Categories
Coronavirus Randomised Controlled Trial (RCT) Research methodology

6-Step vs 3-Step Hand Hygiene Technique

Blog Authors: Tracey Howe, John McVeigh, Walter Patterson, Joe Wilson, Lynn Brown

Image: Tracey Howe

The UK and Scottish Governments and NHS services have been advocating hand washing as the primary public health prevention for the Covid-19 outbreak. So what should we be advocating for our staff and students.

Fortunately we were aware of a study that evaluated the microbiologic effectiveness of the World Health Organization’s 6-step and the Centers for Disease Control and Prevention’s 3-step hand hygiene techniques using alcohol-based handrub.

Here’s what they did

The Glasgow based group used a parallel group randomized controlled trial in an acute care inner-city teaching hospital. Doctors (n =42) and nurses (n =78) undertaking direct patient care. intervention. Random 1:1 allocation of the 6-step (n =60) or the 3-step (n= 60) technique.

Here’s what they found

  • The 6-step technique was microbiologically more effective at reducing the median log10 bacterial count.
  • The 6-step technique reduced the count from 3.28 CFU/mL (95% CI, 3.11–3.38 CFU/mL) to 2.58 CFU/mL (2.08–2.93 CFU/mL), whereas the 3-step reduced it from 3.08 CFU/mL (2.977–3.27 CFU/mL) to 2.88 CFU/mL (−2.58 to 3.15 CFU/mL) (P= .02).
  • However, the 6-step technique did not increase the total hand coverage area (98.8% vs 99.0%, P= .15) and required 15% (95% CI, 6%-24%) more time (42.50 seconds vs 35.0 seconds, P= .002).
  • Total hand coverage was not related to the reduction in bacterial count.
  • For the 6-step technique, the back of hands were more frequently missed, whereas the back of the index and the middle finger of the right hand were less frequently missed, compared with 3-step.
  • Doctors and nurses achieved a comparable level of hand coverage with similar areas of the hands not covered: a median of 1.2% for doctors and 1.1% for nurses.

The author/s concluded

The study provides the first evidence in a randomized controlled trial that the 6-step technique is superior, thus these international guidance documents should consider this evidence, as should healthcare

Our Journal Club’s views

Who are the authors of the paper and where do they work? The Glasgow based team work across NHS Scotland and Glasgow Caledonian University. Tracey Howe declared an interest as she has worked with this team on a number of projects and publications.

What do we know about the journal? Infection Control & Hospital Epidemiology publishes scientifically authoritative, clinically applicable, peer-reviewed research on control and evaluation of the transmission of pathogens in healthcare institutions and on the use of epidemiological principles and methods to evaluate and improve the delivery of care. ICHE is the official publication of the Society for Healthcare Epidemiology of America (SHEA).

What about the methodology used? The pragmatic parallel group randomized controlled trial is an established clinical trial design in health. Pragmatic meaning it was based in ‘normal clinical practice setting’ not a laboratory or constrained environment. It had ethical approval and informed consent of participants. The authors used random allocation of wards and assessments- microbiology and statistics were undertaken blind to allocation. Participants were instructed in the hand hygiene techniques which were standardised. Specific amounts of hand rub were supplied and were detailed in the paper. A standardised technique of collection and analysis of samples was used. Participants were observed and timed. Statistical analyses were well described. Overall this was a very well reported study.

Our conclusions are – that this evidence has a low risk of bias.

Implications for our practice

As a College we have a number of areas that routinely teach hand hygiene these include, health and early years, culinary, sports, beauty and leisure. Many of these areas teach the 6 step method and this study provides evidence that our teaching is evidence based.

Next steps

Convene a cross College group to look at the following:

  • identify curriculum areas delivering hand hygiene
  • identify staff expertise and development needs
  • identify and share physical resources
  • identify and share teaching resources internally and externally
  • provide advice to the College leadership team especially at this time.

View from.. one of the authors

This research led by the SHIP Research Group at Glasgow Caledonian University has had an amazing impact. At the time of publication it was widely discussed in the media worldwide. The evidence it provided has been considered by the World Health Organization for inclusion in their guidelines and the publication won the Society for Healthcare Epidemiology of America 2017 William Jarvis Award.

Professor Lesley Price, Co-Lead SHIP Research Group, Department of Nursing and Community Health, Glasgow Caledonian University.

What do you think?

We would love to hear your view on this blog. Please send us your comments.

References

Keywords: Hand hygiene, 6-steps, 3-steps, RCT, coronavirus

Our Blog Posts are written by staff at City of Glasgow College to inform and inspire our practice. We meet together at the Journal Club to consider the latest evidence to provide insights on hot topics related to learning and teaching, quality assurance and subject needs. It forms part of our activity for General Teaching Council Scotland registration and Professional Standards for lecturers in Scotland’s Colleges demonstrating that we are a self-critical staff community.

css.php