Background: Hand hygiene (HH) compliance of healthcare workers (HCWs) remains suboptimal despite standard multimodal promotion, and evidence for the effectiveness of novel interventions is urgently needed. Aim: Improve HCWs’ HH compliance toward minimizing healthcare associated infection (HCAI) risk in Wadi Al Dawasir Hospital (WDH), central Kingdom of Saudi Arabia (KSA). Methodology: A quasi experimental approach was adopted to achieve study aim. The HCWs’ behavior of HH during the duration between 2015 and 2016 was evaluated before and after a HH educational plan based on the World Health Organization (WHO) “Multimodal HH Improvement Strategy” (MMHHIS). The HCWs’ compliance in response to HH indications represented by the WHO’s “My 5-Moments for HH” and the type of HH action taken, whether hand washing (HW) or hand-rubbing (HR) were analyzed. Results: The number of opportunities observed of HH performance accounted 230 in 2015 (pre-education), and 237 in 2016 (post-education). The HCWs’ HH compliance rate in the pre-education phase did not vary by the 5-moment indications [ χ 2(df 4) = 0.01, p = 0.98]. Conversely, the compliance rate after HH education was higher than non-compliance across all 5-moment indication opportunities (ranged between 57.0% up to 88.9%) [ χ 2(df 1) = 18.25, p < 0.001]. Only the 3 rd and 4 th 5-moment indications (“after body fluid exposure” and “after patient contact,” respectively) were met with a significant HH improvement [ χ 2(df 1) = 8.98, p = 0.003; and χ 2(df 1) = 16.3, p < 0.0001, respectively]. An overall improvement of HH compliance from 49.1% to 69.6% was significantly achieved as a result of submission to the selected HH educational plan (Z = −4.38, p = 0.001). Only physicians and nurses showed a significant “within-profession” improvement in HH compliance after education, compared to that before education (Z = −3.51, p = 0.001, Z = −2.48, p = 0.013, respectively). Conclusions: Applying a HH education plan based on standardized multimodal HH strategy proved effective in improving the HH compliance of the hospital’s staff. An ongoing observation policy within a HH-resourceful environment assures a sustainable and sound HCWs’ HH behavior.
Patient safety involves a multitude of preventive standards and procedures to mitigate a myriad of risks and harmful effects upon the patients in healthcare facilities. Cross-infection at a healthcare facility, known as healthcare-associated infection (HCAI), occurs as a result of transmission of infectious agents during the course of care seeking for other conditions [
The WHO First Global Patient Safety Challenge: “Clean Care is Safer Care” is an initiative aiming to strengthen international commitment to address HCAI [
In the Saudi Arabian healthcare arena, there have been some studies presenting some data on HH improvement. However, most of these studies were centered on specific points of care, such as the ICU [
Wadi Al Dawasir Hospital (100 beds), is a secondary care facility with a number of subspecialties, catering for military personnel and their families. The hospital lies at Al-Dawasir valley in Najd desert within the jurisdiction of the Riyadh region, central KSA. The hospital includes over twelve standard clinical services and equipped with modern technologies. The preventive medicine department of WDH conducted a project to improve the HCWs’ HH attitude among the hospital’s efforts to prevent HCAI and bringing its rates to lowermost. The project extended from 2015 through 2016. The project’s strategy encompassed four steps, first to identify the hospital’s preparedness for sound HH trend, second to carry on baseline observation of the HCWs’ HH practice, third to implement a predesigned HH intervention plan and then evaluate the HCWs’ HH behavior and compliance after the intervention, fourth to assure sound and sustainable HH culture through continued follow-up and evaluation of the experiment. In preparing for the project, financial resources to furnish basic HH practice requirements were forecasted, and project’s aim was related to the hospital’s authority. The number and distribution of HW sinks were reviewed (one sink for each room with two beds and one sink in each isolation room), which were further equipped with un-medicated soap and paper towels. Also ABHR dispensers were located, one inside each inpatient room, one outside each room, one in each medication trolley, as well as all other points of care. All of the hospital’s medical staff, including physicians, nurses, care providing technicians/ auxiliary staff in the departments and outpatient service, including male, female, and pediatric wards, NICU, ICU, dental clinic, and emergency room (ER); were eligible to join the project. We implemented the WHO multimodal strategy and assessed staff’s HH compliance before and after the interventions. Compliance was defined as the proportion of predefined opportunities met by HH actions (HW or HR) [
Study variables: The study’s independent variables include the HCWs’ and hospital’s categorical data, such as profession, specialty, department/unit, as well as the inputs encompassed within the WHO’s observation method, including the 5-moments for HH indications (before patient contact and aseptic procedure, and after body fluid exposure, patient contact and the surroundings). The principal dependent study variable was represented by the HCWs’ compliance (HH “done”/“not done”) with HH indications, and the secondary outcome variable was the action, which involves the type of HH response performed, whether HW or HR. The study’s outcomes would be analyzed before the educational plan (2015) and after education (2016). Since the study’s philosophy was based on promoting for adopting HH by the HCWs as a hygienic behavior and a professional work style, and examining how HH training would improve such behavior, all HCWs were taken as quasi study subjects; no control group. We needed all HCWs to benefit from the experiment timely.
