Hand hygiene is recognized as the best method to prevent transmission of pathogens in the healthcare setting. The use of alcohol-based hand sanitation is preferred in most situations, although soap and water must be used in cases of direct contamination with body fluids, visibly soiled hands, or contact with patients with Clostridium difficile.
It is useful to divide the areas of potential cross contamination into the "patient zone" and the "healthcare zone." In this model, the patient zone is not only the patient's skin, but all the surrounding areas that are assumed to be contaminated by the patient. In the inpatient setting, this would include side rails, bedside tables, linens, and areas frequently touched by healthcare workers such as medical equipment. The healthcare zone is any area outside a specific patient zone, and therefore includes other patient zones and the healthcare facility environment.
In 2007 the World Health Organization (WHO) proposed specific hand hygiene guidelines to prevent cross contamination between patients and the surrounding surfaces. From these recommendations, the following "5 moments for hand hygiene" emerged (Fig. 1):
- After contact with the healthcare zone and before contact with the patient zone. This includes each time the healthcare worker touches a door handle and then shakes the patient hand.
- Before an aseptic task, such as giving an injection or performing wound care. It is important to note that hand hygiene is still required before putting on gloves.
- After contact with any body fluid. Hands should be washed immediately after contact with body fluid and before touching any surfaces—even if gloves are worn. Hand hygiene should be done after removing gloves.
- After patient contact, or contact with any surfaces in the patient zone.
- After exposure to any surface in the patient zone, even if the patient isn't touched.
These guidelines have been adopted in patient contact areas and are often reinforced with posters and screen savers. Numerous methods—including direct observation, self-reporting, and electronic monitors—have been described to monitor adherence to hand hygiene guidelines in the workplace. Each method has advantages, but none is perfect to accurately and effectively monitor hand hygiene.
The NYU experience
The Department of Orthopaedic Surgery at NYU Hospital for Joint Disease has been observing resident practices in the clinic. Hand hygiene is documented for each visit observed by two methods. We started with unannounced standardized patients (USP) or "secret shoppers" who came to the clinic posing as real patients. Recently, we started a structured direct observation of residents by faculty. The 46 USP observations from 2010–2013 observed hand washing or sanitizing in only 21 percent of encounters before the physical exam was performed, and in 15.6 percent of encounters after the physical exam.
In late 2013, a systematic observation of resident encounters in three clinic settings was initiated. This confirmed the lack of adherence to recommended protocols. The most common error was not performing hand hygiene after contact with the patients or the patient care zone surfaces. Resident adherence to hand hygiene did not include hand hygiene with sanitizer or hand washing before or after donning gloves. After implementing curriculum changes and increasing awareness of the guidelines, we have been able to demonstrate a significant improvement in hand hygiene practices in our resident group while being observed by a faculty member (Fig. 2).
It is unclear why residents and clinicians do not routinely engage in hand hygiene in the "five moments," when it has been clearly demonstrated that it is effective in reducing contamination and infection. Hand hygiene may not be a habit with trainees, or with role models. Specific professionals—including physicians—have been noted to have poor compliance. In addition, areas of hospitals such as surgery, intensive care unit, and emergency departments are less compliant, and the use of gloves often substitutes for hand hygiene.
We have previously assumed that clinicians are adhering to well-established guidelines to protect patients and other practitioners from contamination and infection. Our USP and direct observation projects have not only highlighted the poor adherence among trainees, but also have shown the impact on changing behavior by providing immediate feedback individually and in the curriculum.
Our experience indicates that feedback and increased awareness can lead to a change in culture in which hand hygiene is expected and trainees are beginning to self-monitor. Residents will now remind faculty and peers to use appropriate hand hygiene in the clinic and to share literature on surface contamination.
Although we are now at 95 percent adherence to hand hygiene before and after seeing patients in clinic, we do not know if the habit of hand hygiene has continued in busy clinic settings when residents are not being observed. In our preliminary in-patient observations, hand hygiene is variable when moving from patient zones to healthcare zones, as is cleaning of equipment as trainees move from patient to patient. We anticipate that consistent reinforcement, role models, and routine direct observation will ensure that all trainees and faculty will recognize this simple method to improve patient safety.
Donna P. Phillips, MD, is a member of the AAOS Patient Safety Committee and clinical associate professor in the departments of orthopaedic surgery and pediatrics at NYU Hospital for Joint Disease.
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