(Background) Hand hygiene and the use of alcohol-based hand sanitizers are recognized

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2 Abstract (Background) Hand hygiene and the use of alcohol-based hand sanitizers are recognized as the best means to prevent the spread of infection in the hospital setting. (Facts and problem statement) According to the World Health Organization (World Health Organization, 2009), an average of 8.7% of hospitalized patients develop a nosocomial infection during their stay. While emphasis has been placed on healthcare workers and hand hygiene compliance, little effort has been directed toward patient participation. The objective is to analyze and synthesize results from various studies to determine the efficacy of hand hygiene among patient populations. (Methods) The methods include using PubMed, MEDLINE, PubMed and Cochrane Library to uncover documents and reports regarding healthcare-associated infections, infection prevention, the use of hand hygiene, and patient compliance. (Results) Twenty-one unique studies have been analyzed for this review. Current progress shows a lack of research involving patient participation in hand hygiene despite evidence that patient compliance increases overall compliance of hand hygiene among healthcare workers and decreases the incidence of hospitalassociated infection among hospital patients. Observational studies suggest that patients see themselves as an important role in helping healthcare providers to comply with HHP, but few studies implement hand hygiene interventions among patient populations. (Discussion) Any attempt at promoting patient safety should include all stakeholders, including patients and hospital visitors. Little research has been done to evaluate the efficacy of patient-centered hand hygiene despite evidence that hand hygiene significantly decreases nosocomial infection among patient populations. (Importance) A patient-focused hand hygiene program may be as effective at decreasing the spread of infection. 2

3 Chapter I: Statement of the Problem Hand hygiene is universally recognized as a leading means in the prevention and reduction of infection along with the use of alcohol-based hand sanitizers. Healthcare-associated infections are a major determinant of morbidity and mortality. (Allegranzi et al., 2013) According to the World Health Organization (WHO), an average of 8.7% of hospitalized patients develop a nosocomial infection during their stay. (Ducel et al., 2002) Hand hygiene practices (HHP) are the best way to decrease bacteria and prevent the spread of infection. Despite the simplicity and ease of hand-washing, healthcare providers (HCP) compliance with HHP hovers around 40% (Allegranzi et al., 2013). Healthcare workers transmit pathogen-caused infections from patient-to-patient via the chain of infection (See Figure 1). This transmission requires a series of subsequent steps: 1) patients possess pathogens on the skin or in their bodily fluids, 2) the healthcare provider comes into direct contact with the patient or is exposed to bodily fluids and therefore, collects the pathogens on his or her hands, 3) pathogens can survive on the hands of healthcare providers for an extended period of time, 4) healthcare providers fail to perform adequate hand hygiene and 5) the healthcare provider exposes another patient to the pathogens via touch (Pittet et al., 2006). The World Health Organization and United States Centers for Disease Control and Prevention have published very specific hand hygiene protocol to be followed by HCPs (WHO, 2009; Boyce, 2002; Pittet et al., 2009). However, while healthcare professionals are required to utilize hand hygiene practices at five specific instances in the hospital (See Table 1), there is no regulation for patient-focused hand hygiene practices. Patient education and patient participation in health care interventions have been identified as an effective means to promote and maintain patient safety (Longtin). Yet, little 3

4 effort has been directed toward patient-focused hand hygiene practices. The objective of this systematic review is to determine whether patient-centered hand hygiene as opposed to no intervention reduces the incidence of nosocomial infection in the hospital. Chapter III: Methodology The review protocol utilized for this systematic review is the PRISMA (Preferred Reporting Instrument for Systematic reviews or Meta-Analyses) and can be located online ( (Moher et al., 2009) A systematic literature search was performed between October 2014 and February PubMed, MEDLINE, CINAHL and the Cochrane Library databases were searched. The purpose of this systematic review is to analyze the literature to determine the importance of patient involvement in HHP and to analyze the efficacy of patient-centered hand hygiene in the prevention of hospital-acquired infection. Search terms include Healthcare-associated infection linked with hand hygiene and patient safety. Additional accepted terms include nosocomial infection and handwashing and patient education. Studies were included if they had been published within the past fifteen years, if they had been peer-reviewed and if they were published in English. The process for selecting studies include screening, eligibility criteria, number of times the article has been cited and inclusion in a systematic review also reviewed for this study. Data collection was independent, and results were confirmed by availability of the information in other, high-quality, studies. Randomized controlled trials, systematic reviews and meta-analyses were all included for consideration. Studies were excluded if it did not address hand hygiene or hand hygiene compliance as a priority outcome. Each individual study was assessed for bias at the study 4