Statistical analysis: The collected data were entered to MS program with adequate back up, and observations made ready for statistical analysis. First, descriptive statistics, including frequency data, were displayed. The study’s quantitative data were summarized as count (%). Analytical statistics mainly includes nonparametric techniques (NPMT). For instance, testing HH compliance pattern of the HCWs in response to the 5-moments for HH indications either in the pre-education phase or in the post-education phase, chi-square tests could be used. Measuring the difference in HH compliance before and after education, a repeated measure technique, such as the Wilcoxon signed ranks test, for related samples could be used. Also Wilcoxon signed ranks test could be used to measure the change in HH compliance within departments as well as within profession groups; (often, only chi-square test could be applied to measure HH compliance changes in case of unsatisfactory post-education data and corresponding pre-education compliance state (as in analyzing HH responses during individual 5 moment indications) to run repeated measure tests. Measuring the difference in compliance between professions or between departments, and also the type of H action (HW/HR), chi-square test (or Fisher’s exact, where appropriate) could be used. The SPSS (Chicago, IL) software-version-20 was used for statistical analyses. Our level for tolerating type-1 error would be α = 0.05, and results with p-value < 0.05 were considered statistically significant. A clearance from WDH Research Ethics Committee to commence the study was granted.
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The total of opportunities for HH practice accounted 230. Hand-rubbing was done more frequency than HW (57.5% vs. 42.5%), however such difference was not statistically significantly (Fisher’s exact, p = 0.39,
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The overall HCWs’ HH compliance rate after the education plan completion was significantly higher than the one prior to education (Z = −4.38, p < 0.001), (
The variation in HH compliance between professions after HH education was not statistically significant, [nurses and physicians showed an almost equal HH compliance rate: 70.3%, 69.9%, respectively, technicians/auxiliary staff least compliant (62.2%)], [χ2(df 2) = 0.41, p = 0.81].
The variation in HH compliance between departments/units after HH education was statistically significant, [χ2(df 6) = 18.76, p = 0.005], (
HH compliance: pre-education | |||||
---|---|---|---|---|---|
Indication | Done* | Not done | Test statistic | p-value | |
n (%) | n (%) | Total (%) | |||
Before patient contact | 33 (49.3) | 34 (50.7) | 67 (100.0) | χ2(df 4) = 0.01 | 0.98 |
Before clean/aseptic procedure | 9 (50.0) | 9 (50.0) | 18 (100.0) | ||
After body fluid exposure | 11 (50.0) | 11 (50.0) | 22 (100.0) | ||
After patient contact | 26 (50.9) | 27 (49.1) | 53 (100.0) | ||
After contact with patient surroundings | 33 (49.3) | 34 (50.7) | 67 (100.0) | ||
Total | 113 (49.1) | 117 (50.9) | 230 100.0) |
*[HW: 48/113 (42.5%); HR: 65/113 (57.5%); Fisher’s exact, p = 0.39].
