American Journal of Infection Control 46 (2018) 775-780

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American Journal of Infection Control American Journal of

Infection Control

j o u r n a l h o m e p a g e : w w w. a j i c j o u r n a l . o r g

Major Article

A multimodal intervention to improve hand hygiene compliance in a

tertiary care center
Abdul Mannan Laskar MSc a, Deepashree R MD a, Prasanna Bhat MBBS a,
Biju Pottakkat MD b, Sunil Narayan MD c,
Apurba Sankar Sastry MD, DNB, MNAMS, PDCR a,*, R Sneha MBBS a
a
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India
b
Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India
c
Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry 605006, India

Key Words: Background: Healthcare-associated infections (HAIs) are a major threat to patient safety worldwide. HAIs
Hand hygiene are mainly transmitted via the hands of healthcare workers (HCWs), and HCW compliance with hand
Audit hygiene (HH) practices is reportedly low. Therefore, multimodal interventions are needed to develop ef-
Hand hygiene adherence rate (HHAR)
fective HH improvement strategies. In this study, we assessed the effect of multimodal interventions on
Knowledge, attitude, and practice
improvement of HH compliance.
Methods: This study was conducted in 2 intensive care units from August 2016 to October 2016. It en-
compassed 3 phases: pre-intervention (20 days), intervention (1 month), and post-intervention (20 days).
A total of 53 HCWs, including physicians, nurses, and housekeeping staff, were included in the HH audit.
The audit was analyzed by direct observation and by a completed knowledge, attitude, and practice (KAP)
questionnaire.
Results: A total of 6350 HH opportunities were recorded; the results were 34.7%, 35%, and 69.7% for hand
hygiene complete adherence rate (HHCAR), hand hygiene partial adherence rate (HHPAR), and hand hygiene
adherence rate (HHAR), respectively. The HHCAR in the pre-intervention and post-intervention phases
were 3% and 70.1%, respectively. HHCAR was highest among nurses (3.6% in the pre-intervention phase
and 80.7% in the post-intervention phase). Other findings were that senior physicians had better HH com-
pliance than junior physicians; in the pre-intervention phase, the HHCAR was better in the evening (4.8%);
in the post-intervention phase, the HHCAR was better in the morning (72.1%); women had a higher HHCAR
than men; and in the pre-intervention phase, good compliance was seen with Moments 2 and 3 of the
World Health Organization’s (WHO) Five Moments for Hand Hygiene, whereas in the post-intervention
phase, good compliance was seen with Moments 3, 4, and 5. Questionnaire-based data were also ana-
lyzed to assess KAP of HH. We found that only 55%-82% of HCWs were aware of the WHO’s Five Moments
for Hand Hygiene. In the post-intervention phase, we observed a significant improvement in KAP of the
study group.
Conclusion: Significant improvement in HH compliance can be achieved through a systematic, multidi-
mensional intervention involving all types of HCWs.
© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier
Inc. All rights reserved.

* Address correspondence to Apurba Sankar Sastry, MD, DNB, MNAMS, PDCR,
Department of Microbiology, Jawaharlal Institute of Postgraduate Medical Education
and Research (JIPMER), Pondicherry 605006, India.
E-mail address: rapurbasastry@gmail.com (A.S. Sastry).
We declare that all authors have seen and approved the final version of the manu-
script being submitted. The article is the authors’ original work, has not been published
previously, and is not under consideration for publication elsewhere.
The work was done at:
Department of Microbiology, Hospital Infection Control Committee (HICC),
Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India.
BACKGROUND
Hand hygiene (HH) is recognized as the most effective means
of reducing healthcare-associated infections (HAIs). Various studies
worlwide have shown that improving compliance with HH prin-
ciples is achieved by target-specific active interventions. The World
Health Organization (WHO) has enumerated various methods of
measuring HH practices, such as direct observation, the measure-
ment of product use, the conduct of surveys, patient-centered

