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Volume 7, Number 2—April 2001
THEME ISSUE
4th Decennial International Conference on Nosocomial and Healthcare-Associated Infections
Prevention is Primary

Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach

Didier PittetComments to Author 
Author affiliation: University of Geneva Hospitals, Geneva, Switzerland

Main Article

Table 3

Strategies for successful promotion of hand hygiene in hospitals

Parameter Tool for change Selected referencesa
Education Ea (M, S) 14,23,63,74,76
Routine observation and feedback S (E, M) 6,14,23,63,74,76
Engineering controls S 63
Make hand hygiene easy, convenient S 63,74,77,78
Make available alcohol-based hand rub S 63
Alcohol-based hand rub available in high-demand situations S 63,78
Patient education S (M) 79
Reminders in the workplace S 52,63
Administrative sanctions, rewards S 3,20
Change in hand hygiene agent S (E) 21,80
Promote, facilitate skin care for HCW hands S (E) 17,21,47,63
Obtain active participation at individual and institutional level E, M, S 46,63
Ensure institutional safety climate S (M) 46,63
Enhance individual and institutional self-efficacy S (E, M) 46,63
Avoid overcrowding, understaffing, excessive workload S 9,15,63,81,82
Combination of above strategies E, M, S 14,23,46,63,74

aE = education; M = motivation; S = system; HCW = health-care worker
bOnly selected references are listed; refer to more extensive reviews (10,30,46) for exhaustive reference lists.