HH compliance: pre-education | HH compliance: post-education | |||||||
---|---|---|---|---|---|---|---|---|
Indication | Done | Not done | Total (%) | Done | Not done | Total (%) | Test statistic | p-value |
n (%) | n (%) | n (%) | n (%) | |||||
Before patient contact | 33 (49.3) | 34 (50.7) | 67 (100.0) | 45 (57.0) | 34 (43.0) | 79 (100.0) | χ2(df 1) = 0.86 | 0.35 |
Before clean/aseptic procedure | 9 (50.0) | 9 (50.0) | 18 (100.0) | 7 (63.7) | 4 (36.4) | 11 (100.0) | χ2(df 1) = 0.51 | 0.47 |
After body fluid exposure | 11 (50.0) | 11 (50.0) | 22 (100.0) | 24 (88.9) | 3 (11.1) | 27 (100.0) | χ2(df 1) = 8.98 | 0.003 |
After patient contact | 26 (50.9) | 27 (49.1) | 53 (100.0) | 50 (84.7) | 9 (15.3) | 59 (100.0) | χ2(df 1) = 16.3 | <0.0001 |
After contact with patient surroundings | 33 (49.3) | 34 (50.7) | 67 (100.0) | 39 (63.9) | 22 (36.1) | 61 (100.0) | χ2(df 1) = 2.8 | 0.09 |
Total | 113 (49.1) | 117 (50.9) | 230 100.0) | 165 (69.6) | 72 (30.4) | 237 100.0) |
HH compliance: post-education | |||||
---|---|---|---|---|---|
Indication | Done* | Not done | Total (%) | Test statistic | p-value |
n (%) | n (%) | ||||
Before patient contact | 45 (57.0) | 34 (43.0) | 79 (100.0) | χ2(df 4) = 18.25 | 0.001 |
Before clean/aseptic procedure | 7 (63.7) | 4 (36.4) | 11 (100.0) | ||
After body fluid exposure | 24 (88.9) | 3 (11.1) | 27 (100.0) | ||
After patient contact | 50 (84.7) | 9 (15.3) | 59 (100.0) | ||
After contact with patient surroundings | 39 (63.9) | 22 (36.1) | 61 (100.0) | ||
Total | 165 (69.6) | 72 (30.4) | 237 100.0) |
*[HW: 69/165 (41.8%), HR: 96/165 (58.2); Fisher’s exact 13.1, p < 0.0001].
Rank | ||||||
---|---|---|---|---|---|---|
Compliance | n | Mean | Sum | Test statistic | p-value | |
+ve ranks | 81b | 58.0 | 4698.0 | |||
Pre-education-post-education | ?ve ranks | 34a | 58.0 | 1972.0 | Z = ?4.38d | <0.0001 |
Ties | 115c | |||||
Total | 230 |
aCompliance 2016 < Compliance 2015; bCompliance 2016 > Compliance 2015; cCompliance 2016 = Compliance 2015; d Based on positive ranks.
Difference within profession | Difference between profession | ||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|
HH compliance: post-education - pre-education | HH compliance: post-education | ||||||||||||
Rank | |||||||||||||
Profession* | +ve | ?ve | Ties | Total | Test statistic | p-value | Done | Not done | Total | Test statistic | p-value | ||
n | Mean | n | Mean | ||||||||||
Physicians | 43a | 30.0 | 16b | 30.0 | 44c | 103 | Z = ?3.51d | <0.0001 | 72 (69.9) | 31 (30.1) | 103 | χ2(df 2) = 0.41 | 0.81 |
Nurse | 32a | 24 | 15b | 24 | 64 c | 111 | Z = ?2.48d | <0.013 | 78 (70.3) | 33 (29.7) | 111 | ||
Technician | 6a | 5 | 3b | 5 | 7c | 16 | Z = ?1.0d | <0.32 | 10 (62.2) | 6 (37.8) | 16 | ||
Total | 81 | ---- | 34 | ---- | 115 | 230 | 160 (69.6) | 70 (30.4) | 230 |
aCompliance 2016 < Compliance 2015; bCompliance 2016 > Compliance 2015; cCompliance 2016 = Compliance 2015; dBased on positive ranks. *Number of HH actions done within a profession not the number of the individual HCWs in the profession.
