EDITORIALS
It Is Time for Action: Improving Hand Hygiene in Hospitals
A s delivery of medical care moves increasingly
to outpatient settings, patients who require
hospitalization have more acute illness and height-
ened susceptibility to nosocomial infections. Such
infections result in substantial morbidity and are
estimated to cause or contribute to 80 000 deaths
annually in the United States (1). Many nosocomial
infections are caused by pathogens transmitted from
one patient to another by way of health care work-
ers who have not washed their hands between pa-
tients (2, 3). Although Semmelweis (4) demon-
strated 150 years ago that mortality related to
hospital-acquired infections could be reduced when
health care personnel washed their hands with an
antiseptic solution between patient contacts, compli-
ance of health care workers with recommended
handwashing practices remains unacceptably low,
often in the range of 30% to 50% (5– 8). Even the
current spread of multidrug-resistant pathogens in
hospitals has not compelled health care workers to
wash their hands as frequently as recommended (8).
Why is compliance with recommended hand-
washing practices so poor? Many factors are in-
volved, including lack of awareness among person-
nel about the situations that call for handwashing,
personal and organizational attitudes toward hand-
washing, and various logistical barriers (6, 9, 10).
Many health care workers do not wash their hands
after “low-risk” patient contacts (5, 7), probably
because they are not aware that their hands may
become contaminated while measuring the patient’s
blood pressure or pulse, touching intact areas of the
patient’s skin, or lifting the patient (2). For reasons
that are not clear, handwashing frequency varies by
type of health care worker and by clinical service,
and personnel who are required to wear only gloves
when caring for patients do not wash their hands as
often as those who are required to wear both a
gown and gloves (8, 11). When health care workers
were asked which factors deter them from washing
their hands as recommended, they cited 1) skin
irritation and dryness caused by frequent handwash-
ing and 2) being too busy (9, 10). Inconvenient
This paper is also available at http://www.acponline.org.
19 January 1999
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19925/ by a NYU Medical Center Library User on 03/24/2017
location of sinks is considered a less important de-
terrent.
In this issue, Pittet and colleagues (12) report the
results of a large, well-designed observational study
of factors affecting compliance of health care work-
ers with recommended handwashing policies. Sev-
eral aspects of their study are particularly notewor-
thy. More than 2800 opportunities for handwashing
were observed on multiple wards during all shifts
and on all days of the week, and multiple variables
that might influence handwashing were recorded
during each observation period. Multivariate analy-
sis was performed to establish the independent con-
tribution of variables to compliance with handwashing.
The investigators found that the average level of
compliance with recommended handwashing prac-
tices was 48%, which is within the range of compli-
ance noted in previous observational studies (5– 8).
Compliance was higher among nurses than among
physicians and other health personnel and varied by
ward location—findings that confirm previous obser-
vations (5–7). Several new findings of particular
concern include the fact that handwashing compli-
ance was worse before high-risk procedures were
performed; in intensive care units, where highly sus-
ceptible patients are located; and with increasing
intensity of patient care, that is, when nurses were
expected to wash their hands the most frequently
(12). Although nurses have often reported that “be-
ing too busy” is a major deterrent to handwashing
(9, 10), Pittet and colleagues are the first to docu-
ment that a high workload is associated with poor
compliance with handwashing. Low compliance dur-
ing care of patients in intensive care units may help
explain why the spread of resistant pathogens, such
as methicillin-resistant Staphylococcus aureus and
vancomycin-resistant enterococci, has continued to
increase in many hospitals despite appropriate writ-
ten infection control policies.
In addition to washing their hands less frequently
than they should, health care workers often wash
their hands for an average of only 8.5 to 9.5 seconds
(7, 13). Although a minimum of 10 seconds is rec-
ommended, data on the efficacy of soap and water
handwashing often are based on protocols that re-
quire 30 seconds of handwashing. Because washing
• Annals of Internal Medicine • Volume 130 • Number 2 153
 the hands with plain soap and water for less than 10
to 15 seconds has limited efficacy (14, 15), this
aspect of handwashing compliance also requires re-
newed attention.
The report by Pittet and colleagues (12) provides
new insights into our understanding of current
handwashing practices and should serve as a stimu-
lus for hospitals to develop new strategies for im-
proving hand hygiene practices. The term hand hy-
giene is used here to connote cleansing of hands,
either by washing them with unmedicated or medi-
cated soap and water or by performing antisepsis
with a waterless antiseptic agent.
A multidisciplinary approach that addresses both
logistical barriers and behavioral issues that ad-
versely influence handwashing is necessary (16, 17).
One of the major barriers is that frequent hand-
washing with unmedicated or medicated soap and
water often causes skin irritation and dryness, which
deter personnel from washing their hands as fre-
quently as recommended (9, 10). Potential solutions
to this problem include having personnel apply skin
protectants to their hands or providing personnel
with hand hygiene products that minimize skin irri-
tation and dryness (9). For example, several studies
suggest that alcohol-based hand rinses and gels con-
taining emollients may cause less dermatitis than
handwashing with soap and water (15; Boyce JM.
Unpublished data). Such preparations are very effi-
cacious in removing bacterial flora from the hands
of personnel and have been adopted for hand anti-
sepsis by health personnel in several European
countries (15, 18).
Reducing the time required for handwashing may
make it feasible for caregivers with high workloads
to wash their hands more frequently. Because find-
ing a sink and washing the hands with soap and
water require more time than using a waterless
antiseptic agent that is available at each patient’s
bedside (19), placement of an alcoholic rinse or gel
(or similar product) near each patient’s bed and at
other locations on hospital wards should be evalu-
ated to determine whether this strategy results in
improved hand hygiene (12). Further controlled
studies are also needed to determine whether fre-
quent use of alcohol-based hand rinses and gels by
personnel will lead to improved control of nosoco-
mial infections.
