Healthcare workers on intensive care units (ICUs) are
regularly missing opportunities to clean their hands during the care of
patients, despite its critical importance for infection control, according to
new research presented at this year’s European Congress of Clinical
Microbiology & Infectious Diseases (ECCMID) currently being held in Amsterdam.

Worryingly, the authors say, hand hygiene compliance was
lowest when moving from dirtier to cleaner patient care tasks than from cleaner
to dirtier tasks, further increasing the risk of infection.

Interventions to improve hand hygiene compliance should
teach healthcare workers to move from cleaner to dirtier tasks to minimise
risks to patients, researchers say.

To provide more evidence, Professor Loreen Herwaldt from Roy
J. and Lucille A. Carver College of Medicine, Iowa City, USA and colleagues
analysed data from the Strategies to Reduce Transmission of Antimicrobial
Resistant Bacteria in Intensive Care Units (STAR*ICU) study. They assessed when
healthcare workers did hand hygiene during their sequences of care, and
identified factors associated with hand hygiene compliance as defined by the
CDC/HICPAC Guideline for Hand Hygiene in Health-Care Settings.

Researchers linked consecutive tasks that individual
healthcare workers performed into care sequences to identify “task
transitions”-defined as two consecutive patient care tasks, such as touching
a patient’s intact skin followed by handling the patient’s body fluids, and the
intervening hand hygiene opportunities.

In total, 3246 hours of observation were recorded between
December 2005 and August 2006 in ICUs in 18 centres across the US.

Results showed that general compliance with hand hygiene was
poor-with healthcare workers moving from dirtier to cleaner tasks during
two-thirds (10 000) of the transitions recorded, and from cleaner to dirtier
tasks in only a third of instances (5303).

Compared with nurses, physicians were 50% more likely to
move from dirtier to cleaner tasks, whilst other healthcare workers (eg,
radiology technicians, respiratory therapists) were more than twice as likely
to do this.

Hand hygiene was less likely when gloves were worn, with
healthcare workers more likely to move from dirtier to cleaner tasks when they
used gloves.

Worse still, healthcare workers performed proper hand
hygiene in just half the instances when moving from dirtier to cleaner tasks,
and only around 43% of the instances when moving from cleaner to dirtier tasks.

“Our findings indicate that healthcare workers may
inadvertently increase patients’ risks for healthcare-associated infection by
the direction in which they do tasks”, says Professor Herwaldt. “We
need to identify interventions that will help healthcare workers organise their
work in a way that decreases this risk and also reduces their workloads.”

The study has several strengths, say its authors, including
that it is the first to evaluate complete sequences of patient care, to assess
whether healthcare workers moved from cleaner to dirtier tasks or dirtier to
cleaner tasks, and whether the order in which healthcare workers did tasks was
associated with hand hygiene compliance.

This is an observational study so no firm conclusions can be
drawn, and the authors point to several limitations including that healthcare
workers’ behaviour may have been influenced by the presence of observers. They
also note that prospective studies are needed to validate the findings.