Hand Hygiene Decreases Mortality

Frequent hand hygiene is important to reduce the spread of microorganisms. (Adapted from the WHO Alliance for Patient Safety 2006.)


Hand hygiene is the most important component to reducing the spread of infection and is known in healthcare as one of the basic necessities.1, 2 The current recommendation for hand hygiene is to wash hands with soap and water when visibly soiled, to use an anti-germicidal hand sanitizer or soap and water before and after all patient contact — before and after removing gloves — and after having contact with a known contaminant.2

When utilizing an alcohol-based hand sanitizer, the product should be placed onto the hands directly and hands should be rubbed together; all surfaces should be covered, and hands should be rubbed until the hands feel dry. The entire process should take approximately 20 seconds.3 Washing hands with soap and water requires the individual to initially wet the hands with water, then apply the soap to the hands.


Next, rub the hands together for at least 15 seconds ensuring all surfaces are covered including under the nails. The soap is rinsed off, hands are dried with a disposable towel, and the water is turned off with a towel.3 The compliance of healthcare workers washing their hands continues to be a problem in and out of the healthcare system.2 The overall average compliance rate of hand hygiene is 40%.2 Appropriate hand hygiene can decrease the spread of transmissible disease and decrease mortality.

Significance of the Problem

Prehospital providers, regardless of the situation, do not excel in hand hygiene.1 First responders, emergency medical technicians (EMTs), and paramedics work in unique environments such as homes, workplaces, and in the community. While entering these environments, emergency service personnel are in close contact with patients and increase the transmission risk of healthcare associated infections (HCAI) to the patient or hospital setting.1 Hand hygiene is of utmost importance in order to reduce disease transmission. However, there are gaps in compliance, access to equipment, and education.2 In a recent study (n=53) completed in an urban Minnesota region, only 62.8% of paramedics sanitized their hands after patient contact. Only 1.1% sanitized their hands prior to patient contact. Gloves were not worn 12.4% of the time while paramedics were caring for patients. Lastly, hand hygiene only occurred 19% of the time prior to eating and only 59.5% after eating a meal.2

The World Health Organization (WHO) reports that insufficient use of standard precautions puts individuals at risk for infections in healthcare settings. Therefore, healthcare professionals who do not use proper hand hygiene, or only use gloves, potentially increase the spread of infection. Healthcare associated infections (HCAI) can be caused by EMS personnel who do not use proper hand hygiene or those who lack education regarding appropriate hand hygiene. It is estimated at any point in time, 1.4 million individuals worldwide are affected by HCAI.4

HCAI can cause an increase in the length of hospital stays for patients, cause an increase in the number of resistant microorganisms such as methyl-resistant Staphylococcus aureus, increase the cost of healthcare, and increase patient mortality.4 These factors can be significant to both the health system as well as patients.5 All individuals receiving inpatient treatment at hospitals are at risk for HCAI.5 Therefore, any patient transported by EMS will have an increased risk for a HCAI. The goal of this education program was to create a practice improvement project which could be continued for years to come within the EMS community.


Purpose of This Project

The primary goal and purpose of this project was to create and implement a creative and interactive education program related to hand hygiene and infection prevention by targeting individuals working in a prehospital setting and EMS. B-EMS providers need to have continuous education at various points in their careers regarding the importance of the material as well as education of appropriate times for hand hygiene.2 Additionally, it is important to educate B-EMS providers regarding other vectors in which infections can be transmitted.

For instance, placing a mask on individuals with respiratory symptoms, such as a cough — especially if a fever is present — can help to reduce the transmission of infection.6 Additionally, proper hand hygiene after coughing or sneezing, or tissue use in addition to disposing tissues after use, can help to reduce the spread of transmissible infections.6

Clinical Question

The PICOT question formulated for this DNP Project was: In basic emergency medical service providers (B-EMS providers) (P), does a formal education program focused on hand hygiene and infection prevention (I) affect knowledge, feelings of competence, and intent to use hand hygiene and infection prevention practices (O) at the completion of the education program (T)? One group enrolled in this project completed the post-tests immediately after the education program (Group 1); the remaining group completed the post-tests one month after the education (Group 2).


