Compliance with Handwashing in a Teaching Hospital

Nosocomial infections constitute a major challenge of modern medicine. On average, infections complicate 7% to 10% of hospital admissions (1). Transmission of microorganisms from the hands of health care workers is the main cause of nosocomial infections, and handwashing remains the most important preventive measure (2). Unfortunately, compliance with handwashing is unacceptably low in most institutions (3-7). Determinants of adequate handwashing in hospitals are largely unknown. We investigated factors associated with poor compliance with handwashing in a teaching hospital. Methods Study Design We conducted an observational study at the University of Geneva Hospital, Geneva, Switzerland. Handwashing facilities are conveniently located throughout the institution. One to three sinks are located inside every patient room, along with paper towels and unmedicated soap. Dispensers of hand antiseptic solutions are available in high-risk areas. Individual bottles containing an alcohol-based preparation of 0.5% chlorhexidine gluconate are available in every ward. The study took place in a sample of 48 wards (964 of 1382 beds [70%]) in December 1994. Five trained infection-control nurses recorded potential opportunities for and actual performance of handwashing during 20-minute observation periods distributed randomly during day and night over 14 days. Observations could be prolonged until completion of a patient care episode. Usually, health care workers providing patient care in a randomly selected room were observed; in intensive care units, health care workers providing care to two patients in randomly selected beds were observed. Data were recorded on a specially designed report form that had been pretested and adjusted in a pilot study. Interobserver variability was evaluated during 110 monitoring sessions (48 before and 62 during the study) in which 2 to 3 observers worked simultaneously. At the time of the study, interrater reliability was high for all variables (=0.92 [range, 0.81 to 1.0]). We informed department chairs about the upcoming study in November 1994. Personnel were not informed of which aspects of handwashing would be studied, and performance feedback was not reported during the study. In accordance with the requirements of the institutional review board, we did not identify staff members by unique identifier. Study Variables Opportunities for handwashing were all situations in which handwashing is indicated according to published guidelines (2, 8) (Appendix). Compliance with handwashing was defined as either washing the hands with water or plain soap or rubbing the hands with an antiseptic solution. Departure from the room after patient care without handwashing was regarded as noncompliance. Handwashing was required regardless of whether gloves were used or changed. Failure to remove gloves after patient contact or contact between a dirty and a clean body site on the same patient was considered noncompliance. Predictors were hospital ward; patient-to-staff ratio; time of day; day of week; professional category of health care worker; type of patient care; level of risk for cross-contamination (high-risk, before patient contact or care or between a dirty and a clean site on the patient; medium-risk, after contact with patient or body fluid or after patient care; low-risk, activity involving indirect patient contact or hospital maintenance); and intensity of patient care, estimated by the number of observed opportunities for handwashing per hour for each observation period (activity index). Statistical Analysis We used univariate analysis to examine the associations between predictors and compliance. Proportions were compared by using chi-square tests and odds ratios with 95% CIs. Logistic regression models were used for multivariate analysis. To account for interdependence of observations performed in the same unit, we used robust estimates of variance (generalized estimating equations [9]) by including each period of observation as a cluster. The association between the activity index and average compliance was examined across observation periods by using nonparametric regression (10). We used Stata version 5 (Stata Corp., College Station, Texas) for all analyses. All tests were two-tailed, and a P value less than 0.05 was considered statistically significant. Results In 307 sessions totalling 105 hours of observation, observers recorded 2834 opportunities for handwashing among 1043 health care workers (520 nurses, 158 physicians, 166 nursing assistants, and 199 other types of health care workers). We observed no opportunity for handwashing during 14 sessions. The average compliance with handwashing was 48% (Table): Handwashing was done with soap in 34% of instances and hand antisepsis was performed in 14%. Compliance with handwashing differed significantly among professional health care workers and was lower in surgical and intensive care wards than in other locations. Compliance was lowest during morning shifts and on weekdays. Table. Factors Associated with Noncompliance with Handwashing at the University of Geneva Hospitals Handwashing compliance also varied with type of patient care. The four moments (after patient care, during drug preparation, during housekeeping, and after intravenous care) that generated most opportunities for handwashing (78%) were associated with compliance rates of 48% to 52%. Compliance was lower for procedures associated with a high risk for transmission (before intravenous care, 39%; before respiratory care, 18%; and care between a dirty and a clean body site, 11%) and was higher for low-risk activities (after contact with body fluid, 63%; after wound care, 58%) (Table). Compliance with handwashing was worse when the activity index was high (Table). Compliance decreased on average (SD) by 5% 2% every 10 opportunities per hour when the intensity of patient care exceeded 10 opportunities per hour (linear trend, P<0.001) (Figure). The lowest compliance rate (36%) was found in intensive care units, where indications for handwashing were typically more frequent (average, 43.4 opportunities per hour). The highest compliance rate (59%) was observed in pediatric units, where the average activity index was lower than it was elsewhere (average, 24.4 opportunities per hour). Figure. Opportunities to wash hands and compliance with handwashing. In multivariate analysis (Table), care provided in intensive care units, higher-risk procedures, and a high activity index were associated with low compliance. Nurses had better compliance than any other type of health care worker. Compliance was also higher on weekends. Adding the patient-to-staff ratio to the model did not improve the results. Discussion Our study confirms that the primary problem with handwashing is laxity of practice (3-7). During routine patient care, health care workers disinfected or washed their hands in approximately half of the indicated instances. Like other investigators (3, 4), we observed better compliance in pediatric wards and found that nurses washed their hands more often than did other health care workers. This is fortunate, because nurses had the most opportunities (66%) to wash their hands. A disturbing finding was that activities that carried higher risk for transmission were associated with low compliance. In particular, compliance was very low (11%) for care between a dirty and a clean body site. Health care workers are most likely to wash hands after patient care (6, 7); for instance, Thompson and colleagues (7) reported an average compliance rate of 0% during staff-patient interaction that increased to 63% after interaction. Handwashing-education programs that give specific consideration to the sequence of steps in patient care may help address this problem. There has been some concern that using gloves may be considered an alternative to handwashing (11, 12), but failure to change contaminated gloves is at least as common as failure to wash hands (2, 7). Glove use was observed in fewer than 12% of handwashing opportunities in our study and thus was not a major determinant of noncompliance. Of note, we found that high demand for hand cleansing, which reflects high workload (13), was associated with low compliance. Opportunities for handwashing were much more frequent during busier times of the day and during care of critically ill patients. These results confirm reports by health care workers that perceived busyness substantially reduces handwashing (6, 11). Furthermore, understaffing of hospital wards decreases compliance with isolation precautions (14) and increases risk for nosocomial infections (15, 16). Although causality was not established in these reports, the investigators mentioned possible lack of compliance with infection-control measures, particularly handwashing, as a potential explanatory factor (15, 16). To our knowledge, our study is the first to assess the relation between increased need for handwashing and reduced compliance. A disturbing implication of our findings is that full compliance with handwashing guidelines may be unrealistic. Actual wash time in routine hospital practice averages 8 to 20 seconds, which may be too short to be fully effective (2, 8). In intensive care units, health care workers need about 1 minute to walk to the sink, wash their hands, and return to the patient (17). If 40 opportunities to wash the hands occur per hour of care, the total amount of time spent washing hands becomes prohibitive. One possible solution is to replace time-consuming handwashing with bedside hand antisepsis. Whether switching from traditional handwashing to hand antisepsis improves compliance deserves testing in clinical trials. Our study has several limitations. First, although our observations were as unobtrusive as possible, health care workers may have changed their behavior because they were being observed. Such a bias would probably inflate compliance estimates, and the