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


The Department of Epidemiology and Infection Control implemented a hospital-wide set of hand hygiene initiatives, including increased awareness through 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 (Table 1). There were 161,526 unique observations over 54 months, with a total compliance rate of 83%. The majority of observations (78%) were of nursing staff, followed by physician staff (10%), with technical staff and support staff making up the remainder. Observations were better distributed among units, with medical units having the highest count (30%) and pediatric units having the lowest count (10%).

There were a variety of factors that showed compliance differences to a level of statistical significance (Table 2). Compliance rates among nursing staff (84%) and technical staff (85%) were both greater than among physician staff (78%). Support staff were the least compliant (69%). Staff in pediatric units and the ICUs were more compliant (84% and 84%, respectively) than staff in medical and surgical units (82% and 81%, respectively). Lower hand hygiene compliance was observed before entering a patient room (80%) than after leaving it (86%). Higher compliance was also seen when a patient was under contact precautions (85% vs 83%). Compliance was progressively higher from day (80%) to evening (84%) to night (90%). Weekends (84%) were associated with slightly better rates than weekdays (83%). Finally, hand hygiene compliance improved for each of the first 4 years of observation, from a low of 60% in 2008, to a peak of 96% in 2011, with a final compliance rate of 89% in 2012. Each year's compliance was statistically different from that for the previous year. Of note, the total volume of alcohol-based hand hygiene product use per 1,000 patient-days was 31.1 L, 26.8 L, 26.9 L, 36.5 L, and 46.9 L during 2008, 2009, 2010, 2011, and 2012, respectively.

Distribution of observations among units was similar, although the highest proportion came from medical units for nursing staff, as opposed to the ICU for physician staff (Table 3). The majority of physician staff were observed on day shifts (66%), unlike nursing staff (41%). Both professions had significantly higher compliance in pediatric units and the ICU. Both were more compliant after leaving a patient room, when the patient was under contact precautions, and on weekends. Physicians were least compliant during the evening shift, whereas nurses followed the overall pattern of increased compliance through the 3 shifts from morning to night.

In the controlled model, physician staff had higher odds of being noncompliant than did nursing staff (OR, 1.3 [95% CI, 1.2–1.3]; Table 4). Support staff had the highest odds compared with nursing staff (OR, 2.1 [95% CI, 2.0–2.3]), whereas technical staff was equivalent to nursing staff. In terms of location, the ICU and pediatric units had lower odds of being noncompliant than did medical units. Surgical units were again similar to medical units. This model also showed lower odds of noncompliance when leaving a patient room (OR, 0.66 [95% CI, 0.64–0.68]) compared with entering it, lower odds when a patient was under contact precautions (OR, 0.77 [95% CI, 0.74–0.80]), and lower odds the later the shift. There was no difference in the odds of noncompliance when working weekends versus weekdays. Finally, the month and year of the observation period were significant. There was a small yet protective effect for each subsequent month (OR, 0.96 [95% CI, 0.95–0.96]). In a separate multivariate model that substituted a year counter for a month counter, we see a larger effect (OR, 0.58 [95% CI, 0.57–0.58]).

Figure 1 shows the hand hygiene trend of each professional category during the 5 years of observation. There was a large difference in terms of starting compliance rates, with support staff having the lowest compliance (33%), followed by physician staff (47%), nurse staff (62%), and technical staff (71%). Although physician staff had a lower starting compliance than nursing staff, they surpassed nursing staff in year 2, but then they had a flatter trajectory through the final 3 years of observation. Nursing staff, on the other hand, had a more consistent increase throughout the study period. Additionally, it is notable that each professional category reached its peak level of compliance in 2011, before decreasing slightly. Finally, there is a significant pattern of convergence of rates among professional categories, with the range from year 1 (38%) dwarfing that of years 4 (6.1%) and 5 (6.9%).

Figure 1.

Hand hygiene compliance over time by professional category.