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Hand hygiene matters for DCs too

A hand sanitizer dispenser showing the importance of chiropractic hand hygiene

Health care associated infections (HAI) frequently occur and are a leading cause of morbidity and mortality.

They also represent a significant health and cost burden to patients, health care workers, and health delivery systems. HAI now is a leading public health issue and occurs worldwide within all types of health care settings including hospitals, laboratories, and clinics. 

The rise of Methicillin-resistant Staphylococcus aureus (MRSA) skin and soft tissue infection (SSTI) in the United States has become a threat to public health. MRSA/SSTI patient history and infection control behaviors are essential to avoid transmission of MRSA/SSTI between providers and their patients.

According to the National Center for Complementary and Integrative Health (NCCIH) and the National Center for Health Statistics, chiropractic care is one of the most frequently used complementary and alternative medicine (CAM) therapies in the U.S.  Musculoskeletal conditions, such as low-back and neck pain, are among the leading causes of doctor-patient visits in the U.S.  

Chiropractic treatment usually involves skin-to-skin contact during a manual manipulation.  

Patients expect to receive care in a safe environment. To meet those expectations health care providers must have an effective hand hygiene, equipment disinfection, and other recommended infection prevention procedures. Unfortunately, the chiropractic profession did not have industry-specific clinical hand hygiene and infection prevention guidance until 2010.

To assist the health care industry, institutions such as the World Health Organization (WHO) and the Centers for Disease Control (CDC) have developed policy documents and standards. These tools enable the facility to prepare an efficient and effective hand hygiene and infection prevention program.  

The aim of this study was to assess the current level of adherence with infection prevention standards and evaluate the effectiveness of a new educational program and infection prevention kit.  


The methods for this study included developing a standardized assessment, educational training modules, a clinic survey, and an infection control kit, and re-assessment for 30 volunteer clinics in an urban area.

The study included 30 chiropractic outpatient clinics located throughout the 11-county metro areas of Minneapolis and St. Paul, Minnesota. The standardized assessment tool included the CDC’s Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care, 2015; the Association for Professionals in Infection Control and Epidemiology’s (APIC) online infection prevention textbook ambulatory care section; and the American Association of Ambulatory Health Care’s (AAAHC) criteria for certification in outpatient settings for infection prevention. When finished, the tool included 30 different assessment elements.    

The educational program included four modules: hand hygiene; surface cleaning and equipment disinfection; skin infections; and blood draws and acupuncture.

The infection prevention kit included education and infection prevention hygiene products selected by an infection prevention professional based on ease of use, cost, and effectiveness. To ensure the kit met standards, hand hygiene products included at least 60 percent alcohol and a skin softener and were Food and Drug Administration (FDA) approved.

Along with the kit and instructions, the clinics received a best practice checklist for infection prevention in a chiropractic setting and a button for all staff to wear that said, “I washed my hands because I care.” The aim of the button and the checklist was to provide a regular, visual reminder of hand hygiene and infection prevention.

Site Visits

An infection prevention professional visited each participating clinic for an initial and a follow-up site visit. During the site visits the infection prevention professional reviewed the facility, including assessing the medical equipment, standard business equipment (phones, computers, etc.), infection prevention products, staff protocols between patients, and documented procedures.

The infection prevention professional also interviewed the staff to learn about common office infection prevention practices. Each visit was documented using the standard assessment tool to quantify the infection prevention practices in place at each clinic.


There were 30 clinics that had enrolled in the program. The initial assessment included the standardized assessment and site visit. Overall the study had an 87 percent participation rate, with 26 of the 30 clinics successfully completing the initial site visit, the education modules and the follow-up site visit.

During the site visits, the majority of doctors and clinical staff reported they were practicing good hand hygiene and infection prevention techniques.  

After the clinic successfully completed the education modules and started using the infection prevention toolkit, the number of assessment areas in which the clinics achieved 100 percent compliance increased to 13. The results from the second site visit validated the effectiveness of the education program and infection prevention toolkit.   

 While each clinic reported significant improvements, ongoing education and awareness is needed to maintain and continue to improve hand hygiene and infection prevention practices within chiropractic clinics.


The results of this study demonstrated a positive impact regarding hand hygiene and infection prevention awareness, understanding, and compliance. During the course of this project the CAHPS scores for the network increased from the 40th percentile to the 54th percentile. It also demonstrated the effectiveness of the educational modules and the benefits of the infection prevention toolkit.  

The study documents that the value of buy-in by the doctor and clinical staff, the placement of the materials, and the onboarding process of new staff are crucial to ongoing compliance.  

Given that chiropractic clinical guidelines regarding hand hygiene and infection prevention are relatively new, the researchers strongly recommend the chiropractic profession provide ongoing education and continued awareness of the need to improve hand hygiene and infection prevention. This includes increasing the exposure of education resources, such as the ones developed for this study, and expanding the overall adoption of infection prevention practices in the chiropractic outpatient clinic settings.  

Author’s note: Tabatha Erck, MPH, Mary Larweck, RN, MS, CIC, CPHQ, and Matt Holida also contributed to this study. 


Boyce, John M., and Didier Pittet. “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.” American Journal of Infection Control 2002;30.8: S1-S46.

Evans, Marion Willard, et al. “A proposed protocol for hand and table sanitizing in chiropractic clinics and education institutions.” Journal of Chiropractic Medicine 2009;8.1: 38-47.

Evans, Marion W., et al. “Hand hygiene and treatment table sanitizing in chiropractic teaching institutions: results of an education intervention to increase compliance.” Journal of Manipulative and Physiological Therapeutics 2009;32.6: 469-476.

Eveillard, Matthieu, et al. “Measurement of hand hygiene compliance and gloving practices in different settings for the elderly considering the location of hand hygiene opportunities during patient care.” American Journal of Infection Control 2011;39.4: 339-341.

FitzGerald, G., G. Moore, and A. P. R. Wilson. “Hand hygiene after touching a patient’s surroundings: the opportunities most commonly missed.” Journal of Hospital Infection 2013;84.1: 27-31.

Harv Health Lett. “The handiwork of good health. Alcohol-based hand sanitizers are more effective than antibacterial soaps.” Harvard Medical School Journal 2007 Jan;32(3):1-3

Landers, Timothy, et al. “Patient-centered hand hygiene: the next step in infection prevention.” American Journal of Infection Control 2012;40.4: S11-S17.

O’Boyle, Carol A., Susan J. Henly, and Elaine Larson. “Understanding adherence to hand hygiene recommendations: the theory of planned behavior.” American Journal of Infection Control 2001;29.6: 352-360.

Pittet, Didier, et al. “The World Health Organization guidelines on hand hygiene in health care and their consensus recommendations.” Infection Control & Hospital Epidemiology 2009;30.7: 611-622.

Rogers, Karin, et al. “Improving Family and Visitor Hand Hygiene in a Pediatric Tertiary Care Center.” American Journal of Infection Control 2011;39.5: E83.

Son, Crystal, et al. “Practically speaking: rethinking hand hygiene improvement programs in health care settings.” American Journal of Infection Control 2011;39.9: 716-724.

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