Improving hand hygiene compliance with comprehensive interventions over time

ISSUE: Proper hand hygiene (HH) by healthcare workers (HCWs) is a well-established method to prevent nosocomial pathogen transmission. Despite this, HCW HH compliance is not ideal. Alcohol-based hand rub was introduced and multiple interventions were also implemented to improve HH practices. PROJECT: 1) Data collection: In June 2003, an observational, interventional study with five phases (baseline, separate staggered intervention periods) was initiated. Trained members of infection control staff recorded data on patient encounters, including whether or not HCWs washed hands before (HH pre) and after (HH post) patient care. Twenty observation sessions per week were randomly distributed during the hours of 7am to 5pm, Monday through Friday; each session lasted about 30 minutes. 2) Interventions: Alcohol-based hand rub was selected utilizing staff input; decisions regarding placement and labeling gave consideration to feedback from multidisciplinary rounds and focus groups of clinical staff. Placement was standardized wherever possible. During mandatory introductory inservices, HCWs were educated on benefits and appropriate use of hand rub. Importance of HH in preventing infection was re-emphasized and common misconceptions about HH were addressed. Surveys and follow-up surveys were conducted to assess HCW attitudes, beliefs, and knowledge about HH as well as satisfaction with the hand-rub product. Education included an interactive component and a Web-based module. Two separate HH poster campaigns were launched. Refresher inservices provided feedback on floor-specific HH rates, fingertip culture results, and self-assessments of HH practices. Nurse leaders subsequently received monthly feedback on floor-specific HH rates. RESULTS: During 1,476 sessions (total of about 738 hrs of observation over 67 weeks), observers recorded 12,814 opportunities for HH (6,407 complete episodes). Ongoing review of continuous monitoring data has shown overall improvement at the end of each campaign phase. Overall, rates of HH compliance before patient care almost tripled (6.4% at baseline, 16.5% during Phase 4, p LESSONS LEARNED: Improving HH practices is difficult but possible with a comprehensive program of multiphased interventions over time. Our experience has shown that intervention components addressing physical environment, cognitive factors, clinical, and administrative buy-in and HCW involvement are beneficial.