Lau Chun Ling
Lau Chun Ling
Author(s)
Lau, Chun-ling.; .
Citation
Issued Date
URL
Rights
2012
http://hdl.handle.net/10722/179908
MPH Project
The University of Hong Kong
2012
August 2012
Abstract
Hospital-acquired, or nosocomial infections (HAIs) are the major source of mortality and
morbidity for hospitalized patients. It is estimated that 7-10% patients developed HAIs during
their hospital stays, with most patients got infected from intensive care units (ICU) [1,2].
Hand hygiene (HH) is recognized as the most easy and effective way to prevent HAIs. However,
the observed hand hygiene compliance rates among healthcare workers (HCWs) have been
regarded as unacceptably low, especially in ICU [3]. This literature review is to discuss the
factors influencing the hand hygiene compliance among HCWs in ICU, in both the individual
and institutional level, and suggest which factor was important in both levels. Recommendations
in comprehensive approach on hand hygiene practices will also be included.
Declaration
I declare that the project and the research work thereof represents my own work, except where
due acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a degree,
diploma or other qualification.
Signed
Lau Chun Ling
Acknowledgements
I would like to express my sincere appreciation and heartfelt thanks to my supervisor, Dr.
Dennis Ip, for his patient guidance and expert advice on the direction and completion of my
project. This work would not have been possible without his kind comments and support.
I owe the biggest debt of gratitude to my family and friends, especially Mrs. Janet Lau, Miss
Kathy Lau and Big Four, for their endless love and understanding, to support me come across all
the hard time in both my work and study during this master program.
A special acknowledgement and sincere thanks go to Mr. Sammy Tsang, for his continuous
support and encouragement, and for always being my motivation.
Table of Contents
Abstract ................. 1
Declaration.................... 2
Acknowledgements.................................................... 3
Table of Contents ..................... 4
Chapter 1 Introduction..................... 6
1.1 Impact of Hospital-acquired Infections................ 6
1.2 Definitions of Hand Hygiene Compliance............... 6
1.3 Importance of Hand Hygiene Practice and its poor compliance.............. 7
1.4 Current Literature Gaps............... 8
1.5 Objectives..................... 8
Chapter 2 Methods.............................................................................................................. 10
2.1 Search process.................... 10
2.2 Inclusion and exclusion criteria..............10
2.3 Citation assessments...............11
Chapter 3 Results.................13
3.1 Selection of Articles................13
3.2 Individual Factors Affecting the Hand Hygiene Compliance.................19
3.3 Institutional Factors Affecting the Hand Hygiene Compliance..................22
Chapter 4 Discussion...............24
4.1 Summary of Findings..................24
4.2 Recommendations on Hand Hygiene Practice................25
4.3 Future Researches Directions..................28
4.4 Limitations..................29
Chapter 5 Conclusion..............30
References................31
List of diagrams and tables:
Figure1: Inclusion and exclusion process in the systematic review.....................14
Table 1: Summary of the description of studies on factors affecting hand hygiene
compliance................15
Table 2: Summary of the reported impact of HAIs..................39
Chapter 1 Introduction
1.1 Impact of Hospital-acquired Infections
Hospital-acquired infections (HAIs) or nosocomial infections are major global health problems
and are identified as the first priority for Global Patient Safety Challenge by WHO [4]. The
prevalence of HAIs is estimated to be 1.4 million worldwide. It leads to 50,000 attributable
mortality and 2 million attributable morbidity in developed countries every year [5,6], as well as
resulting in an extra 14 days hospital stays and an additional of 3154 annual healthcare
expenses [7,Table 2]. Eliminating HAIs can save millions of treatment costs and relieved its
associated socio-economic burden [8].
[12]
by
proper
hand
hygiene
practice,
including
those
caused
by
1.5 Objectives
To systematically review aims to address the following research questions:
(1) What are the individual factors that affect the hand hygiene compliance in intensive care
units?
(2) What are the institutional factors that affect the hand hygiene compliance in intensive care
units?
(3) What recommendations on hand hygiene practices can be formulated basing on the above
evidence?
