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Patient-centered hand hygiene: The next step in infection prevention


Abstract and Figures

Hand hygiene has been recognized as the most important means of preventing the transmission of infection, and great emphasis has been placed on ways to improve hand hygiene compliance by health care workers (HCWs). Despite increasing evidence that patients' flora and the hospital environment are the primary source of many infections, little effort has been directed toward involving patients in their own hand hygiene. Most previous work involving patients has included patients as monitors or auditors of hand hygiene practices by their HCWs. This article reviews the evidence on the benefits of including patients more directly in hand hygiene initiatives, and uses the framework of patient-centered safety initiatives to provide recommendations for the timing and implementation of patient hand hygiene protocols. It also addresses key areas for further research, practice guideline development, and implications for training of HCWs.
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Review article
Patient-centered hand hygiene: The next step in infection prevention
Timothy Landers RN, PhD
*, Said Abusalem RN, PhD
, Mary-Beth Coty RN, PhD
, James Bingham MS
College of Nursing, The Ohio State University, Columbus, OH
School of Nursing, University of Louisville, Louisville, KY
GOJO Industries, Inc, Akron, OH
Key Words:
Patient safety
Patient participation
Patient empowerment
Carriage return
Health careeassociated infection
Hand hygiene has been recognized as the most important means of preventing the transmission of
infection, and great emphasis has been placed on ways to improve hand hygiene compliance by health
care workers (HCWs). Despite increasing evidence that patientsora and the hospital environment are
the primary source of many infections, little effort has been directed toward involving patients in their
own hand hygiene. Most previous work involving patients has included patients as monitors or auditors
of hand hygiene practices by their HCWs. This article reviews the evidence on the benets of including
patients more directly in hand hygiene initiatives, and uses the framework of patient-centered safety
initiatives to provide recommendations for the timing and implementation of patient hand hygiene
protocols. It also addresses key areas for further research, practice guideline development, and impli-
cations for training of HCWs.
Copyright Ó2012 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.
In efforts to prevent infection and improve patient safety, one
area of priority focus has been the improvement of hand hygiene
compliance health care workers (HCWs). This focus has included
signicant wide-reaching initiatives, including the World Health
Organization (WHO) 5 Moments for Hand Hygiene and the Centers
for Disease Control and Prevention (CDC) hand hygiene guide-
Continuing technological innovation has resulted in
improved monitoring options to evaluate hand hygiene activity,
and the widespread use of alcohol-based hand rubs (ABHRs) have
increased the availability and tolerability of hand hygiene products.
To date, initiatives aimed at improving hand hygiene have primarily
targeted HCW practices, without full consideration of the patient
and the patients caregiver network. However, emerging evidence
suggests that most infections occur as a result of bacteria present
within the patientsownora and bacteria present on surfaces
within the health care environment. Because patients and HCWs
touch surrounding items and surfaces, including patients in the
performance of hand hygiene could decrease pathogen trans-
mission and the risk of health careeassociated infections (HAIs).
In this review, we provide an overview of previous efforts to
include patients in hand hygiene activities, highlight the importance
of patient hand hygiene as a means to prevent infection, and frame
patient hand hygiene in the context of a patient-centered safety
initiative. After reviewing current approaches, we advocate for the
development and implementation of strategies to include patient
hand hygiene as part of routine care. Although the role of the patient
in hand hygiene as a means to prevent infection has been recom-
mended by others, this review suggests that patient hand hygiene
remains an underused method of preventing HAIs. Existing clinical
practice guidelines, recommendations for clinical application, and
implications for HCW training and education are identied.
For the purpose of this review, patient hand hygiene is dened
as hand hygiene practices performed by the patient on his or her
own hands, including handwashing, use of ABHRs, and use of dis-
infecting wipes. In certain situations, this care may need to be
provided to patients by professional caregivers or family members.
It is well documented that the hands of HCWs are involved in the
transmission of health careeassociated pathogens. Transmission via
the hands of HCWs accounts for a high proportion of HAIs, and
improvement of hand hygiene practices has been linked to reduced
transmission of health careeassociated pathogens and reduced
infection rates.
Current evidence clearly indicates that increasing
hand hygiene compliance directlyresults in a reduction in HAIs, and
* Address correspondence to Timothy Landers, RN, PhD, College of Nursing, The
Ohio State University, 1585 Neil Avenue, Columbus, OH 43210-1216.
E-mail address: (T. Landers).
Publication of this article was made possible by GOJO Industries, Inc.
Conict of interest: T.L., M.-B.C., and S.A. received an honorarium or educational
grant from GOJO Industries for their participation in the Consortium. J.B. is an
employee of GOJO Industries.
Contents lists available at ScienceDirect
American Journal of Infection Control
journal homepage:
American Journal of
Infection Control
0196-6553/$36.00 - Copyright Ó2012 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
American Journal of Infection Control 40 (2012) S11-S17
both the CDC and the WHO consider hand hygiene the most impor-
tant measure for preventing HAIs and the spread of pathogens.
To date, hand hygiene guidelines and policies have focused
primarily on HCWs.
In light of strong evidence supporting the
role of HCW hands in HAI transmission, the major focus of studies
regarding the role of patients in hand hygiene has been on patients
as monitors or auditors of HCW hand hygiene. The primary goal of
including patients in hand hygiene has been to improve HCW hand
hygiene compliance, and various campaigns have been created to
involve patients as monitors of hand hygiene.
In the United States, the Joint CommissionsSpeak Upprogram
urges patients to take a role in preventing health care errors by
becoming active, involved, and informed participants in the health
care team.
The Joint Commission publication Five Things You Can
Do to Prevent Infectionsinstructs patients to ask HCWs to clean
their hands before any treatments and provides recommendations
on when and how patients should clean their own hands.
Internationally, various campaigns have been created to include
patients as observers of hand hygiene. In 2009, the Save Lives:
Clean Your Handscampaign, an extension of the 2005 Clean Care
is Safer CareWHO Patient Safety Challenge, was launched to
stimulate international efforts in promoting hand hygiene compli-
ance among HCWs in an endeavor to reduce HAIs.
