European Journal of Cardiovascular Medicine

Healthcare-associated infections (HAIs) remain one of the most critical challenges to patient safety worldwide, especially in intensive care units (ICUs) where invasive procedures, prolonged hospital stays, and close healthcare worker (HCW)–patient interactions increase the risk of cross-transmission.(1) The World Health Organization (WHO) identifies hand hygiene—either through alcohol-based hand rubs (ABHR) or washing with soap and water—as the single most effective and economical intervention for preventing HAIs.(2) The WHO’s “My Five Moments for Hand Hygiene” framework defines five critical points when hand hygiene should be performed: before patient contact, before aseptic procedures, after exposure to body fluids, after patient contact, and after contact with patient surroundings.(3,4) These moments are considered hand hygiene opportunities (HHOs), and compliance with them is globally recognized as a key quality indicator for infection prevention and control (IPC).(5)

Despite decades of advocacy, global adherence to hand hygiene remains suboptimal in healthcare settings. A systematic review of 61 studies reported an average compliance rate of 59.6%, with stark disparities between high-income and low-income settings—reaching as low as 9% in some low-resource environments.(6) Other meta-analyses revealed mean compliance levels of approximately 52% among nurses and 45% among physicians.(7) In many developing countries, studies have documented rates as low as 22%, especially during high-workload periods or in critical care environments.(8) Barriers include lack of awareness, inadequate access to facilities, high workload, understaffing, skin irritation due to hand rubs, and absence of monitoring and feedback systems.(9) These challenges persist despite the proven cost-effectiveness and simplicity of the hand hygiene interventions.

In ICUs, where patients are immunocompromised and exposed to multiple invasive devices, lapses in hand hygiene are directly linked to bloodstream infections, ventilator-associated pneumonia, and multidrug-resistant organism transmission.(10) Therefore, effective surveillance and regular auditing of hand hygiene practices are essential to track compliance, identify gaps, and implement improvement strategies. The WHO recommends direct observation using standardized tools as the “gold standard” for monitoring compliance rates. This method not only quantifies adherence but also guides behavioural change interventions through targeted feedback.(11)

From an Indian perspective, hand hygiene remains an evolving area of research. Although numerous national initiatives have emphasized infection control, systematic audits of hand hygiene compliance, especially within government medical college ICUs, are limited. A multicentric Indian study during the COVID-19 pandemic demonstrated improved awareness of hand hygiene but focused largely on COVID wards rather than general ICUs.(12) In West Bengal, studies among healthcare students have shown concerning gaps, as fewer than 27% had received formal hand hygiene training. (13,14) This finding suggests that knowledge of hand hygiene remains inconsistent, particularly in public sector institutions that handle large patient loads and face infrastructural constraints.

Recognizing these challenges, this study aimed to provide locally relevant data and improvement insights. The objectives were threefold: [1] to evaluate hand hygiene practices among HCWs in the ICU setting; [2] to measure the hand hygiene adherence rate (HHAR) based on WHO’s “Five Moments” framework; and [3] to identify factors contributing to non-compliance, such as professional category, shift timings, workload, and infrastructural limitations. This will be achieved through prospective observational surveillance conducted in the ICU of a government medical college hospital. By integrating surveillance and audits, this study seeks to generate actionable insights to strengthen infection prevention practices and promote a culture of patient safety in tertiary healthcare settings in West Bengal.

Study setting

The study was conducted in the Intensive Care Unit (ICU) of Burdwan Medical College and Hospital, a tertiary care government teaching institution located in Purba Bardhaman district, West Bengal, India. The hospital serves as a major referral center for a large catchment area comprising both rural and semi-urban populations of South Bengal. The ICU caters to critically ill medical and surgical patients with high patient turnover and multidisciplinary staff. As a government institution with constrained resources and a heavy clinical workload, it provides an ideal setting to evaluate real-world hand hygiene practices and identify system-level gaps through surveillance and audits.

Study design

This was a prospective, observational, cross-sectional study conducted over a two-month period.

Study population

All HCWs, including interns, who had direct contact with patients or their surroundings in the ICU of Burdwan Medical College and Hospital, were observed for hand hygiene compliance after obtaining approval from the Institutional Human Ethics Committee and written informed consent from the participants.

