Project Report on

“A research on Compliance with Hand Washing

among Health Care Workers during routine Patient
Care”

A report submitted as a part fulfillment of the

Postgraduate Diploma in Management (2008 – 2010)

Submitted by:
Khushboo Nagpal (66)

Neeta Dudeja (32)

Nibha Sharma (34)
Nikhil Chaudhary (36)

Shival Chaudhary (48)

Siddharth Tewari (51)

HR4

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INDEX:

INTRODUCTION
REVIEW OF LITERATURE
AIMS AND OBJECTIVES
METHOD
LIMITATION OF STUDY
ANALYSIS OF DATA
RESULTS
DISCUSSION
CONCLUSION
RECOMMENDATIONS
BIBLIOGRAPHY
QUESTIONNAIRE

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 Introduction
The hands of physicians and nurses are the most important vehicles
for the transmission of microbes. Hands are frequently implicated
as the route of transmission in an outbreak of infection. It is well
known that pathogens are frequently acquired on the hands in
clinical settings. The patient, weakened by disease, surgery or old
age, is unable to fight against microbes. Microbes can cause super
infections and compromise the successes scored by the nurses and
doctors and other healthcare workers. These microbes are
invisible; their presence does not engender fear. Anything could
happen from wound infections, urinary tract infections, and etc,
through sepsis to a preventable life of suffering and possibly even
the death of the patient.

Hospital-acquired infections exact a tremendous toll, resulting in

increased morbidity and mortality, and increased healthcare costs.
Since most hospital-acquired pathogens are transmitted from
patient to patient via the hands of healthcare workers, hand
washing is the simplest and most effective, proven method to
reduce the incidence of nosocomial infections. Despite this well-
established relationship, compliance with hand washing among all
types of healthcare workers remains variable. Many barriers to
appropriate hand hygiene have been reported including: hand
hygiene agents cause skin irritation and dryness, patient care takes
priority over hand hygiene, sinks are inconveniently located or not
available, glove use, insufficient time for hand hygiene, high
workload and understaffing, inadequate knowledge of guidelines
or lack of protocols for hand hygiene, lack of a role model from
seniors or peers, lack of recognition of the risk of cross
transmission of microbial pathogens and scientific information
showing a definitive impact of improved hand hygiene on
nosocomial infection rates, or simply noncompliance. Whatever be
the reasons, transmission of microorganisms from the hands of

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health care workers remains the main concern for cross infection in
hospitals and can be prevented by hand washing.

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 Review of Literature

Historical Study
Hand washing with soap and water has been considered a measure
of personal hygiene, for generations. The concept of cleansing
hands with an antiseptic agent probably emerged in the early 19th
century. In 1846, Ignaz Semmelweis observed that women whose
babies were delivered by students and physicians in the First Clinic
at the General Hospital of Vienna consistently had a higher
mortality rate than those whose babies were delivered by midwives
in the Second Clinic. The maternal mortality rate in the First Clinic
subsequently dropped dramatically and remained low for years
after intervention by Semmelweis which represents the first
evidence indicating that cleansing heavily contaminated hands
with an antiseptic agent between patient contacts may reduce
health-care–associated transmission of contagious diseases
effectively with hand washing with plain soap and water.
In 1843, Oliver Wendell Holmes concluded independently that
puerperal fever was spread by the hands of health personnel.
Although he described measures that could be taken to limit its
spread, his recommendations had little impact on obstetric
practices at the time. However, as a result of the seminal studies by
Semmelweis and Holmes, hand washing gradually became
accepted as one of the most important measures for preventing
transmission of pathogens in health-care facilities. In 1975 and
1985, formal written guidelines on hand washing practices in
hospitals were published by CDC. These guidelines recommended
hand washing with non antimicrobial soap between the majorities
of patient contacts and washing with antimicrobial soap before and
after performing invasive procedures or caring for patients at high
risk. Use of waterless antiseptic agents (e.g., alcohol-based
solutions) was recommended only in situations where sinks were
not available.

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The 1995 APIC guideline included more detailed discussion of
alcohol-based hand rubs and supported their use in more clinical
settings than had been recommended in earlier guidelines. ). These
guidelines also provided recommendations for hand washing and
hand antisepsis in other clinical settings, including routine patient
care. Although the APIC and HICPAC guidelines have been
adopted by the majority of hospitals, adherence of HCWs to
recommended hand washing practices has remained low.
Normal Bacterial Skin Flora
To understand the objectives of different approaches to hand
cleansing, knowledge of normal bacterial skin flora is essential.
Normal human skin is colonized with bacteria; different areas of
the body have varied total aerobic bacterial counts. Total bacterial
counts on the hands of medical personnel have ranged from 3.9 x
104 to 4.6 x 106. In 1938, bacteria recovered from the hands were
divided into two categories: transient and resident.
Transient flora
Transient flora is acquired on the surface of the skin through
contact with other people, object or the environment. It survives on
the skin for less than 24 hours. These are also easily acquired on
the hands when the object touched is moist and heavily
contaminated substances such as body fluids and are easily
removed mechanically by washing with soap and water even by a
brief 10 seconds wash. Eg: Staph aureus (MRSA) is frequently
found on the skin of nurses who are caring for patient infected with
the organism.
Resident Flora or Normal Flora
Normally inhabit certain areas of the body without causing
infection. They live in deep crevices of the skin, in hair follicles,
and sebaceous glands. The type and distribution of organisms
varies according to humidity, temp, body site and the person’s
general health. Microorganisms present in largest numbers are
gram + ve bacteria. They survive and multiply on the skin. These
can be repeatedly cultured. Gram –ve bacilli are not considered

