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.riginal /esearch0 $valuation of a Hand H1giene Cam'aign in .ut'atient Health
Care Clinics
KuKanich6 Kate Stens&e h>6 >#)? Kaur6 /amandee' )H? %reeman6 Lisa C2 h>6
>#)? owell6 >ouglas A2 h>
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Colla'se @o5
Author Information
Kate Stens&e KuKanich is an assistant 'rofessor in the >e'artment of Clinical
Sciences at Kansas State niversit1 BKS in )anhattan6 KS2 At the time of this
stud16 /amandee' Kaur was a graduate student in the >e'artment of >iagnostic
)edicine"athobiolog1 at KS6 where >ouglas A2 owell is a 'rofessor2 Lisa C2
%reeman is vice 'resident for research and graduate studies at Northern Illinois
niversit1 in >eKalb? at the time of this stud16 she was a 'rofessor and associate
dean for research in the College of #eterinar1 )edicine at KS2 This 'roDect was
funded b1 an unrestricted educational grant from the Kansas Health %oundationB@E,==,2 Contact author0 Kate Stens&e KuKanich6 &stens&eF&su2edu2 The authors
and 'lanners have disclosed no 'otential conGicts of interest6 nancial or otherwise2
Colla'se @o5
Abstract
.bDective0 To im'rove hand h1giene in two out'atient health care clinics through the
introduction of a gel sanitier and an informational 'oster2
)ethods0 In this interventional stud16 health care wor&ers at two out'atient clinics
were observed for freuenc1 of hand h1giene Battem'ts versus o''ortunities2 Eel
sanitier and informational 'osters were introduced together as an intervention2
>irect observation of the freuenc1 of hand h1giene was 'erformed during baseline6
intervention6 and follow!u'2 A 'oststud1 surve1 of health care wor&ers was also
distributed and collected2
/esults0 In both clinics6 the freuenc1 of hand h1giene was 'oor at baseline B,,
and *, but im'roved signicantl1 after intervention B-7 and =9 and was
maintained through the follow!u' 'eriod B-* and =,2 Throughout the stud16
'ostcontact hand h1giene was observed signicantl1 more often than 'recontact
hand h1giene2 In both clinics6 health care wor&ers re'orted a 'reference for soa'
and water? 1et observations showed that when the intervention made gel sanitier
available6 sanitier use 'redominated2 %ift1 'ercent of the surve1ed health care
wor&ers considered the introduction of gel sanitier to be an eective motivating
tool for im'roving hand h1giene2
Conclusions0 Hand h1giene 'erformance b1 health care wor&ers in out'atient clinics
ma1 be im'roved through 'romoting the use of gel sanitier and using informational
'osters2 Com'ared with surve1s6 direct observation b1 trained observers ma1
'rovide more accurate information about wor&er 'references for hand h1giene tools2
The 'ractice of hand h1giene b1 health care wor&ers6 through the use of either soa'
and water or an alcohol!based hand sanitier6 is widel1 considered to be the most
im'ortant and eective means of 'reventing health care8associated infections2
Although numerous studies have demonstrated that hand h1giene reduces health
care8associated infection rates6, adherence to hand h1giene guidelines remainsuniforml1 low among health care wor&ers2*!= To im'rove hand h1giene 'erformance
and sustain such im'rovement over time6 barriers must be recognied and
addressed2 These ma1 include 'oor access to hand h1giene materials6 s&in
irritation6 forgetfulness6 time constraints6 a 'erce'tion that hand h1giene interferes
with wor&er8'atient relationshi's6 lac& of &nowledge of hand h1giene guidelines6
and 'oor habits learned earl1 in life27!:
Cleansing the hands with an alcohol!based sanitier generall1 ta&es less time than
washing with soa' and water2 )oreover6 when used a''ro'riatel16 alcohol!basedsanitiers have been shown to be more eective than soa' and water for
eradicating some bacteria276 ,+ %or these reasons6 both the Centers for >isease
Control and revention BC>C and the World Health .rganiation BWH. recommend
the use of alcohol!based hand rubs or sanitiers for most clinical health care
