Elsevier

The Lancet

Volume 356, Issue 9238, 14 October 2000, Pages 1307-1312
The Lancet

Articles
Effectiveness of a hospital-wide programme to improve compliance with hand hygiene

https://doi.org/10.1016/S0140-6736(00)02814-2Get rights and content

Summary

Background

Hand hygiene prevents cross infection in hospitals, but compliance with recommended instructions is commonly poor. We attempted to promote hand hygiene by implementing a hospital-wide programme, with special emphasis on bedside, alcohol-based hand disinfection. We measured nosocomial infections in parallel.

Methods

We monitored the overall compliance with hand hygiene during routine patient care in a teaching hospital in Geneva, Switzerland, before and during implementation of a hand-hygiene campaign. Seven hospital-wide observational surveys were done twice yearly from December, 1994, to December, 1997. Secondary outcome measures were nosocomial infection rates, attack rates of meticillin-resistant Staphylococcus aureus (MRSA), and consumption of handrub disinfectant.

Findings

We observed more than 20 000 opportunities for hand hygiene. Compliance improved progressively from 48% in 1994, to 66% in 1997 (p<0·001). Although recourse to handwashing with soap and water remained stable, frequency of hand disinfection substantially increased during the study period (p<0·001). This result was unchanged after adjustment for known risk factors of poor adherence. Hand hygiene improved significantly among nurses and nursing assistants, but remained poor among doctors. During the same period, overall nosocomial infection decreased (prevalence of 16·9% in 1994 to 9·9% in 1998; p=0·04), MRSA transmission rates decreased (2.16 to 0.93 episodes per 10 000 patient-days; p<0·001), and the consumption of alcohol-based handrub solution increased from 3.5 to 15.4 L per 1000 patient-days between 1993 and 1998 (p<0·001).

Interpretation

The campaign produced a sustained improvement in compliance with hand hygiene, coinciding with a reduction of nosocomial infections and MRSA transmission. The promotion of bedside, antiseptic handrubs largely contributed to the increase in compliance.

Introduction

Hand hygiene, either by handwashing or hand disinfection, remains the single most important measure to prevent nosocomial infections.1 The importance of this simple procedure is not sufficiently recognised by health-care workers (HCWs),2 and poor compliance has been documented repeatedly.3, 4, 5 Although some previous interventions to improve compliance have been successful, none has achieved lasting improvement.2, 6, 7 This situation led to the creation of a Handwashing Liaison Group8 in the UK in 1997, whose mission is “to modify the behaviour of HCWs to produce sustained improvement in compliance with agreed handwashing standards and so improve the quality of patient care”.8

In our hospital, we documented disappointing levels of hand hygiene compliance and identified several risk factors for non-compliance.5 The observed relation between increased workload and reduced compliance suggested that promotion of bedside hand disinfection, less timeconsuming than handwashing, may improve compliance.5, 9 Hence, we implemented a hospital-wide campaign to promote hand hygiene and, in particular, the use of alcoholbased handrubs.7 We hypothesised that our programme would not only increase compliance with hand hygiene, but also diminish meticillin-resistant Staphylococcus aureus (MRSA) transmission and nosocomial infection rates. We describe the programme and its effectiveness.

Section snippets

Procedure

The University of Geneva Hospitals (UGH) is a large acute-care teaching hospital serving residents of Geneva, Switzerland, and the surrounding area. Handwashing facilities are available everywhere with one to three sinks in every patient's room together with unmedicated soap and paper towels.

The hand-hygiene promotion programme started in January 1995 after a baseline survey.5 The most prominent component was a visual display with A3-size colour posters that emphasised the importance of

Results

Between 1994 and 1997, data were collected from 2629 scheduled observation periods, of which 120 (4·6%) produced no data, mostly during the night when no handhygiene opportunities occurred. The remaining 2509 periods totalled 833 h and 52 min of observation and lasted between 5 and 45 min, most being of 20 min duration (2384 [95%] of observations). We obtained data on 20082 opportunities for hand hygiene in total.

Hand-cleansing opportunities were spread evenly among the seven surveys, between

Discussion

Compliance with hand-hygiene recommendations improved significantly following a hospital-wide education programme, coinciding with a reduction of nosocomial infections and MRSA transmission. The programme was mainly based on a poster campaign together with a generalised promotion of alcoholic handrubs as an alternative to soap-and-water handwashing. Improved adherence was sustained and observed across most hospital locations, in all types of patient-care activities, and among most HCWs present

References (31)

  • BL Thompson et al.

    Handwashing and glove use in a long-term care facility

    Infect Control Hosp Epidemiol

    (1997)
  • D Pittet et al.

    Compliance with handwashing in a teaching hospital

    Ann Intern Med

    (1999)
  • EL Teare et al.

    Hand washing—a modest measure with big effects

    BMJ

    (1999)
  • A Voss et al.

    No time for handwashing!? Handwashing versus alcoholic rub: can we afford 100% compliance?

    Infect Control Hosp Epidemiol

    (1997)
  • ML Rotter

    Hand washing and hand disinfection

  • Cited by (1927)

    View all citing articles on Scopus
    View full text