“ I think it was the fear of a novel virus that nobody knew much about , that was driving compliance . Once the pandemic began to evolve and more data became available , healthcare workers began to relax a bit and I think that ’ s what we ’ re seeing with the COVID-19 pandemic . ”
— John Boyce , MD
rates of hand hygiene compliance as the primary outcome measure . This will not be enough to justify investment in improving hand hygiene during the challenging times that lie ahead .”
What is fascinating is to examine the hand hygiene compliance rates during previous pandemics . For example , Labarca , et al . ( 2011 ) reported that healthcare worker hand hygiene adherence was considerably higher during the H1N1 influenza pandemic in 2009 ( 62 percent ) than in the preceding years ( 48 percent ), but that it declined to 35 percent in the following year . Fulcini , et al . ( 2018 ) observed an increase in the use of alcohol-based handrub during the H1N1 pandemic , although hand hygiene compliance did not increase significantly compared with the period leading up to the pandemic . Several other studies ( Roshan , et al ., and Israel , et al .) found that hand hygiene compliance increased during the pandemic compared to before .
John Boyce , MD , points to a 2011 paper he wrote that addressed hand hygiene practices during the H1N1 influenza pandemic . “ At the time we had alcohol-based hand sanitizer dispensers in our institution ’ s ICU and on a general medical ward , and they measured how many times a healthcare worker used the dispenser . Our data showed that at the very beginning of the H1N1 pandemic , when cases started reporting out of Mexico , there were very severe cases and everyone was afraid ,” Boyce recalls . “ Very early in the pandemic there was a big increase in the frequency of people using the dispensers , and then within a period of several weeks , it dropped back down , close to the baseline hand hygiene compliance rate . So , I think it was the fear of a novel virus that nobody knew much about , that was driving compliance . There was a great deal of concern that H1N1 infection might be very serious and potentially fatal , so there was a fear factor . Once the pandemic began to evolve and more data became available , healthcare workers began to relax a bit and I think that ’ s what we ’ re seeing with the COVID-19 pandemic .”
What many studies are indicating is that hand hygiene compliance increased at the beginning of the pandemic , fueled by healthcare workers ’ fear around a somewhat novel virus , but that as the many months of the public health crisis passed , robust hand hygiene practices were not sustained and in some institutions , they returned to near-baseline levels . [ Note : Clinicians should be aware that many of the studies addressing hand hygiene behavior during the pandemic used electronic monitoring systems , and some of the research was underwritten by manufacturers .]
Williams , et al . ( 2021 ) confirm that the first wave of the COVID-19 pandemic was associated with significant improvement in hand hygiene adherence . The researchers observe , “ There are two notable differences in the improvement in hand hygiene observed with COVID-19 compared to what is observed with other outbreaks . First , the rise in hand hygiene performance was over threefold higher than what has been observed with group electronic hand hygiene monitoring systems during hospital outbreaks unrelated to SARS-CoV-2 . The accentuated improvements in response to SARS-CoV-2 , observed in our study and in previous single-center studies , may be related to the higher degree of fear associated with this novel pathogen , especially early in the pandemic . Second , the improved hand hygiene performance observed in our study was likely associated with the perceived risk of COVID-19 as opposed to the actual risk , since hand hygiene adherence peaked before the highest COVID-19 case numbers .”
As the researchers note , “ We found a significant association between the number of patients admitted with COVID-19 and hand hygiene practices . This finding suggests that the local experience of healthcare workers within their hospital influenced practice , either through the tightened infection control protocols of caring for patients with COVID-19 or because of their overall risk perception . The latter may have played a more important role , given the generalized improvement in hand hygiene adherence that we observed , and its association with daily cases of COVID-19 reported .”
The researchers lamented that the improvements in hand hygiene adherence were not sustained , as performance returned to baseline levels within three months . They note , “ Most strikingly , this decay in adherence began while COVID-19 case numbers were still increasing . This finding is similar to the single-center study in the U . S . that used automated hand hygiene monitoring during the first wave of the pandemic . We hypothesize that the novelty and perceived risk of caring for patients with COVID-19 most likely decreased over time as healthcare workers became accustomed to caring for these patients . Another potential contributor to this decay in performance is the COVID-19 pandemic itself , which has caused higher levels of healthcare worker burnout , a situation that is known to contribute to suboptimal hand hygiene rates .”
In another recent study , Moore , et al . ( 2021 ) examined the impact of the COVID-19 pandemic on hand hygiene performance ( HHP ) rates in acute-care hospitals . They estimated the trajectory of HHP rates in the 10 weeks leading up to a COVID-19-related milestone event ( school closures ) and for 10 weeks after . The researchers report that average HHP rates increased from 46 percent to 56 percent in the months preceding pandemic-related school closures . This was followed by a 6 percent upward shift at the time school closures occurred . HHP rates remained over 60 percent for four weeks before declining to 54 percent at the end of the study period .
Alcohol-based handrub and soap dispensers recorded each actuation as a hand hygiene event . Activity monitors placed near each patient room doorway detected each entry into and exit from the room as a hand hygiene opportunity . Unit-level