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/esearch0 $valuation of a Hand H1giene Cam'aign in222

3 revious Article 4 Ne5t Article (

AJN6 American Journal of Nursing0

)arch *+,- ! #olume ,,- ! Issue - ! ' -789*

doi0 ,+2,+:;"+,2NAJ2++++9*;<;<2<++=-2f;

%eature Articles



.riginal /esearch0 $valuation of a Hand H1giene Cam'aign in .ut'atient Health

Care Clinics

KuKanich6 Kate Stens&e h>6 >#)? Kaur6 /amandee' )H? %reeman6 Lisa C2 h>6

>#)? owell6 >ouglas A2 h>

%ree Access

Continued $ducation

odcasts

Article .utline

Colla'se @o5

Author Information

Kate Stens&e KuKanich is an assistant 'rofessor in the >e'artment of Clinical

Sciences at Kansas State niversit1 BKS in )anhattan6 KS2 At the time of this

stud16 /amandee' Kaur was a graduate student in the >e'artment of >iagnostic

)edicine"athobiolog1 at KS6 where >ouglas A2 owell is a 'rofessor2 Lisa C2

%reeman is vice 'resident for research and graduate studies at Northern Illinois

niversit1 in >eKalb? at the time of this stud16 she was a 'rofessor and associate

dean for research in the College of #eterinar1 )edicine at KS2 This 'roDect was

funded b1 an unrestricted educational grant from the Kansas Health %oundationB@E,==,2 Contact author0 Kate Stens&e KuKanich6 &stens&eF&su2edu2 The authors

and 'lanners have disclosed no 'otential conGicts of interest6 nancial or otherwise2

Colla'se @o5

Abstract

.bDective0 To im'rove hand h1giene in two out'atient health care clinics through the

introduction of a gel sanitier and an informational 'oster2

)ethods0 In this interventional stud16 health care wor&ers at two out'atient clinics

were observed for freuenc1 of hand h1giene Battem'ts versus o''ortunities2 Eel

sanitier and informational 'osters were introduced together as an intervention2

>irect observation of the freuenc1 of hand h1giene was 'erformed during baseline6



intervention6 and follow!u'2 A 'oststud1 surve1 of health care wor&ers was also

distributed and collected2

/esults0 In both clinics6 the freuenc1 of hand h1giene was 'oor at baseline B,,

and *, but im'roved signicantl1 after intervention B-7 and =9 and was

maintained through the follow!u' 'eriod B-* and =,2 Throughout the stud16

'ostcontact hand h1giene was observed signicantl1 more often than 'recontact

hand h1giene2 In both clinics6 health care wor&ers re'orted a 'reference for soa'

and water? 1et observations showed that when the intervention made gel sanitier

available6 sanitier use 'redominated2 %ift1 'ercent of the surve1ed health care

wor&ers considered the introduction of gel sanitier to be an eective motivating

tool for im'roving hand h1giene2

Conclusions0 Hand h1giene 'erformance b1 health care wor&ers in out'atient clinics

ma1 be im'roved through 'romoting the use of gel sanitier and using informational

'osters2 Com'ared with surve1s6 direct observation b1 trained observers ma1

'rovide more accurate information about wor&er 'references for hand h1giene tools2

The 'ractice of hand h1giene b1 health care wor&ers6 through the use of either soa'

and water or an alcohol!based hand sanitier6 is widel1 considered to be the most

im'ortant and eective means of 'reventing health care8associated infections2

Although numerous studies have demonstrated that hand h1giene reduces health

care8associated infection rates6, adherence to hand h1giene guidelines remainsuniforml1 low among health care wor&ers2*!= To im'rove hand h1giene 'erformance

and sustain such im'rovement over time6 barriers must be recognied and

addressed2 These ma1 include 'oor access to hand h1giene materials6 s&in

irritation6 forgetfulness6 time constraints6 a 'erce'tion that hand h1giene interferes

with wor&er8'atient relationshi's6 lac& of &nowledge of hand h1giene guidelines6

and 'oor habits learned earl1 in life27!:

