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 Table of Contents  
Year : 2021  |  Volume : 9  |  Issue : 1  |  Page : 13-16

Hand hygiene compliance – Improvement with multimodal approach in intensive care unit setting

DepartmentofMicrobiology,ABVIMSandDr.RMLHospital,NewDelhi,, India

Date of Submission01-Aug-2020
Date of Decision01-May-2021
Date of Acceptance12-Jun-2021
Date of Web Publication24-Sep-2021

Correspondence Address:
Dr. Shalini Malhotra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpsic.jpsic_22_20

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Introduction: Healthcare associated infections (HCAIs) pose a significant risk to patient's health with increasing morbidity and mortality. A large portion of HCAI can be prevented by hand hygiene, but adherence to hand hygiene has been found to be very low.
Methodolgy: This study was conducted to assess the rate of hand hygiene compliance during 'my five moments of hand hygiene' as per the WHO guidelines in our intensive care units and to implement multimodal intervention strategies to improve hand hygiene compliance.
Results: The average compliance amongst all HCWs in both ICUs was 45.7% before sensitisation which increased to 85.4% after sensitisation using multimodal strategies.
Conclusion: Multimodal Intervention strategies such as the one we employed had a good impact in improving compliance in our ICU and these improvements can be easily duplicated in healthcare settings across the country.

Keywords: Compliance, hand hygiene, healthcare-associated infections, intensive care unit, multimodal strategies

How to cite this article:
Garg S, Malhotra S, Pritikumari P, Kaur A, Kaur N, Duggal N. Hand hygiene compliance – Improvement with multimodal approach in intensive care unit setting. J Patient Saf Infect Control 2021;9:13-6

How to cite this URL:
Garg S, Malhotra S, Pritikumari P, Kaur A, Kaur N, Duggal N. Hand hygiene compliance – Improvement with multimodal approach in intensive care unit setting. J Patient Saf Infect Control [serial online] 2021 [cited 2022 Oct 6];9:13-6. Available from: https://www.jpsiconline.com/text.asp?2021/9/1/13/326620

  Introduction Top

The importance of hand hygiene in preventing healthcare-associated infections (HCAIs) has been known since the study by Semmelweis in 1884.[1] Since then, many studies have clearly established hand hygiene to be the single most effective method in reducing HCAIs.[2]

There are very little data available on awareness on need of hand hygiene practices amongst various sections of healthcare personnel in India. Intended meaning is we conducted a before and after intervention study which was observation based and a prospective study. In the study we assessed rate of hand hygiene compliance among our healthcare workers posted in ICUs before doing any intervention and then after implementation of multiple strategies to improve hand hygiene compliance.

  Materials and Methods Top


This prospective study was conducted in the two intensive care units (medical ICU [MICU] and trauma ICU [TICU]) of a tertiary care hospital in northern India. Our ICUs have conveniently located handwashing facilities (sink: bed ratio is 1:10) and availability of alcohol-based hand rubs with each bed.


A total of 200 subjects were observed (100 from each ICU). A single infection control nurse (ICN) visited the ICU for a period of 20 min to record all possible opportunities for hand hygiene every day for 1 month. The observations were noted for all five moments of hand hygiene during patient care. These five moments include before touching a patient, before any clean/aseptic procedure, after body fluid exposure, after touching a patient and after touching patient's surroundings. A checklist was used for nursing staff and doctors. The procedure was followed for 1 month, and the average was taken to calculate the adherence rate.

Intervention strategies

All the doctors and nursing staff were given sensitisation class by infection control officers (MD Microbiology) on HH practices as per the WHO guidelines. Apart from this, multiple strategies including intensive educational lectures, displaying posters on 'my five moments for hand hygiene' and methods of hand hygiene, easy availability of hand rubs and handwashing facilities and verbal reminders in improving hand hygiene compliance in our ICUs were used.

Post-sensitisation, the same ICN recorded adherence to hand hygiene without the knowledge of staff in a similar checklist. The study was conducted over a short time period so that the subjects do not change.

  Observations and Results Top

During 1 month of observation, around 100 HCWs were observed in each surveillance unit before and after sensitisation class.

Hand hygiene compliance amongst HCWs in both ICUs is shown in [Figure 1] and [Figure 2]. The average compliance amongst all HCWs in both ICUs was 45.7% before sensitisation which increased to 85.4% after sensitisation using multimodal strategies [Table 1]. Nurses had higher overall compliance than the doctors. Statistical analysis was conducted using Chi-square test which showed a statistically significant increase in hand hygiene compliance after interventions in all the moments of hand hygiene (P < 0.05) in both the ICUs.
Figure 1: Hand hygiene compliance amongst healthcare workers in medical intensive care unit

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Figure 2: Hand hygiene compliance amongst healthcare workers in trauma intensive care unit

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{Figure 1}
Table 1: Percentage hand hygiene compliance of healthcare workers pre-/post-sensitisation

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  Discussion Top

Hand hygiene is a simple and a very important step in prevention of spread of infections. The most important factor responsible for the infections acquired in the hospitals, especially in ICUs, is cross-contamination and transmission of microbes from hands of HCWs to patients.[2] As per studies, hand hygiene compliance amongst healthcare personnel in most hospitals is usually < 50%.[3],[4],[5] This poor compliance can be due to factors such as working in busy wards (ICUs), understaffing as well as lack of awareness. Single intervention programmes produce little or temporary success in leaving a lasting impact on hand hygiene compliance.[6] Hence, multipronged interventions, which include behavioural, environmental and social changes, have been suggested and tried in different studies to sustain improved hand hygiene compliance.[3]

In the study, before any sensitisation class, we found that the overall hand hygiene compliance in our ICU staff (doctors and nurses both) was approximately 45.7%. As per the literature, hand hygiene compliance rates in ICUs vary from 35% to 80% depending on the categories of HCWs, the intensity of work in the unit and the type of ICUs studied.[3],[7]

During both the observation periods, although the opportunities for hand hygiene were most in the areas of 'before/after patient contact' or 'before/after procedure', yet the compliance rates specific to these opportunities were amongst the least [Figure 1] and [Figure 2].

