Current Best Practices In
Hand Hygiene
Didier Pittet, MD, MS,
Professor of Medicine
Chair, Infection Control Program
University of Geneva Hospitals , Switzerland
ast v.25.9.02/DP/HHcurrentbestpractices
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Author
• Hand hygiene is considered the most important
measure for reducing the transmission of
nosocomial pathogens in healthcare settings
• Many studies have documented that
compliance of healthcare workers with
recommended practices is unacceptably low
Year Setting
Preston
1981
Albert
1981
Larson
Donowitz
Graham1990
Dubbert
Pettinger
Larson
Doebbeling
Zimakoff
Meengs
Pittet
1983
1987
ICU
1990
1991
1992
1992
1993
1994
1999
Self-reported
Self-reported factors for poor compliance
Compliance
Open ward
ICU
ICUs
ICUs
All wards
PICU
16%
30%
41%
28%
45%
30%
•
•
•
•
32%
ICU
SICU
NICU/others
ICUs
ICUs
Emergency Room
All wards
ICUs
81%
51%
29%
40%
40%
32%
48%
36%
•
•
•
•
Nurses complied more frequently than physicians in all but one study
4
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Hand Hygiene
Compliance with Hand Hygiene, 1981-1999
Background
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Lack of time (understaffing, overcrowding)
Shortage of sinks / often inconveniently located
Lack of soap, paper, ...
Skin damage / fear that hands will be damage
after frequent hand hygiene
Beliefs that glove use dispenses from hand
hygiene
No role model from colleagues or superior(s)
Scepticism …
Disagreement with the recommendations
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Maternal mortality rates,
First and Second Obstetrics Clinics,
GENERAL HOSPITAL OF VIENNA, 1841-1846
Intervention
0 2 4 6 8 1 01 21 41 61 8
May 1847
5
6
N
8
1
8
1
8
N
4
4
4
3
4
2
4
8
8
1
1
8
4
4
1
(%)
First
Second
1
Maternal
Mortality
• Students and doctors were required to:
1
Ignaz Philipp Semmelweis
clean their hands with a chlorinated lime
solution when entering the labor room
in particular when moving from the autopsy
to the labor room
Semmelweis IP, 1861
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It is easy to promote hand
hygiene among HCWs
Maternal mortality rates,
First and Second Obstetrics Clinics,
GENERAL HOSPITAL OF VIENNA, 1841-1850
Intervention
May 15, 1847
True or False ?
Semmelweis IP, 1861
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9
Parameters associated with successful
hand hygiene promotion
Pittet, Infect Control Hosp Epidemiol 2000 / Pittet & Boyce, Lancet Infectious Diseases 2001, April,
9-20
Ignaz Philipp Semmelweis before and after he insisted
that students and doctors clean their hands
with a chlorine solution between each patient
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1. Education
2. Routine observation + feedback
3. Ingeneering control
Make HH possible / easy / convenient / ...
4. Patient education
5. Reminders in the workplace
6. Administrative sanction / rewarding
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Parameters associated with
successful hand hygiene
promotion
Pittet, Infect Control Hosp Epidemiol 2000 / Pittet & Boyce, Lancet Infectious Diseases