Cleansing the hands with an alcohol!based sanitier generall1 ta&es less time than

washing with soa' and water2 )oreover6 when used a''ro'riatel16 alcohol!basedsanitiers have been shown to be more eective than soa' and water for

eradicating some bacteria276 ,+ %or these reasons6 both the Centers for >isease

Control and revention BC>C and the World Health .rganiation BWH. recommend

the use of alcohol!based hand rubs or sanitiers for most clinical health care

settings2,6 7 However6 handwashing with soa' and water remains the 'referred

method when hands are visibl1 soiled6 or when contact with certain infectious



agents Bsuch as Clostridium s'ores and noroviruses is sus'ected6 as these

organisms are highl1 resistant to &illing b1 alcohol2,,!,-

@ac& to To' 4 Article .utline

@ACKE/.N>

Individual health care wor&ers ma1 have dierent hand h1giene 'roduct 'references

and ma1 be aected b1 dierent motivators and barriers to hand h1giene2 revious

interventional studies have determined that a multifaceted cam'aign6 incor'orating

more than one a''roach to change6 is reuired to achieve im'roved hand h1giene

'ractices and sustain them over time2,9!,; Such cam'aigns freuentl1 include the

'romotion of alcohol!based hand sanitiers? indeed6 one hos'ital!wide stud1

credited the increasing use of such sanitiers as the main reason for im'roved

adherence to hand h1giene guidelines2- While there is no evidence that 'osters or

other educational materials alone are eective at changing behavior6 those that use

messages framed in terms of 'otential gains Brather than losses and that invo&e

the health care wor&erMs sense of res'onsibilit1 for 'atient health ma1 be benecial

in combination with other strategies2-6 ,<6 ,:

Several studies have tested interventions for im'roving hand h1giene in teaching

hos'itals and found them to be successful2-6 *+6 *, @ut relativel1 few studies have

tested such interventions in out'atient clinics2**6 *- )ensah and colleagues

observed health care wor&ers in out'atient glaucoma clinics in the nited Kingdom

and found that baseline hand h1giene adherence was ,<2*- After 'resenting aseminar and distributing a memo addressing this6 adherence increased to *< and

was highest among female health care wor&ers and among nurses2 In another stud1

conducted at out'atient dermatolog1 clinics in Israel6 Cohen and colleagues

observed 'h1siciansM behavior and sam'led their hands for bacteria6 but no

interventions were introduced2** Adherence to hand h1giene was low at -,6 and

Sta'h1lococcus aureus was isolated from 7: of 'h1siciansM hands2 In a related

surve16 another grou' of 'h1sicians cited e5cessive wor&loads6 lac& of awareness6

adverse reactions to disinfectants6 and lac& of h1giene facilities as among the main

reasons for lac& of adherence2**

/esearch uestions2 The 'rimar1 research uestions addressed b1 our stud1 were

as follows0



,2 Could an interventional cam'aign in two out'atient health care clinics lead to

im'roved hand h1giene

*2 Are there dierences in the observed freuenc1 of hand h1giene at baseline

com'ared with that at one wee& and one month after introduction of the

intervention

-2 Are there dierences in the observed freuenc1 of hand h1giene based on

wor&ersM se56 wor&ersM 'rofession6 and timing B're! and 'ost'atient contact

92 Which hand h1giene tools do health care wor&ers in these settings 'refer

=2 Would the observed health care wor&ers later re'ort that either or both

interventional tools were motivating and inGuenced their hand h1giene habits


)$TH.>S

>esign and sam'le2 This stud1 used an interventional design6 enrolling two

out'atient clinics and 'erforming direct observation of health care wor&ers to

measure hand h1giene o''ortunities and attem'ts at baseline6 after the

intervention6 and during the follow!u' 'eriod2 To recruit the clinics6 we rst

contacted the administration of a large midwestern health care s1stem to determine

whether there was mutual interest2 S'ecic out'atient clinics were then chosen

from within that s1stem based on willingness to 'artici'ate6 whether the clinic

la1out would be conducive to direct observation6 and whether the antici'ated

caseload during the stud1 'eriod would be suOcient2 @ecause all observations and

surve1s were conducted anon1mousl16 after review b1 the institutional reviewboards of the researchersM institution and the 'artici'ating clinics6 the stud1 was

given e5em't status2

The rst clinic was an out'atient oncolog1 clinic having an o'en la1out? sin&s and

foam sanitiers were available at the nursesM station but not in the immediate

vicinit1 of individual 'atients2 The second clinic was an out'atient gastrointestinal