The Save
Lives campaign, which promoted My 5 Moments for Hand Hygiene
for HCWs, also recommended that patients ask HCWs to wash their
hands in an effort to improve hand hygiene practices among
In the United Kingdom, the National Patient Safety Agency
initiated the Cleanyourhandscampaign, aimed at best practices in
hand hygiene compliance among HCWs, with an emphasis on
performing hand hygiene at the right time and in the right
A central message of this campaign was Its OK to ask,
encouraging patients to ask HCWs whether they had performed
hand hygiene before providing patient care.
Canadas Patient
Safety Institute initiated a national hand hygiene campaign, Stop!
Clean Your Hands,which specied 4 moments for HCWs to wash
their hands and addressed the patients role in hand hygiene.
The literature suggests that patient participation programs can
help to increase HCW hand hygiene compliance. For example, 2
studies found that when patients were encouraged to ask HCWs if
they performed hand hygiene, soap consumption increased by
and 50%,
reecting increased hand hygiene among HCWs.
Similarly, McGuckin et al
reported a 94% increase in hand hygiene
events when patients asked whether HCWs performed hand
hygiene. Although initiatives that engage patients as monitors of
hand hygiene have yielded positive results, the long-term sustained
effect on hand hygiene compliance and impact on infection rates
remain unknown.
A positive byproduct of these efforts has been the inclusion of
patients in health care activities and decisions related to their own
safety. Empowering patients to become partners in ensuring safe
care has been described as patient collaboration, patient involve-
ment, partnership, and patient-centered care. Studies have shown
that patients are willing to participate in hand hygiene programs,
but that their participation often depends on the type of program
and how it was developed.
For example, Longtin et al
that of 198 patients asked to participate in the promotion of HCW
hand hygiene compliance, approximately 75% did not feel
comfortable asking their nurse or physician to perform hand
hygiene. However, when HCWs invited patients to ask about HCW
hand hygiene, 83% of patients felt comfortable asking nurses and
78% felt comfortable asking physicians.
However, despite
patientsapparent willingness to participate, McGuckin and
reported that only 60%-70% of patients actually ask
their HCW about performing hand hygiene.
Including patients in their care has been used as a strategy to
promote medication adherence, improve patient safety after
surgery, and foster open communication with health care
A variety of factors inuence the willingness of HCWs
and patients to share responsibility for patient care (Fig 1). Factors
that inuence patient participation in patient safety include
behavioral aspects, attitudes, norms, and beliefs, as well as
perception of the risk of infection
; for example, it has been sug-
gested that having an extrogverted personality may increase
a patients willingness to participate in hand hygiene moni-
However, only 55% of highly extroverted patients in one
study reported that they would always ask their nurse about hand
Other patient factors associated with willingness to act
as monitors of HCWs hand hygiene activities are shown in Table 1.
The trend of including patients in safety initiatives is growing.
Major organizations involved in patient safety, including Health
Canada and the Joint Commission, have published brochures that
instruct patients on how to help prevent care errors through
appropriate communication and behaviors.
Including patients
as active participants in their care appears to have much potential
for improving patient safety.
Patient participation in
disease-management programs has been shown to be effective for
asthma and type 2 diabetes, resulting in better disease control and
improved patient outcomes.
A review of patientsability to
inuence physician decisions found that patients who asked for
a prescription were 3 times more likely to get it than those who did
not, and patients who asked for a referral were 4 times more likely
to receive one than those who did not.
Finally, a systematic
review of patient-centered safety research by Schwappach et al
suggested that successful interventions had some common key
features: they directly engaged the patientsperspectives, used
multiple measures to promote complex behavior change, empha-
sized the patients at the center of care, and encouraged staff to
engender and maintain a trusting relationship with their patients.
Thus, patient hand hygiene can serve as an important measure to
prevent infection, and also may advance broader patient engage-
ment in safety initiatives.
Increasing patient safety through increased patient engagement
and empowerment presents a potential paradox.
Along with the
desire to improve patient outcomes, there is concern that patients
may feel an undue burden for their own safety in these campaigns,
and that such perceptions could undermine trust.
Fig 1. Conceptual model of factors inuencing patient participation in preventing errors. (Reprinted with permission.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17S12
Despite this paradox, evidence suggests that patient participa-
tion does yield positive results, and that most patients are willing
and able to participate in their own hand hygiene. Accumulating
evidence suggests that attention to patient hand hygiene can play
a critical role in preventing the spread of infection, because patients
can be involved in the spread of pathogens through multiple routes.
Patients may be involved in the transmission of pathogens and
HAI risk in 4 signicant ways: through the transfer of pathogens
within the environment, by directly spreading pathogens to other
patients, by cross-contamination through direct contact with
HCWs, and by increasing their own risk of infection from an
endogenous source. Organisms residing on the skin can be trans-
ferred by hands to other surfaces; thus, patientshands can transfer
pathogens to HCWs, to their surrounding environment, to other
patients, and to high-risk areas on their own bodies, such as inci-
sion sites, healing surgical wounds, access sites of invasive and
intravascular devices, and the mouth.
This underscores the
importance of patients in the carriage and transmission of organ-
isms capable of causing HAIs.
In the hospital environment, patients diagnosed with HAIs,
such as infections with Clostridium difcile, vancomycin-resistant
Enterococcus (VRE), and methicillin-resistant Staphylococcus aureus
(MRSA), contaminate their surrounding environment.
particular, bacterial contamination has been detected on various
high-touch environmental surfaces, such as bed rails, bedside tables,
call buttons, toilet seats, and phones in patient rooms.
addition, asymptomatic carriers of health careeassociated patho-
gens also contribute to contamination of the hospital environment.
In the case of C difcile, patients may continue to shed spores into the
environment for 5-6 weeks after symptoms have resolved and
antibiotic treatment has been stopped.
Health careeassociated
pathogens can survive on inanimate hospital surfaces for months
and can be transferred via hands to other objects.
Cleaning and disinfection regimens do not always eliminate
pathogens from surfaces.
The presence of soil combined with
the need for proper surface coverage and adequate disinfectant
contact time makes proper disinfection a challenge in health care
settings. Although existing policies may contain appropriate
recommendations, actual disinfection practices may be inconsis-
tent within an institution. Consequently, pathogens shed into the
environment might persist despite disinfection and/or cleaning
regimens. As a result, a patient is at greater risk of acquiring an
antibiotic-resistant organism when admitted to a room previously
occupied by a patient infected with such a pathogen.
presence of pathogens in the patient environment make the
patientshands an important vehicle for transmission of organisms
to HCWs, other susceptible patients, environmental surfaces, or
even their own wounds or invasive devices.
