This is the second in our five-part series recap that covers best practices for driving effective hand hygiene compliance. This blog focuses on the issues of coverage, wet time and efficacy, to assure hands are optimally cleaned.
Hand hygiene compliance is a complex issue. A decade of research has shown a multimodal strategy, such as the one recommended in the WHO guidance (2009), to be most effective in improving hand hygiene performance. This would involve a number of components including education and training, monitoring and feedback, and product availability, location and ease of use.
Additionally, good hand hygiene compliance also means paying close attention to wet time and coverage, as this affects efficacy of the hand sanitizer itself. Just going through the motions of cleaning hands is not enough. It’s important to consider the right method for cleaning hands as part of the effort to reduce the incidence of healthcare-associated infections (HAIs), ensure patient safety, and prevent reimbursement penalties.
Proper hand cleaning can be readily achieved with selection of the right product that can ensure healthcare professionals are getting a tested formula that meets the coverage, wet time and efficacy drivers. Let’s start with coverage. It’s vital that healthcare professionals dispense enough of a high quality hand hygiene product to fully cover their hands, ensuring they can spread the product to the frequently missed areas of the hand, including the thumbs, between the fingers, back of fingers and under fingernails. According to the CDC1, applying small volumes (i.e., 0.2-0.5 mL) of alcohol to the hands is not more effective than washing hands with plain soap and water.
The safest approach is for healthcare professionals to adhere to the World Health Organization’s alcohol-based “hand rub” process, (download poster here) which calls for 6 steps and should take 20-30 seconds.2 Hand coverage using the WHO method merits serious attention. While clinicians in a tertiary academic medical center in Switzerland met all five moments of the WHO's hand hygiene guidelines with a compliance rate of 93.2 percent, compliance with all six steps of WHO guidelines for alcohol-based hand rub was just 8.5 percent, according to a 2015 study published in Infection Control and Hospital Epidemiology3.
The study’s authors suggest that the disparities in hand hygiene technique require that “repeated training programs on proper hand hygiene technique be offered through professional life to ensure greater degrees of reduction of bacterial densities.”
Wet time is another significant factor for achieving fully sanitized hands. Adequate wet time, defined as the amount of time a sanitizing product remains on the hands, is essential in killing a significant number of bacteria. While the CDC acknowledges the ideal volume of product to apply to the hands is not known and may vary for different formulations, the CDC guidelines state that “if hands feel dry after rubbing hands together for 10-15 seconds, an insufficient volume of product likely was applied.”1 The WHO guidelines state that using recommended hand sanitizer products developed specifically for healthcare, the wet time should be 20-30 seconds.2
Lastly, healthcare professionals must consider the issue of efficacy—how coverage and wet time work synergistically to kill pathogens and generate high rates of hand hygiene compliance. Measuring hand hygiene efficacy requires scientific research and testing, as not all hand sanitizers are created equally. According to the CDC, “the efficacy of alcohol-based hand hygiene products is affected by several factors, including the type of alcohol used, concentration of alcohol, contact time, volume of alcohol used, and whether the hands are wet when the alcohol is applied.” To effectively kill germs, hand sanitizer must contain at least 60 percent alcohol, and for healthcare environments products must pass clinical testing such as ASTM 1174 or the European EN1500. So the next time you are cleaning your hands in your healthcare facility, or discussing hand hygiene compliance initiatives, remember that it has to be about more than just the act of cleaning hands. Coverage, wet time and efficacy are the key to proper hand-cleaning, which is considered fundamental in preventing HAIs.
Our next blog in this five-part series will move from product drivers to behavioral drivers of hand hygiene compliance, addressing the impact of product availability, location and ease of use on hand hygiene compliance.
3 Tschudin-Sutter, S. et al. Compliance with the World Health Organization Hand Hygiene Technique: A Prospective Observational Study, Infection Control and Epidemiology, April 2015, 36(4), 482-483.