BEI clinic with individual curtained rooms for 'atients2 At each clinic6 the observed

health care wor&ers included 'rimaril1 'h1sicians and nurses6 as well as a few

others2 Sin&s for handwashing were located at the nursesM station6 and foam

sanitier was wall mounted at the entr1 to each curtained 'atient room2 Eel

sanitier was not available at either clinic2

The intervention consisted of introducing alcohol!based gel sanitier and a novel

'oster to each clinic2 We included gel sanitier in this cam'aign to 'rovide health

care wor&ers with an alternative to soa' and water and foam sanitier2

An informational 'oster was created to increase health care wor&ersM awareness of

hand h1giene6 'rovide information about when hand h1giene should be 'erformed6

and encourage them to ta&e 'ersonal res'onsibilit1 for reducing the s'read of

health care8associated infections2 To create the 'oster6 clinic administrators6 nurse

managers6 and the research team rst brainstormed ideas2 Several media

consultants from other universities that have conducted similar hand h1giene

cam'aigns also 'rovided in'ut2 A rst draft was designed and shown to all of these

'eo'le6 and the nal version of the 'oster incor'orated their suggested changes for

im'rovement2

)easures2 %or the 'ur'ose of this stud16 hand h1giene could be acce'tabl1

'erformed using either soa' and water or hand sanitier Bfoam or gel2 We

measured the number of hand h1giene attem'ts against the number of handh1giene o''ortunities2 Hand h1giene o''ortunities were dened as those occurring

immediatel1 before and after a health care wor&er ma&es direct contact with a

'atient? hand h1giene attem'ts were dened as an eort to 'erform hand h1giene

during each o''ortunit12 BThe term Pattem'tQ was used rather than Pcom'liance6Q

because we did not monitor hand h1giene techniue for com'liance with

guidelines2 >irect observers monitored the o''ortunities and recorded the

attem'ts2 To establish intercoder reliabilit1 'rior to the stud16 two observers were

trained and then as&ed to observe and record the same hand h1giene o''ortunities?

the overall 'ercentage agreement between the observers was :72 %or the EI

clinic6 onl1 those o''ortunities and attem'ts that gave observers full visibilit1through an o'en or 'artiall1 o'en curtain were monitored and recorded2

@aseline data were collected on three nonconsecutive da1s6 for four hours each da12

Then a''ro5imatel1 ,+ 'um' bottles of gel sanitier containing 7= eth1l alcohol

were 'rovided in each clinic on the nursesM station counter2 The counters were long6



e5tending the lengths of the clinics6 and the bottles were s'aced out so the1 lined

u' with 'atient areas or rooms as closel1 as 'ossible2 Twent1 'osters were

strategicall1 'laced near sin&s6 at intervals along the nursesM station counter6 and

ne5t to wall!mounted foam sanitier dis'ensers2 .ne inGuential 'h1sician in the EI

clinic was dis'leased when the 'osters were hung6 e5'ressing concern that the ta'e

used to mount them would damage the clinicMs walls? the 'osters were rehung with'ainterMs ta'e to ease his concern and 'revent damage Bthe stud1 design was not

altered2

.ne wee& after the introduction of the intervention6 direct observation of hand

h1giene was 'erformed on ve nonconsecutive da1s6 for four hours each da12 This

design allowed evaluation of the im'act of a short intervention 'eriod2 After these

interventional observations were com'lete6 the 'osters were removed at the

reuest of the clinicsM administration2 The remaining gel sanitier was left behind6

but it too was removed b1 the administration6 in &ee'ing with the clinicsM 'olic12 .nemonth after the last da1 of the interventional observations6 follow!u' direct

observation of hand h1giene was done on three nonconsecutive da1s6 for four hours

each da12 Neither 'osters nor gel sanitiers were 'rovided during the follow!u'

'eriod2

A surve1 was mailed to the nurse managers at both clinics and was distributed to

9; health care wor&ers at the oncolog1 clinic and to 9, health care wor&ers at the EI

clinic6 three months after the last da1 of the follow!u' observations2 The surve1 was

conducted to evaluate the wor&ersM 'erce'tions of the hand h1giene cam'aign6 itsmotivational im'act on their h1giene 'ractice6 'erceived barriers to hand h1giene at

their clinics6 and their 'referred h1giene tools Bsoa' and water6 foam sanitier6 or

gel sanitier2 A ve!item Li&ert scale Branging from Pstrongl1 disagreeQ to Pstrongl1

agreeQ was used for uestions regarding the motivational eOcac1 of the

intervention tools2

Anal1tic strateg12 earsonMs R* anal1ses were used to com'are the freuenc1 of

hand h1giene attem'ts during the three observation 'eriods and to com'are the

'recontact and 'ostcontact freuenc1 of such attem'ts2 $ach calculation had ,degree of freedom2 A value less than or eual to +2+= was considered signicant2