5 level. Then the information gathered in the results and discussion portion were further analyzed for this systematic review. Both publication bias and reporting bias are results of this review. Articles were only reviewed if they appeared in one of the four (PubMed, MEDLINE, CINAHL and the Cochrane Library) peer-reviewed, indexed publications. Many studies addressed social desirability, or the tendency for survey respondent to respond in a way they think the questioner will deem favorable. Chapter IV: Results From the key words and inclusion criteria, two hundred and eighty-four articles were selected for the title review. Nineteen were duplicates found in other databases and were discarded. Seventy-three pertained to something unrelated to hand hygiene and were discarded. Ninety-two pertained to something unrelated to healthcare associated infection and were discarded. One hundred articles were selected for the abstract review. Thirty-five were selected for-text review. Fourteen articles contained information already found in other articles. Twenty-one articles were selected for the final review. (See Figure 2) Of the twenty-one articles selected for final review, 28.6% (6/21) discussed patient involvement as an intervention to prevent the spread of infection % (3/21) were specific to patients, 41.43% (15/21) specific to healthcare providers (physicians, nurses, nursing assistants) and 14.29% (3/21) recommended both patient and healthcare provider intervention. Of the studies reviewed 14.3% (3/21) were conducted in the United States, 4.7% (1/21) in Canada, 52.4% (11/21) in Europe and 9.5% (2/21) in Asia. 14.3% (3/21) were systematic reviews of studies conducted in Europe and North America and 4.8% (1/21) in North America, Europe and South America. 5

6 52.4% (11/21) studies were conducted throughout the hospital in a variety of settings (acute care, intensive care, surgery). 38.1% (8/11) were conducted in acute care settings, 4.8% (1/21) in intensive care and 4.8% (1/21) in surgical care. The six articles that mentioned patient involvement suggest support of a link between 1) patient preference of hand hygiene products and participation in hand hygiene practices; 2) patient attitude of hand hygiene practices and patient participation; and 3) patient education of hand hygiene practices and patient participation. Research offers that patients are stakeholders in the prevention of nosocomial infection. Opinions vary with regards to the level of participation for which patients should be responsible (Seale et al., 2016) For patient, specific characteristics (foam, gel, wipe, etc.) and dispensers indicate a patient s likelihood of participating in HHP. (Tanner & Mistry, 2011) Patients who rate the efficacy and post-use period of the hand hygiene product higher are more likely to actively engage in HHP. It has been suggested that hand hygiene products should be formulated based on patient-preferences and likelihood of participating in HHP rather than with the HCP in mind. (Landers et al., 2012) One study proposes increasing the means by which hand hygiene may be performed simply by increasing the number of alcohol-based hand hygiene product dispensers, utilizing products that are patient-centered and patient-approved, constantly replenishing empty hand hygiene dispensers and increasing the options of different modes of hand hygiene (gel, spray, wipes; wall-mounted dispenser, tabletop dispenser, individual bottle). (Kendall et al., 2012) Education of the proper hand hygiene techniques is also vital. This education should focus not only on increasing the frequency of HHP among patients, but also should include the correct time and specific moments to perform HHP. One study also notes that patients understand the importance of hand washing in instances containing the consumption of food and 6

