Original Article

Hand hygiene compliance – Improvement with multimodal

approach in intensive care unit setting
Saloni Garg, Shalini Malhotra, Patel Pritikumari, Amarjit Kaur, Nirmaljit Kaur, Nandini Duggal
Department of Microbiology, ABVIMS and Dr. RML Hospital, New Delhi, India

Abstract Introduction: Healthcare associated infections (HCAIs) pose a significant risk to patient’s health with
increasing morbidity and mortality. A large portion of HCAI can be prevented by hand hygiene, but adherence
to hand hygiene has been found to be very low.
Methodolgy: This study was conducted to assess the rate of hand hygiene compliance during ‘my five
moments of hand hygiene’ as per the WHO guidelines in our intensive care units and to implement
multimodal intervention strategies to improve hand hygiene compliance.
Results: The average compliance amongst all HCWs in both ICUs was 45.7% before sensitisation which
increased to 85.4% after sensitisation using multimodal strategies.
Conclusion: Multimodal Intervention strategies such as the one we employed had a good impact in
improving compliance in our ICU and these improvements can be easily duplicated in healthcare settings
across the country.

Keywords: Compliance, hand hygiene, healthcare‑associated infections, intensive care unit, multimodal
strategies

Address for correspondence: Dr. Shalini Malhotra, Department of Microbiology, ABVIMS and Dr. RML Hospital, New Delhi, India.
E‑mail: drshalinimalhotra@yahoo.com
Received: 01‑08‑2020 Revised: 01‑05‑2021 Accepted: 12‑06‑2021 Published: 24-09-2021

INTRODUCTION conducted a before and after intervention study which

The importance of hand hygiene in preventing
healthcare‑associated infections (HCAIs) has been
known since the study by Semmelweis in 1884.[1] Since
then, many studies have clearly established hand hygiene
to be the single most effective method in reducing
HCAIs.[2]
was observation based and a prospective study. In the
study we assessed rate of hand hygiene compliance among
our healthcare workers posted in ICUs before doing any
intervention and then after implementation of multiple
strategies to improve hand hygiene compliance.
MATERIALS AND METHODS

There are very little data available on awareness on need Setting

of hand hygiene practices amongst various sections of This prospective study was conducted in the two intensive
healthcare personnel in India. Intended meaning is we care units (medical ICU [MICU] and trauma ICU [TICU])

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How to cite this article: Garg S, Malhotra S, Pritikumari P, Kaur A,

DOI: Kaur N, Duggal N. Hand hygiene compliance – Improvement with
10.4103/jpsic.jpsic_22_20 multimodal approach in intensive care unit setting. J Patient Saf Infect
Control 2021;9:13-6.

© 2021 Journal of Patient Safety & Infection Control | Published by Wolters Kluwer - Medknow 13
 Garg, et al.: Multimodal approach for improving hand hygiene compliance

of a tertiary care hospital in northern India. Our ICUs
have conveniently located handwashing facilities (sink: bed
ratio is 1:10) and availability of alcohol‑based hand rubs
with each bed.
Design
A total of 200 subjects were observed (100 from each ICU).
A single infection control nurse (ICN) visited the ICU for
a period of 20 min to record all possible opportunities for
hand hygiene every day for 1 month. The observations
were noted for all five moments of hand hygiene during
patient care. These five moments include before touching
a patient, before any clean/aseptic procedure, after
body fluid exposure, after touching a patient and after
touching patient’s surroundings. A checklist was used for
nursing staff and doctors. The procedure was followed
for 1 month, and the average was taken to calculate the
adherence rate.
Intervention strategies
All the doctors and nursing staff were given sensitisation
class by infection control officers (MD Microbiology) on
HH practices as per the WHO guidelines. Apart from
this, multiple strategies including intensive educational
lectures, displaying posters on ‘my five moments for hand
hygiene’ and methods of hand hygiene, easy availability
of hand rubs and handwashing facilities and verbal
reminders in improving hand hygiene compliance in our
ICUs were used.
Post‑sensitisation, the same ICN recorded adherence to
hand hygiene without the knowledge of staff in a similar

120.0%
100.0% 97.0% 100.0% 100.0%
100.0% 92.8% 94.0% 90.0% 87.5% 84.6%
83.3%
80.0% 72.0%
65.0%
60.0%
48.0% 46.0%
40.0%
40.0% 36.0% 33.3%
21.0% 20.0%
20.0% 11.0%

0.0%
Before touching a Before clean / After body fluid After touching a After touching
patient aseptic procedure exposure risk patient patient
surroundings
Doctors( before sensitisation) Doctors ( after sensitisation)
Nurses(before sensitisation) Nurses ( after sensitisation)

Figure 1: Hand hygiene compliance amongst healthcare workers in medical intensive care unit

120.0%
100.0%
98.0% 100.0%
100.0% 91.6%

77.0% 80.0% 78.0%

80.0% 73.0% 75.0% 73.6% 73.0%

58.3%
60.0% 55.0%
50.0%
42.8% 42.6% 41.2%
40.0% 33.3% 34.3%
24.0%
20.0%

0.0%
Before touching a Before clean / aseptic After body fluid After touching a After touching
patient procedure exposure risk patient patient surroundings

Doctors( before sensitisation) Doctors ( after sensitisation)

Nurses(before sensitisation) Nurses ( after sensitisation)

Figure 2: Hand hygiene compliance amongst healthcare workers in trauma intensive care unit