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part of resident flora, but they are able to survive in some areas,
notably moist areas beneath rings. The removal of resident skin
flora during routine clinical care is not necessary in many
situations as these microorganisms are not readily transferred to
other people or surfaces and most are low in pathogenecity. Some
resident bacteria could cause infection, if introduced during
invasive procedures into normally sterile body sites or on
particularly vulnerable individuals and are not easily removed by
mechanical action of washing with soap, but their numbers can be
reduced by the combination of a detergent and micro biocide.
Physiology of Normal Skin
The primary function of the skin is to reduce water loss, provide
protection against abrasive action and microorganisms, and act as a
permeability barrier to the environment.
The basic structure of skin includes, from outer- to innermost
layer, the superficial region (i.e., the stratum corneum or horny),
the viable epidermis (50- to 100-μm thick), the dermis (1- to 2-mm
thick), and the hypodermis (1- to 2-mm thick). The barrier to
percutaneous absorption lies within the stratum corneum, the
thinnest and smallest compartment of the skin. The stratum
corneum contains the corneocytes (or horny cells), which are flat,
polyhedral-shaped nonnucleated cells, remnants of the terminally
differentiated keratinocytes located in the viable epidermis.
Corneocytes are composed primarily of insoluble bundled keratins
surrounded by a cell envelope stabilized by cross-linked proteins
and covalently bound lipid. Interconnecting the corneocytes of the
stratum corneum are polar structures (e.g., corneodesmosomes),
which contribute to stratum corneum cohesion.
The intercellular region of the stratum corneum is composed of
lipid primarily generated from the exocytosis of lamellar bodies
during the terminal differentiation of the keratinocytes. The
intercellular lipid is required for a competent skin barrier and
forms the only continuous domain. Directly under the stratum
corneum is a stratified epidermis, which is composed primarily of
10–20 layers of keratinizing epithelial cells that are responsible for

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the synthesis of the stratum corneum. This layer also contains
melanocytes involved in skin pigmentation; Langerhans cells,
which are important for antigen presentation and immune
responses; and Merkel cells, whose precise role in sensory
reception has yet to be fully delineated. As keratinocytes undergo
terminal differentiation, they begin to flatten out and assume the
dimensions characteristic of the corneocytes (i.e., their diameter
changes from 10–12 μm to 20–30 μm, and their volume increases
by 10- to 20-fold). The viable epidermis does not contain a
vascular network, and the keratinocytes obtain their nutrients from
below by passive diffusion through the interstitial fluid.
The skin is a dynamic structure. Barrier function does not simply
arise from the dying, degeneration, and compaction of the
underlying epidermis. Rather, the processes of cornification and
desquamation are intimately linked; synthesis of the stratum
corneum occurs at the same rate as loss. Substantial evidence now
confirms that the formation of the skin barrier is under homeostatic
control, which is illustrated by the epidermal response to barrier
perturbation by skin stripping or solvent extraction. Circumstantial
evidence indicates that the rate of keratinocyte proliferation
directly influences the integrity of the skin barrier.
A general increase in the rate of proliferation results in a decrease
in the time available for 1) uptake of nutrients (e.g., essential fatty
acids), 2) protein and lipid synthesis, and 3) processing of the
precursor molecules required for skin-barrier function. Even
chronic but quantitatively smaller increases in rate of epidermal
proliferation also lead to changes in skin-barrier function remains
unclear. Thus, the extent to which the decreased barrier function
caused by irritants is caused by an increased epidermal
proliferation also is unknown. The current understanding of the
formation of the stratum corneum has come from studies of the
epidermal responses to perturbation of the skin barrier.
Experimental manipulations that disrupt the skin barrier include 1)
extraction of skin lipids with apolar solvents, 2) physical stripping
of the stratum corneum using adhesive tape, and 3)chemically

8
induced irritation. All of these experimental manipulations lead to
a decreased skin barrier as determined by transepidermal water
loss (TEWL). The most studied experimental system is the
treatment of mouse skin with acetone. This experiment results in a
marked and immediate increase in TEWL, and therefore a decrease
in skin-barrier function. Acetone treatment selectively removes
glycerolipids and sterols from the skin, which indicates that these
lipids are necessary, though perhaps not sufficient in themselves,
for barrier function.
Detergents act like acetone on the intercellular lipid domain. The
return to normal barrier function is biphasic: 50%–60% of barrier
recovery typically occurs within 6 hours, but complete
normalization of barrier function requires 5–6 days.
Definition of Terms
Detergent. Detergents (i.e., surfactants) are compounds that
possess a cleaning action. They are composed of both hydrophilic
and lipophilic parts and can be divided into four groups: anionic,
cationic, amphoteric, and nonionic detergents. Although products
used for hand washing or antiseptic hand wash in health-care
settings represent various types of detergents, the term “soap” is
used to refer to such detergents in this guideline.
Hand washing. Washing hands with plain (i.e., non-antimicrobial)
soap and water.
Hand hygiene. A general term that applies to hand washing,
antiseptic hand wash, antiseptic hand rub, or surgical hand
antisepsis.
Alcohol-based hands rub. An alcohol-containing preparation
designed for application to the hands for reducing the number of
viable microorganisms on the hands. Such preparations usually
contain 60%–95% ethanol or isopropanol.
Antiseptic hand wash. Washing hands with water and soap or
other detergents containing an antiseptic agent.
Antiseptic hand rub. Applying an antiseptic hand-rub product on
the surface of the hands to reduce the number of microorganisms
present.

