Research for infection protection

Multimodal hand hygiene programmes to promote compliance

Inadequate hand disinfection compliance levels of around 50 % are a great challenge when it comes to preventing nosocomial infections. And the obstacles to complying with hand hygiene protocols are very diverse. There is a widespread consensus among hygiene experts worldwide that strategies to improve hand hygiene need to consider the differing compliance barriers. According to the current state of knowledge, multimodal hand hygiene programmes that offer potential solutions at many different levels have a chance of success.

Organisational and psychological compliance barriers

According to RKI (Robert Koch-Institute), the factors that have a negative influence on hand disinfection as indicated include [3]:

  • “limited availability of hand disinfectant dispensers
  • missing role model function, e.g. of physicians
  • skin irritations, insufficient skin care
  • frequent interruptions of operating procedures
  • high workload
  • subjective perception of risks of infection for patients
  • subjective perception of risks of infection for staff
  • different standards of knowledge among the staff and partly lack of awareness of the importance of hand hygiene.”

Instruments to increase compliance

One efficient strategy is to eliminate negative influences and promote positive factors with targeted measures. Multimodal hand hygiene programmes focus on the following key points [3]:

  • implementing alcohol-based hand disinfection as gold standard regarding efficacy and skin tolerability
  • making sure that hand disinfectants are available at the point of care or in all situations that are relevant to patient safety
  • clear recommendations for action in terms of when (5 Moments model) and how (avoidance of gaps in coverage) to disinfect hands
  • role model function and support to clinic management
  • education and training
  • observation and feedback on hand hygiene behaviour.

Huge demand for sustainable concepts

As many as 20 studies, which were analysed in a review, demonstrate that multimodal hand hygiene programmes enhance hand hygiene compliance successfully [4].
The focus was, for example, on the availability of hand disinfectants and promoting role models and the personal accountability of staff. Furthermore, it could be shown that multimodal hand hygiene programmes contribute to reducing nosocomial infection, for example catheter-associated bloodstream infections.

However, experts emphasise that interventions have a greater success when they are repeated and conducted regularly. Single programmes are not able to change the behaviour in the long run – an essential factor for a constantly high compliance rate.

Schwadtke et al., for example, observed declining compliance rates at the Hanover Medical School (MHH), partly even under the starting level, after the compliance had been increased with the help of interventions [5]. During the first two years, the compliance had increased from 53 % among physicians and 57 % among nursing staff to 64 % and 71.3 %, respectively. In the subsequent years (2011-2013), the compliance rates decreased again, partly even under the initial level (physicians: 48.4 %; nursing staff: 55.8 %).

Hence, interventions that lead to a sustainable improvement of a right or correct hand hygiene behaviour are needed. A new approach here is the Hand Hygiene Evolution Concept from HARTMANN. The programme combines scientifically proven sets of measures with a continuous specialist support on site: the individual hygiene status is considered to support clinics and units in improving their hand hygiene compliance – step by step. The individual approach, new technologies and continuous support ensure a sustainable effect on the compliance.

Achieving sustainable compliance improvements step by step.

Modul Basic
Consumption measurement
Training washing vs. hand disinfection

Modul 1
Needs assessment
Study supplement
Expert reports

Modul 2
(Animated) Dispenser Checklist
Dispenser placement consulting
Reminders at the workplace

Modul 3
Innovative training devices
Training of healthcare workers
Reminders at the workplace

Modul 4
5 Moments of Hand Hygiene:
Training of healthcare workers
Reminders at the workplace

Modul 5
Tablet based Hand Hygiene Monitoring
Traning of Healthcare workers

Modul 6
Hygienically optimised procedures (SOPs)
Tablet based monitoring and feedback
Training of healthcare workers
Reminders at workplace

The Hand Hygiene Evolution Concept: from the availability of hand disinfectants and dispensers, extensive education and training to the improvement of clinical work processes.

1. World Health Organization (2005): Safe lives. Clean your hands. Guide to Implementation. A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy.
2. Empfehlung des Arbeitskreises Krankenhaus- und Praxishygiene der AWMF. Händedesinfektion und Händehygiene – AWMF-Register Nr. 029/027, S1-Leitlinie. In: HygMed 2015; 40 - 9 Seite 369ff
3. Robert Koch-Institut. Die hygienische Händedesinfektion – ein Beitrag zum Internationalen Tag der Händehygiene am 5.5. Epidemiologisches Bulletin Nr. 17., 29. April 2013.
4. Zingg et al. Hospital organisation, management, and structure for prevention of health-care-associated infection: a systematic review and expert consensus. Lancet Infect Dis. 2015 Feb;15(2):212-224.
5. Schwadtke L. et al. Hygienische Händedesinfektion – Leitlinien-Compliance auf Intensivstationen eines Universitätsklinikums mit chirurgischem Schwerpunkt. Dtsch Med Wochenschr 2014; 1390: 1341–1345.

Want to know more about the Evolution Concept? Then please click here.

Read more about the successful practical implementation of hand hygiene programmes.

Please click here to read study abstracts on multimodal programmes.