Asssigment

American Journal of Medicine and Medical Sciences 2016, 6(1): 7-15

DOI: 10.5923/j.ajmms.20160601.02

Hand Hygiene and Health Care Associated Infection:

An Intervention Study

Slimah N. Abdraboh 1 , Waleed Milaat

1 , Iman K. Ramadan

1,2,* , Fatin M. Al-Sayes

3 , Khaled M Bahy

4

1Community and Family Medicine Department, Faculty of Medicine, King AbdulAziz University, Jeddah, Saudi Arabia 2Community Medicine Department, Faculty of Medicine (for girls), Al-Azhar University, Cairo, Egypt

3Hematology Department, Faculty of Medicine, King AbdulAziz University, Jeddah, Saudi Arabia 4Faculty of Pharmacy, Cairo University, Cairo, Egypt

Abstract Background: Healthcare-associated infection accounts for more deaths. There are millions spent annually as a

direct cost, yet these infections are frequently preventable through hand hygiene. Although the hand hygiene is a relatively

simple procedure, health care workers` compliance remains a major pitfall and a complex phenomenon that is not easily

changed. To our knowledge, there are no published researches on hand hygiene knowledge and compliance changes after an

intervention in King Fahd Armed Forces Hospital. Aim: The current research investigated hand hygiene knowledge and

compliance among HCWs for the period of six months. Methods: A three-phase intervention study was conducted among all

health care workers at King Fahd Armed Forces Hospital, using WHO structured self-administered questionnaire and

Observation checklist, during the period from September 2014 to May 2015. Results: four hundred and eighty health care

workers were invited and completed the study, with a response rate of 100%. Females constituted 78.3% of the population.

More than half of HCWs (51.9%) were married. 85.2% of the HCWs were non- Saudi and two third with nursing background.

Gender, department, baseline knowledge, and knowledge following three months of intervention were significantly

associated with hand hygiene compliance. Conclusions: Hand hygiene improvement is affordable, and effective in

healthcare setting, and a prolonged approach of education intervention and continuous observation results in improving hand

hygiene knowledge and compliance.

Keywords Hand Hygiene and Health Care

1. Introduction

Healthcare-associated infection (HCAI) is a serious

burden disease for patient safety and should be promoted as a

first priority for prevention and making healthcare settings

safer. There are lots of impacts belonged to HCAI like

prolonged hospital stay, long term disability, spread of

antimicrobial resistant organisms, in addition to financial

burdens, high risk of deaths, and extra costs for the health

setting. [1] The Center of Disease Control CDC defined

acute care HCAI as “a localized or systemic condition

resulting from an adverse reaction to the presence of an

infectious agents or its toxins”. “The infection should be

neither present nor at the incubation period at the time of

admission to the Intensive care setting.” [2]

Hundreds of millions of patients around the world each

year were affected by HCAI. [1] Therefore, HCAI remained

a big concern that no organization or country can claim to

have solved as yet.

* Corresponding author:

[email protected] (Iman K. Ramadan)

Published online at http://journal.sapub.org/ajmms

Copyright © 2016 Scientific & Academic Publishing. All Rights Reserved

In developed countries, 5–15% of hospitalized patients

were at risk to acquire infection particularly those admitted

to intensive care units (ICUs). [1] Recent European study

reported wide prevalence of hospital acquired infection

(4.6% - 9.3%). [3] Also, in USA the estimated HCAI

incidence rate was 4.5%. [1]

On the other hand, in developing countries the prevalence

study was carried out in Albania, Morocco, Tunisia and the

United Republic of Tanzania, reported that HCAI was

ranged between 19.1% and 14.8%. [4] Recently a study

conducted in Saudi Arabia, Riyadh reported 8% HAI. [5]

Fortunately, researchers reported that between 20% and

40% of HCAIs are preventable. [4] Hand hygiene at five

moments is considered as the easiest way to anticipate the

dissemination of infection. However, improving hand

washing compliance and maintain this behavioral change is a

significant challenge, because of the complexities of the

health care environment and changing behavior. [6]

Now it is recommended to practice hand hygiene as a

basic for infection control for the sake of assuring patients.

