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Hand hygiene after touching a patient's surroundings: the opportunities most commonly missed

  • G. FitzGerald
    Affiliations
    Department of Microbiology & Virology, University College London Hospitals NHS Foundation Trust, London, UK
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  • G. Moore
    Affiliations
    Department of Microbiology & Virology, University College London Hospitals NHS Foundation Trust, London, UK
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  • A.P.R. Wilson
    Correspondence
    Corresponding author. Address: Department of Microbiology & Virology, University College London Hospitals, 60 Whitfield Street, London W1T 4EU, UK. Tel.: +44 (0) 20 344 79516; fax: +44 (0) 20 344 79211.
    Affiliations
    Department of Microbiology & Virology, University College London Hospitals NHS Foundation Trust, London, UK
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Published:March 04, 2013DOI:https://doi.org/10.1016/j.jhin.2013.01.008

      Summary

      Background

      Healthcare workers generally underestimate the role of environmental surfaces in the transmission of infection, and compliance with hand hygiene following contact with the environment is generally lower than following direct patient contact. To reduce the risk of onward transmission, healthcare workers must identify the need to wash hands with specific tasks or events.

      Aim

      To observe the movement of staff in critical care and general wards and determine the routes most commonly travelled and the surfaces most frequently touched with and without appropriate hand hygiene.

      Methods

      Fifty-eight 90 min sessions of unobtrusive observation were made in open bays and isolation rooms. Link analysis was used to record staff movement from one location to another as well as the frequency of motion. Hand-hygiene audits were conducted using the World Health Organization ‘five moments for hand hygiene’ observational tool.

      Findings

      In critical care, the majority of movement occurred within the bed space. The bedside computer and equipment trolley were the surfaces most commonly touched, often immediately after patient contact. In the general ward, movement between bed spaces was more common and observed hand hygiene ranged from 25% to 33%. Regardless of ward type, observed hand-hygiene compliance when touching the patient immediately on entering an isolation room was less than 30%.

      Conclusions

      Healthcare workers must be made aware that bacterial spread can occur even during activities of perceived low risk. Education and intervention programmes should focus on the potential contamination of ward computers, case notes and door handles.