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Antiseptic agent. Antimicrobial substances that are applied to the
skin to reduce the number of microbial flora. Examples include
alcohols, chlorhexidine, chlorine, hexachlorophene, iodine.
Visibly soiled hands. Hands showing visible dirt or visibly
contaminated with proteinaceous material, blood, or other body
fluids (e.g., fecal material or urine).
Waterless antiseptic agent. An antiseptic agent that does not
require use of exogenous water. After applying such an agent, the
hands are rubbed together until the agent has dried.

Transmission of Pathogens on Hands

Transmission of health-care–associated pathogens from one patient
to another via the hands of Health Care Workers (HCWs) requires
the following sequence of events:
• Organisms present on the patient’s skin, or that have been shed
onto inanimate objects in close proximity to the patient, must be
transferred to the hands of HCWs.
• These organisms must then be capable of surviving for at least
several minutes on the hands of personnel.
• Next, hand washing or hand antisepsis by the worker must be
inadequate or omitted entirely, or the agent used for hand hygiene
must be inappropriate.
• Finally, the contaminated hands of the caregiver must come in
direct contact with another patient, or with an inanimate object that
will come into direct contact with the patient.

Health-care–associated pathogens can be recovered not only from

infected or draining wounds, but also from frequently colonized
areas of normal, intact patient skin. The perineal or inguinal areas
are usually most heavily colonized, and the axillae, trunk, and
upper extremities (including the hands) also are frequently
colonized. The number of organisms (e.g., S. aureus, Proteus
mirabilis, Klebsiella spp., and Acinetobacterspp.) present on intact
areas of the skin of certain patients can vary from 100 to 106cm2.
Persons with diabetes, patients undergoing dialysis for chronic

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renal failure, and those with chronic dermatitis are likely to have
areas of intact skin that are colonized with S. aureus. Because
approximately 106 skin squames containing viable microorganisms
are shed daily from normal skin, patient gowns, bed linen, bedside
furniture, and other objects in the patient’s immediate environment
can easily become contaminated with patient flora. Such
contamination is particularly likely to be caused by staphylococci
or enterococci, which are resistant to dessication.
In the past, attempts have been made to stratify patient-care
activities into those most likely to cause hand contamination, but
such stratification schemes were never validated by quantifying the
level of bacterial contamination that occurred. Nurses can
contaminate their hands with 100–1,000 CFUs
of Klebsiella spp.during “clean” activities (e.g., lifting a patient;
taking a patient’s pulse, blood pressure, or oral temperature; or
touching a patient’s hand, shoulder, or groin). Similarly, in another
study, hands were cultured of nurses who touched the groins of
patients heavily colonized with P. mirabilis; 10–600 CFUs/mL of
this organism were recovered from glove juice samples from the
nurses’ hands. Recently, other researchers studied contamination
of HCWs’ hands during activities that involved direct patient-
contact wound care, intravascular catheter care, respiratory tract
care, and the handling of patient secretions. Agar fingertip
impression plates were used to culture bacteria; the number of
bacteria recovered from fingertips ranged from 0 to 300 CFUs.
Data from this study indicated that direct patient contact and
respiratory-tract care were most likely to contaminate the fingers
of caregivers. Gram-negative bacilli accounted for 15% of isolates
and S. aureus for 11%. Duration of patient-care activity was
strongly associated with the intensity of bacterial contamination of
HCWs’ hands.
HCWs can contaminate their hands with gram-negative bacilli, S.
aureus, enterococci, or Clostridium difficile by performing “clean
procedures” or touching intact areas of the skin of hospitalized
patients. Furthermore, personnel caring for infants with respiratory

11
syncytial virus (RSV) infections have acquired RSV by performing
certain activities (e.g., feeding infants, changing diapers, and
playing with infants). Personnel who had contact only with
surfaces contaminated with the infants’ secretions also acquired
RSV by contaminating their hands with RSV and inoculating their
oral or conjunctival mucosa. Other studies also have documented
that HCWs may contaminate their hands (or gloves) merely by
touching inanimate objects in patient rooms. None of the studies
concerning hand contamination of hospital personnel were
designed to determine if the contamination resulted in transmission
of pathogens to susceptible patients.
Other studies have documented contamination of HCWs’ hands
with potential health care–associated pathogens, but did not relate
their findings to the specific type of preceding patient contact. For
example, before glove use was common among HCWs, 15% of
nurses working in an isolation unit carried a median of 1 x 104
CFUs of S. aureus on their hands. Of nurses working in a general
hospital, 29% had S. aureus on their hands (median count: 3,800
CFUs), whereas 78% of those working in a hospital for
dermatology patients had the organism on their hands (median
count: 14.3 x 106 CFUs). Similarly, 17%–30% of nurses carried
gramnegative bacilli on their hands (median counts: 3,400–38,000
CFUs). One study found that S. aureus could be recovered from
the hands of 21% of intensive-care–unit personnel and that 21% of
physician and 5% of nurse carriers had >1,000 CFUs of the
organism on their hands. Another study found lower levels of
colonization on the hands of personnel in a neurosurgery unit, with
an average of 3 CFUs of S. aureus and 11 CFUs of gram-negative
bacilli. Serial cultures revealed that 100% of HCWs carried gram-
negative bacilli at least once, and 64% carried S. aureus at least
once.

