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Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care

  • Vicki Erasmus (a1), Thea J. Daha (a2), Hans Brug (a1) (a3), Jan Hendrik Richardus (a1), Myra D. Behrendt (a4), Margreet C. Vos (a4) and Ed F. van Beeck (a1)...
Abstract
Objectives.

To assess the prevalence and correlates of compliance and noncompliance with hand hygiene guidelines in hospital care.

Design.

A systematic review of studies published before January 1, 2009, on observed or self-reported compliance rates.

Methods.

Articles on empirical studies written in English and conducted on general patient populations in industrialized countries were included. The results were grouped by type of healthcare worker before and after patient contact. Correlates contributing to compliance were grouped and listed.

Results.

We included 96 empirical studies, the majority (n = 65) in intensive care units. In general, the study methods were not very robust and often ill reported. We found an overall median compliance rate of 40%. Unadjusted compliance rates were lower in intensive care units (30%–40%) than in other settings (50%–60%), lower among physicians (32%) than among nurses (48%), and before (21%) rather than after (47%) patient contact. The majority of the time, the situations that were associated with a lower compliance rate were those with a high activity level and/or those in which a physician was involved. The majority of the time, the situations that were associated with a higher compliance rate were those having to do with dirty tasks, the introduction of alcohol-based hand rub or gel, performance feedback, and accessibility of materials. A minority of studies (n = 12) have investigated the behavioral determinants of hand hygiene, of which only 7 report the use of a theoretical framework with inconclusive results.

Conclusions.

Noncompliance with hand hygiene guidelines is a universal problem, which calls for standardized measures for research and monitoring. Theoretical models from the behavioral sciences should be used internationally and should be adapted to better explain the complexities of hand hygiene.

