Hand hygiene

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Authors

Rittenschober-Böhm J, Schwindt E, Hogeveen M, Mader S, Thiele N

Click on the image to read the standard in brief.

Target group

Infants, parents, families, and staff

User group

Healthcare professionals, neonatal units, hospitals, and health services

Statement of standard

Hand hygiene is a key measure to prevent healthcare associated infections, therefore staff as well as parents and visitors must adhere to best hand hygiene practice.

Rationale

Healthcare associated infections (HAIs) represent a major burden on intensive care units and a challenge for patient safety. Due to their immature immune host defence and invasive procedures, new-borns and preterm born children are especially vulnerable, and HAIs are associated with considerable morbidity and mortality as well as adverse long-term outcome. (1-4) Moreover, HAIs also increase the duration of hospital stay and costs and therefore pose a relevant economic factor. (1)

HAIs are mainly transmitted by the contaminated hands of healthcare workers, parents, and other people taking care of the babies. (5,6) Hand hygiene, meaning the cleaning of the hand, with alcohol-based handrub according to the WHO guidelines is the global standard of care and the most effective measure available to reduce HAIs. (7) Yet, compliance with hand hygiene is mostly reported to be low. (6,8) Therefore, teaching as well as ongoing awareness campaigns are essential to improve hand hygiene and prevent HAIs in neonates.

Benefits

Short-term benefits

Long-term benefits

Components of the standard

Component

Grading of evidence

Indicator of meeting the standard

For parents and family

  1. Parents and other visitors are informed and instructed by healthcare professionals about hand hygiene compliance and technique according to the World Health Organisation’s (WHO) ‘my five moments of hand hygiene’. (12)

A (High quality)
B (High quality)

Parent feedback, patient information sheet1

  1. Parents and visitors are reminded about the importance of hand hygiene by posters, stickers, visual and vocal prompts. (12,13)

A (High quality)

Patient information sheet1

  1. Rings, watches, and bracelets are not to be worn in the neonatal unit. (12)

A (Moderate quality)
B (Moderate quality)

Patient information sheet1

  1. Cell phones are not allowed or only allowed if stored in a plastic bag. (14,15)

A (High quality)

Patient information sheet1

For healthcare professionals (HCW)

  1. A unit guideline on hand hygiene is adhered to by all healthcare professionals. (9,16)

A (High quality)
B (High quality)

Guideline

  1. Training on hand hygiene is attended by all healthcare professionals. (9,12) 

A (Moderate quality)
B (High quality)

Training documentation

  1. Hand hygiene according to WHO’s ‘my five moments of hand hygiene’ is applied. (12)

A (High quality)

Guideline

  1. Single use non-sterile gloves are for self-protection only and are used where there is risk of body fluid contact or contact with multi resistant bacteria, followed by hand disinfection after usage. (12)

A (High quality)

Guideline

  1. Artificial nails, rings, watches, bracelets, ties and long sleeves are not to be worn in the neonatal unit. (12) 

A (Moderate quality)

Guideline

For neonatal unit

  1. Materials and equipment to effectively perform hand hygiene, including alcohol-based hand rub, continuous supplies of safe, clean water, soap and single-use towels are available at the point of care. (12)

A (High quality)

Guideline, audit report2

  1. Posters, stickers, banners, screensavers, etc. are functioning as regular reminders about the importance of hand hygiene. (12)

A (High quality)

Guideline, audit report2

  1. A unit guideline on hand hygiene is available and regularly updated. (12) 

A (High quality)
B (High quality)

Guideline

  1. Regular monitoring of HAIs as well as hand hygiene compliance is done and reported to HCWs in regular intervals (see standard Vascular access). (12)

A (Moderate quality)

Guideline, audit report2

  1. A designated healthcare professional to promote hygiene is available.

B (Moderate quality)

Audit report2

  1. An environment prioritising high compliance with hand hygiene is created. (12)

A (High quality)

