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Original Article

Hand Hygiene Compliance among Health-care Personnel in Intensive

Care Unit of a Tertiary Care Super Specialty Institute
Manodeep Sen, Meenakshi Sharma1, Anupam Das, Amit Kumar Singh1

Department of Microbiology, Introduction: Hospital-acquired infections complicate 7%–10% of hospital admissions.

Abstract
Dr. Ram Manohar Lohia
Institute of Medical Sciences,
Patients in the Intensive Care Units (ICUs) are more likely to be colonized or infected.
Lucknow, 1Department Most of these infections are spread by carriage of microorganisms on the health-care
of Microbiology, Mayo workers’ (HCW) hands. Hand hygiene (HH) is the single most important measure
Institute of Medical Sciences, to prevent this. Despite relative simplicity of HH procedures and recommendations,
Barabanki, compliance with HH is still poor. Aim and Objectives: To assess HH compliance among
Uttar Pradesh, India health-care personnel in the ICU of Ram Manohar Lohia Institute of Medical Sciences,
Lucknow. Materials and Methods: A prospective cross-sectional observational study
using direct observation technique was done. A  single observer collected all HH
data. A  survey was done, before the study, pertaining to perception and knowledge,
opportunities, steps, actions, and attitude toward HH. The nursing staff, doctors, and
allied health-care personnel were taken as a sample size. The observations were noted
for all five moments of HH before and after patient contact. Results: A  total of 10
HCW were observed over 50  h of observation period, spread over 1  month, which
created 535 HH opportunities. HH actions actually performed by the HCW were 498,
and overall compliance of the study group was 93.1%. Conclusion: The average level
of compliance with recommended HH techniques among health-care personnel was
93.1% which is appropriate for critical care areas.

Received: 29-09-2017 Keywords: Hand hygiene compliance, health-care personnel,

Accepted: 23-02-2018 healthcare-associated infections

Introduction HH is a general term that applies to handwashing,

H ealthcare-associated infections (HAIs) have been
a problem worldwide affecting a significant
number of hospitalized patients. World Health
Organization (WHO) had estimated that globally,
7%–12% of hospitalized patients will acquire
health HAIs.[1] International Nosocomial Infection
Control Consortium in 2007 had reported an overall
HAI incidence rate of 4.4% corresponding to 9.06
infections per 1000 Intensive Care Units (ICU) days
from 7 Indian cities.[2]
Patients in the ICUs are more likely to be colonized
or infected during their hospital stay. Most of these
infections are transmitted to the patients by carriage of
microorganisms on the hands of health-care workers
(HCW) while handling patients.[1] Hand hygiene (HH) is
one of the most important measures to prevent HAIs.
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antiseptic hand wash, alcohol-based hand rub, or surgical
HH/antisepsis.[1] While these measures as simple and
inexpensive as handwashing with soap and water can be
implemented to reduce HAIs and save millions of lives,
compliance with it is still low in developing countries.[3,4]
This may be attributed to lack of proper knowledge and
recognition of HH opportunities during patient care.[5]
To address this problem, continuous efforts are being
made to identify effective and sustainable strategies.
One of such efforts is the introduction of an evidence-
based concept of “My five moments for HH” by World
Address for correspondence: Dr. Meenakshi Sharma,
Department of Microbiology, Mayo Institute of Medical Sciences,
Barabanki - 225 001, Uttar Pradesh, India.
E-mail: meenakshi_lhmc@gmail.com
This is an open access journal, and articles are distributed under the terms of the Creative
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Sen M, Sharma M, Das A, Singh AK. Hand hygiene
10.4103/mjdrdypu.MJDRDYPU_194_17 compliance among health-care personnel in intensive care unit of a tertiary
care super specialty institute. Med J DY Patil Vidyapeeth 2018;11:210-4.

