Overview

The WHO guidelines on hand hygiene in health care provide health-care workers (HCWs), hospital administrators and health authorities with a thorough review of evidence on hand hygiene in health care and specific recommendations to improve practices and reduce transmission of pathogenic microorganisms to patients and HCWs.

The present guidelines are intended to be implemented in any situation in which health care is delivered either to a patient or to a specific group in a population. Therefore, this concept applies to all settings where health care is permanently or occasionally performed, such as home care by birth attendants. Definitions of health-care settings are proposed in Appendix 1.

Contents

• INTRODUCTION
• I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
  • 1. Definition of terms
    • Hand hygiene products
    • Hand hygiene practices
    • Associated terms
  • 2. Guidelines’ preparation process
    • 2.1 Preparation of the Advanced Draft
    • 2.2 Pilot testing the Advanced Draft
    • 2.3 Finalization of the WHO Guidelines on Hand Hygiene in Health Care
  • 3. The burden of health care-associated infection
    • 3.1 Health care-associated infection in developed countries
    • 3.2 Burden of health care-associated infection in developing countries
  • 4. Historical perspective on hand hygiene in health care
  • 5. Normal bacterial flora on hands
  • 6. Physiology of normal skin
  • 7. Transmission of pathogens by hands
    • 7.1 Organisms present on patient skin or in the inanimate environment
    • 7.2 Organism transfer to health-care workers’ hands
    • 7.3 Organism survival on hands
    • 7.4 Defective hand cleansing, resulting in hands remaining contaminated
    • 7.5 Cross-transmission of organisms by contaminated hands
  • 8. Models of hand transmission
    • 8.1 Experimental models
    • 8.2 Mathematical models
  • 9. Relationship between hand hygiene and the acquisition of health care-associated pathogens
  • 10. Methods to evaluate the antimicrobial efficacy of handrub and handwash agents and formulations for surgical hand preparation
    • 10.1 Current methods
    • 10.2 Shortcomings of traditional test methods
    • 10.3 The need for better methods
  • 11. Review of preparations used for hand hygiene
    • 11.1 Water
    • 11.2 Plain (non-antimicrobial) soap
    • 11.3 Alcohols
    • 11.4 Chlorhexidine
    • 11.5 Chloroxylenol
    • 11.6 Hexachlorophene
    • 11.7 Iodine and iodophors
    • 11.8 Quaternary ammonium compounds
    • 11.9 Triclosan
    • 11.10 Other agents
    • 11.11 Activity of antiseptic agents against spore-forming bacteria
    • 11.12 Reduced susceptibility of microorganisms to antiseptics
    • 11.13 Relative efficacy of plain soap, antiseptic soaps and detergents, and alcohols
  • 12. WHO-recommended handrub formulations
    • 12.1 General remarks
    • 12.2 Lessons learnt from local production of the WHO-recommended handrub formulations in different settings worldwide
  • 13. Surgical hand preparation: state-of-the-art
    • 13.1 Evidence for surgical hand preparation
    • 13.2 Objective of surgical hand preparation
    • 13.3 Selection of products for surgical hand preparation
    • 13.4 Surgical hand antisepsis using medicated soap
    • 13.5 Surgical hand preparation with alcohol-based handrubs
    • 13.6 Surgical handscrub with medicated soap or surgical hand preparation with alcohol-based formulations
  • 14. Skin reactions related to hand hygiene
    • 14.1 Frequency and pathophysiology of irritant contact dermatitis
    • 14.2 Allergic contact dermatitis related to hand hygiene products
    • 14.3 Methods to reduce adverse effects of agents
  • 15. Factors to consider when selecting hand hygiene products
    • 15.1 Pilot testing
    • 15.2 Selection factors
  • 16. Hand hygiene practices among health-care workers and adherence to recommendations
    • 16.1 Hand hygiene practices among health-care workers
    • 16.2 Observed adherence to hand cleansing
    • 16.3 Factors affecting adherence
  • 17. Religious and cultural aspects of hand hygiene
    • 17.1 Importance of hand hygiene in different religions
    • 17.2 Hand gestures in different religions and cultures
    • 17.3 The concept of “visibly dirty” hands
    • 17.4 Use of alcohol-based handrubs and alcohol prohibition by some religions
    • 17.5 Possible solutions
  • 18. Behavioural considerations
    • 18.1 Social sciences and health behaviour
    • 18.2 Behavioural aspects of hand hygiene
  • 19. Organizing an educational programme to promote hand hygiene