7 use of the bathroom but lack knowledge of other instances of contamination, such as procedures and prior to interaction with visitors to the hospital or other patients. (Bloomfield et al., 2007) Patient attitude and perception is a major determinant in patient participation with HHP. One study in England found that the majority of nurses understand hand hygiene as an important means of preventing the spread of infection and agree that the ease of HHP made it capable for most people to comply with. (Burnett, 2009) Burnett found that older adult nurses (>56) have the most positive attitude toward HHP, and younger adults (<26) has the poorest perception of patient-focused HHP. However, nearly 57% of nurses admit to forgetting to remind patients to wash their hands. (Burnett, 2009) Another study suggests that 96% of physicians do not perceive themselves as role models for HHP, which contributes to the lack of handwashing among physicians before and after patient contact. (Pittet et al., 2004) 79% of patients believed they should take role in helping healthcare providers to remember to perform HHP during their stay in the hospital. In addition, patients who possessed higher levels of extraversion and agreeableness were more likely accept HHP positively and to perform simple HHP. (Duncanson & Pearson, 2005) Empowering and inspiring patients to take a role in their disease management to promote more positive attitudes about hand hygiene practices among patients and focusing on the probability for infection prevention and treatment. (Seale et al., 2016) The number one determinant of patient participation in HHP is patient education. Healthcare provider compliance dramatically increases following implementation of hospital educational programs and gives way to transient improvement in HHP among providers. (Pittet et al., 2002) Similar improvements are expected with patient education. Educational interventions are the most viable strategy and predictor of behavior 7

8 development resulting in increased hand hygiene participation among hospital patients and the reduction of nosocomial infection rates. (Allegranzi & Pittet, 2009) Simple intervention of dayto-day activities minimally impacted patient compliance with HHP. Education with including perceived health threat and risk-benefit outcomes appears to have the greatest influence on behavior. Kretzer and Larson suggest omitting the use of the word compliance with education and substituting phrases that promote a sense of active participation and internalization. (Kretzer & Larson, 1998) Similarly, overwhelming evidence proposes educational intervention is the primary motivation for a behavior change among patients. (Safdar & Abad, 2008) This review provided little evidence of a link between the HCP hand hygiene compliance rate and patient participation. While substantial resources have been delegated to the improvement of healthcare providers HHP, compliance is at an all time low. There is a definite need for increase in HCP participation to become a foundation of patient care. (Mathai et al., 2010) Several studies suggest patients ask healthcare providers whether they had washed their hands before and after touching the patient. (McGukin et al., 2001; Duncanson & Pearson, 2005, Seale et al., 2016) One study found that 79% of patients believes they have responsibility to participate in HHP by helping to remind healthcare providers. (Duncanson & Pearson, 2005) One study supports that half of patients would remind HCPs to practice hand hygiene, and that number increases to nearly 75% if the patient believed the healthcare provider would welcome the suggestion. (Wu et al., 2013) Further research should commence to determine support of a link between these two variables and determine the percentage of patients that do actively remind HCPs to comply with hand hygiene policies. 8

9 Chapter V: Conclusions and Recommendations Further research is required to determine the efficacy of patient-focused hand hygiene in the hospital setting. Any attempt at promoting patient safety in the hospital should involve all stakeholders, including, but not limited to, healthcare providers, patients and hospital visitors. Despite evidence that patients are the primary means of transmitting nosocomial infection (Landers et al., 2012) little research has been published focusing on patient participation in hand hygiene practices. Increasing patient awareness of the significance of HHP as an effective means to decrease infection rates in the hospital is necessary to its acceptance in clinical practice. Initiating education upon admission and continuing throughout the duration of the hospital stay increases the likelihood of compliance in HHP among patients. Healthcare providers are responsible for advocating to establish standards that suggest patient-centered HHP as best practice. Furthermore, regulatory agencies at all levels, local through international, should echo the installation of HHP as a standard. The main limitation of this study was the lack of research available regarding the efficacy of patient-focused hand hygiene. Most studies were observational, narrative reviews and recommended further research to be completed to validate the findings. Whereas more studies utilized descriptive surveys to determine patient preference and patient knowledge of hand hygiene practices related to the development of nosocomial infection or simply encourage patients and visitors to ask healthcare professionals if they completed HHP. The remainder of studies examines the efficacy of hand hygiene among hospital workers and agreed with the World Health Organizations advocacy for enlisting patients in HHP. (World Health Organization, 2009) 9