Chapter 2 Methods
2.1 Search process
In order to identify the individual and institutional levels factors affecting the hand hygiene
compliance in a systematic way, relevant literatures are retrieved from databases Medline(Ovid),
PubMed, EBSOHost. The following medical subject headings (MeSH) are used under 3 key
categories that addressing the research topic: i) Factors-improving OR increasing OR
factor OR determinant AND ii) Hand hygiene-hand hygiene OR hand washing OR
hand disinfection OR hand sanitization OR infection control OR alcohol-based hand rub
OR hand $ OR hand hygiene $ AND iii) compliance- compliance OR non-compliance
OR adherence OR non-adherence OR better compliance OR better tolerance.
The search is then limited to journals. Reference list of the retrieved articles are also manually
screened to identify all related published studies. Search was being done on 10th Aug, 2012. Any
papers published before 10 Aug 2012 that were being picked up by the search and fitting the
inclusion and exclusion criteria were being included.
10
washing, were not identified as hand hygiene practice in this paper. The duration and
appropriate steps of hand hygiene practice were also not considered here since the aim of this
paper is to review the factors affecting the HH compliance but not to assess the adequacy of HH
skills and technique among HCWs.
The inclusion and exclusion criteria were set in prior to select the most relevant journals from
those retrieved. The inclusion criteria were: a) Subjects studied were health care workers who
work in the intensive care unit (both adult, pediatric, neonatal, cardiac, medical and surgical); b)
Factors of hand hygiene compliance were mentioned; c) Original studies were included; d)
Sample and setting were carried in ICU, if discrete data for HH compliance factors can be
retrieved for ICU, even studies in general hospital setting can also be included.
The exclusion criteria were: a) Conference papers, abstracts, protocols, guidelines, unpublished
results, reviews articles. b) Results of effect cannot be separated from other infection control
interventions e.g. gown use, single isolation room. c) Interventional studies were also excluded
since this paper aims at reviewing the underlying factors affecting HH compliance but not the
effectiveness of an intervention on the enhancement or improvement of HH practice.
11
international guideline STROBE (observational studies) [25]. The critical appraisal was based
on: a) Methods (describe the study design, setting, location and period of data collection), b)
Sample size (enough sample size?), c) Descriptive data (statistical methods, characteristics of
study participants and inclusion criteria, statistical information on factors affecting HH
compliance and potential bias and confounders).
The overall quality of the selected articles was assessed by using the STROBE checklist and
rank in A (good), B (average), and C (unsatisfactory).
12
Chapter 3 Results
3.1 Selection of Articles
In the initial search, 1206 related articles were obtained in PubMed, 936 in Medline(Ovid) and
466 in EBSOHost after conducting the MeSH search term mentioned above (i AND ii AND iii).
The search was then limited to original articles and journals and NOT interventional studies. 383
potential papers were retrieved in PubMed, 357 in Medline(Ovid) and 60 in EBSOHost. These
citations were then further evaluated by screening on the title and abstract. Those studies which
were not related to the factors affecting HH compliance among HCWs, not confined in ICU
settings were excluded. The inclusion and exclusion process is summarized in Figure 1. There
were 14 published studies remained for this systematic review. The summary and results of
these studies were listed in Table 1.
13
14
Table 1: Summary of the description of Studies on factors affecting hand hygiene compliance
Reference
Year
Study design
Sample size
Demographics
Settings
Individual factors
Institutional factors
Harbarth et.al
2001
Observational,
2811 hand
Professional category
Type of ICU
hygiene
(being a respiratory
(working in
opportunities
childrens hospital in
therapist-OR=5.1);
NICU-OR=1.6);
opportunities), aids/medical
Boston
Type of patient-care
Grade
A
[26]
activities(before
opportunities)
Nobile et.al
2002
Survey
19 and 5 randomly
Gender
Type of ICU
physicians
selected hospitals in
(female-OR=1.69);
(NICU=9.94);
Campania and
Self-protection (96.5%)
Availability of hand
A
[27]
Calabria(Italy)
hygiene products
(93.9%)
Pessoa-Silva
2005
Questionnaire
61 neonatal
et.al
HCWs
[28]
planned behavior)
Attitude (OR=3.32);
