American Journal of Infection Control xxx (2015) 1-6

Contents lists available at ScienceDirect

American Journal of Infection Control American Journal of

Infection Control

journal homepage: www.ajicjournal.org

Major article

Improved hand hygiene compliance after eliminating mandatory

glove use from contact precautionsdIs less more?
Alexia Cusini MD a, *, Doris Nydegger RN a, Tanja Kaspar RN, MPH a,
Alexander Schweiger MD a, Rolf Kuhn PhD a, b, Jonas Marschall MD a
a
Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Bern, Bern, Switzerland
b
Clinic of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland

Key Words: Background: Guidelines recommend that health care personnel (HCP) wear gloves for all interactions
Hand hygiene with patients on contact precautions. We aimed to assess hand hygiene (HH) compliance during contact
Glove use precautions before and after eliminating mandatory glove use.
Contact precautions
Methods: We assessed HH compliance of HCP in the care of patients on contact precautions in 50 series
before (2009) and 6 months after (2012) eliminating mandatory glove use and compared these results
with the hospital-wide HH compliance.
Results: We assessed 426 HH indications before and 492 indications after the policy change. Compared
with 2009, we observed a significantly higher HH compliance in patients on contact precautions in 2012
(52%; 95% confidence interval [95% CI], 47-57) vs 85%; 95% CI, 82-88; P < .001). During the same period,
hospital-wide HH compliance also increased from 63% (95% CI, 61-65) to 81% (95% CI 80-83) (P < .001).
However, the relative improvement (RI) of HH compliance during contact precautions was significantly
higher than the hospital-wide relative improvement (RI, 1.6; 95% CI, 1.49-1.81 vs 1.29; 95% CI, 1.25-1.34),
with a relative improvement ratio of 1.27 (95% CI, 1.15-1.41).
Conclusion: Eliminating mandatory glove use in the care of patients on contact precautions increased HH
compliance in our institution, particularly before invasive procedures and before patient contacts.
Further studies on the effect on pathogen transmission are needed before revisiting the current official
guidelines on the topic.
Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc.
Published by Elsevier Inc. All rights reserved.

Adequate hand hygiene (HH) is a key measure to prevent Wearing gloves cannot be considered as an alternative to HH.
transmission of health careeassociated infections.1 Over the last Doebbeling et al showed that washing artificially contaminated
few decades, campaigns promoting HH have been launched all over gloves often failed to remove microorganisms and that bacteria
the world.2 Nevertheless, the importance of this simple procedure could penetrate unapparent holes in gloves and eventually
is not sufficiently recognized by all health care personnel (HCP), contaminate the individual’s hands. Therefore, hand disinfection or
and compliance with recommended HH practices is often low. washing is required after glove removal.3
In 1996, the Centers for Disease Control and Prevention (CDC)
introduced a revised version of a preventive concept against
* Address correspondence to Alexia Cusini, MD, Department of Infectious Dis- nosocomial infections that had originated in the 1960s.4 In these
eases and Hospital Epidemiology, University Hospital Bern, CH-3010 Bern, guidelines, basic standard precautions are recommended for all
Switzerland. health care activities. Additionally, contact precautions are inten-
E-mail address: [email protected] (A. Cusini).
ded to prevent transmission of pathogens that are spread by direct
Funding/Support: Cusini has received a travel grants and meeting expenses
from Abbott, MSD, BMS, Gilead, and Astellas. Marschall was paid for consultancy by or indirect contact with the patient or the patient’s environment.
Astelles Switzerland and for development of educational presentations by Cape According to the CDC recommendations and the HH guidelines
Girardeau Medical Society. He received grants from the CDC Prevention Epicenters issued by the World Health Organization (WHO), HCP caring for
Program (ongoing), an NIH KL2 Career Development Award, and an NIH BIRCWH patients on contact precautions should wear gloves for all in-
Award that ended in 2012 and 2013, respectively. He also received travel grant and
teractions with patients or contact with potentially contaminated
meeting expenses from Gilead. The other authors report no conflicts of interest and
have not received any financial support. areas in their environment.5,6 This recommendation was based on
Conflicts of interest: None to report. general consensus and not on high-level evidence. To our

