Atangana, yde

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EMHJ – Vol. 26 No. 2 – 2020Research article

Hand hygiene initiative: comparative study of pre- and
postintervention outcomes
Mohammed Fouad1,2 and Sheref Eltaher3,4

1Microbiology and Immunology Department, Faculty of Medicine, Benha University, Benha, Egypt. 2Public Health Department, Health Sciences
College at Al Leith, Umm Al-Qura University, Saudi Arabia. 3Department of Family Medicine and Community Medicine, Faculty of Medicine, Taibah
University, Taibah, Saudi Arabia. 4Department of Public Health and Community Medicine, Faculty of Medicine, Benha University, Benha, Egypt (Corre-
spondence to: Sheref Eltaher: [email protected]).

Abstract
Background: Adequate hand hygiene is considered the most effective measure to reduce transmission of nosocomial
pathogens.
Aims: To determine the effectiveness of infection control intervention to improve compliance with hand hygiene in the
Emergency Department, Al-Leith General Hospital, Saudi Arabia, and evaluate bacterial load on hands as a possible indi-
cator of improvement.
Methods: The study consisted of 3 phases: Phase I, measurement of basal hand hygiene compliance level; Phase II, mul-
timodal hand hygiene educational programme was initiated; and Phase III, hand hygiene compliance level was measured
again. Data were collected by direct observation of healthcare workers in the emergency department between October
2016 and March 2017, using the standardized World Health Organization method for direct observation, “Five Moments
for Hand Hygiene”. The intervention comprised health education sessions using direct personal contact. Hands of health-
care workers were sampled during Phases I and III by sterile bag method, and bacterial load was determined.
Results: A total of 1374 opportunities for hand hygiene were observed during the triphase study. Implementation of the in-
terventional hand hygiene educational programme significantly improved compliance with hand hygiene guidelines from
30.7% to 45.5% (P < 0.01). Log10 bacterial load per hand dropped from 4.97 (standard deviation = 0.32) to 4.57 (0.47) (P < 0.05).
Conclusions: Hand hygiene educational programmes were effective in improving compliance in the emergency depart-
ment, and bacterial load on hands of healthcare workers could be used as an indicator of improvement in hand hygiene
compliance.
Keywords: bacterial load, compliance, Five Moments for Hand Hygiene, hand hygiene, infection
Citation: Fouad M; Eltaher S. Hand hygiene initiative: comparative study of pre- and post-intervention outcomes. East Mediterr Health J.
2020;26(2):198–205. https://doi.org/10.26719/2020.26.2.198
Received: 10/01/18; accepted: 11/07/18
Copyright © World Health Organization (WHO) 2020. Open Access. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO
license (https://creativecommons.org/licenses/by-nc-sa/3.0/igo).

Introduction
Healthcare-associated infections (HAIs) are acquired dur-
ing treatment for another condition and are not present
or incubating at the time of admission, and they carry a
significant burden of illness and financial costs (1). Ap-
proximately 7% of hospitalized patients in industrialized
nations and 10% in low- and middle-income countries are
affected (2).

Hand hygiene is among the most important measures
to prevent transmission and acquisition of HAIs (3).
Despite recognition of the crucial role of hand hygiene
in reducing infection rates, compliance rates among
healthcare workers remain low (4). In a systematic review
of 96 studies from industrialized nations, the overall
average compliance was 40% (5).

According to the World Health Organization (WHO)
the multimodal “Clean Care Is Safer Care” strategy and
the “Five Moments for Hand Hygiene” concept should be
performed (1) before touching a patient; (2) before aseptic
procedures; (3) after risk of body fluid exposure; (4)

after touching a patient; and (5) after touching patients’
surroundings (6,7).

The emergency department has special environmental
conditions that may interfere with proper hand hygiene
compliance, including crowding, use of nontraditional
care areas such as hallways, frequent interruptions to
care delivery, and close proximity of patients, who are
often separated only by curtains (8,9). Few other studies
have assessed the efficacy of hand hygiene interventions
in emergency departments (10–13), and yet fewer have
used the WHO “Five Moments for Hand Hygiene”. Other
studies have used alternative methods (9). Due to the
rapid turnover in emergency departments, it is difficult
to measure HAI rates as an indicator of improvement.
HAIs, by definition, develop after at least 48 hours of
hospitalization, and most emergency cases are discharged
on the same day.

The aim of this study was to determine the
effectiveness of infection control intervention to improve
compliance with hand hygiene in the Emergency
Department, Al-Leith General Hospital, Saudi Arabia.

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Research article EMHJ – Vol. 26 No. 2 – 2020

We also evaluated bacterial load on hands as a possible
indicator of improvement of hand hygiene compliance.

