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Bull World Health Organ 2020;98:475–483 | doi: http://dx.doi.org/10.2471/BLT.19.247494

Research

475

Introduction
Evidence shows that improving hand-hygiene practices re-
duces the frequency of health-care-associated infections in
hospitals.1,2 Studies have examined the association between
hand-hygiene and health-care-associated infections: some
were conducted over relatively short periods,3,4 some focused
on specific infections, such as central-line-associated infec-
tions or Staphylococcus aureus bacteraemia,5–11 and some
relied on mathematical models to predict the incidence of
such infections.3,9

Several studies have demonstrated improvements in hand-
hygiene compliance after implementation of interventions to
promote hand hygiene,3,9–11 but which individual measures are
most effective or how to maintain long-term improvements
is still unknown.12 Despite promising new electronic systems
for automatic monitoring of hand-hygiene compliance, these
systems have notable limitations in real-world settings; in par-
ticular, they are expensive and require special methods, such
as wireless technology.13–15 These systems also typically only
provide data on hand-hygiene compliance when entering or
leaving patient rooms. In addition, very little evidence exists
on the effectiveness of hand-hygiene improvements at reduc-
ing the incidence of health-care-associated infectionss.12,15,16

We conducted a 6-year hospital-wide internal audit survey
based on the World Health Organization’s (WHO) model for
hand hygiene1 to evaluate hand-hygiene practices by direct
observation by trained observers and provide immediate
feedback. This method is considered the gold standard for
monitoring hand-hygiene performance.1,17 At the same time,

we recorded the incidence of health-care-associated infec-
tions across the hospital using a semi-automated electronic
incidence surveillance programme. We hypothesized that
changes in hand-hygiene compliance observed during our
survey would be reflected in the incidence of health-care-
associated infections.

Methods
Study design and setting

This longitudinal internal audit survey was conducted in Oulu
University Hospital (OYS), a tertiary-care teaching hospital in
northern Finland, between January 2013 and December 2018.
This hospital has 792 beds and provided 223 559 patient days
of care in 2018.

Hand hygiene in the hospital

The hospital’s infection control department had used various
methods to improve hand hygiene in the two decades before
this survey. For example, in May 2010, the department started
a new campaign based on WHO’s hand-hygiene improve-
ment strategy.1 The hospital had previously implemented ele-
ments of this strategy, namely system change, education for
health-care workers, evaluation and feedback, reminders in
the workplace, and an institutional safety climate. As a result,
alcohol-based handrub formulations have been available at
the point of care (with bottles and mounted dispensers in
every patient room or bay, and on every bedhead) since the
early 1990s. In addition, the hospital established a network
of infection-control link nurses in the late 1990s to improve

Objective To determine changes in hand-hygiene compliance after the introduction of direct observation of hand-hygiene practice for
doctors and nurses, and evaluate the relationship between the changes and the incidence of health-care-associated infections.
Methods We conducted an internal audit survey in a tertiary-care hospital in Finland from 2013 to 2018. Infection-control link nurses
observed hand-hygiene practices based on the World Health Organization’s strategy for hand hygiene. We calculated hand-hygiene
compliance as the number of observations where necessary hand-hygiene was practised divided by the total number of observations
where hand hygiene was needed. We determined the incidence of health-care-associated infections using a semi-automated electronic
incidence surveillance programme. We calculated the Pearson correlation coefficient (r) to evaluate the relationship between the incidence
of health-care-associated infections and compliance with hand hygiene.
Findings The link nurses made 52 115 hand-hygiene observations between 2013 and 2018. Annual hand-hygiene compliance increased
significantly from 76.4% (2762/3617) in 2013 to 88.5% (9034/10 211) in 2018 (P < 0.0001). Over the same time, the number of health-care-
associated infections decreased from 2012 to 1831, and their incidence per 1000 patient-days fell from 14.0 to 11.7 (P < 0.0001). We found a
weak but statistically significant negative correlation between the monthly incidence of health-care-associated infections and hand-hygiene
compliance (r = −0.48; P < 0.001).
Conclusion The compliance of doctors and nurses with hand-hygiene practices improved with direct observation and feedback, and this
change was associated with a decrease in the incidence of health-care-associated infections. Further studies are needed to evaluate the
contribution of hand hygiene to reducing health-care-associated infections.

a Research Unit of Nursing Science and Health Management, University of Oulu, Aapistie 5A, 2 krs 90220 Oulu, Finland.
b Department of Infection Control, Oulu University Hospital, Oulu, Finland.
Correspondence to Helena Ojanperä (email: [email protected]).
(Submitted: 14 November 2019 – Revised version received: 19 April 2020 – Accepted: 22 April 2020 – Published online: 26 May 2020 )

Hand-hygiene compliance by hospital staff and incidence of health-
care-associated infections, Finland
Helena Ojanperä,a Outi I Kanstea & Hannu Syrjalab

476 Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, Finland Helena Ojanperä et al.

infection control practices in their
wards, for whom regular education and
group meetings were held six to eight
times a year. The infection control team
provides regular training for health-
care workers (including new staff and
students) on proper hand hygiene. The
hospital’s intranet site has held records
of the annual consumption of alcohol-
based handrub per 1000 patient-days
in different wards since 1997 and of the
annual health-care-associated infection
rates per 1000 patient-days since 2008.
Over the years, the hospital has placed
various reminders about hand hygiene
in patient-care units and staff areas. In
2010, the hospital hung paintings on the
walls of the hospital entrance encour-
aging patients to remind health-care
workers to use handrub. Infection pre-
vention, and hand hygiene in particular,
have been components of the hospital’s
patient-safety strategy since 2013.