2001, April, 9-20
7. Change in HH agent (but not in winter ...!!!)
8. Promote / facilitate HCW’s skin care
9. Obtain active participation at individual
and institutional level
10. Obtain / drive an institutional safety climate
11. Enhance individual and institutitional
self-efficacy
12. and last but not least: Use a multimodal strategy
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Handwashing / Hand antisepsis
Observational study - Methods
Study Objective
Information to HCW at HCUG : November 1994
To determine factors associated
with poor compliance to hand
hygiene practices in a large
university hospital
Hôpitaux Universitaires de Genève
• Observational study : December 5-18th, 1994
• Convenience sample of 48 wards
• 315 20-min observation periods (total,101 hours)
• Observation periods : morning - afternoon - night
week - week-end
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Study variables
Definitions
Compliance and Professional Activity
Pittet et al, Ann Intern Med 1999, 130:126
number of actions *
Compliance = -------------------------------------------number of observed opportunities
**
* Action =
- handwashing (soap + water / water)
- hand antisepsis (use of alcohol-based hand rub)
** Predetermined opportunities for HW/HA
number of opportunities
Activity Index = ----------------------------------------total duration of observation
[opp/hour]
Compliance with hand hygiene (%)
opp > 10 per hour of care
Time constraint is the
main explanatory factor
When the number of opp
> 10 per h,
compliance decreases
on average by 5 % ( + 2
% ) per 10 opp/h of care
50
25
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Compliance and Hospital
Department
Departement
Pediatrics
Medicine
Surgery
Obs / Gyn
ICUs
Opportunities (%)
133
1114
990
147
450
(4.7 %)
( 39 %)
( 35 %)
(5.2 %)
( 16 %)
Compliance
25
50
75
100
Opportunities for hand hygiene per hour of care
59 %
52 %
47 %
48 %
36 %
Pittet et al, Ann Intern Med 1999, 130:126
22
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52 %
43 %
2,834 (100 %)
48 %
47 %
66 %
30 %
28 %
8%
27 %
21
65
pediatrics
medicine
55
surgery
45
23
On avearge,
22 opp / hour
for an ICU nurse
ob / gyn
ICU
35
8
0
Compliance
( 66 %)
(4.7 %)
(13 %)
(1.3 %)
(10 %)
(1.7 %)
(0.4 %)
(2.7 %)
Relation between opportunities for hand hygiene
for nurses and compliance across hospital wards
0
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Opportunities
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, %)
Non-Compliance with hand
hygiene, HUG 1994
75
N
Nurse
(520) 1875
Student nurse (48)
131
Nurses' aide
(166)
378
Mid-wife
(14)
35
Physician
(158)
281
Phys/Resp therapist (23) 48
Radiology Techinician (4) 12
Others
(58)
74
TOTAL
19
Pittet et al, Ann Intern Med 1999, 130:126
100
hospital ward / department
time of the day ( morning - afternoon - night )
time of the week ( week / week-end )
profession
activity index (opportunities per hour)
nursing census of the ward (at time of
observation)
• patient census
• type of care provided
• bed occupancy rate of the ward
Compliance with hand hygiene (
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•
•
•
•
•
•
12
16
20
Opportunities for hand hygiene per patient-hour of care
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adapted from Pittet D et al. Annals Intern Med 1999; 130:126
24
Observed reasons for not washing
hands
Time and system constraints
Time constraint is a major
obstacle for hand hygiene …
• High demand for hand hygiene is
associated with low compliance
• Full compliance with convential
guidelines may be unrealistic
Would it be possible to bypass
the time constraint ?
Yes or No ?
handwashing
hand antisepsis
Voss and Widmer - Inf Control Hosp Epidemiol 1997; 18:205
Pittet et al, Annals Intern Med 1999; 130:126
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Time constraint = major obstacle for hand hygiene
alcohol-based
hand rub
1 to 1.5
min
15 to 20
sec
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Efficacy of hand hygiene products
Alcohol-based handrub is more
efficacous than handwashing
with medicated soap
27
Efficacy of hand hygiene products
Log reduction in bacterial counts after 30 sec
0
Soap
Iodophor
4% CHG 70% Alcohol
-0.5
-1
-1.5
-2
True or False ?
-2.5
-3
-3.5
-4
Ayliffe GAJ et al. J Hosp Infection 1988;11:226
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Successful hand hygiene
promotion is an impossible task
Advantages of alcohol-based hand
antisepsis vs. handwahsing
• Faster and of greater efficacy than soap &
water handwashing
• Improved accessibility
· No sinks (plumbing) required
· In rooms, corridors, nursing stations
Hôpitaux Universitaires de Genève
True or False ?
• Effective against wide array of organisms,
including multi-drug resistant pathogens
Pittet et al, Ann Intern Med 1999 - Boyce, ICHE 2000 - Pittet, ICHE 2000
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Objective
Design and Intervention
33
Alcoholbased
hand rub
• Seven observational, hospital-wide
surveys conducted on a bi-annual basis
from December 1994 to December 1997
• To assess the effectiveness of a
hospital-wide campaign to
promote hand hygiene with an
emphasis on bedside handrub
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34
• Hospital-wide promotion of hand hygiene
with a particular emphasis on hand
rubbing
• Talking walls figuring the importance of
hand hygiene associated with
35
performance feedback
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Before and after any patient cont
Before and after glove use
36
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«Talking walls»
BEFORE
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AFTER
37
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My son,
if they don’t get me,
you will become
multiresistant
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Doctor, in this hospital,
it becomes impossible
to cause infections
as we want !
Outcome measures
• The main outcome measure was overall
compliance with hand hygiene
The University of Geneva
Hospitals
against DIRTY STAPH :
war has started
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Confounding variables included
professional activity, hospital ward, time of
the day/week, type and intensity of patient
care at time of observation, and the use of
standard handwashing with unmedicated
soap and water or hand rub
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www.hopisafe.ch
44
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Pittet D et al, Lancet 2000; 356: 1307-1312
45
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
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Pittet et al. Lancet 2000 356:1307
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Trends over time in compliance with hand
hygiene in ICUs,
ICUs, 1994-1997
Alcohol-based handrub can
bypass the time constraint
Hugonnet, Perneger, and Pittet - Arch Intern Med 2002, 162:1037
Compliance %
60
Beliefs or Science ?