Methods
Study setting
The study was conducted in the Emergency Department at
Al-Leith General Hospital, Saudi Arabia, between October
2016 and March 2017. Al-Leith General Hospital is a sec-
ondary level hospital with a total capacity of 65 beds. This
work was approved by the Bioethics Committee, Health
Sciences College at Alith, Umm Al-Qura University.

Study design
This was an interventional study that consisted of 3 phas-
es: Phase I, the basal hand hygiene compliance level was
measured by direct observation; Phase II, a hand hygiene
educational programme was offered to healthcare staff
working in the hospital emergency department; and
Phase III, hand hygiene compliance level was measured
again to determine the effect of the intervention.

Observations and calculations
Data were obtained from 40 observation sessions; 20 in
Phase I and 20 in Phase III. Each observational session
was ~20 minutes. The timings of the observation ses-
sions were randomly distributed throughout the day and
night. Observations were conducted by trained volunteer
students. All professional healthcare providers and stu-
dents who were working in the emergency department
were included in the study. Healthcare workers were
divided into 3 professional categories: (1) nurse/nurse
student; (2) medical doctor/medical student; and (3) oth-
er healthcare workers (therapists/technicians/dietitians/
dentists/students).

Counting of hand hygiene opportunities and hand
hygiene actions was based on the WHO Five Moments
of Hand Hygiene concept: (1) before touching a patient;
(2) before clean/aseptic procedure; (3) after risk of body
fluid exposure; (4) after touching a patient; and (5) after
touching patients’ surroundings (6,14,15).

A hand hygiene opportunity is defined as a moment
during healthcare activities when hand hygiene is
required, regardless of the number of indications. Several
indications may arise simultaneously, creating a single
opportunity and requiring a single hand hygiene action
(15). Accepted hand hygiene actions include healthcare
workers performing alcohol-based hand rubbing or
handwashing with soap and water. Hand hygiene
compliance was calculated by dividing the number of
performed hand disinfections by the number of hand
hygiene opportunities. Analyses were stratified by
professional group.

Compliance (%)= ×100Actions
Opportunities

Training of auditors
In October 2016, volunteer students were recruited as

hand hygiene auditors after a detailed training process.
Training included prepared PowerPoint presentations
and educational video of actual healthcare workers per-
forming patient care tasks (16). During video watching,
the students were asked to observe and report hand hy-
giene opportunities and actions using the actual observa-
tion form that would be used in the study. Later, students
were engaged in inter-rater reliability testing, in which
a series of hand hygiene practices were co-observed in
the emergency department, and disagreements were
discussed and resolved according to WHO hand hygiene
training tools (16).

Phase I (preintervention: November–December
2016)
Phase I is referred to as baseline assessment. Hand hy-
giene compliance rate in the emergency department was
determined for the above-mentioned Five Moments of
Hand Hygiene by trained assessors. Potential opportuni-
ties for hand hygiene were recorded along with the actual
number of episodes of hand hygiene. Recording was per-
formed on a special observation form. Observations were
done at random times without prior announcement. Ob-
servers acted as unobtrusively as possible but disclosed
their task readily on enquiry. Observation sessions lasted
20 (5) minutes.

Phase II (intervention: January 2017)
Phase II was the interventional phase. This was a mul-
timodal intervention that was conducted in the form of
health education sessions using direct personal contact
by volunteer students; educational lectures that included
a live demonstration of hand hygiene techniques; posters
that demonstrated the Five Moments of Hand Hygiene;
and other posters that emphasized the importance of
hand hygiene (e.g., Hand Hygiene Saves Lives). The post-
ers were placed at strategic sites within the emergency
department, ensuring availability of alcohol-based hand
cleaners and personal protective equipment at all patient
care areas. An additional component of the intervention
was feedback, which consisted of announcing the com-
pliance results from Phase I to the emergency depart-
ment staff.

Phase III (postintervention: February–March
2017)
After the educational interventions, hand hygiene com-
pliance was measured again using the same methods fol-
lowed in Phase I.

Determining hand bacterial load
It is difficult to monitor HAI rates among emergency de-
partment patients because of the short stays involved.
Therefore, we introduced measurement of bacterial
load on hands of healthcare workers as an alternative to
measure the benefit obtained by improvement in hand
hygiene compliance rates. Fifty samples were taken from
hands of healthcare workers during Phase I, and another
50 samples were taken during Phase III. Samples were

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EMHJ – Vol. 26 No. 2 – 2020Research article

taken from the dominant hand in both phases because
hand microbiomes differ between dominant and non-
dominant hands (17). The sampling method was a mod-
ified sterile bag adopted from the method used by Lar-
son et al. (18). Sterile peptone water (50 ml) was poured
into sterile polyethylene bags, after which, the hand of
the healthcare worker was inserted, the bag opening was
secured at the wrist with a tourniquet, and the hand was
uniformly massaged for 1 minute by the research staff
through the wall of the bag. The solution was mixed in
the bag and 0.05-ml aliquots of each sampling solution
were plated on tryptic soy agar plates (Merck, Darmstadt,
Germany). Inocula were spread with bent glass rods.
Plates were incubated at 37°C under aerobic conditions
for 24 hours, and colony-forming units (CFU) were
counted, and bacterial load was calculated and expressed
as CFU/hand. Bacterial load on hands was compared us-
ing the log10-transformed bacterial count.