The hospital uses alcohol-based
handrubs containing 70% (volume/
volume) ethanol (tested according to
European Standard, EN 1500)18 for hand
hygiene in wards and outpatient clinics.
The hospital prohibits the wearing of
watches, hand jewellery and artificial
nails during patient care.

Observation of hand-hygiene

In January 2013, infection control link
nurses began regular direct observation
of hand-hygiene compliance at inpatient
and outpatient locations to improve
hand-hygiene compliance in health-care
workers at the hospital.19 All doctors and
nurses treating patients at the hospital
were the study population. The link
nurses informed doctors and nurses
when they were making observations of
hand-hygiene compliance and explained
that the observations were part of the
hospital’s quality evaluation process.
In addition, the link nurses explained
to patients that the observations were
only on staff behaviour with the aim of
improving professional practices.

The link nurses recorded informa-
tion on the following variables during
each observation: (i) duration of hand
rubbing (in seconds); (ii) the observed
moment according the WHO strategy
(before touching a patient, before a
clean or aseptic procedure, after touch-
ing a patient, after risk of exposure to a
bodily fluid and after touching patient
surroundings);1 (iii) profession of the
person observed (doctor or nurse); and
(iv) the ward where the observation was

made. The target number of observa-
tions was at least 10 observations per
ward a month. This observation and
reporting exercise requires about 4–6
working hours for each ward per three-
week cycle.

Between 2013 and 2016, the link
nurses recorded hand-hygiene obser-
vations on paper (using stopwatches to
measure timings) and transferred the
data to an Excel spreadsheet (Microsoft,
Redmond, United States of America).
To reduce the time required to perform
direct observations, the hospital’s infec-
tion control unit, OYS TestLab, which
offers a systematic approach to enable
and support the development of health
and medical technology products at
Oulu University Hospital, and FCG
Flowmedik Oy (Helsinki, Finland) de-
veloped a mobile device (the web-based
eRub-tool) that facilitates the coding of
observations. Therefore, since 2017, the
link nurses have made their observations
using this device. The reports on the
total number of hand-hygiene obser-
vations and the type of hand-hygiene
moment are made available immediately
after the observation on the hospital’s
intranet. Data gathered between 2013
and 2016 were also transferred to the
eRub-tool.

The implementation costs of this
stu dy we re ne g l i g ibl e b e c aus e t he
hospital had established the link nurse
programme several years before this sur-
vey began. Infection-control link nurses
spent one working day every 3 weeks
observing hand hygiene and checking
all registered antibiotic prescriptions
following patient discharge. Since our
hospital was a pilot hospital where the
web-based eRub-tool was developed, the
use of this system was free of charge for
our hospital.

Variables studied

Use of handrubs

We obtained data on the yearly use of
alcohol-based handrub in litres per
1000 patient-days from the hospital’s
financial records. We determined the
number of 1000 patient-days per month
or per year by summing the correspond-
ing number of overnight stays made by
patients at the hospital and dividing the
total by 1000.

Hand-hygiene compliance

We calculated hand-hygiene compliance
as the number of observations where the

necessary hand hygiene was practised
divided by the total number of observa-
tions where hand hygiene was needed.
We also extracted the duration of hand
rubbing as recorded in the eRub data-
base. We calculated compliance with
the hand-rubbing time on a monthly
basis over the 6-year study period. The
length of hand rubbing recommended
by WHO is 20–30 s.1 Depending on
the size of hands we recommended one
or two measures of handrub from the
dispenser; so the approximate volume of
handrub was 1.6 mL or 3.2 mL).

At the individual level, the link
nurses gave verbal feedback on hand-
hygiene performance immediately after
the hand-hygiene observation. At the
group level, feedback was given during
regular ward meetings to the person-
nel on the wards by the link nurses
and infection control nurses. At the
organization level, the hand-hygiene
compliance results were available to all
staff of the hospital who have access to
the hospital’s intranet.

Health-care-associated infections

We determined the incidence of health-
care-associated infections by analysing
the hospital’s records. The hospital uses
a semi-automated electronic incidence
surveillance programme that is linked to
all the electronic databases of the hospi-
tal.20 When an antibiotic is added to the
patient’s prescription, the programme
automatically opens an enquiry form
that doctors have to complete. Doctors
are required to indicate whether the an-
tibiotic was prescribed to treat a health-
care-associated infection acquired in
the hospital or a community-acquired
infection. In each ward, two infection-
control link nurses checked all of the
registered antibiotic initiations during
the hospital stay after patient discharge.
In our hospital, health-care-associated
infections are classified according to
a modified version of the criteria pro-
posed by the United States Centers for
Diseases Control and Prevention.21 We
calculated the incidence of health-care-
associated infections per 1000 patient-
days on a monthly or annual basis over
the study period.

