Hand hygiene after touching a patient's surroundings: the opportunities most commonly missed

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Summary

Background

Healthcare workers generally underestimate the role of environmental surfaces in the transmission of infection, and compliance with hand hygiene following contact with the environment is generally lower than following direct patient contact. To reduce the risk of onward transmission, healthcare workers must identify the need to wash hands with specific tasks or events.

Aim

To observe the movement of staff in critical care and general wards and determine the routes most commonly travelled and the surfaces most frequently touched with and without appropriate hand hygiene.

Methods

Fifty-eight 90 min sessions of unobtrusive observation were made in open bays and isolation rooms. Link analysis was used to record staff movement from one location to another as well as the frequency of motion. Hand-hygiene audits were conducted using the World Health Organization ‘five moments for hand hygiene’ observational tool.

Findings

In critical care, the majority of movement occurred within the bed space. The bedside computer and equipment trolley were the surfaces most commonly touched, often immediately after patient contact. In the general ward, movement between bed spaces was more common and observed hand hygiene ranged from 25% to 33%. Regardless of ward type, observed hand-hygiene compliance when touching the patient immediately on entering an isolation room was less than 30%.

Conclusions

Healthcare workers must be made aware that bacterial spread can occur even during activities of perceived low risk. Education and intervention programmes should focus on the potential contamination of ward computers, case notes and door handles.

Introduction

During routine patient care, the hands of a healthcare worker can become heavily contaminated.1, 2 Inadequate hand hygiene when caring for a single patient or when moving between patients can lead to the cross-transmission of pathogens.3 To interrupt microbial transmission effectively, hand hygiene is required at pivotal points during the patient care sequence. These have been defined by the World Health Organization (WHO) as being the ‘five moments for hand hygiene’ and they emphasize the importance of hand hygiene before and after patient contact, before performing a clean/aseptic technique and after exposure to body fluids. The ‘fifth moment for hand hygiene’ occurs after touching a patient's surroundings.4

Patients contaminate their immediate environment and the ease with which bacteria can be acquired from environmental surfaces by the hands or gloves of healthcare workers has been demonstrated.5, 6 If these include potential pathogens, the reservoirs that develop on nearby surfaces represent a risk factor for onward transmission. Although the role of environmental surfaces in the transmission of infection is acknowledged within the ‘five moments’, this knowledge may not be sufficiently widespread among healthcare workers.7, 8 Studies have demonstrated that whereas the majority of hand-hygiene opportunities occur after contact with a patient's surroundings, these opportunities are also those most commonly missed (i.e. are associated with the lowest levels of compliance).9, 10, 11

To improve hand-hygiene compliance, interventions should provide the cues healthcare workers use to identify the need to clean their hands while also providing the ability to perform hand hygiene – for example, locating alcohol gel dispensers en route to a task where hand hygiene is required.12 These cues should be tied to specific events or tasks rather than to general behaviour.12 As a result, appropriate cues/interventions may differ with ward type, isolation precautions and/or professional group. The aim of this investigation was to observe the movement of staff in critical care and general wards and, with a view to focus hand-hygiene training, to determine the routes most commonly travelled and the surfaces most frequently touched together with associated hand-hygiene compliance.

Section snippets

Study setting

The study was performed on the medical–surgical intensive care unit (ICU) and on a gastrointestinal ward of a London teaching hospital between August and December 2009. The ICU comprised 11 single rooms; four bays of five beds and one bay of four beds. The median bed centre to bed centre distance was 3.6 m. The gastrointestinal ward comprised seven single rooms; three bays of five beds and 10 bays of four beds with 2.7 m bed spacing. All bed spaces had ready access to a handwash sink, paper

Intensive care unit

Fourteen 90 min observation sessions were conducted within an ICU bay. Hand-hygiene compliance was 60% (based on observable outcomes). Of the 255 hand-hygiene opportunities identified, 101 (40%) occurred after contact with the environment. The sites most frequently touched were within the patient zone (i.e. the patient's immediate surroundings) and included the equipment trolley (211 contacts) and the computer keyboard (170 contacts). Movement between an equipment trolley and a patient was

Discussion

In the ICU and gastrointestinal ward, hand-hygiene compliance was 60% and 36% respectively. As in previous studies, the majority of missed hand-hygiene opportunities occurred after contact with a patient's surroundings.10, 11 The aim of this study was to determine which surfaces were most likely to be touched without appropriate hand hygiene.

The results of this study demonstrate how the movement patterns of staff differ in critical care and general wards. In the ICU, the one-nurse-per-bed

Acknowledgements

We thank the medical and nursing staff on the wards for their help during this study. The trial was approved by the Joint UCL/UCLH Committees on the Ethics of Human Research 06/Q0502/91.

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