- Email: [email protected]
Twenty-four-hour observational study of hospital hand hygiene compliance
Journal of Hospital Infection 76 (2010) 252e255
Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Twenty-four-hour observational study of hospital hand hygiene compliance J. Randle*, A. Arthur, N. Vaughan Nottingham University Hospitals NHS Trust, The Queen’s Medical Centre, Nottingham, UK
a r t i c l e i n f o
s u m m a r y
Article history: Received 24 April 2010 Accepted 28 June 2010 Available online 17 September 2010
This observational study measured healthcare workers’ (HCWs’), patients’ and visitors’ hand hygiene compliance over a 24 h period in two hospital wards using the ‘five moments of hand hygiene’ observation tool. Hand hygiene is considered to be the most effective measure in reducing healthcare-associated infections but studies have reported suboptimal levels of compliance. Most studies have used random observational time-periods for data collection and this has been criticised. We monitored a total of 823 hand hygiene opportunities (HCWs, N ¼ 659; patients and visitors, N ¼ 164). Among HCWs, compliance was 47% for doctors, 75% for nurses, 78% for allied health professionals, and 59% for ancillary and other staff (P < 0.001). There was no difference in compliance between patients and visitors (56% vs 57%, P ¼ 0.87). Hand hygiene compliance varied depending on which of the five moments of hygiene HCWs had undertaken (P < 0.001), with compliance before an aseptic task being 100% (3/3); after body fluid exposure 93% (86/93); after patient contact 80% (114/142); before patient contact 68% (196/290); and after contact with surroundings 50% (65/129). Lower levels of compliance were found for HCWs working during the early shift (P < 0.001). For patients and visitors there was no evidence of an association between moments of hygiene and compliance. Levels of compliance were higher compared with previous reported estimates. Medical staff had the lowest level of compliance and this continues to be a concern which warrants specific future interventions. Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hand hygiene compliance Healthcare-associated infections Healthcare workers Hospital visitors Patients
Introduction The World Health Organization (WHO) identified the risk of acquiring a healthcare-associated infection (HCAI) as being universal.1 As HCAIs cause significant morbidity in the UK, the prevention of HCAIs is recognised as a critical factor for safe healthcare, and effective hand hygiene is vital for healthcare services in order to provide high quality and safe healthcare.2e4 Contaminated hands are thought to be the main vehicle for the spread of certain pathogens; HCWs’ compliance has been reported to be highly variable, however, and in some cases, unacceptably poor.1 Factors affecting poor compliance include heavy workloads, a lack of time, inaccessible resources, skin irritation, gender and professional grouping.1 Despite the identification of these factors,
* Corresponding author. Address: School of Nursing, Midwifery and Physiotherapy, Faculty of Medicine and Health Sciences, University of Nottingham, The Queen’s Medical Centre, Nottingham NG7 2UH, UK. Tel.: þ44 (0)115 8230899; fax: þ44 (0)115 8231211. E-mail address: [email protected] (J. Randle).
many studies have been criticised for their methodological approaches as no well-validated method is available.5 Gould et al. recommend that observations should be timed to capture a complete picture of 24 h activity.5 Methods Study design This study was an observational study of HCWs’, patients’ and visitors’ hand hygiene compliance. The observational study was conducted over a 24 h period in January 2010 in a large teaching hospital, where hand hygiene facilities and resources were available at the entrance of all wards, at patient bedsides and at regular points throughout the hospital. The study was set on two wards (a 28 bed respiratory medicine ward and a 28 bed diabetic care ward). The data collection point was from 07:00 to 07:00 the next day. The wards were in close proximity, thus allowing time for data collection periods of 20 min, breaks and travel from ward to ward. In each hour, 20 min was spent observing on one ward and then
0195-6701/$ e see front matter Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2010.06.027
J. Randle et al. / Journal of Hospital Infection 76 (2010) 252e255
another 20 min observation was conducted on the other ward within the same hour slot. The observer was trained and had conducted pilot observation periods with members of the research team and a senior nurse within the infection prevention and control team. Permission for the study was granted by the local National Health Service (NHS) ethics committee, and by the research and development department. Prior to commencing the study, permission was secured from the clinical lead for infection prevention and control in the Trust and the nurse managers of the wards. Signs informing patients and visitors that an observational study was being conducted were placed at the wards’ entrance and informed them if they did not wish to be observed that they should contact the nurse in charge. No one asked to be excluded from data collection. HCWs were expected to participate as part of an everyday service improvement initiative. Data collection Direct observation is the gold standard to monitor compliance to optimal hand hygiene practice and we conducted observations using a previously validated hand hygiene observation tool.1,6 The inter-observer agreement of the observation tool had previously been established (interclass correlation coefficient ¼ 0.79).6 Within each 20 min time-period all opportunities observed were classified as one of five moments: before patient contact; before an aseptic task; after body fluid exposure risk; after patient contact; and after contact with patient surroundings. Each opportunity was then coded as to