Though, increasing patient morbidity and mortality could be

joined to the worldwide emergence and morbid

dissemination of multidrug resistant pathogens. [7]

“Hand hygiene is a general term that applies to routine

8 Slimah N. Abdraboh et al.: Hand Hygiene and Health Care Associated Infection: An Intervention Study

hand washing, antiseptic hand wash, antiseptic hand rub, or

surgical hand antisepsis.” [8]

Although, it has long been recognized that effective hand

hygiene was the crucial action to decrease the spread of

infection in health care settings. Several studies, have

reported that compliance to hand hygiene remains inefficient

and needs corrective actions to be sustained. Therefore, the

World Health Organization WHO, the CDC, have

announced guidelines for hand hygiene among health care

providers. [9]

Although this simple procedure is very essential, it is not

properly recognized by Healthcare workers HCWs, and a

unsatisfactory compliance has been declared. [10]

Hand hygiene link group defined nine controlled studies,

reporting sound markdown in infections, same in highly

infected places like intensive care units. Hand hygiene also,

documented in reduction of transmission of

Health-care-associated gram negative pathogen. [11]

Therefore in 2005, World Health Organization floated the

“First Global Patient Safety Challenge - Clean Care is Safer

Care” aimed for global reduction of HAIs. Later, “SAVE

LIVES: Clean Your Hands” initiative was declared to

accentuate the role of hand washing in preventing health

related infections. [12] For the sake of standardizing the

optimum application of hand wash procedure, an approach

was applied to distinguish, prepare, audit and address

adherence to hand hygiene. [12] This standard was

formulated as “My five moments for hand hygiene” which

recognizes the basic points for health care providers and

enforce when there is need for hand washing to breakdown

the infection chain during taking care of patients. [11, 12]

Several studies reported inadequate adherence to hand

hygiene among healthcare providers (25% - 40%). [13, 14]

Despite that, systematic reviews of short-term non

randomized studies reported that feedback might be the most

successful intervention. [15, 16] Also, evidence from

systematic reviews of randomized controlled trials, declared

that feedback essentially improves healthcare workers’

compliance with other evidence-based guidelines. [17, 18]

In 2011 an audit was carried out in 36 hospitals reported

74.7% as the average hand hygiene compliance score for all

healthcare workers. Five months later they published the

analyzed results from 42 hospitals and found that the average

compliance had increased to 79.6%. [19]

Education on proper methods of hand hygiene is the clue

for dramatic reduction in the infection rate. A survey found

an improved had hygiene knowledge for nurses in Singapore,

after receiving comprehensive course of education. [20]

Therefore, hospitals should arrange an action plan for

departments that do not meet the target of hand hygiene

compliance. These plans should include organized

educational and training sessions and re-auditing until the

target is achieved. Basically, there are three ways for

investigating hand hygiene compliance; direct observation,

product use measurement and survey conduction. [21]

The gold standard among these methods is the direct

auditing of the practice of hand hygiene among health care

providers. Through, observation the used hand hygiene

products careful cleaning, used equipment and procedure for

dehydrating, used gloves, and providers performance in an

opportunity can be documented. In addition, observation

allows the observers to monitor the adherence to guidelines

and to recommend prompt feedback whenever improvement

is required. In contrast to these benefits, direct observation

could be expensive, needs careful selection and training of

the observers. [21]

Unfortunately, compliance to hand hygiene guidelines is

the lowest in critical care areas, however those patient are

highly vulnerable to infection. [22-24]

So, asserting healthcare workers` knowledge and

awareness grant them efficiently ameliorated compliance

with hand hygiene.

2. Subjects and Methods

A three-phase quasi experimental study was conducted

between September 2014 and May 2015. The study was

carried out in King Fahd Armed Forces Hospital (KFAFH)

in Jeddah. The hospital includes most major branches of

medicine and surgery in addition to other departments like an

intensive care unit, neonatology, and premature unit.

The study population included all healthcare workers of

King Fahd Armed Forces Hospital in critical care,

emergency, medical and surgical departments. Four hundred

eighty participants (100 physicians and 380 nurses) were

recruited. 57 from Intensive Care Unit (ICU) (11 physicians

and 46 nurses), 88 from Neonatal intensive care unit (NICU)

(35physicians and 53 nurses), 100 from Cardiac Intensive

Care Unit (CICU) (17 physicians and 83 nurses), 15 from

Pediatric Intensive Care Unit (PICU) (5physicians and 10

nurses), 132 from Emergency Room (ER) (32 physicians and

100 nurses), 50 nurses from Medical ward who deal with

critical care patients with competency of high dependent care,

and also 38 Surgical ward nurses. All health care workers

were identified by hospital ID.