10 Despite the evidence proving a decrease in healthcare-associated infections with an increase of hand hygiene, there is little research regarding implementation of hand hygiene practices with patients and their visitors. Hand hygiene and the use of alcohol-based hand sanitizers is best means to prevent nosocomial infection. Healthcare providers are required to wash their hands at five specific times: before entering a patient s room, before a clean or aseptic procedure, after exposure to patient bodily fluids, after touching a patient and after touching a patient s surroundings. Patient and family education about hand sanitizers is an effective means to improve patient outcomes. Therefore, patients and their visitors should be mandated to utilize these same practices. And, as a result, the incidence of nosocomial infection will greatly decrease, similar to the reduction of infection with the implementation of hand hygiene practices among HCPs. Patient-centered hand hygiene should be placed at a higher research priority and be evaluated through randomized-controlled trials to determine the efficacy and reduction of nosocomial infection. Funding Sources None. 10

11 Table 1. World Health Organization Hand Hygiene Recommendations Moment Before touching a patient Before a clean or aeseptic technique After exposure to a patient s bodily fluids After touching a patient Rationale To protect the patient from pathogens on the healthcare provider s hands To protect the patient from pathogens on the healthcare provider s hands To protect subsequent patients from pathogens on the healthcare provider s hands To protect subsequent patients from pathogens on the healthcare provider s hands After touching a patient s surroundings To protect subsequent patients from pathogens on the healthcare provider s hands NOTE. Adapted from The World Health Organization Guidelines on Hand Hygiene in Health Care, Table 2. Results Table Author (Year) Setting Intervention Results Allegranzi & Pittet (2009) Hospitalwide setting; narrative review; Switzerland Reviews factors influencing hand hygiene compliance, the impact of education and promotion on nosocomial infections and issues related to universal use of alcohol-based hand sanitizers as the primary system for hand hygiene Multimodal intervention strategies lead to improved hand hygiene compliance and the reduction of nosocomial infections; further research required to evaluate efficacy of multimodal components and to determine the most successful intervention Allegranzi, Sax & Pittet (2013) Hospitalwide setting; narrative review; Switzerland Summarizes available evidence determining need for systemchange and importance within multimodal hand hygiene practices and strategies Multimodal system change is essential to hand hygiene compliance and the reduction of healthcareassociated infection 11

12 Author (Year) Setting Intervention Results Bloomfied, Aiello, Cookson, O Boyle & Larson (2007) Hospital-wide setting; narrative review; United Kingdom Evaluates the use of ABHS as a primary HHP in developed countries (North American and Europe); synthesizes data from interventional studies to determine best hand hygiene strategies HHP significantly reduces the incidence of infection; hand hygiene, whether it be with soap and water or ABHS, is an effective way to decrease infection; education of proper HHP helps reduce nosocomial infections; to maximize benefits, education should accompany hand hygiene promotion Recommendation and indications for handwashing and hand antisepsis, hand hygiene technique, surgical hand antisepsis, selection of hand hygiene agents, skin care, educational/motivational programming, administrative measures 99.8% of respondents believed patient hand hygiene to be important part of preventing healthcare acquired infection; 98% believed patients were capable of passing pathogen-causing infections by a lack of hand hygiene practices; 97% agreed that infection rates can be reduced by implementing patientfocused hand hygiene practices Boyce & Pittet (2002) Hospital-wide setting; Guidelines and Recommendations; Switzerland Provides healthcare professionals a review of data of proper hand hygiene practices in the hospital setting Burnett (2009) Acute care setting; large, teaching hospital; United Kingdom Cross-sectional survey Ducel, Fabry & Nicolle (2002) Hospital-wide setting; guidelines and recommendations; Europe, United States Provide guidelines to aide in the prevention of hospital acquired infections Recommendation for appropriate hand hygiene practices in hospitals to decrease the incidence of nosocomial infection 12