Statistical analysis
The data were tabulated, coded and analysed using SPSS
for Windows version 20.0. Compliance rates at baseline
and follow-up, overall, for the different professional cat-
egories, and for different hand hygiene indications were
compared using the χ2 test. Paired t test was done to test
the significance of the difference in mean CFU counts be-
tween Phases I and III. P < 0.05 was considered significant.

Results
There were 1374 hand hygiene opportunities during the
study. Nurses had the largest number of opportunities
(87.92%) in comparison to other professional groups (Table
1). Profession-specific analysis revealed that hand hygiene
compliance increased significantly in physicians (187% of
baseline) and nurses (147% of baseline) (both P < 0.01). The
compliance of the other healthcare workers can be consid-
ered unchanged since the variation was insignificant (P
= 0.926). The total number of hand hygiene actions sig-
nificantly increased from 203/662 (30.66%) in Phase I to
324/712 (45.51%) in Phase III (P < 0.01) (Table 2).

Compliance results revealed that indication-specific
differences ranged from 12.21% (Indication 2) to 48.84%
(Indication 4) at baseline (Tables 3 and 4). Compliance
before patient contact and before aseptic tasks (Indications
1 and 2) was lower compared to that after patient contact
(Indications 3–5). Significant improvements were seen
only for Indications 1, 2 and 5. The greatest improvement
was seen for Indication 2 (279% of baseline; P < 0.01), and
the lowest for Indication 5 (137% of baseline; P = 0.018).

Bacterial load on hands of healthcare workers was
measured in Phases I and III (Figure 1). In phase I before
intervention average log CFU/hand was 4.97 (0.32). In
Phase III log CFU/hand was significantly increased to
4.57 (0.47) (P < 0.001).

Discussion
The emergency department is an indispensable compo-
nent of the current healthcare system; nevertheless, it
may have special environmental conditions that inter-
fere with proper hand hygiene compliance. Although
there have been many interventional studies of hand hy-
giene, published data from Saudi Arabia are limited and
show contradicting results (19,20). Hand hygiene among
healthcare workers remains low and there is room for im-
provement.

In this study, the educational intervention was
associated with a significant increase in compliance rate
(30.66 to 45.51%). This result is similar to previous studies
showing that educational interventions improve hand
hygiene compliance (21,22). A few studies have reported
hand hygiene compliance rates in Saudi Arabia (13,19,20,
23,24). Our pre- and postintervention compliance rates
(30.66% and 45.51%, respectively) are inferior to an overall
compliance rate of 50.3% reported previously in Saudi
Arabia (13). The lower rate in our study may have been
because it was conducted in the emergency department,
which had unique environmental conditions that
impeded proper application of hand hygiene. In another
study conducted in Saudi Arabia, the compliance
rate was 62.5% (19) but the method of calculation was
based on classifying healthcare workers as compliant
or noncompliant, which is a flawed method, because
compliance varies in the same person over time. The
international consensus is to measure compliance
per opportunity rather than per person. A third study
conducted in intensive care units in a Saudi hospital
reported a compliance rate of 59% (23). In a systematic
review of 96 studies on hand hygiene, compliance levels
in non-intensive care settings were 50–60% (5), which is
superior to the levels obtained in our study. The relatively
low level of postintervention compliance (45.5%) is
comparable to that in other studies performed in the
emergency department. This was evident in a study
performed in emergency departments where compliance
reached 45% after 2 successive interventions (21).

The relatively low hand hygiene compliance rate
in this study (<50%) could be attributed to laxity of the
pre-existing infection control programme in the study
hospital. For example, essential infection control activities

Table 1 Hand hygiene opportunities according to health care
worker professional group

Professional
group

Phase I Phase III Total

n % n % n %
Nurses 582 87.92 566 79.49 1148 83.55

Physicians 71 10.73 127 17.84 198 14.41

Other 9 1.36 19 2.67 28 2.04

Total 662 100.0 712 100.0 1374 100.0

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Research article EMHJ – Vol. 26 No. 2 – 2020

such as surveillance and auditing were performed
irregularly and were merely performed as paperwork.
It could also be attributed to the special characteristics
of the study settings in the emergency department, as
mentioned before. The absence of leadership engagement
in this study could also have been partially responsible
for the modest improvement. Effective leadership
involvement can improve hand hygiene compliance
(25,26). Continuing efforts and further interventions are
needed to address such issues.