Patients not only contaminate their environment with the
organisms that they may be carrying, they also can acquire path-
ogens from the environment and through contact with HCWs. It is
widely believed that many patients who acquire an HAI become
infected with strains originating from their own skin and ora.
Antibiotic-resistant organisms such as VRE, MRSA, Acineto-
bacter spp, C difcile, and Pseudomonas aeruginosa can be detected
on the skin in such areas as the groin, arms, abdomen, chest,
and hands.
Organisms residing on the skin can be readily
transferred by the hands to other surfaces,
again highlighting
the importance of patients in the carriage and transmission of
health careeassociated pathogens. There is also strong evidence
that patients may play a more important role than HCWs in path-
ogen transmission to other patients. For example, patient-indexed
cases of norovirus were associated with signicantly more cases
compared with staff-indexed cases (39.5 cases/patient-indexed vs
24.3 cases/staff-indexed), and exposure to an infected patient was
associated with a markedly increased risk of developing norovirus
infection compared with exposure to an infected staff member
(odds ratio, 4.8).
Thus, patients can play a key role in transmitting
pathogens to other patients.
Even though a complete picture of the role of patientshands in
the transmission of HAIs has not yet emerged, the literature strongly
reinforces the need for patient hand hygiene programs. This appears
to be true for patients with known HAIs as well as those otherwise
assumed to be uninfected; for example, in one study, fecal coliform
colonization was detected in 20.4% of patients in a general medical
ward and 35.8% of patients in a spinal ward.
Hospitalized patients
are more likely to have antibiotic-resistant organismsas part of their
normal ora compared with outpatients.
One study reported that
after 7 days in a hospital, 62% of all patients were positive for en-
terococcal hand contamination, compared with 10.7% of nonhospi-
talized adults.
Similarly, Istenes et al
found that 39% of patients
had at least one hospital-associated pathogen on their hands within
48 hours of admission. Althoughwhether these patientshands were
contaminated on admission was unknown, this study supports
patient hands as an important source of contamination. Taken
together, these studies suggest that the entire patient population
should be included in hand hygiene. Patient hand hygiene may
prove to be a critical aspect in HAI prevention, given the role of
infected and even uninfected patients in transmitting pathogens to
Table 1
Factors associated with patient willingness to participate in prompting HCWs to perform hand hygiene
Factor Reference
Factors that may inuence a patients willingness to participate in hand hygiene monitoring
Extroverted personality Longtin et al
; Duncanson and Pearson
Internal control belief (that he or she can control HCWshand hygiene behavior) Davis et al
Age Duncanson and Pearson
Awareness of severity of HAIs Longtin et al
; Davis et al
Invitation from HCW to ask about hand hygiene Longtin et al
Religious beliefs Longtin et al
Provision of alcohol-based hand sanitizer to patient Pittet et al
Factors that may limit a patients willingness to participate in hand hygiene monitoring
Assumption that HCWs had already cleaned their hands Pittet et al
Older age Duncanson and Pearson
Feeling uncomfortable asking about hand hygiene Longtin et al
Trust that HCW would perform hand hygiene Pittet et al
Role of HCW (physician vs nurse) McGuckin et al
Factors not shown to be related to willingness to participate
Previous hospitalizations, infection, or isolation Duncanson and Pearson
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17 S13
the environment, to HCWs and to other patients, and through
infections originating from their own ora.
Regarding the reported discomfort many patients experience
monitoring HCW hand hygiene, initiatives that focus on patient
hand hygiene may help them overcome this discomfort and allow
them to more fully engage as active participants in other aspects of
their care as well in HAI reduction. Literature focusing on the
engagement of patients in their own hand hygiene is sparse,
however. As early as 1983, Lawrence
speculated on the impor-
tance of patient hand hygiene, and in 1995, Burnett et al
gested that patient hand hygiene could play an important role in
infection control. Yet, only 10 years later, a literature review by
Baneld and Kerr
reported a dearth of studies focusing on patient
hand hygiene and urged an increased focus on this topic.
This call to action has remained largely unaddressed, however.
Few studies have examined the possible impact of patient hand
hygiene practices on the reduction of HAIs, although the existing
reports are compelling.
In one notable study, Gagne et al
uated a comprehensive approach that included greeting patients
and visitors at the door, explaining the importance of hand hygiene,
and instruction on the proper use of ABHRs. The program was well
received by patients and families, with virtually allparticipating,
and produced a 51% reduction in the total number of MRSA infec-
tions and a 71% decrease in overall mortality from MRSA over
a 1-year period. Interestingly, implementing the patient-centered
hand hygiene program was also associated with an w30% increase
in HCWscompliance. Grabsch et al
also indicate that patient hand
hygiene could play a signicant role in reducing VRE contamination,
and in another study, supervised use of ABHR every 4 hours by
psychiatric patients was associated with a decrease in the number of
unit-based respiratory outbreaks from 4 per year to 1 per year and
a decrease in cases of respiratory illness from 60 to 6.
There are few published descriptive studies on patients perfor-
mance of hand hygiene. One observational study conducted during
peak visiting hours in 27 wards in 9 hospitals reported that out of
290 total observed uses of soap or alcohol-based hand rub, not one
of them was by a patient.
To address the need for patient hand hygiene, Ward
a range of strategies to better promote patient hand hygiene.
Although some studies have suggested that patientspoor hand
hygiene can be attributed to lack of knowledge, perceived impor-
tance (as demonstrated by HCWs), impeded movement, and
physical impairments, the fundamental question may be whether
or not patients are encouraged to clean their hands at all.
Prompted by anecdotal reports of patients not being regularly
offered hand wipes intended for patient use at a hospital on the Isle
of Wight, Whiller and Cooper
conducted a small study to identify
whether patients were offered hand-cleansing resources after
using the commode. They found that only 50% of patients were
always offered hand hygiene resources after using the commode,
and 31% of patients were never offered them. After the introduction
of staff reminders and readily accessible resources, all patients
reported having resources offered to themat least some of the time,
and the percentage of patients who were always offered hand
hygiene resources rose from 50% to 85%.
The perception of support and/or importance of patient hand
hygiene also may play a role in promoting patient hand hygiene
behavior. In one study, 64% of nurses reported offering hand
hygiene to patients, but only 15% of patients recalled being offered
the opportunity for hand hygiene.