0196-6553/© 2018 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajic.2017.12.017
776 A.M. Laskar et al. / American Journal of Infection Control 46 (2018) 775-780
surveillance, and the use of electronic modalities, of which direct
observation is considered the gold standard practice. Conducting
surveys on knowledge, attitude, and practice (KAP) will help idenify
gaps and plan for target-based interventions.1
Most patients in intensive care units (ICUs) are
immunocompromised and require long-term supportive care. They
are on devices such as ventilators, urinary catheters, and central lines,
which make them more susceptible to HAIs, thus making ICUs the
epicenters of infection. Therefore, strict HH practices will help reduce
patient morbidity and mortality.2 Continuous education and train-
ing is the most commonly followed approach to increase awareness
and improve HH compliance. Multimodal interventions, such as
training, questionnaires, audits of HH compliance among health-
care workers (HCWs), and reward and punishment systems, are
required to increase HH compliance and reduce HAIs.
This study measured differences in HH compliance prior to and
after a variety of multimodal interventions, including classes and
case scenario discussions, visual reminders, and practical
demonstrations.
METHODOLOGY
This was a prospective interventional study, conducted in 2 ICUs
of a tertiary care hospital with a total occupancy of 12 beds each.
The duration was from August 2016 to October 2016 (3 months).
The study encompassed 3 phases: pre-intervention (20 days), in-
tervention (1 month), and post-intervention (20 days). A total of 53
HCWs, including physicians (ie, faculty, residents, and interns),
nurses, and housekeeping staff, particpated in the audit.
The audit form used in our study was designed based on a WHO
HH audit toolkit.3 The observer was given baseline training on the
WHO Five Moments for Hand Hygiene. He was taught to audit HH,
and then he evaluated using the case scenarios and videos. During
the observation period, the observer recorded 3 elements: HH op-
portunities available to the HCWs, complete HH actions performed
by the HCWs, and partial HH actions performed by the HCWs. Fol-
lowing all the steps of hand rub or hand wash as recommended by
the WHO was considered as completely followed; following fewer
than all the steps was considered as partially followed. Hand hygiene
complete adherence rate (HHCAR), hand hygiene partial adher-
ence rate (HHPAR), and hand hygiene adherence rate (HHAR) were
calculated using standard formulas.1
No. of times hand hygiene
followed completely
HHCAR = × 100
No. of opportunities of hand hygiene
moments available
No. of times hand hygiene
followed partially
HHPAR = × 100
No. of opportunities of hand hygiene
moments available
No. of times hand hygiene
followed (complete + partial)
HHAR = × 100
No. of opportunities of hand
hygiene moments available
Attempts were made to calculate the following: profession-
specific HHCAR (physicians, nurses, and housekeeping staff); the
influence of professional experience on HH compliance among phy-
sicians and nurses (ie, senior vs. junior); sex variation (men vs.
women); and HH practice during all 3 shifts (morning, evening, and
night). The Moment-specific HHAR (complete and partial togeth-
er) for each of the 5 WHO HH Moments was also calculated.
To ensure reliability of the audit and to minimize bias associ-
ated with direct observation, the following measures were taken:
i) the auditor received prior training; ii) the audit was carried out
in a random schedule of the day, thus obviating the confounding
bias of work pressure influencing HH compliance; and iii) the ob-
server was involved in all 3 phases of the audit, thus eliminating
interobserver variation.
Pre-intervention phase
Baseline HHCAR, HHPAR, and total HHAR were analyzed by the
observer. Questionnaires given to HCWs assessed baseline KAP of
HH, based on which multimodal interventions were planned in the
intervention phase.
Intervention phase
Based on the results of the pre-intervention phase, multimodal
strategies were developed. Potential shortcomings were analyzed
and discussed with internal infection control experts, and media-
tion measures were devised. Education and extensive training on
HH practices were given to all participants by multiple approaches.
Classes were given to all HCWs, emphasizing the adverse effects on
patients if HH principles are not followed. The WHO Five Moments
for Hand Hygiene were explained and demonstrated to all HCWs.
Charts of WHO-recommended Moments and steps of HH were dis-
played in all ICUs, wards, and near all wash sinks. Whenever an HCW
forgot to practice HH, he or she was reminded to follow HH pro-
tocols. Additional HH practices were thoroughly monitored and
strengthened by one-on-one interactions. Also, since housekeep-
ing staff members play an important patient care role, interventional
sessions were tailored, taking into account their educational back-
ground and language restrictions, to ease the learning process.
Post-intervention
The effect of interventional strategies was analyzed by measur-
ing the HHCAR, HHPAR, and HHAR. Questionnaires were also given
to the participants to measure changes in KAP.
STATISTICAL ANALYSIS
HHCAR and HHPAR were expressed in frequency and percent-
age. Comparison of HHCAR and HHPAR between the pre-intervention
and post-intervention phases was carried out using the chi-
square or Fisher exact test. Shift-specific, sex-specific, profession-
specific, and Moment-specific compliance were compared using the
χ2 test or Fisher exact test, using Epi Info software (version 6). For
the questionnaire-based study, the same statistical tests were used
for comparison. All statistical analyses were carried out at a 5% level