14 Journal of Patient Safety & Infection Control | Volume 9 | Issue 1 | January-April 2021
 Garg, et al.: Multimodal approach for improving hand hygiene compliance
Table 1: Percentage hand hygiene compliance of healthcare
workers pre‑/post‑sensitisation
TICU MICU Both ICUs
Pre‑sensitisation
Doctors 43.54 35.06
Nurses 60.82 43.4
Average 52.18 39.23 45.7
Post‑sensitisation
Doctors 72.86 90.12
Nurses 82.92 95.72
Average 77.89 92.9 85.39
ICUs: Intensive care units, TICU: Trauma ICU, MICU: Medical ICU
checklist. The study was conducted over a short time period
so that the subjects do not change.
OBSERVATIONS AND RESULTS
During 1 month of observation, around 100 HCWs
were observed in each surveillance unit before and after
sensitisation class.
Hand hygiene compliance amongst HCWs in both ICUs
is shown in Figures 1 and 2. The average compliance
amongst all HCWs in both ICUs was 45.7% before
sensitisation which increased to 85.4% after sensitisation
using multimodal strategies [Table 1]. Nurses had
higher overall compliance than the doctors. Statistical
analysis was conducted using Chi‑square test which
showed a statistically significant increase in hand hygiene
compliance after interventions in all the moments of hand
hygiene (P < 0.05) in both the ICUs.
DISCUSSION
Hand hygiene is a simple and a very important step in
prevention of spread of infections. The most important
factor responsible for the infections acquired in the
hospitals, especially in ICUs, is cross‑contamination and
transmission of microbes from hands of HCWs to
patients.[2] As per studies, hand hygiene compliance amongst
healthcare personnel in most hospitals is usually < 50%.[3‑5]
This poor compliance can be due to factors such as working
in busy wards  (ICUs), understaffing as well as lack of
awareness. Single intervention programmes produce little
or temporary success in leaving a lasting impact on hand
hygiene compliance.[6] Hence, multipronged interventions,
which include behavioural, environmental and social
changes, have been suggested and tried in different studies
to sustain improved hand hygiene compliance.[3]
In the study, before any sensitisation class, we found that the
overall hand hygiene compliance in our ICU staff  (doctors
and nurses both) was approximately 45.7%. As per the
Journal of Patient Safety & Infection Control | Volume 9 | Issue 1 | January-April 2021 15
literature, hand hygiene compliance rates in ICUs vary from
35% to 80% depending on the categories of HCWs, the
intensity of work in the unit and the type of ICUs studied.[3,7]
During both the observation periods, although the
opportunities for hand hygiene were most in the areas of
‘before/after patient contact’ or ‘before/after procedure’,
yet the compliance rates specific to these opportunities
were amongst the least [Figure 1 and 2].
Amongst the various hand hygiene moments, maximum
compliance was recorded after body fluid exposure (65%
in MICU and 75% in TICU). This may be because of
tendency to protect themselves in such visibly contaminated
conditions.
Most HCWs tend to club the different moments because of
lack of awareness (moments 1 and 2 or moments 4 and 5).
Certain additional observations were made during our
study. We found that, at times, although nursing staff
and resident trainees used hand hygiene as indicated,
they unconsciously touched areas of their own body or
their clothes before patient contact, thereby negating the
effect of hand hygiene. Another study by Lam et al. also
noted that HCWs tend to recontaminate their hands by
touching inanimate objects, pens or fomites after hand
hygiene.[8] Hence, attention was drawn to this fact during
the sensitisation class.
In our study, the most common reason cited by health
workers for non‑compliance was that they were too
busy (33.7%). Hence, we emphasised to our health
workers how hand hygiene takes up little time and the
benefits produced far outweighed the time lost in applying
hand hygiene. We provided them with alternative of 30 s
handwashing or use of bedside hand rubs to save time.
In a survey conducted by Pittet et al., amongst physicians
of a large university hospital, it was found that although
many (65%) had a good knowledge of indications, 67%
perceived hand hygiene as a difficult task.[9]
In our study, intensive educational sessions based on ‘my
five moments of hand hygiene’ in different shifts for
all cadres of HCWs including nursing orderly as well as
displaying posters, providing verbal reminders and ensuring
easy availability of hand hygiene products in the unit were
organised. With these strategies, most HCWs who visited
the ICU were reached.
The intervention strategies employed by us had a
significant impact in improving hand hygiene compliance
 Garg, et al.: Multimodal approach for improving hand hygiene compliance
rates (P  <  0.05) in almost all the categorical variables
studied, especially in the areas of ‘before’ and ‘after patient
contact’ [Figures 1 and 2].
After sensitisation, we observed a significant increase
in hand hygiene compliance by both doctors and
nurses [Table 1].
In a study conducted in Hong Kong, the hand hygiene
compliance before and after the implementation of a
multimodal implementation programme in a neonatal ICU
improved from 40% to 53% before patient contact and
from 39% to 59% after patient contact. They concluded
that an effective education programme could improve
hand hygiene compliance.[8] In another study conducted
in five adult ICUs, an intervention strategy consisting
of educational programme and improving standards
of catheter care resulted in a significant decrease in
catheter‑related bloodstream infection rates, with an
increase in hand hygiene compliance from 59% to 65%.[10]
We believe that our intervention was successful because
the programme was multimodal, easy to understand and
was fully supported by every member of the unit as we
can see the marked increase in hand hygiene compliance
rates post‑sensitisation.
CONCLUSION
We conclude that the hand hygiene practices are terribly
low amongst most healthcare personnel working in the
ICU. However, intervention strategies such as the one we
employed had a good impact in improving compliance in
our ICU and these improvements were consistently seen
amongst almost all HCW groups in our unit. The results we
achieved can be easily duplicated in other ICUs across the
country if similar, interventional strategies are employed.
16 Journal of Patient Safety & Infection Control | Volume 9 | Issue 1 | January-April 2021
ACKNOWLEDGEMENT
We would like to thank our ICU staff, doctors as well as
nurses for their co‑operation.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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