Although few formal programs exsist, both patients and HCWs
seem to recognize the importance of hand hygiene. Burnett et al
solicited nursesand patientsperceptions about hand hygiene
and whether nurses encouraged and offered assistance with hand
hygiene to patients. They found that although nurses and patients
alike (100% and 95%, respectively) believed that handwashing is
important in preventing infection, hand hygiene assistance was
offered only once by a nurse in 75 patient hand hygiene opportu-
nities observed.
Burnett et al
followed that study with an effort
to correlate self-reported attitudes with behavior in support of
patient hand hygiene, and found that despite nursesacknowledg-
ment of the importance of patient hand hygiene as an important
component in controlling and preventing HAIs, patients were not
consistently provided with assistance in performing their own hand
Patient performance of hand hygiene has been reported as an
example of patient involvement in the care process by many
authors and organizations, including the WHO Alliance for Patient
Safety, the Joint Commission, and the CDC. These organizations
have provided limited guidelines for patientsinvolvement in
patient safety and hand hygiene-related practices.
If patient
hand hygiene is to become a clinical reality and have an impact on
patient safety and the reduction of HAIs, clear guidelines and
a range of support must be established to promote patient hand
hygiene behavior.
In the health care setting, current best practices to promote
hand hygiene behavior include the use of multimodal strategies. As
with HCWs, successful patient hand hygiene programs will likely
require a multimodal approach that emphasizes important
features, including the formulation, design, and availability of hand
hygiene resources; timing and technique for hand hygiene
behavior; education and training of patients and caregivers;
monitoring adherence and providing feedback and reminders; and
creating a culture of hand hygiene and patient safety among
patients, HCWs, and senior hospital personnel
(Table 2). For
a review of the components of a multimodal strategy,see the article
by Pincock et al.
in this supplement.
Implementing an effective patient hand hygiene programsrelies
on the development of a multimodal set of best practice recom-
mendations specic to the role of patients in infection prevention,
and the needs and challenges of patients in the health care envi-
ronment. In particular, further work is needed on specic compo-
nents of a multimodal patient hand hygiene strategy, including
timing and technique for patient hand hygiene; product, design,
and placement considerations; best patient education and training
strategies; and HCW education and training needs for the imple-
mentation of a multimodal strategy.
Timing and technique for patient hand hygiene
Best practice recommendations are needed for the specic
indications for patient hand hygiene and steps in hand hygiene.
Although guidelines have addressed the timing and techniques of
hand hygiene in HCWs, there are fewrecommendations for both the
frequency and methods techniques applicable to patient hand
hygiene. Future work should use available resources to develop
specic recommendations for the timing of patient hand hygiene,
including preferred techniques and products, as well as methods for
of delivering both patient and HCW education and training. Patient
hand hygiene should be implementedin health professional training
programs and included in local facility policies and procedures.
For HCWs, recommended indications for hand hygiene have been
developed for specic time points or momentsduring patient care.
The WHOs 5 Moments forHand Hygiene include (1) before touching
a patient, (2) before an invasive or aseptic procedure, (3) after
contact with body uids or excretions, (4) after touching the patient,
and (5) after touching the surrounding environment.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17S14
The most appropriate hand-hygiene opportunities should be
identied for patients, which may be signicantly different than
than those recommended for HCWs. For example, it will be
important to identify routine patient activities, such as eating or
bathroom activities, during which hand hygiene should be per-
formed. Table 3 presents a proposed list of moments for patient
hand hygiene based on the timing of exposure to pathogens.
Product design and placement considerations for patient
hand hygiene
Better understanding of patient behavior, with specic attention
to the moments for patient hand hygiene, is needed to identify the
specic design attributes of patient-focused hand hygiene prod-
ucts. Preferred hand hygiene products and optimal product place-
ment require further exploration. Currently, most commercially
available hand hygiene products have been developed specically
for use by HCWs and reect the frequency with which hand
hygiene is performed. Therefore, the formulations of these products
are recommended in routine HCW hand hygiene. For patients,
specic formulations (eg, efcacy, skin performance), formats (ie,
handwash, leave-on, rinse, foam, gel, wipe), and dispensing
systems need to be created and evaluated with the patient specif-
ically in mind.
Because of patientssusceptibility to infection and
likely fewer opportunities for hand hygiene, clinically effective
formulations for patients may differ from those for use by HCWs. In
addition, because many patients face unique environmental
obstacles in addition to physical challenges, more research is
needed on specic product delivery characteristics, including
usability, placement, and durability. With this information, hand
hygiene manufacturers can then create clinicallyeffective solutions
that will be accepted and used by patients.
Patient education and training to support patient hand hygiene
Further study is needed to determine the best methods of
patient education to promote hand hygiene. The same research
used to design HCW education and training programs is needed for
patients to create solutions that will improve patient awareness,
understanding, usage, and compliance. Currently, the Joint
Commission requires hospitals to provide patients with informa-
tion on hand hygiene to patients, which will provide a foundation
for growth.
The Joint Commissions SpeakUp program includes
educational material on measures that patients can take to reduce
infections, including handwashing and use of ABHRs.
evaluation of these tools and initiatives may provide a basis on
which to develop and expand a robust program for educating
patients on patient hand hygiene practices.
HCW education and training to support patient hand hygiene
Efforts to increase awareness of patient hand hygiene among
clinicians and health care profession students should be promoted.
When evaluating the potential role of HCWs in this equation, an
important resource must include the various curricula used to
train HCWs. Specically, the assessment of curricula used to train
health care professionals who have signicant hands-on care
responsibilities, such as physicians, nurses, physical therapists, and
Table 3
Moments for patient hand hygiene
1. After using the toilet, bedpan, or commode
2. When returning to room after test or procedure
3. Before eating, drinking, taking medicine, or putting anything in your mouth
4. When visibly dirty
5. Before touching any breaks in the skin (eg, wounds, dressing, tubes)
or any care procedures (eg, dialysis, IV drug administration, injections)
6. Before dialysis, contact with IV lines or other tubes
7. After coughing, sneezing, or touching nose or mouth
8. Before interacting with visitors and after they leave
9. When there is concern about whether hands are clean
Table 2
Key considerations for future work to promote patient hand hygiene
Content area Rationale Specic steps
Timing and technique
Validate and promote when patients should
perform hand hygiene.
The most critical moments for hand hygiene may
differ between patients and HCWs.
