Short report

Baseline evaluation of hand hygiene compliance

in three major hospitals, Isfahan, Iran
B. Ataei
a
, S.M. Zahraei
b
, Z. Pezeshki
b
, A. Babak
c
, Z. Nokhodian
c
,
S. Mobasherizadeh
c
, S.G. Hoseini
c,
*
a
Nosocomial Infection Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
b
Center for Disease Control, Ministry of Health and Medical Education, Tehran, Iran
c
Infectious Diseases and Tropical Medicine Research Center, Isfahan University of Medical Sciences, Isfahan, Iran
A R T I C L E I N F O
Article history:
Received 8 January 2013
Accepted 4 July 2013
Available online 1 August 2013
Keywords:
Compliance
Hand hygiene
Hospitals
Nosocomial infection
S U M M A R Y
Hand hygiene is the mainstay of nosocomial infection prevention. This study was a baseline
survey to assess hand hygiene compliance of healthcare workers by direct observation in
three major hospitals of Isfahan, Iran. The use of different hand hygiene products was also
evaluated. In 3078 potential opportunities hand hygiene products were available on 2653
occasions (86.2%). Overall compliance was 6.4% (teaching hospital: 7.4%; public hospital:
6.2%; private hospital: 1.4%). Nurses (8.4%) had the highest rates of compliance. Poor hand
hygiene compliance in Isfahan hospitals necessitates urgent interventions to improve both
hospital infrastructure and staff knowledge.
2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
Introduction
Proper hand hygiene is conrmed to be an effective and
simple way to reduce transmission of pathogens from health-
care workers (HCWs) to patients and vice versa; it is the
mainstay of healthcare-associated infection prevention strat-
egies.
1
However, many studies have identied that the
compliance of HCWs with hand hygiene is low, and multimodal
approaches are crucial to improve and maintain optimal hand
hygiene practice in healthcare facilities.
2
Such studies in Iran
are rare, and have shown low compliance ranging from 8% to
22%.
3,4
No previous study on hand hygiene compliance has been
carried out in Isfahan, a large city in central of Iran. This study
was intended to establish baseline hand hygiene compliance
rates, and to help provide an understanding of the barriers to
hand hygiene, ahead of an initiative to promote hand hygiene
in our health region.
Methods
Direct observation was used to assess the hand hygiene
compliance of the HCWs in three hospitals in Isfahan: a 763-bed
teaching hospital, a 186-bed public hospital, and a 124-bed
private hospital. The teaching and the public hospitals are parts
of Isfahan University of Medical Sciences, Ministry of Health.
The teaching hospital is a tertiary referral hospital of relatively
newdesign. The public and private hospitals provide a narrower
range of specialties and are older, although the private hospital
had been recently refurbished and was well-equipped.
Seven observers were selected from those familiar with
clinical care and they underwent intensive training on the
World Health Organization (WHO) ve moments, provided by
a senior researcher and supported by a WHO training lm.
Observers then undertook trial assessments to ensure that their
observations were consistent. The study was conducted in the
* Corresponding author. Address: Infectious Diseases and Tropical
Medicine Research Center, Isfahan University of Medical Science,
Isfahan, Iran. Tel.: 98 311 3359359; fax: 98 311 3353737.
E-mail address: shghaffari@yahoo.com (S.G. Hoseini).
Available online at www.sciencedirect.com
Journal of Hospital Infection
j ournal homepage: www. el sevi erheal t h. com/ j ournal s/ j hi n
0195-6701/$ e see front matter 2013 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jhin.2013.07.001
Journal of Hospital Infection 85 (2013) 69e72
three hospitals over seven working days during a two-week
period in November 2010. HCWs (physician, nursing staff,
student, allied health professional, ancillary staff) were
observed during their routine work for eight episodes of 20 min
in different hours of morning and evening daytime shifts. Ob-
servers were settled in places where they caused minimal
interference with patient care and patient privacy. Only non-
specialized wards and departments were included in the study.
The study was approved by the Ethical Committee of Isfahan
University of Medical Sciences, Ministry of Health, Iran. Hos-
pital administrators and ward managers in all three hospitals
also approved the study. All staff were made aware of the
proposed programme, and were assured that data would be
recorded anonymously.
For each opportunity, the types of hand hygiene products
available (soap and water, alcohol dispenser, or both) and hand
hygiene behaviour of the observed staff (nothing, hand washing
or hand rubbing) were recorded in a predesigned checklist. The
type of hospital and department within the hospital, type of
opportunity according to the My ve moments for hand hy-
giene concept, and time of day when the observation was
made were also recorded.