Hospital administrators should strive to create an
organizational atmosphere in which adherence to
recommended hand hygiene practices is considered
an integral part of providing high-quality care. For
such an approach to be successful, hospitals must
provide visible support and sufficient resources for
new programs. Hospitals need to develop and im-
plement innovative educational and motivational
programs tailored to specific groups of health per-
154 19 January 1999 • Annals of Internal Medicine
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19925/ by a NYU Medical Center Library User on 03/24/2017
sonnel. The strategies that are most appropriate for
nurses, for example, may not achieve the same de-
gree of success with physicians or with other health
personnel (16). Convincing department heads or
other opinion leaders to wash or disinfect their
hands as recommended may be important in mod-
ifying physician behavior (16).
Monitoring compliance of health care workers
and providing them with frequent feedback on their
performance has led to improved handwashing prac-
tices in short-term studies (20). Hospitals should
make this strategy a high priority (17). Newer and
more efficient methods for monitoring hand hygiene
practices, such as the mechanical or electronic
methods used by some restaurants and fast-food
establishments, should be evaluated in hospital set-
tings. Finally, recording adherence to recommended
hand hygiene practices by individual health care
workers and including this record as part of an
annual personnel evaluation or medical staff reap-
pointment process should be evaluated in clinical
studies as another potential strategy for improving
hand hygiene among caregivers.
Careful handwashing or antisepsis between care
of patients remains one of the most important mea-
sures for preventing the spread of pathogens in
hospitals. After tolerating poor handwashing com-
pliance for 150 years, it is time for hospitals and
health care professionals to get serious about im-
proving hand hygiene in hospitals.
John M. Boyce, MD
Miriam Hospital
Providence, RI 02906
Requests for Reprints: John M. Boyce, MD, Miriam Hospital, 164
Summit Avenue, Providence, RI 02906.
Ann Intern Med. 1999;130:153-155.
References
1. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial
infections: morbidity, mortality, cost, and prevention. Infect Control Hosp
Epidemiol. 1996;17:552-7.
2. Casewell M, Phillips I. Hands as route of transmission for Klebsiella species.
Br Med J. 1977;2:1315-7.
3. Larson E. A causal link between handwashing and risk of infection? Exami-
nation of the evidence. Infect Control Hosp Epidemiol. 1988;9:28-36.
4. Carter KC, tr. The Etiology, Concept, and Prophylaxis of Childbed Fever.
Madison: Univ of Wisconsin Pr; 1983:1.
5. Albert RK, Condie F. Hand-washing patterns in medical intensive-care units.
N Engl J Med. 1981;24:1465-6.
6. Larson E. Compliance with isolation technique. Am J Infect Control. 1983;
11:221-5.
7. Meengs MR, Giles BK, Chisholm CD, Cordell WH, Nelson DR. Hand
washing frequency in an emergency department. J Emerg Nurs. 1994;20:
183-8.
8. Slaughter S, Hayden MK, Nathan C, Hu TC, Rice T, Van Voorhis J, et
al. A comparison of the effect of universal use of gloves and gowns with that
of glove use alone on acquisition of vancomycin-resistant enterococci in a
medical intensive care unit. Ann Intern Med. 1996;125:448-56.
9. Larson E, Killien M. Factors influencing handwashing behavior of patient
care personnel. Am J Infect Control. 1982;10:93-9.
10. Zimakoff J, Kjelsberg AB, Larsen SO, Holstein B. A multicenter question-
naire investigation of attitudes toward hand hygiene, assessed by the staff in
• Volume 130 • Number 2
 fifteen hospitals in Denmark and Norway. Am J Infect Control. 1992;20:58-
64.
11. Pettinger A, Nettleman MD. Epidemiology of isolation precautions. Infect
Control Hosp Epidemiol. 1991;12:303-7.
12. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a
teaching hospital. Members of the Infection Control Program. Ann Intern
Med. 1999;130:126-30.
13. Quraishi ZA, McGuckin M, Blais FX. Duration of handwashing in intensive
care units: a descriptive study. Am J Infect Control. 1984;12:83-7.
14. Larson EL, Eke PI, Wilder MP, Laughon BE. Quantity of soap as a variable
in handwashing. Infect Control. 1987;8:371-5.
15. Rotter ML. Hand washing and hand disinfection. In: Mayhall CG, ed. Hos-
pital Epidemiology and Infection Control. Baltimore: Williams & Wilkins; 1996:
1052-68.
16. Seto WH. Staff compliance with infection control practices: application of
19 January 1999
Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/19925/ by a NYU Medical Center Library User on 03/24/2017
behavioural sciences. J Hosp Infect. 1995;30 Suppl:107-15.
17. Larson EL. APIC guideline for handwashing and hand antisepsis in health
care settings. Am J Infect Control. 1995;23:251-69.
18. Larson EL, Eke PI, Laughon BE. Efficacy of alcohol-based hand rinses under
frequent-use conditions. Antimicrob Agents Chemother. 1986;30:542-4.
19. Voss A, Widmer AF. No time for handwashing!? Handwashing versus alco-
holic rub: can we afford 100% compliance? Infect Control Hosp Epidemiol.
1997;18:205-8.
20. Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW. Increasing ICU
staff handwashing: effects of education and group feedback. Infect Control
Hosp Epidemiol. 1990;11:191-3.
© 1999 American College of Physicians–American Society of Internal
Medicine
• Annals of Internal Medicine • Volume 130 • Number 2 155