HD: p< .0001
50
22
40
Hand rub
Handwashing
30
20
Overall: p< .0001
5
33
33
10
0
1
Time constraint is high in the ICU and bugs are everywhere
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Relation between workload and
compliance with handwashing vs.
handrubbing in ICUs
Adapted from Pittet D et al, Lancet 2000; 356: 1307-1312
Hugonnet S et al, Arch Internal Med 2002; 162:1037-1043
100
100
Handwashing
Compliance %
3
4
5
6
7
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Compliance with hand hygiene,
HUG 1994-1998
Hand rub use
p < .001
50
Improved compliance with hand
hygiene decreases nosocomial
infections
50
2
Study period (Dec 94-June 97)
p = .12
50
Beliefs or Science ?
0
0
0
50
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100
150
www.hopisafe.ch
0
50
100
150
Workload (nber opportunities per hour)
52
Pittet D et al, Lancet 2000; 356: 1307-1312
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Hospital-wide nosocomial infections;
trends 1994-1998
Hand rub
MRSA spread is essentially
via the hands of healthcare workers...
Thus, it can be stopped
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
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Trends in prevalence of nosocomial infections
and MRSA cross-transmission, HUG 1993-1998
56
Conclusions
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Hand hygiene promotion is costly
• The campaign resulted in a sustained and
significant improvement in compliance with
the rules of hand hygiene
• Promotion of alcohol-based hand rub was
responsible for more active augmentation
in compliance
• We observed a parallel decrease of
nosocomial infection rates
Pittet et al. Lancet 2000 356:1307
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True or False ?
57
Objective
Direct costs
• To evaluate the cost-effectiveness of the
successful hand hygiene promotion
campaign
• Setting: University of Geneva Hospitals,
Geneva, Switzerland
Indirect costs (Personnel time)
•
•
•
•
• Artist work
• Color posters’ reproduction
• Creation / refreshments of «Talking
Walls»
• Food during monthly meetings of the
Team Performance
•
•
•
•
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
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Outcome indicators
• Office supplies
62
250
Swiss francs 200
(CHF)
150
20
15
100
10
50
Baseline
use before 5
promotion 0
0
1
93
1993
1994
1995
1996
1997
1998
1999
1
2
3
4
5
6
7 2000
8 2001
9
• Additional use of handrub, from 1995
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300
25
• Adjustment for hospital
demographics, 1993-2001
395
496
597 698 799
800
901
Change rate: US$ 1 ~ CHF 1.65
Year
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2
94
Year
75 mL pocketpocket-sized bottle,
bottle, introduced in 1996
100 mL bedside bottle,
bottle, used since 1970 at HUG
64
63
350
Hand rub
promotion
30
• Overall consumption of handrub
solution from 1993 to 2001
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Hand rub use: cost per 100 admissions
35
Liters
Nurse 10%
Hospital epidemiologist 5 %
Support team 2%
Observation sessions and feedback
• Extra nurse for 4 months at beginning
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Use of alcohol-based hand rub, HUG 1993-2001
• Annual nosocomial infection (NI)
rates assessed by repeated
prevalence surveys
Team Performance (~40 individuals)
Preparation of the Talking Walls (painter)
Housekeeping time (poster renewal)
Infection control team (PCI) time
65
An average of US$ 1.22 per admission since 1995
Cost per admission in 2001 : US$ 1.96
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Hand hygiene promotion campaign, HUG 1995-2001
Direct and indirect costs of intervention
Hand hygiene promotion campaign, HUG 1995-2001
Overall costs of intervention
US$
400000
Swiss
francs
CHF
Direct costs
350000
300000
224’165
400000
US$
350000
US$
300000
US$
250000
250000
200000
Indirect costs
200000
US$
16000000
14000000
12000000
10000000
US$ 8000000
6000000
4000000
2000000
0
108’945
100’673
79’112
64’992
150000
150000
100000
100000
Cost comparison: nosocomial infections vs. hand
hygiene promotion campaign, HUG 1994-2001
0
19951-97
0
1
1995-1997
2
3
1998
4
1999
5
2000
6
2001
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Cost comparison: nosocomial infections vs. hand
hygiene promotion campaign, HUG 1994-2001
16000000
14000000
12000000
10000000
US$ 8000000
6000000
4000000
2000000
0
a
er
ith
e
sn
ei
lid
s
,
is
Th take ke
s
mi r a jo
o 3
1 1995
2n 1996
4 1998
5 1999
6
1994
1997
2 1998
3 1999
4 2000
5 2001
6
Total costs : US$ 577’889
Average :
US$ 82’555 per year
S?rie2
7 2001
8
2000
68
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US$ 28.9 mio
25000000
S?rie1
S?rie2
2
US$ 15000000
X 100
3
US$ 0.29 mio
10000000
4
5000000
Costs of NI
