Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene

Previously published guidelines provide comprehensive recommendations for hand hygiene in healthcare facilities. The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change. This expert guidance document is sponsored by the Society for Healthcare Epidemiology of America (SHEA) and is the product of a collaborative effort led by SHEA, the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), the Association for Professionals in Infection Control and Epidemiology (APIC), and The Joint Commission, with major contributions from representatives of a number of organizations and societies with content expertise. The list of endorsing and supporting organizations is presented in the introduction to the 2014 updates.

[1]  A. Marra,et al.  Positive deviance: a program for sustained improvement in hand hygiene compliance. , 2011, American journal of infection control.

[2]  A. Widmer,et al.  Introducing Alcohol-Based Hand Rub for Hand Hygiene The Critical Need for Training , 2007, Infection Control & Hospital Epidemiology.

[3]  J. Vinjé,et al.  Comparative efficacy of seven hand sanitizers against murine norovirus, feline calicivirus, and GII.4 norovirus. , 2010, Journal of food protection.

[4]  S. Cosgrove,et al.  Infection Prevention Promotion Program Based on the PRECEDE Model: Improving Hand Hygiene Behaviors among Healthcare Personnel , 2012, Infection Control & Hospital Epidemiology.

[5]  John M Boyce,et al.  Measuring Healthcare Worker Hand Hygiene Activity: Current Practices and Emerging Technologies , 2011, Infection Control & Hospital Epidemiology.

[6]  D. Srivastava,et al.  A practical guide to alcohol-based hand hygiene infrastructure in a resource-poor pediatric hospital. , 2009, American journal of infection control.

[7]  J. Kelly,et al.  Triclosan exposure increases triclosan resistance and influences taxonomic composition of benthic bacterial communities. , 2013, Environmental science & technology.

[8]  B. Allegranzi,et al.  The World Health Organization Guidelines on Hand Hygiene in Health Care and Their Consensus Recommendations , 2009, Infection Control & Hospital Epidemiology.

[9]  C. Umscheid,et al.  Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings , 2011, Infection Control & Hospital Epidemiology.

[10]  Arjun K Venkatesh,et al.  Use of electronic alerts to enhance hand hygiene compliance and decrease transmission of vancomycin-resistant Enterococcus in a hematology unit. , 2008, American journal of infection control.

[11]  R. Weinstein,et al.  Risk of Hand or Glove Contamination After Contact With Patients Colonized With Vancomycin-Resistant Enterococcus or the Colonized Patients' Environment , 2008, Infection Control & Hospital Epidemiology.

[12]  S. Berenholtz,et al.  Introduction to “A Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals: 2014 Updates” , 2014, Infection Control & Hospital Epidemiology.

[13]  Kerri A. Thom,et al.  Automated hand hygiene count devices may better measure compliance than human observation. , 2012, American journal of infection control.

[14]  R. Wenzel,et al.  Handwashing compliance by health care workers: The impact of introducing an accessible, alcohol-based hand antiseptic. , 2000, Archives of internal medicine.

[15]  L. Peterson,et al.  Prospective, controlled study of vinyl glove use to interrupt Clostridium difficile nosocomial transmission. , 1990, The American journal of medicine.

[16]  G. Kampf,et al.  Efficacy of three ethanol-based hand rubs against feline calicivirus, a surrogate virus for norovirus. , 2005, The Journal of hospital infection.

[17]  M. McGuckin,et al.  Hand Hygiene Product Volume Measurement: An Integral Part of a Multiple-Method Program , 2010, Infection Control & Hospital Epidemiology.

[18]  C. Donskey,et al.  Acquisition of spores on gloved hands after contact with the skin of patients with Clostridium difficile infection and with environmental surfaces in their rooms. , 2012, American journal of infection control.

[19]  B. Allegranzi,et al.  Educating healthcare workers to optimal hand hygiene practices: addressing the need , 2010, Infection.

[20]  D. Rowland,et al.  Effectiveness of a comprehensive hand hygiene program for reduction of infection rates in a long-term care facility. , 2013, American journal of infection control.

[21]  E. Kownatzki.  Hand hygiene and skin health. , 2003, The Journal of hospital infection.

[22]  R. Turner,et al.  Effectiveness of Hand Sanitizers with and without Organic Acids for Removal of Rhinovirus from Hands , 2010, Antimicrobial Agents and Chemotherapy.

[23]  M. Beach,et al.  Reduction in ventilator associated pneumonia in a mixed intensive care unit after initiation of a novel hand hygiene program. , 2011, Journal of critical care.

[24]  J. Streit,et al.  The Precision of Human-Generated Hand-Hygiene Observations: A Comparison of Human Observation with an Automated Monitoring System , 2012, Infection Control & Hospital Epidemiology.

[25]  J. Brug,et al.  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. , 2010, International journal of nursing studies.

[26]  H. Bensadoun,et al.  Hand-rubbing with an aqueous alcoholic solution vs traditional surgical hand-scrubbing and 30-day surgical site infection rates: a randomized equivalence study. , 2002, JAMA.

[27]  A. Kouatchet,et al.  Measurement and interpretation of hand hygiene compliance rates: importance of monitoring entire care episodes. , 2009, The Journal of hospital infection.

