Review
Hand hygiene and patient care: pursuing the Semmelweis legacy

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Summary

Modern medicine still has to contend with the major problem of infections resulting from patient care. Despite considerable evidence that appropriate hand hygiene is the leading measure to reduce cross-infection, compliance with recommendations remains notoriously low among healthcare workers. In high-demand situations, such as in most critical-care units, or at times of overcrowding or understaffing, promoting hand cleansing with an alcohol-based handrub solution seems to be the most practical means of improving compliance. It requires less time, acts faster, irritates hands less often, and is superior to traditional handwashing or medicated hand antiseptic agents. Furthermore, it was used in the only programme that reported a sustained improvement in hand-hygiene compliance associated with decreased infection rates. Although easy access to fast-acting hand-hygiene agents is the main tool of any campaign to obtain sustained improvement with hand-hygiene practices, a multidisciplinary approach is necessary to produce behavioural change.

Section snippets

Historical landmarks

Ignaz Philipp Semmelweis (1818–1865), a native of Hungary, is well-known for his discovery of the aetiology and prevention of puerperal fever, a vital advance in saving the lives of women in childbirth.22 In 1844 Semmelweis was appointed assistant lecturer in the maternity department of the University of Vienna's Allegemeines Krankenhaus, Europe's largest obstetric department of that time (figure 1). During the second half of the 19th century, the Lying-In Women's Hospital in Vienna was divided

Skin flora

The skin harbours mainly two types of microorganisms, resident and transient or contaminant flora.24 Resident flora (mainly coagulase-negative staphylococci, Corynebacterium spp, Micrococcus spp) has a low pathogenic potential unless introduced into the body by invasive devices, and is difficult to remove mechanically. Transient flora (typically Escherichia coli and Pseudomonas aeruginosa) has a short-term survival rate on the skin, but a high pathogenic potential, and is responsible for most

Low compliance and barriers to hand hygiene

In observational studies of hand hygiene, both the frequency and the quality of practices are considerably suboptimal. Average compliance is usually below 50%. Although opportunities for hand hygiene were not recorded in a standardised manner in all studies in table 1, it is still fair to say that compliance was almost universally low. As shown, it varied according to the hospital ward where the observation was conducted. In most surveys, compliance was greater among nurses than among doctors.

Targets for hand-hygiene promotion

Identification of risk factors associated with poor compliance is of utmost importance to the design of an effective promotion campaign.42 Perceived barriers to appropriate hand hygiene reported by HCWs are also a major consideration.8, 36, 37, 38, 39, 40, 42 In-service education, distribution of information leaflets, workshops and lectures, and performance feedback on hand-hygiene compliance rates have been associated with, at best, transient improvement.1, 16, 18, 27, 28 Until recently, the

Tools for change

Improvement in infection-control practices requires: questioning basic beliefs, continuous assessment of the group's (or individual's) stage of behavioural change, intervention(s) with an appropriate process of change, and supporting individual and group creativity. Because of the complexity of the process of change, it is not surprising that single interventions often fail38 and, clearly, a multimodal, multidisciplinary strategy is necessary.

Table 4 proposes a framework that includes factors

Choice of hand-hygiene agent

In 1847, Semmelweis observed that normal hand washing did not always prevent the spread of fatal infection and recommended hand disinfection in a solution of chlorinated water before each vaginal examination.22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 51, 52, 53, 54, 55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 70 Plain soap with water can decrease the load of microorganisms on hands to some degree, but

Success stories

Between 1977 and 2000, several quasi-experimental hospital-based studies of the impact of hand hygiene on the risk of nosocomial infection were published (table 6). Although the studies have design limitations (see below), most reports showed a temporal relation between improved hand-hygiene practices and reduced infection or cross-transmission rates. Similarly, the beneficial effects of hand-hygiene promotion on the risk of cross-transmission have been reported in surveys conducted in schools

Research issues

This review highlights many unresolved questions. Table 7 lists important research issues related to hand hygiene and its promotion in today's healthcare setting.

The practice of hand hygiene is considered as “a modest measure with big effects”.57 In 1997, a Handwashing Liaison Group (now renamed Hand-hygiene Liaison Group78) was created in the UK whose mission is “to modify the behaviour of HCWs to produce sustained improvement in hand hygiene guidelines and so improve the quality of patient

Search strategy and selection criteria

Published and unpublished data for this review were identified by searches of Medline, Current Contents, and references from relevant articles; numerous articles were identified through searches of the extensive files of the two authors. Search terms were “hand hygiene”, “handwashing”, “hygienic handwash”, “hand disinfection”, “handrub”, “cross infection”, “epidemiology”, “healthcare worker”, and “behaviour”. English and French language papers were reviewed. Because many papers on hand

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