Main Article

References
  1. Semmelweis  I. The etiology, concept and prophylaxis of childbed fever [excerpts]. In: Buck C, Llopis A, Najera E, Terris M, editors. The challenge of epidemiology--issues and selected readings. Washington: PAHO Scientific Publication; 1988. p. 46-59.
  2. Rotter  ML. 150 years of hand disinfection--Semmelweis' heritage. Hyg Med. 1997;22:332–9.
  3. Jarvis  WR. Handwashing--the Semmelweis lesson forgotten? Lancet. 1994;344:1311–2. DOIPubMedGoogle Scholar
  4. Rotter  ML. Semmelweis' sesquicentennial: a little-noted anniversary of handwashing. Curr Opin Infect Dis. 1998;11:457–60.PubMedGoogle Scholar
  5. Albert  RK, Condie  F. Hand-washing patterns in medical intensive-care units. N Engl J Med. 1981;304:1465. DOIPubMedGoogle Scholar
  6. Graham  M. Frequency and duration of handwashing in an intensive care unit. Am J Infect Control. 1990;18:77–81. DOIPubMedGoogle Scholar
  7. Doebbeling  BN, Stanley  GL, Sheetz  CT, Pfaller  MA, Houston  AK, Annis  L, Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med. 1992;327:88–93. DOIPubMedGoogle Scholar
  8. Thompson  BL, Dwyer  DM, Ussery  XT, Denman  S, Vacek  P, Schwartz  B. Handwashing and glove use in a long-term care facility. Infect Control Hosp Epidemiol. 1997;18:97–103. DOIPubMedGoogle Scholar
  9. Pittet  D, Mourouga  P, Perneger  TV. members of the Infection Control Program. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126–30.PubMedGoogle Scholar
  10. Larson  EL. CIC 1992-1993, 1994 APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995;23:251–69. DOIPubMedGoogle Scholar
  11. Preston  GA, Larson  EL, Stamm  W. The effect of private isolation rooms on patient care practices, colonization and infection in an intensive care unit. Am J Med. 1981;70:641–5. DOIPubMedGoogle Scholar
  12. Larson  E. Compliance with isolation technique. Am J Infect Control. 1983;11:221–5. DOIPubMedGoogle Scholar
  13. Donowitz  L. Handwashing technique in a pediatric intensive care unit. Am J Dis Child. 1987;141:683–5.PubMedGoogle Scholar
  14. Dubbert  PM, Dolce  J, Richter  W, Miller  M, Chapman  S. Increasing ICU staff handwashing: effects of education and group feedback. Infect Control Hosp Epidemiol. 1990;11:191–3. DOIPubMedGoogle Scholar
  15. Pettinger  A, Nettleman  M. Epidemiology of isolation precautions. Infect Control Hosp Epidemiol. 1991;12:303–7. DOIPubMedGoogle Scholar
  16. Larson  EL, McGinley  KJ, Foglia  A, Leyden  JJ, Boland  N, Larson  J, Handwashing practices and resistance and density of bacterial hand flora on two pediatric units in Lima, Peru. Am J Infect Control. 1992;20:65–72. DOIPubMedGoogle Scholar
  17. Zimakoff  J, Kjelsberg  AB, Larsen  SO, Holstein  B. A multicenter questionnaire investigation of attitudes toward hand hygiene, assessed by the staff in fifteen hospitals in Denmark and Norway. Am J Infect Control. 1992;20:58–64. DOIPubMedGoogle Scholar
  18. Meengs  MR, Giles  BK, Chisholm  CD, Cordell  WH, Nelson  DR. Hand washing frequency in an emergency department. J Emerg Nurs. 1994;20:183–8.PubMedGoogle Scholar
  19. Goldmann  D, Larson  E. Hand-washing and nosocomial infections. N Engl J Med. 1992;327:120–2. DOIPubMedGoogle Scholar
  20. Boyce  JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med. 1999;130:153–5.PubMedGoogle Scholar
  21. Larson  E. Skin hygiene and infection prevention: more of the same or different approaches? Clin Infect Dis. 1999;29:1287–94. DOIPubMedGoogle Scholar
  22. Simmons  B, Bryant  J, Neiman  K, Spencer  L, Arheart  K. The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol. 1990;11:589–94. DOIPubMedGoogle Scholar
  23. Tibballs  J. Teaching hospital medical staff to handwash. Med J Aust. 1996;164:395–8.PubMedGoogle Scholar
  24. Larson  E, Kretzer  EK. Compliance with handwashing and barrier precautions. J Hosp Infect. 1995;30:88–106. DOIPubMedGoogle Scholar
  25. Rotter  ML. Hand washing and hand disinfection. In: Mayhall G, editor. Hospital epidemiology and infection control. Baltimore: Williams & Wilkins; 1996. p. 1052-68.
  26. Selwyn  S, Ellis  H. Skin bacteria and skin disinfection reconsidered. BMJ. 1972;1:136–40. DOIPubMedGoogle Scholar
  27. Lowbury  EJL, Lilly  HA, Bull  JP. Disinfection of hands: removal of transient organisms. BMJ. 1964;2:230–3. DOIPubMedGoogle Scholar
  28. Ayliffe  GAJ, Babb  JR, Quoraishi  AH. A test for hygienic hand disinfection. J Clin Pathol. 1978;31:923–8. DOIPubMedGoogle Scholar
  29. Rotter  ML, Koller  W. European test for the evaluation of the efficacy of procedures for the antiseptic handwash. Hygiene und Medizin. 1991;16:4–12.
  30. Rotter  ML. Hand washing and hand disinfection. In: Mayall CG, editor. Hospital epidemiology and infection control. 2nd ed. Philadelphia: Lippincott, Williams & Wilkins; 1999. p. 1339-55.
  31. Lilly  HA, Lowbury  EJL. Transient skin flora. J Clin Pathol. 1978;31:919–22. DOIPubMedGoogle Scholar
