Strategies to Prevent Healthcare-Associated Infections: Hand Hygiene

1. Healthcare Infection Prevention Practices Advisory Committee (HICPAC), Centers for Disease Control and Prevention (CDC)
2. The World Health Organization (WHO)
3. The Association for Perioperative Registered Nurses (AORN), related to perioperative hand hygiene
4. The Society for Healthcare Epidemiology of America (SHEA) related to hand hygiene for the operating room anesthesia work area. Reference Munoz-Price, Bowdle and Johnston

1. Accessible and functional hand hygiene supplies, including hand sanitizer dispensers with adequate supplies of ABHS, handwashing sinks, plain or antiseptic handwash, disposable or single-use towels, and hand moisturizer that is compatible with other products and gloves
2. Senior and unit-based leadership support that is responsible and accountable for ensuring engagement and adherence of frontline personnel
3. Infection prevention personnel with training and resources to direct programs aimed at improvement of hand hygiene
4. HCP who have received training to recognize indications for hand hygiene throughout care episodes
5. Trained observers to collect adequate observations to evaluate technique and monitor performance (If automated hand hygiene monitoring systems are used, those charged with their oversight should be skilled in validating data obtained from the system.)
6. Support for data analysis and meaningful communication of monitoring results regardless of the measurement method used by the facility.

1. Promote the maintenance of healthy hand skin and fingernails. (Quality of evidence: HIGH)

   1. Promote the preferential use of ABHS in most clinical situations.(Quality of evidence: HIGH)

   2. Perform hand hygiene as indicated by the CDC or the WHO Five Moments (Table 3). (Quality of evidence: HIGH)

   3. Include fingernail care in facility-specific polices related to hand hygiene:

      1. HCP should maintain short, natural fingernails.

      2. Fingernails should not extend past the fingertip.

      3. HCP who provide direct or indirect care in high-risk areas (eg, ICU, perioperative) should not wear artificial fingernail extenders.

      4. Prohibitions against fingernail polish (standard or gel shellac) are at the discretion of the infection prevention program, except among scrubbed individuals who interact with the sterile field during surgical procedures; these individuals should not wear fingernail polish or gel shellac.

   4. Include measures for primary and secondary prevention of dermatitis.

   5. Provide HCP with readily accessible, facility-approved hand moisturizers.

   6. Engage all HCP in primary prevention of occupational irritant and allergic contact dermatitis. (Quality of evidence: HIGH)

      1. Primary prevention of HCP dermatitis should include HCP education about the following:

         1. Strategies to maintain healthy hand skin

         2. Handwashing techniques to promote healthy hand skin, such as avoiding hot water and patting rather than rubbing hands dry

         3. When and how to use gloves, change gloves, take periodic breaks to allow hands to dry, and routinely apply facility-approved moisturizers

         4. The potential for allergic reactions to components in ABHS formulations, antiseptics (eg, CHG), glove material, or products used during these products’ manufacture (eg, accelerants)

      2. Provide facility-approved hand moisturizer that is compatible with antiseptics and gloves

      3. Evaluate new products for the absence of potential allergenic surfactants, preservatives, fragrances, or dyes

      4. Workplace self-screening for dermatitis

      5. Refer HCP to the occupational health department for assistance in cases of hand eczema or dermatitis

   7. Provide cotton glove liners for HCP with hand irritation and educate these HCP on their use (ie, following instructions for use, laundering, and/or discarding) (Quality of evidence: MODERATE)

2. Select appropriate products. (Quality of evidence: HIGH)

   1. For routine hand hygiene, choose liquid, gel, or foam ABHS with at least 60 % alcohol (Quality of evidence: HIGH)

   2. Involve HCP in the selection of products (Quality of evidence: HIGH)

   3. Obtain and consider manufacturers’ product-specific data if seeking ABHS with ingredients that may enhance efficacy against organisms anticipated to be less susceptible to biocides. (Quality of evidence: MODERATE)

   4. Confirm that the volume of ABHS dispensed is consistent with the volume shown to be efficacious. (Quality of evidence: HIGH)

   5. Educate HCP about the appropriate volume of ABHS and the time required to be effective.(Quality of evidence: HIGH)

      1. The volume of hand sanitizer should be sufficient to cover all surfaces of the hands and may require >1 dispenser actuation for large hands. (Quality of evidence: HIGH)

      2. When sanitizing, HCP should rub hands for a minimum of 15 seconds. When handwashing, HCP should scrub for a minimum of 15 seconds. (Quality of evidence: HIGH)

      3. Facilities should consider fluorescent indicators for use when training HCP in the application of ABHS and handwashing.