The study was carried out through three phases:

● Phase I (1 month): The preintervention phase,

consisted of assessing HCWs' knowledge toward hand

hygiene and baseline compliance to hand hygiene at

the “World Health Organization’s (WHO) five

moments” by link nurse in each department. [1]

● Phase II (3 months): Intervention stage, comprised of

the following four suphases:

1. Designing and implementing the intervention,

based on the results of phase I. The intervention

included educational group presentations which

were adopted from WHO. [1] The intervention took

the form of lectures and training workshop. These

address the nessisity of hand washing, suggested

plans to enhance hand washing, and different ways

of observing hand hygiene. Continuos supply of

alcohol gel was guranteed throughout the study.

The reseracher conducted eight sessions with

American Journal of Medicine and Medical Sciences 2016, 6(1): 7-15 9

around 50 HCWs per session.

2. Immediate Posttest assessing knowledge level for

the same selected group of HCWs. It was the same

assessment questions of pre-test, and it was carried

out immediately after the educational intervention.

3. Immediate Observation of hand hygiene

compliance immediately after the educational

intervention through the link nurse who was trained

for optimum filling the observation checklist.

4. Feedback on baseline health care associated

infection rate.

● Phase III (1 month): postintervention follow up phase,

three months later after the intervention stage,

comprised of the following three substages:

1. Three months Post-test to assess knowledge level

three months after the educational intervention

among the same group of selected HCWs.

2. Observation of hand hygiene compliance three

months after the intervention through the link nurse.

3. Feedback on health care associated infection rates

three months after the intervention.

Study Instruments: ∎ Part I Structured self-administered questionnaire

consistingof the following two sections:

A. Basic Characterstics of the study population:

● Demographic data: Age, sex, nationality, marital status,

background, and years of experience.

● Department, work shift, number of patients served by

HCWs, attended training on hand hygiene, and sources

of their hand hygiene knowledge.

B. Questions assessing the knowledge of hand hygiene

adopted from valid reliable, WHO’s hand hygiene

questionnaire for health care workers [1]. This questionnaire

consists of seven questions; six multiple choice questions

and one “true” or “false” question.

The seven questions cover; Situations where hand hygiene

should be performed The efficient way to decrease number

of bacteria on the blood soiled hands, the most frequent

method of transmission of resistant baceria, infections which

could be dissminated between health care providers and

patients particularly when hand hygiene precautions were

not taken into consideration, effect of alcohol-based hand

hygiene products on Clostridium difficile, regular daily

pathogens that survive in the patients` environment, and

facts about alcohol-based hand hygiene products. Correct

answers were coded as one and incorrect answers were

coded as zero. The process of distributing the

self-administered questionnaire among the HCWs was

performed in a private room in the selected units, after

informing HCWs about the study objectives and obtaining

their written informed consent and ensuring the

confidentiality of dealing with data. ∎ Part II Hand Hygiene Observation Checklist. This

checklist was used during direct observation of

healthcare workers providing patient care in the

relevant department by well trained link nurse from

Infection Prevention and Control Department (IPCD).

Each link nurse was allocated to department and had a

uniform educational and training session on how to

observe hand hygiene compliance, and fill in the form

in the relevant department. Each time an observed

health-care worker entered the patient zone from the

health-care area the link nurse observe the “Five

Moments for Hand Hygiene”: before contact with

patient, or an aseptic procedure, after exposure to any

body fluid, after any contact with patient and his

environment. The assigned link nurse noted the

observed or missed hand hygiene actions associated

with these indications and documented the data by

scene and professional group, she also collected the

information during twenty minute sitting (more or less

than 10 min.) and did not observe more than three

health‐care workers simultaneously”.