Study procedure

This prospective, observational, cross-sectional study was conducted in the intensive care unit of Burdwan Medical College and Hospital, Purba Bardhaman, West Bengal, between January and February 2024. All healthcare workers (HCWs), including doctors, nurses, interns, physiotherapists, and housekeeping staff directly involved in patient care or contact with the ICU environment, were included. Hand hygiene surveillance was conducted once a week for one hour, yielding eight observation sessions (480 minutes total). Using the WHO Hand Hygiene Observation Tool, trained observers recorded each hand hygiene opportunity (HHO) and action performed across WHO’s “Five Moments.” The HH complete adherence rate (HHCAR), profession-specific hand hygiene adherence rate (e.g., doctors, nurses, and others), and moment-specific hand hygiene adherence rate (for each WHO moment) were calculated. Data were entered in the prescribed format in Excel, with reasons for non-compliance noted for audit and analysis, and finally validated by the hospital infection control officer.

Table 1: List of indicators used for hand hygiene surveillance

HH - hand hygiene

Data collection

Data were collected using a structured WHO Hand Hygiene Observation Tool adapted for local use to ensure uniformity and reproducibility. The tool was designed to capture detailed information for each hand hygiene opportunity (HHO) according to the WHO’s “Five Moments for Hand Hygiene.” Each observation included the type of healthcare worker (doctor, nurse, intern, or ancillary staff), the type of indication (moment), whether hand hygiene action was performed, the method used (alcohol-based hand rub or soap and water), and the correctness of the technique. Reasons for non-compliance, such as workload, lack of supplies, or forgetfulness, were documented in free-text fields for qualitative audit analysis.

Prior to data collection, two infection control nurses and one microbiologist were trained in WHO-recommended direct observation methodology to minimize observer bias. Observations were carried out discreetly during routine ICU care to prevent alteration of behavior (Hawthorne effect). Each observation session lasted for one hour and covered multiple patient–HCW interactions across different shifts to ensure representativeness. The observers used printed audit forms that were subsequently reviewed daily for completeness and accuracy.

Data from the observation sheets were manually entered into a pre-designed Microsoft Excel spreadsheet. Each record was independently double-entered by two trained data entry personnel to ensure accuracy. Discrepancies were resolved by verifying the original forms. Variables were coded systematically (e.g., HHO moments (1–5), HH action (performed/not performed), HCW category (doctor, nurse, intern, physiotherapists, housekeeping staff)) to facilitate analysis.

To ensure data reliability, periodic crosschecks were performed by the principal investigator. 10% of the observation sheets were randomly selected and revalidated for accuracy and internal consistency. Any ambiguous or incomplete entries were discussed and resolved by consensus. Descriptive statistics, including the compliance rate (Hand Hygiene Adherence Rate, HHAR = [HH actions ÷ HHOs] × 100), were generated.

Data analysis

Data were analyzed using descriptive and analytical statistical methods. Adherence rates were summarized as frequency and percentage. Associations between professional categories and hand hygiene adherence were assessed using the chi-square test of independence (χ²(5) = 23.71, p < 0.001), with pairwise Fisher’s exact tests and Bonferroni correction applied. Logistic regression was used to quantify the influence of profession (reference: nurse), yielding adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Similarly, WHO moment–specific adherence was analyzed using chi-square and logistic regression (reference: moment 3), with significant variation observed across moments (p < 0.001). Statistical significance was set at p < 0.05. Statistical analyses were performed using IBM SPSS Statistics (version 26.0; IBM Corp., Armonk, NY, USA).

Human participant protection

​The study was approved by the Institutional Human Ethics Committee of Burdwan Medical College and Hospital (Ref. No. BMC/IEC/005 dated 1^stFeby,2024). All observations were conducted anonymously without identifying individual HCWs, ensuring confidentiality and voluntary participation of the subjects. No deviation from the approved study protocol was ​observed during the study period.

Month-wise hand hygiene complete adherence rate (HHCAR)

Eight observation periods (each conducted for one hour) were conducted, and 480 minutes of observation were completed during the entire study period. A total of 380 hand hygiene opportunities were observed during the two-month surveillance period, representing the denominator for adherence assessment. Of these, 103 hand hygiene actions were correctly performed, yielding an overall complete adherence rate of 27.1% (103/380). In January 2024, 43 of the 150 observed moments (28.7%) were compliant, whereas in February 2024, 60 of the 230 moments (26.0%) met the criteria. Thus, a slight decline in adherence to hand hygiene practices in the intensive care unit was noted from January to February despite ongoing surveillance and audit initiatives at this government medical college in West Bengal. (Table 2)

Table 2: Month-wise hand hygiene complete adherence rate (HHCAR)