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Sen, et al.: Hand hygiene compliance in ICU
Health Organization which includes use of HH before
touching a patient, before performing aseptic and clean
procedures, after being at risk of exposure to body
fluids, after touching a patient, and after touching patient
surroundings.[6]
In India, technology to monitor adherence may not be
available at every hospital setting; direct observation
remains the gold standard. With this aim, we attempted
to assess HH compliance among HCW in the ICU of a
tertiary care super specialty institute in North India by
direct observation method.
Materials and Methods
The present study was a cross-sectional observational
study. The ICU staff (10 HCW, namely doctors,
outsource nursing staff and nursing staff Grade  II, and
allied health-care personnel) posted in ICU were taken
as sample population. All the ICU staff were briefed
about the current HH practices and five moments of HH
which included use of HH before touching a patient,
before performing aseptic and clean procedures, after
being at risk of exposure to body fluids, after touching
a patient, and after touching patient surroundings as per
WHO guidelines before starting the study. A survey was
done, before the study, by filling a questionnaire. The
questionnaire was to access the perception, knowledge,
opportunities, steps, actions, and attitude toward HH.
The ICU staff was observed for HH compliance by a
single observer for 2  h/working day for 1  month. The
observations were noted for all five moments of HH as
opportunity utilized or missed in a checklist where a tick
was placed if the HH practice was adhered to by the
HCW when the opportunity for the same is there. The
kind of HH practice (hand wash, hand rub, or wearing
gloves) which was practised by the HCW was also
noted. To reduce Hawthorne effect, the observer visits
ICU randomly with no fixed schedule.
Statistical analysis
The data were recorded and analyzed in Microsoft
Office Excel Sheet 2013. Data have been represented as
frequencies and percentages.
Results
During the study, a total of 10 HCW were observed over
50 h of observation period, spread over 1 month, which
created 535 HH opportunities [Figure 1]. The HCW
comprised of one non-PG resident, five nursing staff
Grade II, three outsource nursing staff members, and one
housekeeping staff posted in the ICU.
Total HH opportunities during the study period were
535 (242 [45.2%] from the outsource nursing staff,
Medical Journal of Dr. D.Y. Patil Vidyapeeth  ¦  Volume 11  ¦  Issue 3  ¦  May-June 2018
226 [42.2%] from the hospital nursing staff Grade  II,
21 [3.9%] from resident doctor, and 46 [8.5%] from
housekeeping staffs). HH actions actually performed by
the HCW were 498 and overall compliance of the study
group was estimated as 93.1%.
Maximum hand-hygiene compliance among health care
staff was seen after fluid exposure which is moment 3
of HH moments. Analysis of the survey showed that
100% of the health-care staff had knowledge about HH
methods. However, only 90% of HCW had knowledge
about the correct method of performing HH. Only 50%
had knowledge about the timing of performing hand
wash and hand rub. Thirty percent of HCW were found
wearing jewelry and wrist watches while washing hands.
Except for before aseptic procedure and after fluid
exposure for all the other opportunities, hand rub was the
most common HH practice. Before aseptic procedure,
wearing gloves was the most common practice.
Discussion
Proper HH is the single most important, simplest, and
least expensive means of reducing the prevalence of
HAIs and the spread of antimicrobial resistance.[7,8]
Several studies have demonstrated that handwashing
virtually eradicates the carriage of MRSA which
invariably occurs on the hands of HCW working in
ICUs.[9] In most health-care institutions, adherence to
recommend handwashing practices remains unacceptably
low, rarely exceeding 40 percent of situations in which
HH is indicated.[10,11] Patients in the ICUs are more likely
to be colonized or infected by harmful and multidrug-
resistance microorganisms carried on the HCW hands.
Total 535 HH opportunities were observed during the
study period. HH actions actually performed by the HCW
were 498, and overall compliance of the study group
was estimated as 93.1% [Table 1-4]. Which is higher as
compared to other studies in India.[12-15]
Compliance rate was lower in outsource nursing staff
and housekeeping staff as compared to hospital nursing
Figure 1: Hand hygiene opportunities (n=535)
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Sen, et al.: Hand hygiene compliance in ICU

