By Megan J. DiGiorgio, MSN, RN, CIC, FAPIC
The COVID-19 pandemic has had a lasting impact on healthcare, and its burden on the medical system and healthcare workers (HCW) has led to negative patient safety consequences. Numerous publications have detailed how the pandemic has alarmingly eroded our decade of former progress in reducing healthcare-associated infections (HAI) (Lastinger et al., 2022) and how staffing issues continue to play a role in HAIs (Halverson et al., 2022; Clifford et al., 2022). HCWs, whether temporary or permanent, need better education and training on the basics of infection prevention and control, including hand hygiene. However, while hand hygiene is the most foundational practice, it is also one of the most difficult to improve. Educating a workforce on hand hygiene—which many frontline caregivers should be performing dozens, if not a hundred times per day—is a significant challenge. Where to start?
Where is hand hygiene compliance in hospitals?
To determine where they need to go, hospitals need to determine how they are performing now. A recent meta-analysis published in the Journal of Hospital Infection reported that hand hygiene rates were much lower than where many hospitals had set their goals. The weighted pooled compliance rate, as reported by direct observation, was 52% for nurses and 45% for physicians (Bredin et al., 2022). The pandemic negatively impacted hand hygiene, with several studies reporting that either there were no gains despite the situation or that any improvements were quickly followed by a decrease back to baseline or below (Moore et al., 2021; Sandbøl et al., 2022). This suggests that many healthcare facilities have work to do in regaining lost ground.
Getting back to the basics
When the New England Journal of Medicine published its seminal Perspective article in February 2022 calling for building more resilient healthcare systems (Fleisher et al., 2022), many were seeking innovative next steps. When it comes to improving hand hygiene, however, a back-to-basics approach is a good place to start. Hospitals may believe they are “starting over” by taking this approach, but this is usually not the case. Reinvigorating hand hygiene programs by setting small, attainable, and sustainable goals is important because the work that goes into hand hygiene compliance takes years, not months. Relentless incrementalism is the name of the game. Healthcare facilities with success in this area have made hand hygiene an organizational priority and have built upon a multimodal approach to hand hygiene over the course of years (Sickbert-Bennett et al., 2016).
A multimodal approach
The World Health Organization has built its multimodal approach on a thoroughly compiled set of recommendations. The approach’s five essential elements are system change (making alcohol-based hand rub available), training and education, monitoring hand hygiene practices and giving performance feedback, reminders in the workplace, and creating a safety culture with the participation of HCWs and senior leadership (World Health Organization, 2009).
But for individual HCWs, the most important message is to perform hand hygiene on the way in and on the way out of the patient’s room. That’s a good place to start. Hand hygiene is simple but certainly not easy. Start building the expectation and habits among HCWs. Enlisting unit-based hand hygiene champions, managers, or informal leaders who reside on the unit can have a powerful impact on behavior due to proximity. Unit-based programs for speaking up and encouraging everyone on the front lines to remind others of missed hand hygiene opportunities can help create and sustain a new set of habits and practices (Sickbert-Bennett et al., 2020). While secret shopper programs where trained observers covertly monitor hand hygiene compliance are common, these observers often do not alert HCWs to a missed instance of hand hygiene, nor are they present at all times on the unit. The unit manager or local hand hygiene champions are in a better position to provide this feedback frequently and consistently.
It’s not only important to perform hand hygiene when indicated, especially upon room entry and exit, but also to apply the appropriate amount of product and use the correct technique as recommended by the manufacturer. Hospitals should include these factors in periodic hand hygiene education programs; however, they should also observe product application and technique during patient care. HCWs are busy and move and work quickly. They may unintentionally adopt workaround behaviors such as “splash and dash” or “a little dab’ll do ya” for the sake of time without realizing that they may be compromising patient safety. On-the-spot education and gentle reminders can help raise awareness and course-correct in the moment.
Getting back to the basics during this transition period will strengthen the promise of a safer post-pandemic future. Admittedly, this is hard work. It will take commitment, persistence, and endurance to hold fast to a years-long journey. But this is how hospitals change hand hygiene culture.
Megan J. DiGiorgio, MSN, RN, CIC, FAPIC, is a senior clinical manager at GOJO Industries, the makers of Purell products.
Bredin, D., O’Doherty, D., Hannigan, A., & Kingston, L. (2022). Hand hygiene compliance by direct observation in physicians and nurses: A systematic review and meta-analysis. The Journal of Hospital Infection, 130, 20–33. https://doi.org/10.1016/j.jhin.2022.08.013
Clifford, R. J., Newhart, D., Laguio-Vila, M. R., Gutowski, J. L., Bronstein, M. Z., & Lesho, E. P. (2022). Infection preventionist staffing levels and rates of 10 types of healthcare-associated infections: A 9-year ambidirectional observation. Infection Control & Hospital Epidemiology, 1–6. https://doi.org/10.1017/ice.2021.507
Fleisher, L. A., Schreiber, M., Cardo, D., & Srinivasan, A. (2022). Health care safety during the pandemic and beyond—building a system that ensures resilience. New England Journal of Medicine, 386(7), 609–611. https://doi.org/10.1056/NEJMp2118285
Halverson, T., Mikolajczak, A., Mora, N., Silkaitis, C., & Stout, S. (2022). Impact of COVID-19 on hospital-acquired infections. American Journal of Infection Control, 50(7), 831–833. https://doi.org/10.1016/j.ajic.2022.02.030
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Moore, L. D., Robbins, G., Quinn, J., & Arbogast, J. W. (2021). The impact of COVID-19 pandemic on hand hygiene performance in hospitals. American Journal of Infection Control, 49(1), 30–33. https://doi.org/10.1016/j.ajic.2020.08.021
Sandbøl, S. G., Glassou, E. N., Ellermann-Eriksen, S., & Haagerup, A. (2022). Hand hygiene compliance among healthcare workers before and during the COVID-19 pandemic. American Journal of Infection Control, 50(7), 719–723. https://doi.org/10.1016/j.ajic.2022.03.014
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Sickbert-Bennett, E. E., DiBiase, L. M., Teal, L. J., Summerlin-Long, S. K., & Weber, D. J. (2020). The holy grail of hand hygiene compliance: Just-in-time peer coaching that leads to behavior change. Infection Control & Hospital Epidemiology, 41(2), 229–232. https://doi.org/10.1017/ice.2019.340
World Health Organization. (2009, January 15). WHO guidelines for hand hygiene in health care. https://www.who.int/publications-detail-redirect/9789241597906