In order to minimize the potential bias attributed to

variability in training, skills and experience of the link nurse,

the researcher used the following equation to calculate the

inter-rater reliability: Number of Agreements / (Number of

Agreements + Number of Disagreements). The link nurse

was considered to be consistent if she achieves an inter rater

reliability score ≥ 0.7. [6]

Compliance to hand hygiene through; using alcohol based

hand rubbing and hand washing practices were recorded

against the opportunities.

A pilot study was conducted on 10 HCWs (5 physicians

and 5 nurses) to clarify the applicability and suitability of the

questionnaire, identify difficulties that might be faced during

administration, and estimate the time needed for filling the

questionnaire. Overall, the questionnaire was suitable and

took 3 to 5 minutes on average and no items required

modification.

3. Ethical Considerations

The Ethical Committee at King Fahad Armed Forces

Hospital, and King Abdulaziz University, approved the

research. The permission of the head of each recruited

departemnt was obtained. Consent Form started with simple

explanation of the study aim. It confirmed the confidentiality

of data. It included the researcher phone number and all

possible communicating methods. It guaranteed the safe

withdrawal from the study without affection of the work. It

also, insured that all participants be informed about the study

results.

Statistical Analysis:

Data Coding was carried out manually and then fed to the

computer using STATA, version 13. Personal data that can

identify the personality of the participant (ID) were not

entered to data file to guarantee full confidentiality. The

researcher hired a data entry and then checked randomly

10 Slimah N. Abdraboh et al.: Hand Hygiene and Health Care Associated Infection: An Intervention Study

10% of entries for potential errors. The range, minimum and

maximum values, distributions and cross tabulations were

checked to ensure that all questions had valid codes and

values.

The continuous variable age was summarized as mean and

standard deviation. Frequencies and percentages were

reported for categorical demographic and background data

(gender, nationality, marital status, background, years of

experience, department, shift, number of served patients per

day, training attendance and source of hand hygiene

knowledge).

The outcome hand hygiene knoweldge was reported as a

score ranged between zero and seven, while the compliance

outcome was reported as compliant “1” and noncompliant

“0”.

The relationship between HCWs characteristics and

knoweldge score was tested using a t test; while for marital

status and sources of hand hygien knoweldge the resercher

used one way ANOVA.

The relationship between HCWs` characteristics and hand

hygiene compliance was tested using a chi square test for all

categorical variables

The relationship between three phases of knoweldge and

HCWs basic characteristics was tested using paired t- test.

The relationship between three phases of hand hygiene

compliance and HCWs characteristics was tested using a

McNemar test.

All p values were be two sided and the significance level

was be set at α=0.05.

Conditional Logistic Regression model was plotted to

examine the predictor variables for changes of HCWs` hand

hygiene compliance. The main model consisted of following

predictor variables: gender (male was the reference),

departemnt (ER was the reference), baseline knoweldge

andknoweledge three months after intervention.

Incidence rate ratio was calculated for the health acquired

infection rate at baseline and three months after the

intervention “HCAIs/person-days”.

4. Results

All 480 health care workers were invited and completed

the study, with a response rate of 100%. There were 132

(27.5%) HCWs from the ER, 100 (20.8)% from the CICU,

88 (18.3%) from the NICU, 57 (11.9%) from the ICU, 50

(10.4%) from the medical department, 38 (7.9%) from the

surgical department and only 15 (3.1%) from the PICU

(Figure 1). The average age was 35.5±5.4 years with a

median of 36 years and a range from 24 to 57 years. Females

constituted 78.3% of the sample population. More than half

of HCWs (51.9%) were married. Almost all of the HCWs

were non- Saudi (85.2%) and with nursing background

(79.2%). In terms of their years of experience, 72.2% were

had on average 5-10 years, 16.3% had more than 10 years

and only 11.0% had less than 5 years of experience. More

than half of HCWs (58.9%) were assigned for day shift work.