of significance, and P values less than .05 were considered statis-
tically significant.
RESULTS
A total of 53 HCWs were audited during the study period. A total
of 6350 HH opportunities were recorded during the study period.
The HHCAR, HHPAR, and HHAR were 34.7%, 35%, 69.7%, respective-
ly, as depicted in Table 1. HHCAR in the pre-intervention and post-
intervention phases were 3% and 70.1%, respectively, reflecting a
dramatic improvement in HH compliance. Notably, a decrease in
HHPAR was observed from 47.2% in the pre-intervention phase to
21.4% in the post-intervention phase. These findings further show
the significant effect of interventional modalities on study partici-
pants (P<.001).
 A.M. Laskar et al. / American Journal of Infection Control 46 (2018) 775-780
Table 1
Overall hand hygiene practice among all healthcare workers
Hand hygiene Moments Hand hygiene completely
available followed
Pre-intervention 3351 101
Post-intervention 2999 2103
Total 6350 2204
HHCAR, hand hygiene complete adherence rate; HHPAR, hand hygiene partial adherence rate; HHAR, hand hygiene adherence rate.
Fig 1. Profession-specific hand hygiene compliance
Figure 1 depicts profession-specific HH compliance among the
HCWs. In our study, HHCAR was highest among nurses (3.6% in the
pre-intervention phase and 80.7% in the post-intervention phase),
followed by physicians (2.3% in the pre-intervention phase and 50%
in the post-intervention phase). We also observed a dramatic in-
crease in HH compliance among housekeeping staff, from 2.8% in
the pre-intervention phase to 89.8% in the post-intervention phase.
In our analysis of professional experience (ie, junior vs. senior in-
fluence on HH compliance), we found no significant differences in
HHCAR between junior and senior nurses. Among physicians, senior
physicians demonstrated better HH compliance than junior phy-
sicians (P<.001). We further studied the effects of sex variables on
HH compliance and found that women (3.8% in the pre-intervention
phase and 78.2% in the post-intervention phase) had a higher HHCAR
than men (2.2% in the pre-intervention phase and 62.1% in the post-
intervention phase) (P<.05).
Diurnal variation in HH compliance was also studied (Figure 2).
We found that in the pre-intervention phase, HHCAR was slightly
better during the evening shift (4.8%) than during the morning (2%)
and night shifts (1.9%). In the post-intervention phase, HHCAR was
better during the morning shift (72.1%) than during the night (68.8%)
and evening (67.5%) shifts (P<.001). Moment-specific HH adher-
ence is shown in Figure 3. In the pre-intervention phase, good
compliance was observed with Moments 2 and 3 (51.2% and 48.2%,
respectively) compared to Moments 1, 4, and 5. In the post-
intervention phase, good compliance was observed with Moments
3, 4, and 5 (93.5%, 93%, and 92.7%, respectively) compared to
Moments 1 and 2 (P<.001). Overall, significant improvement was
observed in terms of compliance with all WHO Moments.
Questionnaire-based data were analyzed to assess KAP of HH
among HCWs. In the pre-intervention phase, we found that HCWs
had poor knowledge regarding the importance of strict HH com-
pliance, the WHO Five Moments for Hand Hygiene, and indications
and procedures for hand wash and hand rub. We found that only
55%-82% of HCWs were aware of the WHO Five Moments for Hand
Hygiene and the procedures and indications for hand rub and hand
777
Hand hygiene partially
followed Hand hygiene not followed HHCAR (%) HHPAR (%) HHAR (%)
1582 1668 3.0 47.2 50.2
641 255 70.1 21.4 91.5
2223 1923 34.7 35.0 69.7
wash. Only 55% of HCWs were aware of the effectiveness of HH prac-
tices in preventing HAIs. Many HCWs had never received formal
training on HH practices. Furthermore, considerable gaps existed
in terms of interpersonal motivation to adhere to HH practices. Pit-
falls were thoroughly analyzed, and interventional strategies were
devised. In the post-intervention phase, we found significant im-
provements in the KAP of study participants (Table 2).
DISCUSSION
HH practice is a key to patient safety and the cornerstone of ef-
fective hospital infection control. HH compliance is suboptimal in
clinical settings, and improving HH compliance and sustaining it
remains a significant challenge. An HH audit by direct observation
is considered the gold standard method to monitor HH compliance.4
In our study, the observer recorded 3 elements during the obser-
vation period: HH opportunities available to the HCWs, HH steps
completely followed by the HCWs, and HH steps partially fol-
lowed by the HCWs. Following all hand rub or hand wash steps as
recommended by the WHO was considered completely followed;
following fewer than all the steps was considered partially fol-
lowed. The WHO states that HH is an all-or-nothing phenomenon;
in other words, following all steps is mandatory, and partial HH has
no value on infection control.5 However, we measured partial ad-
herence so as to motivate and encourage HCWs to convert partial
adherence to complete adherence. In our study, we observed a base-
line HHCAR of only 3.0% and a baseline HHPAR of 47.2%. Consistent
with our study, Rosenthal et al., in a systematic review, reported a
low baseline of 17% HH compliance in 3 Argentinean hospitals and
a low overall median compliance.6 Studies conducted by Ashu et
al. and Venkatesh et al. showed that HHAR in the pre-intervention
phase was 29.5% and 36.3% respectively.7,8 To identify the pitfalls,
assess the KAP of HCWs on HH practice, and make HH a part of stan-
dard routines, we developed and analyzed a questionnaire. In the
questionnaire survey carried out in the pre-intervention phase, we
identified factors that affect the hand-washing behavior of HCWs.
778 A.M. Laskar et al. / American Journal of Infection Control 46 (2018) 775-780