[28]  A Voss,et al.  No Time for Handwashing!? Handwashing Versus Alcoholic Rub Can We Afford 100% Compliance? , 1997, Infection Control & Hospital Epidemiology.

[29]  A. Oenema,et al.  Improving hand hygiene behaviour of nurses using action planning: a pilot study in the intensive care unit and surgical ward. , 2010, The Journal of hospital infection.

[30]  M. Drancourt,et al.  Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use , 2000, The British journal of dermatology.

[31]  J. Boyce,et al.  Low Frequency of Fires From Alcohol-Based Hand Rub Dispensers in Healthcare Facilities , 2003, Infection Control & Hospital Epidemiology.

[32]  Susan M. Gorski,et al.  Advanced technologies to curb healthcare-associated infections. , 2009, HealthcarePapers.

[33]  R. D. McCormick,et al.  Effect of education and performance feedback on handwashing: the benefit of administrative support in Argentinean hospitals. , 2003, American journal of infection control.

[34]  R. Weinstein,et al.  Transfer of vancomycin-resistant enterococci via health care worker hands. , 2005, Archives of internal medicine.

[35]  Angela Tavares Paes,et al.  Measuring Rates of Hand Hygiene Adherence in the Intensive Care Setting: A Comparative Study of Direct Observation, Product Usage, and Electronic Counting Devices , 2010, Infection Control & Hospital Epidemiology.

[36]  G. Kampf,et al.  Efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthy volunteers , 2010, BMC infectious diseases.

[37]  M. McGuckin,et al.  Hand Hygiene Compliance Rates in the United States—A One-Year Multicenter Collaboration Using Product/Volume Usage Measurement and Feedback , 2009, American journal of medical quality : the official journal of the American College of Medical Quality.

[38]  D. Armellino,et al.  A Randomized Trial of the Efficacy of Hand Disinfection for Prevention of Rhinovirus Infection , 2012, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[39]  John M Boyce,et al.  Hand hygiene compliance monitoring: current perspectives from the USA. , 2008, The Journal of hospital infection.

[40]  J. Groothoff,et al.  Characteristics of wet work in nurses , 2005, International archives of occupational and environmental health.

[41]  K. Kaye,et al.  Observer Bias in Hand Hygiene Compliance Reporting , 2010, Infection Control & Hospital Epidemiology.

[42]  P. Polgreen.  Badge brings automated edge to infection control. Interview by Alan Joch. , 2009, Materials management in health care.

[43]  A. Widmer,et al.  Effect of Teaching Recommended World Health Organization Technique on the Use of Alcohol-Based Hand Rub by Medical Students , 2010, Infection Control & Hospital Epidemiology.

[44]  S. Luby,et al.  Effect of intensive handwashing promotion on childhood diarrhea in high-risk communities in Pakistan: a randomized controlled trial. , 2004, JAMA.

[45]  J. Schrenzel,et al.  Temporal effects of antibiotic use and hand rub consumption on the incidence of MRSA and Clostridium difficile. , 2008, The Journal of antimicrobial chemotherapy.

[46]  Craig A. Umscheid,et al.  Guideline for Prevention of Catheter-Associated Urinary Tract Infections 2009 , 2010, Infection Control & Hospital Epidemiology.

[47]  E. Calbo,et al.  Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards. , 2012, Clinical microbiology and infection : the official publication of the European Society of Clinical Microbiology and Infectious Diseases.

[48]  P. Holliday,et al.  Acceptability of a wearable hand hygiene device with monitoring capabilities. , 2008, The Journal of hospital infection.

[49]  R. Halden.  On the Need and Speed of Regulating Triclosan and Triclocarban in the United States , 2014, Environmental science & technology.

[50]  J. Steinmann,et al.  Inactivation of feline calicivirus, a surrogate of norovirus (formerly Norwalk-like viruses), by different types of alcohol in vitro and in vivo. , 2004, The Journal of hospital infection.

[51]  E. Larson,et al.  Skin reactions related to hand hygiene and selection of hand hygiene products. , 2006, American journal of infection control.

[52]  S. Saint,et al.  Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: A 1-year postintervention evaluation. , 2011, American journal of infection control.

[53]  J. Fabry,et al.  Better compliance and better tolerance in relation to a well-conducted introduction to rub-in hand disinfection. , 2001, The Journal of hospital infection.

[54]  G. Bearman,et al.  Successful use of alcohol sensor technology to monitor and report hand hygiene compliance. , 2010, The Journal of hospital infection.

[55]  M. Whitby,et al.  Three successful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible? , 2008, American journal of infection control.

[56]  A. Bissery,et al.  Microbiological evaluation of two hand hygiene procedures achieved by healthcare workers during routine patient care: a randomized study. , 2005, The Journal of hospital infection.

[57]  P. Gastmeier,et al.  Establishment of a National Surveillance System for Alcohol-Based Hand Rub Consumption and Change in Consumption over 4 Years , 2012, Infection Control & Hospital Epidemiology.

[58]  F. Korkmaz,et al.  Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts , 2012 .

[59]  M. Jackson,et al.  2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Health Care Settings , 2007, American Journal of Infection Control.

[60]  M. Gilchrist.  Recommendations for Preventing the Spread of Vancomycin Resistance , 1995, Infection Control & Hospital Epidemiology.