of Geneva Hospital
Perception of control
(Switzerland)
(OR=3.1);
Perception of being a
model (OR=2.9)
Skin irritation (57.4%);
Use of gloves (53.3%);
Forgot to wash hand
(50.8%)
15
Cohen et.al
2003
Direct observations
1472 touches
All HCWs
2 university- affiliated
Level of contact
Use of alcohol-based
(P<0.03);
B
[29]
Professional category
(55.1% for physicians,
46.2% for nurses)
Sharma et.al
2011
Cross-sectional
114 HCWs
18 attending physicians, 8
42-bed MICU of a
Professional category
Activity index
hospital in Punjab
(Pakistan)
Age
index);
Risk of
years old)
cross-transmission
Attitude;
Skin irritation
A
[30]
2010
Questionnaire
108 nurses
Attitude (p<0.001);
(based on behavior
University Hospital
Self-efficacy
theory model)
working experience
(Belgium)
(p=0.001);
14-bed MICU
Awareness of being
B
[31]
Maury et.al
2006
4-phase Observational
study
residents, students
B
[32]
observed (p<0.05)
16
Duggan et.al
2008
Covert observation
Awareness of being
opportunities
319-bed teaching
observed (p<0.001)
resident, student
hospital in University of
B
[33]
Toledo (Spain)
Kaplan et.al
1986
Observation
42 HCWs
8 physicians, 30 nurses, 2
Professional category
Sink accessibility
university affiliated
(p<0.001)
(p<0.001);
respiratory technicians
teaching hospital
Professional category
opportunities
physiotherapists(64)
University hospital
(p<0.0001);
B
[34]
Noritomi et.al
2007
Prospective observation
B
[35]
Level of working
experience (p=0.56);
Gender(p=0.02);
Type of patient-care
activities (p<0.0001);
Contagious status of
patient (p<0.0001)
Rumbaua et.al
2001
Point-in-time observation
88 HCWs
53 physicians, 21 nurses, 14
Professional category
Risk of
aids/medical technologists,
cross-transmission/
Workload
B
[36]
Mathai et.al
2011
Observational
105 HCWs
A 13-bed mixed
Professional category
High density
consultants, 31 physiotherapists
medical-surgical AICU
activities/too busy
(33.7%)
in northern India
B
[37]
(~27%)
17
Van de Mortel
2001
Covert observation
~214 HCWs
et.al
at city hospital in
[38]
15 X-ray technicians
Australia
Gender (p=0.0001)
C
2002
Direct observation
32 HCWs
Professional category;
Lack of sinks,
technicians, 1 physiotherapist
(statistics not
products
not mentioned)
mentioned)
(statistics not
C
[39]
mentioned)
HCW, health care workers. AICU, adult intensive care unit. SICU, surgical intensive care unit. MICU, medical intensive care unit. PICU, pediatric intensive care unit. NICU,
neonatal intensive care unit. CICU, coronary intensive care unit.
Hand hygiene opportunities, any potential hand hygiene action for patient care as recommended by
standard guidelines. Hand hygiene touches, any contact by the hands of HCW with a patients skin or the surrounding environment. Phase 1,3, periods of non-announced
observation. Phase 2,4, periods of announced observation.
18
19
ones (OR=1.69) [16]. The gender difference is more significant in the disciplines of
doctors (p=0.047) and ward persons (p=0.0001) [38].
Behavior determinants including self-efficacy, attitude and perception of control
[28,30,31]: Three studies demonstrated the effect of behavior determinants on HH
compliance. They all found that for those who reported higher self-efficacy
(OR=2.9-3.37) , more positive attitudes toward HH practice guidelines (OR=3.32) and
higher perception of control (OR=3.1), were associated with a significantly higher
compliance to the HH practice guidelines (p=0.02, p=0.01) [28,31], probably because of
the belief that adhering to the practice guidelines could improve patient outcomes.
Hand irritation and dryness [28,30]: Two studies assessed the effect of hand irritation and
dryness on HH compliance. Both of them showed that the use of drying and irritating hand
antisepsis products were associated with a decreased HH compliance rate among health
care workers. 57.4% HCWs believed that the products they were using for hand
disinfection and routine hand disinfection would cause skin irritation; hence, and thus less
likely to wash their hands [28].
Disrupted workflow [26]: Only one study examined the effect of disrupted workflow on
HH compliance. It observed that interruption of patient care activities would affect HH
compliance (9%), for example when the HCW left a patient to contact with another patient
or surfaces such as the medication dispenser, telephone and then go back to touch the first
patient [26].
Level of working experience [35]: Only one paper studied the effect of level of working
experience on HH compliance. It stated that the level of working experience was
uncorrelated with hand hygiene adherence rates (p=0.56).
