Studies on compliance with hand hygiene technique commonly focus on observations regarding adherence of healthcare workers to the 5 moments outlined by the World Health Organization (WHO) guidelines. ¹ These guidelines also provide guidance on the proper technique for the use of hand rub, consisting of 6 steps to ensure the complete coverage of the hands. Several studies have provided strong evidence for increased bacterial killing using this technique,Reference Carabin, Gyorkos, Soto, Joseph, Payment and Collet ^{2 –} Reference Ayliffe, Babb and Quoraishi ⁵ but compliance with all 6 steps has not been evaluated. Therefore, we aimed to assess compliance of healthcare workers with the recommended hand hygiene technique.

TABLE 1

Compliance with the World Health Organization Hand Hygiene Technique

This prospective observational study was performed at the University Hospital Basel, a tertiary academic medical care center in Switzerland that admits >32,000 patients annually. During defined study periods from 2010 to 2013, hand hygiene observations were conducted on 15 different wards: 5 medical and 5 surgical wards, as well as 2 wards belonging to the emergency department, 2 wards belonging to the intensive care units, and the bone marrow transplant unit. The study was approved by the institutional review board as part of the quality assurance program.

All hand hygiene observations were performed by 3 trained researchers over 520 hours of direct observation of performance of hand hygiene techniques at the 5 moments of hand hygiene. The 5 moments of hand hygiene as outlined by the WHO ¹ are (1) before touching a patient, (2) after touching a patient, (3) after touching patient surroundings, (4) after body fluid exposure risk, and (5) before clean/aseptic procedure”). The individual steps of the hand hygiene technique as outlined by the WHO are (1) rubbing hands palm to palm, (2) palm to palm with fingers interlaced, (3) right palm over left dorsum with interlaced fingers and vice versa, (4) back of fingers to opposing palms with fingers interlocked, (5) rotational rubbing of left thumb clasped in right palm and vice versa, and (6) rotational rubbing backwards and forwards with clasped fingers of right hand in left palm and vice versa). ^{1 , 6}

Furthermore, information regarding age, profession, and duration of employment at our institution was recorded. Age was categorized as <26 years, 26–35 years, 36–45 years, 46–55 years, and >55 years. Duration of employment was categorized as 0–5 years, 6–10 years, 11–20 years, and >20 years.

The primary outcome was compliance with all 6 steps of the hand hygiene technique. The χ² test was used for comparisons of proportions, and odds ratios (ORs) were calculated using univariable logistic regression models and Stata statistical software, version 12.0 (Stata Corp, College Station, Texas). Two-sided P values <.05 were considered significant.

Overall, 2,662 hand hygiene opportunities were observed, mostly among nurses (65.3%, 1,737 of 2,662), followed by doctors (21.7%, 579 of 2,662) and other healthcare workers (13.0%, 346 of 2,662). The most common indication was “after touching a patient” (41.9%, 1,114 of 2,662), followed by “before touching a patient” (31.9%, 848 of 2,662), “after touching patient surroundings” (11.0%, 292 of 2,662), “after body fluid exposure risk” (9.0%, 240 of 2,662), and “ before clean of aseptic procedure” (6.3%, 168 of 2,662).