Research, validate, fortify, and promote the
framework identied here.
Encourage product providers to research, develop,
and trial various options for a patient hand hygiene
Product, design, and placement
Determine some of the key challenges, barriers, and
needs specic to the patient.
Evaluate appropriate patient product formula-
tion(s) and delivery vehicles.
Pain, mobility, and connement contribute to
a patients ability to participate in hand hygiene.
The formulations most applicable for patient use may
vary from formulations appropriate for HCWs.
Likewise, format (eg, rinse, gel, foam, wipe) should
be considered with the patient specically in mind.
Identify existing barriers to patient hand hygiene.
Encourage product manufacturers to research,
develop, and trial various options for a patient hand
hygiene agenda.
Patient education and training
Provide educational tools for patients and visitors.
Improving patient hand hygiene requires that
patients and HCWs understand the why, how, and
when of patient hand hygiene.
Leverage existing tools on patient hand hygiene
from such resources as the Joint Commissions
SpeakUp program, as well as product providers.
HCW education and training
Provide education and training to HCWs on the
rationale and technique of patient hand hygiene.
Emphasize the role of HCWs in supporting patient
hand hygiene.
Assess and develop opportunities within HCW
curricular agendas to introduce and fortify a focus
on the patient hand hygiene agenda.
Multimodal strategy
Identify opportunities to coordinate efforts to
promote the need for and methods of patient hand
hygiene to participants in the health care
settingdHCWs, patients, families, and visitors
It is not enough to provide the appropriate tools and
educate patients and HCWs about patient hand
hygiene. The practice also must be actively
promoted from various angles and to the full range
of health care setting participants to become part of
the culture, practice, and behavior of health care,
and to contribute to the reduction of HAIs.
Apply some of the lessons learned from multimodal
strategies intended to change hang hygiene
behavior of HCWs. Use posters, displays, reminders,
and other components to promote patient hand
hygiene across health care settings.
T. Landers et al. / American Journal of Infection Control 40 (2012) S11-S17 S15
respiratory therapists. Although each of these disciplines is unique,
with distinct curricular elements, evaluation of the individual
curricular elements of each discipline is an important consider-
ation. Based on our review of foundational literature as well as
textbooks applied to curriculum supporting front-line roles within
health care, a focus on patient hand hygiene appears to be lacking.
Coverage of an approach that teaches patients when and how to
perform hand hygiene is universally absent from the curricula.
Although some hand hygiene product manufacturers have devel-
oped tools that can be adapted to teach patients about hand
hygiene, specic patient-centered tools have not been integrated
into the education of health care professionals.
There are additionalconsiderations involved in engagingpatients
in their own hand hygiene. Technique, education and promotion,
and potential barriers may be unique to each patients condition. An
understanding of the barriers, timing, and other considerations for
patient hand hygiene provides an important foundation for the
ability to educate about and promote the practice. The adoption of
patient hand hygiene as the next important infection prevention
measure will require the inclusion of curricular elements that
support the goal of improved patient hand hygiene. By applying
some of the lessons learned from guidelines associated with the
WHOs 5 Moments, as well as work derived from other guidelines
established for HCWs and families with regard to hand hygiene
practices, we can establish a potential framework for the compo-
nents of a HCW training curriculum that best recognizes and
supports the importance of patient hand hygiene. This work must
then be fortied with an understanding of the barriers, timing,
formal training in indications and techniques, and other consider-
ations specic to the patient, as well as the principles of patient-
centered care as the rationale for patient hand hygiene.
With the patient at the center of this approach, efforts should
focus on educational in-services that are patient-centered and
promote hand hygiene practices even among the most critically ill
patients. Education and training of both patients and HCWs in
patient hand hygiene will provide an important foundation for
teaching about and promoting the practice.
Importance of a multimodal strategy
A single intervention is not sufcient to sustain changes in hand
hygiene behavior in either patients or HCWs. Accordingly, beyond
product design and accessibility considerations, patient and HCW
education must be augmented by a range of other supports, such as
feedback and visual and verbal reminders (eg, posters, brochures,
feedback) that are relevant to and easily understood by patients
and their families to support and sustain behavior change. These
multiple aspects must be identied and adapted to each individual
patients role in his or her personal hand hygiene (Table 3).
Broad support for the creation of a culture of patient-centered
care can promote a shift toward a paradigm of hand hygiene that
accepts the importance of the patients role and places the patient
at the center of the patient safety movement.
HAIs occur in 1.7 million hospitalized US patients every year,
causing approximately 100,000 deaths and costing $6.7 billion
Yet the focus on hand hygiene as the single most
effective means of preventing the spread of infection has primarily
targeted HCWs. As a result, patients have been relegated to roles
that simply support and encourage hand hygiene practices of
others, rather than being engaged as active participants. The
evidence presented in this review indicates that this is a signicant
oversight, but which provides an opportunity for growth.
Twelve years after the launch of the patient safety movement,
reports from many health care agencies indicated continued
challenges in patient safety.
An approach promoting a culture
of safety and HAI reduction involves everyone, top to bottom,
in the process. By necessity, this must include the patient. If
patient-centered caretruly has the patient as the central focus,
and patient safety is our top priority, then hand hygiene practices
must include patients and their caregiver networks in the process.
Patient hand hygiene represents the next big step in infection
prevention and in the evolving eld of patient-centered care. This
review suggests that including patients in hand hygiene practices
has the potential to provide patients with the knowledge and skill
to be true partners in their care. Fully addressing the risk associated
with HAIs requires the appropriate education, products, tech-
niques, practices, and promotional tools to directly engage our
patients to fully participate in maintaining safety and reducing HAIs
through their own hand hygiene.
We wish to acknowledge the assistance of Ebie Hoist, Strategic
Gear, in the preparation of this article and to Ruth Carrico, RN, PhD,
who provided scientic and technical assistance and served as
a scientic advisor to the development of this article.
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... Previous studies conducted regarding the investigation of the relationship between the patient safety engagement and the patient safety demonstrated that the patient himself/ herself and his/her family had distinctive information related to the patient safety of the patient which could yield positive outcomes [38]. Indicators demonstrated that the engagement of the patients facilitated them in the improvement of the patient safety and also assisted in the restraining of the disease [39]. ...
