Implementation of WHO multimodal strategy for improvement of hand hygiene: a quasi-experimental study in a Traditional Chinese Medicine hospital in Xi’an, China
Shen et al. Antimicrobial Resistance and Infection Control
Implementation of WHO multimodal strategy for improvement of hand hygiene: a quasi-experimental study in a Traditional Chinese Medicine hospital in Xi'an, China
Li Shen 0 3
Xiaoqing Wang 0 3
Junming An 2
Jialu An 1
Ning Zhou 0 3
Lu Sun 0 3
Hong Chen 0 3
Lin Feng 4
Jing Han 1
Xiaorong Liu 1
0 Department of Infection Control, Xi'an Hospital of Traditional Chinese Medicine , No.69 Feng Cheng 8th Road, Weiyang District, Xi'an 710021 , China
1 Department of Information Consultation, Library of Xi'an Jiaotong University , No.76 Yan Ta West Road, Yanta District, Xi'an 710061 , China
2 Department of Acupuncture and Moxibustion, Xi'an Hospital of Traditional Chinese Medicine , No.69 Feng Cheng 8th Road, Weiyang District, Xi'an 710021 , China
3 Department of Infection Control, Xi'an Hospital of Traditional Chinese Medicine , No.69 Feng Cheng 8th Road, Weiyang District, Xi'an 710021 , China
4 Department of Cadre Health Care, Xi'an Hospital of Traditional Chinese Medicine , No.69 Feng Cheng 8th Road, Weiyang District, Xi'an 710021 , China
Background: Hand hygiene (HH) is an essential component for preventing and controlling of healthcare-associated infection (HAI), whereas compliance with HH among health care workers (HCWs) is frequently poor. This study aimed to assess compliance and correctness with HH before and after the implementation of a multimodal HH improvement strategy launched by the World Health Organization (WHO). Methods: A quasi-experimental study design including questionnaire survey generalizing possible factors affecting HH behaviors of HCWs and direct observation method was used to evaluate the effectiveness of WHO multimodal HH strategy in a hospital of Traditional Chinese Medicine. Multimodal HH improvement strategy was drawn up according to the results of questionnaire survey. Compliance and correctness with HH among HCWs were compared before and after intervention. Also HH practices for different indications based on WHO “My Five Moments for Hand Hygiene” were recorded. Results: In total, 553 HCWs participated in the questionnaire survey and multimodal HH improvement strategy was developed based on individual, environment and management levels. A total of 5044 observations in 23 wards were recorded in this investigation. The rate of compliance and correctness with HH improved from 66.27% and 47.75% at baseline to 80.53% and 88.35% after intervention. Doctors seemed to have better compliance with HH after intervention (84.04%) than nurses and other HCWs (81.07% and 69.42%, respectively). When stratified by indication, compliance with HH improved for all indications after intervention (P < 0.05) except for “after body fluid exposure risk” and “after touching patient surroundings”. Conclusion: Implementing the WHO multimodal HH strategy can significantly improve HH compliance and correctness among HCWs.
Hand hygiene; Compliance; Correctness; Healthcare-associated infection
Healthcare-associated infection (HAI) represents a major
burden and safety issue for patients in the developing
countries, with severe and greatly underestimated effect
on patients and health care systems [
]. According to the
survey of National HAI Surveillance System, in 2014, at
least 26,972 cases of HAI arose in patients admitted to
hospital in China [
]. HAI resulted in prolonged length of
hospital stay, direct economic loss, morbidity and
mortality among hospitalized patients [
]. A recent study in
China identified that the average cost of hospitalization
increased ¥13,839.16(€1792.64) due to HAI [
]. The hands
of healthcare workers (HCWs) can be a major mode of
transmission of microbial pathogens by touching the
environment or patients’ skin during healthcare delivery,
which supports that hand hygiene (HH) is a critical
component of a bundle approaches for preventing and
controlling HAIs [
]. The World Health Organization
(WHO) launched a multimodal strategy in 2009 to
improve HH practice worldwide, which includes 5 important
components: (1) system change, (2) training and
education, (3) evaluation and feedback, (4) reminders in the
workplace (5) institutional safety climate [
]. It has been
demonstrated the implementation of WHO HH strategy
is feasible and effective to enhance hand hygiene
compliance, which leads to a reduction of HAI [
However, there have been few data on the implementation
of the WHO multimodal HH strategy in China. We
initiated this study of implementation of WHO multimodal
HH strategy in order to improve awareness of HAI and
enhance HH compliance and correctness among HCWs.
