Review
Role of hand hygiene in healthcare-associated infection prevention

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Summary

Healthcare workers' hands are the most common vehicle for the transmission of healthcare-associated pathogens from patient to patient and within the healthcare environment. Hand hygiene is the leading measure for preventing the spread of antimicrobial resistance and reducing healthcare-associated infections (HCAIs), but healthcare worker compliance with optimal practices remains low in most settings. This paper reviews factors influencing hand hygiene compliance, the impact of hand hygiene promotion on healthcare-associated pathogen cross-transmission and infection rates, and challenging issues related to the universal adoption of alcohol-based hand rub as a critical system change for successful promotion. Available evidence highlights the fact that multimodal intervention strategies lead to improved hand hygiene and a reduction in HCAI. However, further research is needed to evaluate the relative efficacy of each strategy component and to identify the most successful interventions, particularly in settings with limited resources. The main objective of the First Global Patient Safety Challenge, launched by the World Health Organization (WHO), is to achieve an improvement in hand hygiene practices worldwide with the ultimate goal of promoting a strong patient safety culture. We also report considerations and solutions resulting from the implementation of the multimodal strategy proposed in the WHO Guidelines on Hand Hygiene in Health Care.

Introduction

Numerous studies document the pivotal role of healthcare workers' (HCWs) hands in the propagation of micro-organisms within the healthcare environment and ultimately to patients.1 As recently described, patient-to-patient transmission of pathogens via HCWs' hands involves five sequential steps.2 Patients' skin can be colonised by transient pathogens that are subsequently shed onto surfaces in the immediate patient surroundings, thus leading to environmental contamination.2 As a consequence, HCWs contaminate their hands by touching the environment or patients' skin during routine care activities, sometimes even despite glove use.2 It has been shown that organisms are capable of surviving on HCWs' hands for at least several minutes following contamination.2 Thus, if hand hygiene practices are suboptimal, microbial colonisation is more easily established and/or direct transmission to patients or a fomite in direct contact with the patient may occur.2

Based on this evidence and the demonstration of its effectiveness, optimal hand hygiene behaviour is considered the cornerstone of healthcare-associated infection (HCAI) prevention.2, 3, 4 Furthermore, not only is it a key element of standard and isolation precautions, but its importance is emphasised also in the most modern ‘bundle’ approaches for the prevention of specific site infections such as catheter-related bloodstream infection (CRBSI), catheter-related urinary tract infection (CRUTI), surgical site infection (SSI), and ventilator-associated pneumonia (VAP).5, 6, 7, 8, 9

Together with other specific prevention measures, environmental cleaning is another essential measure to prevent the spread of some pathogens, particularly Clostridium difficile, vancomycin-resistant enterococci (VRE), norovirus, Acinetobacter spp. and meticillin-resistant Staphylococcus aureus (MRSA), and should not be neglected.10, 11, 12

Over the past few years, scientific evidence to support the role of hand hygiene in the improvement of patient safety has increased considerably, but some key controversial issues still challenge care practitioners and researchers. This review summarises the key themes on the role of hand hygiene in preventing HCAI. Interpretations and solutions based on the evidence and experience available through the work of the First Global Patient Safety Challenge of the WHO World Alliance for Patient Safety are suggested.

Section snippets

Factors influencing hand hygiene compliance

It has been known for many years that HCWs encounter difficulties in complying with hand hygiene indications at different levels.4 Insufficient or very low compliance rates have been reported from both developed and developing countries.1, 4 Reasons which explain suboptimal practices are multiple and may vary according to the setting and the resources available. For example, the lack of appropriate infrastructure and equipment to enable hand hygiene performance, the cultural background, and

Impact of hand hygiene promotion on HCAI

Given the complexity of hand hygiene behaviour and the influence of numerous external factors, promotion of good practices is complex and its potential for success depends on the delicate balance between evaluation of benefits and existent barriers. Demonstration of the effectiveness of recommendations and strategies to improve hand hygiene on the ultimate outcome, i.e. the HCAI rate, is crucial in both motivating HCWs' behavioural change and securing an investment in this preventive measure by

Challenging issues related to the adoption of alcohol-based hand rubs

The adoption of alcohol-based hand rubs is considered the gold standard for hand hygiene in most clinical situations. This recommendation, promoted by the CDC and WHO and embraced by many national hand hygiene guidelines, is based on the evidence of better microbiological efficacy, less time required to achieve the desired effect, point of patient care accessibility and a better skin tolerance profile.1, 29, 50, 51, 52, 53, 54, 55, 56

The WHO Guidelines on Hand Hygiene in Health Care have been

Controversial issues related to the use of alcohol-based hand rubs and Clostridium difficile spread

Following the widespread use of alcohol-based hand rubs as the gold standard for hand hygiene in healthcare, concern has been raised about their lack of efficacy against spore-forming pathogens. Indeed, apart from iodophors, albeit at a concentration remarkably higher than the one used in antiseptics, no hand hygiene agent (including alcohols, chlorhexidine, hexachlorophene, chloroxylenol, and triclosan) is reliably sporicidal against Clostridium or Bacillus spp.1, 58 Mechanical friction while

Discussion

From the available evidence it appears that multimodal interventions are the most suitable strategy to determine behavioural change leading to improved hand hygiene compliance and reduction in HCAI rates. Introduction of alcohol-based hand rubs and continuous educational programmes are key factors to overcome infrastructure barriers and to build solid knowledge improvement. Support by healthcare administrators and commitment by national and local governments are essential to make hand hygiene

Acknowledgements

We wish to thank all members of the Infection Control Programme, University of Geneva Hospitals and members of the WHO First Global Patient Safety Challenge ‘Clean Care is Safer Care’ core group (lead, D. Pittet): J. Boyce, B. Cookson, N. Damani, D. Goldmann, L. Grayson, E. Larson, G. Mehta, Z. Memish, H. Richet, M. Rotter, S. Sattar, H. Sax, W.H. Seto, A. Voss, A. Widmer.

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