Foreword

Hand hygiene in healthcare settings seems like a pretty simple act. One places an antiseptic agent on the hands, rubs the hands together to reduce the transient microorganisms, dries the hands or lets them dry, and thereby reduces the risk of transmission of pathogens to patients and to the healthcare worker. In Hand Hygiene, Drs Pittet, Boyce, and Allegranzi, and their esteemed colleagues, show us how complicated - yet essential - hand hygiene really is.

The book encompasses all the important aspects of hand hygiene. Each chapter has a simple-to-read format: key messages; what we know - the scientific evidence; what we don't know; and the research that needs to be done to fill these gaps. The authors begin by providing a summary of the current status of data on healthcare-associated infections (HAIs) in both developed and resource-limited countries. These data show the enormous impact that HAIs have throughout the world, including morbidity, mortality, and cost. This chapter also illustrates how even now - over thirty-five years since the Centers for Disease Control and Prevention's (CDC) Study of the Efficacy of Nosocomial Infection Control (SENIC) programs documented the preventive impact of HAI surveillance and prevention intervention programs - many countries still do not have adequate surveillance systems in place to even answer what their HAI rates are, much less evaluate the impact of prevention interventions.

Next, the authors describe the history of hand hygiene from the time of Semmelweis, discuss the flora and physiology of skin, describe the dynamics of pathogen transmission from the skin, and culminate in three chapters on mathematical models of hand-borne pathogen transmission, methodological issues in hand hygiene science, and statistical issues in hand hygiene research. These last three chapters highlight the many gaps in our knowledge about hand hygiene, illustrate the weaknesses in many if not most of our current studies, and point out that conducting the studies that are necessary may be more difficult than Semmelweis's challenge of convincing clinicians that hand hygiene should be done at all. Essential issues include antiseptic agent volume, method of application, duration of application, agent formulation, and when these are all optimized, and what percentage of HAIs are prevented by best practices. These methodological chapters are particularly important, as they illustrate that if our Guidelines are supposed to depend solely upon well-designed randomized controlled trials (RCTs) of hand hygiene - rather than on the entire body of epidemiologic data - such RCTs do not and probably never will exist, and hand hygiene will be relegated to an unresolved issue. These methodological issues also should be kept in mind as one reads the rest of this book (or other published literature) in which many studies are referenced that suffer from these methodological design flaws.

The next three chapters discuss the various available hand hygiene agents, the methods for evaluating their efficacy and the hand hygiene technique. These chapters are incredibly important and discuss issues often not known or understood in the infection control/patient safety community. Data show that formulation of alcohol-based hand hygiene agents matters. The chapter on evaluating efficacy illustrates the differences between North American and European standards - that is American Society for Testing Methods (ASTM) vs. Comité Européen de Normalisation (CEN or EN) standard methods. Everyone in infection control should understand the different methods used, what these tests do and do not tell us about efficacy, how in vivo testing does or does not relate to clinical practice, and the importance of demanding that all manufacturers provide such data to us when we are comparing products. Formulation matters, and such testing can document this.

This leads to several chapters on compliance with hand hygiene best practices, barriers to compliance, and a discussion of physicians and the almost universal finding that they are the worst compliers with hand hygiene recommendations of all healthcare workers. We must ask ourselves exactly what compliance with hand hygiene best practices is. Is it as mentioned at the beginning of this foreward simply applying some agent (formulation and amount irrelevant) and rubbing our hands together (duration and method irrelevant)? Or does compliance with hand hygiene best practices mean using a formulation documented to be effective, using the correct volume of that specific product documented in the ASTM or EN standard testing (realizing that volume will differ by product and for gels, foams vs. rubs), applying the product in a specific manner (such as recommended by the World Health Organization [WHO]), for the correct duration, at each of the WHO five moments? With current visual observation of hand hygiene "compliance," how many healthcare workers pay any attention to the volume of agent used, the method of application, the duration of application, and so on. All of these are critical elements in hand hygiene best practices, yet they are often ignored. We need more precise definitions of what hand hygiene best practices are and when they should be done and measured. From the patient's perspective, moments 1 and 2 are most important. From the healthcare worker's perspective, moments 3, 4, and 5 are most important. These chapters also raise questions about who should monitor hand hygiene compliance (self-reporting appears to generally be inaccurate), when and how.

The next general area includes a discussion of behavior and hand hygiene, hand hygiene promotion strategies, the WHO five moments for hand hygiene, system change, and education of healthcare professionals. These chapters illustrate the continual struggle that those of us in infection control/quality improvement have trying to educate our healthcare workers about the importance of hand hygiene and methods to improve behavior, reduce barriers to compliance, and try to change our systems. Do we continue to invest enormous resources (time, personnel, and funding) to these activities to try to get our healthcare "professionals" to comply with hand hygiene best practices, or do we follow the dictates of the chapter on "Personal Accountability for Hand Hygiene"? As we have learned in the United States, if we do not regulate ourselves (e.g., through mandatory reporting of HAI rates, reduced funding for preventable HAIs), outside regulatory agencies will (i.e., the government). We all agree that proper performance of hand hygiene will reduce HAIs and improve patient safety. Then why do we accept noncompliance?

The chapter on monitoring hand hygiene compliance is critical. What should the gold standard be for measuring hand hygiene compliance? The majority of those measuring hand hygiene compliance (and/or publishing such studies) use "trained observer" visual observation. This chapter describes some flaws in such an approach: it is prone to bias, overestimates true performance, often captures <1% of hand hygiene opportunities at the time in the institution (yet is generalized to the entire facility), has large inter-rater variation, etc. As these authors state, "Today, a unique reliable and robust method to measure hand hygiene performance does not exist." We know that indirect and less costly (time, personnel, etc.) methods for estimating hand hygiene compliance, such as measuring the amount of agent used, are not accurate. We know that merely measuring hand hygiene compliance on patient room entry or exit does not predict in-room practices (which are most important for the prevention of pathogen transmission to the patient). We know that self-reporting is grossly inaccurate. However, at least in developing countries, emerging technologies may be the answer for the future. The question becomes what we want the system to measure. Currently, electronic systems can measure whether hand hygiene is performed. Such systems generally do not assess the volume of the specific product, the method and duration of application, or specific compliance with each of the five moments or with specific invasive procedures. Video systems are just emerging and have the capacity not only to measure all these elements, but also to be a record to play back for healthcare workers who deny their noncompliance. In the future, where our systems truly demand individual accountability, such video/electronic systems may become essential. It does appear that at least in the developing world - as personnel clinician accountability is enforced and systems insist that hand hygiene best practices be a patient safety issue and thus must be complied with, for cost and personnel reasons - electronic or video systems for hand hygiene measure will become integral components of our measuring systems.

The book ends with chapters on national and international campaigns and regulatory/accrediting body approaches. Undoubtedly, such campaigns - whether local, system-wide, state or nationwide or worldwide - have improved hand hygiene awareness, importance, and compliance. Given the large number of elements we have learned in this book are required for true "hand hygiene best practices compliance" - that is, the best agent, the correct volume, application in compliance with the five moments, application in the correct fashion and for the correct duration - it is hard to believe local or national hand hygiene compliance rates of 85%-95% or that such levels - even if they can be achieved - can be...