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Study Examines Hand Hygiene Compliance

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Review Of: Fuller C, Savage J, Besser S, et al. The dirty hand in the latex glove: A study of hand hygiene compliance when gloves are worn. Infect Control Hospital Epidemiol. 2011;32(12):1194–1199.

The Science
This is a prospective observational study from England and Wales that examined proper gloving and hand hygiene techniques in various hospitals and wards for elderly patients. Investigators used trained research assistants, using a modified version of a verified observational tool for hand hygiene, to observe when proper technique was used and by whom.

The study’s results demonstrated that glove use was strongly associated with lower levels of hand hygiene. They found that the implications of improper glove use and poor hand hygiene may lead to an increased risk of infection, not only to the provider but also to the patient.

Dr. Wesley: I’m passionate about the hand hygiene issue. We recite the mantra, “Scene safe, BSI” at the beginning of every training scenario, but do we really know what proper BSI is? I’ve personally seen providers don gloves at the beginning of a call, examine the patient, touch every piece of equipment in the ambulance, complete their PCR on the tablet, deliver the patient to the emergency department (ED) and then, and only then, remove their gloves and return to the rig.

The World Health Organization has studied this issue closely, owing to the fact that most of the diseases they’re concerned with are spread by improper hand hygiene. They recommend washing your hands before and after wearing gloves and only using gloves when there’s a risk of disease transmission.

This study further confirms my suspicions. Although it’s hospital-based, I’m confident that it would be easily reproduced in the EMS environment. In this study, they found that gloves wore worn less often than they should have been and worn frequently when they weren’t indicated. Worse, they found that when gloves were worn, providers were significantly less likely to wash their hands.

It’s time for us to examine this issue. We spend millions on ensuring that our rigs transport patients fast and safely, but we refuse to consider the effect that poor hand hygiene may have on the transmission of deadly infections.

I’m challenging all of you to examine this issue in your service and develop appropriate policies to ensure compliance to proper hand hygiene.

Medic Marshall: After reviewing Dr. Wesley’s comments, I really don’t have much to say. The reality of it is that EMS providers generally practice poor hand hygiene. I’d also go as far as saying that we really don’t know when it’s appropriate to put gloves on, either. Every contact we have with patients means our gloves should be on. Clearly, this study shows this isn’t the best approach.

Infection control is huge issue and isn’t very well studied in the prehospital setting. We do know that it starts with hand hygiene: washing, using hand sanitizer, etc. Personally, I think it would be interesting to examine the number of patients that develop infections as a result of contact with EMS. Hospitals track this information, although it’s a little easier for hospitals to monitor and measure it. However, it is no less important for us to know and attempt to track.

At the end of the day, our job is to help our patients and provide the best care we can for them. It always starts with clean hands.

Abstract
Fuller C, Savage J, Besser S, et al. The dirty hand in the latex glove: A study of hand hygiene compliance when gloves are worn. Infect Control Hospital Epidemiol. 2011;32(12):1194-1199.

Background & Objective
Wearing of gloves reduces transmission of organisms by healthcare workers’ hands, but it isn’t a substitute for hand hygiene. Results of previous studies have varied as to whether hand hygiene is worse when gloves are worn. Most studies have been small and used nonstandardized assessments of glove use and hand hygiene. We sought to observe whether gloves were worn when appropriate and whether hand hygiene compliance differed when gloves were worn.

Design: Observational study. Participants and setting. Healthcare workers in 56 medical or care of the elderly wards and intensive care units in 15 hospitals across England and Wales.

Methods: We observed hand hygiene and glove usage (7,578 moments for hand hygiene) during 249 one-hour sessions. Observers also recorded whether gloves were or were not worn for individual contacts.

Results: Gloves were used in 1,983 (26.2%) of the 7,578 moments for hand hygiene and in 551 (16.7%) of 3,292 low-risk contacts; gloves were not used in 141 (21.1%) of 669 high-risk contacts. The rate of hand hygiene compliance with glove use was 41.4% (415 of 1,002 moments), and the rate without glove use was 50.0% (1,344 of 2,686 moments). After adjusting for ward, healthcare worker type, contact risk level, and whether the hand hygiene opportunity occurred before or after a patient contact, glove use was strongly associated with lower levels of hand hygiene (adjusted odds ratio, 0.65 [95% confidence interval, 0.54–0.79]; P ! .0001).

Conclusion: The rate of glove usage is lower than previously reported. Gloves are often worn when not indicated and vice versa. The rate of compliance with hand hygiene was significantly lower when gloves were worn. Hand hygiene campaigns should consider placing greater emphasis on the World Health Organization indications for gloving and associated hand hygiene.

 

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