whether the individual complied (took the opportunity to wash her/his hands) or not. Participants were classified as: HCWs e doctors, nurses, allied healthcare professionals, ancillary and other staff e patients, or visitors. Data analysis All observed data was collected manually on standardised sheets. To test whether compliance varied across HCW type, patient or visitor, ward, time of day, and type of opportunity, c2-tests were used. Logistic regression models were used to test whether associations with compliance remained after adjustment for other covariates. Data analysis was conducted in SPSS version 16 (SPSS Inc., Chicago, IL, USA) and Stata version 9 (Stata Corp., College Station, TX, USA). Results The hand hygiene compliance of HCWs, patients and visitors was monitored for 24 h in the two wards with a total of 823 hand hygiene opportunities, consisting of 659 (80%) for HCWs, 75 (9%) for patients and 89 (11%) for visitors. Compliance to hand hygiene varied between HCW occupations (P < 0.001). Of the 659 hand hygiene opportunities available to HCWs, compliance by doctors was 47%, nurses 75%, ancillary nurses and other staff 59%, and allied health professionals 78%. Among HCWs, compliance varied according to type of contact (P < 0.001) varying from 50% after contact with patient surroundings to 100% before undertaking an aseptic task. For HCWs, compliance did not vary between the two wards (P ¼ 0.53) but did by shift (P < 0.001) with compliance being lower in the morning shift (Table I). Hand hygiene compliance between patients and visitors was lower, with compliance for patients being 56% and visitors 57%. Among patients and visitors there was no evidence that compliance differed between the two wards (P ¼ 0.88). The lowest level of compliance, regardless of person grouping, was 50% after contact with patient surroundings. For HCWs, both type of opportunity (P < 0.001) and occupation type (P < 0.001) were associated with compliance after adjustment
253
Table I Level of compliance among sample of opportunities presented to healthcare workers (N ¼ 659) and patients and visitors (N ¼ 164) Variable Healthcare workers (N ¼ 659) Profession Doctor Nurse Allied health professional Ancillary and other staff Ward Diabetic unit Respiratory medicine Time of day Morning Afternoon Night Type of opportunity Before patient contact Before aseptic task After body fluid exposure After patient contact After contact with patient surroundings Patients and visitors (N ¼ 164) Patients Visitors Ward Diabetic unit Respiratory medicine Time of day Morning Afternoon Night Type of opportunity Before patient contact After body fluid exposure After patient contact After contact with patient surroundings
No. (%)
Proportion complied
P-valuea
81 (12.3) 286 (43.4) 221 (33.5) 71 (10.8)
38/81 (46.9) 214/286 (74.8) 170/219 (77.6) 42/71 (59.2)
<0.001
338 (51.3) 321 (48.7)
241/336 (71.7) 223/321 (69.5)
0.53
241 (36.6) 215 (32.6) 203 (30.8)
151/241 (62.7) 153/213 (71.8) 160/203 (78.8)
0.001
291 (44.2) 3 (0.5) 93 (14.1) 142 (21.5) 130 (19.7)
196/290 (67.6) 3/3 (100.0) 86/93 (92.5) 114/142 (80.3) 65/129 (50.4)
<0.001b
75 (45.7) 89 (54.3)
42/75 (56.0) 51/89 (57.3)
0.87
82 (50.0) 82 (50.0)
47/82 (56.0) 46/82 (57.3)
0.88
35 (21.5) 99 (60.7) 29 (17.8)
21/35 (60.0) 55/99 (55.6) 16/29 (55.2)
0.089
48 40 12 64
26/48 27/40 8/12 32/64
0.30
(29.3) (24.4) (7.3) (38.6)
(54.2) (67.5) (66.7) (50.0)
a c2-Test of difference in proportions of opportunities adhered to, across levels of variable. b Test conducted after excluding opportunities before aseptic task (N ¼ 3).
for each other and type of shift. Adjusted odds of compliance were greater for all occupational groups compared with doctors, nurses being more than twice as likely to comply than doctors (odds ratio: 2.33; 95% confidence interval: 1.36e3.99). Among HCWs, after adjustment for occupation type, compared with ‘before patient contact’ opportunities, odds of compliance were higher for body fluid exposures, and after patient contacts (Table II). Discussion The purpose of this study was to observe hand hygiene compliance of HCWs, patients and visitors over a 24 h period, so a picture of compliance could be gained. Compliance was 67.8% overall, varying between 47% and 78% depending on type of HCW or whether the person being observed was a patient or visitor. A range of 5e89% with an average of 39% has been reported elsewhere.1 All occupational groups, patients and their visitors exceeded this reported norm and allied healthcare professionals and nurses achieved higher levels of compliance. In line with other studies of this kind, the hand hygiene compliance of doctors was lower and in this study was lower than that of patients’ and visitors’ hand hygiene compliance. Patients’ and visitors’ compliance has largely gone unmonitored and so it is impossible to state with confidence that their compliance is improving, although a previous study had reported their compliance as 7%.7 Discussion has ensued about the level at which compliance becomes suboptimal, and although
254
J. Randle et al. / Journal of Hospital Infection 76 (2010) 252e255
Table II Unadjusted and adjusted associations between occupation type, contact type and compliance among healthcare workers (N ¼ 657) Unadjusted OR (95% CI)
P-valuea
1 3.36 (2.02e5.61) 3.92 (2.29e6.74)
<0.001
Variable Profession Doctor Nurse Allied health professional Nursing assistant Type of opportunity Before patient contact After body fluid exposure After patient contact After contact with patient surroundings Time of day Morning Afternoon Night a b
1 2.33 (1.36e3.99) 2.48 (1.39e4.41)
1.64 (0.86e3.12) 1
Adjusted OR (95% CI)
0.0082b
1.57 (0.80e3.08) <0.001
b
1
5.89 (2.62e13.23)
5.12 (2.25e11.61)
1.95 (1.21e3.16)
1.88 (1.15e3.07)
0.49 (0.32e0.74)
0.60 (0.38e0.93)
1 1.52 (1.02e2.26) 2.22 (1.45e3.40)
P-valuea
<0.001
1 1.50 (0.98e2.27) 1.55 (0.98e2.45)
<0.001b
0.085b
Likelihood ratio test. Model excludes three opportunities: before aseptic task.