      Keywords

      Introduction

      During routine patient care, the hands of a healthcare worker can become heavily contaminated.
      • Pittet D.
      • Dharan S.
      • Touveneau S.
      • Sauvan V.
      • Perneger T.V.
      Bacterial contamination of the hands of hospital staff during routine patient care.
      • Pessoa-Silva C.L.
      • Dharan S.
      • Hugonnet S.
      • et al.
      Dynamics of bacterial hand contamination during routine neonatal care.
      Inadequate hand hygiene when caring for a single patient or when moving between patients can lead to the cross-transmission of pathogens.
      • El Shafiea S.S.
      • Alishaqb M.
      • Leni Garciab M.
      Investigation of an outbreak of multidrug-resistant Acinetobacter baumannii in trauma intensive care unit.
      To interrupt microbial transmission effectively, hand hygiene is required at pivotal points during the patient care sequence. These have been defined by the World Health Organization (WHO) as being the ‘five moments for hand hygiene’ and they emphasize the importance of hand hygiene before and after patient contact, before performing a clean/aseptic technique and after exposure to body fluids. The ‘fifth moment for hand hygiene’ occurs after touching a patient's surroundings.
      • Sax H.
      • Allegranzi B.
      • Uçkay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene.
      Patients contaminate their immediate environment and the ease with which bacteria can be acquired from environmental surfaces by the hands or gloves of healthcare workers has been demonstrated.
      • Bhalla A.
      • Pultz N.J.
      • Gries D.M.
      • et al.
      Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients.
      • Duckro A.N.
      • Blom D.W.
      • Lyle E.A.
      • Weinstein R.A.
      • Hayden M.K.
      Transfer of vancomycin-resistant enterococci via health care worker hands.
      If these include potential pathogens, the reservoirs that develop on nearby surfaces represent a risk factor for onward transmission. Although the role of environmental surfaces in the transmission of infection is acknowledged within the ‘five moments’, this knowledge may not be sufficiently widespread among healthcare workers.
      • Erasmus V.
      • Brouwer W.
      • van Beeck E.F.
      • et al.
      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.
      • McLaughlin A.C.
      • Walsh F.
      Individual differences in judgments of hand hygiene risk by health care workers.
      Studies have demonstrated that whereas the majority of hand-hygiene opportunities occur after contact with a patient's surroundings, these opportunities are also those most commonly missed (i.e. are associated with the lowest levels of compliance).
      • Steed C.
      • Kelly J.W.
      • Blackhurst D.
      • et al.
      Hospital hand hygiene opportunities: where and when (HOW2)? The HOW2 Benchmark Study.
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      • Alsubaie S.
      • bin Maither A.
      • Alalmaei W.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      To improve hand-hygiene compliance, interventions should provide the cues healthcare workers use to identify the need to clean their hands while also providing the ability to perform hand hygiene – for example, locating alcohol gel dispensers en route to a task where hand hygiene is required.
      • McLaughlin A.C.
      • Walsh F.
      Self-reported reasons for hand hygiene in 3 groups of health care workers.
      These cues should be tied to specific events or tasks rather than to general behaviour.
      • McLaughlin A.C.
      • Walsh F.
      Self-reported reasons for hand hygiene in 3 groups of health care workers.
      As a result, appropriate cues/interventions may differ with ward type, isolation precautions and/or professional group. The aim of this investigation was to observe the movement of staff in critical care and general wards and, with a view to focus hand-hygiene training, to determine the routes most commonly travelled and the surfaces most frequently touched together with associated hand-hygiene compliance.

      Methods

      Study setting

      The study was performed on the medical–surgical intensive care unit (ICU) and on a gastrointestinal ward of a London teaching hospital between August and December 2009. The ICU comprised 11 single rooms; four bays of five beds and one bay of four beds. The median bed centre to bed centre distance was 3.6 m. The gastrointestinal ward comprised seven single rooms; three bays of five beds and 10 bays of four beds with 2.7 m bed spacing. All bed spaces had ready access to a handwash sink, paper towels and alcohol hand rub.

      Observation of staff movement and hand hygiene

      During the 17-week study period, fifty-eight 90 min sessions of unobtrusive observation were made in open bays and isolation rooms. Observation of activity in ICU was problematic for the most ill patients because of the number of staff involved. In some cases only a specific bed area could be observed at one session.
      Link analysis is a straightforward technique used to record and visualize staff movement from one location to another as well as the frequency of motion.
      • Wolf L.D.
      • Potter P.
      • Sledge J.A.
      • Boxerman S.B.
      • Grayson D.
      • Evanoff B.
      Describing nurses' work: combining quantitative and qualitative analysis.
      A map of the observed area (bay; bed space; isolation room) was made, and, as staff moved from one location to the next, an activity log was generated detailing the time of observation, the physical location where the task/activity occurred and the associated hand-hygiene opportunity.
      Hand-hygiene audits were conducted using the WHO ‘five moments for hand hygiene’ observational tool.
      • Sax H.
      • Allegranzi B.
      • Uçkay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene.
      Alcohol is ineffective against Clostridium difficile.
      • Jabbar U.
      • Leischner J.
      • Kasper D.
      • et al.
      Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands.
      As such, if the patient had a diarrhoeal disease and alcohol gel was used rather than soap and water, this was recorded as a missed opportunity. Covert observation was not practicable as the research nurse was known to the staff on the wards and his role in observing hand hygiene was clear to all.

      Analysis of results

      The link analysis was used to describe the movement of staff within the bay or bed space in terms of sequential events (e.g. equipment trolley → patient; patient → computer; computer → patient; patient → sink). Pivot tables were constructed in Microsoft Excel 2007 and used to determine the routes most travelled and the surfaces of highest contact with and without appropriate hand hygiene.