   6. Provide facility-approved hand moisturizer that is compatible with antiseptics and gloves. (Quality of evidence: HIGH)

   7. For surgical antisepsis, use an FDA-approved surgical hand scrub or waterless surgical hand rub. (Quality of evidence: HIGH)

      1. Complete surgical hand antisepsis by performing a surgical hand rub or surgical hand scrub. (Quality of evidence: HIGH)

      2. Scrub brushes should be avoided because they damage skin. (Quality of evidence: HIGH)

3. Ensure the accessibility of hand hygiene supplies. (Quality of evidence: HIGH)

   1. Ensure that ABHS dispensers are unambiguous, visible, and accessible within the workflow of HCP. (Quality of evidence: HIGH)

      1. Use a systematic method (eg, workflow evaluation, event counters) to determine optimal placement of ABHS dispensers. (Quality of evidence: HIGH)

   2. In private rooms, consider 2 ABHS dispensers per private room the minimum threshold for adequate numbers of dispensers: 1 dispenser in the hallway, and 1 dispenser in the patient room. (Quality of evidence: HIGH)

   3. In semiprivate rooms, suites, bays, and other multipatient bed configurations, consider 1 dispenser per 2 beds as the minimum threshold for adequate numbers of dispensers. Place ABHS dispensers in the workflow of HCP. (Quality of evidence: LOW)

   4. Ensure that the placement of hand hygiene supplies (eg, individual pocket-sized dispensers, bed mounted ABHS dispenser, single use pump bottles) is easily accessible for HCP in all areas where patients receive care. (Quality of evidence: HIGH)

   5. Evaluate for the risk of intentional consumption. Utilize dispensers that mitigate this risk, such as wall-mounted dispensers that allow limited numbers of activations within short periods (eg, 5 seconds). (Quality of evidence: LOW)

      1. If individual pocket-sized dispensers are used when caring for individuals at risk for intentional consumption, they must always remain in the control of the HCP.

   6. Have surgical hand rub and scrub available in perioperative areas. (Quality of evidence: HIGH)

   7. Consider providing ABHS hand rubs or handwash with FDA-approved antiseptics for use in procedural areas and prior to high-risk bedside procedures (eg, central-line insertion). (Quality of evidence: LOW)

4. Ensure appropriate glove use to reduce hand and environmental contamination. (Quality of evidence: HIGH)

   1. Use gloves for all contact with the patient and environment as indicated by standard and contact precautions during care of individuals with organisms confirmed to be less susceptible to biocides (eg, C. difficile or norovirus).

      1. HCP caring for preterm neonate with central lines should perform hand hygiene before donning nonsterile gloves prior to patient and vascular device contact. (Quality of evidence: HIGH)

   2. Educate HCP about the potential for self-contamination and environmental contamination when gloves are worn. (Quality of evidence: HIGH)

      1. Whenever hand hygiene is indicated during episodes of care, HCP should doff gloves and perform hand hygiene.

   3. Clean hands immediately following glove removal. If handwashing is indicated and sinks are not immediately available, use ABHS and then wash hands as soon as possible.

   4. Educate and confirm the ability of HCP to doff gloves in a manner that avoids contamination. (Quality of evidence: HIGH)

      1. Consider using fluorescent indicators applied to gloves during demonstrations of doffing to help HCP visualize how contamination may occur.

5. Take steps to reduce environmental contamination associated with sinks and sink drains. (Quality of Evidence: HIGH)

   1. Ensure that handwashing sinks are constructed according to local administrative codes.

   2. Include handwashing sinks in water infection control risk assessments for healthcare settings.

   3. If possible, dedicate sinks to handwashing.

   4. Educate HCP to refrain from disposing substances that promote growth of biofilms (eg, intravenous solutions, medications, liquid food, or human waste) in handwashing sinks.

   5. Use an EPA-registered hospital disinfectant to clean sink bowls and faucets daily.

   6. Do not keep medications or patient care supplies on countertops or mobile surfaces that are within 1m (3 feet) of sinks.

      1. Install splash guards if countertops must be used to store supplies.

   7. Provide disposable or single-use towels to dry hands. Do not use hot air dryers in patient care areas.

   8. Consult with state or local public health officials when investigating confirmed or suspected outbreaks of healthcare-associated infections due to waterborne pathogens of premise plumbing.