established cut-off points have been suggested e for example, 100% compliance found in NHS Trusts’ hand hygiene policies or a minimum of 90% for NHS Scotland e the reality is that 100% compliance is regarded by some as being impracticable, unsustainable, and as interfering with essential care.8e10 Compliance among ancillary staff (59%) was near that of patients (56%) and visitors (57%). We found no published literature on compliance by ancillary staff; however, doctors have previously been found to have poor compliance with infection prevention and control standards generally.11e13 Hugonnet et al. found that doctors had the highest level of non-compliance, and in other studies only one-third of doctors believed that hand hygiene was necessary before patient contact, and just over half of the doctors believed that it was necessary after patient contact.14e16 Cole identifies an association between nursing and altruism as the reason why previous studies have concluded that nurses’ compliance is higher than doctors.17 This does not explain why patients’ and visitors’ compliance was higher than doctors’ or why allied healthcare professionals’ was higher than nurses’ compliance. It may be that doctors have a distinct culture associated with levels of power which means that they can be ‘difficult’.18 Historically, they have been a powerful pressure group and are perceived as being resistant to change, or opposed to threats to their autonomy.19,20 Similarly, Ferlie and Shortell state that doctors often resist efforts to standardise practices and impose rules, as in complying with effective hand hygiene.21 It may be that this cultural aspect affects doctors’ compliance, and certainly previous studies have indicated that cultural norms have a part to play in HCWs’ compliance.19,22 The results showed that hand hygiene compliance among patients (56%) and visitors (57%) is higher than the 39% average for HCWs reported.1 It was also near ancillary staff’s compliance level which was reported at 59%. The role of patients’ and visitor’s hands in the transmission of HCAIs has been overlooked, even though they also come into frequent contact with hand touch sites, and are therefore at risk of transmitting pathogens.23 Although studies have indicated that patients and visitors would be willing to ask HCWs to clean their hands, commonly HCWs are not challenged about their hand hygiene compliance (National Patient Safety Agency, unpublished observations).13,24 Fletcher has summarised
the reasons as including the fact that patients feel they should be receiving good care without having to request it and they feel uncomfortable asking, as this is often perceived as a criticism of the HCW.24 Additionally, our own experience has been that patients and their visitors do not wish to be perceived as ‘troublemakers’ in case care delivery declines as a result. Patients had the highest level of compliance after exposure to their own body fluids, although compliance was only at 67%. This is unsurprising, as in the general population a quarter of adults sampled had faecal matter on their hands implying low compliance after going to the toilet.25 The difference in this study is that for some patients they would be bed-bound and unable to access hand hygiene facilities themselves. Previous work has indicated that patients do not always have the necessary resources available to them and inaccessible resources are a barrier for compliance.1,26,27 Compliance differed depending on the five moments of hand hygiene (P < 0.001). There was full compliance before conducting an aseptic task which was conducted only by HCWs, and high levels of compliance ‘after body fluid exposure risk’ (93%) and after patient contact (80%). Lower levels of compliance were found before patient contact (68%) and after contact with patient surroundings (50%). The WHO found poor levels of compliance before an aseptic task and it is suggested that activities that are high risk to the patient have lower compliance.1 We are cautious about refuting this since only three aseptic tasks were performed. It could be that recent initiatives such as examining HCWs performing aseptic tasks have resulted in higher levels of compliance; this probably requires further attention. Allegranzi and Pittet explain that HCWs’ compliance is high when hands are visibly dirty or sticky.20 These activities have a perceived element of risk to them, for example, after exposure to body fluids. Lower levels of compliance were found across all groups for the moment ‘after contact with patient surroundings’. The role of the environment in pathogen cross-transmission has been debated, although there is growing evidence that the environment and the issue of environmental cleaning and decontamination are important factors in minimising HCAIs.28,29 Dancer argues that environmental cleaning needs to be improved generally and specifically at hand touch sites.28e30 Hand touch sites with the highest risk to patients are those which are next to the patient, for example, bedrails, lockers, overbed tables and door handles.28,31 Griffith et al. found that more than half of the inanimate objects such as those previously listed were not microbiologically clean when screened.32 This is despite the fact that pathogens such as norovirus, Clostridium difficile and meticillin-resistant Staphylococcus aureus are persistently found on hand touch sites.28,33 Since this moment of hygiene resulted in the lowest compliance level, future