The sample was emergency medical responders (EMRs), fire fighters and emergency medical technicians providing EMS in a prehospital setting. For the purpose of this project, the term basic-emergency medical service provider (B-EMS) was used to define EMRs and EMTs. These individuals had already obtained or were working on obtaining their EMT certification or EMR. A non-randomized convenience sample was used to obtain participants for the sample population. 


The project used a pre- and post-test design to examine whether a formal education program changed knowledge, feelings of competency and intent to use hand hygiene and infection prevention practices in B-EMS providers. In addition to a pre- and post-test participants completed a Likert Survey related to hand hygiene and infection prevention practices (HH-IPP) along with a demographic survey.

The HH-IPP was developed to determine participant’s feelings of competence and their intent to use hand hygiene and infection prevention practices at the completion of the education program. Ready-made tools offered through the WHO were used to provide education, lasting approximately one hour, with an emphasis on hand hygiene with regards to basic hand hygiene facts, appropriate times to perform hand hygiene, the type of hand hygiene that is necessary, glove usage including properly donning and doffing gloves, identification and discussion of antimicrobial resistance organisms, and discussion of appropriate mask usage.7

A slide presentation was adapted from the WHO ready-made tools. Next, an interactive learning portion of the hand hygiene and infection prevention formal education program occurred using GloGerm© lotion. GloGerm© is visible under a black light and allowed participants to identify the quality of hand washing that occurred.8


Statistical experts were consulted after data collection for the completion of the statistical analysis. A paired t-test was used to complete the statistical analysis of the two participant groups; the one month follow up group in addition to the group that took their post-test immediately after receiving the formal education. The paired t-test, which was a comparison of the pre- and post-test scores of each participant, was utilized to analyze both the pre- and post-test scores.

Reliability testing can determine if similar results would be produced with similar conditions, but was not completed on the individual pre- and post-test questions due to a small sample size. An analysis of covariance (ANCOVA) statistical analysis was completed to analyze the HH-IIP pre-and post-total scores.

Group 1 completed the written exam immediately after completing the formal education program while Group 2 completed the written exam at a one-month follow-up session. The pre- and post HH-IPP surveys were all completed immediately after receiving the formal education regarding hand hygiene and infection prevention. A matched pair t-test was used to determine if there was a statistically significant change in mean test scores (for the written exam) after the formal education program. The significance level was set at p < 0.05. An ANCOVA statistical model was utilized to analyze the pre-and post HH-IPP survey results.

Both groups (Group 1 and Group 2) had statistically significant increased mean scores on both the written exam test scores as well as the survey after receiving formal education about hand hygiene and infection prevention specific to EMS (p < .000). Therefore, the education program was effective in affecting knowledge, feelings of competence, and intent to use hand hygiene and infection prevention practices.


EMS personnel have some of the lowest compliance rates with hand hygiene due to limited access to running water, often eating in the same environment in which they work, working in chaotic situations, and the high demands of the job.9, 1, 10 Wearing and changing gloves is another important component to decreasing the transmission of communicable diseases. The failure of EMS personnel to change gloves at appropriate times, to wear gloves, or not use hand hygiene techniques after doffing gloves can increase the incidence of disease transmission.9, 10, 11

In a recent study with EMS workers (n= 1,494), gloves were only worn an average of 4.4% of the time for every patient encounter.1 Gloves are also put on too early and taken off too late.12, 11 This causes cross-contamination risks which were present 36.8% of the time when gloves were worn.12 Additionally, EMS personnel transmitted infections through cross-contamination even when gloves were utilized.12, 11 Although there is limited or no education, EMS personnel who have received formal education have an increased compliance and understanding of appropriate hand hygiene.10, 12 Limited access to products may also be a barrier to completing appropriate hand hygiene.9, 1, 13, 10

Alcohol based hand rubs have become the gold standard in healthcare;4 however, a barrier to some alcohol-based hand rubs is the inability to be effective against some sporous agents such as Clostridium difficile (C. difficile).4 All prehospital care providers who were provided with personalized hand sanitizer had increased use of reported hand hygiene.1 Therefore, if individuals had hand sanitizers in emergency response bags and on themselves, they may have an increased use of reported hand hygiene.


