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

      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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      References

        • Boyce J.M.
        • Pittet D.
        Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
        Infect Control Hosp Epidemiol. 2002; 23: S3-S40
        • Pittet D.
        • Allegranzi B.
        • Boyce J.
        The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations.
        Infect Control Hosp Epidemiol. 2009; 30: 611-622
        • Doebbeling B.N.
        • Stanley G.L.
        • Sheetz C.T.
        • Pfaller M.A.
        • Houston A.K.
        • Annis L.
        • et al.
        Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units.
        N Engl J Med. 1992; 327: 88-93
        • Maki D.G.
        The use of antiseptics for handwashing by medical personnel.
        J Chemother. 1989; 1: 3-11
        • Massanari R.M.
        • Hierholzer W.J.
        A crossover comparison of antiseptic soaps on nosocomial infection rates in intensive care units.
        Am J Infect Control. 1984; 12: 247-248
        • Mortimer Jr., E.A.
        • Lipsitz P.J.
        • Wolinsky E.
        • Gonzaga A.J.
        • Rammelkamp Jr., C.H.
        Transmission of staphylococci between newborns: importance of the hands to personnel.
        Am J Dis Child. 1962; 104: 289-295
        • Webster J.
        • Faoagali J.L.
        • Cartwright D.
        Elimination of methicillin-resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan.
        J Paediatr Child Health. 1994; 30: 59-64
        • Zafar A.B.
        • Butler R.C.
        • Reese D.J.
        • Gaydos L.A.
        • Mennonna P.A.
        Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery.
        Am J Infect Control. 1995; 23: 200-208
      1. The Joint Commission. Speak up: five things you can do to prevent infection. 2009. Available from: http://www.jointcommission.org/Speak_Up_Five_Things_You_Can_Do_To_Prevent_Infection_Poster/. Accessed December 6, 2011.

        • Pittet D.
        • Allegranzi B.
        • Storr J.
        • Donaldson L.
        “Clean Care is Safer Care”: the global patient safety challenge, 2005-2006.
        Int J Infect Dis. 2006; 10: 419-424
        • Storr J.A.
        • Engineer C.
        • Allan V.
        Save Lives: Clean Your Hands: a WHO patient safety initiative for 2009.
        World Hosp Health Serv. 2009; 45: 23-25
      2. National Patient Safety Agency. Cleanyourhands campaign. Available from: http://www.npsa.nhs.uk/cleanyourhands/. Accessed January 15, 2012.

        • Pittet D.
        • Panesar S.S.
        • Wilson K.
        • Longtin Y.
        • Morris T.
        • Allan V.
        • et al.
        Involving the patient to ask about hospital hand hygiene: a National Patient Safety Agency feasibility study.
        J Hosp Infect. 2011; 77: 299-303
      3. Canada Patient Safety Institute. Canada’s hand hygiene challenge. Available from: http://www.handhygiene.ca/English/Pages/default.aspx. Accessed January 18, 2012.

        • McGuckin M.
        • Waterman R.
        • Porten L.
        • Bello S.
        • Caruso M.
        • Juzaitis B.
        • et al.
        Patient education model for increasing handwashing compliance.
        Am J Infect Control. 1999; 27: 309-314
        • McGuckin M.
        • Waterman R.
        • Storr I.J.
        • Bowler I.C.
        • Ashby M.
        • Topley K.
        • et al.
        Evaluation of a patient-empowering hand hygiene programme in the UK.
        J Hosp Infect. 2001; 48: 222-227
        • McGuckin M.
        • Taylor A.
        • Martin V.
        • Porten L.
        • Salcido R.
        Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit.
        Am J Infect Control. 2004; 32: 235-238
        • McGuckin M.
        • Waterman R.
        • Shubin A.
        Consumer attitudes about health care-acquired infections and hand hygiene.
        Am J Med Qual. 2006; 21: 342-346
        • McGuckin M.
        • Storr J.
        • Longtin Y.
        • Allegranzi B.
        • Pittet D.
        Patient empowerment and multimodal hand hygiene promotion: a win-win strategy.
        Am J Med Qual. 2011; 26: 10-17
        • Entwistle V.A.
        Differing perspectives on patient involvement in patient safety.
        Qual Saf Health Care. 2007; 16: 82-83
        • Longtin Y.
        • Sax H.
        • Allegranzi B.
        • Hugonnet S.
        • Pittet D.
        Patients’ beliefs and perceptions of their participation to increase healthcare worker compliance with hand hygiene.
        Infect Control Hosp Epidemiol. 2009; 30: 830-839
        • Duncan C.
        An exploratory study of patient's feelings about asking healthcare professionals to wash their hands.
        J Ren Care. 2007; 33: 30-34
        • Lent V.
        • Eckstein E.C.
        • Cameron A.S.
        • Budavich R.
        • Eckstein B.C.
        • Donskey C.J.
        Evaluation of patient participation in a patient empowerment initiative to improve hand hygiene practices in a Veterans Affairs medical center.
        Am J Infect Control. 2009; 37: 117-120
        • Longtin Y.
        • Sax H.
        • Leape L.L.
        • Sheridan S.E.
        • Donaldson L.
        • Pittet D.
        Patient participation: current knowledge and applicability to patient safety.
        Mayo Clin Proc. 2010; 85: 53-62
        • Schwappach D.L.
        Engaging patients as vigilant partners in safety: a systematic review.
        Med Care Res Rev. 2010; 67: 119-148
        • Duncanson V.
        • Pearson L.S.
        A study of the factors affecting the likelihood of patients participating in a campaign to improve staff hand hygiene.
        Br J Infect Control. 2005; 6: 26-30
        • Leape L.L.
        Errors in medicine.
        Clin Chim Acta. 2009; 404: 2-5
      4. Canadian Patient Safety Institute. Patient and family hand hygiene guide. 2012. Available from: http://www.handhygiene.ca/English/Documents/Patients%20and%20Families/Patient%20Family%20Guide.pdf. Accessed January 18, 2012.