Profession-specific hand hygiene adherence rate

Among 380 hand hygiene opportunities in the ICU, nurses showed the highest adherence (52/128, 40.6%), followed by housekeeping staff (16/53, 30.2%) and physiotherapists (7/27, 25.9%). Doctors demonstrated lower compliance: interns 20.8% (15/72), RMOs 13.5% (12/89), and consultants 9.1% (1/11). Hence, profession was significantly associated with hand hygiene adherence {χ²(5) = 23.71, p = 0.000246}. Because the expected counts for some cells were <5, pairwise Fisher’s exact tests were performed with Bonferroni correction. After adjustment, adherence among nurses was significantly higher than that among RMOs (p = 1.74 × 10⁻⁵). Other pairwise comparisons were not significant after correction. Logistic regression analysis revealed that profession significantly influenced HH adherence (model χ², p < 0.001). Compared with nurses, RMOs (OR 0.23,95%% CI 0.11–0.46, p < 0.001) and interns (OR 0.38,95%% CI 0.20–0.75, p = 0.005) had markedly lower odds of performing HH. Consultants, physiotherapists, and housekeeping staff also showed lower adherence odds, although these did not reach statistical significance. Overall, nurses demonstrated the highest adherence rate (406%), underscoring the need for targeted HH improvement initiatives among both physicians and interns. (Table 3)

Table 3: Profession-specific hand hygiene adherence rates.

Moment-specific hand hygiene adherence rate

Among the 380 hand hygiene opportunities categorized by the five WHO moments, the highest adherence was noted before aseptic procedures (Moment 2:15/35, 42.9%) and after body fluid exposure risk (Moment 3:29/68, 42.6%). Compliance was considerably lower before touching a patient (Moment 1:28/105, 26.6%), after touching a patient (Moment 4:18/97, 18.6%), and after contact with patient surroundings (Moment 5:13/75, 17.3%). Pairwise Fisher’s exact tests with Bonferroni correction for multiple comparisons revealed that adherence at moment 3 was significantly higher than at Moment 4 (raw p = 0.000903; Bonferroni-adjusted p = 0.00903) and Moment 5 (raw p = 0.00160; adjusted p = 0.015998). Other pairwise comparisons were not statistically significant after the adjustment. Logistic regression analysis was performed using moment 3 (after body fluid exposure risk) as the reference category to examine the association between WHO hand hygiene (HH) moments and adherence rates. The overall model was statistically significant (p < 0.001), indicating that the HH adherence varied significantly across the five WHO moments. Compared with Moment 3, adherence was significantly lower for Moment 1 (OR = 0.49, 95% CI: 0.26–0.93, p = 0.030), Moment 4 (OR = 0.31, 95% CI: 0.15–0.62, p = 0.001), and Moment 5 (OR = 0.28, 95% CI: 0.13–0.61, p = 0.001). Adherence for Moment 2 (before aseptic procedure) was comparable to Moment 3 (OR = 1.01, 95% CI: 0.44–2.30, p = 0.984). These findings indicate that HH adherence is highest after potential body fluid exposure and during aseptic procedures but significantly lower before or after patient and environmental contact. (Table 4)

Table 4: Moment-specific hand hygiene adherence rates.

The present surveillance and audit of hand hygiene practices in the intensive care unit of a government medical college in West Bengal revealed persistently suboptimal adherence, despite ongoing monitoring efforts. The findings highlight variations in compliance across professional categories and WHO-defined hand hygiene moments. These observations underscore the enduring behavioral and contextual barriers to achieving consistent adherence, warranting critical discussion of profession-specific gaps, moment-related trends, and implications for infection prevention strategies in resource-limited academic healthcare settings.

Month-wise hand hygiene complete adherence rate (HHCAR)

The overall hand hygiene adherence rate of 27.1% observed in this study aligns with previous reports from Indian ICUs, where compliance typically ranges between 20–40% despite periodic audits and training initiatives (Dhandapani et al., 2022; Ganeshan et al., 2022).(12,15) Similar suboptimal adherence has been attributed to workload pressure, inadequate feedback, and limited accountability mechanisms.(16,17) The slight decline from January to February may reflect observer fatigue or staff turnover, suggesting behavioral sustainability challenges. Persistent low compliance, despite surveillance, indicates that structural monitoring alone may be insufficient without reinforcement through targeted education and leadership engagement, an observation that warrants further hypothesis-driven exploration of institutional culture and behavioral determinants of infection control compliance.