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1
20000000
5
0
1 of NI
Costs
Years
70
69
30000000
1 1995
2 1996
3 1997
4 1998
5 1999
6 2000
7 2001
8
1994
Costs of hand hygiene
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Cost comparison: nosocomial infections vs. hand
hygiene promotion campaign, HUG 1999-2001
NI rates
Years
Costs of NI
Costs of hand hygiene
Costs of NI
Cost comparison: nosocomial infections vs. hand
hygiene promotion campaign, HUG 1994-2001
S?rie1
Years
S3tal co
To
sts
Direct cost
s
S1
Indirect co
sts
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16000000
14000000
12000000
10000000
US$ 8000000
6000000
4000000
2000000
0
S?rie2
1 1995
2 1996
3 1997
4 1998
5 1999
6 2000
7 2001
8
1994
50000
50000
S?rie1
2
3
4 hygiene
5
Costs of hand
Average infection rate, 1999-2001 : 9.7 per 100 admissions
Estimates of US$ 28.9 mio from nosocomial infections
Total costs of US$ 0.29 mio for hand hygiene promotion
Costs of hand hygiene
71
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Conclusions
• The total costs of the campaign averaged
US$ 82’555 per year; US$ 1.62 per admission
• in 2001; it reached US$ 2.30 per admission
• while indirect costs remained stable, direct
costs increased, in particular because of
increased use of alcohol-based handrub that
reached US$ 1.96 per admission in 2001 (85% of
total costs)
• Costs of hand hygiene promotion including
handrub use corresponded to ~ 1% of
costs attributable to NI in a large teaching
institution
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You can
do it
too …
We can
do it
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Handwashing …
an action of the past
Hand hygiene:
(except when hands are soiled)
compliance
and how to get things done
Rub
hands …
it saves
money
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Alcohol-based
hand rub
is standard of care
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75
Poor compliance should be
viewed only as a problematic
individual behavior
True or False ?
Hand Hygiene (HH) Pittet - Infect Control Hosp Epidemiol 2000
Factors associated with
noncompliance
Individual level
•
•
•
•
•
lack of education / experience
being a physician
male gender
lack of knowledge of guidelines
being a refractory noncomplier
True or False ?
Institutional level
• lack of guidelines (written)
• lack of administrative leadership / sanction /
rewarding / support
• lack of available / suitable HH agents
• lack of skin care promotion / agent
• lack of HH facilities
• lack of culture / tradition of compliance
Group level
•
•
•
•
lack of education / performance feedback
working in critical care (high workload)
downsizing / understaffing
lack of encouragement from key staffs
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Parameters for successful hand
hygiene promotion are many
Hand Hygiene (HH) Pittet - Infect Control Hosp Epidemiol 2000
Factors associated with
noncompliance
80
Parameters associated with
... used
successful hand hygiene promotion in Geneva
1. Education
2. Routine observation + feedback
3. Ingeneering control
Make HH possible, easy, convenient
4. Patient education
5. Reminders in the workplace
6. Administrative sanction / rewarding
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yes
yes
yes
no
yes
no
83
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81
Parameters associated with
... used
successful hand hygiene promotion in Geneva
7. Change in HH agent
8. Promote / facilitate HCW’s skin care
9. Obtain active participation at
individual and institutional level
10. Obtain / drive an institutional safety
climate
11. Enhance individual and institutitional
self-efficacy
12. Use a multimodal strategy
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no
yes
yes
?
may be
yes
84
Possible reasons for successful promotion
Each poster was created
by the artist in wards
with the collaboration
of ward nurses and physicians
• Make hand hygiene possible in a timely fashion
• Observation and performance feedback
• Multimodal / multidisciplinary approach:
communication and education tools
reminders and performance feedback
active participation at individual level
active participation at institutional level
make hand hygiene compliance an institutional priority
enhance the image of the institution
enhance the sense of individual / collective
committment
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Geneva Hospitals self-efficacy and perception to health threat
85
Each poster carried the name
of the ward that had proposed
the messag e
–
–
–
–
–
–
–
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Text and wording were
reviewed by a team of
representative HCWs at
HUG
(Team Performance)
86
Sweet
home
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