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Relation of Hand Hygiene and Acquisition of Health-
Care–Associated Pathogens
Hand antisepsis reduces the incidence of health-care– associated
infections. Increased hand washing frequency among hospital staff
has been associated with decreased transmission of Klebsiella spp.
among patients; these studies, however, did not quantitate the level
of hand washing among personnel. In a recent study, the
acquisition of various health-care–associated pathogens was
reduced when hand antisepsis was performed more frequently by
hospital personnel; both this study and another documented that
the prevalence of health-care– associated infections decreased as
adherence to recommended hand-hygiene measures improved.
Outbreak investigations have indicated an association between
infections and understaffing or overcrowding; the association was
consistently linked with poor adherence to hand hygiene. During
an outbreak investigation of risk factors for central venous
catheter-associated bloodstream infections, after adjustment for
confounding factors, the patient-to-nurse ratio remained an
independent risk factor for bloodstream infection, indicating that
nursing staff reduction below a critical threshold may have
contributed to this outbreak by jeopardizing adequate catheter care.
The understaffing of nurses can facilitate the spread of MRSA in
intensive-care settings through relaxed attention to basic control
measures (e.g., hand hygiene). In an outbreak of Enterobacter
cloacae in a neonatal intensive-care unit, the daily number of
hospitalized children was above the maximum capacity of the unit,
resulting in an available space per child below current
recommendations. In parallel, the number of staff members on
duty was substantially less than the number necessitated by the
workload, which also resulted in relaxed attention to basic
infection-control measures. Adherence to hand-hygiene practices
before device contact was only 25% during the workload peak, but
increased to 70% after the end of the understaffing and
overcrowding period. Surveillance documented that being

13
hospitalized during this period was associated with a fourfold
increased risk of acquiring a health-care–associated infection. This
study not only demonstrates the association between workload and
infections, but it also highlights the intermediate cause of
antimicrobial spread: poor adherence to hand-hygiene policies.

Factors influencing adherence to hand-hygiene

practices
Risk factors for poor adherence to recommended hand-hygiene
practices as per source
• Physician status (rather than a nurse)
• Nursing assistant status (rather than a nurse)
• Male sex
• Working in an intensive-care unit
• Working during the week (versus the weekend)
• Wearing gowns/gloves
• Automated sink
• Activities with high risk of cross-transmission
• High number of opportunities for hand hygiene per hour of
patient care
Self-reported factors for poor adherence with hand hygiene
• Hand washing agents cause irritation and dryness
• Sinks are inconveniently located/shortage of sinks
• Lack of soap and paper towels
• Often too busy/insufficient time
• Understaffing/overcrowding
• Patient needs take priority
• Hand hygiene interferes with health-care worker relationships
with patients
• Low risk of acquiring infection from patients
• Wearing of gloves/beliefs that glove use obviates the need for
hand hygiene
• Lack of knowledge of guidelines/protocols

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• Not thinking about it/forgetfulness
• No role model from colleagues or superiors
• Skepticism regarding the value of hand hygiene
• Disagreement with the recommendations
• Lack of scientific information of definitive impact of improved
hand hygiene on health-care–associated infection rates
Additional perceived barriers to appropriate hand hygiene
• Lack of active participation in hand-hygiene promotion at
individual or institutional level
• Lack of role model for hand hygiene
• Lack of institutional priority for hand hygiene
• Lack of administrative sanction of noncompliers/rewarding
compliers
• Lack of institutional safety climate

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 Aims and Objectives

To study the compliance with hand washing among health workers

(HCW) during routine patient care.

To compare the compliance in different types of health care

workers (Doctors, Nurses and Ward aids).

To investigate the probable factors associated with non-compliance

in HCWs and give suggestions to management for improvement of
the same.

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 Methods

Compliance with hand washing is defined as either washing the

hands and wrist with water and plain soap or rubbing with an
antiseptic solution.
We underwent an observation study at Manav Sewa Sang Hospital
and its part Parmarth Hospital , Rohtak, Haryana, where doctors of
different specialty work on full time and on visit basis with
admission and OT facilities.
Our group was the observer and we randomly observed the
subjects during routine patient care. The study was conducted in
June 2009 and the subjects were health care workers working in
different units and wards of the hospital which included the general
wards, private wards and OPDs. The observation periods were
distributed randomly during the day as well as the night for 10
days. In the beginning the subjects were unaware that they were
being observed and later a questionnaire was administered among
the HCW’s. The opportunities were observed and the observation
was recorded with the subject number, type of the event, unit or
ward and compliance or failure to comply with hand washing. No
judgment was taken into account of the duration and efficacy of
hand washing technique. Hand washing facilities were as
conveniently located as possible in the hospital. At least one sink
was located inside every OPD, examination room and patient
ward, along with towels and unmedicated soap. Dispensers of hand
antiseptic solutions are available in high-risk areas. Individual
bottles containing an alcohol-based hand gels are also available
particularly in OPDs.

Guidelines for hand washing were consistent with infection-control

practice recommendations and with the basic principle of universal
precautions. These guidelines suggest that hands be washed with
soap and water or be disinfected
1) Before and after patient contact,

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2)After contact with a source of microorganisms (body fluids and
substances, mucous membranes, broken skin, or inanimate objects
that are likely to be contaminated), and
3) After removing gloves.
Because microbial contamination of hands and possible
transmission of microorganisms have been reported even when
gloves were worn, hand washing with soap and water or hand
antisepsis is required after glove removal.
Guidelines of Infection Control and Epidemiology state that gloves
should be used as an adjunct to (not a substitute for) hand washing.
Glove use is required when contact with mucous membranes,
broken skin, or any moist body substance is anticipated.
During the study, we made no judgment about whether glove use
or hand washing was preferred.
Departure from room after patient care without hand washing was
regarded as noncompliance.
Questions were put to HCWs for cause of their non-compliance.
They were asked to tick the one most appropriate cause they
realized in this hospital setting for non-adherence to hand washing
practices.
• High work load, patient care takes priority over hand
hygiene
• Sink location inconvenient
• Gloves being worn
• Lack of suitable hand hygiene agent
• Inadequate knowledge of guidelines
• Inadequate supply of hand hygiene agent
• Lack of education and encouragement
• Lack of role model from seniors
• Unable to justify for his Non-compliance

