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 Table of Contents  
Year : 2019  |  Volume : 7  |  Issue : 1  |  Page : 5-10

Hand hygiene compliance among healthcare workers in a superspeciality tertiary care hospital

Department of Clinical Microbiology, Kamalnayan Bajaj Hospital, Aurangabad, Maharashtra, India

Date of Web Publication13-Aug-2019

Correspondence Address:
Dr. Neeta Patwardhan
Kamalnayan Bajaj Hospital, Aurangabad, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_4_19

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Introduction: Hand hygiene (HH) is an important tool in the prevention of transmission of infections in hospitals; however, it is often an aspect which is neglected by healthcare workers (HCWs). Therefore, ongoing training and education, introduction of hand rubs at every bedside, displaying posters of the indications of HH as well as the six important steps of HH are some of the important measures to increase compliance. Assessment of compliance and feedback is again important so as to take measures to improve further the compliance and thus the infection rates in the hospital.
Methodology: We studied the compliance rate in the year 2018. We had different categories of HCWs. The total number of HCWs was 594, out of which a representative percentage was taken from each category. The study was conducted according to the WHO guidelines.
Results: We found the compliance rate to be low in months when there was a turnover of staff, that is, some old staff members left and new staff were recruited. Hence, we found the compliance to be good in housekeepers, technicians, doctors/consultants and nurses, but low in resident medical officers and attendants, with the probable reason being they were most of the times not available for training sessions and sometimes negligence.
Conclusion: Ongoing training sessions, education of the HCWs, posters of HH in all wards and intensive care units and motivation are absolutely essential to maintain an effective compliance. Efforts taken by our infection control nurse and administrators did help us in improving our compliance rate this year.

Keywords: Compliance, hand hygiene, healthcare workers

How to cite this article:
Patwardhan N, Patwardhan S. Hand hygiene compliance among healthcare workers in a superspeciality tertiary care hospital. J Patient Saf Infect Control 2019;7:5-10

How to cite this URL:
Patwardhan N, Patwardhan S. Hand hygiene compliance among healthcare workers in a superspeciality tertiary care hospital. J Patient Saf Infect Control [serial online] 2019 [cited 2023 Mar 30];7:5-10. Available from: https://www.jpsiconline.com/text.asp?2019/7/1/5/264396

  Introduction Top

Hand hygiene (HH) is one of the most effective ways of reducing healthcare-associated infections. It also effectively reduces the transmission of multidrug-resistant organisms. However, compliance by healthcare workers (HCWs) with the required HH frequencies and techniques has been reported to be suboptimal.[1]

The possible reasons for non-compliance are (1) time constraint, such as during emergencies; (2) skin integrity and (3) lack of physical resources and absence of role models.[1] Compliance can be improved by (1) education, (2) introduction of alcohol gels/rubs, (3) observation and feedback and (5) local promotion activities.[1]

Adherence of HCWs to HH can be measured by (1) direct observation, (2) indirect measurements (e.g., usage of alcohol gel/rub, soap and water and soap and paper towel) and lastly (3) self-reporting practice. The World Health Organization recommends direct observation as the gold standard.[1] Adherence to infection control program, policies and procedure has been shown to reduce the spread of healthcare-associated infections. Amongst various precautions to prevent healthcare-associated infections is HH. Hence, we decided to start with HH assessment and compliance, so as to obtain data regarding HH and implement measures to increase compliance.

  Methodology Top

This study was carried out at a superspeciality tertiary healthcare hospital in Maharashtra from January 2018 to December 2018. The hospital is a private hospital catering to our city as well as all the neighbouring cities. The study population was all HCWs which included doctors/consultants, resident medical officers (RMOs), technicians, nurses, housekeeping staff and attendants.

For the study, our infection control nurse (ICN) visited all wards including the intensive care unit (ICU) on a daily basis turn by turn in sessions. Each session lasted for 20–30 min. At a time, two HCWs were observed, and details were noted in the observation chart.

Taking all the above into consideration, a standard operating procedure (SOP) was made to provide standardised audit method to limit the disadvantages of direct observation method (such as being labour intensive, time-consuming, requiring trained observers and objectivity of the observer). The SOP was prepared using the 'Hand Hygiene Technical Reference Manual.'[2] HH audits were done using the WHO method for local reporting.

The ICN of our hospital was trained to carry out this audit. In the beginning, HH self-assessment was done according to the 'Hand Hygiene Self-Assessment Framework 2010'.[3] We complied with almost all the points asked as a questionnaire in this framework except that we do not have a 1:1 sink-to-bed ratio in the ICU, but we have alcohol rubs at the bedside of each patient in the ICU as well as in the wards. Training is given to all HCWs as a continuous process by our ICN regarding the (1) six steps for HH (handwash), (2) five moments of HH and (3) time of using alcohol rub (20 s). Posters regarding HH have also been put up in all wards and ICUs.

