In a recently published study in the Journal of Hospital Infection, hand hygiene compliance in German hospitals showed improvements in four of the five moments for hand hygiene, according to data collected between 2015 and 2018. The data also reveals a lack of improvement in hand hygiene compliance before aseptic procedures, which is arguably the most important moment for preventing the spread of nosocomial infections in patient care.
While hygienic hand disinfection is considered the simplest, most economical and most important measure to prevent the spread of nosocomial infections in hospitals, in practice, this measure is often overlooked. In Germany alone, an estimated 600,000 hospital acquired infections could be avoided each year by further improving hand hygiene.
In a recently published study, data from more than 3,300 wards in over 500 hospitals were compiled to evaluate the current status of hand hygiene compliance in German hospitals. The National Reference Centre for Surveillance of Nosocomial Infections (NRZ) has been collecting standardized, country-wide data on hand hygiene compliance in German hospitals as part of the Clean Hands campaign (Aktion Saubere Hände), since 2015.
Background on direct observation of hand hygiene compliance in hospitals
Direct observation is a common way to monitor and record hand hygiene compliance data in hospitals. It consists of trained personnel observing hospital staff during their activities on the ward, noting the type of healthcare worker (e.g. doctor, nurse), and whether or not the healthcare worker performed the appropriate hand disinfection according to the World Health Organization’s (WHO) ‘My 5 Moments for Hand Hygiene’. Published in 2009 and since adapted by the Clean Hands campaign, the five key moments for hand hygiene in hospitals are:
- before patient contact,
- before clean/aseptic procedures,
- after body fluid exposure/risk,
- after patient contact, and
- after contact with the patient’s surroundings.
Hand hygiene compliance lacking before aseptic procedures
Over the course of a single shift, healthcare workers must disinfect their hands a multitude of times to meet the recommendations from the My 5 Moments for Hand Hygiene guidelines. Throughout the duration of the entire observation period between 2015 and 2018, the participating hospitals recorded almost 1,500,000 opportunities for hygienic hand disinfection. Overall, results were positive, showing an increase in hand hygiene compliance from 72% to 76%, when considering all five key moments across all hospital wards. In terms of hand hygiene compliance by ward type, compliance in intensive care units made the biggest leap from 73% to 79% within the reporting period.
Although it is commonly considered the most important moment for infection prevention in patient care, hand hygiene compliance before clean/aseptic procedures has not significantly improved over the years. Clean/aseptic procedures are tasks that take place on a clean site, such as performing wound care, giving an injection, or more invasive procedures like placing a catheter. The risk of developing a nosocomial infection is especially high during this type of task, since contact with the body’s mucous membranes carries with it a major potential for exposure to infection. Hygienic hand disinfection is therefore a critical tool in providing safe patient care.
Additional existing literature also highlights the trend that this moment for hand hygiene in particular, falls behind the other four moments in terms of compliance. In a recently published Danish study, hand hygiene compliance before aseptic activities in emergency medicine was only 2%, falling far below hygienic hand disinfection after patient contact (29%), and hygienic hand disinfection after contact with the direct patient environment (38%). 
While the widespread lack of hand hygiene compliance before clean/aseptic procedures is troubling, there exists an opportunity to implement further measures to improve hand hygiene compliance within the healthcare system and avoid preventable infections. For example, training and refresher courses on the correct use of disposable medical gloves and hand hygiene requirements can support safer patient care. Studies reveal wearing protective gloves can lead to lower hand hygiene compliance among healthcare workers, who also often wear gloves when they are not required.  Having access to hand sanitizers at the point-of-care and regular feedback on hand hygiene compliance are also critical tools in providing safer patient care.
Improve hand hygiene effortlessly
Providing healthcare workers with instant feedback on hand hygiene compliance has never been easier or more convenient, thanks to innovative new products like the ingo-man® SmartNose. When the correct volume of disinfectant has been dispensed, an integrated LED lights up to provide staff with instant feedback that they have successfully completed a hygienic hand disinfection.
Simultaneously, important data on the hand hygiene event, including the time, dispenser location, and amount of product dispensed, is recorded and transmitted to the Kanary. Using this software, hygiene specialists can evaluate hand hygiene compliance data and introduce targeted interventions to further improve hand hygiene compliance and ensure safer patient care.
Kramer, T. S., et al. “No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.” Journal of Hospital Infection (2020).
 Vikke, Heidi Storm, et al. “Hand hygiene perception and self-reported hand hygiene compliance among emergency medical service providers: a Danish survey.” Scandinavian journal of trauma, resuscitation and emergency medicine 27.1 (2019): 1-9.
 Fuller, Christopher, et al. “” The dirty hand in the latex glove”: a study of hand hygiene compliance when gloves are worn.” Infect Control Hosp Epidemiol 32.12 (2011): 1194-1199.