.nl1 descri'tive statistics were used to assess hand h1giene freuenc1 b1 wor&ersM

se5 and 'rofession6 because there were too few observations of male health care

wor&ers and 'h1sicians to 'ermit com'arative anal1ses2 >escri'tive statistics were

also used for com'aring the hand h1giene tools used6 as 'roduct availabilit1 varied

throughout the stud12 @ecause most observed health care wor&ers were nurses and

'h1sicians6 other health care wor&ers were e5cluded from data anal1sis2




/$SLTS

While the number of health care wor&ers varied from da1 to da1 and from clinic toclinic6 on average ve nurses and three 'h1sicians were observed 'er da1 in the

oncolog1 clinic6 and eight nurses and four 'h1sicians were observed 'er da1 in the

EI clinic2 In both the oncolog1 and EI clinics6 at baseline6 the overall rates of hand

h1giene attem'ts to o''ortunities were low B,, and *,6 res'ectivel1? these

im'roved signicantl1 after the intervention was instituted B-7 and =96

res'ectivel16 and remained im'roved at the one!month follow!u' 'eriod B-* and

=,6 res'ectivel1 Bsee Table ,2 Throughout the stud16 female health care wor&ers

demonstrated more consistent hand h1giene than their male counter'arts6 and

nurses demonstrated more consistent hand h1giene than 'h1sicians Bsee Table *2

Table ,

Table ,

Image Tools Table *

Table *

Image Tools

A total of =7 health care wor&ers returned surve1s B9, from the oncolog1 clinic6 ,=from the EI clinic2 %ift1 'ercent of all surve1 res'ondents agreed or strongl1 agreed

that the cam'aign had increased their awareness about hand h1giene6 with more

wor&ers at the EI clinic B<+ re'orting this belief than at the oncolog1 clinic B-:2

.verall6 -9 of all res'ondents agreed that the hand h1giene cam'aign had

im'roved their hand h1giene 'ractices2

At the oncolog1 clinic6 the usage rates for soa' and water and foam sanitier were

almost eual at baseline B=- and 9; of attem'ts6 res'ectivel12 @ut after the

interventionMs introduction of gel sanitier6 these usage rates dro''ed Bto *, and9+6 res'ectivel12 Eel sanitier was used in 9+ of hand h1giene attem'ts2 >uring

the follow!u' observation 'eriod6 the gel sanitier 'rovided b1 the researchers was

removed2 The usage rate for soa' and water remained low B*9 while that for

foam sanitier rose B7-2 Self!'rovided gel sanitier was used also B,-2 At the EI

clinic6 the baseline usage rate for foam sanitier B=: was higher than that for

soa' and water B9+2 After the interventionMs introduction of gel sanitier6 the

usage rates for soa' and water and foam sanitier dro''ed Bto ,: and 9+6



res'ectivel1? gel sanitier was used in 9, of hand h1giene attem'ts2 >uring the

follow!u' 'eriod6 the usage rate for soa' and water remained low B-96 while that

for foam sanitier increased B7*2 Self!'rovided gel sanitier was used also B92

BSome 'ercentages donMt sum to ,++ because of rounding2

.f the =7 surve1 res'ondents6 =+ agreed or strongl1 agreed that the introduction

of gel sanitier was an eective motivator and led to im'roved hand h1giene

freuenc12 As&ed PWhich do 1ou 'refer most as a means of hand h1gieneQ the 9,

res'ondents from the oncolog1 clinic re'orted mi5ed 'references Bsoa' and water6

=<? foam sanitier6 *9? gel sanitier6 **6 whereas <+ of the ,= res'ondents

from the EI clinic re'orted a 'reference for soa' and water6 with the remainder

'referring foam sanitier B*+ and gel sanitier B*+2 Bercentages donMt sum to

,++ because some res'onders at both clinics re'orted 'references for more than

one hand h1giene tool2 As&ed PWhat is the most suitable 'lace to &ee' sanitier6 to

ma&e its use more eectiveQ 77 of all res'ondents 'referred 'lacement in theimmediate vicinit1 of the 'atients2