settings2,6 7 However6 handwashing with soa' and water remains the 'referred
method when hands are visibl1 soiled6 or when contact with certain infectious
agents Bsuch as Clostridium s'ores and noroviruses is sus'ected6 as these
organisms are highl1 resistant to &illing b1 alcohol2,,!,-
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Individual health care wor&ers ma1 have dierent hand h1giene 'roduct 'references
and ma1 be aected b1 dierent motivators and barriers to hand h1giene2 revious
interventional studies have determined that a multifaceted cam'aign6 incor'orating
more than one a''roach to change6 is reuired to achieve im'roved hand h1giene
'ractices and sustain them over time2,9!,; Such cam'aigns freuentl1 include the
'romotion of alcohol!based hand sanitiers? indeed6 one hos'ital!wide stud1
credited the increasing use of such sanitiers as the main reason for im'roved
adherence to hand h1giene guidelines2- While there is no evidence that 'osters or
other educational materials alone are eective at changing behavior6 those that use
messages framed in terms of 'otential gains Brather than losses and that invo&e
the health care wor&erMs sense of res'onsibilit1 for 'atient health ma1 be benecial
in combination with other strategies2-6 ,<6 ,:
Several studies have tested interventions for im'roving hand h1giene in teaching
hos'itals and found them to be successful2-6 *+6 *, @ut relativel1 few studies have
tested such interventions in out'atient clinics2**6 *- )ensah and colleagues
observed health care wor&ers in out'atient glaucoma clinics in the nited Kingdom
and found that baseline hand h1giene adherence was ,<2*- After 'resenting aseminar and distributing a memo addressing this6 adherence increased to *< and
was highest among female health care wor&ers and among nurses2 In another stud1
conducted at out'atient dermatolog1 clinics in Israel6 Cohen and colleagues
observed 'h1siciansM behavior and sam'led their hands for bacteria6 but no
interventions were introduced2** Adherence to hand h1giene was low at -,6 and
Sta'h1lococcus aureus was isolated from 7: of 'h1siciansM hands2 In a related
surve16 another grou' of 'h1sicians cited e5cessive wor&loads6 lac& of awareness6
adverse reactions to disinfectants6 and lac& of h1giene facilities as among the main
reasons for lac& of adherence2**
/esearch uestions2 The 'rimar1 research uestions addressed b1 our stud1 were
,2 Could an interventional cam'aign in two out'atient health care clinics lead to
im'roved hand h1giene
*2 Are there dierences in the observed freuenc1 of hand h1giene at baseline
com'ared with that at one wee& and one month after introduction of the
intervention
-2 Are there dierences in the observed freuenc1 of hand h1giene based on
wor&ersM se56 wor&ersM 'rofession6 and timing B're! and 'ost'atient contact
92 Which hand h1giene tools do health care wor&ers in these settings 'refer
=2 Would the observed health care wor&ers later re'ort that either or both
interventional tools were motivating and inGuenced their hand h1giene habits
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)$TH.>S
>esign and sam'le2 This stud1 used an interventional design6 enrolling two
out'atient clinics and 'erforming direct observation of health care wor&ers to
measure hand h1giene o''ortunities and attem'ts at baseline6 after the
intervention6 and during the follow!u' 'eriod2 To recruit the clinics6 we rst
contacted the administration of a large midwestern health care s1stem to determine
whether there was mutual interest2 S'ecic out'atient clinics were then chosen
from within that s1stem based on willingness to 'artici'ate6 whether the clinic
la1out would be conducive to direct observation6 and whether the antici'ated
caseload during the stud1 'eriod would be suOcient2 @ecause all observations and
surve1s were conducted anon1mousl16 after review b1 the institutional reviewboards of the researchersM institution and the 'artici'ating clinics6 the stud1 was
