Hand Hygiene in the Healthcare Setting

March 15, 2016 | Healthcare Risk, Quality, & Safety Guidance


The idea that physicians should wash their hands before and after patient contact was first recommended in the 12th century when Maimonides wrote, "I dismount my animal, wash my hands, go forth to my patients," and "Never forget to wash your hands after having touched a sick person." In the late 1840s, Semmelweis demonstrated that hand hygiene dramatically reduced maternal deaths in hospitals from puerperal fever (Savio and Ramoska), but less than 40 years later, President James Garfield died of a lingering infection brought on by over a dozen physicians' dirty hands and unsterilized instruments probing the small wound in their attempts to remove an assassin's bullet (Death of Garfield).

It is not surprising, then, that in the 21st century CDC, WHO, and other experts in infection prevention still consider proper hand hygiene by healthcare workers to be the most important practice for preventing HAIs. HAIs can happen anywhere healthcare is delivered, including hospitals, outpatient settings such as ambulatory surgical centers and dialysis facilities, and long-term care facilities such as nursing homes and rehabilitation centers. They may be caused by any infectious agent, although most are caused by bacteria and viruses.

A variety of national and international organizations, such as CDC and WHO, have issued recommendations on how and when to perform hand hygiene. The annual compendium of strategies to prevent HAIs (a collaborative effort by virtually all organizations and societies with expertise on this topic, including the Society for Healthcare Epidemiology of America (SHEA), the Infectious Diseases Society of America, the American Hospital Association, the Association for Professionals in Infection Control and Epidemiology (APIC), The Joint Commission, CDC, the Institute for Healthcare Improvement (IHI), the Pediatric Infectious Diseases Society, and the Surgical Infection Society) summarizes practices based on the quality of the supporting evidence. This compendium lists hand hygiene as one of the "basic practices" for preventing all of the infections identified in the National HAI Action Plan (Yokoe et al.). Despite the focus on hand hygiene as an important patient safety practice, compliance is often low, and study after study finds compliance rates among healthcare workers hovering at or below 50% (IHI).

This guidance article briefly outlines standards and guidelines related to hand hygiene, such as those from CDC and WHO, and provides recommendations as to how to monitor and improve hand hygiene compliance. (See Definitions for explanations of terms related to hand hygiene. )

While one failure by a healthcare worker to perform proper hand hygiene does not automatically mean that the patient will contract an HAI, repeated failures over the course of patient care certainly increase the odds. In the United States, approximately 1 of every 25 hospital patients acquires at least one HAI while hospitalized, for a total of almost 648,000 inpatients with 722,000 infections each year. Pneumonia and surgical-site infection are the most common HAIs, and Clostridium difficile is the most common of the more than 480 pathogens that cause HAIs (Magill et al.). About 75,000 inpatients with HAIs die during their...

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