13 Author (Year) Setting Intervention Results Duncanson & Pearson (2005) Acute care setting; large, teaching hospital; United Kingdom Descriptive survey of 200 hospitalized patients 150 responses (75% return rate); 118 (79%) believed they should take part in hand hygiene by reminding healthcare providers to wash their hands; age is significant factor in perception of hand hygiene Kendall, Landers, Kirk & Young (2012) Hospitalwide setting; narrative review; United States Review practices and recommendations to implement new hand hygiene behaviors with patients at specific times and locations that are identified as high-risk for pathogen transmission Support of evidence that healthcare providers should be utilizing HHP with the 5 Moments of Hand Hygiene Standard (WHO, 2009); recommendations for increasing number of permanent, wall-mounted alcohol-based hand sanitizer (ABHS) dispensers and increased use of individual bottles of ABHS with patients, increased use of tabletop ABHS dispensers; recommends patient participation in hand hygiene practices to reduce nosocomial infection rates Kretzer & Larson (1998) Hospitalwide setting; narrative review; United States Examines various behavioral interventions (Health Belief Model, Theory of Reasoned Action and Theory of Planned Behavior) to increase hand hygiene practices and improve infection control Include beliefs, perceived health threat, attitude, perceived norms and behavioral control and intention into hand hygiene education; promote a sense of active participation and internalization among patients with hand hygiene practices 13

14 Author (Year) Setting Intervention Results Landers, Abusalem, Coty & Bingham (2012) Hospitalwide setting; narrative review; United States Reviews the evidence of benefits of implementing hand hygiene practices with patients Lack of focus on patient hand hygiene regulation, opportunity for growth; patient-centered hand hygiene is next step in prevention of infection Longtin, Sax, Leape, Sheridan, Donaldson & Pittet (2010) Hospitalwide setting; critical review; Switzerland Critically review evidence of effective patient participation in hand hygiene practices, summarizes factors influencing implementation Patients can modify the behavior of healthcare professionals hand hygiene practices; current environments promote passive hand hygiene, and therefore patients are not likely to want to participate in HHP; patient reminders and education increased patient participation rate; patient participation in HHP is a critical element of hand hygiene promotion and the reduction of infection Mathai, Allegranzi, Kilpatrick & Pittet (2010) Hospitalwide setting; narrative review; India Review the role of hand hygiene with respect to the transmission of pathogen-caused infections Nosocomial infection rates remain high despite increased focus on HHP; recommendation to increase resources to further engage healthcare professionals in HHP 14

15 Author (Year) Setting Intervention Results McGuckin, Waterman, Storr, Bowler, Ashby, Topley & Porten (2001) Acute care setting; large hospital; United Kingdom Controlled, prospective intervention study; comparative study; 39 patients asks healthcare proessionals, did you wash your hands? ; measures compliance through soap and alcohol usage by healthcare professionals before and after intervention question from patients Healthcare professionals were more likely to wash their hands when taking care of a surgical patient than a medical patient; 62% of patients in the study were comfortable asking the healthcare provider about completing recommended hand hygiene practices; patients were more likely to ask nurses (100%) than physicians (35%) about hand hygiene practices Nevo, Fitzpatrick, Thomas, Gluck, Lenchus, Arheart & Birnbach (2010) Acute care setting; large hospital; United States Randomized, controlled trial; 150 healthcare providers (75 physicians, 75 nurses) performed a physical evaluation on a patient; researchers observes for healthcare professionals to maintain proper hand Visual interventions improved hand hygiene compliance from baseline (line of sight=53.3%, baseline and flicker=60%, line of sight and flicker=66%, warning sign=93%); only line of sight and flicker AND warning sign produced statistically significant increase pre-examintion, only warning sign produced statistically significant increase post-examination Pittet, Hugonnet, Harbarth, Mourouga, Sauvan, Touveneau & Perneger (2000) Acute care setting; large, teaching hospital; Switzerland Observed over 20,000 opportunities for hand hygiene; seven hospital-wide observational surveys were done twice yearly from December 1994 to December 1997; measured nosocomial infection rates Compliance with hand hygiene practices improved from 48% to 66% (p<0.001) in a three year period; compliance approved among nurses and nursing assistants, but remained poor with doctors 15