The study was conducted in Xi’an Hospital of Traditional
Chinese Medicine (TCM), Xi’an, China, between
September 2015 and August 2016. It is the largest
public hospital in north Xi’an, which is the capital
city of Shaanxi Province. This hospital has 1001 beds
in 27 clinical departments including acupuncture and
moxibustion, intensive care, emergency, surgical and
TCM subspecialties with 1377 HCWs. We performed
this two-part quasi-experimental study including
questionnaire survey of factors affecting HH behaviors
of HCWs and direct observation of compliance and
correctness with HH before and after intervention.
Part I: Questionnaire survey
In this part, we did a questionnaire survey on
possible factors affecting HH behaviors of HCWs. Each
participant voted those factors contributing to HH
noncompliance from the questionnaire. On the basis
of the reasons for HH noncompliance summarized in
the questionnaire, multimodal improvement strategy
was developed accordingly.
Part II: Observation of compliance and correctness before
and after intervention
In this part, detailed intervention measures were drawn
up and then implemented according to the multimodal
improvement strategy acquired from the results of
questionnaire survey. We collected observational data on
compliance and correctness with HH before and after
Observation sessions were performed by 9 trained
student nurses. The training course included HH
indications and correct HH techniques recommended by
WHO. A standard form was used to record the HH
compliance and correctness. Observers were taught how
to complete the form and record the number of HH
actions and HH opportunities. We defined an opportunity
as the occurrence of any indication during the observed
care sequences. We recorded actions, either
handwashing or hand rubbing based on WHO “My Five Moments
for Hand Hygiene”: before touching a patient, before
clean/aseptic procedure, after body fluid exposure risk,
after touching a patient, and after touching patient
]. Since an indication for HH was related
to the risk of pathogen transmission from one surface to
another, we added two more WHO recommended
indications in our study: if moving from a contaminated
body site to a clean body site during patient care, after
removing gloves [
]. An action with correct HH
techniques must satisfy three criteria: (1) rub hands with
6step HH techniques; (2) duration of the rub procedure
lasts 15 s at least; (3) dry hands with disposable paper
towels. Each observer monitored the HH practice of
HCWs for 45–60 min.
Compliance and correctness with HH were compared
before and after the implementation. HCWs including
doctors, nurses, technicians, interns and cleaners were
observed for HH actions and HH opportunities. Data of
technicians, interns and cleaners was combined as other
HCWs. We expressed HH compliance as the proportion
of predefined opportunities met by HH actions. And HH
correctness was regarded as the proportion of all HH
actions met by HH actions with correct techniques. All the
data was analyzed with SPSS version 16.0. The Chi
square test was applied to test the statistical difference
in HH compliance and correctness before and after the
implementation. Also HH compliance stratified by
professional category and indication was calculated. Results
with P < 0.05 were considered statistically significant.
Part I: Questionnaire survey
A total of 558 HCWs from 37 departments participated
in this survey. Of these, 553 (99.10%) completed the
baseline questionnaire. The general information of all
participants was summarized in Table 1. Each participant
voted those factors contributing to HH noncompliance
from the questionnaire. All the possible factors affecting
HH behaviors of HCWs were arranged in descending
order according to the number of votes (Fig. 1). The main
reasons for HH noncompliance were classified into
individual, environment and management levels. Multimodal
improvement strategy was drafted accordingly (Fig. 2)
and detailed intervention measures were drawn up at
the same time.
For the individual reasons such as poor HH awareness,
full training campaign on HH techniques among HCWs
was carried out. Our management of infection control
department first participated in the training of WHO
“My Five Moments for Hand Hygiene” provided by Xi’an
Quality Control Center of Nosocomial Infection. Then
we shoot instructional videos on five key moments for
HH and correct HH techniques in our hospital wards
with our HCWs. After that they were called together to
study HH knowledge via videos and PPT (based on
WHO training slides). All the HCWs including doctors,
nurses, interns, student nurses, lab technicians and
cleaners should attend educational courses on HH every
year. A posttest format was used to assess training
efficacy after each course.
Inadequate HH supplies and inconvenient HH
facilities was another cause for noncompliance with HH in
our hospital. We took a series of measures to improve
HH facilities: increasing supplies of pocket alcohol-based
hand rub (ABHR) and disposable paper towels; making
sure every wash basin equipped with disposable paper
towels and poster for correct handwashing techniques;
replacing water tap in nurse station with automatic
electronic sensor tap; distributing skin care products to
HCWs. Colorful HH posters were placed in the doctor’s
office in each ward with WHO “My Five Moments for
Hand Hygiene”. A little tip for HH was placed at the
edge of the computer screen of nurse station. Visible
reminders for HH were also set at the entrance of each
ward. To create a better environment for HH, we offered
large-scale HH improvement campaign to both HCWs
and patients with knowledge contest, visible display
boards, and live performance.