[61]  J. Reinertsen,et al.  Reducing harm to patients. Using patient safety dashboards at the board level. , 2007, Healthcare executive.

[62]  J. Haas,et al.  Measurement of compliance with hand hygiene. , 2007, The Journal of hospital infection.

[63]  J. Richardus,et al.  Systematic Review of Studies on Compliance with Hand Hygiene Guidelines in Hospital Care , 2010, Infection Control & Hospital Epidemiology.

[64]  W. Stamm,et al.  Examination gloves as barriers to hand contamination in clinical practice. , 1993, JAMA.

[65]  A. Marra,et al.  Hand hygiene compliance in the critical care setting: a comparative study of 2 different alcohol handrub formulations. , 2013, American journal of infection control.

[66]  Alberto Maria Segre,et al.  A Mobile Handheld Computing Application for Recording Hand Hygiene Observations , 2010, Infection Control & Hospital Epidemiology.

[67]  J. Lucet,et al.  Hand contamination before and after different hand hygiene techniques: a randomized clinical trial. , 2002, The Journal of hospital infection.

[68]  M. Jackson,et al.  Guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings 2007. , 2007 .

[69]  Teresa C. Horan,et al.  Guideline for Prevention of Surgical Site Infection, 1999 , 1999, Infection Control & Hospital Epidemiology.

[70]  D. Pittet,et al.  Improving adherence to hand hygiene practice: a multidisciplinary approach. , 2001, Emerging infectious diseases.

[71]  G. Kampf,et al.  Influence of rub-in technique on required application time and hand coverage in hygienic hand disinfection , 2008, BMC infectious diseases.

[72]  Pengbo Liu,et al.  Laboratory Evidence of Norwalk Virus Contamination on the Hands of Infected Individuals , 2013, Applied and Environmental Microbiology.

[73]  E. Perencevich,et al.  Searching for an optimal hand hygiene bundle: a meta-analysis. , 2014, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[74]  E. Steinmann,et al.  Comparison of virucidal activity of alcohol-based hand sanitizers versus antimicrobial hand soaps in vitro and in vivo. , 2012, The Journal of hospital infection.

[75]  C. Skudlik,et al.  Prevention of occupational skin disease: a workplace intervention study in geriatric nurses , 2009, The British journal of dermatology.

[76]  B. Allegranzi,et al.  Role of hand hygiene in healthcare-associated infection prevention. , 2009, The Journal of hospital infection.

[77]  Mary J. Ogg,et al.  Recommended Practices for Hand Hygiene in the Perioperative Setting , 2013 .

[78]  Dinesh Nathwani,et al.  Effectiveness of an audible reminder on hand hygiene adherence. , 2012, American journal of infection control.

[79]  I. Gould.  Alexander Gordon, puerperal sepsis, and modern theories of infection control--Semmelweis in perspective. , 2010, The Lancet. Infectious diseases.

[80]  Matthew H Samore,et al.  Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance , 2002, The Pediatric infectious disease journal.

[81]  C. Brun-Buisson,et al.  Efficacy of handrubbing with alcohol based solution versus standard handwashing with antiseptic soap: randomised clinical trial , 2002, BMJ : British Medical Journal.

[82]  E. Larson,et al.  Analysis of alcohol-based hand sanitizer delivery systems: efficacy of foam, gel, and wipes against influenza A (H1N1) virus on hands. , 2012, American journal of infection control.

[83]  P. Dubbert,et al.  Increasing ICU staff handwashing: effects of education and group feedback. , 1990, Infection control and hospital epidemiology.

[84]  Alberto Maria Segre,et al.  Method for Automated Monitoring of Hand Hygiene Adherence without Radio-Frequency Identification , 2010, Infection Control & Hospital Epidemiology.

[85]  Jeannie P. Cimiotti,et al.  Adverse reactions associated with an alcohol-based hand antiseptic among nurses in a neonatal intensive care unit. , 2003, American journal of infection control.

[86]  Hugo Sax,et al.  Ha ndhyg ien e , 2018, Medicines Management for Residential and Nursing Homes.

[87]  J A Sellick,et al.  The use of statistical process control charts in hospital epidemiology. , 1993, Infection control and hospital epidemiology.

[88]  Lisa Saiman,et al.  Feedback as a strategy to change behaviour: the devil is in the details. , 2013, Journal of evaluation in clinical practice.

[89]  S. Sattar,et al.  Improved Inactivation of Nonenveloped Enteric Viruses and Their Surrogates by a Novel Alcohol-Based Hand Sanitizer , 2008, Applied and Environmental Microbiology.

[90]  T. Agner,et al.  Skin care education and individual counselling versus treatment as usual in healthcare workers with hand eczema: randomised clinical trial , 2012, BMJ : British Medical Journal.

[91]  C R Davis,et al.  Infection-free surgery: how to improve hand-hygiene compliance and eradicate methicillin-resistant Staphylococcus aureus from surgical wards. , 2010, Annals of the Royal College of Surgeons of England.

[92]  Fatma Demi̇r Korkmaz,et al.  Comparison of the efficiency of nail pick and brush used for nail cleaning during surgical scrub on reducing bacterial counts. , 2012, American journal of infection control.

