Healthcare Hygiene magazine December 2019 | Page 20

Boosting Hand
Hygiene Compliance:
FPO
Educate Around the Right
Moments and Proper Technique
By Kelly M. Pyrek
S
tudies have extensively documented the suboptimal rates
of hand hygiene compliance by healthcare personnel,
as well as established the numerous barriers to compliance.
One of the very latest data sets is provided by Salmon, et al.
(2019) who conducted a hospital-wide survey to investigate
improvement in handwashing. Their results revealed that
healthcare workers (HCWs) acknowledge the serious
consequences of developing a hospital-acquired infection
(HAI); however, 35 percent of physicians, 32 percent of
allied health workers and 20 percent of nurses admitted to
omitting hand hygiene over focusing on the clinical task.
Similarly, 35 percent of physicians, 40 percent of allied health
workers and 25 percent of nurses struggled to remember
the right ‘moment’ to perform hand hygiene. Let’s examine
several key issues.
Defining opportunities must be an ongoing educational
objective in healthcare institutions.
Ellingson, et al. (2014) remind us that to measure hand
hygiene adherence, the opportunities for hand hygiene
must be defined in clear and measurable ways. The most
commonly recognized framework for measuring hand
hygiene opportunities is the World Health Organization
(WHO)’s 5 Moments for Hand Hygiene. As the experts
explain, these moments include the many indications for
hand hygiene defined in the CDC and WHO guidelines
summarized into “moments” to promote clarity in education
and measurement.
Significant variation in hand hygiene
CLICK FOR
opportunities
across institutions has
The 5
been observed by numerous researchers.
Moments for
Hand Hygiene As Ellingson, et al. (2014) explain, “Some
organizations teach the concepts of the
5 moments but simplify measurement by observing hand
hygiene opportunities only before and after care (the entry
and exit method). Many institutions in the U.S. have, for
communication and assessment purposes, compressed
the number of hand hygiene opportunities to entry to and
exit from a patient-care area, which roughly corresponds
with the WHO’s moment 1 and moment 4 or 5. Although
there is some concern that this leaves out moment 2
(before an aseptic procedure) and other opportunities for
contamination within the patient-care encounter, there is
some evidence that the entry and exit method may be an
adequate proxy for measurement of hand hygiene for the
entire patient encounter.”
The researchers continue, “Operationally, the entry and
exit method is easier to institute for measurement purposes
and respects patient privacy. Emphasis on moment 1 and
moment 4 (or 5) also highlights the priority for reducing
cross-transmission of pathogens in healthcare … The CDC’s
protocol for multidrug-resistant organism and C. difficile
20
infection (CDI) surveillance includes hand hygiene mea-
surement as a ‘supplemental prevention process measure.’
For simplification of measurement, the protocol stipulates
observation of hand hygiene opportunities after healthcare
personnel con tact with a patient or with inanimate objects in
the vicinity of the patient (moments 4 and 5 only). Monitoring
hand hygiene on exit from a patient room (or after care) is
convenient for observers because the indication for hand
hygiene is obvious.”
One of the challenges of convincing HCWs about
the criticality of hand hygiene is the lack of randomized
trials or epidemiologically rigorous observational studies,
despite numerous strong recommendations in the CDC and
WHO guidelines. As Ellingson, et al. (2014) observe, “This
lack of rigor occurs in part because of ethical considerations
in randomizing control groups and in part because investment
in the science behind hand hygiene has lagged behind
other healthcare research topics.” They add, “The lack of
randomized trials to test recommendations for hand hygiene
indications that have become standard of care is likely to
persist, largely due to ethical concerns. However, more
rigorous studies could provide a better evidence base for
other important aspects of hand hygiene, such as optimizing
methods for hand hygiene measurement. Similarly, more
rigorous multisite studies of implementation of hand hygiene
programs and studies of hand hygiene in non-acute care
settings are needed. Finally, establishing consistent methods
for assessing the efficacy of various products relative to the
volume and technique used in clinical settings is critical.”
Regarding product efficacy, studies have been conducted to
compare the relative efficacy against bacteria. In most studies,
ABHRs (with alcohol concentrations between 62 percent and
95 percent) are described as being more effective than either
plain or antimicrobial soaps over a broad range of testing
conditions. Of clinical studies of hand hygiene product efficacy
against bacteria that compare ABHR with soap products in use
by HCP, many report ABHR to be superior to soap formulations
or at least equivalence of ABHR with soap products. Likewise,
most studies show that ABHRs have significantly better efficacy
in removing several different viruses than nonantimicrobial
and antimicrobial soap and water, suggesting that ABHRs are
likely to provide some protection against several respiratory
and enteric viruses on the hands. As Ellingson, et al. (2014)
caution, “One issue of concern is that study conditions may
not always be reflective of clinical situations because artificial
contamination with microorganisms and controlled hand
hygiene regimens are sometimes used.
When it comes to hand hygiene technique, the CDC and
WHO guidelines provide general guidance on technique
and recommend that manufacturer guidance be followed
for volume of hand hygiene product used and contact time
december 2019 • www.healthcarehygienemagazine.com