  32. Garner  JS, Favero  MS. CDC guideline for handwashing and hospital environmental control, 1985. Infect Control. 1986;7:231.PubMedGoogle Scholar
  33. Ehrenkranz  J. Bland soap handwash or hand antisepsis? The pressing need for clarity. Infect Control Hosp Epidemiol. 1992;13:299–301. DOIPubMedGoogle Scholar
  34. Mittermayer  H, Rotter  M. Vergleich der Wirkung von Wasser, einigen Detergentien und äthylakohol auf die transiente flora der hände. Zentralbl Bakteriol Hyg. 1975;160:163–72.
  35. Lilly  HA, Lowbury  EJL, Wilkins  MD. Limits to progressive reduction of resident skin bacteria by disinfection. J Clin Pathol. 1999;32:382–5. DOIPubMedGoogle Scholar
  36. Semmelweis  I. The etiology, concept and prophylaxis of childbed fever. Madison: University of Wisconsin Press; 1983.
  37. Graham  DR, Anderson  RL, Ariel  FE, Ehrenkranz  NJ, Rowe  B, Boer  HR, Epidemic nosocomial meningitis due to Citrobacter diversus in neonates. J Infect Dis. 1981;144:203–9. DOIPubMedGoogle Scholar
  38. Kager  L, Brismar  B, Malmborg  AS, Nord  C. Imipenem concentrations in colorectal surgery and impact on the colonic microflora. Antimicrob Agents Chemother. 1989;33:204–8.PubMedGoogle Scholar
  39. Eckert  DG, Ehrenkranz  NJ, Alfonso  BC. Indications for alcohol or bland soap in removal of aerobic gram-negative skin bacteria: assessment by a novel method. Infect Control Hosp Epidemiol. 1989;10:306–11. DOIPubMedGoogle Scholar
  40. Ehrenkranz  NJ, Alfonso  BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidemiol. 1991;12:654–62. DOIPubMedGoogle Scholar
  41. Larson  E, McGinley  KJ, Grove  GL, Leyden  JJ, Talbot  GH. Physiologic, microbiologic, and seasonal effects of hanswashing on the skin of health care personnel. Am J Infect Control. 1986;14:51–9. DOIPubMedGoogle Scholar
  42. Larson  E. APIC guideline for use of topical antimicrobial agents. Am J Infect Control. 1988;16:253–66. DOIPubMedGoogle Scholar
  43. Pittet  D, Dharan  S, Touveneau  S, Sauvan  V, Perneger  TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821–6. DOIPubMedGoogle Scholar
  44. Conly  JM, Hill  S, Ross  J, Lertzman  J, Louie  T. Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control. 1989;17:330–9. DOIPubMedGoogle Scholar
  45. Sproat  LJ, Inglis  TJ. A multicentre survey of hand hygiene practice in intensive care units. J Hosp Infect. 1994;26:137–48. DOIPubMedGoogle Scholar
  46. Kretzer  EK, Larson  EL. Behavioral interventions to improve infection control practices. Am J Infect Control. 1998;26:245–53. DOIPubMedGoogle Scholar
  47. Larson  E, Killien  M. Factors influencing handwashing behavior of patient care personnel. Am J Infect Control. 1982;10:93–9. DOIPubMedGoogle Scholar
  48. Voss  A, Widmer  AF. No time for handwashing? Handwashing versus alcoholic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol. 1997;18:205–8. DOIPubMedGoogle Scholar
  49. Larson  E. Handwashing and skin: physiologic and bacteriologic aspects. Infect Control. 1985;6:14–23.PubMedGoogle Scholar
  50. Larson  E, McGeer  A, Quraishi  ZA, Krenzischek  D, Parsons  BJ, Holdford  J, Effects of an automated sink on handwashing practices and attitudes in high-risk units. Infect Control Hosp Epidemiol. 1991;12:422–8. DOIPubMedGoogle Scholar
  51. Michelson  A, Kamp  HD, Schuster  B. Sinusitis in long-term intubated, intensive care patients: nasal versus oral intubation. Anaesthesist. 1991;40:100–4.PubMedGoogle Scholar
  52. Khatib  M, Jamaleddine  G, Abdallah  A, Ibrahim  Y. Hand washing and use of gloves while managing patients receiving mechanical ventilation in the ICU. Chest. 1999;116:172–5. DOIPubMedGoogle Scholar
  53. Doebbeling  BN, Pfaller  MA, Houston  AK, Wenzel  RP. Removal of nosocomial pathogens from the contaminated glove. Ann Intern Med. 1988;109:394–8.PubMedGoogle Scholar
  54. Broughall  JM, Marshman  C, Jackson  B, Bird  P. An automatic monitoring system for measuring handwashing frequency in hospital wards. J Hosp Infect. 1984;5:447–53. DOIPubMedGoogle Scholar
  55. McLane  C, Chenelly  S, Sylwestrak  ML, Kirchhoff  KT. A nursing practice problem: failure to observe aseptic technique. Am J Infect Control. 1983;11:178–82. DOIPubMedGoogle Scholar
  56. Haley  RW, Culver  DH, White  JW, Morgan  WM, Emori  TG, Munn  VP, The efficacy of infection surveillance and control programs in preventing nosocomial infections in U.S. hospitals. Am J Epidemiol. 1985;121:182–205.PubMedGoogle Scholar
  57. Bauer  TM, Ofner  E, Just  HM, Just  H, Daschner  F. An epidemiological study assessing the relative importance of airborne and direct contact transmission of microorganisms in a medical intensive care unit. J Hosp Infect. 1990;15:301–9. DOIPubMedGoogle Scholar
  58. Casewell  M, Phillips  I. Hands as route of transmission for Klebsiella species. BMJ. 1977;2:1315–7. DOIPubMedGoogle Scholar