In order to strengthen the supervision of HH practice
among HCWs, a seasonal feedback and evaluation
system was established. Management of infection control
department regularly reported HH compliance and HH
products consumption in the meeting of Nosocomial
Infection Control Management Committee, which
included hospital management, department heads, head
nurses and focal persons. Also HH compliance and HH
products consumption was directly related to the scores
of quality control of each department through HH
rewards and punishment mechanism. Department with
noncompliant HCWs had to pay a fine.
Part II: Observation of compliance and correctness before
and after intervention
In our study, a total of 5044 opportunities for HH were
recorded in 23 wards before and after intervention. The
rate of compliance with HH improved from 66.27% at
baseline to 80.53% after intervention (shown in Table 2).
After implementing the improvement strategy, doctors
had better HH compliance (84.04%) than nurses and
other HCWs (81.07% and 69.42%, respectively). The rate
of compliance with HH was statistically increased after
intervention for each professional category (P < 0.05).
A total of 2927 actions with correct HH techniques
were recorded. The rate of correctness with HH
improved from 47.75% to 88.35% after intervention
(shown in Table 3). The increase of correctness
applied for all professional categories, which was
statistically significant (P < 0.05).
HH compliance by indication
The rate of compliance with HH was statistically
elevated after intervention for all indications (P < 0.05)
except for “after body fluid exposure risk” and “after
touching patient surroundings”. The highest relative
improvement appeared to be indication “if moving from a
contaminated body site to a clean body site during
patient care”, from 30.61% to 59.82% (shown in Table 4).
Our study identified that implementation of WHO
multimodal HH improvement strategy was effective to
enhance HH compliance and correctness among HCWs.
In the questionnaire survey, over 50% of the participants
thought frequently washing hands led to hand skin
irritation and dryness, which was a vital cause for
noncompliance with HH. In addition, irritated hands might
be more vulnerable to be colonized with pathogens [
Since cleaning hands frequently is essential for every
health care worker, it is important for health care
settings to provide proper HH products. Compared with
detergent and soap, ABHR has been reported to cause
less skin irritation, especially those with emollient
]. The application of skin care products can
preserve unimpaired skin, reduce the incidence of skin
irritation and dryness and ensure effective hand hygiene
. In the last decades, there were concerns that skin
care products might pose a negative influence on the
efficacy of hand disinfection [
]. With the wide
research of well-formulated disinfectants with emollients
in recent years, it seems that the efficacy of disinfectants
would not be impaired when they are applied with
selected, compatible skin care products [
]. In our
study, we provided skin care products to our HCWs to
minimize the influence on HH compliance due to skin
irritation and dryness. Moreover, we encourage our
HCWs to use skin care products before work, cleaning
and after work under recommendations [
Epidemiological evidence have shown that hand
contamination of nurses could cause cross-infection in a
direct or indirect way, especially in intensive care unit
and hemodialysis unit where nurses have many patient
contact opportunities [
]. In our study, HH
compliance of doctors seemed superior to nurses when
stratified by professional category. There were far more
opportunities of HH for nurses in most departments
than for doctors. Then overcrowding workload of nurses
made them provide clinical care to multiple patients
without HH to finish their tasks faster. HH compliance
in other HCWs was generally lower than doctors and
nurses. Poor HH compliance was witnessed among
technicians during physiotherapy . Gloves were often
used during cleaning work to replace HH by cleaners,
which might increase the risk of transmission of bacteria
via contaminated gloved hands [
]. Besides, the
growing mobility of cleaners and interns made it difficult
to accomplish full training on HH. All in all, HH
compliance was improved in different professional categories
Data of compliance by different HH indication was
also investigated in the present study. Compliance with
HH improved after intervention across all indications
except for “after body fluid exposure” and “after
touching patient surroundings” in the observation. We
recognized that compliance rates were above 70% for these
two indications before intervention, which suggested
that our HCWs intended to perform HH when they
thought there might be microbial contamination and
infection risk. In addition, compliance rates for “before”
related indications were promoted after intervention,
such as “before touching a patient” and “before clean/
aseptic procedures”. These findings revealed that HCWs
were inclined to wash their hands to protect themselves
rather than protect patients from potential infection,
which was noted in previous studies [
]. As for
indication “after touching patient surroundings”, HH
opportunities with this indication were most commonly
associated with lower levels of compliance than
following direct patient contact . Traditional Chinese
Medicine treatments such as acupuncture and
moxibustion are often combined with diathermy machine and
herb fumigation device to get better curative effect. Most
of our HCWs could perform HH after therapy devices
were turned off. But when there was need to adjust the
setting of therapy devices, required HH practices were
not performed according to our observers. Multiple
studies indicated that HAI could be caused by many
pathogenic organisms present in the hospital
environment and objects frequently touched by patients’ hands,
such as bed side rail, door knob, patient record, nurse
call button [
]. Moreover, it was of vital
importance to strengthen the effectiveness of cleaning and
in order to prevent the transmission of pathogens
from patient surrounding environment to HCWs and
To well acknowledge whether our HCWs mastered
the standard handwashing techniques, HH correctness
was investigated at the same time. In general,
correctness rate was far below our standards before
intervention. During the period of investigation, we found two
most commonly reasons for low HH correctness rate in
our hospital. Most of our HCWs knew the right HH
technique procedures but the duration of rubbing hands
did not meet our requirement (15 s at least). Inadequate
disposable paper towel was another cause for unpleasant
HH correctness rate. Therefore our infection control
staff took steps to promote correct HH techniques,
which included correct HH techniques training,
increasing supplies of pocket ABHR and disposable paper
towels. As a result, our HCWs’ HH correctness rates
were elevated after intervention.