given e5em't status2
The rst clinic was an out'atient oncolog1 clinic having an o'en la1out? sin&s and
foam sanitiers were available at the nursesM station but not in the immediate
vicinit1 of individual 'atients2 The second clinic was an out'atient gastrointestinal
BEI clinic with individual curtained rooms for 'atients2 At each clinic6 the observed
health care wor&ers included 'rimaril1 'h1sicians and nurses6 as well as a few
others2 Sin&s for handwashing were located at the nursesM station6 and foam
sanitier was wall mounted at the entr1 to each curtained 'atient room2 Eel
sanitier was not available at either clinic2
The intervention consisted of introducing alcohol!based gel sanitier and a novel
'oster to each clinic2 We included gel sanitier in this cam'aign to 'rovide health
care wor&ers with an alternative to soa' and water and foam sanitier2
An informational 'oster was created to increase health care wor&ersM awareness of
hand h1giene6 'rovide information about when hand h1giene should be 'erformed6
and encourage them to ta&e 'ersonal res'onsibilit1 for reducing the s'read of
health care8associated infections2 To create the 'oster6 clinic administrators6 nurse
managers6 and the research team rst brainstormed ideas2 Several media
consultants from other universities that have conducted similar hand h1giene
cam'aigns also 'rovided in'ut2 A rst draft was designed and shown to all of these
'eo'le6 and the nal version of the 'oster incor'orated their suggested changes for
im'rovement2
)easures2 %or the 'ur'ose of this stud16 hand h1giene could be acce'tabl1
'erformed using either soa' and water or hand sanitier Bfoam or gel2 We
measured the number of hand h1giene attem'ts against the number of handh1giene o''ortunities2 Hand h1giene o''ortunities were dened as those occurring
immediatel1 before and after a health care wor&er ma&es direct contact with a
'atient? hand h1giene attem'ts were dened as an eort to 'erform hand h1giene
during each o''ortunit12 BThe term Pattem'tQ was used rather than Pcom'liance6Q
because we did not monitor hand h1giene techniue for com'liance with
guidelines2 >irect observers monitored the o''ortunities and recorded the
attem'ts2 To establish intercoder reliabilit1 'rior to the stud16 two observers were
trained and then as&ed to observe and record the same hand h1giene o''ortunities?
the overall 'ercentage agreement between the observers was :72 %or the EI
clinic6 onl1 those o''ortunities and attem'ts that gave observers full visibilit1through an o'en or 'artiall1 o'en curtain were monitored and recorded2
@aseline data were collected on three nonconsecutive da1s6 for four hours each da12
Then a''ro5imatel1 ,+ 'um' bottles of gel sanitier containing 7= eth1l alcohol
were 'rovided in each clinic on the nursesM station counter2 The counters were long6
e5tending the lengths of the clinics6 and the bottles were s'aced out so the1 lined
u' with 'atient areas or rooms as closel1 as 'ossible2 Twent1 'osters were
strategicall1 'laced near sin&s6 at intervals along the nursesM station counter6 and
ne5t to wall!mounted foam sanitier dis'ensers2 .ne inGuential 'h1sician in the EI
clinic was dis'leased when the 'osters were hung6 e5'ressing concern that the ta'e
used to mount them would damage the clinicMs walls? the 'osters were rehung with'ainterMs ta'e to ease his concern and 'revent damage Bthe stud1 design was not
altered2
.ne wee& after the introduction of the intervention6 direct observation of hand
h1giene was 'erformed on ve nonconsecutive da1s6 for four hours each da12 This
design allowed evaluation of the im'act of a short intervention 'eriod2 After these
interventional observations were com'lete6 the 'osters were removed at the
reuest of the clinicsM administration2 The remaining gel sanitier was left behind6
but it too was removed b1 the administration6 in &ee'ing with the clinicsM 'olic12 .nemonth after the last da1 of the interventional observations6 follow!u' direct
