A Moment for Hand Hygiene in the Intensive Care Unit: How Can Compliance be Improved?

INTRODUCTION. Patients in Intensive Care Units (ICUs) are particularly vulnerable to infection. Although appropriate hand hygiene (HH) practices are recognised as the most effective preventative strategy for infection, adherence continues to be suboptimal. The aims were to take a scientific approach to improving hand hygiene in order to identify a sustainable intervention that is appropriate for improving hand hygiene compliance in the ICU. METHODS. The research was founded upon Michie et al’s Behaviour Change Wheel. A multi-methods approach was taken to conducting the research. The methods included: a systematic reviews of  38 published HH intervention studies conducted in ICU settings; a systematic review of 61 studies reporting levels of HH compliance in ICU settings; interviews with 12 Irish HH policy makers; a review of 4 Irish HH policy documents; interviews with 26 ICU staff about barriers and enablers of HH compliance; 292 responses to a questionnaire assessing attitudes to barriers and enablers of HH compliance; and observations of 712 Moments of HH in four ICUs. RESULTS. The systematic reviews found that best practices in improving HH compliance in the ICU is unestablished. HH compliance levels reported in the literature were a weighted mean of 59.3%. The policy-makers interviewed identified a range of barriers and facilitators of HH compliance. However, there was a lack of guidance in policy documents on how to improve HH compliance. ICU staff interviews showed that time and workload factors are occasionally a barrier to compliance. Social norms, the sense of being watched or monitored, and explicit encouragement and reminders were motivating factors in in HH compliance reported by staff. The questionnaire study found that capability and motivation were significant predictors of self-reported behavioural intention. The observed average HH compliance was 56.9% across the four ICUs, with healthcare providers more likely to engage in HH practices that protect themselves than those that protect the patient. DISCUSSION. Best practices in improving HH compliance in the ICU are unestablished, and guidance on how to improve HH is lacking. There is a need to reconsider how HH compliance is being measured, and the design of interventions to improve HH compliance. CONCLUSIONS. There is a need for guidance not only on the ‘what’ (the HH compliance standards that must be met), but also the ‘how’ (guidance on how to achieve targets). LESSONS LEARNED. There is a need to take an evidence based-approach that uses information gather from observations, as well as other methodologies,(e.g. interviews, attitude questionnaire), in order to devise interventions tailored to the needs of specific ICUs. LIMITATIONS. The systematic reviews only included peer reviewed articles published in English. The data was only collected in Ireland. Therefore, the findings may not generalise to other countries. SUGGESTIONS FOR FUTURE RESEARCH. There is a need to measure the effectiveness of HH interventions designed specifically to meet the needs of individual  IUCs, to ensure that limited resources are being used effectively.