Audit report2

  1. Sufficient HCW stuffing is ensured to enable optimal hand hygiene (see standard Nurse staffing in neonatal intensive care). (17)

A (High quality)

Audit report2

For hospital

  1. Training on hand hygiene for all professionals is ensured.

B (High quality)

Training
documentation

  1. Hand hygiene facilities e.g. sinks and disinfection solutions are provided at the point of care. (12)

A (Moderate quality)

Audit report2

  1. Resources for hand hygiene programmes and initiatives are available and supported by the leaders and management. (12)

A (Moderate quality)
B (High quality)

Audit report2

For health service

  1. A national guideline on hand hygiene is available and regularly updated. (12,13)

A (High quality)
B (High quality)

Audit report2, guideline

1The indicator “patient information sheet” is an example for written, detailed information, in which digital solutions are included, such as web-based systems, apps, brochures, information leaflets, and booklets.

2The indicator “audit report” can also be defined as a benchmarking report.

Where to go

Further development

Grading of evidence

For parents and family

  • Parents are motivated to remind HCW about the 5 moments of hand hygiene. (18)

A (Low quality)

  • An electronic tool for self-assessment is available giving objective feedback on hand hygiene performance. (19)

A (Low quality)

For healthcare professionals

  • Regularly use an electronic tool – provided at the unit – for self-assessment giving objective feedback on hand hygiene performance. (19,20)

A (Medium quality)

For neonatal unit

  • Establish an integrated hand hygiene adherence system that electronically provides quality feedback on hand hygiene performance of HCWs and visitors.

A (Moderate quality)

  • Identify determinants and barriers of HCW’s hand hygiene compliance.

A (Moderate quality)

  • Establish motivators, like signs with “days without nosocomial infection”.

B (High quality)

For hospital

  • Regularly conduct multimodal hand hygiene compliance campaigns.

A (Moderate quality)

  • Set incentives hand hygiene programmes and initiatives.

B (High quality)

For health service

  • Report on hand hygiene adherence.

A (Low quality)

Getting started

Initial steps

For parents and family

  • Parents and family are verbally informed and instructed by healthcare professionals about the importance of hand hygiene and steps of hand disinfection according to the WHO guideline. (12)

For healthcare professionals

  • Attend training on hand hygiene.
  • Perform hand hygiene with alcohol-based hand rub according to the WHO guidelines. (12)

For neonatal unit

  • Develop and implement a unit guideline on hand hygiene.
  • Develop information material on hand hygiene for parents and family.
  • Develop material used as reminders on hand hygiene.
  • Develop a formal education programme to cover all aspects of hand hygiene.
  • Measure adherence to hand hygiene guideline on regular basis.
  • Monitor nosocomial infection rate.

For hospital

  • Support healthcare professionals to participate in training on hand hygiene.
  • Support hand hygiene programmes and allocate resources.

For health service

  • Develop and implement a national guideline on hand hygiene.