      5. Health Canada. It’s your health: the benefits of hand washing. 2010. Available from: http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/diseases-maladies/hands-mains-eng.php. Accessed January 18, 2012.

        • Davis R.E.
        • Jacklin R.
        • Sevdalis N.
        • Vincent C.A.
        Patient involvement in patient safety: what factors influence patient participation and engagement?.
        Health Expect. 2007; 10: 259-267
        • Davis R.E.
        • Koutantji M.
        • Vincent C.A.
        How willing are patients to question healthcare staff on issues related to the quality and safety of their healthcare? An exploratory study.
        Qual Saf Health Care. 2008; 17: 90-96
        • Lyons M.
        Should patients have a role in patient safety? A safety engineering view.
        Qual Saf Health Care. 2007; 16: 140-142
        • Hayden M.K.
        • Blom D.W.
        • Lyle E.A.
        • Moore C.G.
        • Weinstein R.A.
        Risk of hand or glove contamination after contact with patients colonized with vancomycin-resistant enterococcus or the colonized patients' environment.
        Infect Control Hosp Epidemiol. 2008; 29: 149-154
        • Stiefel U.
        • Cadnum J.L.
        • Eckstein B.C.
        • Guerrero D.M.
        • Tima M.A.
        • Donskey C.J.
        Contamination of hands with methicillin-resistant Staphylococcus aureus after contact with environmental surfaces and after contact with the skin of colonized patients.
        Infect Control Hosp Epidemiol. 2011; 32: 185-187
        • Jury L.A.
        • Guerrero D.M.
        • Burant C.J.
        • Cadnum J.L.
        • Donskey C.J.
        Effectiveness of routine patient bathing to decrease the burden of spores on the skin of patients with Clostridium difficile infection.
        Infect Control Hosp Epidemiol. 2011; 32: 181-184
        • Sethi A.K.
        • Al-Nassir W.N.
        • Nerandzic M.M.
        • Bobulsky G.S.
        • Donskey C.J.
        Persistence of skin contamination and environmental shedding of Clostridium difficile during and after treatment of C difficile infection.
        Infect Control Hosp Epidemiol. 2010; 31: 21-27
        • Kim K.H.
        • Fekety R.
        • Batts D.H.
        • Brown D.
        • Cudmore M.
        • Silva Jr., J.
        • et al.
        Isolation of Clostridium difficile from the environment and contacts of patients with antibiotic-associated colitis.
        J Infect Dis. 1981; 143: 42-50
        • Kramer A.
        • Schwebke I.
        • Kampf G.
        How long do nosocomial pathogens persist on inanimate surfaces? A systematic review.
        BMC Infect Dis. 2006; 6: 130
        • McFarland L.V.
        • Stamm W.E.
        Review of Clostridium difficile–associated diseases.
        Am J Infect Control. 1986; 14: 99-109
        • Mulligan M.E.
        • George W.L.
        • Rolfe R.D.
        • Finegold S.M.
        Epidemiological aspects of Clostridium difficile–induced diarrhea and colitis.
        Am J Clin Nutr. 1980; 33: 2533-2538
        • Wagenvoort J.H.
        • Penders R.J.
        Long-term in-vitro survival of an epidemic MRSA phage group III-29 strain.
        J Hosp Infect. 1997; 35: 322-325
        • Wagenvoort J.H.
        • Sluijsmans W.
        • Penders R.J.
        Better environmental survival of outbreak vs sporadic MRSA isolates.
        J Hosp Infect. 2000; 45: 231-234
        • Byers K.E.
        • Durbin L.J.
        • Simonton B.M.
        • Anglim A.M.
        • Adal K.A.
        • Farr B.M.
        Disinfection of hospital rooms contaminated with vancomycin-resistant Enterococcus faecium.
        Infect Control Hosp Epidemiol. 1998; 19: 261-264
        • Corbella X.
        • Pujol M.
        • Argerich M.J.
        • Ayats J.
        • Sendra M.
        • Pena C.
        • et al.
        Environmental sampling of Acinetobacter baumannii: moistened swabs versus moistened sterile gauze pads.
        Infect Control Hosp Epidemiol. 1999; 20: 458-460
