Hospitals have known for a long time that hands carry infection from one patient to the next. In 1847, Ignaz Semmelweis made the students and doctors in his Vienna clinic clean their hands with a chlorine solution between patients, and deaths among new mothers dropped sharply. Knowing was never the hard part.
In December 1994, observers at the University of Geneva Hospitals began the first of seven hospital-wide surveys of routine care. Every time a nurse or doctor reached a moment when hands should be cleaned, the observer noted whether it happened. It happened 48% of the time.
The misses had a pattern. In a study of 2,834 such moments, published in 1999, Didier Pittet and his colleagues found that the more often care called for clean hands, the less often staff managed it. Intensive care, with about 20 opportunities per patient-hour, had the lowest rate, 36%. Pediatric wards, at about eight an hour, had the highest, 59%. Doctors missed more often than nurses.
A sink wash takes time a busy nurse doesn’t have. One intensive care study found nurses needed an average of 62 seconds to leave the bedside, walk to a sink, wash and get back. The usual remedy for poor compliance was more persuasion. A 2002 US guideline that Pittet wrote with John Boyce summed up the record: lectures, leaflets, workshops, feedback and even automated dispensers “have been associated with transient improvement.” Full adherence to the old rules, they wrote, “may be unrealistic.”
The Geneva campaign kept the persuasion. It had posters, a team drawn from several professions, and regular feedback to staff on how they were doing. But its special emphasis was alcohol hand rub at the bedside, which is quicker than a sink. Individual bottles of rub went to every ward. Custom-made holders were mounted on every bed. Staff were encouraged to carry bottles in their pockets, and in 1996 a flat bottle replaced the round one so it would fit better. A rub at the bedside takes, by the guideline’s estimate, about a quarter of the time of a trip to the sink.
By 1997, compliance had reached 66%. Washing with soap and water stayed about where it was; the gain came from the rub. The hospital’s use of hand rub went from 3.5 to 15.4 liters per 1,000 patient-days between 1993 and 1998. Over the same years, the share of patients with a hospital-acquired infection fell from 16.9% in 1994 to 9.9% in 1998, and MRSA transmission fell by more than half.
The authors wrote that promoting bedside hand rub “largely contributed” to the rise. The study followed one hospital before and during a campaign with several parts, so it can’t separate the bottles from the posters and feedback. The hospital had also started screening patients for MRSA at the same time, which may explain part of that drop. The guideline called Geneva’s the first hand-hygiene campaign to report an improvement sustained over several years.
Among doctors, hand hygiene stayed poor.