Data were analysed using SPSS-PC version 16.0 (SPSS Inc.,
Chicago, IL, USA). Variation of hand hygiene compliance was
assessed by c
2
-test or Fishers exact test whenever appro-
priate. Logistic regression models were used to calculate the
odds ratios and 95% condence intervals. P < 0.05 was
considered statistically signicant.
Results
In all, 3078 hand hygiene opportunities were recorded in the
three hospitals. At least one type of hand hygiene product
(water supply and plain soap, or alcohol dispensers) was
available in all opportunities in the teaching and the private
hospitals but only in 62% of opportunities in the public hospital
(Table I). Hand-wash basins were located at the entrance to all
patient rooms and wards in teaching and private hospitals, but
the public hospital mostly had only a single hand-wash basin in
each ward or department, and with limited availability of pa-
per towels. Alcohol dispensers, when available, were attached
to nursing trolleys or were xed on the wall in patient rooms,
but were not available at all points of care.
In 2653 opportunities with available hand hygiene products
(either soap and water, or alcohol dispensers) the rate of hand
hygiene compliance was 6.4%. When both soap and alcohol
dispensers were available, HCWs preferred to wash their hands
rather than rub with alcohol (6.1% vs 1.7% of potential 1532
opportunities, P < 0.001). Hand hygiene compliance was
different in three hospitals ranging from 7.4% in the teaching
hospital to 6.2% in the public hospital and 1.4% in the private
hospital (P < 0.001).
Multivariate analysis showed that type of hospital, type of
ward or department, type of HCW and type of hand hygiene
opportunity were associated with degree of hand hygiene
compliance after adjustment of each variable for other cova-
riates (Table II).
Discussion
Hand hygiene has been considered a critical component of
standard precautions in Iran since 2003. Since then, hospital
infection control nurses have been routinely trained and
assessed by experts, and were then made responsible for
cascade training of other hospital staff. Manufacture of alcohol
solutions, gels and foams commenced in Iran, and these
products were distributed to all hospitals. In 2005 the National
Nosocomial Infection Surveillance (NNIS) system was initiated
in Iran and infection control units and committees in all public
and private hospitals were required to monitor and report
nosocomial infections and promote standard safety measures
including hand hygiene according to national published guide-
lines.
5
The Global Patient Safety Challenge Clean Care is Safer
Care was launched in Iran in May 2007. Four hundred hospitals
across the country have joined the challenge so far, the highest
rate in the Eastern Mediterranean Region.
Because evaluation (as opposed to promotion) of hand hy-
giene compliance has not been the subject of national guid-
ance in Iran, rates of compliance are unknown. The purpose of
this study was to provide a baseline evaluation of hand hygiene
compliance in different hospital settings in Isfahan. The overall
compliance was 6.4% ranging from 0% to 26.3% depending on
the type of hospital and department within that hospital.
Studies reported by the WHO showed compliance ranging from
5% to 80% with an average of 38.7%; thus the rate of hand hy-
giene compliance is unacceptably low in our hospitals.
1
It
seems that despite national policies on hand hygiene in Iran,
and afrmation of these by health leaders and managers, the
majority of HCWs had either insufcient knowledge or no
incentive to improve their practice.
Hospitals included in this study were different in their
infrastructure, economics and policies. The private hospital
had the lowest compliance despite better facilities in com-
parison with the teaching and the public hospitals; lower in-
comes and lack of a hierarchical management system for HCWs
in the private hospital might have reduced their motivation to
attend training courses and to comply with good practice.
Further work to investigate the reasons for poor compliance in
the private hospital is required.
Where a choice of hand-washing facilities and alcohol rub
were available the latter was infrequently employed by HCWs
(1.7% vs 6.1%). The reluctance to use alcohol rub was probably
due to lack of knowledge and concern about the drying effect
of alcohol on skin. There are no religious objections to the use
Table I
Availability of hand hygiene products at potential hand hygiene opportunities in three hospitals
Available products Teaching hospital Public hospital Private hospital Overall
Soap and water only 561/1665 (33.7%) 290/1117 (26%) e 851/3078 (27.6%)
Alcohol rub only e 270/1117 (24.2%) e 270/3078 (8.8%)
Both products 1104/1665 (66.3%) 132/1117 (11.8%) 296/296 (100%) 1532/3078 (49.8%)
None e 425/1117 (38.0%) e 425/3078 (13.8%)
B. Ataei et al. / Journal of Hospital Infection 85 (2013) 69e72 70
of alcohol for disinfection in Iran, and permission from religious
leaders to use alcohol for medical applications has been widely
disseminated for several years.