In the EI clinic6 :- of the ,= surve1ed health care wor&ers re'orted being aware of

the new 'osters? of these6 -7 agreed or strongl1 agreed that the 'osters were

eective as a motivational tool for encouraging hand h1giene2 In the oncolog1 clinic6

9: of the 9, surve1ed wor&ers re'orted being aware of the 'osters6 and of these6

9= agreed or strongl1 agreed that the1 were eective2 Among all surve1

res'ondents6 9* re'orted nding neither the introduction of gel sanitier nor the

'oster motivating6 while *- were motivated b1 both interventional tools2

erceived barriers to hand h1giene among all surve1 res'ondents included Ps&in

irritationQ B-96 PforgetfulnessQ B-*6 PinsuOcient timeQ B*96 Pinterference with

'atient careQ B,,6 Plac& of facilities or inaccessible materialsQ B=6 and

PinsuOcient trainingQ B=? some res'ondents selected multi'le barriers2 Twent1!

three 'ercent re'orted that none of the above was a barrier in their clinic2 Although

no obDective data were collected to assess the incidence of s&in irritation associated

with use of the available h1giene tools6 numerous health care wor&ers in both clinics

were overheard commenting during both observation 'eriods that the gel sanitierwas less irritating than either the foam sanitier or soa' and water2

At baseline6 the freuenc1 of observed hand h1giene attem'ts was greater after

'atient contact than before 'atient contact B +2++, in oncolog1 clinic6 +2++*

in EI clinic2 This was also the case at one wee& after the intervention B ( +2++, in



each clinic and during the follow!u' observation 'eriod B ( +2++, in each clinic2

Hand h1giene im'roved from baseline to the intervention 'eriod for 'recontact and

'ostcontact observations6 and this im'rovement was sustained with no signicant

decreases in h1giene in both clinics during the follow!u' 'eriod2 A similar nding

was seen in the surve1 res'onses Bn =- for this uestion0 more res'ondents

re'orted Palwa1sQ 'erforming hand h1giene after contact with 'atients B<- thanre'orted Palwa1sQ 'erforming hand h1giene before contact with 'atients B=;2


>ISCSSI.N

The stud1 ndings indicate that the freuenc1 of hand h1giene b1 health care

wor&ers in bus1 out'atient health care settings is low6 and that short!term e5'osure

to interventional tools can lead to modest im'rovement still evident at one!month

follow!u'2 Among our surve1 res'ondents6 individual res'onses to the motivational

eectiveness of the 'osters or gel sanitier varied6 suggesting that 'retesting

interventions in a given clinic and using a multifaceted im'lementation a''roach

might hel' to achieve the greatest im'rovements2 $stablishing or reinforcing a

clinic!wide e5'ectation that health care wor&ers will adhere to hand h1giene

recommendations is another measure that ma1 further 'romote such adherence2,6

-6 *- )odeling and su''ort of 'ro'er hand h1giene from clinic leaders Bsuch as

'h1sicians and nurse managers have also been suggested as im'ortant factors for

im'roving hand h1giene2,6 -6 *9 In our stud16 the lower freuenc1 of hand h1giene

among 'h1sicians at baselineand6 at the EI clinic6 the negative attitude of one

inGuential 'h1sician toward the 'ostersmight have contributed to the relativel1modest overall im'rovement in h1giene among all health care wor&ers2 This also

su''orts the need to encourage the involvement and investment of clinic leaders in

future hand h1giene cam'aigns2

To minimie s'read of infection6 C>C guidelines recommend that hands be washed

or sanitied immediatel1 before and after ever1 direct contact with a 'atient27 At

both clinics6 observations showed that hand h1giene 'erformance was consistentl1

better after 'atient contact than before 'atient contact? this trend was also

su''orted b1 the surve1 res'onses2 These ndings are consistent with those ofother studies2:6 *=6 *7 As&ed wh1 health care wor&ers tend to P'ractice better

h1giene after 'atient contact than before 'atient contact6Q our surve1 res'ondents

named several 'ossibilities6 including a belief that self!'rotection is a 'riorit16 a

sense that 'atient contact acts as a reminder to 'erform h1giene6 and a belief that