Fig 2. Diurnal variation (shift-specific hand hygiene compliance)

Fig 3. Moment-specific hand hygiene compliance rate

Beliefs and perceptions needed to be changed to improve the per-
formance of HH practice. We found that many HCWs lacked basic
knowledge about HH Moments; about indications and methods of
performing hand wash and hand rub; and about appropriate use
of gloves in patient care. HCWs did not assist their colleagues by
reminding them to perform HH; thus, there was no positive envi-
ronment that encouraged HCWs to make HH the norm. During their
initial work period, many HCWs had not received basic training on
HH. A similar survey, in the form of a self-report questionnaire, was
conducted by Pittet et al. among physicians of a large university
hospital.9 This survey assessed KAP and found that only 65% of phy-
sicians had a good knowledge of HH indications, and 67% perceived
HH as a difficult task.
In 2005, the WHO World Alliance for Patient Safety launched a
campaign, the First Global Patient Safety Challenge—“Clean Care is
Safer Care”—aiming to improve HH in healthcare. This campaign pro-
motes a multimodal strategy consisting of 5 components: system
change, training and education, observation and feedback, remind-
ers in the hospital, and hospital safety climate.1 Based on these
aspects and after analyzing results in the pre-intervention phase,
we designed a multifaceted educational training program.
Srigley et al. enumerated various other types of HH interven-
tions, such as obtaining feedback from HCWs, analyzing the effects
of HCW KAP on HH, providing visual reminders, providing pocket
hand rubs to HCWs, and conducting patient-centered education.10
In our study, we used 3 modalities—education, visual reminders,
 A.M. Laskar et al. / American Journal of Infection Control 46 (2018) 775-780 779

