Indian Journal of Medical Specialities 8 (2017) 197–199

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Indian Journal of Medical Specialities

journal homepage: www.elsevier.com/locate/injms

Original research article

Hand hygiene compliance among health care workers in pediatric

oncology ward of a tertiary care hospital: A cross sectional
observational study
Bineeta Kashyapa,* , Kavita Guptab , Sunil Gomberc , Neha Guptaa , Abhilasha Bhardwaja ,
NP Singha , Ashwani Kumara
a
Department of Microbiology, UCMS & GTB Hospital, Delhi, India
b
Department of Microbiology, Dharamshila Cancer Hospital, Delhi, India
c
Department of Pediatrics, UCMS & GTB Hospital, Delhi, India

A R T I C L E I N F O A B S T R A C T

Article history: Background: Hand hygiene compliance was incorporated in the Global Patient Safety Challenge initiative
Received 15 September 2017 by WHO with the goal of reducing the burden of Health care Associated Infections (HAIs), however,
Received in revised form 2 November 2017 compliance rates among healthcare workers remain low.
Accepted 5 November 2017
Methods: All possible opportunities for Hand Hygiene were recorded for 15 days in a cross sectional study
Available online 6 November 2017
among healthcare workers in a 10-bedded Pediatric Oncology Ward. The observations were noted for all
five moments of Hand hygiene by WHO. Each moment was counted as one opportunity.
Keywords:
Results: Hand Hygiene compliance rates of 53.4%, 42.5% and 32.6% were observed for nurses, doctors and
Hand hygiene
Compliance
other HCWs respectively. 100% and 26.4% compliance rates were observed for moments 3 and 5
Monitoring respectively. Nurses had the best compliance in all five moments of hand hygiene.
Healthcare workers Conclusions: Infection trends can vary with hand hygiene indicators. Hand hygiene monitoring is the key
Moments intervention in prevention of spread of multi-drug resistant organisms in health care settings.
© 2017 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical
Specialities.

1. Introduction personnel‘s hands. Routine hand hygiene practices removes the

In the 1840s, the effectiveness of hand hygiene was demon-
strated by Semmelweis as hand hygiene practices significantly
reduced maternal deaths in patients suffering from puerperal fever
[1]. Even after several decades later, the hand hygiene message of
Semmelweis is not translated consistently into clinical practices
and compliance of health-care workers towards hand hygiene
practices is unacceptably very low regardless of advances in
infection control measures [2,3]. To reduce the healthcare-
associated infections across the world, a campaign was launched
in 2005 by WHO as Global Patient Safety Challenge: ‘Clean Care is
Safer Care’ [4]. Many consensus guidelines were subsequently
published on hand hygiene practices in healthcare systems [5,6].
Nevertheless, hand hygiene is the simplest but most effective
measure when practiced meticulously can prevent nosocomial
infections. The microorganism are usually transmitted via health
* Corresponding author.
E-mail address: dr_bineetakashypa@yahoo.co.in (B. Kashyap).
transient flora, colonizing the superficial layers of the skin. These
organisms residing in transient flora of health care worker’s hands
are most frequently associated with health care associated
infections [7]. The burden of infectious diseases is still very high
especially in developing countries. Compliance to recommended
hand-washing practices remains unacceptably low in most of the
health care facilities, it rarely exceeds more than 40 per cent of
situations where hand hygiene is indicated [8,9]. Hospital acquired
infections have been acknowledged as a grave problem for more
than a century ago, it badly affects the quality of patient care
provided in health care facilities. Hand hygiene and patient
isolation are the two essential principles that have been recognized
as most effective methods of reducing hospital-acquired infections
There is paucity of published data for Hand hygiene surveillance in
developing countries like India especially in government hospital,
keeping this in mind the study was conducted in pediatric
oncology ward among all health care workers to assess the exact
compliance rate of hand hygiene in the pediatric oncology ward.
The real aim of the study was to stress on the hand hygiene
practices in our hospital.