      Results

      Intensive care unit

      Fourteen 90 min observation sessions were conducted within an ICU bay. Hand-hygiene compliance was 60% (based on observable outcomes). Of the 255 hand-hygiene opportunities identified, 101 (40%) occurred after contact with the environment. The sites most frequently touched were within the patient zone (i.e. the patient's immediate surroundings) and included the equipment trolley (211 contacts) and the computer keyboard (170 contacts). Movement between an equipment trolley and a patient was observed on 50 occasions (Table I). Hand-hygiene compliance when moving from a patient to a trolley was 11% (based on observable outcomes; 1/9). Observed hand-hygiene compliance when moving from a trolley to a patient was 43% (12/28). Healthcare workers were also observed to regularly move from a patient to the bedside computer (electronic records); the observed hand-hygiene compliance associated with this movement route was 14% (1/7).
      Table IStaff movement within the intensive care unit: routes most travelled and associated hand-hygiene compliance
      RouteObserved no. of times route travelledHand-hygiene compliance
      Compliance based upon observed outcomes.
      OriginDestination
      Five-bedded bay
       Equipment trolleyPatient
      Hand-hygiene opportunity.
      3843%
       Apron dispenser
      Hand-hygiene opportunity.
      Equipment trolley2333%
       PatientBin
      Hand-hygiene opportunity.
      1690%
       Patient
      Hand-hygiene opportunity.
      Equipment trolley1211%
       Patient
      Hand-hygiene opportunity.
      Computer1014%
       Bed
      Hand-hygiene opportunity.
      Bay door (exit bay)1070%
      Single isolation room
       Equipment trolleyPatient
      Hand-hygiene opportunity.
      3668%
       Door (enters room)Door (exits room)
      Hand-hygiene opportunity.
      2950%
       PatientBin
      Hand-hygiene opportunity.
      2253%
       Door (enters room)Patient
      Hand-hygiene opportunity.
      2029%
       Door (enters room)Equipment trolley17NA
       Door (enters room)Computer16NA
       Patient
      Hand-hygiene opportunity.
      Computer1322%
       Patient
      Hand-hygiene opportunity.
      Door (exits room)1375%
       Patient
      Hand-hygiene opportunity.
      Equipment trolley1329%
       Computer
      Hand-hygiene opportunity.
      Door (exits room)1175%
      NA, not applicable.
      a Compliance based upon observed outcomes.
      b Hand-hygiene opportunity.
      Seventeen 90 min observation sessions were conducted within a single isolation room. Hand-hygiene compliance was 62% (169/271). In all, 154 people were observed to enter the room and 137 people were observed to leave; contact with the inner or outer door handle was thus observed on 291 occasions. Inside the room, the sites most commonly touched were the equipment trolley (183 contacts) and the computer keyboard (159 contacts). As in the bay, most movement was between the equipment trolley and the patient and observed hand-hygiene compliance was higher when moving from trolley to patient (68%) than from patient to trolley (29%; Table I). Observed hand-hygiene compliance when moving from a patient to the bedside computer was 22% (2/9).