Our results show that physicians had less compliance
for hand hygiene than nurses had (23.9% vs 31.4% in Phase
I, respectively). This result is in accordance with other local
and international studies (13,27). Previous studies have
shown that physicians in general show poor compliance
with infection control standards (28). This was evident in a
study conducted in Saudi Arabia in which adherence rates
were reported as 60% for nurses and 20% for physicians at
the completion of a hand hygiene improvement campaign
(13). It is noticeable that although physicians’ compliance
level was inferior to that of nurses, they showed a higher
level of improvement in Phase III.

Our study showed that most hand hygiene
opportunities were encountered by nurses (1148/1374;
83.6%). This represents an opportunity to target nurses by
tailored educational programmes to foster hand hygiene
compliance improvements among such an influential

group. It has been shown that the level of knowledge
and compliance with hand hygiene practice differs
significantly among nurses according to years of service;
the highest level of knowledge was achieved by nurses
with < 1 year of service, while the highest compliance
level was achieved by more experienced nurses (16–20
years of service). The same study showed that higher
levels of nurse education (receiving post-basic course)
was associated with increased hand hygiene compliance
(29). These finding reflects that hand hygiene education
should be continuous and target not only newly recruited
nurses, but also those with more experience. Other
strategies, beside nurse education, that were proved to
positively influence hand hygiene compliance include
those aimed at social influence within teams and
enhanced leadership (30).

Although hand hygiene compliance levels improved
in physicians and nurses, there was no significant
change in the other groups, which included technicians,
therapists and radiologists. However, the number of
observed opportunities for this group in Phase I was
relatively small, which was reflected in their statistical
results. The compliance rate in this group could also have
been affected by the difficulty in targeting such a group
in educational activities, which were held using a variety
of methods, but mainly by interpersonal communication
in the emergency department. Therefore, we can
speculate that the chance of receiving an educational
session is increased by the average period spent by the
personnel in the emergency department. Educational and
motivational programmes adapted to specific groups of
health personnel are needed to address such a situation.

In this study, the compliance rate before patient
contact (23.93%) was lower than after patient contact
(48.84%). Similar results have been reported in other local
(23) and international (21) studies. This is a phenomenon
worth mentioning, because, paradoxically, situations that
pose more risk of infection to patients are associated with
less hand hygiene compliance from healthcare workers.
Hand hygiene before patient contact and before aseptic
tasks (Indications 1 and 2) plays a major role in controlling
HAIs and avoiding cross-transmission of multiresistant
bacteria, thus compliance with these 2 indications is a
cornerstone in infection control (6). These 2 indications
also showed the highest percentage of improvement
after intervention; Indication 2, in particular, showed

Table 2 Hand hygiene compliance rates according to professional group

Professional
group

Phase I Phase III Total P*

Opportunities HH
Action

Compliance
(%)

Opportunities HH
Action

Compliance
(%)

Nurses 582 183 31.44 566 261 46.11 < 0.001

Physicians 71 17 23.94 127 57 44.88 0.004

Other 9 3 33.33 19 6 31.58 0.926

Total 662a 203 30.66 712 324 45.51 < 0.001
*Calculated by χ2 test.
aSum of indications is not equal to the sum of opportunities because 1 opportunity may cover 2 overlapping indications.

Table 3 Hand hygiene opportunities according to WHO Five
Moments for Hand Hygiene

Hand hygiene
encounter

Phase I Phase III

n % n %
1. Before touching a

patient
117 17.38 116 16.11

2. Before aseptic
procedures

172 25.56 217 30.14

3. After body fluid
exposure risk

87 12.93 106 14.72

4. After touching a
patient

172 25.56 137 19.03

5. After touching patient
surroundings

125 18.57 144 20.00

Total 673a 100.0 720 100.0
aNumber of opportunities according to Five Moments for Hand Hygiene is larger than
according to healthcare worker professional group due to the fact that an opportunity may
be counted twice for 2 indications and once for 1 HCW if 2 indications overlapped.

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EMHJ – Vol. 26 No. 2 – 2020Research article

more than double improvement (12.21% to 34.1%). The
ignorance of Indication 2 (before aseptic procedure)
may have been due to an incorrect assumption that
performing hand hygiene before patient contact was
enough, and this misconception could be corrected by
administering proper hand hygiene education.