... Tis fnding conveys that the engagement of the patient in the practices for patient safety is predicted through the level of self-efcacy of the patients. Tis fnding is similar to the fndings of Lee and Garvin [37], Schwappach [36], Davis et al. [35], Landers et al. [39], and Khan et al. [38]. ...
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Patient safety and involvement of the patients in their safety engagement activities are considered the most important elements in the healthcare professions due to their impact on various individual and organizational outcomes. The study used responses of 456 patients. The simple random sampling (SRS) technique was used to collect data from the respondents. The researcher used individuals as the unit of analysis in this study. The results revealed that patient safety engagement had a positive significant effect on patient safety. When the mediating variable of self-efficacy was analyzed, it showed a significant mediated effect on patient safety. Therefore, it was concluded that self-efficacy mediated the relationship between patient safety engagement and patient safety. The findings of the current study convey that engagement of the patient in the practices for patient safety is predicted through the level of self-efficacy of the patient. The study discussed various implications for theory and practice. The study also discussed potential avenues for future research.
... Organizational commitment refers to a common cognition that medical staff trust in the goals and values of the respective organization (Becker, 1960), including value commitment, effort commitment, and retention commitment (Chen et al., 2017). HHB referred to medical staff sanitizing hands with an alcohol-based hand rub under some specific situations (WHO, 2009), such as before and after interacting with patients (Landers et al., 2012). ...
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Hand hygiene behavior (HHB) in healthcare settings remains suboptimal globally. Self-expectation leadership and organizational commitment are emphasized as important factors influencing HHB. However, there are no studies to support any relationship between self-expectation leadership and organizational commitment to HHB. This study will fill the gap by applying implicit leadership theory (ILT) to support the further promote HHB among medical staff. A cross-sectional study of 23,426 medical staff was conducted in all second-level and third-level hospitals in Hubei province, China. Based on ILT, an online self-administered and anonymous questionnaire was designed for measuring the medical staff’s self-expectation leadership, organizational commitment, and HHB based on Offermann’s 8 dimensions scale, Chang’s 3 dimensions scale, and the specification of hand hygiene for healthcare workers , respectively, in which self-expectation leadership was divided into positive traits and negative traits parts. The structural equation model was used to examine the direct, indirect, and mediating effects of the variables. Positive traits of self-expectation leadership had a positive effect on organizational commitment (β = 0.617, p < 0.001) and HHB (β = 0.180, p < 0.001). Negative traits of self-expectation leadership had a negative effect on organizational commitment (β = –0.032, p < 0.001), while a positive effect on HHB (β = 0.048, p < 0.001). The organizational commitment had a positive effect on HHB (β = 0.419, p < 0.001). The mediating effect of the organizational commitment showed positively between positive traits of self-expectation leadership and HHB (β = 0.259, p < 0.001), while negatively between negative traits of self-expectation leadership and HHB (β = –0.013, p < 0.001). Positive traits of self-expectation leadership are important predictors of promoting organizational commitment and HHB, while negative traits of self-expectation leadership have a limited impact on organizational commitment and HHB in the field of healthcare-associated infection prevention and control. These findings suggest the need to focus on positive traits of self-expectation leadership; although negative traits of self-expectation leadership can also promote HHB to a lesser degree among medical staff, it will reduce their organizational commitment.
... Furthermore, increased compliance with best practices for hand hygiene, not only by healthcare staff but also by patients, could have contributed to our findings, as previous studies have demonstrated high rates of visitor and patient hand contamination by DRO species during hospital admission and stay. [22][23][24] Further studies are needed to confirm our hypothesis. ...
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Introduction: We aimed to compare the rate of postoperative infection and drug-resistant organism (DRO) before and during the COVID-19 pandemic in urology departments. Methods: A retrospective cohort study was carried out. Data from all elective surgical procedures carried out in two urology departments between April and June 2018 and the homologous period in 2020 were collected. Main outcomes were the number of postoperative infections during the pandemic, and the number of DROs. Sample size was calculated based on a 50% relative reduction of infections during the pandemic. Variables were compared by Chi-squared test, and multivariable logistic regression was used to estimate predictors. Results: A total of 698 patients undergoing elective surgery were included. The postoperative infection rate during the pre-pandemic period was of 14.1% compared to 12.1% during the pandemic (p=0.494). DROs were lower during the pandemic (92.3% vs. 52.4%, p=0.002). The pandemic period was the main predictor for reduced multi-drug-resistant isolates, with an odds ratio of 0.10 (p=0.010, 95% confidence interval 0.016-0.57). Conclusions: Postoperative infection rates were not significantly reduced during the COVID-19 pandemic, despite the adoption of enhanced infection preventive measures. There was, however, a decrease in the rate of DROs during this period, suggesting a secondary benefit to enhanced infection prevention practices adopted during the COVID-19 era.
... This raises questions on the roles of clients and their families in infection prevention, especially as contact with nurses or professional caregivers is of relatively short duration . Some effort s have been made to engage and involve clients to become active partners in infection prevention, but this approach is still underused ( Landers et al., 2012 ). Thus, further research to involve and engage clients and their families in infection prevention measures might prove fruitful in the prevention of home-based nursing care acquired infections. ...
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Background : Home-based nursing care continues to expand, delivering care to increasingly older clients with multiple, chronic and complex conditions that require the use of additional and more numerous invasive medical devices. Therefore, the prevention of infections poses a challenge for nurses, professional caregivers and clients. Objective : This article explores infection prevention practices and related behavioural factors in both nurses and clients to identify barriers and facilitators of infection prevention practices in home-based nursing care. Design : A qualitative, exploratory design Setting : Four healthcare organisations providing home-based nursing care in the Netherlands Methods : Participant observations were used as the main source of data collection complemented with focus group discussions and semi-structured interviews. Participants : Participant observations: 16 nurses, three professional caregivers and 80 clients Semi-structured interviews: 11 clients Focus group discussions: 15 nurses and four professional caregivers Results : A total of 87 unique care delivery situations were observed for 55 hours, complemented with three focus group discussions and 11 individual semi-structured client interviews. Infection prevention practices in home-based nursing care appeared to be challenged by 1. The specific context or environment in which the care occurred, which is more autonomous, less structured, less controlled and less predictable than other care settings; 2. Suboptimal and considerable variation in professional performance concerning the application of hand hygiene and the proper use of personal protective equipment such as face masks, barrier gowns and disposable gloves; 3. Extensive use in and outside the client's surroundings of communication devices that are irregularly cleaned and tend to interrupt nursing procedures; and 4. Inadequate organisational support in the implementation and evaluation of new information or policy changes and fragmentation, variation and conflicting information regarding professional guidelines and protocols. Conclusions : From a first-hand observational viewpoint, this study showed that the daily practice of infection prevention in home-based nursing care appears to be suboptimal. Furthermore, this research revealed considerable variation in the work environment, the application of hand hygiene, the proper use of personal protective equipment, the handling of communication devices and organisational policies, procedures and support. Finally, the study identified a number of important barriers and facilitators of infection prevention practices in the work environment, professional and team performance, clients and organisations.