Table 2 of 23% among physicians compared to 52% among nurses.9 Karaaslan

Questionnaire to assess knowledge, attitude, and practice of hand hygiene among et al. reported a similar finding (41% among nurses and 31% among
healthcare workers (P<.05)
physicians).16 Our root-cause analysis of non-compliance among phy-
Correct responses (%) sicians revealed that most non-compliers were junior physicians
Knowledge-based questions Pre-intervention Post-intervention (interns or postgraduates). In our study, HHCAR and HHPAR among
WHO-assigned hand hygiene Moments 22 (55) 40 (100) junior physicians during the pre-intervention phase were 2.2% and
Duration of hand rub and hand wash 24(60) 40 (100) 35.6%, respectively; in the post-intervention phase, HHCAR and
application HHPAR among junior physician were 45.9% and 33.8%, respective-
Indication of hand wash and hand rub 33 (82.5) 40 (100) ly. This could be because junior physicians get more patient contacts
Effectiveness of HH practices in 22 (55) 29 (72.5)
preventing HAIs
and have more HH opportunities, hence less compliance. We ana-
Partial compliance is not effective 26 (65) 35 (87.5) lyzed the effect of professional experience on HH compliance among
Transmission of MDR pathogens in 31 (77.5) 38 (95) nursing staff, and we found that HHCAR was slightly better among
hospital junior nursing staff.
Indications for glove use and glove 21 (52.5) 33 (82.5)
Given the paucity of data on diurnal variation of HH, we studied
removal
Attitude- and practice-based questions HH compliance during all 3 shifts (morning, evening, and night) in
Motivated to follow HH due to 30 (75) 36 (90) both the pre-intervention and post-intervention phases. We ob-
continuous audit served that HH compliance dropped significantly among HCWs on
Your colleague reminds you if you 8 (20) 15 (37.5) the night shift compared to HCWs on the day shift. Similar to our
forget to follow HH and vice versa
Awareness of trophy for the best HH 28 (70) 31 (77.5)
study, Sahay et al.17 and Suzuki et al.18 observed that HH was lower
practice circulated during the night shift. They concluded that this higher frequency
Patient education will enhance the HH 5(12.5) 21 (52.5) of HH neglect at night could be explained by a lack of supervision
practices of HCWs to monitor HH compliance. HCWs on the day shift had more work
Presence of observer influences your 13 (32.5) 2 (5)
pressure and more patient contact, whereas HCWs on the night shift
HH practice during audit
Receiving formal educational training 18 (45) 30 (75) did not have proper supervision and were not subject to routine HH
on HH earlier audits. In our study, we did not find a significant difference in diurnal
Role model helps others to follow 31 (77.5) 34 (85) HH compliance. However, overall, we found that, in the pre- inter-
better HH practices vention phase, HHAR was slightly better during the evening shift;
HAI, healthcare-associated infection; HH, hand hygiene; MDR, multidrug resistant; we also found that, during the post-intervention phase, HHAR was
WHO, World Health Organization. slightly better during the morning shift.
Additionally, we analyzed sex differences in HH compliance and
found that women demonstrated better HH compliance than men.
and practical demonstrations—during the intervention period. Ed- Consistent with our study, Van de Mortel et al.19 reported that female
ucation was given by infection control experts after educational critical care unit staff washed their hands significantly more often
modules were developed, based on the needs of all HCWs. Visual than their male counterparts. Also, Zimakoff et al. found that female
reminders were placed in the ICUs to reinforce the practice. HH prac- HCWs reported handwashing more frequently.20
tice was monitored during the intervention phase; and many The Five Moments for Hand Hygiene concept has been consis-
practical demonstrations were given to demonstrate the practice, tently emphasized by the WHO.5 The “before” indications (Moments