'ostcontact h1giene for one 'atient serves as adeuate 'recontact h1giene for the

ne5t2 %indings from other studies also su''ort the idea that self!'rotection acts as a

strong motivator for hand h1giene2:6 *= This suggests that future cam'aigns should



focus on encouraging health care wor&ers to ta&e 'ersonal res'onsibilit1 in a more

clinic!s'ecic6 'atient safet18oriented a''roach2,:6 *=

)ost surve1 res'ondents re'orted a 'reference for soa' and water over either t1'e

of sanitier2 This re'orted 'reference ma1 stem from 'revious training or from a

belief that soa' and water is the best method of hand h1giene and therefore the

PcorrectQ answer on a surve12 Currentl16 both the C>C and the WH. recommend

handwashing with soa' and water when hands are visibl1 soiled with blood or other

bod1 Guids and after contact with certain infectious organisms6 including clostridial

s'ores and norovirus? but both recommend using an alcohol!based sanitier for all

other clinical situations2,6 76 ,,6 ,* %uture cam'aigns should em'hasie these

recommendations2 >es'ite our surve1 res'ondentsM re'orted 'reference for soa'

and water6 we observed health care wor&ers using sanitier Bgel6 foam6 or both

more often than soa' and water once gel sanitier was made available at the

clinics2 ossible causal factors include increased access to gel sanitier during theintervention6 convenience6 faster usage time6 and a 'erceived decrease in s&in

irritation2 After administrators removed gel sanitier from the clinics6 some health

care wor&ers began carr1ing gel sanitier in their 'oc&ets for 'ersonal use6

suggesting an ongoing 'reference2 This discre'anc1 between self!re'orted

'references and actual observed 'ractice suggests that there are man1 factors and

'otential barriers that inGuence hand h1giene 'erformance2 To im'rove adherence6

the C>C recommends 'roviding a variet1 of hand h1giene 'roducts6 routinel1

'erforming direct observation of h1giene 'erformance6 and monitoring 'roduct

usage27

The 'rimar1 barriers to hand h1giene re'orted b1 our surve1 res'ondents were s&in

irritation6 forgetfulness6 and insuOcient time6 and these are similar to those

re'orted b1 others2;6 <6 **6 *; The consistenc16 smell6 and content Bsome 'roducts

contain aloe6 a moisturier of soa's and sanitiers can also inGuence adherence2

>uring the interventional and follow!u' observation 'eriods6 health care wor&ers at

both clinics were overheard discussing their 'reference for gel over foam sanitier6

feeling that the gel was less irritating to their s&in? itMs 'ossible that these wor&ers

might cleanse their hands more freuentl1 if gel sanitier were available2 .ut'atient

clinic administrators should consider health care wor&er 'references as well as

'roduct costs when deciding which to 'urchase2 lacing hand sanitier in the

immediate vicinit1 of 'atients Bsuch as at or near the entrances to 'atient rooms

can both save time and serve as a visual reminder of the need to lower the ris& of

health care8associated infection2



The 'oster was designed to im'rove hand h1giene b1 increasing awareness6

'roviding information6 and encouraging health care wor&ers to ta&e 'ersonal

res'onsibilit1 for reducing the s'read of infection2 /easons for its limited eect

might include a lac& of su''ort from inGuential health care wor&ers6 se5 dierences6

and ineective 'oster design2 The inGuential 'h1sician who was dis'leased with

'oster 'lacement in his clinic ma1 have negativel1 swa1ed other health carewor&ers6 thus hindering the cam'aignMs overall im'act2 The eect of wor&ersM se5 on

hand h1giene might also have been a factor2 There is evidence that men and

women res'ond dierentl1 to health 'romotion messages0 women ma1 be more

motivated b1 &nowledge!based messages that remind them wh1 hand h1giene is

im'ortant6 whereas men ma1 be more motivated b1 messages that elicit emotions

such as disgust2*-6 *< Involving clinic sta in 'oster design and messages6

designing 'osters to be more clinic!s'ecic6 'eriodicall1 'roviding 'osters with new

messages6 and 'ositioning 'osters near both hand h1giene materials and 'atients

ma1 also hel' health care wor&ers to feel more involved in and committed to a hand

h1giene cam'aign2

Limitations and recommendations for further research2 .ne limitation of this stud1

is the 'ossibilit1 of the Hawthorne eect? some health care wor&ers might have

realied that the1 were being observed and cleansed their hands more freuentl1 as

a result2 While using video cameras or training sta in covert observation might

have minimied this 'ossibilit16 the clinic la1outs6 time constraints6 and the need to

ensure 'atient 'rivac1 made such solutions less than desirable2 To minimie

'ossible bias6 onl1 clinic administrators6 nurse managers6 and medical directors

were consulted regarding stud1 design2 The 'ossibilit1 of the Hawthorne eect

notwithstanding6 we recommend that future researchers6 after collecting baseline

data6 see& the ongoing su''ort and involvement of inGuential health care wor&ers6

