Driving Hand Hygiene Compliance, Improvements, and Sustainability

Hand hygiene. It’s one of the most important things we can do to stop the spread of infectious microorganisms and yet one of our biggest struggles in health care. For infection prevention programs, working to increase and then maintain hand hygiene compliance is often an insurmountable task. Historically, hand hygiene compliance rates have been at or below 50% within the United States health care system. Part of the challenge is in maintaining engagement and, frankly, making it a habit instead of a chore.

Although hand hygiene is an infection prevention effort we’re struggling within the United States, we’re not alone. Perhaps understanding what other countries are doing could help guide our own efforts. Investigators in Japan have provided insight into their efforts and lessons learned in a new study published in the American Journal of Infection Control. Using a multimodal intervention in 3 hospitals, the research team pieced together guidance from the World Health Organization (WHO), US Centers for Disease Control and Prevention (CDC), and other initiatives.

The multimodal intervention began in 2012 and employed the suggestions of the WHO by focusing on educating health care workers on the importance of hand hygiene while also ensuring there was adequate alcohol-based hand gel (ABHG) for health care workers to use. Each health care facility was allowed to choose which interventions to implement, allowing for a sense of personalization in their efforts. The personalization was in addition to basic efforts, including ABHG in patient rooms, staff education, informational posters, and feedback from both the department heads and the infection prevention team. All hand hygiene was monitored internally through direct observation or hand gel consumption. Leadership support of this effort was important and observations took place across at least 3 units within the hospitals—inpatient surgical, inpatient medicine, emergency, and intensive care units.

What was interesting about this approach is that investigators also included a particularly novel institutional-level contest. A cash prize of $5000 was awarded to the hospital with the highest hand hygiene compliance after the intervention efforts. The winner also received a trophy.

The research team found an improvement in hand hygiene pre- and post-intervention. Improvement was roughly 18% pre-intervention, compared with 33% post-intervention. This study is unique in that it also monitored the sustainability of these efforts and hand hygiene compliance over 5 years. During this observational period, 2679 observations were collected from the pre-intervention period and 2982 observations from the 6-month post-intervention period.

Perhaps one of the most interesting aspects was that the investigators evaluated awareness and attitudes about hand hygiene practices across the 3 hospitals by giving self-assessments to health care workers.

Although hand hygiene compliance improved, in some cases by 29% (in hospital A), there was no statistically significant change between post-intervention and the 5-year assessment. Across all 3 hospitals, investigators found largely unchanged compliance rates between post-intervention and the 5-year assessment, meaning that changes were made from pre-intervention and post-intervention, but little progress was made after 5 years.

What can we learn from hand hygiene initiatives? Initial change is achievable but maintaining improvement and upwards efforts is difficult. Changes in post-intervention and at the 5-year assessment were not significant and ultimately show that we can maintain the initial improvements but not go far beyond those compliance rates. This study is a helpful reminder that although we might drive initial changes, maintaining continuous improvement will always be a challenge and resources/efforts should be allocated to driving sustainable improvements in hand hygiene.