Table 1: Observed compliance for nursing staff Grade II which observed compliance of 43.2%, and it was more
WHO’s 5 moments Observation Opportunity Compliance (%) in doctors (50.8%) than nurses (41.3%).[12] In contrary,
Before patient 54 56 96.4 Pittet et al. observed compliance of 48% and nurses had
contact the highest handwashing adherence rates (52%), while
Before aseptic 30 33 90.9 physicians were the worst offenders (23%).[11]
procedure
After fluid exposure 12 12 100 Maximum compliance was seen after body fluid
After patient 65 66 98.5 exposure, that is, the staffs were very careful after body
contact fluid contact as it was perceived important for self-
After contact 58 59 98.3 protection. Statistically significant (P  <  0.05) difference
with patient was seen in HH compliance before patient contact and
surroundings after patient contact.
Total 219 226 96.9
WHO: World Health Organization Almost all the HCW included in the study perceived HH
as useful measure to prevent hospital-acquired infections;
yet, the knowledge was not converted to actions. In
Table 2: Observed compliance of outsource nursing staff
response to the questionnaire, 100% of the health-care
WHO’s 5 moments Observation Opportunity Compliance (%)
Before patient 62 66 93.9
staff claimed to have knowledge about HH methods.
contact However, only 50% had knowledge about the correct
Before aseptic 22 26 84.6 timing of performing hand wash and hand rub. About
procedure 30% of HCWs were found wearing jewelry and wrist
After fluid exposure 15 18 83.3 watches while washing hands.
After patient contact 62 66 93.9
After contact with 62 66 93.9
Hand rub was the most common HH practice (significant
patient surrounding difference: P  <0.001) followed by the participants for
Total 223 242 92.1 most of the opportunities except before aseptic procedure
WHO: World Health Organization and after fluid exposure for which the participants
preferred washing hands over using hand rub. Wearing
gloves was the most common practice (significant
Table 3: Observed compliance for resident
difference: P  <0.001) before aseptic procedure as it
WHO’s 5 moments Observation Opportunity Compliance (%)
Before patient 5 5 100
is considered safe and less time-consuming by the
contact participants.
Before aseptic 4 4 100 Less time in emergency situations, lack of knowledge,
procedure
and allergy to soap/hand rub were the most common
After fluid exposure 4 4 100
reasons given by the participants for lack of compliance.
After patient contact 4 4 100
After contact with 4 3 75 Limitations
patient surroundings Direct observations have limitations; they are time-
Total 20 21 95.2 consuming, workforce intensive, and do not allow
WHO: World Health Organization continuous monitoring. They probably provide information
about a very low percentage of all HH opportunities. If
Table 4: Observed compliance for housekeeping staff staff is aware, direct observation may affect health-care
WHO’s 5 moments Observation Opportunity Compliance (%) personnel behavior (Hawthorne effect). We have tried
Before patient 2 6 33.3 to limit these difficulties by engaging a single trained
contact observer. However, there could be opportunities that were
Before aseptic 7 9 77.8 missed. The sample size in our study was very low which
procedure
may have affected the overall results.
After fluid exposure 9 9 100
After patient contact 8 11 72.7
After contact with 9 11 81.8
Conclusion
patient surroundings The average level of compliance with recommended
Total 35 46 76.1 HH techniques among health-care personnel was 93.1%
WHO: World Health Organization which is appropriate for critical care areas. Routine
observation of HCW can also help in evaluation of
staff Grade  II and doctor for all the opportunities. This HH technique and can check compliance rates among
result is consistent with study done by Sharma et al. different health-care personnels.

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Sen, et al.: Hand hygiene compliance in ICU
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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Sen, et al.: Hand hygiene compliance in ICU

Hand Hygiene Knowledge Questionnaire

S.no Date Time Department
1. Junior resident/Senior resident/Faculty/Nursing staff/Other health-care worker
2. Knowledge about hand hygiene recommendations: Yes/No
3. Hand hygiene refers to
a. Handwashing using soap
b. Handwashing using alcohol hand rub
c. Decontaminating using 4% chlorhexidine
d. All the above.
4. When to perform hand hygiene:
a. Before touching a patient
b. Immediately after a risk of body fluid exposure
c. After exposure to the immediate surroundings of a patient
d. Immediately before a clean/aseptic procedure.
5. Knowledge about technique of hand hygiene: Yes/No
6. Duration of hand hygiene:
a. 5 s
b. 10 s
c. 15 s
d. 60 s.
7. Hand hygiene performed
a. Before patient contact Yes/No
b. Before aseptic procedure Yes/No
c. After body fluid exposure Yes/No
d. After patient contact Yes/No
e. After contact with patient surroundings Yes/No
8. Which type of hand hygiene method is required in the following situations?
a. Before palpation of the abdomen
• Rubbing/Washing/None
b. Before giving an injection
• Rubbing/Washing/None
c. After emptying a bedpan
• Rubbing/Washing/None
d. After removing examination gloves
• Rubbing/Washing/None
e. After making a patient’s bed
• Rubbing/Washing/None
f. After visible exposure to blood
• Rubbing/Washing/None
9. Wearing jewellery or wrist watch while washing hands: Yes/No
10. Which of the following should be avoided, as associated with increased likelihood of colonization of hands
with harmful germs?
a. Wearing jewellery
b. Damaged skin
c. Artificial fingernails
d. Regular use of a hand cream.

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