Hand Hygiene Compliance: Not That Simple

By Barbara Connell | January 27, 2017

In 1847, Ignaz Semmelweiss made a landmark discovery. He noted that the incidence of puerpal (childbed) fever, a female reproductive tract infection occurring after childbirth or miscarriage could be drastically cut by the use of hand washing with chlorinated lime solutions. Semmelweiss’ hypothesis — that there was only one cause and all that mattered was cleanliness — was extreme at the time, and was largely ignored, rejected or ridiculed. It was years after his tragic and untimely death in 1865 at age 47 that the concept of hand hygiene gained acceptance.

By the 1950s, infection preventionists had taken a leading role in preaching the benefits of hand hygiene. In 1975, the Centers for Disease Control and Prevention (CDC) published formal guidelines on hand washing practices in hospitals. Today, hand hygiene is considered to be the cornerstone of infection prevention and the best way to reduce healthcare associated infections and prevent the transmission of organisms from the healthcare workers’ hands to the patient. Despite the body of evidence in its favor, hand hygiene compliance remains low across healthcare settings. Worldwide hand hygiene rates are between 40 and 60 percent ¹, while it is reported that in the United States, the rate, on average, is as low as 38 percent.²

There is a recent example of how even basic skin sterilization protocols may not always be followed properly appeared in a study published in the American Journal of Infection Control (AJIC.) The study reported that healthcare professionals at outpatient care facilities fail 37 percent of the time to follow recommendations for hand hygiene and 33 percent of the time for safe injection practices, even after having policies in place about these infection control issues.³

So what are the barriers to hand hygiene compliance? Evidence-based practices supported by the World Health Organization and the CDC have identified the placement of hand hygiene products at the point of care (POC) as a fundamental component. The POC is defined as the place where the following three elements come together: patient, healthcare worker and the provision of care or treatment.4

This necessitates that a hand hygiene product be easily accessible and as close as possible — ideally within arm’s reach of where the patient care or treatment is taking place. This allows for the integration of hand hygiene into the natural workflow of patient care. In another study published in AJIC, a cross-sectional examination of healthcare workers using a survey of knowledge, attitude and self-reported practice of POC hand hygiene was conducted. More than half of the 350 respondents from the United States and Canada agreed or strongly agreed that they would be more likely to wash their hands at the appropriate moments if the alcohol-based hand rub was closer to the patient.5

Other barriers of hand hygiene identified in this study include:

  • Inconveniently placed dispensers/sinks
  • Being busy
  • Empty product dispensers
  • Product drying out hands
  • Lack of knowledge of hand hygiene guidelines
  • Inadequate knowledge of the risk of cross contamination of pathogens
  • Poor habits learned early in life

An additional challenge for ambulatory care facilities occurs when trying to apply the concept of POC hand hygiene. The ambulatory setting does not look the same as an acute care hospital, where the patient is in a room and much of the care happens in that space. In the ambulatory setting, the patient environment touched by the patient and the healthcare provider is not static; it moves beyond the walls of a single room or cubicle.

Implementing and maintaining a high level of hand hygiene compliance can sometimes feel like a daunting task, but it can be accomplished. Single interventions or one-size fits- all solutions, such as in-service education training, leaflets, lectures or compliance feedback, often provide transient but unsustainable results. Understanding the culture, workflow and challenges of your organization can help you to target specific issues to address.

The APIC Guide to Hand Hygiene Programs for Infection Prevention offers suggestions to implement and sustain a successful hand hygiene compliance program. Industry also plays an important role in the struggle to increase hand hygiene compliance. Hand hygiene programs must be supported by ongoing research and product development to build on established science and continue to promote improved patient outcomes. Industry needs to invest in research and development of improved product formulations and new technologies to bolster monitoring of hand hygiene.

As healthcare workers, we need to embrace more rigorous adoption of hand hygiene practices across healthcare settings and consider the patient’s role in hand hygiene. Patients and visitors should not be exempt from performing hand hygiene. They should clean their hands before they eat, after they use the restroom and as they enter and exit their rooms.

Hand hygiene compliance is complex and the solution is not as simple as asking everyone to please wash their hands. The intricate dynamic of behavioral change requires a multidimensional approach engaging a combination of education, motivation and system change. Improved hand hygiene compliance among all hospital personnel, patients and visitors could have a significant impact on HAIs, healthcare and patient safety.

This article originally appeared in Outpatient Outcomes magazine. Click here to sign up to receive future issues.


1. Systematic review of studies on compliance with hand hygiene guidelines in hospital care, https://www.ncbi.nlm.nih.gov/pubmed/20088678 , Infection Control & Hospital Epidemiology, Accessed March 31, 2010.

2. The impact of time at work and time off from work on rule compliance, https://www.ncbi.nlm.nih.gov/pubmed/25365728 , Journal of Applied Psychology, Accessed November 3, 2014.

3. Using medical student observers of infection prevention, hand hygiene, and injection safety in outpatient settings, Available at: https://www.ncbi.nlm.nih.gov/pubmed/26804308 , American Journal of Infection Control, April 1, 2016.

4. Point of care hand hygiene—where’s the rub?, Available at: http://www.sciencedirect.com/science/article/pii/S0196655316002285, Accessed September 27, 2016.

5. APIC Implementation Guide: Guide to Hand Hygiene Programs for Infection Prevention, Available at: http://www.apic.org/Professional-Practice/Implementation-guides

Categories: Expert Views, Infection Prevention, Perioperative

Barbara Connell

Director of Medical Affairs

Barbara Connell has over 20 years’ experience as a medical technologist working specifically in the areas of microbiology, hematology and blood banking. Connell also has 15 years of experience in the IVD laboratory diagnostics business.

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