policies and research should focus on the role of patient surroundings in cross-transmission. The unadjusted results showed a significant difference between shift time and hand hygiene compliance (P < 0.001). Lack of time is a factor for non-compliance.22,34e36 However, in the multivariable analysis this was no longer significant, suggesting that it is the nature of the work conducted on early shifts that explains the unadjusted finding. Recommendations have been made for observation of hand hygiene compliance to be timed to capture a complete picture of 24 h activity.5 In this study, we followed this recommendation, but it cannot be concluded that this is justifiable in terms of costs, so further studies should be undertaken to ascertain whether observing hand hygiene compliance during this time-period is warranted. This is because we acknowledge the potential of the Hawthorne effect, which has been well-documented. So although HCWs are used to being observed for their hand hygiene practices, at certain times over the 24 h period (i.e. in the early hours of the
J. Randle et al. / Journal of Hospital Infection 76 (2010) 252e255
morning) there was a minimum of participants to be observed and thus the likelihood of them being directly observed was very high. Such a bias might distort compliance percentages. The fact that we conducted our study at a single hospital may limit general application of our findings as the specific infrastructure and organisation of work may influence behaviour. In conclusion, the levels of hand hygiene compliance found in this study were better than the average previously reported, and, in some professional groupings such as allied health professionals and nurses, the level of compliance was maintained in three of every four opportunities observed.1 As hand hygiene is an influential and costeffective way of reducing HCAIs, the results are promising and imply that, for the short term at least, the numerous strategies implemented to increase compliance have had an impact. Doctors were the exception to this trend, but this is consistent with previous findings. Some studies have looked into the effect of role models on hand hygiene compliance.37,38 One study found that hand hygiene behaviour of senior practitioners plays a crucial part in influencing junior staff and we suggest that targeting of consultants is the way forward to improve medic compliance levels.37 Conflict of interest statement None declared. Funding source Hospital Infection Society. References 1. WHO. Guidelines on hand hygiene in health care. First global patient safety challenge: clean care is safer care. Geneva: World Health Organization; 2009. 2. Health Protection Agency. Surveillance of healthcare associated infections report: 2008. London: HPA; 2008. 3. Bertinato L, Ganter B, Allegranzi B, Cookson B. International consultation on healthcare associated infections. Quarterly Communicable Disease Report 2004; CD News, Issue No. 34. Geneva: WHO. 4. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225e1230. 5. Gould D, Chudleigh J, Drey N, et al. Measuring handwashing performance in health service audits and research studies. J Hosp Infect 2007;66:109e115. 6. McAteer J, Stone S, Fuller C, et al. Development of an observational measure of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT). J Hosp Infect 2008;68:222e229. 7. Brown J, Froesefretz A, Luckey D, et al. High rate of hand contamination and low rate of hand washing before infant contact in a neonatal intensive care unit. Pediatr Infect Dis J 1996;15:908e910. 8. Stone S, Teare L, Cookson B, et al. Guiding hands of our teachers. Lancet 2001;357:479e480. 9. Voss A, Widmer A. No time for handwashing, can we achieve 100% compliance? Infect Control Hosp Epidemiol 1997;18:205e208. 10. Weeks A. Handwashing: why I don’t wash my hands between each patient. Letter. BMJ 1999;319:518. 11. Venier A, Zaro-Goni M, Pefau J, et al. Performance of hand hygiene in 214 healthcare facilities in South-Western France. J Hosp Infect 2009;71:280e282.
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12. Feather A, Stone S, Wessier A, Boursicot KA, Pratt C. ‘Now please wash your hands’: the handwashing behaviour of final MBBS candidates. J Hosp Infect 2000;45:62e64. 13. Randle J, Clarke M, Storr J. Hand hygiene compliance in healthcare workers. J Hosp Infect 2006;64:205e209. 14. Hugonnet S, Perenger TV, Pittet D. Alcohol-based hand rub improves compliance with hand hygiene in intensive care unit. Arch Intern Med 2002;162:1037e1043. 15. Sharir R, Teitler N, Lavi I, Raz R. High-level handwashing compliance in a community teaching hospital: a challenge that can be met! J Hosp Infect 2001;47:173e180. 16. Davies H, Nutley S, Mannion R. Organisational culture and quality health care. BMJ 2000;9:111e119. 17. Cole M. Comment on ‘Editorial: hand hygiene e it’s still important’ by Paul Weaving. Br J Infect Control 2007;8:4e5. 18. Brooks I, Brown RB. The role of the ritualistic ceremonial in removing barriers between subcultures in the National Health Service. J Adv Nurs 2002;38: 341e352. 19. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection control programme. Lancet 2000;356:1307e1312. 20. Allegranzi B, Pittet D. The role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009;73:305e315. 21. Ferlie E, Shortell S. Improving the quality of health care in the United Kingdom and the United States: a framework for change. Milbank Q 2001;79:281e315. 