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Alcohol-Based Handrub Improves Compliance With Hand Hygiene in Intensive Care Units
Stéphane Hugonnet, MD, MSc;
Thomas V. Perneger, MD, PhD;
Didier Pittet, MD, MS
Arch Intern Med. 2002;162:1037-1043.
ABSTRACT
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Background Nosocomial infection is a leading complication in intensive care units.
Although hand hygiene is the single most efficient preventive measure, compliance
with this simple action remains low.
Objectives To assess the effect of an intervention to promote hand hygiene and
to investigate risk factors for noncompliance in intensive care units.
Methods We performed 7 observational surveys and implemented a promotional campaign
after baseline in medical, surgical, and pediatric intensive care units of
a teaching hospital. Health care workers were observed during routine patient
care. The intervention consisted of a hospitalwide promotional campaign, including
observation and performance feedback, posters display, and distribution of
individual bottles of alcohol-based handrub. The main outcome measure was
compliance with hand hygiene through handwashing or handrubbing.
Results We observed 2743 opportunities for hand hygiene distributed over 248
periods. Overall compliance increased from 38.4% to 54.5% during the study
(P<.001). Although recourse to handwashing remained stable
at around 30%, handrubbing increased from 5.4% at baseline to 21.7% at the
last survey (P<.001). Compliance increased among nurses and
nursing assistants, but remained stable among physicians. Handwashing compliance
decreased, on average, by 4.7% for an increase of 10 opportunities for hand
hygiene per hour of patient care (P<.001), whereas no such
association existed for handrubbing.
Conclusions Our intervention induced a marked and sustained increase in compliance
with hand hygiene. In intensive care units, less time-consuming handrubbing
might replace standard handwashing and overcome the barrier of time constraints.
INTRODUCTION
HAND HYGIENE is the single most important measure to prevent cross-transmission
of microorganisms from one patient to another,1
and several studies2-8
have demonstrated a reduction in infection rates after improvement in hand-hygiene
practices. In intensive care units (ICUs), most endemic infections are due
to the carriage of microorganisms on health care workers' hands,9
and outbreaks of infections resulting from cross-transmission are frequent.10 Critically ill patients are more likely to be colonized
or infected with harmful and multiresistant pathogens. The intensity of patient
care and number of contacts between health care workers and patients in ICUs
are high, and procedures with a high risk of cross-transmission are common.
However, compliance with hand hygiene has been documented as being low, usually
below 50%. Although it has been a challenge for infection control teams to
design and implement interventions to improve compliance in ICUs, few have
had sustained success.6, 11-14
Following a baseline survey of hand-hygiene practices conducted in 1994,15 we implemented a hospitalwide campaign to promote
hand hygiene. The overall evaluation of this campaign has been published recently.16 Most important, we showed that workloads were highest
in the ICUs, but compliance there was lowest. The present study focuses on
the specific setting of ICUs and on an alternative way to achieve hand hygiene,
using an alcohol-based handrub. Because high workload is a barrier to good
compliance in ICUs15, 17 and because
frequent handwashing requires time,18 we hypothesized
that the use of less time-consuming alcohol-based handrub might improve overall
compliance. The aim of this study was to assess the effect of the alcohol-based
handrub promotion in the ICU setting and to investigate risk factors for noncompliance.
SUBJECTS AND METHODS
SETTING
The study was conducted in the medical (18 beds), surgical (22 beds),
and neonatal and pediatric (30 beds) ICUs of the University of Geneva Hospitals,
a 2300-bed tertiary care institution covering a population of about 500 000.
Several hospitalwide or ICU-specific infection control policies were
in place at the time of the study. These included contact isolation (geographical
isolation and wearing of gloves, gown, and mask when indicated) for suspected
or known methicillin-resistant Staphylococcus aureus-colonized
or -infected patients, as described elsewhere.19
In the medical ICU, an intervention to reduce catheter-related infections
was implemented in March 1997, including detailed information to all clinical
staff about pathogenesis of these infections and guidelines on device insertion,
maintenance, and use. Included in the guidelines were maximum barrier precautions
(sterile gloves, gown, cap, mask, and a large sheet) for all but peripheral
lines.20
DESIGN
After a baseline survey,15 we implemented
a hospitalwide campaign to promote hand hygiene from January 1995 onward.