Our hospital is making all efforts to increase the compliance of all activities in the ward including HH compliance. We have incentivised HCWs of different wards in the hospital by announcing an award to the best ward, fulfilling all the criteria of an audit we conducted, to judge the different activities in the ward. Different activities are observed such as ward cleanliness, completion of files, prompt action by resident medical officers (RMOs) and physicians, patient safety-related criteria, crash trolley completions, medication errors and HH compliance. The feedback given to the wards and appreciation with awards by our hospital management have been very helpful in changing their practices.

Our hospital administrators, for example, our NABH co-ordinator and RMO in charge, take rounds and also impress upon the staff, the importance of all these activities including HH.

As has been mentioned earlier, training regarding HH is given to all HCWs as a continuous process and to all new staff during their entry-level training programme.

We also carry out methicillin-resistant Staphylococcus aureus Scientific Name Search  ( MRSA) screening of HCWs in the ICU every 6 months to assess the effectiveness of HH (increased compliance of which will reduce the MRSA carriers and spread of infection) and to impress upon the staff of ICU as well as other HCWs in wards stressing the importance of HH.

All these measures have largely helped us in motivating our HCWs regarding HH.

We started our study by direct monitoring of HH compliance. In our hospital, hand rub is used for HH. Hand wash is used whenever necessary such as when hands are soiled, before a procedure and before and after removing gloves when gloves are used. Direct monitoring was done monthly, and findings were presented during the hospital infection committee (HIC) meeting.

HH observation was done based on the 'Hand Hygiene Observational Audit: standard Operating Procedures, September 2014'.[4] The HCWs were divided into the following professional categories: (1) doctors, (2) RMOs, (3) nursing staff, (4) technicians, (5) housekeepers (HKs) and (6) attendants. Sample size was taken according to the Hand Hygiene Technical Reference Manual.[1] They were included in numbers representative in terms of professional category, for example, If the workforce in a given setting is 50 % nurses, then 50% of the professional category observed in the study would be nurses. Direct monitoring was done, and results were noted.

Observation and results

[Table 1] summarises the number of HCWs in each category and the number of each category included as per the representation percentage.
Table 1: Category-wise distribution of healthcare workers included in the study

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Because our healthcare professionals numbered more than 500, observation was done in sessions of limited duration, with each session done in different settings with different HCWs and also at different times in the same setting. This was to ensure a representative sample. Each observation session lasted for 20 ± 10 min. The number of HCWs observed during each session was only one or two. This was as per the Hand Hygiene Observational Audit: standard Operating Procedures, September 2014.[4] Indications for HH for observation were according to the WHO guidelines.[5]

In this study, glove use was not recorded. Positive HH was recorded according to the method used i.e. by using an alcohol rub or washing hands with soap and water, or a combination of both. A negative HH was also recorded. Observation chart was made accordingly [Figure 1].
Figure 1: Hand Hygiene observation - Data collection form

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Later, basic compliance calculation was done according to the WHO guidelines in Hand Hygiene Technical Reference manual.[2] Compliance was calculated by adding up the results of each session and dividing the total number of positive actions by the total number of opportunities. In other words, compliance with HH is the ratio of number of actions performed to the number of opportunities as expressed by the following formula:

In the observation form, the indications observed were classified as opportunities for HH (the denominator) against which the positive HH action was set (the action serving as numerator).[2]

Results for compliance were broken down by professional categories [Table 1].

In this study, overall compliance was studied from January 2018 to December 2018 [Table 2]. It was lowest in February and highest in June. Category-wise study was also done [Table 3].
Table 2: Opportunities and month-wise compliance of hand hygiene

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Table 3: Category-wise compliance of hand hygiene

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  Results Top

A total of 594 HCWs were studied. The representative HCWs selected for each category in our study were as follows: doctors: 13, RMOs: 09, nurses: 34, technicians: 11, HKs: 08 and attendants: 25.

Observation chart was prepared, and data were filled in accordingly [Figure 1].

The compliance of HH was lowest in February (69.6) and highest in June (92.90) [Table 2] and [Graph 1].

The compliance was highest in HKs (94%) followed by technicians (92%), doctors (91%) and nurses (91%). However, it was low in the RMOs (85%) and attendants (85%) [Table 3] and [Graph 2].

  Discussion Top

The average compliance rate in the present study was 85.51%, which is similar to the compliance in other studies[6],[7],[8] (86%, 80.9% and 75%). In many other studies, compliance rates were very low,[9],[10],[11],[12],[13] but in one study, the compliance rate was high [Table 4].[14]
Table 4: Overall compliance rates in different studies

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In the category-wise study, the compliance ranged from 85% to 94%. It was lowest in RMOs and attendants; this was because the RMOs as well as the attendants were not available for training most of the times. The compliance was high in housekeeping staff probably because they had fewer opportunities for HH besides receiving good training.