observation of hand h1giene was done on three nonconsecutive da1s6 for four hours
each da12 Neither 'osters nor gel sanitiers were 'rovided during the follow!u'
'eriod2
A surve1 was mailed to the nurse managers at both clinics and was distributed to
9; health care wor&ers at the oncolog1 clinic and to 9, health care wor&ers at the EI
clinic6 three months after the last da1 of the follow!u' observations2 The surve1 was
conducted to evaluate the wor&ersM 'erce'tions of the hand h1giene cam'aign6 itsmotivational im'act on their h1giene 'ractice6 'erceived barriers to hand h1giene at
their clinics6 and their 'referred h1giene tools Bsoa' and water6 foam sanitier6 or
gel sanitier2 A ve!item Li&ert scale Branging from Pstrongl1 disagreeQ to Pstrongl1
agreeQ was used for uestions regarding the motivational eOcac1 of the
intervention tools2
Anal1tic strateg12 earsonMs R* anal1ses were used to com'are the freuenc1 of
hand h1giene attem'ts during the three observation 'eriods and to com'are the
'recontact and 'ostcontact freuenc1 of such attem'ts2 $ach calculation had ,degree of freedom2 A value less than or eual to +2+= was considered signicant2
.nl1 descri'tive statistics were used to assess hand h1giene freuenc1 b1 wor&ersM
se5 and 'rofession6 because there were too few observations of male health care
wor&ers and 'h1sicians to 'ermit com'arative anal1ses2 >escri'tive statistics were
also used for com'aring the hand h1giene tools used6 as 'roduct availabilit1 varied
throughout the stud12 @ecause most observed health care wor&ers were nurses and
'h1sicians6 other health care wor&ers were e5cluded from data anal1sis2
While the number of health care wor&ers varied from da1 to da1 and from clinic toclinic6 on average ve nurses and three 'h1sicians were observed 'er da1 in the
oncolog1 clinic6 and eight nurses and four 'h1sicians were observed 'er da1 in the
EI clinic2 In both the oncolog1 and EI clinics6 at baseline6 the overall rates of hand
h1giene attem'ts to o''ortunities were low B,, and *,6 res'ectivel1? these
im'roved signicantl1 after the intervention was instituted B-7 and =96
res'ectivel16 and remained im'roved at the one!month follow!u' 'eriod B-* and
=,6 res'ectivel1 Bsee Table ,2 Throughout the stud16 female health care wor&ers
demonstrated more consistent hand h1giene than their male counter'arts6 and
nurses demonstrated more consistent hand h1giene than 'h1sicians Bsee Table *2
Table ,
Table ,
Image Tools Table *
Table *
Image Tools
A total of =7 health care wor&ers returned surve1s B9, from the oncolog1 clinic6 ,=from the EI clinic2 %ift1 'ercent of all surve1 res'ondents agreed or strongl1 agreed
that the cam'aign had increased their awareness about hand h1giene6 with more
wor&ers at the EI clinic B<+ re'orting this belief than at the oncolog1 clinic B-:2
.verall6 -9 of all res'ondents agreed that the hand h1giene cam'aign had
im'roved their hand h1giene 'ractices2
At the oncolog1 clinic6 the usage rates for soa' and water and foam sanitier were
almost eual at baseline B=- and 9; of attem'ts6 res'ectivel12 @ut after the
interventionMs introduction of gel sanitier6 these usage rates dro''ed Bto *, and9+6 res'ectivel12 Eel sanitier was used in 9+ of hand h1giene attem'ts2 >uring
the follow!u' observation 'eriod6 the gel sanitier 'rovided b1 the researchers was
removed2 The usage rate for soa' and water remained low B*9 while that for
foam sanitier rose B7-2 Self!'rovided gel sanitier was used also B,-2 At the EI
clinic6 the baseline usage rate for foam sanitier B=: was higher than that for
soa' and water B9+2 After the interventionMs introduction of gel sanitier6 the
usage rates for soa' and water and foam sanitier dro''ed Bto ,: and 9+6
each clinic and during the follow!u' observation 'eriod B ( +2++, in each clinic2
Hand h1giene im'roved from baseline to the intervention 'eriod for 'recontact and
'ostcontact observations6 and this im'rovement was sustained with no signicant
decreases in h1giene in both clinics during the follow!u' 'eriod2 A similar nding
