Quantifying use of alcohol handrub (AHR) & soap by non-healthcare workers (HCW) in hand hygiene intervention studies

Background:           The volumes of alcohol hand rub &soap procured by wards provide a  proxy measure of hand hygiene compliance. This may  be distorted by use of AHR at ward entrances & bedside use of AHR/soap by patients’ & visitors. In England & Wales, the national cleanyourhands campaign  promoted use of bedside AHR by HCWs. An unintended consequence of the campaign was that many hospitals had AHR at ward entrances & encouraged staff, patients & visitors to use it. An evaluation of the campaign 2004-8 showed  procurement of soap & AHR had tripled but it not clear how much of the increase was due to non HCW use of consumables at ward entrances & the bedside. Such use has not been studied previously.   
Objective:               To estimate the proportion of ward procurement of AHR and soap attributable to use of AHR at ward entrances, and to use of soap & AHR by non- HCWs at the bedside.                
 
Methods:         
Proportion of AHR & soap used by visitors/patients inside the ward: Thirty six hours of direct observation of bedside hand hygiene behaviours by HCWs, patients and visitors were performed during weekday ward visiting hours (13.00-20.00hrs) on 27 acute medical wards and ITUs in 9 English trusts.

Proportion of AHR used at ward entrances: Each bag/bottle of AHR was collected from ward entrance dispensers for four consecutive days on 10 wards in 4 hospitals. Mean daily volume used was compared with mean daily ward procurement for the previous 12 months  
Results: At the bedside, only 6 (3.95%) out of 152 observed uses of AHR and 6 (4.35%)  of 138 uses of soap were by visitors. No patient used soap or AHR. Mean daily use of AHR at ward entrances was 21.4% (range 7.8-32.8%) of mean daily procurement.

 Conclusions: In this multicentre study, 96% of all bedside soap/AHR use appeared to be by HCWs.   Although the proportion of AHR used at ward entrances varies widely, as much of its use occurs outside visiting hours, it seems reasonable to assume at least half of such use is by HCWs, which implies that at least 85% of ward AHR procurement represents use by HCWs.  The rise in consumables reported during the cleanyourhands campaign are largely attributable to their use by HCWs, rather than visitors & patients. We suggest that hand hygiene intervention studies using consumables as a proxy measure should assess & adjust for such use.