who can also serve as role models for others2

Another limitation is that observations werenMt tagged with health care wor&ersM

identities2 ItMs 'ossible that wor&ers with e5cellent hand h1giene habits were

observed with greater freuenc1 than those with 'oor habits6 thus s&ewing the data

and the statistical anal1sis2 Although health care wor&ers 'robabl1 'refer to remain

anon1mous during such observations6 we recommend recording and associating

wor&er identities with h1giene 'erformance so that statistical anal1ses can be as

accurate as 'ossible2

@ecause resource limitations led to interventional and follow!u' observation 'eriods

of dierent durations6 and because of Guctuating 'atient caseloads during these

'eriods6 not all health care wor&ers had the same number of o''ortunities for hand



h1giene? future studies could schedule additional observation 'eriods in order to

achieve more eual sam'le sies2 %inall16 leaving interventions in 'lace for a longer

time 'eriod and e5tending follow!u' observations be1ond one month Bto three6 si56

and ,* months would be useful in evaluating whether the interventions had

sustained eects2


C.NCLSI.NS AN> /ACTIC$ I)LICATI.NS

This hand h1giene cam'aign showed that introducing a gel sanitier and 'roviding

informational 'osters can 1ield modest short!term im'rovements in overall hand

h1giene 'erformance in out'atient clinics2 To ma5imie the clinical im'act of such a

cam'aign6 we suggest that administrators and inGuential health care wor&ers wor&

together to create an environment in which adherence to hand h1giene is e5'ected?

'rovide a variet1 of hand h1giene 'roductsincluding gel sanitier in either 'oc&et!

sie or 'um' dis'ensersin the immediate vicinit1 of 'atients? and encourage

health care wor&ers to create several motivational6 setting!s'ecic 'osters that can

be rotated throughout the clinic on a regular basis2 The ndings of this stud1 should

also 'rom't increased attention to 'recontact h1giene in out'atient clinics6 in order

to minimie the 'otential s'read of infection2 Indeed6 the intermittent evaluation of

hand h1giene6 using direct observation6 is essential for identif1ing as'ects that need

im'rovement and maintaining adherence as a to' 'riorit12


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,2 World Health .rganiation2 WH. guidelines on hand h1giene in health care2

Eeneva6 Switerland? *++:2

htt'0""whlibdoc2who2int"'ublications"*++:":;<:*9,=:;:+7Ueng2'df2

Cited Here222

*2 Eraham )2 %reuenc1 and duration of handwashing in an intensive care unit Am J

Infect Control2 ,::+?,<B*0;;8<,

Cited Here222

-2 ittet >6 et al2 $ectiveness of a hos'ital!wide 'rogramme to im'rove com'liance

with hand h1giene2 Infection Control rogramme Lancet2 *+++?-=7B:*-<0,-+;8,*



Cited Here222

92 /andle J6 et al2 Hand h1giene com'liance in healthcare wor&ers J Hos' Infect2

*++7?79B-0*+=8:

Cited Here222

=2 Slade& /)6 et al2 Wh1 donMt doctors wash their hands A correlational stud1 of

thin&ing st1les and hand h1giene Am J Infect Control2 *++<?-7B70-::89+7

Cited Here222

72 @o1ce J)6 et al2 Euideline for hand h1giene in health!care settings2/ecommendations of the Healthcare Infection Control ractices Advisor1 Committee

and the HICAC"SH$A"AIC"I>SA Hand H1giene Tas& %orce2 Societ1 for Healthcare

$'idemiolog1 of America"Association for rofessionals in Infection Control"Infectious

>iseases Societ1 of America ))W/ /ecomm /e'2 *++*?=,B//!,70,89=

Cited Here222

;2 ittet >6 et al2 Com'liance with handwashing in a teaching hos'ital2 Infection

Control rogram Ann Intern )ed2 ,:::?,-+B*0,*78-+

Cited Here222

<2 Sic&bert!@ennett $$6 et al2 Com'arative eOcac1 of hand h1giene agents in the

reduction of bacteria and viruses Am J Infect Control2 *++=?--B*07;8;;

