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Year : 2020  |  Volume : 13  |  Issue : 1  |  Page : 66-70  

An observational study to assess hand hygiene compliance rate among health care workers at a tertiary care hospital

Department of Microbiology and Hospital Administration, Tertiary Care Hospital, Pune, Maharashtra, India

Date of Submission12-Feb-2019
Date of Decision13-Feb-2019
Date of Acceptance03-Sep-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Kanwaljit Kaur
Tertiary Care Hospital, Pune, Maharashtra
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/mjdrdypu.mjdrdypu_57_19

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Background: Wearing of gloves by health-care workers (HCWs) reduces the transmission of pathogens between patient contacts. However, it is not a substitute for hand washing. The present study aimed to observe the gloving behavior versus its indications and hand hygiene (HH) compliance with and without gloves. Materials and Methods: HCWs working in intensive care units (ICUs) and acute care setup of a tertiary care hospital were observed for the use of gloves and HH practices as laid down by the World Health Organization (WHO). Results: Of a total 4301 opportunities, HH actions were performed in 2312 (53.74%) opportunities. In ICU, of 2053 opportunities, HH actions were performed in 1169 (56.94%) opportunities, which was better than other acute care settings where HH was performed in only 50.8% occasions. Out of 1989 missed opportunities where HH was not performed, in 525 occasions (26.39%) the gloves were worn. Conclusion: The rate of HH compliance was higher in ICU than other acute wards. At the same time, HH rate was lower when gloves are worn. Sensitizing HCWs about the WHO five moments of HH and glove pyramid can improve HH practices and gloving practices.

Keywords: Gloves, hand hygiene, health-care workers, infections, surveillance

How to cite this article:
Mumtaz Rahim V K, Kaur K, Yadav S, Srinivas V, Devrani S, Singh H, Chakravarty A. An observational study to assess hand hygiene compliance rate among health care workers at a tertiary care hospital. Med J DY Patil Vidyapeeth 2020;13:66-70

How to cite this URL:
Mumtaz Rahim V K, Kaur K, Yadav S, Srinivas V, Devrani S, Singh H, Chakravarty A. An observational study to assess hand hygiene compliance rate among health care workers at a tertiary care hospital. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2021 Jan 17];13:66-70. Available from: https://www.mjdrdypv.org/text.asp?2020/13/1/66/272883

  Introduction Top

Hand hygiene (HH) is an important health-care issue and it is the most cost effective and practical measure to reduce the incidence of hospital acquired infections (HAIs). By wearing gloves, the rate of transmission of organisms, through health-care workers (HCWs) hands gets reduced, but it is not a substitute for effective HH. However, if gloves are not changed between patient contacts, they themselves become vectors of pathogen transmission. The World Health Organization (WHO) guidelines [1] state that whenever patient contact is anticipated, hands should be cleaned, and then only gloves should be worn (when a moment for HH occurs). HH should also be performed immediately after removing gloves. HCWs' compliance with respect to glove-wearing and HH vary. They may wear gloves whether indicated or not and perform HH at their choice rather than adhering to guidelines.[2],[3] Some studies have reported lower rates of HH compliance whenever gloves are worn [2],[3],[4] while others report unchanged or better rates of compliance.[5],[6] The present study was conducted at a tertiary care hospital with the aim first to observe the gloving behavior versus its indications and second to assess HH compliance with and without gloves.

  Materials and Methods Top

An observational study using the WHO HH observation form [Figure 1] was conducted from May 2017 to July 2017. The ethical clearance was taken vide letter no. 1001/Path/Ethics/17 dated March 20, 2017. The study was conducted on HCWs coming in contact with patient care in intensive care units (ICUs), pediatric medicine, pediatric surgery, and neurosurgery wards for compliance of HH. Different professional categories, including nurses, physicians, and paramedics, were observed separately. The HCWs were not informed of the active surveillance, but they were aware that infection control nurses (ICNs) were recording data. Indication for HH means the reason why HH is necessary at a given moment to effectively interrupt microbial transmission during patient care. Opportunity for HH is defined as the need to perform the HH action. Hence, the reasons or indications can be single or multiple in an opportunity.
Figure 1: World Health Organization hand hygiene observation form

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All HCWs were observed for five moments of HH as described by the WHO which include: before touching patient; before doing any clean or aseptic procedure; after coming in contact with body fluids; after touching the patient and after touching patient surroundings. One session of HH was observed every day which lasted for 20 min (±10 min) and a maximum of three HCWs were observed during this session. HCWs were observed for each opportunity of HH and HH action performed by them was marked in the column, as mentioned in the form [Figure 1]. HH action can be either hand wash with soap and water or hand rub with 2% chlorhexidine/70% alcohol hand rub solutions. Missed HH means neither of the actions have been performed. HCWs who wore gloves during this missed HH action were recorded in the column of gloves. Data were calculated using the WHO basic HH calculation form. HH compliance rate was obtained by using the formula:

HH compliance rate = Number of action/total number of opportunities × 100.