was seen in the surve1 res'onses Bn =- for this uestion0 more res'ondents
re'orted Palwa1sQ 'erforming hand h1giene after contact with 'atients B<- thanre'orted Palwa1sQ 'erforming hand h1giene before contact with 'atients B=;2
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>ISCSSI.N
The stud1 ndings indicate that the freuenc1 of hand h1giene b1 health care
wor&ers in bus1 out'atient health care settings is low6 and that short!term e5'osure
to interventional tools can lead to modest im'rovement still evident at one!month
follow!u'2 Among our surve1 res'ondents6 individual res'onses to the motivational
eectiveness of the 'osters or gel sanitier varied6 suggesting that 'retesting
interventions in a given clinic and using a multifaceted im'lementation a''roach
might hel' to achieve the greatest im'rovements2 $stablishing or reinforcing a
clinic!wide e5'ectation that health care wor&ers will adhere to hand h1giene
recommendations is another measure that ma1 further 'romote such adherence2,6
-6 *- )odeling and su''ort of 'ro'er hand h1giene from clinic leaders Bsuch as
'h1sicians and nurse managers have also been suggested as im'ortant factors for
im'roving hand h1giene2,6 -6 *9 In our stud16 the lower freuenc1 of hand h1giene
among 'h1sicians at baselineand6 at the EI clinic6 the negative attitude of one
inGuential 'h1sician toward the 'ostersmight have contributed to the relativel1modest overall im'rovement in h1giene among all health care wor&ers2 This also
su''orts the need to encourage the involvement and investment of clinic leaders in
future hand h1giene cam'aigns2
To minimie s'read of infection6 C>C guidelines recommend that hands be washed
or sanitied immediatel1 before and after ever1 direct contact with a 'atient27 At
both clinics6 observations showed that hand h1giene 'erformance was consistentl1
better after 'atient contact than before 'atient contact? this trend was also
su''orted b1 the surve1 res'onses2 These ndings are consistent with those ofother studies2:6 *=6 *7 As&ed wh1 health care wor&ers tend to P'ractice better
h1giene after 'atient contact than before 'atient contact6Q our surve1 res'ondents
named several 'ossibilities6 including a belief that self!'rotection is a 'riorit16 a
sense that 'atient contact acts as a reminder to 'erform h1giene6 and a belief that
'ostcontact h1giene for one 'atient serves as adeuate 'recontact h1giene for the
ne5t2 %indings from other studies also su''ort the idea that self!'rotection acts as a
strong motivator for hand h1giene2:6 *= This suggests that future cam'aigns should
)ost surve1 res'ondents re'orted a 'reference for soa' and water over either t1'e
of sanitier2 This re'orted 'reference ma1 stem from 'revious training or from a
belief that soa' and water is the best method of hand h1giene and therefore the
PcorrectQ answer on a surve12 Currentl16 both the C>C and the WH. recommend
handwashing with soa' and water when hands are visibl1 soiled with blood or other
bod1 Guids and after contact with certain infectious organisms6 including clostridial
s'ores and norovirus? but both recommend using an alcohol!based sanitier for all
other clinical situations2,6 76 ,,6 ,* %uture cam'aigns should em'hasie these
recommendations2 >es'ite our surve1 res'ondentsM re'orted 'reference for soa'
and water6 we observed health care wor&ers using sanitier Bgel6 foam6 or both
more often than soa' and water once gel sanitier was made available at the
clinics2 ossible causal factors include increased access to gel sanitier during theintervention6 convenience6 faster usage time6 and a 'erceived decrease in s&in
irritation2 After administrators removed gel sanitier from the clinics6 some health
care wor&ers began carr1ing gel sanitier in their 'oc&ets for 'ersonal use6
suggesting an ongoing 'reference2 This discre'anc1 between self!re'orted
'references and actual observed 'ractice suggests that there are man1 factors and