The difficulty in targeting particular groups of health
personnel, the need to improve the modest adherence to
hand hygiene in emergency departments, as well as the
need to achieve sustainable improvement, all impose
challenging demands on healthcare organizations to
develop and maintain an innovative and multidisciplinary
approach to improve adherence to hand hygiene.
Successful and sustained hand hygiene improvement
can be achieved by implementing multiple actions to
tackle different obstacles and behavioural barriers. WHO
has proposed a multimodal strategy that includes 5 key
components: (1) supportive infrastructure; (2) training
and education; (3) evaluation and feedback; (4) reminders
in the workplace; and (5) creating an institutional
safety awareness climate (31). All these elements were
implemented in the present study.

Suggestions for further improvements to be
implemented include patient participation and leadership
involvement. These components were missing from the
current study. Patient participation has been shown to be
effective in improving compliance (32) and is increasingly
recognized as an important item to be included in
multimodal strategies to improve hand hygiene adherence
(33). Leadership involvement was also absent from our
study. Absence of leadership has been linked with loss
of sustainable change in hand hygiene compliance (34).
Other studies have shown that inclusion of administrative
leadership is linked with improvements in hand hygiene
compliance rates and most importantly with enhanced
sustainability of such improvements (25, 26).

Measurement of HAI rates as an indicator of improved
hand hygiene in emergency departments is difficult due
to rapid patient turnover rate. This study attempted
to evaluate bacterial hand load as an indicator of
improvement after infection control intervention. It has

been demonstrated previously that there are significant
differences in mean CFU counts before and after
handwashing according to frequency of hand washing;
bacterial counts tend to decrease with increasing
frequency of hand washing (35). We tried to use bacterial
load on healthcare workers’ hands as an indirect indicator
of overall hand hygiene compliance. The average bacterial
load per hand decreased significantly, which suggests
that average bacterial load on hands of healthcare
workers can be used as an objective measurement for
overall hand hygiene compliance. Although bacterial
load count tends to show great variability from person
to person and from time to time, we showed that change
in the average count may be used as an indicator for
overall compliance. It is difficult to prove the validity of
this method due to natural variability of bacterial count

Table 4 Indication specific hand hygiene compliance rates according to the WHO Five Moments for Hand Hygiene

Hand hygiene
indication

Phase I Phase III P*

Opportunities HH
Action

Compliance
(%)

Opportunities HH
Action

Compliance
(%)

1. Before touching a
patient

117 28 23.93 116 53 45.69 < 0.001

2. Before aseptic
procedures

172 21 12.21 217 74 34.10 0.004

3. After body fluid
exposure risk

87 27 31.03 106 43 40.57 0.926

4. After touching a
patient

172 84 48.84 137 81 59.12 < 0.001

5. After touching patient
surroundings

125 48 38.40 144 76 52.78 0.02

*Calculated by χ2 test.

Lo
g

CF
U

p
er

h
an

d

6.0

5.5

5.0

4.5

4.0

Phase

3.5

3.0

Phase I Phase III

60

74

Figure 1 Box and whisker plots showing bacterial load on
hands of healthcare workers measured during Phases I and III.

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Research article EMHJ – Vol. 26 No. 2 – 2020

مبادرة نظافة األيدي: دراسة مقارنة للمخرجات قبل التدخل وبعده
حممد فؤاد، رشيف الطاهر

اخلالصة
اخللفية: ُتعد نظافة األيدي الكافية أكثر التدابري فعالية للحد من انتقال اجلراثيم املستشفوية.

األهداف: حتديد مدى فعالية التدخل بشأن مكافحة العدوى لتحسني االلتزام بنظافة األيدي يف قسم الطوارئ، بمستشفى الليث العام، يف اململكة
العربية السعودية، وحتديد كمية اجلراثيم عىل األيدي بوصفها مؤرشًا حمتماًل ملستوى التحسن.

طرق البحث: تكونت الدراسة من 3 مراحل: املرحلة األوىل: قياس املستوى القاعدي لاللتزام بنظافة األيدي؛ واملرحلة الثانية: بدء تنفيذ برنامج تثقيفي
متعدد النامذج حول نظافة األيدي؛ واملرحلة الثالثة: قياس مستوى نظافة األيدي جمددًا. وُجعت البيانات من خالل املالحظة املبارشة للعاملني يف جمال
الرعاية الصحية يف قسم الطوارئ يف الفرتة من أكتوبر/ترشين األول 2016 وحتى مارس/آذار 2017، باستخدام طريقة منظمة الصحة العاملية املوحدة
للمالحظة املبارشة، »اللحظات اخلمس لنظافة اليدين«. وقد اشتمل التدخل عىل جلسات تثقيفية عن الصحة من خالل التواصل الشخيص املبارش.