      Gastrointestinal ward

      Twenty 90 min observation sessions were conducted within an open bay on the gastrointestinal ward. Hand-hygiene compliance was 34% (106/310). Of those opportunities that were missed, 102 (50%) occurred after contact with a patient's surroundings. The sites most commonly touched were the bed (207 contacts) and the medical notes trolley (165 contacts). The nurse-to-patient staffing ratio in the ICU and gastrointestinal ward was 1:1 and 1:8 respectively and, as a consequence, staff movement between patients and/or bed spaces was more frequent in the gastrointestinal ward. Observed hand-hygiene compliance associated with these journeys was between 25% and 33% (Table II). Unlike in the ICU, most staff movement in and around the gastrointestinal ward was observed to take place outside the patient zone (i.e. within the wider ward environment) and did not require hand hygiene (Table II). Movement between the patient toilet/shower facilities and the patient bed was observed on 26 occasions. However, the movement of patients in and around the ward was not the focus of the study and as such was underestimated.
      Table IIMovement within the gastrointestinal ward: routes most travelled and associated hand-hygiene compliance
      RouteObserved no. of times route travelledHand-hygiene compliance
      Compliance based upon observed outcomes.
      OriginDestination
      Four-bedded bay
       Patient toilet
      Hand-hygiene opportunity.
      Bed26Unobserved
       Medical notes trolleyNurses' station18NA
       Patient
      Hand-hygiene opportunity.
      Patient
      Hand-hygiene opportunity.
      ,
      Hand hygiene indicated after patient contact and before next patient contact, although one episode of hand hygiene would fulfil both indications.
      1333%
       Medical notes trolleyBay desk13NA
       Nurses' stationMedical notes trolley13NA
       Patient record folder
      Hand-hygiene opportunity.
      Bay desk1214%
       Bed
      Hand-hygiene opportunity.
      Bed1225%
       Patient
      Hand-hygiene opportunity.
      Sluice room1150%
      Single isolation room
       Door (enters room)Door (exits room)
      Hand-hygiene opportunity.
      1650%
       Door (enters room)Patient
      Hand-hygiene opportunity.
      1220%
       PatientBin
      Hand-hygiene opportunity.
      425%
       Patient
      Hand-hygiene opportunity.
      Door (exits room)20
      NA, not applicable.
      a Compliance based upon observed outcomes.
      b Hand-hygiene opportunity.
      c Hand hygiene indicated after patient contact and before next patient contact, although one episode of hand hygiene would fulfil both indications.
      Seven 90 min observation sessions were conducted within a single isolation room on the gastrointestinal ward. Activity levels were considerably less than that observed in the bay or in ICU. Sixty people were observed to enter the room and 34 people were observed to leave; contact with the inner or outer door handle was thus observed on 94 occasions. Staff activity within the isolation room was limited. Healthcare workers were most commonly observed to enter the room and to exit almost immediately, with or without first touching the patient (Table II). Hand-hygiene compliance after touching the patient's surroundings was 37.5% (9/24).