6. Monitor adherence to hand hygiene. (Quality of evidence: HIGH)

   1. Use multiple methods to measure adherence to hand hygiene.

   2. Consider advantages and limitations of each type of monitoring.

      1. Direct observation

         1. Direct overt observation

            1. To evaluate and improve HCP technique and adherence to facility-specific policies

            2. To prevent lapses during high-risk procedures such as insertion of invasive devices.

         2. Direct covert observation

            1. To monitor rates of adherence

            2. To elucidate contextual barriers and facilitators to hand hygiene

            3. To provide corrective feedback to individuals.

   3. Use a systematic approach to determine where and when observations should occur.

      1. Provide training for individuals who will collect observations. Ensure observers are prepared to address nonadherence.

      2. Limit observation periods to no more than 15 minutes.

      3. Collect enough observations to detect statistically significant changes in practice.

   4. Use an AHHMS to monitor trends in adherence on all shifts and days of the week.

      1. Collaborate with HCP in the implementation of an AHHMS and empower them to identify ways to improve the system (eg, who to notify when real-time reminders are not accurate or when maintenance is needed).

   5. Use patient-as-observer methods in areas with limited resources, such as outpatient departments.

   6. Use product volume measurement for large-scale planning and benchmarking.

      1. Audit the accessibility and functionality of hand hygiene equipment and supplies to ensure hand hygiene is supported by the physical environment of care.

7. Provide timely and meaningful feedback to enhance a culture of safety. (Quality of evidence: MODERATE)

   1. Provide feedback in multiple formats (eg, verbal, written) and on multiple occasions (ie, real-time, weekly)

   2. Consider debriefing unit managers as soon as possible after each direct covert observation session. This can be done in a manner that preserves the observer’s confidentiality.

   3. Provide meaningful data with clear targets linked to actions to improve adherence.

      1. Meaningful data may include unit or role-based adherence data rather than overall performance.

      2. Real-time displays of hand hygiene adherence may provide incentive for improvement on a shift-by-shift basis.

1. Consider educating HCP using a structured approach (eg, WHO steps) for handwashing or hand sanitizing. Evaluate HCP adherence to technique. (Quality of evidence: LOW)

2. For waterborne pathogens in the plumbing of the facility, consider disinfection of sink drains using an EPA-registered disinfectant with claims against biofilms. Consult with state or local public health for assistance in determining appropriate protocols for use and other actions needed to ensure safe supply. (Quality of evidence: LOW)

3. For C. difficile and norovirus, in addition to contact precautions, encourage hand washing with soap and water after the care of patients with known or suspected infections. (Quality of evidence: LOW)

1. Do not supply individual pocket-sized ABHS dispensers in lieu of minimum thresholds for accessible wall-mounted dispensers.

2. Do not refill or “top-off” soap dispensers, moisturizer dispensers, or ABHS dispensers intended for single use.

3. Do not use antimicrobial soaps formulated with triclosan as an active ingredient.

4. Do not routinely double-glove except when specifically recommended for certain job roles or in response to certain high-consequence pathogens.

   1. Certain scrubbed surgical team members must wear double gloves because of the risk for glove perforations that may contaminate sterility or expose the HCP to infectious materials.

   2. Anesthesia personnel may wear double gloves during airway management.

   3. Personnel compounding medications according to the US Pharmacopeia 797 may be required to wear double gloves.

5. Do not routinely disinfect gloves during care except when specifically recommended in response to certain high-consequence pathogens.

6. Do not remove access to ABHS for HCP responding to organisms that are anticipated to be less susceptible to biocides (eg, C. difficile, norovirus).

7. Do not attempt to remediate potential biofilms in sink drains with disinfectants lacking EPA registration for this use.

Engage

1. Develop a multidisciplinary team that includes representatives from administrative leadership as well as unit and department managers and unit-level and department-level champions.

   1. Align hand hygiene goals with the organizational mission and vision for high-quality patient care.

   2. Assure that institutional leadership is aware and supportive of hand hygiene improvement strategies and supports these efforts with adequate resources.

   3. When implementing improvement programs, secure the active commitment of unit and department-based leadership. Set targets in collaboration with leaders and teams.

      1. Ensure that unit and department managers hold the HCP they supervise accountable for hand hygiene performance.

2. Utilize peer networking to encourage persistent salience of hand hygiene.

   1. Consider rewards or recognition for wards modeling good hand hygiene behaviors or improvement. Qualitative studies suggest that role modeling, particularly that of physicians, is important yet underappreciated.