The majority serve from 5 to 10 patients per day compared to

20.2 % who served more than 10 patients per day. Almost all

HCWs (97.1%) were previously attended training courses

regarding hand hygiene practice and nearly the same

percentage (81.5%) reported that their knowledge towards

hand hygiene was gained through training courses. (Table 1)

HCWs baseline knowledge got statistically significantly

improved immediately and three months after implementing

educational intervention. On the other hand, when

comparing knowledge of HCWs immediately to three

month after intervention, their mean knowledge level

became a bit worse. All these changes are statistically

significant (p <0.001) however, clinically the magnitude of

difference between post-test and 3 month post-test was only

0.2 knowledge points. (Table 2)

Figure 1. Distribution of health care workers according to specialty

0

5

10

15

20

25

30

Percentage of HCWs

according to their specialty

American Journal of Medicine and Medical Sciences 2016, 6(1): 7-15 11

Table 1. Basic characteristics of the studied health care workers

Variable Mean SD

Age 35.5 5.4

N %

Gender Male 104 21.7

Female 376 78.3

Marital Status

Single 195 40.6

Married 249 51.9

Widowed 8 1.7

Divorced 28 5.8

Nationality Saudi 71 14.8

Non-Saudi 409 85.2

Hospital Staff Role Nurse 380 79.2

Physician 100 20.8

Years of Experience

< 5 53 11.0

5 – 10 349 72.7

>10 78 16.3

Work Shift Day 283 58.9

Night 197 41.1

Served Patients Per Day

5 – 10 382 79.6

11 – 20 25 5.2

>20 73 15.2

Source of Knowledge

Training Courses 391 81.5

Education 88 18.3

Internet 1 0.2

Training Attendance Yes 466 97.1

No 14 2.9

Table 2. Effect of educational intervention on health care workers` hand hygiene knowledge

Knowledge Mean ± SD T Test P

Baseline and Immediately after Intervention

Pre-test 4.9±0.06 - 26.7 < 0.001

Post-test 6.6±0.03

Baseline and three months after Intervention

Pre-test 4.9±0.06 - 21.5 < 0.001

Three months after Post-test 6.4±0.04

Immediately and three months after Intervention

Post-test 6.6±0.03 5.7 < 0.001

Three months after Post-test 6.4±0.04

The study showed that more than two third of hand

hygiene non-complaints HCWs (80.6%) became complaints

immediately after educational intervention. Also, It was

found that, two third of baseline non complaint HCWs

(66.1%) changed their behavior to be complaint three

months after implementation of educational intervention.

Moreover, the study concluded that; more than two thirds

(70.9%) of non-complaint HCWs immediately after the

intervention changed to practice hand hygiene three months

after the intervention. These differences are significant

statistically (p<0.001). (Table 3)

Gender, department, baseline knowledge, and knowledge

following three months of intervention were significantly

associated with hand hygiene compliance (p≤0.05). Controlling for other variables; females were two times more

likely to have a better compliance than males. NICU, ICU,

12 Slimah N. Abdraboh et al.: Hand Hygiene and Health Care Associated Infection: An Intervention Study

CICU, PICU and Medical HCWs were 35, 24, 12 and 4.6

times respectively more likely to have high hand hygiene

compliance compared to ER HCWs. Also, HCWs who had

good knowledge were 20% more likely to practice hand

hygiene. On the other hand, HCWs with good knowledge

three months after the intervention were 30% less likely

complaints to hand hygiene. (Table 4)

Regarding the changes in HCAI rates after the

implementation of intervention, it was revealed that, HCAI

rates non-significantly decreased after the implementation of

educational intervention (p>0.05) (Table 5)

Table 3. Implementation of educational intervention and changes of health care workers` hand hygiene compliance

Hand Hygiene

Compliance

Post-test

McNemar

Chi Square P Compliant Non-Compliant Total

Pre-test N % N % N %

Compliant 256 85.3 44 14.7 300 62.5

53.9 <0.001 Non-Compliant 145 80.6 35 19.4 180 37.5

Total 401 83.7 79 16.3 480 100

Three months after Post-test

Compliant Non-Compliant Total

Pre-test N % N % N %

11.2 <0.001 Compliant 227 75.7 73 24.3 300 62.5

Non-Compliant 119 66.1 61 33.9 180 37.5

Total 346 72.1 134 27.9 480 100

Post Test N % N % N %

18.1 <0.001 Compliant 290 72.3 111 27.7 401 83.5

Non-Compliant 56 70.9 23 29.1 79 16.5

Total 346 72.1 134 27.9

Table 4. Conditional logistic regression of hand hygiene compliance predictors

Variables Odds Ratio St Err Z P

Female 2.4 0.7 3.0 0.003

ICU 23.8 11.6 6.5 <0.001

CICU 11.8 3.9 7.4 <0.001

PICU 8.7 5.6 3.4 0.001

NICU 34.7 17.2 7.2 <0.001

Medical 4.6 1.7 4.2 <0.001

Surgical 1.2 0.5 0.4 0.7

Baseline knowledge 1.2 0.1 1.9 0.05

After intervention Knowledge 0.7 0.1 -2.3 0.02

Table 5. Health acquired infections among health care workers before and three months after the intervention

