Removing barriers to hand hygiene compliance

Posted: Monday, April 27, 2015 at 12:00:00 am

Becker’s Clinical Quality and Infection Control recently featured a study published in Infection Control and Hospital Epidemiology that explored the most common barriers to hand hygiene compliance. In the study, 123 healthcare workers in a Thai hospital were observed for compliance with the World Health Organization’s “five moments” of hand hygiene. Based on direct observation, their hand hygiene compliance was 23.2%, but the participants self-reported their compliance at 82.4%. Participants were also surveyed on why they failed to perform hand hygiene compliance.

Below are the participants’ responses for why they failed to perform hand hygiene practices and how these barriers can be overcome.

  1. “I hurry/emergent patient conditions” (45.5%) – With the advent of alcohol-based hand sanitizer, hands can be cleansed with a quick dispense and rubbed on the way to patient care in a few seconds’ time. While sanitizer is not appropriate in all situations since C. diff is not affected by sanitizer, sanitizer makes it easier in appropriate situations for the healthcare worker to perform hand hygiene.
  2. “I don’t see any dirt/I think it’s not dirty” (24.4%) – Touch is one of the biggest ways that infections spread. Bacteria and viruses are invisible to the eye but can be easily transferred between patient care to equipment and back to other patients. Following recommended hand hygiene protocols before entry and after exit of a patient room ensures that hands are clean, even if they do not appear to be dirty.
  3. “I forget” (19.5%) – Healthcare workers have many duties and responsibilities on their mind. With so many demands during the day, it is easy to forget a task if it is not an established habit. By creating a habit of hand cleansing at a minimum on every entry into and exit from patient rooms, hand hygiene is added to a routine and is not as hard to remember.
  4. “I’m busy/too many patients” (15.4%) – While it can seem that skipping hand hygiene will allow a healthcare worker more time with patients, a patient who gets an infection while in the hospital increases the time and cost of treating that patient, and these negative outcomes override the few seconds needed to cleanse hands.
  5. “It is inconvenient” (13.8%) – Again, the advent of alcohol-based hand sanitizer allows hand sanitizers to be placed anywhere in the hospital and not just around a sink, meaning that hospitals can be flexible and place sanitizers in locations that are most convenient to healthcare worker workflow.
  6. “I don’t care” (8.1%) – Hand hygiene is a standard of care, and healthcare workers have a professional responsibility to provide the highest level of safe and quality care. Management at the hospital can support healthcare workers on all levels by setting an example for hand hygiene and encouraging high compliance on the individual and unit level.
  7. “I’m lazy” (5.7%) – Similar to the above statement, hand hygiene is a standard of care and cannot be excused for laziness when patient safety is on the line. Management can create a hospital culture where hand hygiene is non-negotiable, while at the same time supporting healthcare workers who are making efforts to improve hand hygiene compliance.
  8. “I wear gloves/no direct contact with patients” (4.9%) – Hands should be cleansed before donning gloves. Gloves protect the healthcare worker more than they do the patient. Even if a healthcare worker does not touch the patient, the environments both inside and outside the patient rooms are not sterile and touching these surfaces contaminates both gloves and hands.
  9. “There are adverse effects of soap/cleanser” (4.9%) – Frequent sanitizing often causes hands to dry out, but washing with soap and water every third or fourth time after using alcohol-based sanitizer helps alleviate these adverse effects. Many manufacturers also provide lotions and moisturizing formulas of sanitizer to help combat drying.
  10. “It wastes time” (4.1%) – Patient safety is never a waste of time and should always be a high priority. Hand hygiene is known as one of the best ways to prevent the spread of infections.
  11. “My hands are clean” (2.4%) – This statement is similar to saying that hands do not look or feel dirty, since you cannot see the germs that cause infections. It is also easy to unconsciously touch something that is contaminated between cleansings and not have remembered, which is why it is important to cleanse at entry and exit of a patient room.

With the appropriate workflow, encouragement, leadership, training, behavioral changes and the right tools, many of these barriers can be overcome. However, some of these barriers – “I don’t care” or “I’m lazy” – point to a larger problem of priorities and the need for professional responsibility to the patient and their care. Each hospital’s culture is different, but recognizing the culture and addressing these barriers in a way that speaks to the healthcare workers at the hospital can create a culture supportive of hand hygiene.

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