3. Identify barriers and facilitators to hand hygiene adherence specific to the unit or institution. Facilitators of adherence may be as simple as having a place to set items prior to entering the patient environment. This information is then used to create interventions specific to their needs.

4. Consider enthusiastically inviting patients to take an active role in reminding HCP to perform hand hygiene

   1. Ensure HCP respond to patient requests for them to perform hand hygiene in a positive manner. Consider providing a brief script (ie, “Thank you for reminding me.”)

   2. Utilize patient education materials on the CDC website.

Educate

1. Educate HCP and assure knowledge and skill on the following items:

   1. The importance of hand hygiene in reducing the risk for HAI

   2. HHOs using WHO Five Moments or CDC indications

   3. Fingernail and hand condition, primary prevention of dermatitis

   4. Facility-specific policies regarding jewelry

   5. Delineation of the patient zone, particularly when patients are housed in bays or crowded areas

   6. Technique, ensuring coverage of all hand surfaces, duration of hand rubbing or washing

   7. Use of hand-care products that are compatible with hand hygiene products specific to the area in which HCP work

   8. Use of gloves in a manner that reduces hand or environmental contamination.

2. Use interactive methods to educate HCP about technique for hand sanitizing, handwashing, and doffing of gloves.

3. Use short, frequent educational interventions to continually build HCP knowledge and practice of hand hygiene.

   1. Assess HCP knowledge of hand hygiene with written tests or quizzes.

   2. Assess HCP skill in hand hygiene and use of gloves by return demonstration.

4. Use principles of adult education to encourage participation and ongoing learning.

Execute

1. Provide access to ABHS within the workflow of HCP.

2. Implement a multimodal (ie, bundled) hand hygiene improvement program. Accessibility and visibility of dispensers and supplies may be the most important bundle element. A culture of safety that penetrates to the individual level (ie, psychological safety) has also been associated with improved hand hygiene. Real-time verbal or electronic reminders to perform hand hygiene are likely more effective than signage. Interventions must be ongoing to maintain behavior change and improved adherence.

3. Focus on targeted behavior change. Posters, if used, should be motivational in nature rather than simply conveying information. Emphasize the protective nature of hand hygiene and altruism.

Evaluate

1. Measure hand hygiene adherence performance. A combination of approaches may be most appropriate (see Section 2).

2. Measurement may need to be adjusted for facility-specific needs. Use or build upon existing tools:

   1. WHO observation forms are available online.

   2. A variety of other forms are available for free in The Joint Commission’s hand hygiene monograph.

   3. The Joint Commission Center for Transforming Healthcare’s Targeted Solutions Tool for Hand Hygiene are available free for organizations accredited by The Joint Commission.

   4. Several iOS and Android applications, including the iScrub application, are available to assist with direct observation.

3. Provide meaningful feedback on hand hygiene performance with clear targets connected with an action plan in place for improving adherence.

   1. Feedback of hand hygiene adherence rates has long been recognized as an important component of multimodal hand hygiene improvement program, although the independent impact of feedback apart from other bundled hand hygiene interventions is not known.

   2. Feedback may be most effective when provided more than once, when both verbal and written feedback are provided, and when a superior or colleague is responsible for the audit and feedback.

   3. Providing overall hand hygiene adherence rates for a facility may not be as effective as unit based or role-based reports at identifying problem areas and planning focused training efforts.

   4. Hand hygiene data may be displayed on dashboards that provide the most recent or cumulative hand hygiene adherence rates compared with a target rate. Statistical process control charts can be used to show data trends over time and whether changes in rates are due to specific interventions or normal variation. Some automated monitoring systems can give real-time displays of hand hygiene adherence on the unit, providing some incentive for improvement on a shift-by-shift basis.

   5. Use feedback to engage HCP in identifying problems at individual hospital or unit level and use data to tailor ongoing interventions.

   6. If individually identified hand hygiene adherence rates are used, consider providing feedback privately versus in a public staff setting.

   7. Some facilities report hand hygiene adherence data in conjunction with hospital-associated infection rates. Although the association between hand hygiene and HAI reductions has been reported in the literature, the association may not be evident in individual unit or facility data due to confounding factors (eg, environmental cleanliness and small sample sizes).

   8. Use monitoring data to inform action plans at the most specific level possible (administrative area, service line, unit, or even individual) and follow through on improving these process measures as a step towards improving hand hygiene overall.