      Discussion

      In the ICU and gastrointestinal ward, hand-hygiene compliance was 60% and 36% respectively. As in previous studies, the majority of missed hand-hygiene opportunities occurred after contact with a patient's surroundings.
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      • Alsubaie S.
      • bin Maither A.
      • Alalmaei W.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      The aim of this study was to determine which surfaces were most likely to be touched without appropriate hand hygiene.
      The results of this study demonstrate how the movement patterns of staff differ in critical care and general wards. In the ICU, the one-nurse-per-bed policy reduced staff movement between bed spaces. In the gastrointestinal ward, movement from patient to patient or from bed to bed was more frequent. The observed hand-hygiene compliance associated with these movement routes was low (25–33%; Table II) and may have been due to the perceived low risk of the activity being performed (e.g. taking blood pressure; reading case notes).
      • Whitby M.
      • McLaws M.-L.
      • Ross R.W.
      Why healthcare workers don't wash their hands: a behavioral explanation.
      Healthcare workers consistently misjudge the danger of surfaces.
      • McLaughlin A.C.
      • Walsh F.
      Individual differences in judgments of hand hygiene risk by health care workers.
      However, extensive contamination of blood pressure cuffs can occur either through direct patient contact or inadequate staff hand hygiene.
      • Manian F.A.
      • Meyer L.
      • Jenne J.
      Clostridium difficile contamination of blood pressure cuffs: a call for a closer look at gloving practices in the era of universal precautions.
      • de Gialluly C.
      • Morange V.
      • de Gialluly E.
      • Loulergue J.
      • van der Mee N.
      • Quentin R.
      Blood pressure cuff as a potential vector of pathogenic microorganisms: a prospective study in a teaching hospital.
      Case records are unlikely to be cleaned and during a concurrent microbiological survey the record folders in the gastrointestinal ward were found to harbour high numbers of bacteria including meticillin-resistant Staphylococcus aureus, Enterococcus spp., Escherichia coli and Acinetobacter baumannii (unpublished data).
      In the gastrointestinal ward, the nurse-to-patient staffing ratio was 1:8. Two nurses were observed to have particularly poor compliance with hand hygiene. Pharmacists frequently entered the patient zone to read medication charts and moved from bed to bed without performing hand hygiene. Non-compliant peripatetic healthcare workers (i.e. healthcare workers with a large number and/or diverse number of contacts) may play a disproportionate role in disseminating pathogens in and around a hospital ward.
      • Temimea L.
      • Opatowski L.
      • Panneta Y.
      • Brun-Buisson C.
      • Yves Boelle P.
      • Guillemot D.
      Peripatetic health-care workers as potential superspreaders.
      • Hornbeck T.
      • Naylor D.
      • Segre A.M.
      • Thomas G.
      • Herman T.
      • Polgreen P.M.
      Using sensor networks to study the effect of peripatetic healthcare workers on the spread of hospital-associated infections.
      Education and raising the awareness of the risk of bacterial transfer from surfaces, even when conducting seemingly innocuous tasks, is important in rectifying such issues. Case record folders could be illustrated in such a way as to prompt healthcare workers to perform hand hygiene, and, where possible, ward rounds should be conducted using electronic means rather than moving from bed to bed.
      In the ICU, patient records, notes and observation charts were stored and displayed electronically. A computer keyboard was located within every bed space – this piece of equipment and the bedside equipment trolley were the surfaces most frequently touched, often immediately after patient contact. The associated hand-hygiene compliance (Table I) suggests that significant bacterial transfer may occur from patient to either surface, which, if inadequately cleaned, could act as a source from which healthcare workers might contaminate their hands.
      Several studies have reported heavy contamination of computer keyboards.
      • Schultz M.
      • Gill J.
      • Zubairi S.
      • Huber R.
      • Gordin F.
      Bacterial contamination of computer keyboards in a teaching hospital.
      • Hartmann B.
      • Benson M.
      • Junger A.
      • et al.
      Computer keyboard and mouse as a reservoir of pathogens in an intensive care unit.
      The keyboards in the ICU were designed to be easy-to-clean and incorporated a visual alarm to promote cleaning compliance.
      • Wilson A.P.R.
      • Ostro P.
      • Magnussen M.
      • Cooper B.
      Laboratory and in-use assessment of methicillin-resistant Staphylococcus aureus contamination of ergonomic computer keyboards for ward use.
      However, a visual alarm is easy to ignore, and, if cleaning compliance is poor, even ‘easy-to-clean’ keyboards can become heavily contaminated. In an attempt to improve cleaning compliance, software that causes a cleaning reminder to appear on the monitor screen has been developed and is currently under trial. A similar strategy could be used to remind healthcare workers to perform hand hygiene after using ward computers.
      In the ICU and gastrointestinal ward, observed hand-hygiene compliance when touching the patient immediately after entering an isolation room was 29% and 20% respectively (Table I, Table II). Hand hygiene should be performed before touching a patient.