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 Limitation of study
• The study only covers HCWs working at present time and
practices being followed in Manav Sewa Sang Hospital ,
Rohtak, Haryana. Whether our results can be generalized to
other health care institutions is uncertain because both the
infrastructure and the organization of work influence
behavior.
• Duration and proper technique of hand washing, whether
HCWs were adherent to, were not taken into account. (Proper
technique that is wet hands first with water, apply an amount
of product recommended to hands, and rub hands together
vigorously for at least 15 seconds, covering all surfaces of the
hands and fingers including thumb and pads of fingerprint
area, and wrists and knuckles which are commonly missed.
Rinse hands with water and dry thoroughly with a disposable
towel)
• Questionnaires had been set, for non compliance, based on
probable causes noticed in the hospital.

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 Analysis of data
Presented below is a statistical analysis of the study results made in
the hospital covering surgical and medical wards as well as OPDs.
Out of a total strength of 70 HCWs, the study covered 50 HCWs.

Following health care workers (HCWs) were the participant

HCWs Number Percent
Doctors 15 30
Nurses 20 40
Ward Aides 15 30
Total 50 100
Out of 50 HCWs, 15 were the doctors, 20 nurses and 15 aides
taken into study.

Compliance seen in different departments

Department Number ofCompliance Percent
opportunities
noticed
OPDs 172 65 37.79

Surgical Wards 88 42 47.71

Medical Wards 80 48 60.00
Total 340 155 45.58

Compliance with hand washing differed among various

departments also. Compliance was 37.79% in OPDs, 60% in
medical wards and unfortunately 47.71% in surgical wards.

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Compliance seen among different health care workers
HCWs Number ofCompliance Percent
opportunities
Doctors 102 45 44.11
Nurses 118 78 66.10
Ward Aides 120 32 26.66
Total 340 155 45.58
Average compliance seen was very low as 45.6%. Compliance was
44.11% among doctors, 66.10% in nurses and 26.66% in ward
aides in present study.

Insights from questionnaire – reasons for non-adherence to hand

washing
Reasons Given by no. ofPercent
HCWs
High work load, patient care 17 34
takes priority over hand hygiene
Justifying that they are using 6 12
gloves
Lack of suitable hand hygiene 7 14
agent
Inadequate supply of hand 8 16
hygiene agent
Shortage of sinks or 6 12
inconveniently located
Lack of Education and 2 4
encouragement
Unable to justify for his Non- 4 8
compliance
Total 50 100

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34% HCWs say high workload and under staffing is the reason for
their noncompliance, 12% say that they are using gloves, 14%
say hand hygiene agent cause irritation, 16% excuse
for inadequate supply of hand hygiene agent. Shortage of sinks
was given as reason by 12% of HCWs. 8% were unable to justify
for noncompliance and lack of education and encouragement were
suggested by 4 %.

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 Results

In the present study we observed 340 hand washing opportunities.

The categories of staff were doctors, nurses and ward aides.
The average compliance was very low as 45.58%. Hand washing
was done by soap and water in 108 opportunities. In remaining 47
opportunities hand disinfectant was used.
Compliance for hand washing differed among the different
categories of HCWs. Nurses were significantly compliant with a
compliance level of 66.10% followed by doctors of 44.11%. Ward
aides showed least compliance of 26.66%.
Compliance also differed in different department. There was
60.00% compliance in the medical wards unfortunately 47.71% in
the surgical wards which is high risk area. Compliance was least in
OPDs with level of 37.79% which may be because of high
workload.
Main reason for noncompliance given by HCWs in present study
was high workload followed by shortage of sinks and inadequate
supply of hand hygiene agent followed by lack of encouragement
or simply noncompliance.

23
 Discussion

Transmission of microorganisms from the hands of health care

workers is the main cause of nosocomial infections, and hand
washing remains the most important preventive measure.
Unfortunately, compliance with hand washing is unacceptably low
in the present study.

This study shows that the primary problem with hand washing may
be the laxity of practice. During routine patient care, HCWs
disinfected or washed their hands in about less than half the
indicated instances. One reason for poor hand washing compliance
could be that the importance of this simple protocol for decreasing
infections is routinely underestimated by healthcare workers
particularly ward aides who showed least compliance in the
present study. Many other risk factors for non-compliance with
hand hygiene guidelines have been identified, including
professional category (e.g., physician, nurse, ward aides), different
department, lack of time, heavy workload, and type and intensity
of patient care. Nurses showed significant compliance in the
present study. A probable reason for the significant compliance
level among the nurses could be because they are under constant
scrutiny. Doctors on the other hand showed low compliance levels.
There has also been some concern about the substitution of glove
use for hand washing. One potential adverse effect of hand
washing for healthcare workers is skin irritation. Indeed, skin
irritation constitutes an important barrier to appropriate compliance
with hand washing guidelines. Another potential harm of
increasing compliance with hand washing is the amount of time
required to do it adequately. Current recommendations for standard

