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Hand hygiene in routine glaucoma clinics
  1. E Mensah,
  2. I E Murdoch,
  3. K Binstead,
  4. C Rotheram,
  5. W Franks
  1. Moorfields Eye Hospital NHS Foundation Trust, City Road, London EC1V 2PD, UK
  1. Correspondence to: E Mensah Moorfields Eye Hospital NHS Foundation Trust, City Road, London EC1V 2PD, UK;

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Nosocomial infection occurs via the hands of healthcare workers (HCWs).1 Hand hygiene reduces hospital infection rates; however, HCWs seldom comply with this.2

We determined how often ophthalmologists and allied professionals cleaned their hands and whether intervention was effective.

Participants, methods, and results

We conducted the study in the daily glaucoma clinics of Moorfields Eye Hospital where policy states that all HCWs must clean their hands between patients.

For 1 week, hand hygiene practice was monitored covertly by two observers. Potential hand cleaning opportunities were before or during patient contact, before or after manipulative procedures, and after glove removal. Manipulative procedures were defined as 5-fluorouracil subconjunctival injection, taking an eye swab, suture, or supramid removal, and bleb needling or massage.

Without revealing how the study was conducted, preliminary results were presented and also distributed by memo. Two weeks after this intervention, hand hygiene was re-monitored for 1 week.

Baseline hand hygiene episodes were 18% but increased significantly to 28% (p = 0.005) following intervention (table 1). Before intervention two out of seven people performing procedures cleaned their hands, but not for the single episode that 5-fluorouracil was used. However, after intervention six out of seven HCWs cleaned their hands (p = 0.04), including all three episodes in which 5-fluorouracil was handled.

Table 1

 Effect of intervention on hand hygiene compliance

Before intervention, female HCWs cleaned their hands significantly more than males (30% v 9%, p<0.001). After intervention hand hygiene increased further for females (54%, p<0.001) with no change for males (11%, p = 0.57).

Nurses had the highest frequency of hand cleaning but with no change after intervention (69% v 58%, p = 0.36). Increased hand hygiene was significant for doctors following intervention (11% v 20%, p = 0.01).


Recently, nosocomial infection has attracted considerable media interest. While problematic worldwide, the United Kingdom has one of the highest rates of methicillin resistant Staphylococcus aureus (MRSA).3 The hands of HCWs are a major route of transmission. Hand hygiene frequencies range from 3%,2 increasing to more than 60% when HCWs are aware of being observed.4

In our study, hand hygiene was low (18%). Although significant improvement followed intervention (28%) this was far from the hospital standard. Our new level of hand cleaning is likely to be transient as all but one study has demonstrated sustained improvement.5

Previous studies, including our own, have shown that female HCWs clean their hands more often than males.6 In general, sex differences in hand washing are explained by the social role theory—that is, females are communal whereas men are agentic.7 Hence, women are more likely than men to participate in socially acceptable behaviour such as hand washing.8 In our study, intervention produced a significant improvement in hand hygiene for females with no effect on males. Behaviourally, men are less easily influenced than women,7 which may explain why intervention had no effect on male HCWs.

As with previous studies5,9 our nurses had the highest frequency of hand hygiene (69%). This could be because most nurses are female or because of an emphasis on hand washing in their undergraduate training. However, with our nurses hand hygiene did not increase following intervention. Possibly few nurses were present at the lecture, hence, they only received written information concerning initial study results.

As observed by others,5,6,9 we found hand hygiene among doctors was low (11%). However, intervention had its greatest effect on the doctors (p = 0.01). Although numbers are small, intervention had a positive effect on manipulative procedures, especially when using 5-fluorouracil.

Our study demonstrates that hospital policy is not being practised. Getting HCWs to clean their hands has been an ongoing struggle since Semmelweis. It has been suggested that patients should ask their healthcare professional to hand wash.10 Although controversial, this may help in the eradication of hospital acquired infection.



  • Local ethics approval was obtained for this study.