https://doi.org/10.1016/j.injms.2017.11.001
0976-2884/© 2017 Published by Elsevier, a division of RELX India, Pvt. Ltd on behalf of Indian Journal of Medical Specialities.
198 B. Kashyap et al. / Indian Journal of Medical Specialities 8 (2017) 197–199
2. Material & methods
A cross sectional observational study was conducted in the
pediatric oncology ward (consisting of 10 beds) of Guru Teg
Bahadur Hospital. The study was done in the month of August’2016
among all health care workers including doctors, nurses and health
care workers working in that time period. A pretested close ended
validated questionnaire was conducted before the analysis. All
possible opportunities for hand hygiene in the ward were recorded
for a period of 15 days. The observations were noted for all five
moments of Hand hygiene by WHO. Each moment counted as 1
opportunity.
2.1. WHO five moments of hand hygiene
1 – Before touching a patient, 2 – Before clean/Aseptic
procedure, 3 – After body fluid exposure, 4 – After touching a
patient, 5 – After touching patient surroundings.
A total of 308 opportunities were noted among doctors, nurses
and other health care workers. Hand Hygiene compliance rate was
calculated by dividing the no. of preformed actions by number of
opportunities as per WHO guidelines.
Compliance (%) = performed actions/opportunities  100
3. Results
Out of the total 308 opportunities, nurses comprised of the
highest number 202 (65.5%) followed by doctors 54 (17.5%) and
other health care workers 52 (16.8%). Compliance rate for nurses
was 53.4% while 42.5% and 32.6% compliance rate was observed in
doctors and other health care workers respectively. Table 1
describes the distribution of opportunities with compliance rate in
each group whereas frequency of distribution of all five moment of
hand hygiene varies and have been shown in Table 2. Overall
compliance rate in each five moments of hand hygiene shown in
Table 2. Highest compliance rate was observed in moment 3 (100%)
followed by moment 2(82%) whereas least compliance rate was
seen in moment 5 (26.4%). Compliance rate among nurses was
better compared to doctors and other health care workers in all five
moments of hand hygiene.
4. Discussion
Hand hygiene remains a “corner stone” for prevention of health
care associated infections. It remains as the most indispensable
measure to prevent any health care associated infections [10].
Despite the significance of hand hygiene, it is not correctly and
consistently followed in any health care facility. The overall
compliance rate in our study is 48% percent based on the WHO’s
“My Five Moments for Hand Hygiene” and compliance definition of
WHO. However our study demonstrated higher compliance rate
than reported by WHO (38.7%) [5] in the past but a much lower
compliance have been published by WHO recently in 2013 (51.0%)
[6]. Recently a study done in India have demonstrated compliance
rate as high as 78% [11]. In most health care institutions, adherence
to recommended hand-washing practices remains unacceptably
Table 1
Distribution of opportunities with compliance rate in each group of Healthcare workers (HCW) under study.
Performed actions
Nurses 108
Doctors 23
Other Health Care Workers 17
Total 148
low, rarely exceeds above 40% [8]. As per the goal of infection
control the hand hygiene compliance rate must be above 70%. The
reason for lower compliance observed in our hospital, may be due
to lack of knowledge among newly recruited health care personnel,
who have not yet attended the training for hand hygiene at their
previous hospitals, limited number of sinks and resources for hand
hygiene such as soap and hand rub are the major contributors.
Most of the health care worker believes that wearing of gloves
substitutes hand hygiene and can reduce the high number of
opportunities for hand hygiene per hour of patient care. Highest
compliance rate was seen among nurses was 53.4% while doctors
and other health care workers had 42.5% and 32.6% compliance
rate respectively. However, Nurses demonstrated higher compli-
ance rate among all health care providers but much higher
adherence rate (63%) was observed in a study done in India [11]
other studies also demonstrated comparatively higher prevalence
among nursing staffs [8,12,13]. Among all the WHO five moments
of hand hygiene maximum adherence/compliance (100%) was
observed for moment 3- After body fluid exposure. However the
number of opportunities being very less so it will be wrong to
derive any conclusion from this in true sense. Nevertheless, it is
noticed that all the health care workers were very careful after
body fluid exposure and they perceive it as an important measure
for self-protection. Moment 3 was closely followed by moment 2
with 82% compliance rate and the goal of infection control (hand
hygiene compliance must be above 70%) was achieved in this