22. Barrett R, Randle J. Hand hygiene practices: nursing students’ perceptions. J Clin Nurs 2008;17:1851e1857. 23. Ward D. Improving patient hand hygiene. Nurs Standard 2003;17:39e42. 24. Fletcher M. Hand hygiene and infection in hospitals: what do the public know; what should the public know? J Hosp Infect 2009;73:397e399. 25. Judah G, Aunguer R, Wolf-Peter S, Michie S, Granger S, Curtis V. Experimental pretesting of hand-washing interventions in a natural setting. Am J Public Health 2009;99(Suppl. 2):405e411. 26. Mayers D, King S. Hand hygiene for patients with rheumatic disease. Nurs Times 2000;96:47e48. 27. Whiller J, Copper T. Clean hands: how to encourage good hygiene by patients. Nurs Times 2000;96:37e38. 28. Dancer SJ. The role of environmental cleaning in the control of hospitalacquired infection. J Hosp Infect 2009;73:378e385. 29. Dancer SJ. Pants, policies and paranoia. J Hosp Infect 2010;74:10e15. 30. Pittet D. Healthcare-associated infection moving behind headlines to clinical solutions. J Hosp Infect 2009;73:293e295. 31. Gallimore C, Taylor C, Gennery A, et al. Environmental monitoring for gastroenteric viruses in a pediatric primary immunodeficiency unit. J Clin Microbiol 2006;44:395e399. 32. Griffith C, Cooper R, Gilmore J, Davies C, Lewis M. An evaluation of hospital cleaning regimes and standards. J Hosp Infect 2000;45:19e28. 33. Koopmans M. Noroviruses in healthcare settings: a challenging problem. J Hosp Infect 2009;73:331e337. 34. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. J Hosp Infect 2002;30:S1e46. 35. Harris A, Samore M, Nafziger R, DiRosario K, Roghmann M, Carmel Y. A survey on hand washing practices and opinions of healthcare workers. J Hosp Infect 2000;45:318e321. 36. Schneider J, Morosimato D, Zemetra B, et al. Hand hygiene adherence is influenced by the behaviour of role models. Pediatr Crit Care Med 2009;10: 360e363. 37. Lankford M, Zembower T, Trick W, et al. Influence of role models and hospital design on hand hygiene of healthcare workers. Emerg Infect Dis 2003;9: 217e223. 38. McGuckin M, Shubin A, McBride P, et al. The effect of random voice hand hygiene messages delivered by medical, nursing, and infection control staff on hand hygiene compliance in intensive care. Am J Infect Control 2006;34:673e675.
Available online at www.sciencedirect.com
Journal of Hospital Infection journal homepage: www.elsevierhealth.com/journals/jhin
Twenty-four-hour observational study of hospital hand hygiene compliance J. Randle*, A. Arthur, N. Vaughan Nottingham University Hospitals NHS Trust, The Queen’s Medical Centre, Nottingham, UK
a r t i c l e i n f o
s u m m a r y
Article history: Received 24 April 2010 Accepted 28 June 2010 Available online 17 September 2010
This observational study measured healthcare workers’ (HCWs’), patients’ and visitors’ hand hygiene compliance over a 24 h period in two hospital wards using the ‘five moments of hand hygiene’ observation tool. Hand hygiene is considered to be the most effective measure in reducing healthcare-associated infections but studies have reported suboptimal levels of compliance. Most studies have used random observational time-periods for data collection and this has been criticised. We monitored a total of 823 hand hygiene opportunities (HCWs, N ¼ 659; patients and visitors, N ¼ 164). Among HCWs, compliance was 47% for doctors, 75% for nurses, 78% for allied health professionals, and 59% for ancillary and other staff (P < 0.001). There was no difference in compliance between patients and visitors (56% vs 57%, P ¼ 0.87). Hand hygiene compliance varied depending on which of the five moments of hygiene HCWs had undertaken (P < 0.001), with compliance before an aseptic task being 100% (3/3); after body fluid exposure 93% (86/93); after patient contact 80% (114/142); before patient contact 68% (196/290); and after contact with surroundings 50% (65/129). Lower levels of compliance were found for HCWs working during the early shift (P < 0.001). For patients and visitors there was no evidence of an association between moments of hygiene and compliance. Levels of compliance were higher compared with previous reported estimates. Medical staff had the lowest level of compliance and this continues to be a concern which warrants specific future interventions. Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved.
Keywords: Hand hygiene compliance Healthcare-associated infections Healthcare workers Hospital visitors Patients
Introduction The World Health Organization (WHO) identified the risk of acquiring a healthcare-associated infection (HCAI) as being universal.1 As HCAIs cause significant morbidity in the UK, the prevention of HCAIs is recognised as a critical factor for safe healthcare, and effective hand hygiene is vital for healthcare services in order to provide high quality and safe healthcare.2e4 Contaminated hands are thought to be the main vehicle for the spread of certain pathogens; HCWs’ compliance has been reported to be highly variable, however, and in some cases, unacceptably poor.1 Factors affecting poor compliance include heavy workloads, a lack of time, inaccessible resources, skin irritation, gender and professional grouping.1 Despite the identification of these factors,
* Corresponding author. Address: School of Nursing, Midwifery and Physiotherapy, Faculty of Medicine and Health Sciences, University of Nottingham, The Queen’s Medical Centre, Nottingham NG7 2UH, UK. Tel.: þ44 (0)115 8230899; fax: þ44 (0)115 8231211. E-mail address: [email protected] (J. Randle).
