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


Our study shows an increase in hand hygiene compliance over the 5 years of observation and intervention. The hospital-wide rate increased from 60% in 2008 to a peak of 96% in 2011, with an average rate of 83%. This figure is at the upper end of levels reported in the literature.[1] We attribute this high compliance to the breadth and length of interventions as outlined in Table 1, which spanned almost the entire observation period, and to the strong likelihood of an observer effect. It is probable that observers were witnessed by healthcare workers and preferentially so by those who were most noncompliant. This is attributable to the fact that observers were instructed to record the names of noncompliant workers and frequently asked them their names directly. This is likely to have exacerbated the Hawthorne effect.

Our observations are similar to those of others in that nursing staff were more compliant than physician staff, although our adjusted OR for physician noncompliance was on the lower side compared with the findings of other studies.[3] Although we do not attempt to isolate the underlying cause for increased nursing compliance, hypotheses include the differences in workflow and patient contact; the frequency of hand hygiene opportunities for nurses; the increased opportunity cost of time for physicians; differences in education, employment structure, and stature; and differing responses to feedback. On the other hand, we find that both nursing and physician staff had similarly impressive improvements throughout the 5-year period, which differs from the findings of a study by Pittet et al[4] that saw large improvements for nurses but not physicians over the course of a hospital-wide program. Some of these differences from the literature may be attributable to our clustering of healthcare worker types. Finally, although there are limited published data regarding compliance among other professional categories, we found striking differences between technical and support staff, with technical staff mirroring nursing adherence, whereas support staff had the lowest compliance of any group. It is notable, however, that all hospital workers saw a large increase in compliance over the course of the intervention period.

Our findings regarding other risk factors for noncompliance mirror the established literature. The ICU and pediatric units performed better than medical units, although we differed from established results in finding that surgical units and medical units were statistically equivalent. Although our study did not control for level of activity, we found the least compliance during times of higher activity: weekdays (although this was not significant in the multivariate model) and daytime shifts. We found better compliance with hand hygiene when patients were under contact precautions, which is supported by studies demonstrating that higher risk perception increases compliance.[10] Finally, our study is in agreement with the literature in finding that hospital workers were more compliant to hand hygiene when leaving a patient room than when entering it.

There are significant limitations to our study. There is a strong likelihood of observer bias, because observation with identification and feedback was part of the intervention. The generalizability of this study may be limited. Although Rhode Island Hospital is a typical, large, urban, academic medical center, the extent and duration of observation and intervention may be difficult to duplicate in another hospital setting. There are limitations to our methods in obtaining hand hygiene data. We did not take into account technique or duration when measuring compliance. Also, we only monitor entrance into and exit from patient rooms, without monitoring the myriad of other hand hygiene opportunities that undoubtedly have an impact on reducing the risk of hospital-acquired infection.[20] We did not take into account the interobserver variability. However, this limitation is partially offset by observers being rotated through each unit in a semi-fixed fashion, creating some randomization of observations. Additionally, other factors, such as activity index, were not accounted for in our study. We did not track individuals over time, which could lead to skewed results if there were significant personnel shifts during the study period. Finally, we did not measure the volume of our chlorhexidine-based product available for hand washing, which may explain some discordance between observed hand hygiene compliance and the volume of our alcohol-based hand hygiene product used. Nevertheless, observed compliance and volume of alcohol-based hand hygiene product use per 1,000 patient-days increased from 60% and 31.1 L in 2008 to 89% and 46.9 L in 2012.

The uniqueness of our study includes the duration of observation (most studies are cross-sectional points in time or months after an intervention) and the size of the study. In addition, we believe this to be one of the few studies to include technical and support staff with nursing and physician staff.

In conclusion, this study finds strong evidence that a multidimensional hand hygiene initiative is effective in significantly increasing compliance rates for all healthcare workers, regardless of profession. Equally important is the continuous nature of intervention and observation, which likely helped garner such improved compliance. The literature often identifies the temporary nature of improvements from one-off initiatives, and, in fact, we noted a decrease in compliance in the final year of observation coinciding with the end of new initiatives. Additionally, this study helps to identify factors correlated with noncompliance, which may assist other hospitals to focus on specific areas of weakness and perhaps on hospital staff who may not generally be the target of hand hygiene campaigns.