0196-6553/$36.00 - Copyright Ó 2015 by the Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.ajic.2015.05.019
2 A. Cusini et al. / American Journal of Infection Control xxx (2015) 1-6

knowledge, no studies have directly compared the efficacy of precautions and to change gloves if an indication for HH occurred
standard precautions alone versus standard plus contact pre- during the encounter with the isolated patient. Afterward, glove
cautions for the control of multidrug-resistant (MDR) use in this setting was only required according to standard pre-
microorganisms.7 cautions (contact with body fluids, nonintact skin, or mucosa and
Of note, when gloving is required, it may become more chal- before invasive procedures). We communicated this policy change
lenging to perform optimal HH. Indeed, several authors have in written form to all hospital floors and highlighted it in the hos-
identified the use of gloves as an important risk factor for poor pital’s infection prevention guidelines. For 1 month, HCP providing
HH.1,8-14 care for patients on contact precautions were personally informed
In 2009, an observational study of HH compliance at our insti- about the change in policy. On special request, we scheduled HH
tution showed that the requirement to wear gloves during contact training sessions for individual floors. All HH indications were be-
precautions caused HCP to neglect HH, thereby potentially ing taught to HCP since the 2005 national campaign. There was no
increasing the risk of pathogen transmission.15 In light of this special promotion of the HH indications during the study period
finding our infection prevention unit implemented a policy change (eg, after the publication of the 2009 WHO guidelines), and there
in 2011, eliminating mandatory gloving from the care of patients on was no other specific HH intervention.
contact precautions knowing that this new strategy followed
neither CDC nor WHO guidelines. Data collection
The objective of this study was to assess the compliance with
HH before and after this policy change took place. HH observations in patients on contact precautions and for the
entire hospital were performed during routine patient care in the
MATERIAL AND METHODS patients’ rooms or in the ICU in series of 20 minutes each. For the
observations we used a standardized questionnaire offered by
Hospital setting Swissnoso16 evaluating HH in the following situations: (1) before
patient contact, (2) after patient contact, (3) before an aseptic
Our institution is a 950-bed tertiary care teaching hospital procedure, (4) after body fluid exposure, and (5) after touching the
covering all medical specialties, including a 30-bed mixed intensive patient’s environment.17 Additionally, we monitored the compli-
care unit (ICU). There are on average 38,000 admissions annually, ance with gloving in contact precautions. Before the policy change
resulting in 290,000 patient days. Institutional guidelines for we assessed if (1) gloves were worn before entering a room with a
infection prevention are based on the CDC’s Guidelines for Isolation patient on contact precautions, (2) HH was performed before and
Precautions5 and are regularly updated by the infection prevention after glove use, and (3) gloves were changed to perform HH. After
unit. Patients colonized or infected with MDR bacteria (eg, the policy change, we evaluated if gloves were worn when indi-
methicillin-resistant Staphylococcus aureus, vancomycin-resistant cated by standard precautions.
Enterococcus, MDR gram-negative bacteria) are placed on contact All HH observers were members of the infection prevention
precautions. team. All of them were instructed in HH observation with the same
The promotion of HH has a high priority among the infection educational tools provided by Swissnoso and underwent annual
prevention measures in our hospital. The hospital provides an refreshers in HH observation. One author (D.N.) performed all HH
alcohol-based solution for handrubs in wall-mounted and bed- observations in contact precautions in 2009 and performed most in
mounted dispensers that has also been distributed as coat-pocket 2012 (D.N. performed 389 and T.K. performed 103 observations in
bottles for many years. There was no change in the availability of 2012). The hospital-wide HH observations were conducted with
the alcohol-based solution during the study period. Since 2005, the same methodology by the entire infection prevention team
when a national campaign by Swissnoso (the Swiss national expert consisting of 10 staff members in 2009 and 7 in 2011. Two authors
group for the prevention of hospital-acquired infections) launched (D.N. and T.K.) and 1 additional staff member participated in the
the 5 HH indications (before patient contact, after patient contact, observations in both years.
before an aseptic procedure, after body fluid exposure, and after
touching the patient’s environment), we have promoted these Ethics
recommendations.16 These 5 HH indications were later adopted by
the WHO concept My 5 Moments for Hand Hygiene in 2009.17 This study did not require approval by the local ethics com-
As a quality indicator, the hospital-wide compliance of HCP with mittee because it was deemed a quality improvement project. The
HH has been assessed annually since 2005 (with direct feedback to directors of the involved clinical departments were informed of the
the wards). study and the research methodology before research activities
started. The observed health care workers were aware of the fact
Study design that they participated in an HH study.