HCAI continue to be a growing concern within healthcare systems and for patients globally.9, 1, 11, 14 Through a proper understanding of handwashing and utilization of alcohol hand rubs, HCAI can be minimized.9 Hand hygiene continues to be the number one way at preventing and transmitting infections to others.1, 2

The results of this project support the implementation of a formal education program related to hand hygiene and infection prevention in B-EMS providers to increase knowledge, feelings of competence, and likelihood to use hand hygiene and infection prevention measures. Standardization of hand hygiene and infection prevention education for B-EMS providers could help to improve the quality of care to patients which therefore would help to decrease the transmission of disease.


  1. Bucher, J., Donovan, C., Ohman-Strickland, P., & McCoy, J. (2015). Hand washing practices among emergency medical services providers. Western Journal of Emergency Medicine, 16(5), 727-735. doi: 10.5811.westjem.2015/7.25917.
  2. Ho, J. D., Ansari, R. K., & Page, D. (2014). Hand sanitization rates in an urban emergency medical services system. The Journal of Emergency Medicine, 47(2), 163-168. Retrieved from http://dx.doi.org/10.1016/j.jemermed.2013.08.070.
  3. Centers for Disease Control and Prevention. (2019). Keeping hands clean. Retrieved from https://www.cdc.gov/healthywater/hygiene/hand/handwashing.html.
  4. World Health Organization. (2009). First global patient safety challenge clean care is safer care. WHO guidelines on hand hygiene in health care: A summary, 1-64. Retrieved from http://apps.who.int/iris/bitstream/10665/70126/1/WHO_IER_PSP_2009.07_eng.pdf?ua=.
  5. Zimlichman, E., Henderson, D., Tamir, O., Franz, C., Song, P., Yamin, C. K,”¦ Bates, D. W. (2013). Health care-associated infections: A meta-analysis of costs and financial impact on the US health care system. Journal of the American Medical Association Internal Medicine, 173(22), 2039-2046. Doi.10.1001/jamainternmed.2013.9763.
  6. Centers for Disease Control and Prevention. (2012). Respiratory hygiene/cough etiquette in healthcare settings. Retrieved from https://www.cdc.gov/flu/professionals/infectioncontrol/resphygiene.htm.
  7. World Health Organization. (2009). Infection prevention and control; hand hygiene tools and resources. Retrieved from https://www.who.int/infection-prevention/tools/hand-hygiene/en/.
  8. Walmsley, C., Mahoney, A., Durgin, A., & Poling, A. (2013). Fostering hand washing before lunch by students attending a special needs young adult program. Research in Developmental Disabilities, 34(1), 95-101.
  9. Barr, N., Holmes, M., Roiko, A., Dunn, P., & Lord, B. (2017). Major Article: Self-reported behaviors and perceptions of Australian paramedics in relation to hand hygiene and gloving practices in paramedic-led health care. AJIC: American Journal of Infection Control, 45, 771-778. doi:10.1016/j.ajic.2017.02.020.
  10. McGuire-Wolfe, C., Haiduven, D., & Hitchcock, C. D. (2012). A multifaceted pilot program to promote hand hygiene at a suburban fire department. American Journal of Infection Control, 40(4), 324-327. doi: 10.1016/j.ajic.2011.06.003.
  11. Mehta, Y., Gupta, A., Todi, S., Myatra, S. N., Samaddar, D. P., Patil, V., “¦ Ramasubban, S. (2014). Guidelines for prevention of hospital acquired infections. Indian Journal of Critical Care Medicine, 18(3), 149-163. doi: 10.4103/0972-5229.128705.
  12. Loveday, H.P., Lynam, S., Singleton, J. & Wilson, J. (2013). Clinical glove use: Healthcare workers’ actions and perceptions. Journal of Hospital Infection, 86, 110-116. Retrieved from http://dx.doi.org/10.1016/j.jhin.2013.11.003.
  13. Carter, E. J., Wyer, P., Giglio, J., Jia, H., Nelson, G., Kauari, V. E., & Larson, E. L. (2016). Environmental factors and their association with emergency department hand hygiene compliance: An observational study. BMJ Quality & Safety, 25(5), 372-378. doi: 10.1136/bmjqs-2015-004081.
  14. Scheithauer, S., Kamerseder, V., Petersen, P., Brokmann, J. C., Lopez-Gonzalez, L., Mach, C., & “¦Lemmen, S. W. (2013). Improving hand hygiene compliance the emergency department: getting to the point. BMC Infectious Diseases, 13(1), 1-6. doi: 10.1186/1471-2334-13-367.


