It is time for action: improving hand hygiene in hospitals.

As delivery of medical care moves increasingly to outpatient settings, patients who require hospitalization have more acute illness and heightened susceptibility to nosocomial infections. Such infections result in substantial morbidity and are estimated to cause or contribute to 80 000 deaths annually in the United States (1). Many nosocomial infections are caused by pathogens transmitted from one patient to another by way of health care workers who have not washed their hands between patients (2, 3). Although Semmelweis (4) demonstrated 150 years ago that mortality related to hospital-acquired infections could be reduced when health care personnel washed their hands with an antiseptic solution between patient contacts, compliance of health care workers with recommended handwashing practices remains unacceptably low, often in the range of 30% to 50% (5-8). Even the current spread of multidrug-resistant pathogens in hospitals has not compelled health care workers to wash their hands as frequently as recommended (8). Why is compliance with recommended handwashing practices so poor? Many factors are involved, including lack of awareness among personnel about the situations that call for handwashing, personal and organizational attitudes toward handwashing, and various logistical barriers (6, 9, 10). Many health care workers do not wash their hands after low-risk patient contacts (5, 7), probably because they are not aware that their hands may become contaminated while measuring the patient's blood pressure or pulse, touching intact areas of the patient's skin, or lifting the patient (2). For reasons that are not clear, handwashing frequency varies by type of health care worker and by clinical service, and personnel who are required to wear only gloves when caring for patients do not wash their hands as often as those who are required to wear both a gown and gloves [8, 11]. When health care workers were asked which factors deter them from washing their hands as recommended, they cited 1) skin irritation and dryness caused by frequent handwashing and 2) being too busy (9, 10). Inconvenient location of sinks is considered a less important deterrent. In this issue, Pittet and colleagues (12) report the results of a large, well-designed observational study of factors affecting compliance of health care workers with recommended handwashing policies. Several aspects of their study are particularly noteworthy. More than 2800 opportunities for handwashing were observed on multiple wards during all shifts and on all days of the week, and multiple variables that might influence handwashing were recorded during each observation period. Multivariate analysis was performed to establish the independent contribution of variables to compliance with handwashing. The investigators found that the average level of compliance with recommended handwashing practices was 48%, which is within the range of compliance noted in previous observational studies (5-8). Compliance was higher among nurses than among physicians and other health personnel and varied by ward locationfindings that confirm previous observations (5-7). Several new findings of particular concern include the fact that handwashing compliance was worse before high-risk procedures were performed; in intensive care units, where highly susceptible patients are located; and with increasing intensity of patient care, that is, when nurses were expected to wash their hands the most frequently (12). Although nurses have often reported that being too busy is a major deterrent to handwashing (9, 10), Pittet and colleagues are the first to document that a high workload is associated with poor compliance with handwashing. Low compliance during care of patients in intensive care units may help explain why the spread of resistant pathogens, such as methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci, has continued to increase in many hospitals despite appropriate written infection control policies. In addition to washing their hands less frequently than they should, health care workers often wash their hands for an average of only 8.5 to 9.5 seconds (7, 13). Although a minimum of 10 seconds is recommended, data on the efficacy of soap and water handwashing often are based on protocols that require 30 seconds of handwashing. Because washing the hands with plain soap and water for less than 10 to 15 seconds has limited efficacy (14, 15), this aspect of handwashing compliance also requires renewed attention. The report by Pittet and colleagues (12) provides new insights into our understanding of current handwashing practices and should serve as a stimulus for hospitals to develop new strategies for improving hand hygiene practices. The term hand hygiene is used here to connote cleansing of hands, either by washing them with unmedicated or medicated soap and water or by performing antisepsis with a waterless antiseptic agent. A multidisciplinary approach that addresses both logistical barriers and behavioral issues that adversely influence handwashing is necessary (16, 17). One of the major barriers is that frequent handwashing with unmedicated or medicated soap and water often causes skin irritation and dryness, which deter personnel from washing their hands as frequently as recommended (9, 10). Potential solutions to this problem include having personnel apply skin protectants to their hands or providing personnel with hand hygiene products that minimize skin irritation and dryness (9). For example, several studies suggest that alcohol-based hand rinses and gels containing emollients may cause less dermatitis than handwashing with soap and water (15; Boyce JM. Unpublished data). Such preparations are very efficacious in removing bacterial flora from the hands of personnel and have been adopted for hand antisepsis by health personnel in several European countries (15, 18). Reducing the time required for handwashing may make it feasible for caregivers with high workloads to wash their hands more frequently. Because finding a sink and washing the hands with soap and water require more time than using a waterless antiseptic agent that is available at each patient's bedside (19), placement of an alcoholic rinse or gel (or similar product) near each patient's bed and at other locations on hospital wards should be evaluated to determine whether this strategy results in improved hand hygiene (12). Further controlled studies are also needed to determine whether frequent use of alcohol-based hand rinses and gels by personnel will lead to improved control of nosocomial infections. Hospital administrators should strive to create an organizational atmosphere in which adherence to recommended hand hygiene practices is considered an integral part of providing high-quality care. For such an approach to be successful, hospitals must provide visible support and sufficient resources for new programs. Hospitals need to develop and implement innovative educational and motivational programs tailored to specific groups of health personnel. The strategies that are most appropriate for nurses, for example, may not achieve the same degree of success with physicians or with other health personnel (16). Convincing department heads or other opinion leaders to wash or disinfect their hands as recommended may be important in modifying physician behavior (16). Monitoring compliance of health care workers and providing them with frequent feedback on their performance has led to improved handwashing practices in short-term studies (20). Hospitals should make this strategy a high priority (17). Newer and more efficient methods for monitoring hand hygiene practices, such as the mechanical or electronic methods used by some restaurants and fast-food establishments, should be evaluated in hospital settings. Finally, recording adherence to recommended hand hygiene practices by individual health care workers and including this record as part of an annual personnel evaluation or medical staff reappointment process should be evaluated in clinical studies as another potential strategy for improving hand hygiene among caregivers. Careful handwashing or antisepsis between care of patients remains one of the most important measures for preventing the spread of pathogens in hospitals. After tolerating poor handwashing compliance for 150 years, it is time for hospitals and health care professionals to get serious about improving hand hygiene in hospitals.