HH compliance: post-education - pre-education | ||||||||
---|---|---|---|---|---|---|---|---|
Rank | ||||||||
Department | +ve | ?ve | Ties | Total | Test statistic | p-value | ||
n | Mean | n | Mean | |||||
ER (n = 24) | 7a | 7 | 6b | 7 | 11c | 24 | Z = ?0.28d | 0.78 |
ICU | 12a | 11 | 9b | 11 | 14c | 35 | Z = 0.65d | 0.51 |
Male ward | 15 a | 10 | 4b | 10 | 28c | 47 | Z = ?2.52d | 0.012 |
Female ward | 21a | 12.5 | 3b | 12.5 | 20c | 44 | Z = ?3.67d | <0.0001 |
NICU | 9a | 6.5 | 3b | 6.5 | 14c | 26 | Z = ?1.73d | 0.083 |
Pediatrics | 12a | 9.5 | 6b | 9.5 | 14c | 32 | Z = ?1.41d | 0.15 |
Dental clinic | 5a | 4.5 | 3b | 4.5 | 14c | 22 | Z = ?0.70d | 0.48 |
Total | 81 | ---- | 34 | ----- | 115 | 230 |
HH compliance: post-education | |||||
---|---|---|---|---|---|
Department/unit | Done | Not done | Total | Test statistic | p-value |
n (%) | n (%) | n (%) | |||
ER | 10 (41.7) | 14 (58.3) | 24 (100.0) | χ2(df 6) = 18.76 | 0.005 |
ICU | 20 (57.1) | 15 (42.9) | 35 (100.0) | ||
Male ward | 37 (78.7) | 10 (21.3) | 47 (100.0) | ||
Female ward | 36 (81.8) | 8 (18.2) | 44 (100.0) | ||
NICU | 21 (80.8) | 5 (19.2) | 26 (100.0) | ||
Pediatrics | 20 (62.5) | 12 (37.5) | 32 (100.0) | ||
Dental clinic | 16 (72.7) | 6 (27.3) | 22 (100.0) | ||
Total | 160 (69.6) | 70 (30.4) | 230 (100.0) |
An HCAI-free environment, mandates a prevailing sound HH culture of the healthcare facility’s staff. By far, HH may well be the single most effective measure for reducing HCA rates to lowest possible [
Overall HH compliance rate: In the pre-education phase, the HCWs’ HH compliance was as low as 49.1%. It seems that such low baseline compliance rate is a universal trend. Bukhari et al. (2011) in Saudi Arabia [
HH by the 5-moment indications: In our study, only the compliance after body fluid exposure (5-moment indication 3) significantly improved from 50% up to 88.9%, as well as the compliance after patient contact (5-moment indication 4) from 50.9% to 84.7%. Most HH studies which have deployed standardized HH improvement strategies showed such partial compliance improvement in the 5-moment indications analyses. In Farhoudi et al. (2016), [
HH by profession: Hand hygiene compliance trend may vary by the HCW’s individual professions. [
HH by department/unit: In our study, only in male -and female wards showed a significant improvement in the HH compliance trend as a result of the education plan. Unlike the HH performance among professions during the post-education period, the departments/units significantly varied in their HH compliance as observed during that period, e.g., female and male wards and NICU recorded maximum compliance rate ranging between 78.7% - 81.8%. The compliance in our ICU reached only 57.1% vs. 42.9% non-compliance rate, despite the HH education. In the study by Alsubaie S, et al. [
How far was the HH improvement achieved? The level for compliance with recommended HH techniques often varies between healthcare organizations; based on the quality and patient safety policy in place and the particular phases of the healthcare system’s development. For instance, a national benchmark level of HH compliance among HCWs in Manitoba, Canada, was set at 70% in 2015-2016 and was increased to 75% in 2016-2017 until it reached 80% in 2017-2018 [
Limitations and strengths: The study scale may have been limited by the number of the observing team members, given the limited ability, e.g., to recruit some of the hospital’s staff and train them to join the observation team. Having the adequate number of observers, especially at critical areas, such as the ICU, helps alleviate the remarkable non-compliance rate at such critical care point. Otherwise, the study had several strengths, adding to the findings validity and generalizability potential. First, the overall target set for HH improvement (70%) was almost accomplished (69.6%). The study adopted rigorous WHO multimodal strategy in establishing the HH project, the impact of which upon improving HH behavior among HCWs is evident. The direct observation method not only stands as a superior HH follow-up tool in the healthcare arena, but it can both determine the compliance with all 5 moments of HH and evaluate HH technique and check compliance rates according to the HCWs [
The study aim has been achieved, using the selected study design and implementing the WHO multimodal strategy in WDH. With the intervention applied, HH compliance significantly improved. Moreover, the benchmark level (70%) for HH compliance among our HCWs was achieved. With the available resources to monitor HH adherence among WDH staff, direct observation remains our gold standard. As planned, further improvement to reach the 80% benchmark level for HH after the initial post-education year is underway. Important care areas, such as the ICU would be stressed upon to lift-up the low compliance observed in such critical point of care. A sustainable and sound HH behavior of WDH staff requires engaging each staff member in the training, so that a timely and correct HH becomes a genuine component of the quality improvement and safety culture of WDH personnel. As such, a multifaceted approach advocating a diversity of educational methods for a wider coverage and a better compliance, as well as an effective feedback to relate the observation outcome both to staff and WDH authority are recommended.
The authors declare no conflicts of interest regarding the publication of this paper.
Saad, A.E., Al-Natig, A.-W.T., Sadek, M.M. and Afifi, R.M. (2019) A Quasi Experiment to Implement Multimodal Strategy to Improve Hand Hygiene Behavior in a Healthcare Facility in Central Saudi Arabia. Advances in Infectious Diseases, 9, 49-63. https://doi.org/10.4236/aid.2019.91005