moment both by nurses and doctors. This may be attributed to the
awareness about the risk of hospital acquired infections that can be
transmitted during any invasive procedure. Poor compliance rate
was observed for moment 1(before touching a patient) and
moment 4 (after touching a patient) while worst compliance rate
was seen for moment 5 (after touching patient surroundings) other
studies have also reported poor performance for moment 5 across
all health care workers [11]. In our study doctors behaved worst
both for moment 4 & 5.
There is no standard protocol to monitor compliance to hand
hygiene. Most of the studies conducted in past have included direct
observation as a method to assess hand hygiene compliance [14–
16] and has also been recommended by WHO. Direct observation
method provides qualitative as well as quantitative information
about why and when failures occur [5]. In a developing country like
India, due to non availability of technologies like electronic
machines to monitor compliance, direct observation method
remains as a gold standard. The questionnaire round was
conducted before the study period as a part of regular feedback
training. Any feedback for their performance was not given during
the study period as awareness of healthcare worker just before
study may affect health care workers behavior ultimately direct
observation results may be affected (Hawthorne effect) [17].
There were certain limitations in our study like we were not
able to monitor them continuously, the data was collected for
30 min period twice a day for 15 days that probably provides
information about a very low percentage of all hand hygiene
opportunities.
Hand hygiene practices reflect attitudes, behavior and beliefs of
health care personnel. Several factors can affect the performance of
hand hygiene like health care worker related factors clinical factors
Opportunities Compliance rate (%)
202 53.4
54 42.5
52 32.6
308 48.0
 B. Kashyap et al. / Indian Journal of Medical Specialities 8 (2017) 197–199
Table 2
Hand hygiene compliance rate (%) in each group of Health care workers for five moments of Hand Hygiene by WHO.
Compliance rate (%) in WHO 5 moments of hand hygiene
Moment 1 (Before touching Moment 2 (Before clean/aseptic Moment 3 (After body fluid Moment 4 (After touching Moment 5 (After touching patient
a patient) procedure) exposure)
n = 83 n = 50 n = 05
Nurses 31/58 (53.4) 33/39 (84.6) 3/3 (100)
Doctors 9/17 (52.9) 8/11 (72.7) 0 4/17 (23.5)
Other 3/8 (37.5) 0 2/2 (100)
HCW
Total 43/83 (51.8) 41/50 (82) 5/5 (100)
and environmental/institutional factors [18]. Poor compliance of
hand hygiene may be attributed to lack of knowledge, workload
pressure. An induction course should be conducted monthly for all
new recruits in the hospital where microbiologist will train them.
Educational sessions should focus on benefits of hand hygiene,
ideal duration and steps of hand hygiene and the extent of
reduction of hospital acquired infections by hand hygiene. There
should be posters at strategic locations to educate and aware all
health care workers about the significance of hand hygiene. There
should be sufficient supply of alcohol-based hand rubs in the
hospital premises and it should be placed bedside so that it can be
utilized as and when required. Since 2008, every year on 15th of
October Global Hand washing Day has been celebrated to motivate
and mobilize people around the world towards hand washing.
Multimodal strategies have been shown to be more successful in
improving rates of adherence with hand hygiene among health
care workers rather than single interventions [19].
Although we have progressed so far and have developed many
evidence based guidelines for infection control, it still remains
difficult to implement them especially in developing countries.
Hand hygiene practices are vital by which we can reduce the cross
contamination of multi-drug resistant organisms (MDROs) as
treatment of patients infected with these MDROs is challenging
and it overburdens our health care system. Lack of basic health care
facilities, surveillance networks and enough resources like to build
sinks at places where required are major deterrents. The use of
WHO recommended alcohol based hand rubs is a practical solution
to conquer all these constraints, because it can be distributed
individually to a health care worker and they can carry it with them
and can use when required [20]. Therefore, by increasing the
emphasis on infection control measures, regular training and
continuous monitoring are important steps to prevent any
nosocomial infection.
Conflict of interest
None.
Source of funding
None.
199
a patient) surroundings)
n = 83 n = 87
29/58 (50) 12/44 (27.2)
2/9 (22.2)
3/8 (37.5) 9/34 (26.4)
36/83 (43.3) 23/87 (26.4)
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