We performed a nonrandomized observational before-after Statistical analyses

study comparing HH compliance in contact precautions caused by
colonization or infection with MDR microorganisms before and 6 We used Stata/SE10.0 (StataCorp, College Station, TX) to
months after eliminating mandatory glove use (September- perform statistical analyses. HH compliance was defined as the
December 2009 and April-June 2012, respectively). The hospital- percentage of opportunities in which HCP adhered to HH guide-
wide HH compliance in nonisolated patients in both periods lines (indications with adequate HH/all HH indications
100). We
served as the control. Patients on contact precautions because of an evaluated differences in HH compliance in the care of patients on
infection with Clostridium difficile were excluded from the study. contact precautions between 2009 and 2012 and differences in HH
compliance in the care of patients on contact precautions versus
Policy change and implementation the hospital-wide compliance during the respective year, using the
c2 test, and calculated the corresponding 95% confidence intervals.
Prior to September 2011, all HCP were expected to perform HH Additionally, we calculated the absolute difference in HH
and wear gloves before entering the room of a patient on contact compliance between 2009 (baseline) and 2012 for patients on
 A. Cusini et al. / American Journal of Infection Control xxx (2015) 1-6 3

Table 1
Hand hygiene compliance before (2009) and after (2012) elimination of mandatory glove use in the care of patients on contact precautions and in the entire hospital

2009 2012

Indications for Hand Hygiene No. of observations Compliance (95% CI) No. of observations Compliance (95% CI) P value
Contact precautions
Before patient contact 127 32.3 (24.0-40.5) 116 76.7 (68.9-84.5) <.001
After patient contact 105 94.3 (88.0-97.9) 131 93.9 (89.8-98.7) .90
Before aseptic procedure 88 23.9 (14.8-32.9) 75 72.0 (61.6-82.4) <.001
After body fluid exposure 106 56.6 (46.6-66.2) 110 90.9 (85.5-96.4) <.001
After contact to patients surroundings No observations 60 90.0 (82.2-97.8)
All indications 426 51.9 (47.1-56.6) 492 85.4 (82.2-88.5) <.001
Entire hospital
Before patient contact 582 46.9 (42.8-51.0) 539 71.8 (68.0-75.6) <.001
After patient contact 841 75.2 (72.3-78.2) 1,132 87.3 (85.3-89.2) <.001
Before aseptic procedure 253 60.5 (54.4-66.5) 285 76.8 (71.9-81.8) <.001
After body fluid exposure 305 66.6 (61.2-71.9) 391 83.9 (80.2-87.5) <.001
After contact to patients surroundings 264 56.8 (50.8-62.8) 314 78.0 (73.4-82.6) <.001
All indications 2,245 62.9 (60.9-64.9) 2,661 81.4 (80.0-82.9) .001

CI, confidence interval.

contact precautions and for the entire hospital, respectively, and

expressed these differences as relative improvement (RI) with 95%
confidence intervals (ie, 2012 compliance/2009 compliance). In a
second step we compared the RI of the patients on contact pre-
caution with the RI of the entire hospital and expressed this
relationship as the RI ratio with a corresponding 95% confidence
interval.

