Nancy A. Melville

May 20, 2011

May 20, 2011 (Milan, Italy) — Nearly half of healthcare professionals around the world fail to comply with the World Health Organization (WHO)'s Moment 1: Before Touching a Patient hand-hygiene initiative, according to a global WHO survey presented here at the 21st European Congress of Clinical Microbiology and Infectious Diseases.

The hand-hygiene initiative is 1 of 5 measures, or "moments," of Save Lives: Clean Your Hands (SLCYH), a global campaign launched by the WHO's Clean Care is Safer Care program in an effort to promote sustained hand-hygiene improvement by registering medical facilities and providing guidance.

"We all know that hand-hygiene compliance is very low; in general, compliance is only about 38.7%," said lead author Benedetta Allegranzi, MD, from the WHO World Alliance for Patient Safety, in Geneva, Switzerland.

"The 5 moments have become the gold standard for practicing and measuring hand hygiene around the world."

Moment 1 is among the most critical measures, she added. "We know Moment 1 — before touching the patient — is particularly important, as this indication protects patients from the powerful germs carried on healthcare workers' hands after they touch other patients."

In the first global survey on hand-hygiene compliance before patient contact, WHO collected data from 327 healthcare facilities registered with the SLCYH campaign, representing 47 countries and 1527 hospital wards.

The analysis showed that compliance with Moment 1 hand-hygiene in 76,803 hand-hygiene opportunities was just 51.4% (weighted mean adjusted by number of opportunities per facility).

Of those that were compliant, the hand-hygiene actions involved hand-rubbing in 60.7% of cases, hand-washing in 37.6% of cases, and both methods in 1.7% of cases.

The survey recommended that healthcare facilities collect approximately 50 hand-hygiene opportunities in selected wards or departments. Moment 1 hand-hygiene compliance was highest in European countries (64% of 22,278 opportunities) and lowest in the Americas (26% of 23,183 opportunities). Nurses showed much better compliance (64%) than physicians (48%).

Surprisingly, higher levels of hand-hygiene compliance were seen in ambulatory (72%), medical (60%), and intensive care (59%) departments; the lowest was seen in obstetrics departments (37%).

Limitations of the study include the short period of surveillance and the fact that the survey took place during a hand-hygiene awareness campaign, Dr. Allegranzi said. "Since this took place during the promotion of hand hygiene, levels of compliance can be expected to be higher than normal."

According to Shira I. Doron, MD, MS, an assistant professor of medicine at Tufts University School of Medicine in Boston, Massachusetts, "before-care" compliance rates are commonly lower than "after-care" rates. Although experts believe that this is because of a prioritization of self-protection over protection of the patient, many healthcare workers might, in fairness, also believe that this will sanitize their hands for the next patient.

"In fact, we know that this is not true," Dr. Doron explained. "If they've touched anything at all in between those 2 patients (computer keyboard, telephones, their own cellular phone, etc.), their hands are likely to be contaminated with microbes, and potentially antimicrobial-resistant ones."

Antibiotic-resistant bacteria have indeed been isolated from such objects at Tufts, underscoring the importance of before-care hand hygiene, Dr. Doron added.

"If a healthcare worker washed before touching a patient every time, and never washed after touching a patient, there would be no transmission of microorganisms between patients on healthcare workers' hands. So to patients, only the before-care hand hygiene really matters."

Just as the evidence of low overall compliance is consistent with previous research, so is the finding of lower compliance rates among physicians than among nurses. With the pool of nurses typically made up of a larger proportion of women and the pool of physicians made up of a greater proportion of men, the discrepancy might be gender-related, Dr. Doron suggested.

"Research shows that women are more likely to perform hand hygiene than men, and that translates into better compliance by nurses than physicians, overall," Dr. Doron said.

"Another theory is that nurses are often very strong patient advocates, prioritizing their patients' needs over most other things in a way that physicians are not, and that leads to better hand hygiene to protect their patients."

Hand-hygiene campaigns can help address the problem, but can also suffer from their own success as a sense of urgency wanes, Dr. Doron noted.

"Commonly, once success is achieved in hand hygiene, resources within the hospital are redirected to other important programs. As a result, hand-hygiene observations may be less frequent and less abundant, compliance rates may not be fed back to personnel as regularly as they had been, and incentive programs may be discontinued," she said.

"The biggest challenge for institutions is, therefore, not how to improve hand-hygiene compliance, but how to maintain it in the face of the many other important patient safety goals that hospitals are focusing on these days."

Dr. Allegranzi and Dr. Doron have disclosed no relevant financial relationships.

21st European Congress of Clinical Microbiology and Infectious Diseases (ECCMID): Abstract 0141. Presented May 8, 2011.

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