Copyright
Corresponding author
Department of Public Health, Erasmus University Medical Center, PO Box 2040, 3000 CA Rotterdam, The Netherlands(, v.erasmus@erasmusmc.nl)
References
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1.World Health Organization (WHO). Clean care is safer care: the first global patient safety challenge, http://www.who.int/gpsc/en/. Accessed May 25, 2009.
2.Donaldson L. Dirty hands: the human cost. London: UK Department of Public Health, 2006.
3.Day M. Chief medical officer names hand hygiene and organ donation as public health priorities. BMJ 2007;335(7611):113.
4.Pittet D, Allegranzi B, Sax H, et al.Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6(10):641652.
5.Gould DJ, Chudleigh JH, Moralejo D, Drey N. Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 2007(2):CD005186.
6.Bartholomew LK, Parcel GS, Kok G, Gottlieb NH. Planning health promotion programs: an intervention mapping approach. San Francisco, CA: Jossey-Bass, 2006.
7.Whitby M, Pessoa-Silva CL, McLaws ML, et al.Behavioral considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2007;65(1):18.
8.Hugonnet S, Pittet D. Hand hygiene—beliefs or science? Clin Microbiol Infect 2000;6(7):350356.
9.Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerg Infect Dis 2001;7(2):234240.
10.Pittet D. Compliance with hand disinfection and its impact on hospital-acquired infections. J Hosp Infect 2001;48(suppl A):S40S46.
11.Pittet D, Boyce JM. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1(0):920.
12.Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000;21(6):381386.
13.Jumaa PA. Hand hygiene: simple and complex. Int J Infect Dis 2005;9(1):314.
14.O'Boyle CA, Henly SJ, Duckett LJ. Nurses' motivation to wash their hands: a standardized measurement approach. Appl Nurs Res 2001;14(3):136145.
15.Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: performance, beliefs, and perceptions. Ann Intern Med 2004;141(1):18.
16.Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Handwashing practices in an intensive care unit: the effects of an educational program and its relationship to infection rates. Am J Infect Control 1989;17(6):330339.
17.Golan Y, Doron S, Griffith J, et al.The impact of gown-use requirement on hand hygiene compliance. Clin Infect Dis 2006;42(3):370376.
18.Harris AD, Samore MH, Nafziger R, DiRosario K, Roghmann MC, Carmeli Y. A survey on handwashing practices and opinions of healthcare workers. J Hosp Infect 2000;45(4):318321.
19.Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible sinks. Infect Control 1986;7(8):408410.
20.McArdle FI, Lee RJ, Gibb AP, Walsh TS. How much time is needed for hand hygiene in intensive care? A prospective trained observer study of rates of contact between healthcare workers and intensive care patients. J Hosp Infect 2006;62(3):304310.
21.O'Boyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned behavior. Am J Infect Control 2001;29(6):352360.
22.Raju TN, Kobler C. Improving handwashing habits in the newborn nurseries. Am J Med Sci 1991;302(6):355358.
23.Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing compliance by health care workers: the impact of introducing an accessible, alcohol-based hand antiseptic. Arch Intern Med 2000;160(7):10171021.
24.Girou E, Oppein F. Handwashing compliance in a French university hospital: new perspective with the introduction of hand-rubbing with a waterless alcohol-based solution. J Hosp Infect 2001;48(suppl A):S55S57.
25.Harbarth S, Pittet D, Grady L, et al.Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance. Pediatr Infect Dis J 2002;21(6):489495.
26.Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162(9):10371043.
27.Maury E, Alzieu M, Baudel JL, et al.Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. Am J Respir Crit Care Med 2000;162(1):324327.
28.Pittet D, Hugonnet S, Harbarth S, et al; Infection Control Programme. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene [published correction appears in Lancet 2000;356(9248): 2196]. Lancet 2000;356(9248):13071312.
29.Lankford MG, Zembower TR, Trick WE, Hacek DM, Noskin GA, Peterson LR. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis 2003;9(2):217223.
30.Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installation of dispensers of a rapidly acting hand antiseptic. Am J Infect Control 2000;28(3):273276.
31.Creedon SA. Healthcare workers' hand decontamination practices: compliance with recommended guidelines. J Adv Nurs 2005;51(3):208216.
32.Nobile CG, Montuori P, Diaco E, Villari P. Healthcare personnel and hand decontamination in intensive care units: knowledge, attitudes, and behavior in Italy. J Hosp Infect 2002;51(3):226232.