  Results Top

ICNs made a total of 4301 observations on the professional category of nurses, doctors, and paramedical staff in ICU, neurosurgical wards, and pediatric wards (both pediatric medicine and surgery). As depicted in [Table 1], total HH compliance rate was 53.74%. In opportunities where the HH action was missed, but the HCWs were wearing gloves was 26.39%. In ICU setup, gloves substituted the missed HH action almost three times than that observed in other wards (40.04% as compared to 15.4%) [Table 1]. [Table 1] shows a statistically significant difference in HH rates in ICU and other acute care set up.
Table 1: Hand hygiene rate and use of gloves in missed hand hygiene moments

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Besides this, further evaluation was done in ICU based on the WHO five moments of HH as enumerated in [Table 2]. Results show that before touching the patient, the HH compliance rate was 51.7%. The maximum compliance was observed when HCWs had to do HH after touching the patient, i.e. 66.2%. However, the least compliance rates were observed after touching patient surrounding, i.e. 50.8%. Among the missed HH actions, HCWs were wearing gloves maximally before any aseptic technique and after touching body fluid (80% and 74.2%, respectively). This indicates whenever the gloves are worn; the rate of HH was poor.
Table 2: Hand hygiene rate as per five moments of hand hygiene in intensive care unit

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Among various categories of HCWs [Table 3], it was found that nurses had a maximum number of HH opportunities as well as compliance rate (69.8%). It was followed by doctors (49.6%) and rate among paramedics was 38.6%. It was also observed that among missed HH actions percentage of glove usage in paramedics was 64.8% followed by nurses (51%) and doctors (33%). [Table 3] shows a statistically significant difference in HH performance between nurses, doctors, and paramedics.
Table 3: Hand hygiene rate in intensive care unit: Professional category wise

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  Discussion Top

A total of 4301 opportunities of HH were observed in different categories of HCWs. The two main findings of this study were that missed HH moments were less in ICU as compared to other acute wards but on most of such occasions gloves were worn by HCWs in ICU. It was also observed that whenever the gloves were worn, HH was not performed. Gloves substituted HH action mainly before aseptic technique (80.6%) and after touching body fluids (74.2%). This observation has great clinical implication in pathogenic transmission because organisms like methicillin-resistant Staphylococcus aureus can be transmitted through HCWs gloves if not changed between patient contact. It is already emphasized in many studies that gloves do not provide complete protection against acquisition of microorganisms. Few studies have reported that microorganisms causing HAI in patients have also been recovered from the hands of HCWs who wore gloves, and this rate of transmission had been up to the extent of 30%.[7],[8]

The spread of infections in developing countries remains a serious problem, especially in high-risk health-care facilities due to the lack of awareness in HCWs which is compounded by “omo syndrome” (a belief that they are super clean and sterile).[9] The low availability of alcohol-based hand rubs as reported by Anargh et al.[10] had been taken care of in our study as hand rubs were available with a frequency of one per each bed. However, as per our observations, few more reasons for sub-optimal compliance to HH have been found. These are summed up in [Figure 2].
Figure 2: Cause and effect diagram: Contributing factors to sub-optimal compliance to hand hygiene

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It has been observed that glove use is associated with poor HH compliance. However, both gloves use and performance of HH are distinct behaviors. HCWs may have a wrong perception that if gloves are worn it not only protects them from the pathogens but also protects patients from the pathogens on their hands. Besides, HH behavior can be either inherent, i.e. motivated by the feeling of revulsion or disapproval after coming in contact with dirt or elective, i.e. performed by choice. However, in our study, no such analysis of gloving behavior has been done. The present study also reveals that HCWs do not always clean their hands before wearing gloves, so during high-risk contacts, there is great possibility that their hands will pick up further organisms. Besides, it was also observed that the hands are not always washed/alcohol rubbed after the removal of gloves. This type of behavior may result in what may be called “The dirty hand in the latex glove” as coined by Fuller et al.[11]