Level of contact/Contagious status of patient/ Type of patient care activity/Self-protection
[26,27,29,35]: Four studies assessed the effect of contagious status of patient on HH
20
compliance. One showed that hand hygiene compliance (50.3%) increased with the level
of contact with neonates, HCWs were more likely to wash their hands when they need to
directly touching the neonates [29]. Moreover, the others also exhibited that 77% HCWs
would wash their hands when they have to do with dirty tasks such as before contact with
body fluid secretions [26], as well as for those procedures associated with patients under
isolation or contact precaution due to their contagious status (p<0.0001) [35], this
confirmed with the finding that almost all (96.5%) HCWs perceived HH practice as a
means of self-protection [27].
Excessive use of gloves [28,39]: Two studies examined the effect of use of gloves on HH
compliance. Karabey observed that HCWs were more unwilling to wash their hands when
they wore gloves. The use of gloves provided them with a sense of self-protection, thus,
lowered their HH compliance [39]. 53.3% HCWs reported that they prefer to use gloves
rather than washing their hands [28].
Perception of being a model [28]: Only one study assessed the effect of perception of
being a model on HH compliance. When a HCW was aware that he/she became a role
model to other colleagues, they would be more committed and adhered to the HH practice
guidelines. The perception of being a model or superiors was independently associated
with the HH compliance (p=0.035) [28].
Awareness of being observed [32,33]: Two studies examined the effect of awareness of
being observed on HH compliance. It is a strong indicator of higher HH compliance as the
one being observed believed that they set a positive role model (p<0.001, p<0.05) [32,33].
The social influence and peer pressure also affected the compliance rate.
Forgetful in wash hands [28,37]: Two studies assessed the effect of forgetfulness on HH
compliance. Approximately 27%-50.8% HCWs said they failed to remember that they
have to perform HH [28,37], and it was also the second most common reason for HH
21
22
towels on the wall and not enough number of sinks in ward can be a significant indicator
for poor HH compliance. 93.9% HCWs believed that HH can be supported by the
availability of HH products [27] and poor accessibility of sinks would decrease the HH
compliance rate in ICU (p<0.01) [34].
Administrative apathy [30]: Only one study stated the effect of administrative apathy on
HH compliance. HCWs claimed that one of the reasons for their low compliance was
attributed to the administrative apathy and the low institutional priority for hand hygiene
support [30].
23
Chapter 4 Discussion
4.1 Summary of Findings
Individual factors
Our result suggested that a number of important individual factors were affecting HH
compliance in the ICU setting. These included professional category, age, gender, behavior
determinants, hand irritation and dryness, disrupted workflow, contagious status of patients,
use of gloves, perception of being a model, awareness of being observed and forgetfulness.
Among all the factors being studied, the contrasting result regarding the different patterns of
HH compliance among different professional groups probably served to highlight the
existence of fundamental differences in conception and attitude regarding HH practice and in
consequence underlying reasons sharping their degree of compliance among different
professional groups. Despite this controversy, a number of studies had reported the highest
HH compliance rate among nurses in comparison with other HCWs in ICU due to their higher
number of HH opportunities in patient care, which was in accordance with landmark studies
about hospital wide predictors for HH compliance [15,40]. Couple of studies in the review
also indicated that disrupted workflow and forgetfulness would affect the HH compliance,
probably related to the high workload in ICU setting [26,28,37]. This also confirmed with the
findings in general hospital setting about that the inverse correlation between the intensity of
patient care and rate of HH compliance [41-52]. In other words, the higher the demand for
hand hygiene, the lower the compliance rate, possibly related to the lack of time due to the
amount of workload. This may explain why ICU always have the lowest HH compliance rate
when compared to elsewhere [53].
Institutional factors
For the institutional factors, workload, type of ICU, use of alcohol-based hand hygiene
products, poor accessibility to sinks and HH products and administrative climate were all
24
definitively related to the HH compliance. The higher observed HH compliance rate in NICU
(39-56%) than the other type of ICU can also be explained by the lower intensity of patient
care in NICU, which was allied with the finding in a WHO study [4]. Other perceived
institutional factors affecting HH compliance have been assessed in this paper also remained
accordant with other observational studies [54-60].