33.Larson EL, Bryan JL, Adler LM, Blane C. A multifaceted approach to changing handwashing behavior. Am J Infect Control 1997;25(1):310.
34.Maury E, Moussa N, Lakermi C, Barbut F, Offenstadt G. Compliance of health care workers to hand hygiene: awareness of being observed is important. Intensive Care Med 2006;32(12):20882089.
35.Larson EL, Albrecht S, O'Keefe M. Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems. Am J Crit Care 2005;14(4):304311; quiz 12.
36.Berhe M, Edmond MB, Bearman G. Measurement and feedback of infection control process measures in the intensive care unit: Impact on compliance. Am J Infect Control 2006;34(8):537539.
37.Cohen B, Saiman L, Cimiotti J, Larson E. Factors associated with hand hygiene practices in two neonatal intensive care units. Pediatr Infect Dis J 2003;22(6):494499.
38.Davenport SE. Frequency of hand washing by registered nurses caring for infants on radiant warmers and in incubators. Neonatal Netw 1992;11(1):2125.
39.Doebbeling BN, Stanley GL, Sheetz CT, et al.Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. N Engl J Med 1992;327(2):8893.
40.Earl ML, Jackson MM, Rickman LS. Improved rates of compliance with hand antisepsis guidelines: a three-phase observational study. Am J Nurs 2001;101(3):2633.
41.Eckmanns T, Schwab F, Bessert J, et al.Hand rub consumption and hand hygiene compliance are not indicators of pathogen transmission in intensive care units. J Hosp Infect 2006;63(4):406411.
42.Girard R, Amazian K, Fabry J. Better compliance and better tolerance in relation to a well-conducted introduction to rub-in hand disinfection. J Hosp Infect 2001;47(2):131137.
43.Girou E, Chai SH, Oppein F, et al.Misuse of gloves: the foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect 2004;57(2):162169.
44.Gould D. Nurses' hand decontamination practice: results of a local study. J Hosp Infect 1994;28(1):1530.
45.Graham M. Frequency and duration of handwashing in an intensive care unit. Am J Infect Control 1990;18(2):7781.
46.Harbarth S, Pittet D, Grady L, Goldmann DA. Compliance with hand hygiene practice in pediatric intensive care. Pediatr Crit Care Med 2001;2(4):311314.
47.Johnson PD, Martin R, Burrell LJ, et al.Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 2005;183(10):509514.
48.Kim PW, Roghmann MC, Perencevich EN, Harris AD. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control 2003;31(2):97103.
49.Mayer JA, Dubbert PM, Miller M, Burkett PA, Chapman SW. Increasing handwashing in an intensive care unit. Infect Control 1986;7(5):259262.
50.Moret L, Tequi B, Lombrail P. Should self-assessment methods be used to measure compliance with handwashing recommendations? A study carried out in a French university hospital. Am J Infect Control 2004;32(7):384390.
51.Nishimura S, Kagehira M, Kono F, Nishimura M, Taenaka N. Handwashing before entering the intensive care unit: what we learned from continuous video-camera surveillance. Am J Infect Control 1999;27(4):367369.
52.Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130(2):126130.
53.Sharek PJ, Benitz WE, Abel NJ, Freeburn MJ, Mayer ML, Bergman DA. Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU. J Perinatol 2002;22(2):137143.
54.Simmons B, Bryant J, Neiman K, Spencer L, Arheart K. The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 1990;11(11):589594.
55.Aragon D, Sole ML, Brown S. Outcomes of an infection prevention project focusing on hand hygiene and isolation practices. AACN Clin Issues 2005;16(2):121132.
56.Jenner EA, Fletcher BC, Watson P, Jones FA, Miller L, Scott GM. Discrepancy between self-reported and observed hand hygiene behavior in healthcare professionals. J Hosp Infect 2006;63(4):418422.
57.Raboud J, Saskin R, Wong K, et al.Patterns of handwashing behavior and visits to patients on a general medical ward of healthcare workers. Infect Control Hosp Epidemiol 2004;25(3):198202.
58.Whitby M, McLaws ML. Handwashing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect 2004;58(4):247253.
59.Sax H, Uckay I, Richet H, Allegranzi B, Pittet D. Determinants of good adherence to hand hygiene among healthcare workers who have extensive exposure to hand hygiene campaigns. Infect Control Hosp Epidemiol 2007;28(11):12671274.
60.Sladek RM, Bond MJ, Phillips PA. Why don't doctors wash their hands? A correlational study of thinking styles and hand hygiene. Am J Infect Control 2008;36(6):399406.
61.Vernon MO, Trick WE, Welbel SF, Peterson BJ, Weinstein RA. Adherence with hand hygiene: does number of sinks matter? Infect Control Hosp Epidemiol 2003;24(3):224225.