وُأخذت عينات من أيدي العاملني يف جمال الرعاية الصحية خالل املرحلتني األوىل والثالثة باستخدام الكيس امُلعقم، وحتددت كمية اجلراثيم.
النتائج: بلغ إجايل فرص نظافة األيدي 1374 فرصًة ُرِصدت أثناء الدراسة املكونة من 3 مراحل. وأدى تنفيذ الربنامج التثقيفي التدخيل لنظافة
األيدي إىل زيادة االلتزام بصورة كبرية باملبادئ التوجيهية اخلاصة بنظافة األيدي، إذ ارتفعت من 30.7% إىل 45.5% )القيمة االحتاملية > 0.01(.

Initiative en faveur de l’hygiène des mains : étude comparative des résultats
pré- et post-intervention
Résumé
Contexte : Une hygiène des mains adéquate est considérée comme la mesure la plus efficace pour réduire la transmission
des agents pathogènes nosocomiaux.
Objectifs : Déterminer l’efficacité d’une intervention visant à améliorer le respect des règles d’hygiène des mains pour la
lutte contre les infections au service des urgences de l’Hôpital général d’Al-Leith, en Arabie saoudite, et évaluer la charge
bactérienne sur les mains comme indicateur d’amélioration possible.
Méthodes : L’étude s’est déroulée en trois phases : Phase I, évaluation du niveau de conformité avec les règles de base
d’hygiène des mains ; Phase II, lancement d’un programme multimodal d’éducation en matière d’hygiène des mains ; et
Phase III, nouvelle évaluation du niveau de conformité avec les règles de base d’hygiène des mains. Les données collectées
découlent de l’observation directe du personnel soignant du service des urgences entre octobre 2016 et mars 2017, en
utilisant la méthode d’observation directe standardisée de l’Organisation mondiale de la Santé, les « 5 indications pour
l’hygiène des mains ». L’intervention comprenait des sessions d’éducation pour la santé avec contact personnel direct. Des
échantillons ont été prélevés sur les mains du personnel soignant durant les Phases I et III selon la méthode du sac stérile
afin de déterminer la charge bactérienne.
Résultats : Au total, l’observation a permis de relever 1 374 opportunités d’amélioration de l’hygiène des mains durant
l’étude en trois phases. La mise en œuvre du programme interventionnel d’éducation en matière d’hygiène des mains a
permis d’améliorer de manière significative la conformité avec les règles d’hygiène des mains, qui est passée de 30,7 %
à 45,5 % (p < 0,01). La charge bactérienne logarithmique (log10) par main a chuté, passant de 4,97 (écart type = 0,32)
à 4,57 (0,47) (p < 0,05).
Conclusions : Les programmes d’éducation en matière d’hygiène des mains se sont avérés efficaces pour améliorer la
conformité dans le service des urgences. La charge bactérienne sur les mains des agents de soins de santé pourrait servir
d’indicateur d’amélioration du degré de conformité avec les règles d’hygiène des mains.

on hands of healthcare personnel throughout the day.
This is evident in Figure 1, which shows a wide range
of bacterial counts in both phases of the study. Further
research is needed to enhance the validity of this method
to be used in clinical scenarios.

The limitations of our study included the lack of
leadership and patient involvement. We measured short-
term improvement, and repeated measurement of sustained
improvement over the long term was not performed.

Conclusion
Educational intervention was effective in improving
hand hygiene compliance. Average bacterial load on
hands of healthcare workers may be used as an addi-
tional indicator of overall compliance with hand hy-
giene procedures, especially in rapid patient turnover
areas such as emergency departments.

Funding: None.

Competing interests: None declared.

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References
1. Pittet D, Allegranzi B, Storr J, Donaldson L. ‘Clean Care is Safer Care’: the Global Patient Safety Challenge 2005–2006. Int J Infect

Dis. 2006 Nov;10(6):419–24. http://dx.doi.org/10.1016/j.ijid.2006.06.001 PMID:16914344

2. Report on the burden of endemic health care-associated infection worldwide. Geneva: World Health Organization; 2011 (https://
apps.who.int/iris/bitstream/handle/10665/80135/9789241501507_eng.pdf;jsessionid=A1D9102FBF66AFA2A8EAA1EE40898CBE?se-
quence=1, accessed 13 August 2019).

3. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control
Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol.
2002 Dec;23(12 Suppl):S3–40. http://dx.doi.org/10.1086/503164 PMID:12515399

4. Mukerji A, Narciso J, Moore C, McGeer A, Kelly E, Shah V. An observational study of the hand hygiene initiative: a compari-
son of preintervention and postintervention outcomes. BMJ Open. 2013 3(5). http://dx.doi.org/10.1136/bmjopen-2013-003018
PMID:23793705

5. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, et al. Systematic review of studies on compliance with hand
hygiene guidelines in hospital care. Infect Control Hosp Epidemiol. 2010 Mar;31(3):283–94. http://dx.doi.org/10.1086/650451
PMID:20088678

6. WHO guidelines on hand hygiene in health care : first global patient safety challenge : clean care is safer care. Geneva: World
Health Organization; 2009 (https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1, ac-
cessed 13 August 2019).