In comparison to the systematic reviews about the factors affecting the hand hygiene
compliance among HCWs in general hospital settings [15,16], we found consistent results
with those in ICU in our papers. One interesting finding was that the level of working
experience was not associated with HH compliance in ICU [35] but a positive result was
found in general hospital settings [15,16]. Further prudent research is necessary to explore the
underlying reason for this finding. As high workload in ICU is the common factor attributing
to lower HH compliance in both the individual and institutional level, it may reflect that the
amount of workload is an important factor affecting HH compliance in ICU setting.
25
26
Another factor affecting HH compliance was the problem of hand irritation and dryness
associated with hand rubs, despite the fact that many nurses still believed that alcohol-based
hand rubs would cause more harm to their skins than hand washing agents, studies show that
they caused less irritation and dryness to skin, and applying hand rubs after hand washing can
even reduce the irritation caused by the washing [66]. These concepts should be effectively
communicated in promotional programs that were particularly targeted on nurses. Hospitals
have to ensure the easy access to alcohol-based hand rubs with emollients, and distributing
pocket size hand rub to each HCWs can also be considered [44,67]. Furthermore,
interventions proved that providing hand cream to HCWs can minimize irritant contact
dermatitis that resulted from HH practice [68], hand lotions or creams are thus indispensable
items in ICU. Possibility to place hand creams next to hand rubs and sinks should be assessed
locally. Good accessibility to hand rubs and hand creams should both be guaranteed as they
were pivotal factors affecting HH compliance.
v) Keep HCWs alert
Apart from coping with an ever-expanding workload, being oblivious in washing hands was
another reason for HH non-compliance reported by HCWs in ICU. Posters and warning signs
about hand hygiene such as Hand hygiene practice at five moments or Wash hands after use
gloves can be put on ventilators, doors and walls to continuously remind HCWs to wash their
hands [69].
vi) Enhance behavior determinants
Behavior determinant was another factor for HH compliance. It should be targeted and
enhanced by the aid of interventions. Attitude can be improved by increasing ones knowledge
via education program while self-efficacy can be enhanced by social learning from role
models or providing positive performance feedback and rewards. A compliment or positive
feedback from senior staff or peers can invoke more positive attitude and better self-efficacy;
27
28
successes and failures. They could be definite contributions to improve patient safety.
Furthermore, this paper does not include appropriate duration and steps of hand hygiene
practice which are important factors attributed to proper hand hygiene practice. Further
research should be thoroughly undertaken so as to review this part.
An interventional study conducted in Hong Kong stated that the HH compliance in a neonatal
ICU among HCWs was 40% in general [76]. Another cross-sectional study conducted in four
acute Hong Kong hospitals explored cognitive factors affecting HH compliance and some
effective interventions to improve the compliance rate [77]. However, local data about HH
compliance rate in ICU are still scarce and factors affecting the local HH compliance are also
inconclusive.
4.4 Limitations
As most of studies were being conducted in developed countries with a Western culture, some
of the results may have limited generalizability to the local situation in Hong Kong, especially
regarding factors that may be more culturally sensitive such as gender, workload.
As most of the studies form this systematic review were based either on direct observation or
self-reporting, there may be inherent limitation on validity due to the Hawthorne effect,
observer bias and sampling bias. As different methods were used for the indicators of HH
compliance in different studies, such as hand hygiene opportunities, touches, it is difficult to
compare them and draw a conclusion on the effect size of each variables and hence to explore
the most determinant factor of HH compliance in ICU.
Another area of limitation is that some HCWs groups such as occupational therapists may not
have been underrepresented as nurses being the predominant sample in most of the studies of
this review.
29
Chapter 5 Conclusion
ICU has the highest prevalence rate of HAIs but the lowest HH compliance rate. It is
important to understand the root cause of the lowest HH compliance rate.
This review has reported a number of important underlying factors affecting the HH
compliance in ICU, in both the individual and institutional level, and suggested that the
amount of workload may be an important factor contributing to HH compliance as it was
reflected in both levels.
This review also highlighted the fact that probably no single approach for improving HH
compliance can be adequately successful and fit all HCWs. Most effective interventions
should be adopting a comprehensive approach for addressing both the individual factors and
institutional factors, targeting different problems and barriers, with continual reinforcement,
in order to achieve lasting changes in HH practices. A real change following guideline
dissemination cannot be achieved unless individual efforts and explicit institutional
administrative support are fostered.
30
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38
HAI effect
Mean costs ( )
1628
4782 3154
22
14
Deaths (%)
13
11
23
29
39