Cited Here222

:2 Whitb1 )6 )cLaws )L2 Handwashing in healthcare wor&ers0 accessibilit1 of sin&

location does not im'rove com'liance J Hos' Infect2 *++9?=<B90*9;8=-

Cited Here222



,+2 Lill1 HA6 Lowbur1 $J2 Transient s&in Gora0 their removal b1 cleansing or

disinfection in relation to their mode of de'osition J Clin athol2 ,:;<?-,B,+0:,:8**

Cited Here222

,,2 Centers for >isease Control and revention2 Norovirus in healthcare settings2

*+,+2 htt'0""www2cdc2gov"HAI"organisms"norovirus2html2

Cited Here222

,*2 Cohen SH6 et al2 Clinical 'ractice guidelines for Clostridium diOcile infection in

adults0 *+,+ u'date b1 the Societ1 for Healthcare $'idemiolog1 of America BSH$A

and the Infectious >iseases Societ1 of America BI>SA Infect Control Hos' $'idemiol2

*+,+?-,B=09-,8==

Cited Here222

,-2 Liu 6 et al2 $ectiveness of liuid soa' and hand sanitier against Norwal& virus

on contaminated hands A''l $nviron )icrobiol2 *+,+?;7B*0-:98:

Cited Here222

,92 Lan&ford )E6 et al2 InGuence of role models and hos'ital design on hand

h1giene of healthcare wor&ers $merg Infect >is2 *++-?:B*0*,;8*-

Cited Here222

,=2 Nai&oba S6 Ha1ward A2 The eectiveness of interventions aimed at increasing

handwashing in healthcare wor&ersa s1stematic review J Hos' Infect2

*++,?9;B-0,;-8<+

Cited Here222

,72 #ietri NJ6 et al2 The eect of moving to a new hos'ital facilit1 on the 'revalence

of methicillin!resistant Sta'h1lococcus aureus Am J Infect Control2 *++9?-*B=0*7*8;

Cited Here222



,;2 Whitb1 )6 et al2 Three successful interventions in health care wor&ers that

im'rove com'liance with hand h1giene0 is sustained re'lication 'ossible Am J

Infect Control2 *++<?-7B=0-9:8==

Cited Here222

,<2 Eould >J6 et al2 The CleanVourHandsCam'aign0 critiuing 'olic1 and evidence

base J Hos' Infect2 *++;?7=B*0:=8,+,

Cited Here222

,:2 Jenner $A6 et al2 Hand h1giene 'osters0 selling the message J Hos' Infect2

*++=?=:B*0;;8<*

Cited Here222

*+2 @ischo W$6 et al2 Handwashing com'liance b1 health care wor&ers0 the im'act

of introducing an accessible6 alcohol!based hand antise'tic Arch Intern )ed2

*+++?,7+B;0,+,;8*,

Cited Here222

*,2 )cEuc&in )6 et al2 The eect of random voice hand h1giene messages delivered

b1 medical6 nursing6 and infection control sta on hand h1giene com'liance in

intensive care Am J Infect Control2 *++7?-9B,+07;-8=

Cited Here222

**2 Cohen HA6 et al2 Handwashing 'atterns in two dermatolog1 clinics >ermatolog12

*++*?*+=B90-=<87,

Cited Here222

*-2 )ensah $6 et al2 Hand h1giene in routine glaucoma clinics @r J .'hthalmol2

*++=?<:B,,0,=9,8*



Cited Here222

*92 ittet >6 et al2 Hand h1giene among 'h1sicians0 'erformance6 beliefs6 and

'erce'tions Ann Intern )ed2 *++9?,9,B,0,8<

Cited Here222

*=2 @ahal A6 et al2 Hand h1giene com'liance0 universall1 better 'ost!contact than

're!contact in healthcare wor&ers in the K and Australia @ritish Journal of Infection

Control2 *++;?<B,0*98<

Cited Here222

*72 Whitb1 )6 et al2 Wh1 healthcare wor&ers donMt wash their hands0 a behavioral

e5'lanation Infect Control Hos' $'idemiol2 *++7?*;B=09<98:*

Cited Here222

*;2 #oss A6 Widmer A%2 No time for handwashing Handwashing versus alcoholic

rub0 can we aord ,++ com'liance Infect Control Hos' $'idemiol2

,::;?,<B-0*+=8<

Cited Here222

*<2 Judah E6 et al2 $5'erimental 'retesting of hand!washing interventions in a

natural setting Am J ublic Health2 *++:?::BSu''l *0S9+=8S9,,

Cited Here222

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