24
hand washing suggest 15-30 seconds of hand washing is necessary
for adequate hand hygiene. Lack of time is one of the most
common reasons cited for failure to wash hands.
Since many different risk factors including skin irritation, sinks are
inconveniently located, glove use, insufficient time for hand
hygiene, high workload and understaffing, inadequate knowledge
of guidelines or lack of protocols for hand hygiene have been
identified for non-compliance with hand washing, it is not
surprising that a variety of different interventions are required in an
effort to improve this practice. No single strategy seems to sustain
improved compliance with hand washing protocols.
Interventions designed to improve hand washing may require
significant financial and human resources. This is true both for
multifaceted educational/feedback initiatives, as well as for
interventions that require capital investments in recruitment of staff
to combat the workload and in equipment such as more sinks,
automated sinks, or new types of hand hygiene products.
Education is a cornerstone for improvement with hand hygiene
practices. Topics that must be addressed by educational programs
include the lack of
1) Scientific information for the definitive impact of improved
hand hygiene on healthcare– associated infection and resistant
organism transmission rates;
2) Awareness of guidelines for hand hygiene and insufficient
knowledge concerning indications for hand hygiene during daily
patient care;
3) Knowledge concerning the low average adherence rate to hand
hygiene by the majority of HCWs; and
4) Knowledge concerning the appropriateness, efficacy, and
understanding of the use of hand-hygiene and skin-care–protection
agents.
Some elements of health-care worker educational and motivational
programs discussed are as per given in appendices

25
Minutes of discussion are as under:

Interventions discussed with Response of management

management to improve
compliance with hand
washing
Proper location of sinks Management feel necessity but
apprehensive of budgetary
constraint
Alcohol based hand rubs which Assurance given by management
are less irritant and take less
time
Educational and motivational Management realized but no
programs commitment for near future
Problem of workload and Management will review the
understaffing problem and then decide
Proving bed side availability of Apprehensive of getting misused
hand hygiene agent by non staff
Hanging posters showing proper Management ready for that and
technique of hand washing over committed for implication
sinks

Many questions regarding hand-hygiene products and strategies for

improving adherence of personnel to recommended policies still
remain unanswered. There are several concerns which must still be
addressed by researchers in industry and by clinical investigators
given in Hand-Hygiene Research Agenda (in appendices)

26
 Conclusion

Noncompliance with hand washing is a substantial problem in a

hospital setting. From the responses indicated by the HCWs, it
becomes evident that a behavioral change is required. It involves a
combination of education, motivation and system change. The
factors necessary for change include dissatisfaction with the
current situation, the perception of alternatives and the recognition,
both at the individual and institutional level, of individual’s ability
and potential to change. Intervention must target reasons for non-
compliance at all levels of healthcare (i.e., individual, group,
institution) in order to be effective. A more detailed study of the
cost (and potentially cost savings) of hand washing initiatives
would also foster greater enthusiasm among healthcare
organization to support such initiatives. The costs incurred by such
interventions can be balanced against the potential gain derived
from reduced numbers of nosocomial infections with improved
quality of patient care.

27
 Recommendations

CDC Recommendations
As per CDC guidelines these recommendations are designed to
improve hand hygiene practices of HCWs and to reduce
transmission of pathogenic microorganisms to patients and
personnel in healthcare settings.
1. Indications for hand washing and hand antisepsis
A. When hands are visibly dirty or contaminated with
proteinaceous material or are visibly soiled with blood or other
body fluids, wash hands soap and water.
B. If hands are not visibly soiled, use an alcohol-based hand rub
for routinely decontaminating hands in all other clinical situations
C. Decontaminate hands before having direct contact with patients
D. Decontaminate hands before donning sterile gloves when
inserting a central intravascular.
E. Decontaminate hands before inserting indwelling urinary
catheters, peripheral vascular catheters, or other invasive devices
that do not require a surgical.
F. Decontaminate hands after contact with a patient’s intact skin
(e.g., when taking a pulse or blood pressure, and lifting a patient).
G. Decontaminate hands after contact with body fluids or
excretions, mucous membranes, nonintact skin, and wound
dressings if hands are not visibly soiled.
H. Decontaminate hands if moving from a contaminated-body site
to a clean-body site during patient.
I. Decontaminate hands after contact with inanimate objects
(including medical equipment) in the immediate vicinity.
J. Decontaminate hands after removing gloves.

28
K. Before eating and after using a restroom, wash hands with a
non-antimicrobial soap and water or with an antimicrobial soap
and water.
L. Antimicrobial-impregnated wipes (i.e., towelettes) may be
considered as an alternative to washing hands with non-
antimicrobial soap and water. Because they are not as effective as
alcohol-based hand rubs or washing hands with an antimicrobial
soap and water for reducing bacterial counts on the hands of
HCWs, they are not a substitute for using an alcohol-based hand
rub or antimicrobial soap.
M. Wash hands with non-antimicrobial soap and water or with
antimicrobial soap and water if exposure to Bacillus anthracis is
suspected or proven. The physical action of washing and rinsing
hands under such circumstances is recommended because alcohols,
chlorhexidine, iodophors, and other antiseptic agents have poor
activity against.
N. No recommendation can be made regarding the routine use of
nonalcohol-based hand rubs for hand hygiene in health-care
settings.
2. Hand-hygiene technique
A. When decontaminating hands with an alcohol-based hand rub,
apply product to palm of one hand and rub hands together,
covering all surfaces of hands and fingers, until hands are dry.
Follow the manufacturer’s recommendations regarding the volume
of product to use.
B. When washing hands with soap and water, wet hands first with
water, apply an amount of product recommended by the
manufacturer to hands, and rub hands together vigorously for at
least 15 seconds, covering all surfaces of the hands and fingers.
Rinse hands with water and dry thoroughly with a disposable
towel. Use towel to turn off the faucet. Avoid using hot water,
because repeated exposure to hot water may increase the risk of
dermatitis.