[93]  K Azarnoush,et al.  An in-use microbiological comparison of two surgical hand disinfection techniques in cardiothoracic surgery: hand rubbing versus hand scrubbing. , 2007, The Journal of hospital infection.

[94]  D. Raoult,et al.  Low Frequency of Fires From Alcohol-Based Hand Rub Dispensers in Healthcare Facilities , 2003 .

[95]  M. Cullen,et al.  Urinary Triclosan is Associated with Elevated Body Mass Index in NHANES , 2013, PloS one.

[96]  E. Larson,et al.  Survival of influenza virus on hands and fomites in community and laboratory settings. , 2012, American journal of infection control.

[97]  L. Mermel,et al.  Factors Associated with Hand Hygiene Compliance at a Tertiary Care Teaching Hospital , 2013, Infection Control & Hospital Epidemiology.

[98]  Jane M. Young,et al.  Audit and feedback: effects on professional practice and healthcare outcomes. , 2012, The Cochrane database of systematic reviews.

[99]  M. Kundi,et al.  The influence of hand hygiene prior to insertion of peripheral venous catheters on the frequency of complications. , 2001, The Journal of hospital infection.

[100]  P. Lipsett,et al.  Isolation status and voice prompts improve hand hygiene. , 2007, American journal of infection control.

[101]  M. T. Wong,et al.  National and regional assessment of the antibacterial soap market: a step toward determining the impact of prevalent antibacterial soaps. , 2001, American journal of infection control.

[102]  J. Palmer,et al.  Avagard hand antisepsis vs. traditional scrub in 3600 pediatric urologic procedures. , 2010, Urology.

[103]  E. Larson,et al.  Assessment of two hand hygiene regimens for intensive care unit personnel , 2001, Critical Care Medicine.

[104]  W Schaffner,et al.  Nosocomial Transmission of Salmonella Gastroenteritis to Laundry Workers in a Nursing Home , 1994, Infection Control & Hospital Epidemiology.

[105]  J. L. Paquin,et al.  Activity of non antiseptic soaps and ethanol for hand disinfection. , 1985, Zentralblatt fur Bakteriologie, Mikrobiologie und Hygiene. 1. Abt. Originale B, Hygiene.

[106]  A. Kramer,et al.  Virucidal activity of a new hand disinfectant with reduced ethanol content: comparison with other alcohol-based formulations , 2005, Journal of Hospital Infection.

[107]  T. Palmore,et al.  Big brother is washing...Video surveillance for hand hygiene adherence, through the lenses of efficacy and privacy. , 2012, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[108]  R. Butler,et al.  Use of 0.3% triclosan (Bacti-Stat) to eradicate an outbreak of methicillin-resistant Staphylococcus aureus in a neonatal nursery. , 1995, American journal of infection control.

[109]  E. Larson,et al.  Consumer antibacterial soaps: effective or just risky? , 2007, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[110]  Shereen Smith.  A review of hand-washing techniques in primary care and community settings. , 2009, Journal of clinical nursing.

[111]  Jennifer Davis,et al.  Bacterial hand contamination among Tanzanian mothers varies temporally and following household activities , 2011, Tropical medicine & international health : TM & IH.

[112]  A. Detsky,et al.  Public reporting of hospital hand hygiene compliance--helpful or harmful? , 2010, Journal of the American Medical Association (JAMA).

[113]  A. Haverich,et al.  Hand hygiene compliance in transplant and other special patient groups: an observational study. , 2013, American journal of infection control.

[114]  H. Isenberg,et al.  Is hand washing really needed in an intensive care unit? , 1995, Critical care medicine.

[115]  P. Cooper,et al.  Competency assessment for infection control in the undergraduate dental curriculum , 2007, European journal of dental education : official journal of the Association for Dental Education in Europe.

[116]  D. Dwyer,et al.  An Outbreak of Viral Gastroenteritis in a Nursing Home: Importance of Excluding Ill Employees , 1996, Infection Control & Hospital Epidemiology.

[117]  E. Fendler,et al.  Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. , 2003, American journal of infection control.

[118]  Sanjay Saint,et al.  Guidelines for the prevention of intravascular catheter-related infections. , 2002, American journal of infection control.

[119]  G. Kampf,et al.  Less and less–influence of volume on hand coverage and bactericidal efficacy in hand disinfection , 2013, BMC Infectious Diseases.

[120]  I. Barr,et al.  Efficacy of soap and water and alcohol-based hand-rub preparations against live H1N1 influenza virus on the hands of human volunteers. , 2009, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[121]  M. Beach,et al.  Reduction in Ventilator-Associated Pneumonia in a Mixed Intensive Care Unit After Initiation of a Novel Hand Hygiene Program , 2012 .

[122]  Nico Hanenkamp,et al.  The Process Model for Shop Floor Management Implementation , 2013 .

[123]  Didier Pittet,et al.  Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HIPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. , 2002, American journal of infection control.

[124]  V. Curtis,et al.  Hand washing for preventing diarrhoea. , 2008, The Cochrane database of systematic reviews.

[125]  N. Eldridge,et al.  Using the six sigma process to implement the centers for disease control and prevention guideline for hand hygiene in 4 intensive care units , 2006, Journal of General Internal Medicine.

[126]  S. Hugonnet,et al.  Effectiveness of a hospital-wide programme to improve compliance with hand hygiene , 2000, The Lancet.