such as training on common aseptic procedures routinely con- 1 and 2) are intended to protect patients from the risk of microbi-
ducted in ICUs, including venipuncture, insertion of urinary catheters, al transmission from HCWs, whereas the “after” indications
and giving intravenous and intramuscular injections. In a study by (Moments 3, 4, and 5) are intended to reduce the risk of microbial
Lam et al., HH compliance before and after the implementation of transmission from patients or the environment to HCWs. We ob-
a multimodal intervention program in a neonatal ICU showed sig- served that HH compliance before and after an aseptic procedure
nificant improvement. 11 Similar interventional studies were was better than other WHO-enumerated Moments. In the post-
conducted by Patel et al.12 and Moghnieh et al.13 intervention phase, an overall increase in HH compliance was
The intervention strategies employed in our study significantly observed in all Moments; but “before” HH Moments were fol-
improved HH compliance rates in almost all of the categorical vari- lowed less frequently than “after” Moments. This finding is similar
ables studied. In the post-intervention phase, we observed very good to ones reported by Lam et al., who found that HH compliance both
improvement in the KAP of HCWs, which also reflected on their HH before and after implementation of a multimodal intervention
practice in routine healthcare. Similar multimodal interventions can program in a neonatal ICU improved from 40% to 53% before patient
be extrapolated to various sectors of healthcare and can make HH contact and from 39% to 59% after patient contact.11 The reason could
practice the norm for all HCWs, thus reducing HAIs. In the post- be the attitude of HCWs: HCWs tend to practice HH more when they
intervention phase HH audit analysis, we observed a significant are at risk of contracting microorganisms from patients, but they
increase in the HHCAR (3% and 70% in pre-intervention and post- often forget or ignore HH practices when it is the patients who are
intervention phases, respectively). This significant difference can be at risk of contracting microorganisms from the HCWs themselves.
attributed to the effective interventions given during the study period HCWs should be educated about the importance of every HH
and the elaborate practical discussions that addressed all identi- Moment, and HH compliance during the full sequence of health-
fied gaps. We also observed a significant shift from partial to care delivery should be emphasized in a compact “Five-Moment”
complete adherence, which is depicted in Table 1. Similar post- concept.
intervention findings were reported by Mu et al., showing an HHAR
of 75.90%,14 and by Avila-Aguero et al., showing an HHAR of 74%.15
Profession-specific HH compliance was analyzed in both the pre- CONCLUSION
intervention and post-intervention phases. In the pre-intervention
phase, the highest HHCAR was among nurses (pre-intervention: 3.6%; Our study demonstrated that significant improvements in HH
post-intervention: 80.7%), followed by physicians and housekeep- compliance can be achieved through a systemic, multidimen-
ing staff. Consistent with our study, Pittet et al. observed a compliance sional intervention approach involving all types of HCWs in a hospital
780 A.M. Laskar et al. / American Journal of Infection Control 46 (2018) 775-780
setting, which may result in a decrease of the HAI rate. We found
that HH practices are abysmally low among most HCWs working
in ICUs. However, intervention strategies, such as the ones we em-
ployed, effectively improved HH compliance in our ICUs, and these
improvements were consistently seen among almost all HCW groups.
Our results can be easily duplicated in other ICUs across the country
if similar interventional strategies are employed.
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