Amongst the various hand hygiene moments, maximum compliance was recorded after body fluid exposure (65% in MICU and 75% in TICU). This may be because of tendency to protect themselves in such visibly contaminated conditions.

Most HCWs tend to club the different moments because of lack of awareness (moments 1 and 2 or moments 4 and 5).

Certain additional observations were made during our study. We found that, at times, although nursing staff and resident trainees used hand hygiene as indicated, they unconsciously touched areas of their own body or their clothes before patient contact, thereby negating the effect of hand hygiene. Another study by Lam et al. also noted that HCWs tend to recontaminate their hands by touching inanimate objects, pens or fomites after hand hygiene.[8] Hence, attention was drawn to this fact during the sensitisation class.

In our study, the most common reason cited by health workers for non-compliance was that they were too busy (33.7%). Hence, we emphasised to our health workers how hand hygiene takes up little time and the benefits produced far outweighed the time lost in applying hand hygiene. We provided them with alternative of 30 s handwashing or use of bedside hand rubs to save time. In a survey conducted by Pittet et al., amongst physicians of a large university hospital, it was found that although many (65%) had a good knowledge of indications, 67% perceived hand hygiene as a difficult task.[9]

In our study, intensive educational sessions based on 'my five moments of hand hygiene' in different shifts for all cadres of HCWs including nursing orderly as well as displaying posters, providing verbal reminders and ensuring easy availability of hand hygiene products in the unit were organised. With these strategies, most HCWs who visited the ICU were reached.

The intervention strategies employed by us had a significant impact in improving hand hygiene compliance rates (P < 0.05) in almost all the categorical variables studied, especially in the areas of 'before' and 'after patient contact' [Figure 1] and [Figure 2].

After sensitisation, we observed a significant increase in hand hygiene compliance by both doctors and nurses [Table 1].

In a study conducted in Hong Kong, the hand hygiene compliance before and after the implementation of a multimodal implementation programme in a neonatal ICU improved from 40% to 53% before patient contact and from 39% to 59% after patient contact. They concluded that an effective education programme could improve hand hygiene compliance.[8] In another study conducted in five adult ICUs, an intervention strategy consisting of educational programme and improving standards of catheter care resulted in a significant decrease in catheter-related bloodstream infection rates, with an increase in hand hygiene compliance from 59% to 65%.[10]

We believe that our intervention was successful because the programme was multimodal, easy to understand and was fully supported by every member of the unit as we can see the marked increase in hand hygiene compliance rates post-sensitisation.

  Conclusion Top

We conclude that the hand hygiene practices are terribly low amongst most healthcare personnel working in the ICU. However, intervention strategies such as the one we employed had a good impact in improving compliance in our ICU and these improvements were consistently seen amongst almost all HCW groups in our unit. The results we achieved can be easily duplicated in other ICUs across the country if similar, interventional strategies are employed.

  Acknowledgement Top

We would like to thank our ICU staff, doctors as well as nurses for their co-operation.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Pittet D, Boyce JM. Hand hygiene and patient care: Pursuing the Semmelweis legacy. Lancet Infect Dis 2001;1:9-20.  Back to cited text no. 1
Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307-12.  Back to cited text no. 2
Chakravarthy M, Myatra SN, Rosenthal VD, Udwadia FE, Gokul BN, Divatia JV, et al. The impact of the International Nosocomial Infection Control Consortium (INICC) multicenter, multidimensional hand hygiene approach in two cities of India. J Infect Public Health 2015;8:177-86.  Back to cited text no. 3
Chhapola V, Brar R. Impact of an educational intervention on hand hygiene compliance and infection rate in a developing country neonatal intensive care unit. Int J Nurs Pract 2015;21:486-92.  Back to cited text no. 4
Mukherjee R, Roy P, Parik M. Achieving perfect hand washing: an audit cycle with surgical internees. Indian Journal of Surgery 2020;6:1-7. [doi: https://doi.org/10.1007/s12262-020-02619-8].  Back to cited text no. 5
Clancy C, Delungahawatta T, Dunne CP. Hand-hygiene-related clinical trials reported between 2014 and 2020: A comprehensive systematic review. J Hosp Infect 2021;111:6-26.  Back to cited text no. 6
Hussein R, Khakoo R, Hobbs G. Hand hygiene practices in adult versus pediatric intensive care units at a university hospital before and after intervention. Scand J Infect Dis 2007;39:566-70.  Back to cited text no. 7
Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: A multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565-71.  Back to cited text no. 8
Pittet D, Simon A, Hugonnet S, Pessoa-Silva CL, Sauvan V, Perneger TV. Hand hygiene among physicians: Performance, beliefs, and perceptions. Ann Intern Med 2004;141:1-8.  Back to cited text no. 9
Zingg W, Imhof A, Maggiorini M, Stocker R, Keller E, Ruef C. Impact of a prevention strategy targeting hand hygiene and catheter care on the incidence of catheter-related bloodstream infections. Crit Care Med 2009;37:2167-73.  Back to cited text no. 10


  [Figure 1], [Figure 2]

  [Table 1]


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