Hand hygiene compliance among paramedics “remarkably low”

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Paramedics’ compliance with WHO hand hygiene guidelines seems to be “remarkably low,” according to a new observational study of ambulance staff practice in Australia and three other countries. And over-reliance on gloves suggests paramedics may be more aware of their own infection risk rather than that of their patients, says the researchers. 

Despite concerted efforts to tackle the prevalence of healthcare associated infections (HAI), the risk remains high, affecting up to one in 10 patients in developed countries. These infections are associated with a heightened risk of ill health and death as well as additional health service costs. Good hand hygiene is the most effective way of stopping the spread of bacteria/viruses, and is associated with the quality of patient care.

The researchers wanted to assess how well paramedics in different countries complied with World Health Organization recommended hand and basic hygiene standards, including the use of gloves, to protect themselves and their patients from the risk of infection. The study observed ambulance staff practice in in Australia, Finland, Sweden and Denmark, and found that compliance appears to be lacking. Compliance rates varied substantially among the four countries, with paramedics in Denmark coming out best - Australia the worst.

In the study “Compliance with hand hygiene in emergency medical services: an international observational study” published in BMJ's Emergency Medicine Journalcompliance was assessed against WHO guidelines on the five triggers for hand hygiene using either antiseptic rub or soap and water. These triggers were:

  1. Before touching the patient
  2. Before any ‘clean’ procedure, such as an injection or cleaning a wound
  3. After contact with bodily fluids/wounds
  4. After touching the patient
  5. After handling the patient’s belongings or anything in the immediate vicinity, such as the stretcher harness

Between December 2016 and May 2017, 77 paramedics dealt with 87 patients, resulting in 240 hours of observation.

While compliance with basic hygiene standards was high: short, clean nails (83%); hair short or tied back (99%); and no jewellery worn (62%), compliance with hand hygiene was poor. In all, 1,344 hand hygiene triggers were recorded during this period, but complied with in only 15% of instances.

When broken down separately by trigger, compliance was just 3% before touching a patient and 2% before any ‘clean’ procedure. This rose to 8% after contact with bodily fluids, 29% after touching the patient, and to 38% after touching belongings, etc.

Hand hygiene is about protecting the patient. Using gloves is primarily about protecting oneself. 

Paramedics used gloves in just over half (54%) of the recommended instances, with new gloves worn before touching patients around half the time (48%), but in only 14% of ‘clean’ procedures. There was a tendency to wear the same pair of gloves throughout different indications, e.g. after touching a contaminated site and touching the patient for the first time (21%) or before a ‘clean’ procedure (64%). Gloves were also worn when there was no obvious need, such as when there was no risk of bodily fluids. 

Hand hygiene was less likely when gloves were worn. Proper hand hygiene was observed in only 2% of times when gloves were worn, compared to 30% of the time when no gloves were worn. This, the researchers say, suggests an over reliance on gloves to ward off the risk of infection. “Hand hygiene compliance among [emergency medical service] providers was remarkably low. There was an over reliance on gloves, indicating a tendency towards self-protection instead of patient protection,” they said.

The researchers added: “it is important to note that [hand hygiene] is about preventing the spread of microbes and thus protecting the patient. Whereas the use of gloves primarily is about protecting oneself from bodily fluids, and so on.”

This is an observational study, and it is very likely that behaviours might have been influenced by the presence of the observers, say the researchers. As such, no firm conclusions can be drawn about the findings. Nevertheless, the researchers suggest their findings show that further research is warranted on the barriers to good hand hygiene and how healthcare providers understand its value.