Tuesday, November 4, 2008

Hand hygiene in Dutch hospitals: compliance and determinants.

Today I chaired a meeting that reported and discussed the results of a comprehensive study on hand hygiene among health care workers in IC units and surgical wards in Dutch hospitals. Hand hygiene is of utmost importance in prevention of hospital acquired infections. Earlier studies suggest that hand hygiene compliance is less than optimal, to say the least, with compliance rates of about 50%.
In this age of high tech medicine, simply adhering to basic hand hygiene instructions to prevent ill health seems so obvious. But the compliance rates indicate that washing your hands when this is necessary and according to the instructions may not be that simple and straightforward.
The study that was presented included observations in Dutch hospitals to get objective assessments of hand hygiene compliance (since most compliance data are based on self reports, which may obviously be biased), and a Delphi study and a cross-sectional survey among doctors, nurses, and trainees to explore potential determinants of hand hygiene compliance and possibilities to promote better compliance.

The study was led by Dr. Ed van Beeck of the Department of Public Health, Erasmus University Medical Center (http://www.erasmusmc.nl/MAGE/), and Vicky Erasmus of the same department (http://survey.erasmusmc.nl/intern/pwp/front.php).

The study showed that observed hand hygiene compliance was even worse than expected based on self-reports. Compliance rates were below 30% overall. Especially worrying was the extremely low hand hygiene compliance before patient contacts, with hospital workers showing good hand hygiene in only a few % of the events when hand washing was needed. Somewhat better hand hygiene was observed after patient contacts, especially when the health care worker had been in contact with bodily fluid. Differences in compliance were found according to the kind of hospital investigated (small peripheral hospitals > university hospitals) and the hospital unit (surgical ward > IC unit). The observations also showed the frequency of events that require hand hygiene behavior. Basically, if appropriate hand hygiene indeed performed before or after each event that officially requires hand washing or hand alcohol, health care workers would spend a substantial part of their day ‘cleaning’ their hands. Such a time investment may just not be possible.

The exploration of potential determinants indicated that lack of knowledge of the importance of hand hygiene (among doctors only), low perceived control (i.e. most probably related to the time restraints) regarding hand hygiene practices, lack of positive descriptive norms regarding hand hygiene (among nurses only) were associated with low compliance. Furthermore, doctors were more likely to show higher compliance if they thought lack of hand hygiene could have severe health consequences for themselves, while nurses were more likely to be compliant if they perceived the potential consequences for their patients as severe.

Interventions to improve hand hygiene may include educational activities to further improve knowledge of hand hygiene recommendations, and to further stress the importance of hand hygiene practices, but should also include changes in the physical and social environments that will make compliance easier and normative.

The study was financially supported by the Netherlands Organisation for Health Research and Development, ZonMW (http://www.zonmw.nl/).