        • Eckstein B.C.
        • Adams D.A.
        • Eckstein E.C.
        • Rao A.
        • Sethi A.K.
        • Yadavalli G.K.
        • et al.
        Reduction of Clostridium difficile and vancomycin-resistant Enterococcus contamination of environmental surfaces after an intervention to improve cleaning methods.
        BMC Infect Dis. 2007; 7: 61
        • French G.L.
        • Otter J.A.
        • Shannon K.P.
        • Adams N.M.
        • Watling D.
        • Parks M.J.
        Tackling contamination of the hospital environment by methicillin-resistant Staphylococcus aureus (MRSA): a comparison between conventional terminal cleaning and hydrogen peroxide vapour decontamination.
        J Hosp Infect. 2004; 57: 31-37
        • Jeanes A.
        • Rao G.
        • Osman M.
        • Merrick P.
        Eradication of persistent environmental MRSA.
        J Hosp Infect. 2005; 61: 85-86
        • Kaatz G.W.
        • Gitlin S.D.
        • Schaberg D.R.
        • Wilson K.H.
        • Kauffman C.A.
        • Seo S.M.
        • et al.
        Acquisition of Clostridium difficile from the hospital environment.
        Am J Epidemiol. 1988; 127: 1289-1294
        • Wu H.M.
        • Fornek M.
        • Schwab K.J.
        • Chapin A.R.
        • Gibson K.
        • Schwab E.
        • et al.
        A norovirus outbreak at a long-term-care facility: the role of environmental surface contamination.
        Infect Control Hosp Epidemiol. 2005; 26: 802-810
        • Huang S.S.
        • Datta R.
        • Platt R.
        Risk of acquiring antibiotic-resistant bacteria from prior room occupants.
        Arch Intern Med. 2006; 166: 1945-1951
        • Nseir S.
        • Blazejewski C.
        • Lubret R.
        • Wallet F.
        • Courcol R.
        • Durocher A.
        Risk of acquiring multidrug-resistant gram-negative bacilli from prior room occupants in the intensive care unit.
        Clin Microbiol Infect. 2011; 17: 1201-1208
        • Shaughnessy M.K.
        • Micielli R.L.
        • DePestel D.D.
        • Arndt J.
        • Strachan C.L.
        • Welch K.B.
        • et al.
        Evaluation of hospital room assignment and acquisition of Clostridium difficile infection.
        Infect Control Hosp Epidemiol. 2011; 32: 201-206
        • Lemmen S.W.
        • Hafner H.
        • Zolldann D.
        • Stanzel S.
        • Lutticken R.
        Distribution of multi-resistant gram-negative versus gram-positive bacteria in the hospital inanimate environment.
        J Hosp Infect. 2004; 56: 191-197
        • Cheng V.C.
        • Wu A.K.
        • Cheung C.H.
        • Lau S.K.
        • Woo P.C.
        • Chan K.H.
        • et al.
        Outbreak of human metapneumovirus infection in psychiatric inpatients: implications for directly observed use of alcohol hand rub in prevention of nosocomial outbreaks.
        J Hosp Infect. 2007; 67: 336-343
        • Sanderson P.J.
        • Weissler S.
        Recovery of coliforms from the hands of nurses and patients: activities leading to contamination.
        J Hosp Infect. 1992; 21: 85-93
        • Larson E.L.
        • Cronquist A.B.
        • Whittier S.
        • Lai L.
        • Lyle C.T.
        • Della L.P.
        Differences in skin flora between inpatients and chronically ill outpatients.
        Heart Lung. 2000; 29: 298-305
        • Banfield K.R.
        • Kerr K.G.
        • Jones K.A.
        • Snelling A.M.
        Hand hygiene and health care–associated infections.
        Lancet Infect Dis. 2007; 7 ([letter]): 304
        • Istenes N.A.
        • Hazelett S.
        • Bingham J.E.
        • Kirk J.
        • Abell G.
        • Fleming E.
        Hand hygiene in healthcare: the role of the patient.
        Am J Infect Control. 2011; 39 ([abstract]): E182
        • Lawrence M.
        Patient hand hygiene: a clinical inquiry.
        Nurs Times. 1983; 79: 24-25
        • Burnett E.
        • Lee K.
        • Kydd P.
        Hand hygiene: What about our patients?.