62.Watanakunakorn C, Wang C, Hazy J. An observational study of hand washing and infection control practices by healthcare workers. Infect Control Hosp Epidemiol 1998;19(11):858860.
63.Trick WE, Vernon MO, Welbel SF, et al.Multicenter intervention program to increase adherence to hand hygiene recommendations and glove use and to reduce the incidence of antimicrobial resistance. Infect Control Hosp Epidemiol 2007;28(1):4249.
64.Cromer AL, Latham SC, Bryant KG, et al.Monitoring and feedback of hand hygiene compliance and the impact on facility-acquired methicillin-resistant Staphylococcus aureus. Am J Infect Control 2008;36(9):672677.
65.Grayson ML, Jarvie LJ, Martin R, et al.Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust 2008;188(11):633640.
66.Duggan JM, Hensley S, Khuder S, Papadimos TJ, Jacobs L. Inverse correlation between level of professional education and rate of handwashing compliance in a teaching hospital. Infect Control Hosp Epidemiol 2008;29(6):534538.
67.Pan A, Mondello P, Posfay-Barbe K, et al.Hand hygiene and glove use behavior in an Italian hospital. Infect Control Hosp Epidemiol 2007;28(9): 10991102.
68.Giannitsioti E, Athanasia S, Antoniadou A, et al.Does a bed rail system of alcohol-based handrub antiseptic improve compliance of health care workers with hand hygiene? Results from a pilot study. Am J Infect Control 2009;37(2):160163.
69.Cantrell D, Shamriz O, Cohen MJ, Stern Z, Block C, Brezis M. Hand hygiene compliance by physicians: marked heterogeneity due to local culture? Am J Infect Control 2009;37(4):301305.
70.MacDonald A, Dinah F, MacKenzie D, Wilson A. Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs. J Hosp Infect 2004;56(1):5663.
71.Aizman A, Stein JD, Stenson SM. A survey of patterns of physician hygiene in ophthalmology clinic patient encounters. Eye Contact Lens 2003;29(4):221222.
72.Shimokura G, Weber DJ, Miller WC, Wurtzel H, Alter MJ. Factors associated with personal protection equipment use and hand hygiene among hemodialysis staff. Am J Infect Control 2006;34(3):100107.
73.Feather A, Stone SP, Wessier A, Boursicot KA, Pratt C. ‘Now please wash your hands’: the handwashing behavior of final MBBS candidates. J Hosp Infect 2000;45(1):6264.
74.Arenas Jimenez MD, Sanchez-Paya J, Gonzales C, Rivera F, Antolin A. Audit on the degree of application of universal precautions in a haemodialysis unit. Nephrol Dial Transplant 1999;14(4):10011003.
75.Arenas MD, Sanchez-Paya J, Barril G, et al.A multicentric survey of the practice of hand hygiene in haemodialysis units: factors affecting compliance. Nephrol Dial Transplant 2005;20(6):11641171.
76.Alp E, Haverkate D, Voss A. Hand hygiene among laboratory workers. Infect Control Hosp Epidemiol 2006;27(9):978980.
77.Venkatesh AK, Lankford MG, Rooney DM, Blachford T, Watts CM, Noskin GA. Use of electronic alerts to enhance hand hygiene compliance and decrease transmission of vancomycin-resistant Enterococcus in a hematology unit. Am J Infect Control 2008;36(3):199205.
78.Angtuaco TL, Oprescu FG, Lai SK, et al.Universal precautions guideline: self-reported compliance by gastroenterologists and gastrointestinal endoscopy nurses—a decade's lack of progress. Am J Gastroenterol 2003;98(11):24202423.
79.Dorsey ST, Cydulka RK, Emerman CL. Is handwashing teachable?: failure to improve handwashing behavior in an urban emergency department. Acad Emerg Med 1996;3(4):360365.
80.el Mikatti N, Dillon P, Healy TE. Hygienic practices of consultant anaesthetists: a survey in the north-west region of the UK. Anaesthesia 1999;54(1):1318.
81.Lipsett PA, Swoboda SM. Handwashing compliance depends on professional status. Surg Infect (Larchmt) 2001;2(3):241245.
82.Meengs MR, Giles BK, Chisholm CD, Cordell WH, Nelson DR. Handwashing frequency in an emergency department. Ann Emerg Med 1994;23(6):13071312.
83.Pittet D, Stéphan F, Hugonnet S, Akakpo C, Souweine B, Clergue F. Hand-cleansing during postanesthesia care. Anesthesiology 2003;99(3):530535.
84.Thomas M, Gillespie W, Krauss J, et al.Focus group data as a tool in assessing effectiveness of a hand hygiene campaign. Am J Infect Control 2005;33(6):368373.
85.van de Mortel T, Bourke R, Fillipi L, et al.Maximising handwashing rates in the critical care unit through yearly performance feedback. Aust Crit Care 2000;13(3):9195.
86.van de Mortel T, Bourke R, McLoughlin J, Nonu M, Reis M. Gender influences handwashing rates in the critical care unit. Am J Infect Control 2001;29(6):395399.
87.Benton C. Hand hygiene—meeting the JCAHO safety goal: can compliance with CDC hand hygiene guidelines be improved by a surveillance and educational program? Plast Surg Nurs 2007;27(1):4044.
