Photo by Piron Guillaume on Unsplash
Photo by Piron Guillaume on Unsplash

ICU healthcare workers should take note of these 3 steps to cleaner hands

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Healthcare workers on intensive care units - ICUs - are not regularly cleaning their hands during the care of patients, despite the risk of spreading infection, according to US research being presented at this year's European Congress of Clinical Microbiology & Infectious Diseases. At the same conference, Swiss researchers present their findings on a technique for hand washing which is shorter and simpler than current World Health Organization (WHO) recommendations, but just as effective. The WHO recommends a six step and 30 second technique, however the new findings suggest a three step and 15 second technique is just as good at killing bacteria. This could make it easier for healthcare workers to fit hand hygiene into their busy routines, they say.

Journal/conference: European Congress of Clinical Microbiology & Infectious Diseases

Organisation/s: Carver College of Medicine, USA and University Hospital Basel, Switzerland

Media Release

From: European Congress of Clinical Microbiology & Infectious Diseases

Study finds low hand hygiene compliance on ICUs

18-site US study finds healthcare workers less likely to clean their hands when moving from dirtier to cleaner tasks, increasing risk of transmitting infections to patients

Healthcare workers on intensive care units (ICUs) are regularly missing opportunities to clean their hands during the care of patients, despite its critical importance for infection control, according to new research being presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) in Amsterdam, Netherlands (13-16 April).

Worryingly, the authors say, hand hygiene compliance was lowest when moving from dirtier to cleaner patient care tasks than from cleaner to dirtier tasks, further increasing the risk of infection.

Interventions to improve hand hygiene compliance should teach healthcare workers to move from cleaner to dirtier tasks to minimize risks to patients, researchers say.


Despite concerted efforts to tackle the prevalence of healthcare associated infections, they are still one of the most common complications of hospital care, affecting around 30% of patients in ICUs in high-income countries [1]. These infections are associated with a substantial amount of ill health and death as well as considerable health service costs.

Hand hygiene is critical to preventing health care-associated infections, which kill about 100,000 people a year in the USA and cost about US$33 billion to treat.

According to the US CDC, roughly 1 in every 25 patients acquires a health care-associated infection during their hospital care, adding up to about 722,000 infections a year. Of these, 75,000 patients die of their infections.

Good hand hygiene is the most effective way of stopping the spread of bacteria and viruses. Few studies of hand hygiene compliance have evaluated the order in which healthcare workers perform patient care tasks, or whether the order in which they do these tasks affects hand hygiene compliance.

To provide more evidence, Professor Loreen Herwaldt from Roy J. and Lucille A. Carver College of Medicine, Iowa City, USA and colleagues analysed data from the Strategies to Reduce Transmission of Antimicrobial Resistant Bacteria in Intensive Care Units (STAR*ICU) study [2]. They assessed when healthcare workers did hand hygiene during their sequences of care, and identified factors associated with hand hygiene compliance as defined by the CDC/HICPAC Guideline for Hand Hygiene in Health-Care Settings [3].

Researchers linked consecutive tasks that individual healthcare workers performed into care sequences to identify "task transitions"-defined as two consecutive patient care tasks, such as touching a patient's intact skin followed by handling the patient's body fluids, and the intervening hand hygiene opportunities.

In total, 3246 hours of observation were recorded between December 2005 and August 2006 in ICUs in 18 centres across the USA.

Results showed that general compliance with hand hygiene was poor-with healthcare workers moving from dirtier to cleaner tasks during two-thirds (10,000) of the transitions recorded, and from cleaner to dirtier tasks in only a third of instances (5, 303).

Compared with nurses, physicians were 50% more likely to move from dirtier to cleaner tasks, whilst other healthcare workers (eg, radiology technicians, respiratory therapists) were more than twice as likely to do this [4].

Hand hygiene was less likely when gloves were worn, with healthcare workers more likely to move from dirtier to cleaner tasks when they used gloves.

Worse still, healthcare workers performed proper hand hygiene in just half the instances when moving from dirtier to cleaner tasks, and only around 43% of the instances when moving from cleaner to dirtier tasks.

"Our findings indicate that healthcare workers may inadvertently increase patients' risks for healthcare-associated infection by the direction in which they do tasks", says Professor Herwaldt. "We need to identify interventions that will help healthcare workers organise their work in a way that decreases this risk and also reduces their workloads."

The study has several strengths, say its authors, including that it is the first to evaluate complete sequences of patient care, to assess whether healthcare workers moved from cleaner to dirtier tasks or dirtier to cleaner tasks, and whether the order in which healthcare workers did tasks was associated with hand hygiene compliance.