Before the

intervention

Three months after the

intervention Total

Number of HAIs 62 58 120

Inpatient days 38322 37635 75957

Incidence rate

(HAIs/person-days) 0.0016 0.0015 0.0016

Incidence Rate Ratio 0.95 P value 0.86

American Journal of Medicine and Medical Sciences 2016, 6(1): 7-15 13

5. Discussion

Despite proper hand hygiene compliance remains as a

backbone for HAIs prevention, lots of studies in a developed

and a developing countries continued to identify improper

compliance. The same dilemma is being faced at King Fahad

Armed Forces Hospital, Jeddah (KFAFH) which is a tertiary

hospital which serves as a referral center for all military

population in the western region in the Kingdom of Saudi

Arabia. An indefinite number of variables are related to

insufficient compliance with variable methods in auditing

and declaring depending on the available resources and

different settings. Defining the missed opportunities during

providing care to patient is absolutely necessary so can be

figured out for implementing a new policy.

It was deep-seated that the WHO campaign is efficient at

enhancing HCWs hand hygiene compliance and determined

definite interventions that effectively advance the hand

hygiene practices in hospitals, when appropriately

implemented appropriately. [25]

Although the hand hygiene is a relatively simple

procedure which only takes 60 seconds for hand wash and 20

to 30 seconds for hand rubs as recommended by the WHO,

HCWs` compliance remains a major pitfall and a complex

phenomenon that is not easily explained or changed. This is

obviously due to each time a healthcare worker stops to wash,

gel, or foam their hands, it takes only short time, though the

situations could add up to a reasonable period of time over

the day.

The researcher was aroused by the various available

studies, however contrary to last documents from Saudi

Arabia, it is the novel research specifying both hand hygiene

knowledge and compliance in Jeddah using the “WHO hand

hygiene knowledge and observation”. [26]

The current study showed a dramatic improvement in

hand hygiene knowledge among health care workers

immediately and three months following a hospital-wide

educational intervention. This finding could be attributed to

an effective educational intervention and setting hand

hygiene as a priority for patient safety among health care

workers.

These findings are supported by what was reported by Tan

and Olivo, 2015 that knowledge of health related infections

and hand hygiene among health care providers is pretty great.

[27]

Improved knowledge was maintained and audited allover

many hospital areas. [21] This is consistent with the present

study results which demonstrated the best knowledge at

baseline and after three months of intervention in the NICU

followed by surgical, ICU, CICU, PICU and ER. When

assessing the knowledge three months after intervention, we

found better knowledge among physicians compared to

nurses. This is possibly because of a higher level of

education or different cultural aspects. This is supported with

what previous study reported that a less compliant nurses

reporting inefficient attitude towards time. [35] Surprisingly

optimal knowledge was reported among physicians who

served more than twenty patients per shift this could be

explained by their willing to learn more about hand hygiene

to protect themselves and their patients.

This is inline with what a previous four phases study

reported; prior to the intervention the most adherence was in

the NICU which sustained across the study phases then

dropped in Phase IV, and the least was in the kidney center.

However, great maintained advancement in adherence was

noticed in the ICU all over the study. [28]

Interestingly, regarding HCWs` hand hygiene compliance,

the present study demonstrated higher baseline compliance

(62.5%) compared to what was reported by other study (21%)

(Elsevier 2012) they explained this low rate by the lack of

sinks and work overload. The higher base line compliance in

the current study could be attributed to several factors; there

was MERS-CoV outbreak before starting the study in this

case Saudi Arabia media was directed to the significance of

hand hygiene and distribution of educational material to

emphasize this issue. Also we could not ignore the effect of

endorsing Islamic habits by Muslin healthcare providers in

their daily practice. Hand hygiene is not only an activity

proposed for body cleaning but it is made for traditional

aspects and because it conveys a cardinal obligation in

everyday life situations as proposed by many cultures and

religions. Prophet Muhammad often praised Muslims to

wash hands thoroughly and after apparently definite act:

before and after eating; after using the bathroom; and after

touching a soiled object. So, as Islam begins, a firm

observation of hand hygiene with clear running water has

been proposed to be Muslims. [29]

Despite this good baseline compliance, we observed a

striking improvement after educational intervention and

those who was non compliant turned to be compliant.