16 Author (Year) Setting Intervention Results Pittet, Simon, Hugonnet, Pessoa-Silva, Sauvan & Perneger (2004) Pittet, Allegranzi & Boyce (2009) Safdar & Abad (2008) Seale, Chughtai, Kaur, Rhillipson, Novytska & Travaglia (2016) Acute care setting; large, teaching hospital; Switzerland; Europe, United States, Canada Hospital-wide setting; Guidelines and Recommendations; Switzerland Intensive care setting; systematic review; Europe, North America, South America Surgical setting; large hospital; Australia Cross-sectional survey of 163 physicians (practices, beliefs, attitudes) Provide guidelines and recommendation for appropriate hand hygiene practices in health care Randomized trials that included an educational intervention and provided data on the occurrence of nosocomial infections; 26 studies targeted populations of healthcare providers to determine their effect on the rate Semi-structured, open-ended interviews with 29 staff members 57% of physicians adhered to hand hygiene policies (variable depending on specialty); adherence was higher when physicians knew they were being observed (61% vs. 44%); 85% reported awareness of possible crosscontamination with lack of hand hygiene; 77% intended to adhere to hand hygiene policies; 74% were motivated to improve hand hygiene practices Recommendation and indications for hygiene techniques and timing, surgical hand preparation, selection and handling hand hygiene products, skin care, use of gloves, governmental and institutional responsibilities 21 studies (80%) showed a significant decrease in infection rate after educational intervention (risk ratio ) Unanimous agreement among participants that patients should be seen as stakeholders and should have an active role in the prevention of healthcareassociated infection 16

17 Author (Year) Setting Intervention Results Tanner & Mistry (2011) We, Lee, Chen, Tsai, Li, Chao, Chou, Chen, Ke, Huang, Sy, Tseng & Chen (2013) Acute care setting; large teaching hospital; United Kingdom Acute care setting; large, teaching hospital; Taiwan 200 patients given five hand hygiene products (alcohol foam, alcohol wipes, wet cloths with antiseptic solutions, bowls of soapy water, mobile sinks) 2-week, cross-sectional survey of patients and their family members; anonymous, selfreporting questionnaire Alcohol foam has the highest satisfaction score among patients and has a significantly higher satisfaction rate than the other products 859 respondents; 89.8% considered hand hygiene important; 75.9% would take HHP into consideration when choosing a hospital; 78.4% requested more information on hand hygiene; 76.3% would be willing to ask a doctor or nurse to wash his or her hands if they knew the healthcare provide would appreciate the reminder Figure 1. The Chain of Infection (Tweeten, 2014) Infectious Agent Susceptible Host Reservoirs Portal of Entry Portal of Exit Means of Transmission 17

18 Figure 2. Methodology Records identified through database searching (n=284) Number of duplicates removed (n=19) Records after duplicates removed (n=265) Records pertaining to something unrelated to hand hygiene and discarded (n=73) Records pertaining to outcomes unrelated to healthcare-associated infection and were discarded (n=92) Full-text articles assessed for eligibility (n=92) Studies included in qualitative syntesis review (n=35) Records containing information found in other reviews (n=14) Studies included in quantitative synthesis (n=21) 18