This is an observational study so no firm conclusions can be drawn, and the authors point to several limitations including that healthcare workers' behaviour may have been influenced by the presence of observers. They also note that prospective studies are needed to validate the findings.

Notes to editors:

[1] https://apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf?sequence=1

[2] STAR*ICU is a randomised trial examining whether rates of colonization and infection with two resistant Gram positive bacteria-methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococci are lower in adult ICUs that use an intensive infection control strategy plus standard care compared to ICUs that use standard care alone .

[3] https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

[4] Nurses dirtier to cleaner tasks: 7746/12284, 63%; cleaner to dirtier: 4538/12284, 40%. Physicians dirtier to cleaner: 1142/1600, 71%; cleaner to dirtier: 458/1600, 40%. Other healthcare workers dirtier to cleaner: 1112/1419, 78%; cleaner to dirtier: 307/1419, 22%.

The authors declare no conflicts of interest.

This press release is based on poster presentation 2680 at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID). The material has been peer reviewed by the congress selection committee. There is no full paper at this stage, but the authors are happy to answer your questions. The research has not yet been submitted to a medical journal for publication.

For full abstract click here

For full poster click here

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Applying hand rub with three steps for 15 seconds as effective at reducing bacteria as WHO-recommended 6 steps for 30 seconds

A shortened 15-second application time and a simpler three-step technique for use of alcohol-based hand rub is as effective in reducing bacteria as the 30-second application and six-step technique recommended by WHO, and could improve hand hygiene compliance.

The new research is being presented at this year's European Congress of Clinical Microbiology & Infectious Diseases (ECCMID) in Amsterdam, Netherlands (13-16 April).

Hand hygiene is the single most effective thing healthcare workers can do to reduce the spread of infectious diseases, but there is limited evidence on which technique is most effective.

WHO recommends a six-step 'how to hand rub' technique for using alcohol-based hand rub [1]. However, adherence to all six steps is low and previous research indicates that a simplified three-step hand rub technique is superior to the six-step technique in terms of compliance and killing bacteria [2].

The current recommended application time for hand rubs is 30 seconds. However, recent research suggests that 15 seconds of hand rubbing could be just as effective at reducing bacteria. [3]

In this randomised cross-over trial, Dr Sarah Tschudin-Sutter and colleagues from University Hospital Basel, Switzerland investigated combining the simpler three-step technique with a shorter application time of 15 seconds.

20 healthy volunteers (aged 18 to 51 years) were randomly assigned to rub their hands by following four different techniques-the six-step hand hygiene technique for 30 seconds; the six-step hand hygiene technique for 15 seconds; the three-step hand hygiene technique for 30 seconds; and the three-step hand hygiene technique for 15 seconds. Because this was a randomised crossover trial, each participant was assigned to all four groups.

Results showed that a shorter application time of 15-second rubs was as effective at reducing bacterial counts on the hands of participants compared to the recommended 30-second hand rub, irrespective of the hand hygiene technique [see table].

"The time pressure and heavy workload experienced by healthcare workers reduces compliance with hand hygiene standards. Our findings suggest that shortening hand rubbing time and simplifying the technique for use of hand rub could be a safe alternative that is easier to fit into their busy routine, could enhance the overall quality of hand hygiene performance, and have a positive effect on adherence", says Professor Tschudin-Sutter. "Further studies are needed to validate the performance of the shorter application time in everyday clinical practice."

The authors point to several limitations, the most important being that the study assesses the efficacy of the two different hand hygiene techniques and two different application times in an experimental setting, so the results cannot be extrapolated to a clinical setting. They also note that they measured the reduction of bacterial counts, therefore conclusions cannot be made about the impact of different hand hygiene techniques on transmission of pathogens.

Notes to editors:

[1] https://www.who.int/gpsc/5may/tools/9789241597906/en/

[2] https://www.sciencedirect.com/science/article/pii/S1198743X16306644

[3] https://www.cambridge.org/core/journals/infection-control-and-hospital-epidemiology/article/hand-hygiene-with-alcoholbased-hand-rub-how-long-is-long-enough/B580E66A5C5C4C19DCDE43261FA7A181

The authors declare no conflicts of interest.

This press release is based on poster presentation 1786 at the European Congress of Clinical Microbiology & Infectious Diseases (ECCMID). The material has been peer reviewed by the congress selection committee. There is no full paper at this stage, but the authors are happy to answer your questions. The research has not yet been submitted to a medical journal for publication.

For full abstract click here

For full poster click here

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