7. Pittet D, Allegranzi B, Sax H, Bertinato L, Concia E, Cockson B. Considerations for a WHO European strategy on healthcare-asso-
ciated infection, surveillance, and control. Lancet Infect Dis. 2005 Apr;5(4):242–50. http://dx.doi.org/10.1016/s1473-3099(05)70055-
4 PMID:15792742

8. Carter EJ, Wyer P, Giglio J, Jia H, Nelson G, Kauari VE, et al. Environmental factors and their association with emergency
department hand hygiene compliance: an observational study. BMJ Qual Saf. 2016 May;25(5):372–8. http://dx.doi.org/10.1136/
bmjqs-2015-004081 PMID:26232494

9. Carter EJ, Pouch SM, Larson EL. Common infection control practices in the emergency department: a literature review. Ameri-
can Journal of Infection Control. 2014 Sep;42(9):957–62. http://dx.doi.org/10.1016/j.ajic.2014.01.026 PMID:25179326

10. Haas JP, Larson EL. Impact of wearable alcohol gel dispensers on hand hygiene in an emergency department. Acad Emerg Med.
2008 Apr;15(4):393-6. 10.1111/j.1553-2712.2008.00045.x PMID:18370997

11. Saint S, Conti A, Bartoloni A, Virgili G, Mannelli F, Fumagalli S, et al. Improving healthcare worker hand hygiene adherence be-
fore patient contact: a before-and-after five-unit multimodal intervention in Tuscany. Qual Saf Health Care. 2009 Dec;18(6):429–
33. http://dx.doi.org/10.1136/qshc.2009.032771 PMID:19955452

12. Saint S, Bartoloni A, Virgili G, Mannelli F, Fumagalli S, di Martino P, et al. Marked variability in adherence to hand hygiene: a
5-unit observational study in Tuscany. Am J Infect Control. 2009 May;37(4):306–10. http://dx.doi.org/10.1016/j.ajic.2008.08.004
PMID:19135761

13. Bukhari SZ, Hussain WM, Banjar A, Almaimani WH, Karima TM, Fatani MI. Hand hygiene compliance rate among healthcare
professionals. Saudi Med J. 2011 May;32(5):515–9. PMID:21556474

14. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design ap-
proach to understand, train, monitor and report hand hygiene. J Hosp Infect. 2007 Sep;67(1):9-21. http://dx.doi.org/10.1016/j.
jhin.2007.06.004 PMID:17719685

15. Hand hygiene technical reference manual: to be used by health-care workers, trainers and observers of hand hygiene practices
Geneva: World Health Organization; 2009 (https://apps.who.int/iris/bitstream/handle/10665/44196/9789241598606_eng.pdf?se-
quence=1&isAllowed=y, accessed 13 August 2019).

16. Tools for training and education. Geneva: World Health Organization; 2012 (https://www.who.int/gpsc/5may/tools/training_ed-
ucation/en/, accessed 13 August 2019).

17. Fierer N, Hamady M, Lauber CL, Knight R. The influence of sex, handedness, and washing on the diversity of hand surface bac-
teria. Proc Natl Acad Sci U S A. 2008 Nov18;18;105(46):17994–9. http://dx.doi.org/10.1073/pnas.0807920105 PMID:19004758

18. Larson EL, Strom MS, Evans CA. Analysis of three variables in sampling solutions used to assay bacteria of hands: type of solu-
tion, use of antiseptic neutralizers, and solution temperature. J Clin Microbiol. 1980 Sep;12(3):355–60. PMID:7012171

19. Abdraboh SN, Milaat W, Ramadan IK, Al-Sayes FM, Bahy KM. Hand hygiene and health care associated infection: an interven-
tion study. Am J Med Med Sci. 2016;6(1):7–15 http://dx.doi.org/10.5923/j.ajmms.20160601.02

وشهد اللوغاريتم العرشي كمية اجلراثيم لكل يد انخفاضًا من 4.97 )االنحراف املعياري = 0.32( إىل 4.57 )القيمة االحتاملية > 0.05(.
االستنتاجات: أثبتت الربامج التثقيفية املعنية بنظافة األيدي فعاليتها يف زيادة االلتزام يف قسم الطوارئ، ويمكن استخدام كمية اجلراثيم املوجودة

ن االلتزام بنظافة األيدي. عىل أيدي العاملني يف جمال الرعاية الصحية بوصفها مؤرشًا عىل حتسُّ