  59. Maki  D, Hecht  J. Antiseptic containing hand-washing agents reduce nosocomial infections: a prospective study [Abstract #188]. Program and abstracts of the 22nd Interscience Conference of Antimicrobial Agents and Chemotherapy, Miami, Oct 4-6, 1982. Washington, DC: American Society for Microbiology; 1982.
  60. Massanari  RM, Heirholzer  WJJ. A crossover comparison of antiseptic soaps on nosocomial infection rates in intensive care units. Am J Infect Control. 1984;12:247–8.
  61. Webster  J, Faoagali  JL, Cartwright  D. Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan. J Paediatr Child Health. 1994;30:59–64. DOIPubMedGoogle Scholar
  62. Zafar  AB, Butler  RC, Reese  DJ, Gaydos  LA, Mennonna  PA. Use of 0.3% triclosan (Bacti-Stat*) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. Am J Infect Control. 1995;23:200–8. DOIPubMedGoogle Scholar
  63. Pittet  D, Hugonnet  S, Harbarth  S, Mourouga  P, Sauvan  V, Touveneau  S, Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307–12. DOIPubMedGoogle Scholar
  64. Maki  DG. The use of antiseptics for handwashing by medical personnel. J Chemother. 1989;1:3–11.PubMedGoogle Scholar
  65. Butz  AM, Larson  E, Fosarelli  P, Yolken  R. Occurrence of infectious symptoms in children in day care homes. Am J Infect Control. 1990;6:347–53. DOIPubMedGoogle Scholar
  66. Early  E, Battle  K, Cantwell  E, English  J, Lavin  JE, Larson  E. Effect of several interventions on the frequency of handwashing among elementary public school children. Am J Infect Control. 1998;26:263–9. DOIPubMedGoogle Scholar
  67. Kimel  LS. Handwashing education can decrease illness absenteeism. J Sch Nurs. 1996;12:14–6. DOIPubMedGoogle Scholar
  68. Master  D, Hess Longe  SH, Dickson  H. Scheduled hand washing in an elementary school population. Fam Med. 1997;29:336–9.PubMedGoogle Scholar
  69. Khan  MU. Interruption of shigellosis by handwashing. Trans R Soc Trop Med Hyg. 1982;76:164–8. DOIPubMedGoogle Scholar
  70. Shahid  NS, Greenough  WB, Samadi  AR, Huq  MI, Rahman  N. Hand washing with soap reduces diarrhoea and spread of bacterial pathogens in a Bangladesh village. J Diarrhoeal Dis Res. 1996;14:85–9.PubMedGoogle Scholar
  71. Stanton  BF, Clemens  JD. An educational intervention for altering water-sanitation behaviors to reduce childhood diarrhea in urban Bangladesh. Am J Epidemiol. 1987;125:292–301.PubMedGoogle Scholar
  72. Teare  EL, Cookson  B, French  G, Gould  D, Jenner  E, McCulloch  J, Hand washing--A modest measure-with big effects. BMJ. 1999;318:686.PubMedGoogle Scholar
  73. Teare  EL, Cookson  B, French  GL, Jenner  EA, Scott  G, Pallett  A, U.K. handwashing initiative. J Hosp Infect. 1999;43:1–3. DOIPubMedGoogle Scholar
  74. Larson  EL, Bryan  JL, Adler  LM, Blane  CB. A multifaceted approach to changing handwashing behavior. Am J Infect Control. 1997;25:3–10. DOIPubMedGoogle Scholar
  75. Weeks  A. Why I don't wash my hands between each patient contact. BMJ. 1999;319:518.PubMedGoogle Scholar
  76. Aspöck  C, Koller  W. A simple hand hygiene exercise. Am J Infect Control. 1999;27:370–2. DOIPubMedGoogle Scholar
  77. Kaplan  LM, McGuckin  M. Increasing handwashing compliance with more accessible sinks. Infect Control. 1986;7:408–10.PubMedGoogle Scholar
  78. Raad  I, Darouiche  RO, Dupuis  J, Abi-Said  D, Gabrielli  A, Hachem  R, Central venous catheter coated with minocycline and rifampine for the prevention of catheter-related colonization and bloodstream infections. A randomized, double-blind trial. Ann Intern Med. 1997;127:267–74.PubMedGoogle Scholar
  79. McGuckin  M, Waterman  R, Porten  L, Bello  S, Caruso  M, Juzaitis  B, Patient education model for increasing handwashing compliance. Am J Infect Control. 1999;27:309–14. DOIPubMedGoogle Scholar
  80. Veenstra  DL, Saint  S, Saha  S, Lumley  L, Sullivan  SD. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection. A meta-analysis. JAMA. 1999;281:261–7. DOIPubMedGoogle Scholar
  81. Harbarth  S, Sudre  P, Dharan  S, Cadenas  M, Pittet  D. Outbreak of Enterobacter cloacae related to understaffing, overcrowding and poor hygiene practices. Infect Control Hosp Epidemiol. 1999;20:598–603. DOIPubMedGoogle Scholar
  82. Haley  RW, Bregman  D. The role of understaffing and overcrowding in recurrent outbreaks of staphylococcal infection in a neonatal special-care unit. J Infect Dis. 1982;145:875–85. DOIPubMedGoogle Scholar
  83. Kelen  GD, Green  GB, Hexter  DA, Fortenberry  DC, Taylor  E, Fleetwood  DH, Substantial improvement in compliance with universal precautions in an emergency department following institution of policy. Arch Intern Med. 1991;151:2051–6. DOIPubMedGoogle Scholar
  84. Lundberg  GD. Changing physician behavior in ordering diagnostic tests. JAMA. 1998;280:2036. DOIPubMedGoogle Scholar
  85. Phillips  DF. "New look" reflects changing style of patient safety enhancement. JAMA. 1999;281:217–9. DOIPubMedGoogle Scholar

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