Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center?


      • An educational intervention study was completed to improve patient hand hygiene opportunities for patients at a large academic medical center.
      • After the intervention, it was possible to study the effects of improved patient hand hygiene on health care facility–onset Clostridium difficile infection events.
      • C difficile infection events decreased significantly (P ≤ .05) for 6 months after the intervention.
      • Patient hand hygiene may be an underused prevention measure for C difficile disease; successful implementation requires staff to engage the patient with opportunities, reminders, and encouragement to keep their hands clean.


      Hand hygiene plays an important role in the prevention of Clostridium difficile (CD) infection (CDI). Patient hand hygiene (PHH) may be a potentially underused preventative measure for CDI. Patient mobility and acuity along with a lack of education present obstacles to PHH for the hospitalized patient. Surveys of patients at our institution showed a need for increased PHH opportunities. The objective of this study was to increase PHH and to examine if PHH affected CDI at our hospital.


      A biphasic, quasi-experimental study was performed to increase PHH through education for staff and to provide education, assistance, and opportunities to the patient for hand cleaning. PHH practice was assessed by patient surveys and analyzed by χ2 test. PHH effect on CDI was determined by following health care facility–onset CD laboratory–identified events data analyzed by National Healthcare Safety Network standardized infection ratios (SIRs).


      PHH opportunities improved significantly (P < .0001) after staff and patient education. CD SIRs deceased significantly for 6 months (P ≤ .05) after the PHH intervention.


      PHH opportunities can be increased by providing education and opportunities for patients to clean their hands. PHH should be considered a relevant preventative measure for CDI in hospitalized patients.

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        • Healthcare Infection Control Practices Advisory Committee (HICPAC)
        Guideline for hand hygiene in health-care settings: recommendations of the healthcare infection control practices advisory committee and HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force.
        MMWR Recomm Rep. 2002; 51: 1-45
        • Aiello A.E.
        • Larson E.L.
        What is the evidence for a causal link between hygiene and infection?.
        Lancet Infect Dis. 2002; 2: 103-110
        • Aiello A.E.
        • Coulborn R.M.
        • Perez V.
        • Larson E.L.
        Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis.
        Am J Public Health. 2008; 98: 1372-1381
        • World Health Organization (WHO)
        WHO guidelines on hand hygiene in health care: first global patient safety challenge, clean care is safer care.
        World Health Organization, Geneva, Switzerland2009
        • Srigley J.A.
        • Furness C.D.
        • Gardam M.
        Measurement of patient hand hygiene in multiorgan transplant units using a novel technology: an observational study.
        Infect Control Hosp Epidemiol. 2014; 35: 1336-1341
        • Gagne D.
        • Bedard G.
        • Maziade P.J.
        Systematic patients' hand disinfection: impact on MRSA infection rates in a community hospital.
        J Hosp Infect. 2010; 75: 269-272
        • Ward D.
        Improving patient hand hygiene.
        Nurs Stand. 2003; 17: 39-42
        • Burnett E.
        Perceptions, attitudes and behavior towards patient hand hygiene.
        Am J Infect Control. 2009; 37: 638-642
        • Ardizzone L.L.
        • Smolowitz J.
        • Kline N.
        • Thorn B.
        • Larson E.L.
        Patient hand hygiene practices in surgical patients.
        Am J Infect Control. 2013; 41: 487-491
        • National Healthcare Safety Network (NHSN)
        Patient Safety Component Manual. Multidrug resistant organism and Clostridium difficile infection (MDRO/CDI) laboratory-identified event module.
        (Available from) (Accessed November 23, 2016)
        • Lessa F.C.
        • Mu Y.
        • Bamberg W.M.
        • Beldavs Z.G.
        • Dumyati G.K.
        • Dunn J.R.
        • et al.
        Burden of Clostridium difficile infection in the United States.
        N Engl J Med. 2015; 372: 825-835
        • Dubberke E.R.
        • Carling P.
        • Carrico R.
        • Donskey C.J.
        • Loo V.G.
        • McDonald L.C.
        • et al.
        Strategies to prevent Clostridium difficile infections in acute care hospitals: 2014 update.
        Infect Control Hosp Epidemiol. 2014; 35: 628-645
        • Hall J.
        • Horsley M.
        Diagnosis and management of patient with C. difficile-associated diarrhea.
        Nurs Stand. 2007; 21: 49-56
        • Banfield K.R.
        • Kerr K.G.
        Could hospital patients' hands constitute a missing link?.
        J Hosp Infect. 2005; 61: 183-188
        • Istenes N.
        • Bingham J.
        • Hazelett S.
        • Fleming E.
        • Kirk J.
        Patients' potential role in the transmission of healthcare associated infections: prevalence of contamination with bacterial pathogens and patient attitudes toward hand hygiene.
        Am J Infect Control. 2013; 9: 783-798
        • Sunkesula V.C.K.
        • Knighton S.
        • Zabarsky T.F.
        • Kundrapu S.
        • Higgins P.A.
        • Donskey C.J.
        Four moments for patient hand hygiene: a patient-centered, provider-facilitated model to improve patient hand hygiene.
        Infect Control Hosp Epidemiol. 2015; 36: 986-989
        • O'Donnell M.
        • Harris T.
        • Horn T.
        • Midamba B.
        • Primes V.
        • Sullivan N.
        • et al.
        Sustained increase in resident meal time hand hygiene through an interdisciplinary intervention engaging long term care facility residents and staff.
        Am J Infect Control. 2015; 43: 162-164
        • Pokrywka M.
        • Feigel J.
        • Douglas B.
        • Grossberger S.
        • Hensler A.
        • Weber D.
        A bundle strategy including patient hand hygiene to decrease C. difficile infections.
        Medsurg Nurs. 2014; 23: 145-148
        • Knighton S.C.
        • McDowell C.
        • Rai H.
        • Higgins P.
        • Burant C.
        • Donskey C.J.
        Feasibility: an important but neglected issue in patient hand hygiene.
        Am J Infect Control. 2017; 45: 626-629
        • Trick W.E.
        • Vernon M.O.
        • Hayes R.A.
        • Nathan C.
        • Rice T.W.
        • Peterson B.J.
        • et al.
        Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital.
        Clin Infect Dis. 2003; 36: 1383-1390
        • Knight N.
        • Strait T.
        • Anthony N.
        • Lovell R.
        • Norton H.J.
        • Sautter R.
        • et al.
        Clostridium difficile colitis: a retrospective study of incidence and severity before and after institution of an alcohol-based hand rub policy.
        Am J Infect Control. 2010; 38: 523-528
        • Sunkesula V.C.K.
        • Kundrapu S.
        • Knighton S.
        • Cadnum J.L.
        • Donskey C.J.
        Hand hygiene intervention on contamination of hospitalized patient's hands with healthcare-associated pathogens.
        Infect Control Hosp Epidemiol. 2017; 38: 595-597