Factors Associated With Hand Hygiene Compliance at a Tertiary Care Teaching Hospital

Benjamin Kowitt, MD; Julie Jefferson, RN, MPH; Leonard A. Mermel, DO, ScM


Infect Control Hosp Epidemiol. 2013;34(11):1146-1152. 

In This Article

Abstract and Introduction


Objective. To identify factors associated with hand hygiene compliance during a multiyear period of intervention.

Design. Observational study.

Setting. A 719-bed tertiary care teaching hospital.

Participants. Nursing, physician, technical, and support staff.

Methods. Light-duty staff performed hand hygiene observations during the period July 2008–December 2012. Infection control implemented hospital-wide hand hygiene initiatives, including education modules; posters and table tents; feedback to units, medical directors and the executive board; and an increased number of automated alcohol hand hygiene product dispensers.

Results. There were 161,526 unique observations; overall compliance was 83%. Significant differences in compliance were observed between physician staff (78%) and support staff (69%) compared with nursing staff (84%). Pediatric units (84%) and intensive care units (84%) had higher compliance than did medical (82%) and surgical units (81%). These findings persisted in the controlled multivariate model for noncompliance. Additional factors found to be significant in the model included greater compliance when healthcare workers were leaving patient rooms, when the patient was under contact precautions, and during the evening shift. The overall rate of compliance increased from 60% in the first year of observation to a peak of 96% in the fourth year, and it decreased to 89% in the final year, with significant improvements occurring in each of the 4 professional categories.

Conclusions. A multipronged hand hygiene initiative is effective in increasing compliance rates among all categories of hospital workers. We identified a variety of factors associated with increased compliance. Additionally, we note the importance of continuous interventions in maintaining high compliance rates.


Hospital-acquired infections have a far-reaching impact on healthcare in the United States. In 2004, they accounted for approximately 99,000 deaths, affecting 1.7 million patients, with a total cost of $6.5 billion to the healthcare system.[1] Hand hygiene is considered the most important measure in preventing these infections.[2] However, adherence of healthcare workers to recommended hand hygiene practices has been poor, ranging from 5% to 89%, with an overall average under 40%.[1]

Many factors have correlated with poor hand hygiene compliance. Observational factors from bivariate and multivariate analysis include being a physician versus being a nurse, intensive care unit (ICU) and surgical unit setting versus medical unit setting, wearing gown and gloves, before patient contact versus after patient contact, performing high-risk activities, weekdays versus weekends, having a high number of opportunities for hand hygiene per hour, and overcrowding or understaffing.[3–11] Self-reported factors include irritation and dryness, inconvenience secondary to lack of sinks or supplies, insufficient time, low perceived risk, and forgetfulness.[12,13]

Several interventions have been implemented by hospitals to improve hand hygiene compliance. These generally fall into the categories of increased accessibility through the use of alcohol rub dispensers compared with soap and water,[14–16] education,[17] and direct feedback.[18,19] Most successful programs have included a combination of all three.[3]

The objective of our study is to identify factors associated with hand hygiene compliance in our hospital during a 5-year period of intervention. Specifically, we focus on differences by professional category and how they persist over time.