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Maximizing Hand Hygiene Effectiveness In Healthcare Settings Part 1

Barry Michaels
January 09, 2013
WHO 5 Moments

In response to last week’s Deb Hand Hygiene, Infection Prevention and Food Safety Blog post titled 

Hand Hygiene Alone Isn’t Enough”, Julie Storr provided an interesting comment regarding the WHO 5 Moment Approach .  While I agree if strictly applied this would prevent mistakes that often follow even "exceptional hand hygiene", we know that these negative events compromising patient safety (such as touching contaminated surfaces) occur on regular frequency in spite of knowledge of best practices and thus cross-contamination takes the lives of one patient after another.   


Discussing this in risk terms and then looking at issues involving training and education, I thought might be helpful.   We can do this by following the steps that a health care worker takes after having hands contaminated and risking transmission.  After contamination with visible soil, it is a given that health care workers will wash and sanitize hands.  At this point the risk of transmission is reduced from a theoretical probability of maybe in the 70-100% range to that of zero (0% or close to it). This assumes that hands contamination level is effectively surpassed by hand hygiene efficacy level.   For example a 5 Log10 contamination level met with or exceeded by a 5 log10 sanitary efficacy (99.999%).  This is what was presented in the C. diff Part 2 blog post of a few weeks ago showing how C. diff control and prevention programs can achieve success. 


If effective hand hygiene is followed by contact with a contaminated surface than we find we have now gone from a state of zero or low risk to one of unknown risk.  Perhaps the microorganism picked up on the contaminated surfaces is of greater pathogenicity than that which was eliminated from initially contaminated hands.  Instead of simply trading a known level of risk for an unknown one, risk level may have been amplified and this is where a higher level of consciousness is need and afforded by the 5 Moment Approach.  This approach provides detailed guidance as to exactly when health-care workers shall clean their hands as:


1          before touching a patient,

2          before clean/aseptic procedures,

3          after body fluid exposure/risk,

4          after touching a patient, and

5          after touching patient surroundings.


A great number of studies show that hand hygiene compliance rate improvement can reduce the risk of infection in households, day care, schools, senior care and the military.  Infection rate reductions of around 40% have been shown in gastrointestinal infections and 30% with respiratory tract infections in these settings.   


Healthcare clinical studies incorporating hand hygiene compliance improvement along with specific infection type best practices for control of a number of different categories of hospital associated infections and ward groupings have also shown considerable efficacy.   It was found that improvement in infections rates was sometimes dependent on initial rates of infection.  Where infection rates were high or above average than interventions brought these infection rates down significantly.  In other instances with certain infection types or ward groupings, lowering of rates were independent of initial infection rates.  In other words, no matter what the baseline rate, when improved hand hygiene and best practices were implemented, infection rates were reduced.


In 43 clinical studies I evaluated, where statistically significant hospital associated rates of infection rates were reduced, mean rates of reduction was around 50%. Categories of infections or wards where infection rates were reduced, from greatest effect to least were: VRE/MRSA infections, overall ICU rates, hospital wide, respiratory tract infections, urinary tract infections, blood stream infections, surgical site infections and gastrointestinal tract infections.  In these studies a higher reduction was seen in respiratory tract infections (55%) verses gastrointestinal tract infections at 40%.


What is striking about these figures for healthcare and non-healthcare venues is that the rate reductions are very similar.  In addition, they account for notions expressed by many experts involved in infection control whether it is food processing/service or healthcare that some 40% of infections or outbreaks are caused by poor personal hygiene and linked to cross-contamination. This conclusion results because this is right around the amount (40%) that can be reduced when improved hand hygiene is implemented.   To me the numbers are also strongly indicative that we are dealing with very same basic phenomena, no matter what the venue; we use hands for touching everything, dirty hands transmit disease and clean hands reduce infection and saves lives.


In part 2 of this blog looking at maximizing effectiveness of hand hygiene in healthcare settings, we will look at proven methods of increasing compliance and the roles of education, motivation and facilities coming full circle back to Kelly M. Pyrek’s initial proposition “Hand Hygiene Alone Isn’t Enough”. 

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