Nursing staff (8.4%) had higher hand hygiene compliance
rates than physicians (3.8%), which is consistent with most
previous studies.
6,7
It seems that in our setting lack of knowl-
edge is possibly the most important cause of physicians non-
compliance; currently there is no specic training on infection
prevention and hand hygiene in our medical curriculum.
Because of the observational method of the study, behav-
iour change of the participants (the Hawthorne effect) might
have occurred.
8
However, given the very low levels of
compliance observed, it is unlikely that this was an important
issue. The extended period of time that was spent in the hos-
pitals by observers before formal data collection began may
have helped prevent adaptations of behaviour to occur during
the study period. As in any observational study the possibility of
inter-observer bias cannot be ruled out. Our failure to observe
night shifts might also be considered a limitation, but it is un-
likely that compliance overnight would have differed much
from the poor daytime performance.
This study was performed against a background of national
promotion of hand hygiene, but before any specic initiatives
to improve compliance within our regional health system. Our
study has shown a need to improve the hospital infrastructure
particularly in public hospitals. Providing alcohol rubs at the
point of patient care will only be of value if HCWs are moti-
vated to use it: further work is clearly required to overcome
resistance to using alcohol rub in our country.
Other investigators have shown that where alcohol rub is used
hand hygiene compliance rates are better than when only hand-
washing facilities are available.
2,9
Extensive education and
training, promotion of hand hygiene guidelines, and regular
evaluationwill bekey components of an improvement strategy in
our region. We believe that the WHO Multimodal Hand Hygiene
Improvement Strategy and related tools will be the best re-
sources for this programme.
9
This will bea particular challengein
privatehospitals, whicharenot linkedtoacademic resources and
may not have routine access to learning materials.
Conict of interest statement
None declared.
Funding source
This study was funded by the Center for Disease Control,
Ministry of Health and Medical Education, Iran.
References
1. World Health Organization. Guidelines on hand hygiene in health
care. First Global Patient Safety Challenge: Clean Care is Safer
Care. Geneva: WHO; 2009.
Table II
Hand hygiene compliance by healthcare workers according to several variables
Variables Complied opportunities P-value
a
Adjusted OR (95% CI) P-value
b
Overall 171/2653 (6.4%)
Hospital <0.001
Private 4/296 (1.4%) 1 0.037
Public 43/692 (6.2%) 3.50 (1.18e10.43)
Teaching 124/1665 (7.4%) 3.82 (1.37e10.68)
Hospital area <0.001
Intensive care unit 58/871 (6.7%) 1 <0.001
Emergency 0/35 0
Internal medicine 22/538 (4.1%) 0.56 (0.33e0.96)
Labour ward 20/76 (26.3%) 3.41 (1.84e6.34)
Surgery 28/650 (4.3%) 0.61 (0.37e1.02)
Paediatric 29/422 (6.9%) 0.87 (0.53e1.42)
Paediatric surgery 14/61 (23.0%) 2.95 (1.48e5.89)
Profession <0.001
Physician 14/365 (3.8%) 1 0.002
Nursing staff 122/1461 (8.4%) 1.81 (1.01e3.26)
Student 32/440 (7.3%) 1.47 (0.75e2.87)
Allied health professional 0/57 (0%) 0
Ancillary staff 3/330 (0.9%) 0.19 (0.06e0.70)
Type of opportunity <0.001
Before patient contact 25/679 (3.7%) 1 <0.001
Before an aseptic task 35/372 (9.4%) 1.82 (1.06e3.15)
After body uid exposure 43/428 (10%) 2.45 (1.44e4.16)
After patient contact 52/645 (8.1%) 2.26 (1.37e3.73)
After contact with patient environment 16/528 (3.0%) 0.88 (0.46e1.68)
Daytime 0.92
Morning 130/2027 (6.4%)
Evening 40/618 (6.5%)
OR, odds ratio; CI, condence interval.
a
c
2
-Test or Fishers exact test for differences in hand hygiene compliance across different variables.
b
Logistic regression analysis considering type of hospital, hospital area, healthcare worker profession, and type of opportunity.
B. Ataei et al. / Journal of Hospital Infection 85 (2013) 69e72 71
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