    • 19.1 Process for developing an educational programme when implementing guidelines
    • 19.2 Organization of a training programme
    • 19.3 The infection control link health-care worker
  • 20. Formulating strategies for hand hygiene promotion
    • 20.1 Elements of promotion strategies
    • 20.2 Developing a strategy for guideline implementation
    • 20.3 Marketing technology for hand hygiene promotion
  • 21. The WHO Multimodal Hand Hygiene Improvement Strategy
    • 21.1 Key elements for a successful strategy
    • 21.2 Essential steps for implementation at heath-care setting level
    • 21.3 WHO tools for implementation
    • 21.4 “My five moments for hand hygiene”
    • 21.5 Lessons learnt from the testing of the WHO Hand Hygiene Improvement Strategy in pilot and complementary sites
  • 22. Impact of improved hand hygiene
  • 23. Practical issues and potential barriers to optimal hand hygiene practices
    • 23.1 Glove policies
    • 23.2 Importance of hand hygiene for safe blood and blood products
    • 23.3 Jewellery
    • 23.4 Fingernails and artificial nails
    • 23.5 Infrastructure required for optimal hand hygiene
    • 23.6 Safety issues related to alcohol-based preparations
  • 24. Hand hygiene research agenda
• II. CONSENSUS RECOMMENDATIONS
  • Ranking system for evidence
  • 1 Indications for hand hygiene
  • 2 Hand hygiene technique
  • 3 Recommendations for surgical hand preparation
  • 4 Selection and handling of hand hygiene agents
  • 5 Skin care
  • 6 Use of gloves
  • 7 Other aspects of hand hygiene
  • 8 Educational and motivational programmes for health-care workers
  • 9 Governmental and institutional responsibilities
• III. PROCESS AND OUTCOME MEASUREMENT
  • 1. Hand hygiene as a performance indicator
    • 1.1 Monitoring hand hygiene by direct methods
    • 1.2 The WHO-recommended method for direct observation
    • 1.3 Indirect monitoring of hand hygiene performance
    • 1.4 Automated monitoring of hand hygiene
  • 2. Hand hygiene as a quality indicator for patient safety
  • 3. Assessing the economic impact of hand hygiene promotion
    • 3.1 Need for economic evaluation
    • 3.2 Cost–benefit and cost–effectiveness analyses
    • 3.3 Review of the economic literature
    • 3.4 Capturing the costs of hand hygiene at institutional level
    • 3.5 Typical cost-savings from hand hygiene promotion programmes
    • 3.6 Financial strategies to support national programmes
• IV. TOWARDS A GENERAL MODEL OF CAMPAIGNING FOR BETTER HAND HYGIENE: A NATIONAL APPROACH TO HAND HYGIENE IMPROVEMENT
  • 1. Introduction
  • 2. Objectives
  • 3. Historical perspective
  • 4. Public campaigning, WHO, and the mass media
    • 4.1 National campaigns within health care
  • 5. Benefits and barriers in national programmes
  • 6. Limitations of national programmes
  • 7. The relevance of social marketing and social movement theories
    • 7.1 Hand hygiene improvement campaigns outside of health care
  • 8. Nationally driven hand hygiene improvement in health care
  • 9. Towards a blueprint for developing, implementing, and evaluating a national hand hygiene improvement programme within health care
  • 10. Conclusion
• V. PATIENT INVOLVEMENT IN HAND HYGIENE PROMOTION
  • 1. Overview and terminology
  • 2. Patient empowerment and health care
  • 3. Components of the empowerment process
    • 3.1 Patient participation
    • 3.2 Patient knowledge
    • 3.3 Patient skills
    • 3.4 Creation of a facilitating environment and positive deviance
  • 4. Hand hygiene compliance and empowerment
    • 4.1 Patient and health-care worker empowerment
  • 5. Programmes and models of hand hygiene promotion, including patient and health-care worker empowerment
    • 5.1 Evidence
    • 5.2 Programmes
  • 6. WHO global survey of patient experiences
  • 7. Strategy and resources for developing, implementing, and evaluating a patient/health-care worker empowerment programme in a health-care facility or community
• VI. COMPARISON OF NATIONAL AND SUB-NATIONAL GUIDELINES FOR HAND HYGIENE
• REFERENCES
• APPENDICES
  • Appendix 1 Definitions of health-care settings and other related terms
  • Appendix 2 Guide to appropriate hand hygiene in connection with Clostridium difficile spread
  • Appendix 3 Hand and skin self-assessment tool
  • Appendix 4 Monitoring hand hygiene by direct methods
  • Appendix 5 Example of a spreadsheet to estimate costs
  • Appendix 6 WHO global survey of patient experiences in hand hygiene improvement
• ABBREVIATIONS
• AKNOWLEDGEMENTS

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