The intervention has been described previously.16
Briefly, we displayed posters (29.5 x 42 cm) in strategic areas throughout
the institution concerning nosocomial infection, cross-transmission, and the
importance of hand hygiene in general. Individual bottles of alcohol-based
handrub solution were made available, and all staff were encouraged to carry
them in their pockets. The alcohol-based solution was prepared by the central
pharmacy of the hospital and was ordered by each ward as with any other drug
or pharmaceutical preparation. Consequently, the bottles were available in
each ward for all persons working there or consultants. These bottles are
made for pocket carriage, are equipped with a flip-top lid (easily opened
and closed with one finger), are usually emptied within 3 days, and are not
reused. Handrubbing is performed after closing and reintroducing the bottle
into the pocket, thus preventing hand contamination after handrubbing. Clips
were installed on all beds to hold additional bottles to promote bedside use.
We performed 7 biannual observational surveys, from December 1994 to
December 1997, as described elsewhere.15-16
Each survey lasted 2 to 3 weeks. We scheduled 20-minute observation periods,
randomly distributed throughout the study. Infection control nurses observed
health care workers during routine patient care and recorded opportunities
for hand hygiene according to established criteria,1, 15
as well as the number and type of hand cleansings. Observers were visible
but as unobtrusive as possible. Handwashing referred to washing hands with
water alone or with unmedicated soap, and handrubbing referred to the use
of an alcohol-based handrub solution (75% isopropyl alcohol, weight-to-weight
ratio) containing 0.5% chlorhexidine gluconate and skin emollients. No judgment
on the quality of hand hygiene was made.
Concordance among observers and sensitivity to detect opportunities
for hand hygiene were excellent.16
Performance feedback was provided shortly after each survey.16 In brief, it was performed 2 months after each survey
through a hospital newsletter that is distributed with employee paychecks.
In addition, regular informal discussions about the results were held between
ICU staff and infection control nurses.
STATISTICAL ANALYSIS
The dependent variable was compliance with hand hygiene, through either
handwashing or handrubbing. Independent variables included the category of
staff (nurses, physicians, nursing assistants, and other health care workers),
time of day and week when the observation was performed, number of patients
and staff in the unit, patient-staff ratio at the time of observation, activity
index (defined as the number of opportunities for hand hygiene during each
observation period per hour of care), and type of care that generated the
opportunity.15 Opportunities were categorized
into low to medium risk of cross-transmission (after direct patient contact,
intravenous or arterial care, urinary care, respiratory care, wound care,
contact with biological fluid, indirect patient contact, and hospital maintenance)
or high risk of cross-transmission (between care of a dirty and care of a
clean body site and before intravenous or arterial care, urinary care, respiratory
care, and wound care).1, 15 Indirect
patient contact was defined as a contact with inanimate objects (including
medical equipment) in the immediate vicinity of the patient.
We first investigated the effect of the campaign, then assessed factors
predicting noncompliance, and finally investigated factors associated with
the use of handrubbing vs handwashing. In the latter, we considered only opportunities
followed by a hand-hygiene action. The dependent variable was the hand-hygiene
technique (handwashing or handrubbing).
We compared categorical variables by the  2 test or Fisher
exact test, and continuous variables by the t test
or by nonparametric methods when departure from normality was observed. The
association between continuous variables was graphically explored by nonparametric
regression analysis21 and summarized by linear
regression if appropriate. This method was used to investigate the association
between compliance and workload.
All independent variables were first examined in a univariate analysis
using the Mantel-Haenszel method and logistic regression. Variables associated
with the dependent variable with a probability of 0.1 or less were further
investigated in a multivariate logistic regression model. In the final multivariate
models, we investigated whether the effect of the variables changed over time
by adding an interaction term between the variable "study" and all the other
independent variables. Measures of association are summarized by odds ratios
(ORs), displayed with their 95% confidence intervals (CIs). We used a generalized
estimating equation because of interdependence of observations within an observation
period.22
All tests were 2-tailed, and P<.05 was considered
statistically significant. We used commercially available statistical software
(Stata, version 6; Stata Corp, College Station, Tex) for all analyses.
RESULTS
STUDY SAMPLE
We performed 7 surveys on a biannual basis from December 1994 to December
1997. We observed 2743 opportunities for hand hygiene, distributed over 248
scheduled observation periods. Most (98%) of these periods lasted about 20
minutes (range, 15-45 minutes), totaling 84 hours of observation. The periods
were spread throughout all times of the day (47% of the opportunities in the
morning, 33% in the evening, and 20% during the night) and week.