      • Sax H.
      • Allegranzi B.
      • Uçkay I.
      • Larson E.
      • Boyce J.
      • Pittet D.
      ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene.
      Standard contact precautions require adequate hand hygiene to be performed before entering an isolation room. Although not observed (the research nurse was stationed inside the isolation room) the majority of staff probably washed/decontaminated their hands before entering the room and, because of this, considered the hand-hygiene opportunity fulfilled. However, studies have demonstrated that the handles used to enter an isolation room can become contaminated.
      • Oie S.
      • Hosokawa I.
      • Kamiya A.
      Contamination of room door handles by methicillin-sensitive/methicillin-resistant Staphylococcus aureus.
      Hands decontaminated outside the room could become re-contaminated on entry, potentially leading to pathogens being transferred to the patient or to surfaces inside the room. Frequent and effective cleaning of door handles, particularly those associated with busy isolation rooms, is essential. Healthcare workers should be encouraged to perform hand hygiene before and after entering an isolation room. Alternatively, consideration should be given to alternative entry/exit systems [e.g. foot-operated or automatic (non-contact) doors].
      Much emphasis has been placed on improving staff hand-hygiene compliance but patient hand hygiene must also be encouraged.
      • Landers T.
      • Abusalem S.
      • Coty M.-B.
      • Bingham J.
      Patient-centered hand hygiene: the next step in infection prevention.
      Previous studies have suggested that patient mobility can contribute greatly to the spread of bacteria within a ward.
      • Muzslay M.
      • Moore G.
      • Turton J.
      • Wilson A.P.R.
      Dissemination of antibiotic-resistant enterococci within the ward environment: the role of airborne bacteria and the risk posed by unrecognized carriers.
      In the gastrointestinal ward, the movement of patients between toilet/shower facilities and bed was frequent. Patients should be encouraged to clean their hands after using the toilet and when leaving and returning to their bed space.
      • Landers T.
      • Abusalem S.
      • Coty M.-B.
      • Bingham J.
      Patient-centered hand hygiene: the next step in infection prevention.
      Appropriate hand-hygiene products should be visible and accessible. Providing each patient with hand sanitizer could be considered and would be acceptable to patients, but visual and verbal reminders are needed.
      • Landers T.
      • Abusalem S.
      • Coty M.-B.
      • Bingham J.
      Patient-centered hand hygiene: the next step in infection prevention.
      • Pittet D.
      • Panesar S.S.
      • Wilson K.
      • et al.
      Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study.
      Hand hygiene is central to the campaign to reduce hospital-acquired infection, and encouraging compliance is the main focus of infection control education within hospitals. Hand-hygiene compliance following contact with the environment is generally lower than that following other aspects of patient care. This study has recorded frequently performed contact patterns that may result in the spread of hospital pathogens, and the results could help focus hand-hygiene training and/or behaviour change. However, there were some limitations.
      Staff were observed for 90 min sessions during the working day. The optimal period for monitoring hand-hygiene compliance is 60 min but it has been recommended that observations are timed to capture a complete picture of 24 h activity.
      • Stone S.
      • Fuller C.
      • Michie S.
      • McAteer J.
      • Charlett A.
      What is the optimal period for measuring hand hygiene compliance: are longer periods better than 20-minute periods?.
      • Gould D.J.
      • Chudleigh J.
      • Drey N.S.
      • Moralejo D.
      Measuring handwashing performance in health service audits and research studies.
      The number of staff and level of activity within the gastrointestinal isolation rooms was generally low, so that fewer observations could be collected and the likelihood of staff altering their behaviour as a direct result of being observed was increased.
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      Manual data capture was inadequate to record rapid multiple simultaneous activities and observation was often obscured by curtains or other objects. Continuous automatic contact monitoring is required and a system that can detect direct contact between healthcare worker and environmental surface and any subsequent hand hygiene has been evaluated.

      Storey S, Wilson APR, Moore G, et al. Trial of hand hygiene monitoring system with immediate feedback. Presented at: Infection Prevention 2012, Liverpool, 1–3 October, 2012.

      Acknowledgements

      We thank the medical and nursing staff on the wards for their help during this study. The trial was approved by the Joint UCL/UCLH Committees on the Ethics of Human Research 06/Q0502/91.

      Funding sources

      The project was supported by a grant from the Department of Health HCAI Technology Innovation Programme . A.P.R.W. was part funded by the UCLH/UCL/LSHTM Comprehensive Biomedical Centre .

      Conflict of interest statement

      None declared.

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