[127]  M. Tavolacci,et al.  Surgical hand rubbing compared with surgical hand scrubbing: comparison of efficacy and costs. , 2006, The Journal of hospital infection.

[128]  G. Ayliffe,et al.  Preliminary study of test methods to assess the virucidal activity of skin disinfectants using poliovirus and bacteriophages. , 1993, The Journal of hospital infection.

[129]  E. Larson,et al.  A causal link between handwashing and risk of infection? Examination of the evidence. , 1988, Infection control : IC.

[130]  Jeannie P. Cimiotti,et al.  Effect of antiseptic handwashing vs alcohol sanitizer on health care-associated infections in neonatal intensive care units. , 2005, Archives of pediatrics & adolescent medicine.

[131]  Stéphane Hugonnet,et al.  Alcohol-based handrub improves compliance with hand hygiene in intensive care units. , 2002, Archives of internal medicine.

[132]  Elaine L. Larson,et al.  An Organizational Climate Intervention Associated With Increased Handwashing and Decreased Nosocomial Infections , 2000, Behavioral medicine.

[133]  J. Chernova,et al.  Brushes and picks used on nails during the surgical scrub to reduce bacteria: a randomised trial. , 2009, The Journal of hospital infection.

[134]  Stéphane Hugonnet,et al.  Reduction of Health Care–Associated Infection Risk in Neonates by Successful Hand Hygiene Promotion , 2007, Pediatrics.

[135]  E. Petracci,et al.  Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants. , 2008, American journal of infection control.

[136]  S. Goyal,et al.  In-vivo efficacy of hand sanitisers against feline calicivirus: a surrogate for norovirus. , 2008, The Journal of hospital infection.

[137]  T. van Achterberg,et al.  The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program. , 2012, American journal of infection control.

[138]  B. Allegranzi,et al.  Surgical hand preparation: state-of-the-art. , 2010, The Journal of hospital infection.

[139]  Hugo Sax,et al.  The World Health Organization hand hygiene observation method. , 2009, American journal of infection control.

[140]  A. Kramer,et al.  Hand Rub–Associated Fire Incidents During 25,038 Hospital-Years in Germany , 2007, Infection Control & Hospital Epidemiology.

[141]  D. Gould,et al.  Measuring handwashing performance in health service audits and research studies. , 2007, The Journal of hospital infection.

[142]  J. Theis,et al.  Bacterial contamination of unused, disposable non-sterile gloves on a hospital orthopaedic ward. , 2013, The Australasian medical journal.

[143]  E. Talbot,et al.  Variability in the Hawthorne Effect With Regard to Hand Hygiene Performance in High- and Low-Performing Inpatient Care Units , 2009, Infection Control & Hospital Epidemiology.

[144]  L. Taylor.  An evaluation of handwashing techniques-1. , 1978, Nursing times.

[145]  Jaffar A Al-Tawfiq,et al.  Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections. , 2013, American journal of infection control.

[146]  Andrew G. Sahud,et al.  Measuring Hand Hygiene Compliance A New Frontier for Improving Hand Hygiene , 2009, Infection Control & Hospital Epidemiology.

[147]  J. Webster,et al.  Elimination of methicillin‐resistant Staphylococcus aureus from a neonatal intensive care unit after hand washing with triclosan , 1994, Journal of paediatrics and child health.

[148]  A. Gonzaga,et al.  Transmission of staphylococci between newborns. Importance of the hands to personnel. , 1962, American journal of diseases of children.

[149]  A. Muller,et al.  Lack of correlation between consumption of alcohol-based solutions and adherence to guidelines for hand hygiene. , 2005, The Journal of hospital infection.

[150]  S. Saint,et al.  Adoption of Alcohol-Based Handrub by United States Hospitals: A National Survey , 2008, Infection Control & Hospital Epidemiology.

[151]  R. Chaitow.  Guideline for prevention of catheter-associated urinary tract infections. , 1981, Infection control : IC.

[152]  R A Weinstein,et al.  Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant enterococcus species by health care workers after patient care. , 2001, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[153]  M. Taljaard,et al.  Interventions to improve hand hygiene compliance in patient care (Review) , 2015 .

[154]  K. Yuen,et al.  Introduction of an electronic monitoring system for monitoring compliance with Moments 1 and 4 of the WHO "My 5 Moments for Hand Hygiene" methodology , 2011, BMC infectious diseases.

[155]  Didier Pittet,et al.  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 , 2002 .

[156]  Nandini Dendukuri,et al.  Hand Hygiene with Soap and Water Is Superior to Alcohol Rub and Antiseptic Wipes for Removal of Clostridium difficile , 2009, Infection Control & Hospital Epidemiology.

[157]  Sanjay Saint,et al.  Guidelines for the prevention of intravascular catheter-related infections. , 2011, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[158]  E. Larson,et al.  Hand hygiene behavior in a pediatric emergency department and a pediatric intensive care unit: comparison of use of 2 dispenser systems. , 2005, American journal of critical care : an official publication, American Association of Critical-Care Nurses.

[159]  P. Gastmeier,et al.  Pathways to clean hands: highlights of successful hand hygiene implementation strategies in Europe. , 2010, Euro surveillance : bulletin Europeen sur les maladies transmissibles = European communicable disease bulletin.