  1. 1. Legeay C, Bourigault C, Lepelletier D, Zahar JR. Prevention of healthcare-associated infections in neonates: room for improvement. J Hosp Infect. 2015 Apr;89(4):319–23.
  2. 2. Giannoni E, Agyeman PKA, Stocker M, Posfay-Barbe KM, Heininger U, Spycher BD, et al. Neonatal Sepsis of Early Onset, and Hospital-Acquired and Community-Acquired Late Onset: A Prospective Population-Based Cohort Study. J Pediatr. 2018 Oct;201:106-114.e4.
  3. 3. Pichler K, Giordano V, Tropf G, Fuiko R, Berger A, Rittenschober-Boehm J. Impact of Different Types of Nosocomial Infection on the Neurodevelopmental Outcome of Very Low Birth Weight Infants. Children (Basel). 2021 Mar 9;8(3):207.
  4. 4. Flannery DD, Edwards EM, Coggins SA, Horbar JD, Puopolo KM. Late-Onset Sepsis Among Very Preterm Infants. Pediatrics. 2022 Dec 1;150(6):e2022058813.
  5. 5. Pittet D, Allegranzi B, Sax H, Dharan S, Pessoa-Silva CL, Donaldson L, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis. 2006 Oct;6(10):641–52.
  6. 6. Lotfinejad N, Peters A, Tartari E, Fankhauser-Rodriguez C, Pires D, Pittet D. Hand hygiene in health care: 20 years of ongoing advances and perspectives. Lancet Infect Dis. 2021 Aug;21(8):e209–21.
  7. 7. Pittet D, Allegranzi B, Boyce J, World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts. The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol. 2009 Jul;30(7):611–22.
  8. 8. Musu M, Lai A, Mereu NM, Galletta M, Campagna M, Tidore M, et al. Assessing hand hygiene compliance among healthcare workers in six Intensive Care Units. J Prev Med Hyg. 2017 Sep;58(3):E231–7.
  9. 9. Helder OK, Brug J, Looman CWN, van Goudoever JB, Kornelisse RF. The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison. Int J Nurs Stud. 2010 Oct;47(10):1245–52.
  10. 10. Pessoa-Silva CL, Hugonnet S, Pfister R, Touveneau S, Dharan S, Posfay-Barbe K, et al. Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics. 2007 Aug;120(2):e382-390.
  11. 11. Sewell E, Roberts J, Mukhopadhyay S. Association of Infection in Neonates and Long-Term Neurodevelopmental Outcome. Clin Perinatol. 2021 Jun;48(2):251–61.
  12. 12. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care Is Safer Care [Internet]. Geneva: World Health Organization; 2009. (WHO Guidelines Approved by the Guidelines Review Committee). Available from: http://www.ncbi.nlm.nih.gov/books/NBK144013/
  13. 13. Allegranzi B, Gayet-Ageron A, Damani N, Bengaly L, McLaws ML, Moro ML, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet Infect Dis. 2013 Oct;13(10):843–51.
  14. 14. Beckstrom AC, Cleman PE, Cassis-Ghavami FL, Kamitsuka MD. Surveillance study of bacterial contamination of the parent’s cell phone in the NICU and the effectiveness of an anti-microbial gel in reducing transmission to the hands. J Perinatol. 2013 Dec;33(12):960–3.
  15. 15. Kirkby S, Biggs C. Cell Phones in the Neonatal Intensive Care Unit: How to Eliminate Unwanted Germs. Adv Neonatal Care. 2016 Dec;16(6):404–9.
  16. 16. Kingston L, O’Connell NH, Dunne CP. Hand hygiene-related clinical trials reported since 2010: a systematic review. J Hosp Infect. 2016 Apr;92(4):309–20.
  17. 17. Küng E, Waldhör T, Rittenschober-Böhm J, Berger A, Wisgrill L. Increased nurse workload is associated with bloodstream infections in very low birth weight infants. Sci Rep. 2019 Apr 19;9(1):6331.
  18. 18. Bellissimo-Rodrigues F, Pires D, Zingg W, Pittet D. Role of parents in the promotion of hand hygiene in the paediatric setting: a systematic literature review. J Hosp Infect. 2016 Jun;93(2):159–63.
  19. 19. Lehotsky Á, Szilágyi L, Ferenci T, Kovács L, Pethes R, Wéber G, et al. Quantitative impact of direct, personal feedback on hand hygiene technique. J Hosp Infect. 2015 Sep;91(1):81–4.
  20. 20. Lehotsky Á, Morvai J, Szilágyi L, Bánsághi S, Benkó A, Haidegger T. [Hand hygiene technique assessment using electronic equipment in 26 Hungarian healthcare institutions]. Orv Hetil. 2017 Jul;158(29):1143–8.

Second edition, December 2024. Previous edition reviewed by Bilgin H & Gemma N.

Lifecycle

5 years/next revision: 2029

Recommended citation

GFCNI, Rittenschober-Böhm J et al., European Standards of Care for Newborn Health: Hand hygiene. 2024.

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