19 References Allegranzi, B., & Pittet, D. (2009). Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection, 73(4), doi: /j.jhin Allegranzi, B., Sax, H., & Pittet, D. (2013). Hand hygiene and healthcare system change within multi-modal promotion: A narrative review. Journal of Hospital Infection, 83. doi: /s (13) Bloomfield, S. F., Aiello, A. E., Cookson, B., O'boyle, C., & Larson, E. L. (2007). The effectiveness of hand hygiene procedures in reducing the risks of infections in home and community settings including handwashing and alcohol-based hand sanitizers. American Journal of Infection Control, 35(10). doi: /j.ajic Boyce JM., & Pittet D. (2002) Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. Morb Mortal Wkly Rep Recomm Rep 2002;51(RR-16):1 45. Burnett, E. (2009). Perceptions, attitudes, and behavior towards patient hand hygiene. American Journal of Infection Controll, 37(8), doi: /j.ajic Ducel, G., Fabry, J., & Nicolle, L. E. (2002). Prevention of hospital-acquired infections: A practical guide (Vol. 2). Geneva: World Health Organization. Duncanson, V., & Pearson, L. (2005). A study of the factors affecting the likelihood of patients participating in a campaign to improve staff hand hygiene. British Journal of Infection Control, 6(4), doi: /

20 Kendall, A., Landers, T., Kirk, J., & Young, E. (2012). Point-of-care hand hygiene: Preventing infection behind the curtain. American Journal of Infection Control, 40(4). Retrieved March 23, Kretzer, E. K., & Larson, E. L. (1998). Behavioral interventions to improve infection control practices. American Journal of Infection Control, 26(3), doi: /s (98) Landers, T., Abusalem, S., Coty, M., & Bingham, j. (2012). Patient-centered hand hygiene: The next step in infection prevention. American Journal of Infection Control, 40(4). doi: /j.ajic Longtin, Y., Sax, H., Leape, L. L., Sheridan, S. E., Donaldson, L., & Pittet, D. (2010). Patient Participation: Current Knowledge and Applicability to Patient Safety. Mayo Clinic Proceedings, 85(1), Retrieved November 19, Mathai, E., Allegranzi, B., Kilpatrick, C. & Pittet, D. (2010). Prevention and control of health care-associated infections through improved hand hygiene. Indian Journal of Medical Microbiology Indian J Med Microbiol, 28(2), doi: / Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., Touveneau, S., & Perneger, T., (2000). "Effectiveness of a hospital-wide programme to improve compliance with hand hygiene". The Lancet (North American edition) ( ), 356(9238), p Pittet, D., Allegranzi, B., Sax, H., Dharan, S., Pessoa-Silva, C. L., Donaldson, L., & Boyce, J. M. (2006). Evidence-based model for hand transmission during patient care and the role of improved practices. The Lancet Infectious Diseases, 6(10), doi: /s (06)

21 Pittet, D., Allegranzi, B., & Boyce, J. (2009). The World Health Organization Guidelines on Hand Hygiene in Health Care and Their Consensus Recommendations. Infection Control and Hospital Epidemiology Infect Control Hosp Epidemiol, 30(7), doi: / Safdar, N., & Abad, C. (2008). Educational interventions for prevention of healthcare-associated infection: A systematic review. Critical Care Medicine, 36(3), doi: /ccm.0b013e318165faf3 Seale, H., Chughtai, A. A., Kaur, R., Phillipson, L., Novytska, Y., & Travaglia, J. (2016). Empowering patients in the hospital as a new approach to reducing the burden of health care associated infections: The attitudes of hospital health care workers. American Journal of Infection Control, 44(3), doi: /j.ajic Tanner, J., & Mistry, N. (2011). Hand hygiene: Product preference and compliance. Nursing Times, 107(6), Tweeten, S (2014). General Principles of Epidemiology. Apic Text Online. Chapter 10. Retrieved on September, from World Health Organization. Guidelines on hand hygiene in health care. Geneva: WHO; Wu, K., Lee, S. S., Chen, J., Tsai, H., Li, C., Chao, H., Chou, H., Chen, Y., Ke, C., Huang, Y., Sy, C. L., Tseng, Y., & Chen, Y. (2013). Hand hygiene among patients: Attitudes, perceptions, and willingness to participate. American Journal of Infection Control, 41(4), doi: /j.ajic