Profession-specific hand hygiene adherence rate

The finding that nurses demonstrated the highest adherence (40.6%), followed by ancillary staff, while doctors—particularly consultants and RMOs—showed lower compliance, is consistent with observations from multiple Indian and international studies (Ganesan, 2022; Erasmus et al., 2010).(18,19) Similar professional variability has been linked to differences in role perception, workload, and risk awareness. Nurses, who are directly involved in bedside care and infection prevention protocols, often exhibit higher compliance due to stronger institutional reinforcement and training exposure. Conversely, physicians’ lower adherence has been attributed to time constraints, glove overreliance, and underestimation of transmission risk (Sax et al., 2007; Pittet er al., 2004).(20,21) The significant association between profession and adherence in this study underscores the behavioral and hierarchical influences on infection control compliance. The unexpectedly low rate among consultants (9.1%)—though based on fewer observations—may indicate modelling gaps in leadership behaviour, warranting hypothesis-driven inquiry into the impact of senior clinician practices on team-wide hand hygiene culture.(22) Targeted, profession-sensitive interventions and role-model-based reinforcement strategies may therefore be essential to strengthen adherence across all cadres.

Moment-specific hand hygiene adherence rate

Moment-specific findings—higher adherence for aseptic procedures (Moment 2) and after body-fluid exposure (Moment 3) with markedly lower rates before/after routine patient contact or environmental contact—mirror patterns reported in multicentre Indian and international studies, which consistently show better compliance for “after” moments and aseptic tasks than for “before” moments.(23,24) This trend is commonly ascribed to self-protection bias and greater perceived risk during invasive tasks, whereas routine patient contact is often deprioritised under workload pressures.(19) Consequences include the ongoing risk of pathogen transfer between patients despite good practice during high-risk procedures, highlighting the need for moment-specific education and reminders. The relatively high adherence at moments 2–3 in our ICU may reflect targeted training or visibility of aseptic tasks; conversely, low adherence at Moments 1, 4, and 5 suggests gaps in habit formation and environmental prompts.(25) The unexpected pattern of relatively stronger moment-2 adherence warrants a hypothesis-driven study of task visibility, supply placement, and perceived urgency as behavioral drivers.

Implications of the findings

The present study has significant implications for infection prevention policies and behavioral change strategies in resource-constrained governmental healthcare settings. By systematically auditing hand hygiene adherence across professional categories and WHO moments, it provides authentic insight into on-ground practices within an Indian intensive care unit, complementing global data largely derived from high-income contexts.

Strengths of the study

The strength of this study lies in its feasibility and contextual relevance, as it was conducted using direct observation without additional resource investment, demonstrating that periodic internal audits can yield actionable data even in busy government hospitals. Its novelty stems from linking profession- and moment-specific adherence trends through logistic regression analysis, offering a granular behavioral perspective rather than a purely descriptive overview of the results. Ethical rigor was maintained by ensuring non-interventional observation and confidentiality of participants, reinforcing its acceptability for institutional monitoring.

Limitations of the study

However, this study had several limitations that must be acknowledged. The relatively short observation period and limited sample size may not have captured temporal fluctuations or seasonal influences on adherence. The presence of an observer may have induced the Hawthorne effect, marginally inflating compliance rates. Additionally, the study did not correlate hand hygiene adherence with healthcare-associated infection rates or microbiological surveillance, which could have strengthened the causal inference. The exclusion of qualitative assessments of attitudes and facility-level barriers limits the interpretation of behavioral determinants.

This study revealed persistently low hand hygiene adherence in the ICU, with nurses outperforming physicians. Surveillance identified profession- and moment-specific gaps, emphasizing behavioral and structural barriers. Institutionalizing regular hand hygiene surveillance, including continuous monitoring, targeted education, leadership-driven motivation models, and feedback-driven interventions, is essential to enhance compliance, strengthen infection prevention, and improve patient safety in resource-limited governmental hospitals. Future research should evaluate multimodal behavioral interventions, electronic monitoring systems, and leadership-driven motivation models. Continuous assessment of adherence trends will support evidence-based infection control policies and optimize patient safety and healthcare quality in government medical colleges.

Conflicts of Interest

The authors declare no conflicts of interest.

Acknowledgement

I express my heartfelt thanks and gratitude to the administration, faculty members, and staff of the Department of Anesthesiology and Microbiology, Burdwan Medical College and Hospital, for allowing me to conduct this study.

Funding

Funding: This study was supported by the author.

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