many studies have been criticised for their methodological approaches as no well-validated method is available.5 Gould et al. recommend that observations should be timed to capture a complete picture of 24 h activity.5 Methods Study design This study was an observational study of HCWs’, patients’ and visitors’ hand hygiene compliance. The observational study was conducted over a 24 h period in January 2010 in a large teaching hospital, where hand hygiene facilities and resources were available at the entrance of all wards, at patient bedsides and at regular points throughout the hospital. The study was set on two wards (a 28 bed respiratory medicine ward and a 28 bed diabetic care ward). The data collection point was from 07:00 to 07:00 the next day. The wards were in close proximity, thus allowing time for data collection periods of 20 min, breaks and travel from ward to ward. In each hour, 20 min was spent observing on one ward and then
0195-6701/$ e see front matter Ó 2010 The Hospital Infection Society. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.jhin.2010.06.027
J. Randle et al. / Journal of Hospital Infection 76 (2010) 252e255
another 20 min observation was conducted on the other ward within the same hour slot. The observer was trained and had conducted pilot observation periods with members of the research team and a senior nurse within the infection prevention and control team. Permission for the study was granted by the local National Health Service (NHS) ethics committee, and by the research and development department. Prior to commencing the study, permission was secured from the clinical lead for infection prevention and control in the Trust and the nurse managers of the wards. Signs informing patients and visitors that an observational study was being conducted were placed at the wards’ entrance and informed them if they did not wish to be observed that they should contact the nurse in charge. No one asked to be excluded from data collection. HCWs were expected to participate as part of an everyday service improvement initiative. Data collection Direct observation is the gold standard to monitor compliance to optimal hand hygiene practice and we conducted observations using a previously validated hand hygiene observation tool.1,6 The inter-observer agreement of the observation tool had previously been established (interclass correlation coefficient ¼ 0.79).6 Within each 20 min time-period all opportunities observed were classified as one of five moments: before patient contact; before an aseptic task; after body fluid exposure risk; after patient contact; and after contact with patient surroundings. Each opportunity was then coded as to whether the individual complied (took the opportunity to wash her/his hands) or not. Participants were classified as: HCWs e doctors, nurses, allied healthcare professionals, ancillary and other staff e patients, or visitors. Data analysis All observed data was collected manually on standardised sheets. To test whether compliance varied across HCW type, patient or visitor, ward, time of day, and type of opportunity, c2-tests were used. Logistic regression models were used to test whether associations with compliance remained after adjustment for other covariates. Data analysis was conducted in SPSS version 16 (SPSS Inc., Chicago, IL, USA) and Stata version 9 (Stata Corp., College Station, TX, USA). Results The hand hygiene compliance of HCWs, patients and visitors was monitored for 24 h in the two wards with a total of 823 hand hygiene opportunities, consisting of 659 (80%) for HCWs, 75 (9%) for patients and 89 (11%) for visitors. Compliance to hand hygiene varied between HCW occupations (P < 0.001). Of the 659 hand hygiene opportunities available to HCWs, compliance by doctors was 47%, nurses 75%, ancillary nurses and other staff 59%, and allied health professionals 78%. Among HCWs, compliance varied according to type of contact (P < 0.001) varying from 50% after contact with patient surroundings to 100% before undertaking an aseptic task. For HCWs, compliance did not vary between the two wards (P ¼ 0.53) but did by shift (P < 0.001) with compliance being lower in the morning shift (Table I). Hand hygiene compliance between patients and visitors was lower, with compliance for patients being 56% and visitors 57%. Among patients and visitors there was no evidence that compliance differed between the two wards (P ¼ 0.88). The lowest level of compliance, regardless of person grouping, was 50% after contact with patient surroundings. For HCWs, both type of opportunity (P < 0.001) and occupation type (P < 0.001) were associated with compliance after adjustment
253
Table I Level of compliance among sample of opportunities presented to healthcare workers (N ¼ 659) and patients and visitors (N ¼ 164) Variable Healthcare workers (N ¼ 659) Profession Doctor Nurse Allied health professional Ancillary and other staff Ward Diabetic unit Respiratory medicine Time of day Morning Afternoon Night Type of opportunity Before patient contact Before aseptic task After body fluid exposure After patient contact After contact with patient surroundings Patients and visitors (N ¼ 164) Patients Visitors Ward Diabetic unit Respiratory medicine Time of day Morning Afternoon Night Type of opportunity Before patient contact After body fluid exposure After patient contact After contact with patient surroundings
No. (%)
Proportion complied
P-valuea
81 (12.3) 286 (43.4) 221 (33.5) 71 (10.8)
38/81 (46.9) 214/286 (74.8) 170/219 (77.6) 42/71 (59.2)
<0.001
338 (51.3) 321 (48.7)
241/336 (71.7) 223/321 (69.5)
0.53
241 (36.6) 215 (32.6) 203 (30.8)
151/241 (62.7) 153/213 (71.8) 160/203 (78.8)
0.001
291 (44.2) 3 (0.5) 93 (14.1) 142 (21.5) 130 (19.7)
196/290 (67.6) 3/3 (100.0) 86/93 (92.5) 114/142 (80.3) 65/129 (50.4)
<0.001b
75 (45.7) 89 (54.3)
42/75 (56.0) 51/89 (57.3)
0.87
82 (50.0) 82 (50.0)
47/82 (56.0) 46/82 (57.3)
0.88
35 (21.5) 99 (60.7) 29 (17.8)
21/35 (60.0) 55/99 (55.6) 16/29 (55.2)
0.089
48 40 12 64
26/48 27/40 8/12 32/64
0.30
(29.3) (24.4) (7.3) (38.6)
(54.2) (67.5) (66.7) (50.0)
a c2-Test of difference in proportions of opportunities adhered to, across levels of variable. b Test conducted after excluding opportunities before aseptic task (N ¼ 3).