In the last few years, domestic researches on
improving HH practice have been reported in succession
]. It is noteworthy that our study is the first
observational before-and-after intervention study on
improving HH compliance in Xi’an, Shaanxi province.
Meanwhile it is the first study implementing WHO
multimodal strategy to promote HH practice in a
hospital of Traditional Chinese Medicine. HCWs have
many patient contact opportunities in the process of
Traditional Chinese Medicine treatments such as
acupuncture and moxibustion, massage, cupping and
other physical therapies. If standard HH practice were
not performed, it might increase the risk of
crossinfection. Our study summarized the reasons for
noncompliance with HH and provided scientific evidence
to promote HH practice for other hospitals of
Traditional Chinese Medicine. Nevertheless, this study also
had certain limitations. The entire observation of HH
compliance and correctness were only carried out in
general inpatient wards. We planned to observe HH
practice in critical departments for infection control
management such as emergency, intensive care unit
and hemodialysis unit. These places are characterized
by high patient volume, critically ill patients and more
invasive operations. Improving HH compliance in
such places would be meaningful for better infection
control. Furthermore, using student nurses as
observers might have an impact on observation process.
These student nurses observed HH practice of HCWs
in clinical wards during their clinical clerkships. Some
students told us they recognized their former teaching
nurses and classmates in the observation process and
thus we concerned that this covert investigation
might present the Hawthorn effect. In order to lessen
the influence of the Hawthorn effect on HH
compliance of HCWs, we plan to train every HCW in our
hospital to become a competent observer for HH
compliance of their co-workers. In this way every
HCW could be our covert observer and we could
collect reliable data of HH practice.
In conclusion, this intervention study has shown that
implementation of WHO multimodal improvement
strategy could significantly increase compliance and
correctness with HH in our hospital. Further investigations
with sufficient sample size and larger multicenter series
are needed to validate the effectiveness of long-term
persistence of HH compliance improvement strategy.
Additional file 1: HH raw data. (SAV 12 kb)
Additional file 2: Possible factors. (SAV 2 kb)
Additional file 3: Questionnaire survey raw data. (SAV 25 kb)
ABHR: Alcohol-based hand rub; HAI: Healthcare-associated infection;
HCWs: Health care workers; HH: Hand hygiene; TCM: Traditional Chinese
Medicine; WHO: World Health Organization
Project supported by Key Science and Technology R & D Program of Shaanxi
Province, China (Grant No.2016SF-213).
Availability of data and materials
The raw data supporting the results of this study are included within
the article and its additional files. Additional file 1, Additional file 2 and
Additional file 3.
LS carried out the study and drafted the manuscript. XW conceived of the
study, participated in its design and coordination. JA contributed to the
design of the study. JA participated in the literature review and performed
statistical analysis. NZ, LS and HC provided training of hand hygiene indications
and correct hand hygiene techniques for observers and collected data. LF
organized workers to improve hand hygiene products and facilities. JH
and XL contributed to check and enter data. All authors read and approved the
Ethics approval and consent to participate
Our study was approved by the Ethics Committee of Xi’an Hospital of Traditional
Chinese Medicine (No.XAZYYLS2015–05). The need for consent to participate was
waived as no individual person’s data were collected in any form.
Consent for publication
The authors declare that they have no competing interests.
Springer Nature remains neutral with regard to jurisdictional claims in
published maps and institutional affiliations.
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