[160]  Alberto Maria Segre,et al.  Healthcare Personnel Perceptions of Hand Hygiene Monitoring Technology , 2011, Infection Control & Hospital Epidemiology.

[161]  Amanda G. Garcia-Williams,et al.  To Ask or Not to Ask?: The Results of a Formative Assessment of a Video Empowering Patients to Ask Their Health Care Providers to Perform Hand Hygiene , 2010, Journal of patient safety.

[162]  Ruy Guilherme Rodrigues Cal,et al.  Positive Deviance A New Strategy for Improving Hand Hygiene Compliance , 2010, Infection Control & Hospital Epidemiology.

[163]  S. Sattar.  Microbicides and the environmental control of nosocomial viral infections , 2004, Journal of Hospital Infection.

[164]  B. Guidet,et al.  Availability of an alcohol solution can improve hand disinfection compliance in an intensive care unit. , 2000, American journal of respiratory and critical care medicine.

[165]  L. Saiman,et al.  Outbreak of Extended-Spectrum Beta-Lactamase–Producing Klebsiella Pneumoniae in a Neonatal Intensive Care Unit Linked to Artificial Nails , 2004, Infection Control & Hospital Epidemiology.

[166]  J. Bayas,et al.  Handwashing with soap or alcoholic solutions? A randomized clinical trial of its effectiveness. , 1999, American journal of infection control.

[167]  Janice Fitzgerald,et al.  A Surgical Site Infection Cluster: The Process and Outcome of an Investigation—The Impact of an Alcohol-Based Surgical Antisepsis Product and Human Behavior , 2010, Anesthesia and analgesia.

[168]  D. Ramsing,et al.  Temperature dependency of skin susceptibility to water and detergents. , 1996, Acta dermato-venereologica.

[169]  A. Widmer,et al.  Alcohol-Based Handrub: Evaluation of Technique and Microbiological Efficacy with International Infection Control Professionals , 2004, Infection Control & Hospital Epidemiology.

[170]  G. Scott,et al.  Discrepancy between self-reported and observed hand hygiene behaviour in healthcare professionals. , 2006, The Journal of hospital infection.

[171]  L. Hutwagner,et al.  A Prolonged Outbreak of Pseudomonas Aeruginosa in a Neonatal Intensive Care Unit Did Staff Fingernails Play a Role in Disease Transmission? , 2000, Infection Control & Hospital Epidemiology.

[172]  J. Dowd,et al.  The Impact of Bisphenol A and Triclosan on Immune Parameters in the U.S. Population, NHANES 2003–2006 , 2010, Environmental health perspectives.

[173]  Susun Bellew,et al.  A double-blind, randomized study to assess the effectiveness of different moisturizers in preventing dermatitis induced by hand washing to simulate healthcare use , 2011 .

[174]  Alexander I. Levchenko,et al.  The feasibility of an automated monitoring system to improve nurses' hand hygiene , 2011, Int. J. Medical Informatics.

[175]  Titus L. Daniels,et al.  Sustained Improvement in Hand Hygiene Adherence: Utilizing Shared Accountability and Financial Incentives , 2013, Infection Control & Hospital Epidemiology.

[176]  T. F. van de Mortel,et al.  An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions. , 2006, American journal of infection control.

[177]  William E. Trick,et al.  Influence of Role Models and Hospital Design on the Hand Hygiene of Health-Care Workers , 2003, Emerging infectious diseases.

[178]  A. Marra,et al.  Controlled Trial Measuring the Effect of a Feedback Intervention on Hand Hygiene Compliance in a Step-Down Unit , 2008, Infection Control & Hospital Epidemiology.

[179]  F. Gordin,et al.  Reduction in Nosocomial Transmission of Drug-Resistant Bacteria After Introduction of an Alcohol-Based Handrub , 2005, Infection Control & Hospital Epidemiology.

[180]  Martin Fortin,et al.  Canadian Task Force on Preventive Health Care , 2012 .

[181]  Kerri A. Thom,et al.  Accuracy of a radiofrequency identification (RFID) badge system to monitor hand hygiene behavior during routine clinical activities. , 2014, American journal of infection control.

[182]  O. Arah,et al.  Alcohol handrubbing and chlorhexidine handwashing protocols for routine hospital practice: a randomized clinical trial of protocol efficacy and time effectiveness. , 2012, American journal of infection control.

[183]  J. Brug,et al.  Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior. , 2012, American journal of infection control.

[184]  Jeannie P. Cimiotti,et al.  Assessing Nurses’ Hand Hygiene Practices by Direct Observation or Self-Report , 2004, Journal of Nursing Measurement.

[185]  R. Burgess,et al.  Effects of triclosan on marine benthic and epibenthic organisms , 2012, Environmental toxicology and chemistry.

[186]  D. Snydman,et al.  A multifaceted approach to education, observation, and feedback in a successful hand hygiene campaign. , 2011, Joint Commission journal on quality and patient safety.

[187]  P. Marcy,et al.  A prospective multicenter study evaluating skin tolerance to standard hand hygiene techniques. , 2011, American journal of infection control.

[188]  G. Ayliffe,et al.  Comparison of two methods for assessing the removal of total organisms and pathogens from the skin , 1975, Journal of Hygiene.