'otential barriers that inGuence hand h1giene 'erformance2 To im'rove adherence6
the C>C recommends 'roviding a variet1 of hand h1giene 'roducts6 routinel1
'erforming direct observation of h1giene 'erformance6 and monitoring 'roduct
usage27
The 'rimar1 barriers to hand h1giene re'orted b1 our surve1 res'ondents were s&in
irritation6 forgetfulness6 and insuOcient time6 and these are similar to those
re'orted b1 others2;6 <6 **6 *; The consistenc16 smell6 and content Bsome 'roducts
contain aloe6 a moisturier of soa's and sanitiers can also inGuence adherence2
>uring the interventional and follow!u' observation 'eriods6 health care wor&ers at
both clinics were overheard discussing their 'reference for gel over foam sanitier6
feeling that the gel was less irritating to their s&in? itMs 'ossible that these wor&ers
might cleanse their hands more freuentl1 if gel sanitier were available2 .ut'atient
clinic administrators should consider health care wor&er 'references as well as
'roduct costs when deciding which to 'urchase2 lacing hand sanitier in the
immediate vicinit1 of 'atients Bsuch as at or near the entrances to 'atient rooms
can both save time and serve as a visual reminder of the need to lower the ris& of
The 'oster was designed to im'rove hand h1giene b1 increasing awareness6
'roviding information6 and encouraging health care wor&ers to ta&e 'ersonal
res'onsibilit1 for reducing the s'read of infection2 /easons for its limited eect
might include a lac& of su''ort from inGuential health care wor&ers6 se5 dierences6
and ineective 'oster design2 The inGuential 'h1sician who was dis'leased with
'oster 'lacement in his clinic ma1 have negativel1 swa1ed other health carewor&ers6 thus hindering the cam'aignMs overall im'act2 The eect of wor&ersM se5 on
hand h1giene might also have been a factor2 There is evidence that men and
women res'ond dierentl1 to health 'romotion messages0 women ma1 be more
motivated b1 &nowledge!based messages that remind them wh1 hand h1giene is
im'ortant6 whereas men ma1 be more motivated b1 messages that elicit emotions
such as disgust2*-6 *< Involving clinic sta in 'oster design and messages6
designing 'osters to be more clinic!s'ecic6 'eriodicall1 'roviding 'osters with new
messages6 and 'ositioning 'osters near both hand h1giene materials and 'atients
ma1 also hel' health care wor&ers to feel more involved in and committed to a hand
h1giene cam'aign2
Limitations and recommendations for further research2 .ne limitation of this stud1
is the 'ossibilit1 of the Hawthorne eect? some health care wor&ers might have
realied that the1 were being observed and cleansed their hands more freuentl1 as
a result2 While using video cameras or training sta in covert observation might
have minimied this 'ossibilit16 the clinic la1outs6 time constraints6 and the need to
ensure 'atient 'rivac1 made such solutions less than desirable2 To minimie
'ossible bias6 onl1 clinic administrators6 nurse managers6 and medical directors
were consulted regarding stud1 design2 The 'ossibilit1 of the Hawthorne eect
notwithstanding6 we recommend that future researchers6 after collecting baseline
data6 see& the ongoing su''ort and involvement of inGuential health care wor&ers6
who can also serve as role models for others2
Another limitation is that observations werenMt tagged with health care wor&ersM
identities2 ItMs 'ossible that wor&ers with e5cellent hand h1giene habits were
observed with greater freuenc1 than those with 'oor habits6 thus s&ewing the data
and the statistical anal1sis2 Although health care wor&ers 'robabl1 'refer to remain
anon1mous during such observations6 we recommend recording and associating
wor&er identities with h1giene 'erformance so that statistical anal1ses can be as
accurate as 'ossible2
@ecause resource limitations led to interventional and follow!u' observation 'eriods
of dierent durations6 and because of Guctuating 'atient caseloads during these
'eriods6 not all health care wor&ers had the same number of o''ortunities for hand