Nurses contributed 82% of the opportunities; physicians, 9%; nursing
assistants, 6%; and other health care workers, 3%.
The overall median activity index and patient-staff ratio were 30 (range,
3-144) opportunities per hour and 1.12 (range, 0.13-6.25) patients per nurse.
Both remained stable throughout the study (linear regression, P = .97 and P = .63, respectively). For nurses,
the median number of opportunities for hand hygiene was 21 (range, 3-144)
per hour of patient care.
Table 1 shows the distribution
of the observed opportunities for hand hygiene stratified by the level of
risk of cross-transmission. More than 50% (1382/2743) were of medium risk
and 21% (580/2743) were of high risk of cross-transmission, with the dominant
group being "before intravenous or arterial care." The distribution of the
opportunities according to the level of risk did not change over time (P = .45).
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Table 1. Distribution of Opportunities for Hand Hygiene According to
Level of Risk for Cross-transmission in Critical Care, 1994 to 1997*
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IMPROVEMENT OF COMPLIANCE OVER TIME
The overall compliance with hand hygiene increased from 38.4% at baseline
to 54.5% at the last survey (score test for trend, P<.001).
Whereas handwashing remained stable at around 30% across the surveys (P = .09), recourse to handrubbing significantly increased
from 5.4% to 21.7% (P<.001) (Figure 1).
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Figure 1. Trends over time in compliance
with hand hygiene in intensive care units, 1994 through 1997. Compliance is
indicated separately for handwashing and alcohol-based handrubbing.
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The effect of the intervention differed according to professional categories.
Compliance increased among nurses (mean difference between 2 consecutive surveys;
OR, 1.09; 95% CI, 1.01-1.18; P = .02) and nursing
assistants (OR, 1.31; 95% CI, 1.05-1.63; P = .02),
whereas it remained stable among physicians (OR, 0.98; 95% CI, 0.83-1.16; P = .85) and other health care workers (OR, 0.99; 95% CI,
0.71-1.38; P = .96).
Compliance did not significantly change for low- to medium-risk opportunities
(P = .13), but increased for opportunities associated
with high risk of cross-transmission (OR, 1.12; 95% CI, 1.03-1.21; P = .003).
RISK FACTORS FOR NONCOMPLIANCE
Factors associated with noncompliance are displayed in Table 2. Even after adjustment for potential confounders, compliance
improved over time. The level of risk and activity index remained independent
predictors of noncompliance. The odds of noncompliance among physicians and
other health care worker categories remained significantly higher than among
nurses. No interaction was found.
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Table 2. Factors Predicting Noncompliance With Hand Hygiene in Intensive
Care Units, 1994 to 1997*
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HANDRUBBING VS HANDWASHING
The frequency of handwashing decreased, on average, by 4.7% for an increase
of 10 opportunities per hour (95% CI, 3.2%-6.1%; P<.001),
whereas no such association existed for the frequency of handrubbing (P = .12) (Figure 2).
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Figure 2. Association between workload and
compliance with handwashing and alcohol-based handrubbing.
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We examined the tendency over time to use handrubbing compared with
handwashing among opportunities that generated a hand-hygiene action. Recourse
to handrubbing among nurses increased considerably from one survey to the
next (OR, 1.28; P<.001), more so than among physicians
(OR, 1.16; P = .33). Similarly, recourse to handrubbing
increased during activities associated with a low to medium risk of cross-transmission
(OR, 1.28; P<.001), with a high risk of cross-transmission
(OR, 1.24; P = .02), and among most strata of the
activity index. We did not find any interaction between time and these variables.
Factors associated with preferential recourse to handrubbing are displayed
in Table 3. Physicians tended
to use handrubbing more often than nurses, and nursing assistants less often.
As expected, handrubbing was used more often than handwashing in high-risk
situations. Interestingly, we found an association between recourse to handrubbing
and workload, as health care workers tended to perform handrubbing more often
when the activity index was high (>60 opportunities per hour) compared with
when it was low (0-20 opportunities per hour).
