Hand hygiene project pays off

October 2010   Comments

Hospital-acquired infections are ranked by the World Health Organization as one of the top 10 causes of hospital deaths worldwide (WHO Guidelines on Hand Hygiene in Health Care, 2009). WHO has suggested that improvements in hand hygiene compliance can prevent up to 50 per cent of hospital-acquired infections, making hand hygiene the single most important practice in reducing the rate of these infections. With these guidelines in mind, the staff in our 35-bed general surgical unit resolved to give patients safer care, focusing primarily on hand hygiene. We formed a multidisciplinary working group that consisted of an infection control practitioner, the acute care manager, the permanent day charge nurse and three other front-line nurses from our surgical unit.


In June 2008, the acute care manager invited infection prevention and control (IPC) professionals to directly observe the hand hygiene practices of all health-care workers in the unit — primarily nurses and physicians — during their regular work activities. The frequency of compliance with performing hand hygiene before and after activities of patient care was a disappointing 38 per cent. These results triggered the development of our project. Our working group began by asking staff to identify the barriers to performing hand hygiene. Then, we investigated and implemented evidence-based strategies for removing these barriers — strategies that could be easily adopted by other health-care facilities.

Why is hand hygiene compliance consistently low? Research on hand hygiene practices among health-care workers has shown that compliance rates range from 30 to 40 per cent, which is consistent with our own unit’s compliance rate. Although our unit was not alone in our failure to comply, we knew we could improve. When our working group asked staff to identify barriers to performing appropriate hand hygiene, they came up with the following list:

  • Physical resources. Staff cited a lack of hand sanitizer dispensers and easily accessible sinks.

  • Time management. Staff stated that performing hand hygiene made it more difficult to manage their demanding workload. They reported a lack of awareness of the importance of hand hygiene and did not believe that it could be performed efficiently as a regular part of their routine.

  • Lack of knowledge. Staff had misconceptions about the circumstances that require hand hygiene practices — particularly in relation to patient equipment, gloves and “clean duties,” such as the taking of vital signs. Nurses reported a lack of awareness that they could carry micro-organisms from one patient to another when performing these types of tasks.

  • Skin irritation. The frequent use of soaps and hand sanitizers was thought to cause irritation and dryness of the skin.

Our group initiated an aggressive program to improve hand hygiene compliance. We followed the recommendations of the Safer Healthcare Now! campaign to reduce the rate of methicillin-resistant Staphylococcus aureus (MRSA) infection. After some brainstorming, we implemented Plan-Do-Study-Act (PDSA) cycles for the following evidence-based interventions:

  • Education. Our working group created a clear, concise handout on the severity and scope of hospital-acquired infections, the importance of hand hygiene in reducing and preventing these infections, the activities that require hand hygiene, and the evidence-based strategies that would be implemented to improve hand hygiene. The handout included a reminder that rings and artificial nails should not be worn because they interfere with appropriate hand hygiene. We gave the handout to everyone who worked in the surgical unit, including practicum students. All employees except physicians were required to submit a completed knowledge-assessment questionnaire to the unit manager. The acute care manager spoke with physicians individually and found that each one readily supported and embraced the project. On a staff bulletin board dedicated to the project, IPC professionals posted detailed descriptions of actual cases of hospital-acquired infection from across Canada, with the names of patients and hospitals removed for confidentiality. New case reports were posted monthly, as was educational information about a featured “bug of the month.” The working group also developed a brochure, which is included in each patient’s admission packet and available for any visitor to take as they enter our unit.

  • Access to hand hygiene supplies. Our group ensured that alcohol-based hand sanitizer dispensers were mounted inside and outside all patient rooms, and in other common areas that were easily accessible to staff, patients and visitors. In addition, sinks for health-care providers were installed in private rooms, which are often used for patient isolation. Hand lotion, recommended for use with the alcohol-based hand sanitizer to prevent skin dryness and irritation, was provided for staff through wall-mounted dispensers at the main desk area and in the conference room.

  • Motivational tools. Our working group chose the slogan “Clean Care is Safe Care” to identify and promote the project. It was featured on posters that were displayed near the hand sanitizer dispensers and in patient rooms.

  • Monthly updates. The IPC professionals continued to collect data on hand hygiene compliance by directly observing our unit’s health-care staff, who were told that hand hygiene compliance was regularly monitored but were not informed of exactly when or how they would be observed. Each month, the IPC professionals posted graphs that showed the latest hand hygiene compliance rates — along with the numbers of MRSA cases attributed to our unit — on the bulletin board.

  • Strong commitment from management. Support from management was essential for ensuring that the necessary infrastructure, equipment and supplies were readily available. Our working group received funding for the planning time we needed to reach our goals. Throughout the project, management supported nurses’ efforts to encourage physicians, and each other, to use hand hygiene. Because of this effective and committed leadership, our unit was able to create an environment where any employee, regardless of position, would feel comfortable reminding others to perform appropriate hand hygiene.

Within the first six months of implementing the program, hand hygiene compliance more than doubled, increasing from 38 to 81 per cent. Furthermore, this improvement has been sustained, with an average of 76 per cent (range: 65%-94%) compliance over the past 18 months. During the 18-month period before we started the project, the rate of hospital-acquired MRSA infection on our unit was 3.5 cases per 10,000 patient days; during the 18-month period after implementation, the infection rate was 1.7 cases per 10,000 patient days.

On our unit, the culture has changed. Health-care workers are taking ownership of improving their hand hygiene so that it becomes a habitual behaviour before and after every contact with a patient. Our working group remains enthusiastic, and we serve as role models for our colleagues. Other units at our facility have noticed the positive outcomes of the project and are implementing their versions of our program, tailored to their specialties.

As the hand hygiene compliance in our unit continues to improve, the working group is looking at better ways to clean environmental surfaces and patient equipment. To help meet this new goal, we have expanded our group to include our unit assistant and an environmental services staff member.

Valerie Potts RN, BN, MHST

Valerie Potts, RN, BN, MHST, is an Acute Care Manager for a General Surgical Unit at the Red Deer Regional Hospital Centre, Red Deer, Alberta.

Alison Devine, BScN, RN, CIC

Alison Devine, BScN, RN, CIC, is an Infection Control Professional for Alberta Health Services, Red Deer, Alberta.

Alicia Cortright, BSc, MPH

Alicia Cortright, BSc, MPH, is an Infection Control Professional for Alberta Health Services.

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