        Br J Infect Control. 2008; 9: 19-24
        • Banfield K.R.
        • Kerr K.G.
        Could hospital patients’ hands constitute a missing link?.
        J Hosp Infect. 2005; 61: 183-188
        • Ward D.
        Improving patient hand hygiene.
        Nurs Stand. 2003; 17: 39-42
        • Gagne D.
        • Bedard G.
        • Maziade P.J.
        Systematic patient hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital.
        J Hosp Infect. 2010; 75: 269-272
        • Grabsch E.A.
        • Burrell L.J.
        • Padiglione A.
        • O’Keefe J.M.
        • Ballard S.
        • Grayson M.L.
        Risk of environmental and healthcare worker contamination with vancomycin-resistant enterococci during outpatient procedures and hemodialysis.
        Infect Control Hosp Epidemiol. 2006; 27: 287-293
        • Savage J.
        • Fuller C.
        • Besser S.
        • Stone S.
        Use of alcohol hand rub (AHR) at ward entrances and use of soap and AHR by patients and visitors: a study in 27 wards in 9 acute NHS trusts.
        J Infect Prev. 2011; 12: 54-58
        • Sierla M.
        • Tamminen P.
        Patient hand hygiene in the hemodialysis environment [thesis].
        Helsinki Polytechnic, Helsinki [Finland]2007
        • Whiller J.
        • Cooper T.
        Clean hands: how to encourage good hygiene by patients.
        Nurs Times. 2000; 96: 38
        • Burnett E.
        Perceptions, attitudes, and behavior towards patient hand hygiene.
        Am J Infect Control. 2009; 37: 638-642
        • Pittet D.
        • Allegranzi B.
        • Storr J.
        • Bagheri N.S.
        • Dziekan G.
        • Leotsakos A.
        • et al.
        Infection control as a major World Health Organization priority for developing countries.
        J Hosp Infect. 2008; 68: 285-292
        • Pincock T.
        • Bernstein P.
        • Wartham S.
        • Holst E.
        Bundling hand hygiene interventions and measurement to decrease health care-associated infections.
        Am J Infect Control. 2012; 40: S18-S27
        • Tanner J.
        • Mistry N.
        Hand hygiene: product preference and compliance.
        Nurs Times. 2011; 107: 16-19
        • Klevens R.M.
        • Edwards J.R.
        • Richards Jr., C.L.
        • Horan T.C.
        • Gaynes R.P.
        • Pollock D.A.
        • et al.
        Estimating health care–associated infections and deaths in US hospitals, 2002.
        Public Health Rep. 2007; 122: 160-166
        • Scott R.D.
        The direct medical costs of healthcare-associated infections in US hospitals and the benefit of prevention.
        Division of Healthcare Quality Promotion National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta [GA]2009 (Available from: http://www.cdc.gov/ncidod/dhqp/pdf/Scott_CostPaper.pdf. Accessed January 18, 2012)
        • Agency for Healthcare Research and Quality
        2007 National Healthcare Disparities Report. AHRQ Report 08-0040.
        US Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville [MD]2008
        • Agency for Healthcare Research and Quality
        2010 National Healtcare Disparities Report. AHRQ Report 11-0005.
        US Department of Health and Human Services, Agency for Healthcare Research and Quality, Rockville [MD]2011
      6. Cunningham TR, Geller ES. Organizational behavior management in health care: applications for large-scale improvements in patient safety. In: Henriksen K, Battles JB, Keyes MA, Grady ML, editors. Advances in Patient Safety: New Directions and Alternative Approaches (Vol 2: Culture and Redesign). Rockville [MD]: Agency for Healthcare Research and Quality (US); 2008. p. 1-7. Available from: http://www.ahrq.gov/downloads/pub/advances2/vol2/Advances-Cunningham_11.pdf. Accessed December 6, 2011.

        • Davis R.E.
        • Sevdalis N.
        • Vincent C.A.
        Patient involvement in patient safety: how willing are patients to participate?.
        BMJ Qual Saf. 2011; 20: 108-114