The method of HH is very simple, but it is often found that HCWs workers do not adhere to it strictly. Wearing of gloves gives a false perception to HCWs that gloves may be a replacement for HH. However, in fact, they are lacking in their knowledge regarding indications of gloves use. Sensitizing the HCWs about the chain of the spread of infections, indication to wear gloves using the WHO gloves pyramid [Figure 3] and presence of institutionally appointed observers (ICN) may be used as an effective way to improve the HH compliance rate in wards. Thus, from this study, we conclude that targeted educational activities for paramedics are the need of the hour as the HH rates are lowest among them. Mathur has also stated that educational interventions for all category of HCWs, the involvement of administrative authorities in infection control, continuous surveillance, and effective feedback are few more important steps to achieve the goal of infection control.[12] Kumar et al.[13] have also suggested that HH should be incorporated in children as health teaching intervention right from the school days.
Figure 3: World Health Organization gloves pyramid

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  Conclusion Top

We suggest that hand hygiene training should be incorporated in children right from the school days and especially in health care workers at the inception of their training. It will not only change their attitude for infection control but will also contribute to patient safety.

Limitations of the study

This study was carried out in a relatively short period with no control group. The entire sampling method is based on the reliability of observer. The results of the present study are limited to acute wards of a specific tertiary healthcare establishment and cannot be generalized.

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Conflicts of interest

There are no conflicts of interest.

  References Top

World Health Organization. World Health Organization (WHO) Guidelines on Hand Hygiene. Geneva: World Health Organization; 2009.  Back to cited text no. 1
Girou E, Chai SH, Oppein F, Legrand P, Ducellier D, Cizeau F, et al. Misuse of gloves: The foundation for poor compliance with hand hygiene and potential for microbial transmission? J Hosp Infect 2004;57:162-9.  Back to cited text no. 2
Hitoto H, Kouatchet A, Dubé L, Lemarié C, Mercat A, Joly-Guillou ML, et al. Factors affecting compliance with glove removal after contact with a patient or environment in four intensive care units. J Hosp Infect 2009;71:186-8.  Back to cited text no. 3
Flores A, Pevalin D. Healthcare workers compliance with glove use and the effect of glove use on compliance with hand hygiene. J Infect Prev 2006;7:15-8.  Back to cited text no. 4
Sánchez-Payá J, Galicia-García MD, Gracia-Rodríguez RM, García-González C, Fuster-Pérez M, López-Fresneña N, et al. Compliance with hand hygiene guidelines and determinants of compliance. Enferm Infecc Microbiol Clin 2007;25:369-75.  Back to cited text no. 5
Kim PW, Roghmann MC, Perencevich EN, Harris AD. Rates of hand disinfection associated with glove use, patient isolation, and changes between exposure to various body sites. Am J Infect Control 2003;31:97-103.  Back to cited text no. 6
Olsen RJ, Lynch P, Coyle MB, Cummings J, Bokete T, Stamm WE. Examination gloves as barriers to hand contamination in clinical practice. JAMA 1993;270:350-3.  Back to cited text no. 7
Tenorio AR, Badri SM, Sahgal NB, Hota B, Matushek M, Hayden MK, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin Infect Dis 2001;32:826-9.  Back to cited text no. 8
Saloojee H, Steenhoff A. The health professional's role in preventing nosocomial infections. Postgrad Med J 2001;77:16-9.  Back to cited text no. 9
Anargh V, Singh H, Kulkarni A, Kotwal A, Mahen A. Hand hygiene practices among health care workers (HCWs) in a tertiary care facility in Pune. Med J Armed Forces India 2013;69:54-6.  Back to cited text no. 10
Fuller C, Savage J, Besser S, Hayward A, Cookson B, Cooper B, et al. “The dirty hand in the latex glove”: A study of hand hygiene compliance when gloves are worn. Infect Control Hosp Epidemiol 2011;32:1194-9.  Back to cited text no. 11
Mathur P. Hand hygiene: Back to the basics of infection control. Indian J Med Res 2011;134:611-20.  Back to cited text no. 12
[PUBMED]  [Full text]  
Kumar RS, Aruna S, Sasikala M. Effectiveness of hand hygiene teaching on knowledge and compliance of hand washing among the students at a selected school in Mugalivakkam village, Kancheepuram District. J Nurs Health Sci 2014;3;56-60.  Back to cited text no. 13


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3]


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