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Table 3. Factors Associated With Recourse to Handrubbing vs Handwashing
in Critical Care, 1994 to 1997*
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COMMENT
Compliance with hand-hygiene recommendations at baseline was low (38%)
and fell in the range of that found in other studies.6, 11, 23-25
This study is the first to show a marked and sustained improvement in compliance
with hand hygiene. The effect was mostly attributable to the increased recourse
to handrubbing.16 Improvement was observed
most among nurses and nursing assistants and was absent among physicians and
other health care workers. Furthermore, a high level of activity and high-risk
opportunities were associated with noncompliance in all surveys.
The rationale underlying the promotional campaign was that a wider use
of handrubbing would shorten the time required to perform hand hygiene, thus
increasing compliance. Waterless hand disinfection is fast-acting and can
be performed at the bedside, using individual bottles or dispensers made available.
Current guidelines recommend that handwashing be performed for at least
20 seconds,1 but this figure does not include
the time required to walk to the sink, rinse and dry the hands, and walk back
to the patient. The whole procedure takes 1 to 2 minutes.18
Proper adherence to these recommendations is impossible in ICUs, where the
number of contacts with patients is high.15-16
In this study, the median number of opportunities per hour (reflecting workload)
for hand hygiene was 30, requiring 30 to 60 minutes per hour for hand hygiene,
assuming 100% compliance. This time constraint is not compatible with adequate
patient care. In contrast, 20 seconds are sufficient to perform handrubbing.
In a hypothetical model, Voss and Widmer18
calculated that in a 14-bed ICU, the time required to perform handwashing
would be 16 hours of nursing time per day shift, but only 3 hours for handrubbing.
This is a conservative estimate, because they assumed 2 to 3 opportunities
for hand hygiene per health care worker and per hour, which is much fewer
than what we and others measured.15-16,25-26
Recourse to the less time-consuming handrubbing might be the solution to bypass
the time constraint, as illustrated by our data. Compliance with handwashing
was inversely associated with a high workload, decreasing, on average, by
almost 5% for an increase of 10 opportunities per hour, whereas no such association
existed with handrubbing.
More than 20% of the opportunities for hand hygiene in our ICUs carried
a high risk of cross-transmission. Compliance in this group was low (26%),
lower than in the group of low- to medium-risk opportunities, as previously
reported by others,27 but it significantly
increased during our study. This is consistent with our policy that high-risk
opportunities are an indication for the use of an alcohol-based handrub solution,
as opposed to standard handwashing.
Good accessibility to hand-hygiene supplies is a prerequisite to adequate
compliance.28 Inconveniently located facilities
increase the time spent by health care workers to achieve hand hygiene and
jeopardize compliance.18 Bischoff et al25 illustrated this by measuring compliance with hand
hygiene at baseline and after providing alcohol-based waterless handrub dispensers,
initially at a ratio of 1 dispenser per 4 beds and, later, 1 dispenser per
bed. Compliance significantly increased with the better availability of the
dispensers. Similarly, Maury et al26 observed
a marked improvement in compliance with hand hygiene after providing individual
bottles and dispensers of an alcohol-based solution. The present study extends
the observation in these reports by demonstrating amelioration of noncompliance
due to time constraint and by reporting sustained effect of the waterless
hand-disinfection strategy. Before this study, the standard for hand hygiene
at our institution was handwashing. We promoted the use of handrub solution
at the bedside by distributing individual bottles for pocket carriage and
by installing dispensers in patient rooms, thus optimizing accessibility.
Adverse effects of hand-hygiene agents are reported as a reason for
noncompliance.29 This issue is of particular
relevance in ICUs, where the frequency of opportunities for hand hygiene is
high and much higher than in other wards.15-16
Boyce et al30 performed a clinical trial to
compare the occurrence of adverse effects when using an alcohol-based hand
gel vs an unmedicated soap. Dryness and irritation of the skin increased when
using soap, whereas the use of the gel did not induce any adverse effects.
The handrub solution used in our institution contains skin emollients, and
hand-care lotion was provided throughout the intervention, possibly contributing
to the absence of any major skin reaction in our experience.
For many decades, handwashing has been the standard technique for hand
hygiene, and the introduction of a new method raises the question of its efficacy.