... To date, little is known about how patients and families could be effectively engaged in IPAC, an important area of patient safety (18,33,34). Patient and family engagement in infection prevention remains unclear and is subject to barriers that have been studied previously (18,35,36). Moreover, the COVID-19 pandemic has raised important tradeoffs between patient safety/IPAC practices on one hand and patient and family engagement as essential partners in the other hand (37)(38)(39). ...
Harm reduction is a grassroots practice and philosophy. Yet, this concept has been adopted into large institutions and often delivered in a manner that does not align with the philosophy. This article explores one approach to try and integrate concepts of harm reduction while aligning with grassroots movements. This article was published in the University of British Columbia Medical Journal, 13(2), 5 - 9.
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Introduction Healthcare-associated infections are an important patient safety concern, especially in the context of the COVID-19 pandemic. Infection prevention and control implemented in healthcare settings are largely focused on the practices of healthcare professionals. Patient and family engagement is also recognised as an important patient safety strategy. The extent to which patients and families can be engaged, their specific roles and the strategies that support their engagement in infection prevention remain unclear. The overarching objective of the proposed study is to explore how patients and families can effectively be engaged in infection prevention by developing a consensus framework with key stakeholders. Design and methods The proposed study is based on a cross-sectional exploratory study at one of the largest university hospitals in North America (Montreal, Canada). The targeted population is all healthcare professionals, managers and other non-clinical staff members who work on clinical units, and the in-patients and their families. The study is based on Q methodology that takes advantage of both quantitative and qualitative methods to identify the consensus among the various stakeholders. This exploratory Q research approach will provide a structured way to elicit the stakeholders’ perspectives on patient and family engagement in infection prevention. Ethics and dissemination The research ethics board approved this study. The research team plans to disseminate the findings through different channels of communication targeting healthcare professionals, managers in healthcare settings, and patients and family caregivers. The findings will also be disseminated through peer-reviewed journals in healthcare management and in quality and safety improvement.
Introduction: The WHO states that hospital-acquired infections may be transmitted through contaminated hands. Practicing hand hygiene using alcohol-based handrub or soap and water reduces harmful organisms. The Joanna Briggs Institute (JBI) best practice recommends empowering patients with hand hygiene knowledge and engaging their involvement to strengthen hand hygiene practices. Aims: The aim of this project was to improve hand hygiene among surgical inpatients. Methods: This evidence-based quality improvement project was conducted in three phases: the baseline audit, implementing best practice, and the postimplementation audit. Participants were patients hospitalized in three surgical wards of a 1200-bed acute care tertiary hospital. This project utilized the online JBI Practical Application of Clinical Evidence System and The Getting Research into Practice program to identify barriers and strategies. Nurses provided patients with an education pamphlet and regularly reminded them to improve their hand hygiene practices. Results: Ninety-four patients were audited between April and June 2018. Patients' hand hygiene practices improved from 19.1% at baseline audit to 61.7% (P < 0.01) at first follow-up audit. Patients' hand hygiene improved from 48.9 to 72.3% (P = 0.03) before meals, and from 92.6 to 98.9% (P = 0.65) after toileting. The proportion of patients who received a hand hygiene information leaflet in an appropriate language increased from 64.9 to 89.4% (P < 0.01). Conclusion: Patients' involvement in the hand hygiene program has significantly improved their hand hygiene practices. Patient education and patient information leaflet continue to be an effective strategy to improve knowledge and practices.
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Background: Human hands are home to thousands of microorganisms, which may be transmitted to surfaces that the hands come into contact with. When in contact with people who are ailing or have weakened immune systems, some of these microorganisms can cause infections and disease. Correct hand hygiene goes a long way in eradicating these potentially infective microorganisms and forms the cornerstone of infection prevention and control (IPC) within healthcare facilities and beyond. The healthcare industry is constantly challenged by healthcare-associated infections (HAIs) and their negative effects on patient safety and clinical outcomes. Hospitals in Pretoria are facing similar challenges posed by HAIs and there is no report available on compliance of healthcare professionals (HCPs) to the World Health Organization’s (WHO) ‘five moments of hand hygiene’. Healthcare professional’s compliance to all of the five moments of hand hygiene, particularly within the patient zone, is crucial in mitigating and reducing the spread of contact-based infections in the healthcare setting. Methods: A quantitative longitudinal design was used in a covert direct observation of HCP compliance to the WHO’s five moments of hand hygiene. The observations were conducted over 4 weeks in three hospitals, covering 25 wards, inclusive of four adult critical care units using the WHO’s ‘five moments of hand hygiene’ observation form. Results: A total of 1906 hand hygiene opportunities were directly observed in three hospitals. Hand hygiene compliance was 17.26% (n = 329). Allied health professionals had higher compliance (23.02%) than medical (19.26%) and nursing professionals (15.76%). The moment before patient contact had the lowest compliance (8.21%) as compared with all other moments. Conclusions: In general, HCPs had low compliance to the five moments of hand hygiene within the patient zone. Allied health professionals had higher compliance than medical and nursing professionals. Compliance in public hospitals was lower than in private hospitals. Critical care units had higher compliance compared to general wards. Healthcare professionals better complied to the moments meant for their safety as compared to those indicated for patient safety.
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Ward procurement of hand hygiene consumables is a proxy measure of hand hygiene compliance. The proportion of this due to use of alcohol hand rub (AHR) at ward entrances, and bedside use of consumables by patients and visitors, is unknown. Thirty-six hours of direct observation of bedside hand hygiene behaviours by healthcare workers (HCWs), patients and visitors on 27 wards in nine hospitals was undertaken. AHR containers from ten ward entrances were collected for four days. Mean daily volume used was compared with mean daily volume procured. Only 4% of bedside soap and AHR use was by visitors. Patients used neither. An average 21% (range 7—38%) of all AHR procured by wards was used at ward entrances. Non-HCW use of soap or AHR at the bedside is low. Ward entrance use of AHR is modest but varies. Hand hygiene intervention studies using consumables as an outcome should assess and adjust for such usage.
