title: A large-scale assessment of hand hygiene quality and the effectiveness of the "WHO 6-steps".
abstract: BACKGROUND
  Hand hygiene compliance is generally assessed by observation of adherence to the "WHO five moments" using numbers of opportunities as the denominator. The quality of the activity is usually not monitored since there is no established methodology for the routine assessment of hand hygiene technique. The aim of this study was to objectively assess hand rub coverage of staff using a novel imaging technology and to look for patterns and trends in missed areas after the use of WHO's 6 Step technique.
  
  
  METHODS
  A hand hygiene education and assessment program targeted 5200 clinical staff over 7 days at the National University Hospital, Singapore. Participants in small groups were guided by professional trainers through 5 educational stations, which included technique-training and UV light assessment supported by digital photography of hands. Objective criteria for satisfactory hand hygiene quality were defined a priori. The database of images created during the assessment program was analyzed subsequently. Patterns of poor hand hygiene quality were identified and linked to staff demographic.
  
  
  RESULTS
  Despite the assessment taking place immediately after the training, only 72% of staff achieved satisfactory coverage. Failure to adequately clean the dorsal and palmar aspects of the hand occurred in 24% and 18% of the instances, respectively. Fingertips were missed by 3.5% of subjects. The analysis based on 4642 records showed that nurses performed best (77% pass), and women performed better than men (75% vs. 62%, p<0.001). Further risk indicators have been identified regarding age and occupation.
  
  
  CONCLUSIONS
  Ongoing education and training has a vital role in improving hand hygiene compliance and technique of clinical staff. Identification of typical sites of failure can help to develop improved training.
authors.affiliation: Department of Control Engineering and Information Technology (BME-IIT), Budapest University of Technology and Economics, Magyar tudósok krt, 2, Budapest H-1117, Hungary.
authors.forename: László
authors.initials: L
authors.lastname: Szilágyi
authors.forename: Tamás
authors.initials: T
authors.lastname: Haidegger
authors.forename: Akos
authors.initials: A
authors.lastname: Lehotsky
authors.forename: Melinda
authors.initials: M
authors.lastname: Nagy
authors.forename: Erik-Artur
authors.initials: EA
authors.lastname: Csonka
authors.forename: Xiuying
authors.initials: X
authors.lastname: Sun
authors.forename: Kooi Li
authors.initials: KL
authors.lastname: Ooi
authors.forename: Dale
authors.initials: D
authors.lastname: Fisher
mesh_terms: D000328:Adult; D005260:Female; D063373:Hand Hygiene / Q000379:methods / Q000592:standards* / Q000706:statistics & numerical data; D006266:Health Education; D006282:Health Personnel / Q000592:standards* / Q000706:statistics & numerical data; D006801:Humans; D008297:Male; D008875:Middle Aged; D015397:Program Evaluation; D012846:Singapore; D014944:World Health Organization