The effectiveness of handwashing in reducing the bacterial count on hands
is a function of the time spent to wash hands, a 0.6 log10 reduction
after 15 seconds to 3.3 after 2 minutes.31
In contrast, a solution containing 50% of n-propanol
alcohol achieves a 3.7 log10 reduction after 30 seconds. Time spent
washing hands has been measured in several studies11, 13, 32-34
and usually does not exceed 25 seconds. Alcohol not only achieves a greater
reduction in bacterial count but also acts much quicker. Moreover, the hand-cleansing
method before patient care could affect the degree of bacterial contamination
during care. Compared with those who used an alcohol-based handrub solution,
health care workers who washed their hands with soap and water had an excess
of 52 colony-forming units on their fingertips.35
Similarly, Zaragoza et al36 demonstrated in
a randomized clinical trial the better efficacy of alcohol-based solutions
vs soap in reducing hand contamination.
Therefore, the use of an alcohol-based handrub solution is an alternative
to standard handwashing, is less time-consuming, is at least as efficient,
and has fewer adverse effects on the skin than soap. In our view, it should
replace handwashing in all indications, except when hands are macroscopically
soiled.
Compliance among physicians was low, as previously documented,11, 37-38 although during the
study they indicated a preference for the handrub. We are investigating reasons
for the lack of compliance among physicians and are implementing an intervention
targeting ICU physicians.
It has been a challenge for infection control practitioners to improve
compliance with hand hygiene. Many interventions have been implemented, although
none have had a lasting effect, if any at all.6, 13, 23-24,27, 39-41
The most successful strategies were those aiming to improve accessibility
to hand-hygiene agents11, 25 or
those providing performance feedback.12, 24
Monocompound strategies had limited effects.14, 28
To be successful, interventions must address individual factors, interactions
within a group, and institutional constraints and climate.14, 28, 42
Our intervention, which addressed system modification and behavioral change,
was successful because it was inspired by these concepts. The program was
multimodal, was fully supported by the institution, and involved every level
of the organization.16
Because attitude and compliance with hand hygiene are behavioral in
essence, several other strategies to induce behavioral changes have been proposed,
such as patient education,25, 41
administrative sanction or reward,43-44
enhancement of role modeling by superiors, and establishment of an institutional
safety climate.14 Larson and colleagues45 implemented an intervention based on creating an
organizational culture in which hand hygiene was a definitive administrative
expectation.
Our study has several limitations. We did not have a control group because
hand hygiene was an institutional priority and was therefore implemented hospitalwide.
Having a control group in another hospital would have been logistically demanding
and would have introduced some uncontrollable confounding factors. We are
unable to estimate the relative efficacy of the different components of our
intervention. Interventions need to be multifactorial to be effective.14, 16, 28 Therefore, we would
not have wanted to dissect the campaign. We cannot rule out a Hawthorne effect
to explain the improvement in compliance. However, this seems unlikely because
of the steady and regular increase in compliance during the study and the
reported increase in the overall consumption of the alcohol-based handrub
solution.16 Finally, we are unable to estimate
the effect of our campaign on nosocomial infection rates, as we did not measure
these throughout the study. However, the prevalence of nosocomial infection
and the attack rate of methicillin-resistant S aureus
decreased throughout the institution.16 This
issue needs further assessment by controlled trials in critical care settings.
In summary, increased recourse to an alcohol-based handrub solution
induced a marked and sustained improvement in compliance with hand-hygiene
recommendations among ICU staff. Handrubbing is an alternative to standard
handwashing, is less time-consuming, and is at least as efficient.
AUTHOR INFORMATION
Accepted for publication September 6, 2001.
We thank the members of the Infection Control Program, in particular
Nadia Colaizzi, for data management, and Anna Alexiou, Marie-Noëlle Constantin-Chraiti,
Nicole Henry, Pascale Herrault, Valérie Sauvan, and Sylvie Touveneau,
for conducting field observations. We are grateful to the Hospital Pharmacy
(in particular William Griffiths, MRPhS) for the development, production,
and supply of the alcohol-based handrub solution. We also thank Rosemary Sudan
for providing editorial assistance.
Corresponding author and reprints: Didier Pittet, MD, MS, Infection
Control Program, Department of Internal Medicine, University of Geneva Hospitals,
24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland (e-mail: didier.pittet{at}hcuge.ch).
From the Infection Control Program, Department of Internal Medicine
(Drs Hugonnet and Pittet), Quality of Care Unit and Institute of Social and
Preventive Medicine (Dr Perneger), University of Geneva Hospitals, Geneva,
Switzerland.
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