 187.8; p=0.000) and provider level (OR 1.7; 95% CI 1.1 to 2.4; p=0.007), but not associated with gender (OR 1.3; 95% CI 0.9 to 1.9; p=0.107).

Conclusion HH compliance among EMS providers was remarkably low, with higher compliance after patient contacts compared with before patient contacts, and an over-reliance on gloves. We recommend further research on contextual challenges and hygiene perceptions among EMS providers to clarify future improvement strategies.

  • emergency medical services
  • hand hygiene
  • prehospital care

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  • Contributors HSV wrote the protocol under supervision from MG, HJK, KS, MC and VL. The planning and execution of data collection were conducted by HSV and SV with support from MC, KS and VL. All statistics were conducted by HSV under the supervision of HJK. Writing the article was done by HSV under the supervision of MG, HJK, KS, MC and VL. All authors read and approved the final manuscript.

  • Funding Falck Denmark A/S and the Danish Innovation fund co-funded the study in a Business PhD partnership.

  • Competing interests None declared.

  • Patient consent Not required.

  • Ethics approval All study phases were conducted under strict consideration of the Declaration of Helsinki. Participation was voluntary and all observations anonymised. In Denmark, the study was exempted from specific ethical approval due to the non-interventional nature of the study. Ethical approval in Finland, Sweden and Australia was obtained according to local regulations and local human research ethics committees. All observations prioritised the well-being of the patients.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement The datasets generated and analysed during the current study are not publicly available due to commercial interests but are available from the corresponding author on reasonable request.