Sixteen percent of hospital room surfaces remained colonized by vancomycin-resistant enterococci (VRE) after routine terminal disinfection. Disinfection with a new "bucket method" resulted in uniformly negative cultures. Conventional cleaning took an average of 2.8 disinfections to eradicate VRE from a hospital room, while only one cleaning was required with the bucket method.
objective. The purpose of this study was to provide a national estimate of the number of healthcare-associated infections (HAI) and deaths in United States hospitals. Methods. No single source of nationally representative data on HAIs is currently available. The authors used a multi-step approach and three data sources. The main source of data was the National Nosocomial Infections Surveillance (NNIS) system, data from 1990-2002, conducted by the Centers for Disease Control and Prevention. Data from the National Hospital Discharge Survey (for 2002) and the American Hospital Association Survey (for 2000) were used to supplement NNIS data. The percentage of patients with an HAI whose death was determined to be caused or associated with the HAI from NNIS data was used to estimate the number of deaths. Results. In 2002, the estimated number of HAIs in U.S. hospitals, adjusted to include federal facilities, was approximately 1.7 million: 33,269 HAIs among newborns in high-risk nurseries, 19,059 among newborns in well-baby nurseries, 417,946 among adults and children in ICUs, and 1,266,851 among adults and children outside of ICUs. The estimated deaths associated with HAIs in U.S. hospitals were 98,987: of these, 35,967 were for pneumonia, 30,665 for bloodstream infections, 13,088 for urinary tract infections, 8,205 for surgical site infections, and 11,062 for infections of other sites. Conclusion. HAIs in hospitals are a significant cause of morbidity and mortality in the United States. The method described for estimating the number of HAIs makes the best use of existing data at the national level.
Previous studies 1 of the transmission of staphylococci to newborn infants suggested that organisms on the hands of personnel carriers are more important than organisms expelled into the air from the respiratory tracts of such carriers. In addition, these studies provided evidence which indicates that the air is not a major route of spread of organisms between infants. The fact that organisms nonetheless do spread readily from one infant to another suggests that the hands of personnel may play a role in the transport of staphylococci between infants. The present studies were designed to test the effectiveness of handwashing by nursery personnel in preventing the spread of organisms between infants and thus to provide indirect evidence regarding the importance of this mode of spread. In addition, an attempt was made to test the role of the airborne route in the transmission of staphylococci among newborns. In order to provide results
Conference Paper
Background: Clostridium difficile spores may persist in the hospital environment for extended periods of time. The purpose of the study was to evaluate whether admission to a room previously occupied by a patient with CDAD increased a patient’s risk of acquiring CDAD. Methods: A retrospective cohort of patients admitted to the medical intensive care unit (ICU) between 1/1/05 to 6/30/06 was evaluated. Medical records, microbiology records, and infection control records were used to identify CDAD cases. CDAD was considered hospital-acquired if diagnosis was after 48 hours of admission or within 30 days of discharge from the unit. CDAD patients were considered capable of environmental contamination up to 30 days after diagnosis. Medical records were reviewed for other risk factors for CDAD acquisition. Statistical analysis was completed using Chi squared test, Kaplan-Meier survival and cox proportional hazards models. Results: Of 1844 ICU admissions, 136 CDAD cases were identified. 47 patients had CDAD infection prior to or at the time of ICU admission. Of the remaining 1797 admissions, 1685 patients had a prior occupant without CDAD, 91 had a prior occupant with CDAD, and 89 (4.95%) acquired CDAD within 30 days of room occupation. Of the 89 CDAD patients, 79 out of 1685 (4.69%) had a prior occupant with no CDAD, while 10 out of 91 (11%) had a prior occupant with CDAD (p=0.002). Effect of prior occupant’s CDAD status remained significant (p = 0.0432) when controlling for the current patient’s age and Acute Physiology and Chronic Health Evaluation (APACHE) III score. Further analysis to control for antibiotic and proton pump inhibitor use is ongoing. Conclusions: These results suggest that a prior room occupant with CDAD is a significant risk for CDAD acquisition, independent of age and APACHE III score. These findings have future implications for room placement and room cleaning practices.
Effective hand hygiene practice within health care is widely recognised as being one of the single most important interventions to control and prevent the spread of healthcare associated infection (HCAI). This study aimed to explore nurses' and patients' perceptions towards patient hand hygiene and determine whether patients who required assistance with their hand hygiene were encouraged and offered appropriate facilities at appropriate times. In January 2007, within an acute teaching hospital in Scotland, six observational sessions, each lasting 4 hours were undertaken, 33 nurses completed a survey questionnaire, and interviews were carried out with 22 patients who required hand hygiene assistance. 100% of nurses and 95% of patients believed that patient hand hygiene was an important part of controlling and preventing HCAI. 64% of nurses reported having offered patients facilities to decontaminate their hands during the observational period, but only 14% of patients agreed with this. Out of 75 patient hand hygiene opportunities identified, facilities were provided on only one occasion. Despite nurses believing patient hand hygiene is an important part of preventing and controlling HCAI, unless patients are able to undertake this task independently, they are rarely encouraged or offered facilities to do so.
his study aimed to seek patient opinion on being asked to participate in a campaign to improve staff compliance with handwashing and to identify factors that may influence the likelihood of patients asking staff to wash their hands. A descriptive survey of 200 patients (150 participants, response rate 75 per cent) about to be discharged from an acute NHS Trust was completed. The age, gender, previous experience, opinions and personality traits of participants were explored. The results showed that 118 (79 per cent) thought they should be involved in helping staff improve hand hygiene and that extraversion was the only personality trait with a significant association with this tendency of wanting to be involved. Age was a significant factor in how likely participants were to ask different groups of staff and how they would feel about asking, with older people being more reluctant. Participants valued measures that facilitated them asking — staff wearing badges was the most popular of these. Groups of patients in this and other studies (National Patient Safety Agency, 2004) indicate that patients want to be involved in helping to improve hand hygiene. In practice, we need to acknowledge the complex nature of involving individuals in challenging staff to improve their own care, and also that hand hygiene is ultimately the responsibility of health professionals.