29
C. Liquid, bar, leaflet or powdered forms of plain soap are
acceptable when washing. When bar soap is used, soap racks that
facilitate drainage and small bars of soap should be used.
D. Multiple-use cloth towels of the hanging or roll type are not
recommended for use in health-care settings.

3. Surgical hand antisepsis

A. Remove rings, watches, and bracelets before beginning the
surgical hand scrub.
B. Remove debris from underneath fingernails using a nail cleaner
under running water.
C. Surgical hand antisepsis using either an antimicrobial soap or an
alcohol-based hand rub with persistent activity is recommended
before donning sterile gloves when performing surgical
procedures.
D. When performing surgical hand antisepsis using an
antimicrobial soap, scrub hands and forearms for the length of time
recommended by the manufacturer, usually 2–6 minutes. Long
scrub times (e.g., 10 minutes) are not necessary.
E. When using an alcohol-based surgical hand-scrub product with
persistent activity, follow the manufacturer’s instructions. Before
applying the alcohol solution, prewash hands and forearms with a
non-antimicrobial soap and dry hands and forearms completely.
After application of the alcohol-based product as recommended,
allow hands and forearms to dry thoroughly before donning sterile
gloves.
4. Selection of hand-hygiene agents
A. Provide personnel with efficacious hand-hygiene products that
have low irritancy potential, particularly when these products are
used multiple times per shift. This recommendation applies to
products used for hand antisepsis before and after patient care in
clinical areas and to products used for surgical hand antisepsis by
surgical personnel.

30
B. To maximize acceptance of hand-hygiene products by HCWs,
solicit input from these employees regarding the feel, fragrance,
and skin tolerance of any products under consideration. The cost of
hand hygiene products should not be the primary factor influencing
product selection.
C. When selecting non-antimicrobial soaps, antimicrobial soaps, or
alcohol-based hand rubs, solicit information from manufacturers
regarding any known interactions between products used to clean
hands, skin care products, and the types of gloves used in the
institution.
D. Before making purchasing decisions, evaluate the dispenser
systems of various product manufacturers or distributors to ensure
that dispensers function adequately and deliver an appropriate
volume of product.
E. Do not add soap to a partially empty soap dispenser. This
practice of “topping off” dispensers can lead to bacterial
contamination of soap.
5. Skin care
A. Provide HCWs with hand lotions or creams to minimize the
occurrence of irritant contact dermatitis associated with hand
antisepsis or hand washing
B. Solicit information from manufacturers regarding any effects
that hand lotions, creams, or alcohol based hand antiseptics may
have on the persistent effects of antimicrobial soaps being used in
the.
6. Other Aspects of Hand Hygiene
A. Do not wear artificial fingernails or extenders when having
direct contact with patients at high risk (e.g., those in intensive-
care units or operating rooms).
B. Keep natural nails tips less than 1/4-inch long.
C. Wear gloves when contact with blood or other potentially
infectious materials, mucous membranes, and nonintact skin could
occur.

31
D. Remove gloves after caring for a patient. Do not wear the same
pair of gloves for the care of more than one patient, and do not
wash gloves between uses with different patients.
E. Change gloves during patient care if moving from a
contaminated body site to a clean body.
F. No recommendation can be made regarding wearing rings in
health-care settings. Unresolved issue.
7. Health-care worker educational and motivational programs
A. As part of an overall program to improve hand hygiene
practices of HCWs, educate personnel regarding the types of
patient-care activities that can result in hand contamination and the
advantages and disadvantages of various methods used to clean
their.
B. Monitor HCWs’ adherence with recommended hand-hygiene
practices and provides personnel with information regarding their
performance.
C. Encourage patients and their families to remind HCWs to
decontaminate their hands.
8. Administrative measures
A. Make improved hand-hygiene adherence an institutional
priority and provide appropriate administrative support and
financial.
B. Implement a multidisciplinary program designed to improve
adherence of health personnel to recommended hand-hygiene.
C. As part of a multidisciplinary program to improve hand-hygiene
adherence, provide HCWs with a readily accessible alcohol-based
hand-rub product.
D. To improve hand-hygiene adherence among personnel who
work in areas in which high workloads and high intensity of
patient care are anticipated, make an alcohol-based hand rub
available at the entrance to the patient’s room or at the bedside, in
other convenient locations, and in individual pocket-sized
containers to be carried by HCWs.
E. Store supplies of alcohol-based hand rubs in cabinets or areas
approved for flammable materials.

32
Elements of health-care worker educational and
motivational programs
Rationale for hand hygiene
• Potential risks of transmission of microorganisms to patients
• Potential risks of health-care worker colonization or infection
caused by organisms acquired from the patient
• Morbidity, mortality, and costs associated with health-care–
associated infections
Indications for hand hygiene
• Contact with a patient’s intact skin (e.g., taking a pulse or blood
pressure, performing physical examinations, lifting the patient in
bed)
• Contact with environmental surfaces in the immediate vicinity of
patients
• After glove removal
Techniques for hand hygiene
• Amount of hand-hygiene solution
• Duration of hand-hygiene procedure
• Selection of hand-hygiene agents
1. Alcohol-based hand rubs are the most efficacious agents for
reducing the number of bacteria on the hands of personnel.
2. Antiseptic soaps and detergents are the next most effective, and
non-antimicrobial soaps are the least effective.
3. Soap and water are recommended for visibly soil hands.
4. Alcohol-based hand rubs are recommended for routine
decontamination of hands for all clinical indications (except
when hands are visibly soiled) as one of the options for surgical
hand hygiene.
Methods to maintain hand skin health
• Lotions and creams can prevent or minimize skin dryness and
irritation caused by irritant contact dermatitis
• Acceptable lotions or creams to use
• Recommended schedule for applying lotions or creams

33
Expectations of patient care managers/administrators
• Written statements regarding the value of, and support for,
adherence to recommended hand-hygiene practices
• Role models demonstrating adherence to recommended hand
hygiene practices Indications for, and limitations of, glove use
• Hand contamination may occur as a result of small, undetected
holes in examination gloves
• Contamination may occur during glove removal
• Wearing gloves does not replace the need for hand hygiene
• Failure to remove gloves after caring for a patient may lead to
transmission of micro organisms from one patient to another.