[189]  G. Guyatt,et al.  GRADE: an emerging consensus on rating quality of evidence and strength of recommendations , 2008, BMJ : British Medical Journal.

[190]  Yee-Chun Chen,et al.  Comparative antimicrobial efficacy of alcohol-based hand rub and conventional surgical scrub in a medical center. , 2015, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[191]  Alberto Maria Segre,et al.  Monitoring Hand Hygiene via Human Observers: How Should We Be Sampling? , 2012, Infection Control & Hospital Epidemiology.

[192]  N. Love,et al.  Triclosan Promotes Staphylococcus aureus Nasal Colonization , 2014, mBio.

[193]  S. Hugonnet,et al.  Dynamics of Bacterial Hand Contamination During Routine Neonatal Care , 2004, Infection Control & Hospital Epidemiology.

[194]  S. Green,et al.  Prevalence and correlates of skin damage on the hands of nurses. , 1997, Heart & lung : the journal of critical care.

[195]  Deverick J Anderson,et al.  Observing and Improving Hand Hygiene Compliance Implementation and Refinement of an Electronic-Assisted Direct-Observer Hand Hygiene Audit Program , 2013, Infection Control & Hospital Epidemiology.

[196]  M. Roivainen,et al.  Single treatment with ethanol hand rub is ineffective against human rhinovirus—hand washing with soap and water removes the virus efficiently , 2012, Journal of medical virology.

[197]  John M. Boyce,et al.  Evaluation of an Electronic Device for Real-Time Measurement of Alcohol-Based Hand Rub Use , 2009, Infection Control & Hospital Epidemiology.

[198]  H. Isenberg,et al.  Is the use of boxed gloves in an intensive care unit safe , 1993 .

[199]  J. Dumville,et al.  Surgical hand antisepsis to reduce surgical site infection. , 2016, The Cochrane database of systematic reviews.

[200]  Helen Burstin,et al.  Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals , 2008, Infection Control & Hospital Epidemiology.

[201]  S. Cronin,et al.  Infection prevention and control competencies for hospital-based health care personnel , 2008, American Journal of Infection Control.

[202]  Yee-Chun Chen,et al.  Compliance of Health Care Workers with Hand Hygiene Practices: Independent Advantages of Overt and Covert Observers , 2013, PloS one.

[203]  E. Perencevich,et al.  Comprehensive survey of hand hygiene measurement and improvement practices in the Veterans Health Administration. , 2013, American journal of infection control.

[204]  H. Sax,et al.  Impact of observation and analysis methodology when reporting hand hygiene data. , 2011, The Journal of hospital infection.

[205]  K. Wilhelm,et al.  Do atopics tolerate alcohol-based hand rubs? A prospective, controlled, randomized double-blind clinical trial. , 2006, Acta dermato-venereologica.

[206]  P. Hartemann,et al.  Prospective observational study to assess hand skin condition after application of alcohol-based hand rub solutions. , 2012, American journal of infection control.

[207]  Curtis J Donskey,et al.  Nosocomial transmission of vancomycin-resistant enterococci from surfaces. , 2002, JAMA.

[208]  Valerie Smith,et al.  Prospective, Controlled, Cross-Over Trial of Alcohol-Based Hand Gel in Critical Care Units , 2008, Infection Control & Hospital Epidemiology.

[209]  E. Fee,et al.  Oliver Wendell Holmes (1809-1894) and Ignaz Philipp Semmelweis (1818-1865): preventing the transmission of puerperal fever. , 2010, American journal of public health.

[210]  C. Landelle,et al.  Contamination of Healthcare Workers' Hands with Clostridium difficile Spores after Caring for Patients with C. difficile Infection , 2014, Infection Control & Hospital Epidemiology.

[211]  D. Becker,et al.  Nurses’ perceptions of the benefits and adverse effects of hand disinfection: alcohol‐based hand rubs vs. hygienic handwashing: a multicentre questionnaire study with additional patch testing by the German Contact Dermatitis Research Group , 2009, The British journal of dermatology.

[212]  B. Allegranzi,et al.  'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene. , 2007, The Journal of hospital infection.

[213]  Kerri A. Thom,et al.  Is hand hygiene before putting on nonsterile gloves in the intensive care unit a waste of health care worker time?--a randomized controlled trial. , 2013, American journal of infection control.

[214]  E. Medeiros,et al.  Assessment of Healthcare Professionals' Adherence to Hand Hygiene After Alcohol-Based Hand Rub Introduction at an Intensive Care Unit in São Paulo, Brazil , 2007, Infection Control & Hospital Epidemiology.

[215]  B. Allegranzi,et al.  Successful Implementation of the World Health Organization Hand Hygiene Improvement Strategy in a Referral Hospital in Mali, Africa , 2010, Infection Control & Hospital Epidemiology.

[216]  Donald Goldmann,et al.  Use of an Alcohol-Based Hand Rub and Quality Improvement Interventions to Improve Hand Hygiene in a Russian Neonatal Intensive Care Unit , 2003, Infection Control & Hospital Epidemiology.

[217]  P. Lipsett,et al.  Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit* , 2004, Critical care medicine.

[218]  J. Newman,et al.  Triclosan: a review of effectiveness and safety in health care settings. , 2000, American journal of infection control.