In some studies, compliance rate was high in doctors as compared to nurses [Table 5].[11],[12],[14]
Table 5: Category-wise hand hygiene compliance

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Whereas other studies observed that nurses had higher compliance rate than doctors [Table 5].[10],[13]

In our study, the compliance rate of nurses and consultants was the same.

  Conclusion Top

HH is an important aspect of hospital care which can reduce hospital infections to a great extent. The average compliance rate in our hospital ranged from 80% to 90% in different categories of HCWs. We found it very essential to continuously train all HCWs regarding HH, and motivation definitely helps them in achieving compliance. We are also making efforts to make RMOs and attendants available so as to be able to train them. We also aim to correlate the HH compliance and infection rates in our hospital in the future.


We would like to thank our hospital's ICN for performing the audit and collecting data regarding HH. We would also like to thank our NABH coordinator for her technical help. Lastly, we would also like to thank our CEO for his constant encouragement and guidance.

The data in the manuscript were presented in the HIC meeting on 8 January 2019.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Hand Hygiene Observation Audit, Standard Operating Procedure. Royal College of Physicians of Ireland; 2014. Available from: http://www.hpsc.ie/a-z/gastroenteric/handwashing/ha. [Last accessed on 2019 Feb 09].  Back to cited text no. 1
Hand Hygiene Technical Reference Manual. World Health Organization Patient Safety. Available from: http://apps.who.int/iris/bitstream/handle/10665/44196; http://www.whqlibdoc.who.int/publications/2009/9789241598608. [Last accessed on 2019 Feb 04].  Back to cited text no. 2
Hand Hygiene Self Assessment Framework. World Health Organization; 2010. Available from: http://www.who.int/gpsc/country_work/hhsa-framework.pdf. [Last accessed on 2019 Feb 02].  Back to cited text no. 3
HSE Hand Hygiene Observation Audit. Standard Operating Procedure. Royal College of Physicians of Ireland; 2014. Available from: http://www.hpsc.ie/a-2/gastroenteric/handwashing/h. [Last accessed on 2019 Feb 02].  Back to cited text no. 4
Hand Hygiene: Why, How and When? World Health Organization. Available from: http://www.who.int/gpsc/hand-hygiene-why-how-and-when. Brochure.pdf. [Last accessed on 2019 Feb 02].  Back to cited text no. 5
Sharma R, Sharma M, Kaushal V. Hand Washing Compliance among Healthcare Staff in Intensive Care Unit 9ICU) of a Multispeciality Hospital of North India. Available from: http://sciedu.ca/journal/index/jha/article/viewfile/i. [Last accessed on 2019 Feb 20].  Back to cited text no. 6
Tomar S, Das BK, Lodha R, Kapil A. Hand Hygiene Compliance of Healthcare Workers in a Paediatric Intensive Care Unit. Available from: http://medmd.nic.in/ibv/t15/i7p620. [Last accessed on 2019 Feb 20].  Back to cited text no. 7
Monteiro A. Evaluating Hand Hygiene Compliance among Healthcare Workers in a Specialized Pediatric Hospital. Available from: http://www.scholarworks.gsu.edu/cgi/viewcontent.cgi?artic. [Last accessed on 2019 Feb 20].  Back to cited text no. 8
Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit Care Med 2011;15:6-15.  Back to cited text no. 9
[PUBMED]  [Full text]  
Karaaslan A, Kepenekli Kadayifci E, Atıcı S, Sili U, Soysal A, Çulha G, et al. Compliance of healthcare workers with hand hygiene practices in neonatal and pediatric intensive care units: Overt observation. Interdiscip Perspect Infect Dis 2014;2014:306478.  Back to cited text no. 10
Rynga D, Kumar S, Gaind R, Rai AK. Hand Hygiene Compliance and Associated Factors among Healthcare Workers in a Tertiary Care Hospital: Self Reported Behaviour and Direct Observation. Available from: http://www.ijic.info/article/viewfile/17137/11477. [Last accessed on 2019 Feb 20].  Back to cited text no. 11
Sharma S, Sharma S, Puri S, Whig J. Hand Hygiene Compliance in Intensive Care Units of a Tertiary Care Hospital. Available from: hrttp://www.ijcm.org.in/printarticle.asp?issn=0970-0218.yea. [Last accessed on 2019 Feb 20].  Back to cited text no. 12
Sastry AS, Deepashree R, Bhat P. Impact of Hand Hygiene Audit on Hand Hygiene Compliance in a Tertiary Care Public Sector Teach in Hospital in South India. Available from: http://www.ssciencedirect.com/science/article/pii/S0196655316311737; https://doi.org/10.1016/j.ajic. 2016.12.013. [Last accessed on 2019 Feb 20].  Back to cited text no. 13
Sen M, Sharma M, DasA, Singh AK. Hand Hygiene Compliance among Healthcare Personnel in Intensive Care Unit of a Tertiary Care Super Speciality Institute. Available from: http://www.mjdrdypv.org. [Last accessed on 2019 Feb 20].  Back to cited text no. 14


  [Figure 1]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]

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