205

Research article EMHJ – Vol. 26 No. 2 – 2020

20. Basurrah MM, Madani TA. Handwashing and gloving practice among health care workers in medical and surgical wards in a
tertiary care centre in Riyadh, Saudi Arabia. Scand J Infect Dis. 2006;38(8):620–4. http://dx.doi.org/10.1080/00365540600617025
PMID:16857605

21. Scheithauer S, Kamerseder V, Petersen P, Brokmann JC, Lopez-Gonzalez L-A, Mach C, et al. Improving hand hygiene compliance
in the emergency department: getting to the point. BMC Infect Dis. 2013 Aug 7;13(1):367. http://dx.doi.org/10.1186/1471-2334-13-367

22. Creedon SA. Healthcare workers’ hand decontamination practices: compliance with recommended guidelines. J Adv Nurs. 2005
Aug;51(3):208–16. http://dx.doi.org/10.1111/j.1365-2648.2005.03490.x PMID:16033588

23. Mahfouz AA, El Gamal MN, Al-Azraqi TA. Hand hygiene non-compliance among intensive care unit health care workers in Aseer
Central Hospital, south-western Saudi Arabia. International Journal of Infectious Diseases. 2013 Sep;17(9):e729-e32. http://dx.doi.
org/10.1016/j.ijid.2013.02.025 PMID:23602356

24. ALSofiani AM, AlOmari F, AlQarny M. Knowledge and practice of hand hygiene among healthcare workers at Armed
Forces Military Hospitals, Taif, Saudi Arabia. Int J Med Sci Public Health, 2015;5(6):1282–91. http://dx.doi.org/10.5455/ijm-
sph.2016.15042016439

25. Midturi JK, Narasimhan A, Barnett T, Sodek J, Schreier W, Barnett J, et al. A successful multifaceted strategy to improve hand
hygiene compliance rates. Am J Infect Control. 2015 May 1;43(5):533–6. http://dx.doi.org/10.1016/j.ajic.2015.01.024 PMID:25769618

26. Staines A, Amherdt I, Lecureux E, Petignat C, Eggimann P, Schwab M, et al. Hand Hygiene Improvement and Sustainability:
Assessing a Breakthrough Collaborative in Western Switzerland. Infect Control Hosp Epidemiol. 2017 Dec;38(12):1420–27. http://
dx.doi.org/10.1017/ice.2017.180 PMID:28899451

27. Han K, Dou FM, Zhang LJ, Zhu BP. [Compliance on hand-hygiene among healthcare providers working at secondary and tertiary
general hospitals in Chengdu]. Zhonghua Liu Xing Bing Xue Za Zhi. 2011 Nov;32(11):1139–42 (in Chinese). PMID:22336552

28. Venier AG, Zaro-Goni D, Pefau M, Hauray J, Nunes J, Cadot C, et al. Performance of hand hygiene in 214 healthcare facilities in
South-Western France. J Hosp Infect. 2009 Mar;71(3):280–82. http://dx.doi.org/10.1016/j.jhin.2008.11.020 PMID:19162370

29. Ho SE, Ho CC, Hng SH, Liu CY, Jaafar MZ, Lim B. Nurses compliance to hand hygiene practice and knowledge at Klang Valley
hospital. Clin Ter. 2013;164(5):407–11. http://dx.doi.org/10.7417/ct.2013.1604 PMID:24217826

30. Huis A, Holleman G, van Achterberg T, Grol R, Schoonhoven L, Hulscher M. Explaining the effects of two different strategies for
promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial. Implementa-
tion Sci. 2013 Apr 8;Article number 41. https://implementationscience.biomedcentral.com/articles/10.1186/1748-5908-8-41

31. A guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: World Health Organiza-
tion; 2009 (https://apps.who.int/iris/handle/10665/70030, accessed13 August 2019).

32. McGuckin M, Waterman R, Porten L, Bello S, Caruso M, Juzaitis B, et al. Patient education model for increasing handwashing
compliance. Am J Infect Control. 1999 Aug;27(4):309–14. PMID:10433668

33. Lastinger A, Gomez K, Manegold E, Khakoo R. Use of a patient empowerment tool for hand hygiene. Am J Infect Control. 2017
Aug 1;45(8):824–29. http://dx.doi.org/10.1016/j.ajic.2017.02.010 PMID:28768590

34. Lieber SR, Mantengoli E, Saint S, Fowler KE, Fumagalli C, Bartolozzi D, et al. The effect of leadership on hand hygiene: assessing
hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany. Infect Control Hosp Epidemiol. 2014
Mar;35(3):313–6. http://dx.doi.org/10.1086/675296 PMID:24521600

35. Larson E. Effects of handwashing agent, handwashing frequency, and clinical area on hand flora. American Journal of Infection
Control. Am J Infect Control. 1984 Apr;12(2):76–82 https://doi.org/10.1016/0196-6553(84)90020-8 PMID:6563870

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