Discussion

For most items, we did not find significant differences in the attitudes and preferences of physician and nurse members of the infection control team. Only elbow use of dispensers was significantly more important for physicians than for nurses, although there is no evidence for its practical value despite a theoretical rationale of less contamination of the dispenser itself.

Most infection control preventionists report that their institutional standard operating procedures define the time needed for hand disinfection as the 30 seconds indicated by the WHO Five Moments and still favor 30 seconds for alcohol-based hand disinfection. However, they acknowledge that in daily practice disinfection times of 30 seconds are almost never reached and that most disinfect their hands <15 seconds. However, most infection control preventionists think that a more realistic time requirement would increase the motivation of staff and overall adherence to hand hygiene policies, which is in accordance with the findings of Kramer et alReference Kramer, Pittet and Klasinc¹ in their observational study in a neonatal intensive care unit. The reported preference of 30 seconds but with an expectation of higher adherence with shorter times might be a sign of reluctance to change long-standing formal rules, which is a barrier in the conceptual frame of change management and implementation science.Reference Clack, Zingg and Saint⁵ This theory is underscored by the fact that two-thirds of the respondents agreed with the statement that you need a buffer between the formal requirement in a standard operating procedure SOP and scientifically sound minimum to generate an additional safety corridor. Although this concept is often used to define technical safety limits, it can be deleterious in behavioral psychology because it undermines trust in the scientific base of infection control recommendations.

In most institutions patients are specifically targeted in hand hygiene programs, although <20% of hospitals have a formal “speak up” campaign. Most survey respondents indicated that they would use alcohol-containing wipes as an alternative mode for hand disinfection for patients only and not for use by staff, and this idea is supported by the findings of Ory et al.Reference Ory, Zingg and de Kraker⁴

The respondents described many different ways that alcohol-based hand disinfectant is provided in their respective institutions. Most described conventional wall-mounted dispensers, which leaves improvement potential for bedside-mounted systems that might better facilitate work flow. Technical problems with automatic systems seem to be a relevant issue, which supports the findings by Roth et al.Reference Roth, Batzer, Hug and Widmer²

We observed great variance in the way dispenser systems are cleaned and maintained: To do nothing, as reported by 15% of all respondents, is clearly unacceptable, whereas cleaning triggered by visual inspection is done by a weak majority and is supported by the literature.Reference Schulz-Stübner, Zimmer, Leonards and Schaumann³

In summary, our survey indicated some improvement potentials regarding the infrastructure as well as the use of alcohol-based hand disinfection in German hospitals. We noted a certain amount of resistance by members of the infection control team irrespective of professional affiliation toward changing established formal practice patterns, despite new scientific evidence.