1) Hand hygiene is important for reducing infection rates in hospitals, which average between 8-12% but can be higher in critical care units at 15-40%. 2) Compliance with hand hygiene has increased with the introduction of alcohol-based hand rubs but barriers still exist including a lack of peer pressure and leadership support for hand hygiene practices. 3) There is debate around which specific moments should require hand hygiene and how many moments are realistically feasible for healthcare workers to comply with, though the WHO guidelines of 5 moments provide a clear framework.

1. 13-11-18
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Prof. dr. Andreas Voss
MD, PhD, FSHEA, FESCMID, FISAC
President-Elect ISAC
Nijmegen, The Netherlands
Sorry, I know you expected ….
OF HAND HYGIENE
Average infection rate:
8 - 12 % of patients in acute care
hospitals in developed countries
Risk is higher in critical care (15-40 %)

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61.368 cfu/cm2
658 cfu/cm2
847 cfu/cm2
223 cfu/cm2
Source: McGinley et al. (1988) J. Clin. Microbiol. 26: 950-3.
nail: 89 cfu/cm2
Back of hand: 250 cfu/cm2
Compliance with Hand Hygiene
024681012141618
1841
1842
1843
1844
1845
1846
1847
1848
1849
1850
MaternalMortality
First
Second
Ignaz Philipp Semmelweis before and after his HH campaign Pittet D et al, Lancet 2000; 356: 1307-1312
12/94 12/95 12/96 12/97
Alcohol-based handrubbing
Handwashing (soap + water)

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Beware the Semmelweis’ effect of HH campaigns
It is not that we
don’t have the
stuff …
It is not knowledge …
It’s that I just
DON’T CARE
Certainly true with regard to HCWs and Infection Control.
More MDs
& RNs
Secretary
New HCW
CEO
MD
RNs
Certainly true with regard to Infection Control.
Less new
HCW
Secretary
CEO
MD
RNs
… don’t HCWs care to follow rules

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4
¤ Peer-pressure
¤ Patients involvement
¤ Leadership and role moddels
¤ Safety climate of the institution
¤ Make prominent members of the medical and nursing
staff leaders of your hand hygiene campaign
¤ Make your “rules” and “performance” public and visible
in the hospital
² monitors, posters OR internal communications
¤ Make people openly commit to the “rules”
² published statements, pins, …
¤ Folders
¤ Video’s
¤ Serious gaming
¤ Pin for HCW
² talk to me
Pilot who is
80% compliant
Almost Good, MD

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www.sciencexpress.org / 20 November 2008 / Page 1 / 10.1126/science.1161405
If rules aren’t followed …
§ Orderly alley:
33% littering
§ Graffiti alley:
§ 69% littering
¤ when people observe inappropriate behavior, this
weakens their concern for appropriateness
§ Orderly alley
§ No graffiti sign
§ Flyer on handlebar
§ avoid littering
¤ Short sleeves versus long sleeves ?
¤ Too many moments that need HH ?
¤ Alcohol tolerance ?
¤ Are five moments feasible or too many ?
¤ What is social contact ?
John et al. ICHE 2018:;39:233
¤ Randomized crossover trail involving simulated patient care
interactions to test pathogen transmission using Cauliflower
mosaic virus DNA
John et al. ICHE 2018:;39:233
Sleeves cuffs touched
mannequin in >70%
of cases and in >40%
the environment
John et al. ICHE 2018:;39:233
… go short sleeve

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¤On average, 134 (internal ICU) and 182 (surgical ICU) HHOs per
patient /12 h. Including nightshift (estimate) 218 (internal ICU)
and 271 (surgical ICU) HHOs per patient-day.
¤The average duration of hand disinfection was 7.6 s. Overall HH
compliance was 42.6%.
¤The time spent on HH was 8.3 (internal ICU) and 11.1 (surgical
ICU) min during the day shift for each patient for all HCWs
¤If nurses fully complied with guidelines, 58.2 (internal ICU) and
69.8 (surgical ICU) min would be spent on HH for each patient
during the day shift.
So what? HCWs can still
do thinks during HH:
e.g. move around or
think about next thing
to do
HH in the ICU
Supporting the 5 moments?
ABHR breeds
Superbugs
Pidot et al., Sci. Transl. Med. 10, eaar6115 (2018) 1 August 2018
v We tested alcohol tolerance of 139
hospital isolates of E. faecium
(1997 to 2015).
v E. faecium isolates after 2010
were 10-fold more tolerant to
killing by alcohol.
Potential to undermine the
effectiveness of ABHR
• Laboratory based study
• Australia uses a lot of alcohol for
surface disinfection – is that
equally or more important
• Importance of adequate ABHR use
WHO
Moments
1
2
3
4
5
Clear, robust and simple conceptual framework

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Less moments More moments
combined
deleted
Hand hygiene moments
(OPD)
Between patients
Before aseptic procedures
After contact with body
fluids
We don’t know, but less
My personal bias:
“ Many HCWs only know and want one moment*
namely when they think that it is needed”
¤ Should Social contacts be excluded as a
HH moment?
It presently includes moment
1 (before) and
4 (after)

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Internal Medicine
taking puls
Surgeon examines
forearm
Neurologist checking
biceps
Orthopedic surgeon checking
rotator cuff
Internal Medicine
taking puls
Surgeon examines
forearm
Neurologist checking
biceps
Orthopedic surgeon checking
rotator cuff
¤ Highest transfer of bacteria: hand-shake
¤ Lowest transfer of bacteria: fist bump
(high five was in the middle)
¤ Explanation: handshakes have the greatest
surface area in contact, for a longer time
Mela et al. Am J Infect Control 2014;42:916-7
Yoh doc

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¤ The microbes can’t
differentiate between
care and social contact …
A B
Which one is social contact skin?
For as long as you have no better, universally applicable and easy to memorize plan …