Unfortunately, this compliance is reduced after three month

from educational intervention (83.5% to 72%). This could be

explained by work overload, visitors’ inflow, the availability

of facilities. This could be associated with the fact that time

the hospital was flooded with patients and thus

outnumbering the facilities available in the hospital. This is

in agreement with a study which reported 67% total hospital

hand hygiene compliance rate, and this rate was raised to

81% in the post-intervention phase, but decreased again after

six months to be 59%. [21]

Females tended to care about their hand hygiene compared

to males and this is documented by the current results which

found better female baseline compliance. This is due to that

majority of females are married and they are taking care of

their family and so they are keen to protect themselves

against infections.

All HCWs who worked in critical care area are practicing

hand hygiene better than others; on the other hand ER had

the lowest baseline compliance this could possibly due to the

large number of patients served in ER so the HCWs did not

have time to wash their hands properly between patients.

By evaluating the effect of the educational intervention on

the improvement of HCWs` compliance the current study

observed a significant improvement either immediately or

14 Slimah N. Abdraboh et al.: Hand Hygiene and Health Care Associated Infection: An Intervention Study

after three months following the intervention and it was

obvious in both NICU and PICU and this could be related to

effective ongoing auditing, monitoring and leadership

especially in those two units. This is confirmed with what

Nteli et al. (2012) [30] demonstrated that educational

session was among the most essential activities to develop

HCWs` hand hygiene compliance. Contradicting to the

present study results, De Wandel et al. (2010) claimed that

enhancing hand hygiene compliance was not achieved either

with concurring a high level of knowledge or with social

influence. Self-efficacy is an important agent for hand

hygiene compliance. Also, this is This is confronted with

what a 2010 Cochrane systematic review reported

inadequate proves that interventions could enhance hand

hygiene in the hospital. One study reported a significant hand

hygiene improvement four months following the

intervention, and other study did not find any effect after

three months of the intervention. [31]

There are many published researches assessing the long

term impact of proper hand hygiene compliance on reducing

the incidence of healthcare associated infection.

Pessoa-Silva et al. (2007) [32] and Min (2013) [33]

recorded that regular auditing is sufficient to improve

adherence and is autonomously linked with reducing the

infection rate. Despite, that many researches showed a

transient association between advanced hand-hygiene

compliance and declined infections, no one reached a

continuous amelioration for long period “> 6 months”.

Indeed, we have shown that there is no link between

improving hand hygiene compliance and reduction in the

HAI rate. As this needs a long term not only three months

program.

By analyzing the relationship between knowledge and

hand hygiene compliance, the present study showed a

significant relation and this is a very good sign that

knowledge is aligned with practice.

By constructing a model for the potential factors which

could possibly predict good HCWs` hand hygiene

compliance following the intervention, the study showed that,

being married, divorced, working in the ICU or NICU,

during day shift, and with good knowledge meant that you

are a good hand hygiene compliant.

All in all, the present study showed a significant

relationship between knowledge and hand-hygiene

compliance, providing a very good indication that

knowledge is indeed aligned with practice.

Lack of a true control group from health care workers

might be considered as a limitation, finding a truly

comparable group was difficult because it is part of the

program to allow each health care worker to gain this type of

knowledge. In addition, there was potential confounding by

secular trends as there were other changes that occurred

between the pre- and post-intervention periods aside from

the intervention itself.

Future studies are recommended to explore both hand

hygiene compliance and its long term effectiveness on

reducing healthcare associated infection rate. Patient and

Staff engagement and positive role modeling are expressive

interventions to advocate and enhance hand hygiene

compliance. All service providers and receiver should

consider hand hygiene a basic superiority.

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