Hand-hygiene research agenda Education and

promotion
• Provide health-care workers (HCWs) with better education
regarding the types of patient care activities that can result
in hand contamination and cross-transmission of microorganisms.
• Develop and implement promotion hand-hygiene programs in
pregraduate courses.
• Study the impact of population-based education on hand-hygiene
behavior.
• Design and conduct studies to determine if frequent glove use
should be encouraged or discouraged.
• Determine evidence-based indications for hand cleansing
(considering that it might be unrealistic to expect HCWs to
clean their hands after every contact with the patient).
• Assess the key determinants of hand-hygiene behavior and
promotion among the different populations of HCWs.
• Develop methods to obtain management support.
• Implement and evaluate the impact of the different components
of multimodal programs to promote hand hygiene.
Hand-hygiene agents and hand care

34
• Determine the most suitable formulations for hand-hygiene
products.
• Determine if preparations with persistent antimicrobial activity
reduce infection rates more effectively than do preparations
whose activity is limited to an immediate effect.
• Study the systematic replacement of conventional handwashing
by the use of hand disinfection.
• Develop devices to facilitate the use and optimal application of
hand-hygiene agents.
• Develop hand-hygiene agents with low irritancy potential.
• Study the possible advantages and eventual interaction of hand-
care lotions, creams, and other barriers to help minimize
the potential irritation associated with hand-hygiene agents.

Laboratory-based and epidemiologic research and

development
• Develop experimental models for the study of cross-
contamination from patient to patient and from environment to
patient.
• Develop new protocols for evaluating the in vivo efficacy of
agents, considering in particular short application times and
volumes that reflect actual use in health-care facilities.
• Monitor hand-hygiene adherence by using new devices or
adequate surrogate markers, allowing frequent individual feedback
on performance.
• Determine the percentage increase in hand-hygiene adherence
required to achieve a predictable risk reduction in infection rates.
• Generate more definitive evidence for the impact on infection
rates of improved adherence to recommended hand hygiene
practices.
• Provide cost-effectiveness evaluation of successful and
unsuccessful promotion campaigns.

35
 Bibliography

1. Haley RW, Culver DH, White JW, Morgan WM, Emori TG,
Munn VP. The efficacy of infection surveillance and control
programs in preventing nosocomial infection in US hospitals. Am J
Epidemiol1985;121:182-205.
2 John M, Pitter D. Guideline for hand hygiene in health care
settings vol. 51/RR-16.
3. Larson E. A causal link between handwashing and risk of
infection? Examination of the evidence. Infect Control Hosp
Epidemiol 1988;9:28-36.
4. Doebbeling BN, Stanley GL, Sheetz CT, Pfaller MA, Houston
AK, Annis L, et al. Comparative efficacy of alternative
handwashing agents in reducing nosocomial infections in intensive
care units. N Engl J Med1992;327:88-93.
5. Jarvis WR. Hand washing the Semmelweis lesson
forgotten? Lancet 1994;344:1311-2.
6. Larson EL. APIC guideline for handwashing and hand antisepsis
in health care settings. Am J Infect Control. 1995;23:251-69.
7. Voss A, Widmer AF. No time foe handwashing? Handwashing
versus alcoholic rub: can we afford Control Hosp
Epidemiol. 1997;18:205-8.
8. Steere AC, Mallison GF. Handwashing practices for the
prevention of nosocomial infections. Ann Intern
Med. 1975;83:683-90.

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9. Coppage CM. Hand washing in patient care [Motion picture].
Washington , DC : US Public Health Service, 1961.
10. Larson E, Killien M. Factors influencing handwashing
behavior of patient care personnel. Am J Infect Control
1982;10:93–9.
11.OJHAS Vol 5 Issue 4(2) - Suchitra JB, Lakshmidevi N. Hand
washing Compliance - Is It A Reality?
12 Chapter 12. Practices to Improve Handwashing
Compliance Ebbing Lautenbach, M.D., M.P.H., MSCEUniversity
of Pennsylvania School of Medicine
13.Didier Pittet, MD, MS; Philippe Mourouga, MD, MSc;Thomas
V. Perneger, MD, PhD; and the Members of the Infection Control
Program. Compliance with Handwashing in a Teaching Hospital.

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 Questionnaire
1. Please select your profession:

Doctor Nurse Ward Aide

2. Please select the department you belong to:

OPD Surgical Ward Medical Ward

3. In your opinion what is the main reason for non - adherence

to hand washing by Health Care Workers in this hospital:
(Please tick one option)

High work load

Causes skin irritation

Inconvenient sink location

Gloves are used

Lack of suitable hand hygiene agent

Unaware of guidelines

Inadequate supply of hand hygiene age

Lack of education and encouragement

Patient care is more important than hand hygiene

Cannot say

Others (please specify)……………………………………

Thank you

38
39