Demographic Survey

Personal ID: ____________

What is your age?

  • 18-25 years old
  • 26-35 years old
  • 36-45 years old
  • 46-65 years old
  • 65+ years old

What is your gender?

  • Male
  • Female

How would you describe yourself?

  • Caucasian or White
  • Hispanic or Latino
  • African American or Black
  • Asian
  • American Indian or Alaskan Native
  • Native Hawaiian or Other Pacific Islander
  • Other

What is your certification level?

  • Emergency Medical Responder (EMR)
  • Basic Emergency Medical Technician (EMT-B)
  • Intermediate Emergency Medical Technician (EMT — I)

What is the highest degree or level of school you have completed (if you are currently enrolled in school, please indicate the highest degree you have received).

  • High school degree or equivalent (ex: GED)
  • Vocational Degree or Technical Certification (ex: EMT)
  • Associate degree (ex: AA, AS)
  • Bachelor’s degree (Ex: BA, BS)
  • Master’s degree (Ex: MA, MS, MEd)
  • Professional degree (Ex: MD, DDS, DVM)
  • Doctorate (Ex: PhD, EdD)

What is your current occupation? ______________

How many years of emergency medical service experience do you have? __________

Personal ID: ____________

Hand Hygiene and Infection Prevention Practices Survey

**Please mark the most appropriate box until you reach the black line.  Then, wait for further instructions*

Date:                                                           Personal ID:

Hand Hygiene and Infection Prevention Test

**Please circle the correct answer.

1. True or False

Contact precautions are common infection control practices used by healthcare professionals to reduce the transmission of microorganisms in the healthcare setting.

2. Who do standard precautions protect?

A. The patient

B. The patient and EMS Personnel

C. EMS Personnel

D. Hospital Personnel

3.  True or False

Wearing a mask with the presence of a cough, runny nose, or fever is the most important way to reduce the transmission of disease.

4. Select all that apply

What does PPE include?

A. Gown

B. Mask

C. Alcohol based hand sanitizer

D. Eye protection

E. Gloves

5. Select all that apply.

When is hand hygiene necessary?

A. Immediately before touching a patient, performing an invasive procedure, or manipulating an invasive device

B. Before and after removing gloves

C. After touching items or surfaces in the immediate patient care environment, even if you don’t touch the patient

D. Immediately after touching a patient, contaminated item or surface, or removing gloves

E. Before and after eating

6. How long can bacteria survive on surfaces?

A. Seconds

B. Hours

C. Months

D. Days

7. Which hand hygiene method is more effective at killing bacteria?

A. soap and water

B. alcohol-based hand rub (foam or gel)

8. True or False

Alcohol-based hand rubs can be used when hands are visibly soiled.

9.  How long should hand washing last to effectively reduce the growth of microorganisms on your hands?

A. until they seem clean

B. 5 seconds

C. 15-25 seconds

D. 40-60 seconds

10.  How long should you rub your hands together when applying an alcohol-based hand rub?

A. until your hands are dry

B. 5 seconds

C. 15 seconds

D. 1 minute

11. What is the proper way to turn off the water when washing your hands with soap and water?

A. use the backside of your hand

B. with your bare hands

C. with a paper towel

D. use your elbow

12. What does the term “proper contact time” refer to?

A. The amount of personal contact time an EMS provider has with a patient

B. The amount of time a disinfecting solution is on a surface

C. The amount time it takes to get to a patient after receiving a call

13. True or False

Always make sure your PPE is clean and stored in a clean environment.

14.  True or False

If necessary, after removal of PPE, consider the need to shower after going home, where you should change your clothes. 

15. True or False

Do not take dirty PPE home or store it in your vehicle.

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