for each other and type of shift. Adjusted odds of compliance were greater for all occupational groups compared with doctors, nurses being more than twice as likely to comply than doctors (odds ratio: 2.33; 95% confidence interval: 1.36e3.99). Among HCWs, after adjustment for occupation type, compared with ‘before patient contact’ opportunities, odds of compliance were higher for body fluid exposures, and after patient contacts (Table II). Discussion The purpose of this study was to observe hand hygiene compliance of HCWs, patients and visitors over a 24 h period, so a picture of compliance could be gained. Compliance was 67.8% overall, varying between 47% and 78% depending on type of HCW or whether the person being observed was a patient or visitor. A range of 5e89% with an average of 39% has been reported elsewhere.1 All occupational groups, patients and their visitors exceeded this reported norm and allied healthcare professionals and nurses achieved higher levels of compliance. In line with other studies of this kind, the hand hygiene compliance of doctors was lower and in this study was lower than that of patients’ and visitors’ hand hygiene compliance. Patients’ and visitors’ compliance has largely gone unmonitored and so it is impossible to state with confidence that their compliance is improving, although a previous study had reported their compliance as 7%.7 Discussion has ensued about the level at which compliance becomes suboptimal, and although
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J. Randle et al. / Journal of Hospital Infection 76 (2010) 252e255
Table II Unadjusted and adjusted associations between occupation type, contact type and compliance among healthcare workers (N ¼ 657) Unadjusted OR (95% CI)
P-valuea
1 3.36 (2.02e5.61) 3.92 (2.29e6.74)
<0.001
Variable Profession Doctor Nurse Allied health professional Nursing assistant Type of opportunity Before patient contact After body fluid exposure After patient contact After contact with patient surroundings Time of day Morning Afternoon Night a b
1 2.33 (1.36e3.99) 2.48 (1.39e4.41)
1.64 (0.86e3.12) 1
Adjusted OR (95% CI)
0.0082b
1.57 (0.80e3.08) <0.001
b
1
5.89 (2.62e13.23)
5.12 (2.25e11.61)
1.95 (1.21e3.16)
1.88 (1.15e3.07)
0.49 (0.32e0.74)
0.60 (0.38e0.93)
1 1.52 (1.02e2.26) 2.22 (1.45e3.40)
P-valuea
<0.001
1 1.50 (0.98e2.27) 1.55 (0.98e2.45)
<0.001b
0.085b
Likelihood ratio test. Model excludes three opportunities: before aseptic task.
established cut-off points have been suggested e for example, 100% compliance found in NHS Trusts’ hand hygiene policies or a minimum of 90% for NHS Scotland e the reality is that 100% compliance is regarded by some as being impracticable, unsustainable, and as interfering with essential care.8e10 Compliance among ancillary staff (59%) was near that of patients (56%) and visitors (57%). We found no published literature on compliance by ancillary staff; however, doctors have previously been found to have poor compliance with infection prevention and control standards generally.11e13 Hugonnet et al. found that doctors had the highest level of non-compliance, and in other studies only one-third of doctors believed that hand hygiene was necessary before patient contact, and just over half of the doctors believed that it was necessary after patient contact.14e16 Cole identifies an association between nursing and altruism as the reason why previous studies have concluded that nurses’ compliance is higher than doctors.17 This does not explain why patients’ and visitors’ compliance was higher than doctors’ or why allied healthcare professionals’ was higher than nurses’ compliance. It may be that doctors have a distinct culture associated with levels of power which means that they can be ‘difficult’.18 Historically, they have been a powerful pressure group and are perceived as being resistant to change, or opposed to threats to their autonomy.19,20 Similarly, Ferlie and Shortell state that doctors often resist efforts to standardise practices and impose rules, as in complying with effective hand hygiene.21 It may be that this cultural aspect affects doctors’ compliance, and certainly previous studies have indicated that cultural norms have a part to play in HCWs’ compliance.19,22 The results showed that hand hygiene compliance among patients (56%) and visitors (57%) is higher than the 39% average for HCWs reported.1 It was also near ancillary staff’s compliance level which was reported at 59%. The role of patients’ and visitor’s hands in the transmission of HCAIs has been overlooked, even though they also come into frequent contact with hand touch sites, and are therefore at risk of transmitting pathogens.23 Although studies have indicated that patients and visitors would be willing to ask HCWs to clean their hands, commonly HCWs are not challenged about their hand hygiene compliance (National Patient Safety Agency, unpublished observations).13,24 Fletcher has summarised
the reasons as including the fact that patients feel they should be receiving good care without having to request it and they feel uncomfortable asking, as this is often perceived as a criticism of the HCW.24 Additionally, our own experience has been that patients and their visitors do not wish to be perceived as ‘troublemakers’ in case care delivery declines as a result. Patients had the highest level of compliance after exposure to their own body fluids, although compliance was only at 67%. This is unsurprising, as in the general population a quarter of adults sampled had faecal matter on their hands implying low compliance after going to the toilet.25 The difference in this study is that for some patients they would be bed-bound and unable to access hand hygiene facilities themselves. Previous work has indicated that patients do not always have the necessary resources available to them and inaccessible resources are a barrier for compliance.1,26,27 Compliance differed depending on the five moments of hand hygiene (P < 0.001). There was full compliance before