[219]  G. Kampf,et al.  Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance. , 2011, American journal of infection control.

[220]  James Christopher Post,et al.  An Electronic Hand Hygiene Surveillance Device: A Pilot Study Exploring Surrogate Markers for Hand Hygiene Compliance , 2010, Infection Control & Hospital Epidemiology.

[221]  J. Boyce,et al.  Lack of Association Between the Increased Incidence of Clostridium difficile–Associated Disease and the Increasing Use of Alcohol-Based Hand Rubs , 2006, Infection Control & Hospital Epidemiology.

[222]  J. Meeker,et al.  Relationship between urinary triclosan and paraben concentrations and serum thyroid measures in NHANES 2007-2008. , 2013, The Science of the total environment.

[223]  D. Gould,et al.  Hand hygiene technique. , 2008, Nursing standard (Royal College of Nursing (Great Britain) : 1987).

[224]  Y. Carmeli,et al.  A survey on handwashing practices and opinions of healthcare workers. , 2000, The Journal of hospital infection.

[225]  Adam M. Grant,et al.  It’s Not All About Me , 2011, Psychological science.

[226]  A. Calafat,et al.  Urinary Concentrations of Triclosan in the U.S. Population: 2003–2004 , 2007, Environmental health perspectives.

[227]  D. Zerr,et al.  Decreasing Hospital-Associated Rotavirus Infection: A Multidisciplinary Hand Hygiene Campaign in a Children's Hospital , 2005, The Pediatric infectious disease journal.

[228]  D. Pittet,et al.  Impact of a prevention strategy targeted at vascular-access care on incidence of infections acquired in intensive care , 2000, The Lancet.

[229]  J. Arbogast,et al.  Efficacy of Novel Alcohol-Based Hand Rub Products at Typical In-Use Volumes , 2013, Infection Control & Hospital Epidemiology.

[230]  N. J. Ehrenkranz,et al.  Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. , 1991, Infection control and hospital epidemiology.

[231]  D. Gerding,et al.  Effectiveness of Hand Hygiene for Removal of Clostridium difficile Spores from Hands , 2013, Infection Control & Hospital Epidemiology.

[232]  H. von Baum,et al.  Differences in Hand Hygiene Behavior Related to the Contamination Risk of Healthcare Activities in Different Groups of Healthcare Workers , 2004, Infection Control & Hospital Epidemiology.

[233]  S. Michie,et al.  Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study , 2012, BMJ : British Medical Journal.

[234]  Stuart Johnson,et al.  Effectiveness of Alcohol-Based Hand Rubs for Removal of Clostridium difficile Spores from Hands , 2010, Infection Control & Hospital Epidemiology.

[235]  V. Rogiers,et al.  Skin condition associated with intensive use of alcoholic gels for hand disinfection: a combination of biophysical and sensorial data , 2006, Contact dermatitis.

[236]  J. Schwartzman,et al.  Reduction in Intraoperative Bacterial Contamination of Peripheral Intravenous Tubing Through the Use of a Novel Device , 2009, Anesthesiology.

[237]  K. Bergstrom.  Update on antibacterial soaps: the FDA takes a second look at triclosans. , 2014, Journal of drugs in dermatology : JDD.

[238]  G. Scott,et al.  Hand hygiene posters: selling the message. , 2005, The Journal of hospital infection.

[239]  A. Abaza,et al.  Comparative study on efficacy of different alcohol hand rubs and routine hand wash in a health-care setting, alexandria, egypt. , 2010, The Journal of the Egyptian Public Health Association.

[240]  R. Taylor,et al.  Electronic surveillance of wall-mounted soap and alcohol gel dispensers in an intensive care unit. , 2007, The Journal of hospital infection.

[241]  S Creedon,et al.  Routine hand hygiene audit by direct observation: has nemesis arrived? , 2011, The Journal of hospital infection.

[242]  C. Donskey,et al.  Acquisition of Nosocomial Pathogens on Hands After Contact With Environmental Surfaces Near Hospitalized Patients , 2004, Infection Control & Hospital Epidemiology.

[243]  C. Gupta,et al.  Comparison of two alcohol-based surgical scrub solutions with an iodine-based scrub brush for presurgical antiseptic effectiveness in a community hospital. , 2007, The Journal of hospital infection.

[244]  E. Larson,et al.  Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities. , 2014, American journal of infection control.

[245]  J. Ferenc.  Handy solutions. Hygiene compliance monitoring goes high-tech. , 2012, Health facilities management.

[246]  Samantha Wu,et al.  Focus Group Study of Hand Hygiene Practice among Healthcare Workers in a Teaching Hospital in Toronto, Canada , 2010, Infection Control & Hospital Epidemiology.

[247]  D. Armellino,et al.  Replicating changes in hand hygiene in a surgical intensive care unit with remote video auditing and feedback. , 2013, American journal of infection control.

[248]  G. Ayliffe,et al.  A test for the assessment of 'hygienic' hand disinfection using rotavirus. , 1993, The Journal of hospital infection.

[249]  J. Brug,et al.  A Qualitative Exploration of Reasons for Poor Hand Hygiene Among Hospital Workers Lack of Positive Role Models and of Convincing Evidence That Hand Hygiene Prevents Cross-Infection , 2009, Infection Control & Hospital Epidemiology.