RESULTS

In 2009 we observed a total of 426 HH indications in HCP

providing care for 32 patients on contact precautions (19 patients
were observed once, and 13 patients were observed repeatedly,
after transfer to another floor or in case of a second hospitalization).
In 2012 we observed a total of 492 indications in 44 patients on
Fig 1. Hand hygiene compliance before (2009, white bar) and after (2012, grey bar)
contact precautions (38 patients once, 6 patients twice). During the
eliminating mandatory glove from contact precautions compared with all hospitalized
hospital-wide HH observations we assessed 2,245 HH indications patients. Error bars indicate 95% confidence interval.
in 2009 and 2,661 indications in 2012.
The HH compliance in the care of patients on contact pre-
cautions and in the entire hospital in the years 2009 and 2012, 60.5; 95% CI, 54.4-66.5; P < .001). In 43.2% of 88 observed in-
respectively, is summarized in Table 1 and depicted in Figure 1. We dications before performing aseptic procedures, there was no
found a significant increase of HH compliance in contact pre- hand disinfection and no change of gloves was performed, and in
cautions between 2009 and 2012 (51.9%; 95% confidence interval 33% of observations gloves were either disinfected or changed
[CI], 47.1-56.6 vs 85.4; 95% CI, 82.2-88.5; P < .001). During the same without in-between hand disinfection. Compliance with the
period the hospital-wide HH compliance also improved (62.9%; 95% indication after patient contact was significantly higher in the
CI, 60.9-64.9 vs 81.4; 95% CI, 80.0-82.9; P < .001). The RI of HH care of isolated patients than the hospital-wide compliance for
compliance in contact precaution situations was significantly this indication (94.3%; 95% CI, 88.0-97.9 vs 75.2; 95% CI, 72.3-
higher than the hospital-wide RI (1.6; 95% CI, 1.49-1.81 in contact 78.2; P < .001).
precaution situations vs 1.29; 95% CI, 1.25-1.34 in hospital-wide In 2012, the overall HH compliance in the care of patients on
observations), with a RI ratio of 1.27 (95% CI, 1.15-1.41). contact precautions was slightly higher than the hospital-wide
In contact precaution settings, HH compliance improved compliance (85.4%; 95% CI, 82.2-88.5 vs 81.4; 95% CI, 80.0-82.9;
particularly before patient contact (32.3%; 95% CI, 24.0-40.5 in P ¼ .04). No difference was found for the indications before pa-
2009 vs 76.7; 95% CI, 68.9-84.5 in 2012; P < .001) and before tient contact (76.7%; 95% CI, 68.9-84.5 vs 71.8; 95% CI, 68.0-75.6;
performing aseptic procedures (23.9%; 95% CI, 14.8-32.9 vs 72.0; P ¼ .30) and before performing aseptic procedures (72.0%; 95% CI,
95% CI, 61.6-82.4; P < .001). HH compliance after patient contact 61.6-82.4 vs 76.8; 95% CI, 71.9-81.8; P ¼ .40). We observed 197
remained high (94.3%; 95% CI, 88.0%-97.9% vs 93.9%; 95% CI, 89.8- indications in which wearing gloves was required as part of
98.7; P ¼ .90) (Fig 2). standard precautions in the care of patients on contact pre-
In 2009, when gloving still was a mandatory component of cautions in 2012. In 193 (98%) occasions gloves where worn when
contact precautions, the overall HH compliance in the care of it was indicated.
patients on contact isolation was significantly lower than the A quality assessment showed the 2 authors (D.N. and T.K.) who
hospital-wide HH compliance (51.9%; 95% CI, 47.1-56.6 vs 62.9; performed all observations in the setting of contact precautions and
95% CI, 60.9-64.9; P < .001). The difference in HH compliance was also participated in the hospital-wide observations in 2009 and
particularly remarkable for the indications before patient contact 2012 achieved a similar global compliance in the hospital-wide
(32.3%; 95% CI, 24.0-40.5 vs 46.9; 95% CI, 42.8-51.0; P < .001) and observations when compared with the rest of the infection
before performing aseptic procedures (23.9%; 95% CI, 14.8-32.9 vs control team (data not shown).
4 A. Cusini et al. / American Journal of Infection Control xxx (2015) 1-6

Fig 2. Hand hygiene compliance for all observed indications in the care of patients on contact precautions before (2009, white bar) and after (2012, grey bar) eliminating mandatory
glove use. Error bars indicate 95% confidence interval.