conducting an aseptic task which was conducted only by HCWs, and high levels of compliance ‘after body fluid exposure risk’ (93%) and after patient contact (80%). Lower levels of compliance were found before patient contact (68%) and after contact with patient surroundings (50%). The WHO found poor levels of compliance before an aseptic task and it is suggested that activities that are high risk to the patient have lower compliance.1 We are cautious about refuting this since only three aseptic tasks were performed. It could be that recent initiatives such as examining HCWs performing aseptic tasks have resulted in higher levels of compliance; this probably requires further attention. Allegranzi and Pittet explain that HCWs’ compliance is high when hands are visibly dirty or sticky.20 These activities have a perceived element of risk to them, for example, after exposure to body fluids. Lower levels of compliance were found across all groups for the moment ‘after contact with patient surroundings’. The role of the environment in pathogen cross-transmission has been debated, although there is growing evidence that the environment and the issue of environmental cleaning and decontamination are important factors in minimising HCAIs.28,29 Dancer argues that environmental cleaning needs to be improved generally and specifically at hand touch sites.28e30 Hand touch sites with the highest risk to patients are those which are next to the patient, for example, bedrails, lockers, overbed tables and door handles.28,31 Griffith et al. found that more than half of the inanimate objects such as those previously listed were not microbiologically clean when screened.32 This is despite the fact that pathogens such as norovirus, Clostridium difficile and meticillin-resistant Staphylococcus aureus are persistently found on hand touch sites.28,33 Since this moment of hygiene resulted in the lowest compliance level, future policies and research should focus on the role of patient surroundings in cross-transmission. The unadjusted results showed a significant difference between shift time and hand hygiene compliance (P < 0.001). Lack of time is a factor for non-compliance.22,34e36 However, in the multivariable analysis this was no longer significant, suggesting that it is the nature of the work conducted on early shifts that explains the unadjusted finding. Recommendations have been made for observation of hand hygiene compliance to be timed to capture a complete picture of 24 h activity.5 In this study, we followed this recommendation, but it cannot be concluded that this is justifiable in terms of costs, so further studies should be undertaken to ascertain whether observing hand hygiene compliance during this time-period is warranted. This is because we acknowledge the potential of the Hawthorne effect, which has been well-documented. So although HCWs are used to being observed for their hand hygiene practices, at certain times over the 24 h period (i.e. in the early hours of the
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morning) there was a minimum of participants to be observed and thus the likelihood of them being directly observed was very high. Such a bias might distort compliance percentages. The fact that we conducted our study at a single hospital may limit general application of our findings as the specific infrastructure and organisation of work may influence behaviour. In conclusion, the levels of hand hygiene compliance found in this study were better than the average previously reported, and, in some professional groupings such as allied health professionals and nurses, the level of compliance was maintained in three of every four opportunities observed.1 As hand hygiene is an influential and costeffective way of reducing HCAIs, the results are promising and imply that, for the short term at least, the numerous strategies implemented to increase compliance have had an impact. Doctors were the exception to this trend, but this is consistent with previous findings. Some studies have looked into the effect of role models on hand hygiene compliance.37,38 One study found that hand hygiene behaviour of senior practitioners plays a crucial part in influencing junior staff and we suggest that targeting of consultants is the way forward to improve medic compliance levels.37 Conflict of interest statement None declared. Funding source Hospital Infection Society. References 1. WHO. Guidelines on hand hygiene in health care. First global patient safety challenge: clean care is safer care. Geneva: World Health Organization; 2009. 2. Health Protection Agency. Surveillance of healthcare associated infections report: 2008. London: HPA; 2008. 3. Bertinato L, Ganter B, Allegranzi B, Cookson B. International consultation on healthcare associated infections. Quarterly Communicable Disease Report 2004; CD News, Issue No. 34. Geneva: WHO. 4. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. Lancet 2003;362:1225e1230. 5. Gould D, Chudleigh J, Drey N, et al. Measuring handwashing performance in health service audits and research studies. J Hosp Infect 2007;66:109e115. 6. McAteer J, Stone S, Fuller C, et al. Development of an observational measure of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT). J Hosp Infect 2008;68:222e229. 7. Brown J, Froesefretz A, Luckey D, et al. High rate of hand contamination and low rate of hand washing before infant contact in a neonatal intensive care unit. Pediatr Infect Dis J 1996;15:908e910. 8. Stone S, Teare L, Cookson B, et al. Guiding hands of our teachers. Lancet 2001;357:479e480. 9. Voss A, Widmer A. No time for handwashing, can we achieve 100% compliance? Infect Control Hosp Epidemiol 1997;18:205e208. 10. Weeks A. Handwashing: why I don’t wash my hands between each patient. Letter. BMJ 1999;319:518. 11. Venier A, Zaro-Goni M, Pefau J, et al. Performance of hand hygiene in 214 healthcare facilities in South-Western France. J Hosp Infect 2009;71:280e282.
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