88.Samraj S, Westbury J, Pallett A, Rowen D. Compliance with hand hygiene in a genitourinary medicine department. Int J STD AIDS 2008;19(11):782783.
89.Haas JP, Larson EL. Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department. Acad Emerg Med 2008;15(4):393396.
90.Perry C, Gore J. Now, wash your hands please. Nurs Times 1997;93(19):6468.
91.Sproat LJ, Inglis TJ. A multicentre survey of hand hygiene practice in intensive care units. J Hosp Infect 1994;26(2):137148.
92.Snow M, White GL JrAlder SC, Stanford JB. Mentor's hand hygiene practices influence student's hand hygiene rates. Am J Infect Control 2006;34(1):1824.
93.Diekema DJ, Schuldt SS, Albanese MA, Doebbeling BN. Universal precautions training of preclinical students: impact on knowledge, attitudes, and compliance. Prev Med 1995;24(6):580585.
94.Afif W, Huor P, Brassard P, Loo VG. Compliance with mefhicillin-resistant Staphylococcus aureus precautions in a teaching hospital. Am J Infect Control 2002;30(7):430433.
95.Coignard B, Grandbastien B, Berrouane Y, et al.Handwashing quality: impact of a special program. Infect Control Hosp Epidemiol 1998;19(7):510513.
96.Lund S, Jackson J, Leggett J, Hales L, Dworkin R, Gilbert D. Reality of glove use and handwashing in a community hospital. Am J Infect Control 1994;22(6):352357.
97.Randle J, Clarke M, Storr J. Hand hygiene compliance in healthcare workers. J Hosp Infect 2006;64(3):205209.
98.Wendt C, Knautz D, von Baum H. Differences in hand hygiene behavior related to the contamination risk of healthcare activities in different groups of healthcare workers. Infect Control Hosp Epidemiol 2004;25(3):203206.
99.Wurtz R, Moye G, Jovanovic B. Handwashing machines, handwashing compliance, and potential for cross-contamination. Am J Infect Control 1994;22(4):228230.
100.Hussein R, Khakoo R, Hobbs G. Hand hygiene practices in adult versus pediatric intensive care units at a university hospital before and after intervention. Scand J Infect Dis 2007;39(6-7):566570.
101.Pessoa-Silva CL, Hugonnet S, Pfister R, et al.Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics 2007;120(2):e382e390.
102.Rose L, Rogel K, Redl L, Cade JF. Implementation of a multimodal infection control program during an Acinetobacter outbreak. Intensive Crit Care Nurs 2009;25(2):5763.
103.Rupp ME, Fitzgerald T, Puumala S, et al.Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol 2008;29(1):815.
104.Traore O, Hugonnet S, Lubbe J, Griffiths W, Pittet D. Liquid versus gel handrub formulation: a prospective intervention study. Crit Care 2007;11(3):R52.
105.Zimakoff J, Stormark M, Larsen SO. Use of gloves and handwashing behavior among health care workers in intensive care units. A multi-centre investigation in four hospitals in Denmark and Norway. J Hosp Infect 1993;24(1):6367.
106.Dedrick RE, Sinkowitz-Cochran RL, Cunningham C, et al.Hand hygiene practices after brief encounters with patients: an important opportunity for prevention. Infect Control Hosp Epidemiol 2007;28(3):341345.
107.Tvedt C, Bukholm G. Alcohol-based hand disinfection: a more robust hand-hygiene method in an intensive care unit. J Hosp Infect 2005;59(3):229234.
108.van de Mortel T, Murgo M. An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions. Am J Infect Control 2006;34(3):9599.
109.Larson EL, Quiros D, Lin SX. Dissemination of the CDC's Hand Hygiene Guideline and impact on infection rates. Am J Infect Control 2007;35(10):666675.
110.Meengs MR, Giles BK, Chisholm CD, Cordell WH, Nelson DR. Hand washing frequency in an emergency department. J Emerg Nurs 1994;20(3):183188.
111.Bittner MJ, Rich EC. Surveillance of handwashing episodes in adult intensive-care units by measuring an index of soap and paper towel consumption. Clin Perform Qual Health Care 1998;6(4):179182.
112.McGuckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control 2004;32(4):235238.
113.Haas JP, Larson EL. Measurement of compliance with hand hygiene. J Hosp Infect 2007;66(1):614.
114.Erasmus V, Brouwer W, van Beeck EF, et al.A qualitative exploration of reasons for poor hand hygiene among hospital workers: lack of positive role models and of convincing evidence that hand hygiene prevents cross-infection. Infect Control Hosp Epidemiol 2009;30:415419.
115.Barrett R, Randle J. Hand hygiene practices: nursing students' perceptions. J Clin Nurs 2008;17(14):18511857.
116.Whitby M, McLaws ML, Ross MW. Why healthcare workers don't wash their hands: a behavioral explanation. Infect Control Hosp Epidemiol 2006;27(5):484492.
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