DISCUSSION They found that gloves are often worn when not indicated and vice
versa and described a significant association between glove use and
In 2009 we observed that HH compliance in the care of patients lower rates of HH compliance.12 In contrast, only a few studies
on contact precautions was significantly worse than the hospital- showed increasing HH compliance when gloves were used.19-22 In
wide compliance despite the fact HH following the 5 indications these studies, the authors argued that wearing gloves may remind
had been promoted since 2005 and substantial improvement of HH health care workers of the personal risk of pathogen transmission
compliance had been achieved across the hospital since then and therefore prompt them to disinfect hands after a clinical
(global HH compliance had improved from 46.9%-62.9% in those encounter. This perception is supported by our results in 2009
years). We observed that HCP donned gloves before entering the when HH compliance for the indication after patient contact was
room of an isolated patient and tended to remove them only after significantly higher in the contact precaution setting than in non-
leaving the room, without changing them and without performing isolated patients. However, gloving in itself should not be seen as a
adequate HH when indicated. marker for good compliance.
It is not surprising that gloving can have a negative impact on To our knowledge, our study is the first to analyze the impact of
HH because it can be time-consuming under these circumstances. modified contact precautions eliminating mandatory glove use on
Other reasons for neglecting HH could be a false sense of safety compliance with HH. One important strength of our study is the
with gloving or the erroneous belief that glove use obviates HH.18 use of a standardized HH observation tool that considered all in-
In consequence of our own observations we decided to elimi- dications as proposed by the WHO in a systematic way,17 by
nate the practice of default gloving during contact precautions in infection prevention personnel specifically trained in HH obser-
2011, which was a departure from both CDC and WHO recom- vation. A systematic review including 96 studies on HH compli-
mendations on isolation precautions. The second HH observation in ance reported an overall median compliance rate of 40%, with a
contact precautions (6 months after the policy change) showed that wide range from 4%-100%. Only 25% of studies reported compli-
these modified contact precautions were associated with a ance rates >50% across all professions.2 Compared with these
considerably better HH compliance in our institution. Given that rates, the hospital-wide HH compliance at our institution was
there was no other intervention and that the hospital-wide moderate in 2009 (62.9%) and good in 2012 (81.4%). Similar to the
improvement of HH compliance over the same period was signifi- results of the aforementioned review, HH compliance in our study
cantly smaller, we assume that eliminating mandatory glove use in was better after than before patient contact and better for nurses
the care of patients on contact precautions had a positive attrib- than for physicians (data not shown). The use of alcohol-based
utable effect on compliance, beyond the hospital-wide trend to- handrub (as opposed to handwashing), its good accessibility in
ward better HH practices. the hospital, and the periodically performed observations of HH
The scientific literature on the impact of glove use on health care with feedback to the observed health care workers could be
workers’ HH compliance is limited and contradictory. A number of reasons for the continuous improvement in our institution.
studies identified the use of gloves as an important risk factor for Nevertheless, because HCP were aware of being observed, they
poor HH.1,8-14 In agreement with these reports, we identified the may have displayed different behavior (Hawthorne effect).23
failure to change potentially contaminated gloves as the major Therefore, the HH compliance in our study may overestimate
barrier for proper HH.8-10 These studies were limited by different clinical reality, particularly in the setting of contact precautions
methods, different indications for glove use, and a small number of where the 2 sole observers were physically close to the observed
observations. To overcome these limitations, Fuller et al performed HCP (because patients on contact precautions are mostly located
a study on gloving and HH in 15 hospitals in the United Kingdom. in single rooms).
 A. Cusini et al. / American Journal of Infection Control xxx (2015) 1-6 5

Our study has other limitations. Although its quasi- Acknowledgments

experimental design using the hospital-wide HH compliance as a
control can be considered high quality, important confounding We thank all of the health care workers of the University Hos-
variables may have been missed because of the lack of randomi- pital of Bern for their enormous effort in improving hand hygiene
zation.24 The main limitation is certainly that in light of the overall during daily patient care and all patients that allowed us to perform
trend of improving HH compliance throughout our hospital since the observations of hand hygiene during their hospitalization. We
2005 (overall compliance was 46.9% in 2005, 56.3% in 2006, 62.2% also thank the members of the infection prevention team for
in 2007, 61.9% in 2008, 62.9% in 2009, 68.4% in 2010, 73.0% in 2011, participating in data collection and especially Kathrin Mühlemann,
and 81.4% in 2012, with a notable improvement for all 5 in- MD, PhD, who initiated and provided supervision of the first part of
dications), the RI that is directly caused by the policy change in study but, unfortunately, passed away prematurely in 2012.
contact precautions may have been overestimated.
Moreover, the higher improvement ratio in HH compliance in
contact precautions may in part be because it is easier to improve References
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