Question 11

You are asked to put in place initiatives to improve hand washing in your intensive care unit. List what initiatives you would institute.

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College Answer

Hand hygiene considered to be most effective measure to prevent health care related infections. However very poor compliance with hand washing in ICUs


a) Education

Lectures to medical and nursing staff

Recognition that compliance amongst medical staff is worse

Education of relatives/visitors

Education needs to be ongoing

b) Signage

Entrance and exit to unit


Labels on ventilators

Voice prompts by nurses at bedside

c) Introduce best handwashing products

New emollient soap

Alcohol hand rub at each bed

Non-allergenic handwash liquid

d) Sinks

Automated sinks

Adequate number of sinks in the unit.

e) Audit

Data collection before and after instituting initiatives: Hand washing surveys

Microbiological surveillance

f) Feedback to staff


LITFL have an excellent resource on this. Indeed, one can add little to the college answer, except some references. The definitive guide worldwide would probably be this WHO Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy. The entire 45 page document is a thrilling read. A summary of the major recommendations in point form is available at the end, and I will summarise it in the form of an answer to this question.

System change

  • Regular workplace survey to assess unmet goals
  • Ensure that products for hand hygiene are available at the point of care.
  • Improve tolerability of hand hygiene products
  • Improve ward infrastructure to improve access to handwashing facilities

Training and education

  • Health-care workers should check each others' compliance
  • Regular education meetings
  • Engage external educators
  • Engage internal educations who can act as role models
  • Focus on the doctors, who are generally the worst offenders

Reminders in the workplace

  • Posters
  • Promotions and rewards
  • Schedule presentations
  • Frequent educational sessions

Evalation and feedback

  • Regular monitoring of compliance
  • System of observers with centralised reporting
  • Rewards and demerits for compliance (or its lack)
  • Audit of changes in incidence of health care associated infections
  • Establish a system for continuous recording and reporting hand hygiene product consumption

There is a massive amount of literature out there.

Here is a synopsis of a few papers:

According to Kaplan et al:

  • Complicance with handwashing seems to be proportional to the number of sinks per patient.Ideally, the ratio should be 1:1.

According to Dubbert et al:

  • Handwashing classes are helpful
  • Feedback to staff about observed handwashing errors (it improves compliance to 97%!)

According to Panhotra et al:

  • Education campaign must be continuous
  • Posters are helpful

According to Mayer et al:

  • A good emollient handwash is all-important

According to Naikoba and Hayward:

  • Once-off education sessions have little effect
  • Automated sinks improve the quality of handwashing
  • Continued feedback of performance seems to be the strongest strategy.

Ultimately, all authors note that the best way to improve handwashing is "regular feedback" - that is to say, somebody constantly watching everyone, and telling them off for not washing their hands.


Dubbert, Patricia M., et al. "Increasing ICU staff handwashing: effects of education and group feedback." Infection Control and Hospital Epidemiology(1990): 191-193.


Panhotra, B. R., A. K. Saxena, and Al-Ghamdi AM Al-Arabi. "The effect of a continuous educational program on handwashing compliance among healthcare workers in an intensive care unit." British Journal of Infection Control 5.3 (2004): 15-18.


Mayer, Joni A., et al. "Increasing handwashing in an intensive care unit."Infection Control (1986): 259-262.


Naikoba, Sarah, and Andrew Hayward. "The effectiveness of interventions aimed at increasing handwashing in healthcare workers-a systematic review." Journal of Hospital Infection 47.3 (2001): 173-180.


Kaplan, Lois M., and Maryanne McGuckin. "Increasing handwashing compliance with more accessible sinks." Infection Control (1986): 408-410.


WHO have this statement: A Guide to the Implementation of the WHO Multimodal Hand Hygiene Improvement Strategy (2009)