hand hygiene include: location of the sink and
soap; the type of sink and faucets; the type of
paper towels for drying hands or automatic
hand dryers; location and ease of use of the
ABHRs dispensers; the products and whether
the staff likes it or not; application time required
by manufacturers’ instructions for use; and the
patient’s complexity and the patient’s need for
transmission based precautions.
Understanding human behavior via behavioral
health models is another process to identify the
key element for improving compliance with
recommended infection prevention strategies.
One early example was the use of multi-faceted
bundles of care to prevent central line-associated
bloodstream infections (CLABSIs) via improve
compliance with recommended practices. Hand
hygiene and use of sterile techniques were
some of the prevention strategies included in
the bundle. This national project also focused
on institutional culture and feedback to clinical
teams and required leadership support for the
prevention program. Implementation of the
CLABSI bundle in hospitals across the country
has resulted in significant reductions in this type
of healthcare-associated infection.
Subsequently, hand hygiene programs have
used behavioral health models to identify and
address barriers to compliance.
Building a successful hand hygiene program
requires intentional work and the use of imple-
mentation science to establish a program that
addresses the key factors related to appropriate
hand hygiene.
Important steps include:
A. Establish a system that teaches the proper
steps for hand hygiene to all new employees and
measure competency by demonstration after ini-
tial training and then at least annually thereafter.
The employee should be able to vocalize when
hand hygiene should be performed and be able
to demonstrate proper handwashing and also
the application of AHBR to clean their hands.
B. Use creative ways to demonstrate the
impact of proper hand hygiene in the removal
of bacteria found on the skin.
➊ Culturing of hands: There are several
ways to do it: the bag-rinse method by putting
hands into a bag with media and then culturing
the fluid; swabbing hands and then plating on
an agar plate; and finally, culturing the hand on a
large agar plate. Culturing the hands by placing a
dirty hand on an agar plate and then clean hands
on another plate and incubate for 24-48 hours is
very effective. After incubation of the plates, each
person should be shown their before and after
results. Although the results are not immediately
available, the realization of what effective hand
hygiene does in reducing the microbial load is “a
picture is worth a thousand words.”
www.healthcarehygienemagazine.com • may 2020
➋ A variety of dyes or markers such as
fluorescent dyes are available to mimic the
removal of the bioburden on hands after hand
hygiene. A black light will be needed to show
the fluorescents dye. Feedback to the healthcare
worker is immediate with these markers and
some consider it is advantageous to see the
results in close proximity to performing hand
hygiene procedure.
B. Monitoring of hand hygiene practices
should be done consistently via an established
schedule.
C. The monitor should note that the appro-
priate supplies are available at the point of care
including alcohol-based handrubs, soap and paper
towels plus gloves.
D. Provide feedback of monitoring results per
protocol to staff individually or to the group/unit
and to infection prevention program, quality
committees and leadership.
E. The monitor should be trained on how
to provide individual feedback should include
scripting of messages and when to do it in order to
how to create a positive culture of patient safety.
F. Keeping hands healthy without redness,
cracks, rashes, etc. is also key to decreasing the
microbial load on hands. Facilities should provide
hand lotion that is compatible with their hand
hygiene products and gloves. If the healthcare
provider has extensive skin breakdown of their
hands, occupational health services should see the
person and make appropriate recommendations
of care to heal the skin.
The challenge with hand hygiene protocols is
to achieve compliance 100 percent. Reductions
in HAIs have been reported in multiple studies
when compliance with hand hygiene protocol
increased. Healthcare facilities must ensure
that each healthcare worker is appropriately
performing hand hygiene to reduce the risk of
transmission of microbes.
In that light, the Joint Commission -- to
emphasize the importance of hand hygiene
in preventing infections -- has begun to cite
non-compliance with hand hygiene when it is
observed. Previously when non-compliance was
observed the Joint Commission would evaluate
compliance monitoring activities, improvement
strategies and compliance rates and not cite
unless there was a significant breach in practices.
According to the CDC Guideline for Hand
Hygiene in All Healthcare Settings 2002, han-
washing should be performed when hands are
visibly soiled. Handwashing is also recommended
when spores are the suspected pathogen such
as Clostridioides difficile or Candida auris. Spores
are not killed or removed from hands by ABHR
hand hygiene products. Therefore, handwashing
is recommended because it removes and dilutes
the presence of the spores by friction and rinsing
Understanding
human
behavior via
behavioral
health models
is another
process to
identify the
key element
for improving
compliance
with
recommended
infection
prevention
strategies.
25