Analyses

We did not calculate a sample size be-
fore the survey. Our goal was to obtain
at least 50 000 hand-hygiene observa-
tions, which we considered sufficient for
comparison of monthly hand-hygiene

477Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, FinlandHelena Ojanperä et al.

compliance figures with the incidence
of health-care-associated infections.
We used SAS, version 9.4 (SAS Institute,
Cary, USA) for all analyses. We calcu-
lated the monthly change in incidence of
health-care-associated infections (from
1 May 2013 to 31 December 2018) using
a Poisson regression model. We give the
results of the Poisson regression analysis
as incidence rate ratio. We calculated
the Pearson correlation coefficient (r)
to evaluate the relationship between
the incidence of health-care-associated
infections and compliance with hand
hygiene. For each year of the study, we
calculated the mean monthly frequency
of hand-hygiene compliance and 95%
confidence interval (CI). We calculated
the median and 25th and 75th centiles
of rubbing times.

Ethical considerations

The Hospital District Medical Direc-
tor and Chief Nursing Officer of Oulu
University Hospital approved this audit
survey (registration number 246/2018).
In Finland, the Medical Research Act
(no. 488/1999) states that approval
from the local ethics committee is not
required for register-based sur veys
that do not process identifiable infor-
mation. We consulted the secretary of
the Regional Ethics Committee of the
Hospital District who confirmed that
our study was conducted in accordance
with all applicable research regulations
and norms of Finland.

Results
B etwe en May 2013 and D e cemb er
2018, the link nurses made 52 115
observations where hand hygiene was
needed (Table 1). In the past 3 years of
the survey (2016–2018), these nurses

made more than 10 000 observations
each year.

T h e a n n u a l h a n d – h y g i e n e
c ompl i anc e i nc re as e d f rom 7 6 . 4 %
(2762/3617) to 88.5% (9034/10 211;
P < 0·0001; Table 1) and the monthly
hand-hygiene compliance increased
from 77.5% (328/423) in May 2013 to
94.4% (456/483) in December 2018
( Ta b l e 2 a n d F i g . 1 ) . T h e m e d i a n
hand-rubbing time over the 6 years
was 21 s, with the 25th and 75th centile
times being 13 s and 30 s, respectively.
The consumption of alcohol-based
handrub was 57 L per 1000 patient-
d a y s i n 2 0 1 3 a n d 7 4 L p e r 1 0 0 0
patient-days in 2018.

The number of health-care-asso-
ciated infections decreased from 2012
infections in 2013 to 1831 in 2018 and
the incidence of health-care-associated
infections decreased from 14.2 (95%
CI: 13.4–14.9) to 11.7 (95% CI: 11.1–
12.2) per 1000 patient-days (incidence
rate ratio for monthly change = 0.999,
P < 0.0001; Table 1 and Fig. 1). As
shown in Fig. 2, we found a weak but
statistically significant negative correla-
tion between the monthly incidence of
health-care-associated infections and
hand-hygiene compliance (r = −0.48;
P < 0.001).

Discussion
Our results show that during the 6-year
period of regular hand-hygiene ob-
ser vations and immediate feedback,
the frequency of annual hand-hygiene
compliance of doctors and nurses im-
proved from 76.4% in 2013 to 88.5%
in 2018 (P < 0.0001). At the same time
the hospital-wide incidence of health-
care-associated infections decreased
significantly.

Two previous studies have exam-
ined the association between hand-hy-
giene compliance and all hospital-wide
health-care-associated infections. The
first study showed that over a 4-year
period when hand-hygiene improved
f rom 47.6% (1349/2834) to 66.2%
(1701/2569), the prevalence of health-
care-associated infections decreased
from 16.9% to 9.9%.2 The second study
examined hand-hygiene compliance
after implementation of an infection-
control programme and health-care-
associated infections in both general
wards and an intensive care unit.4 Over
a 16-month follow-up period, hand-hy-
giene compliance increased from 41.0%
(2235/5454) to 50.5% (3246/6428).
Over the same time, the incidence of
health-care-associated infections in
the general ward was unchanged, but
t he numb er of s e vere he alt h-care-
associated infections in the intensive
care unit decreased.4

In our study, when monthly hand-
hygiene compliance was more than
80.0% over 2 years, the incidence of
health-care-associated infections started
to decrease (Fig. 2). In earlier studies
where health-care-associated infections
decreased, hand-hygiene compliance
was at least 66.2% at the end of the study
(number of opportunities = 2569 during
the last observation period, December
1997)2 and the duration of the study
period was at least 17 months.2,5,6,9,22 In
a study with exceptionally high initial
hand-hygiene compliance of 82.6%,
compliance increased to 95.9% while
the rate of health-care-associated infec-
tions fell by 6.0% during the 17-month
study period.22 Further reductions in
the incidence of health-care-associated
infections at our hospital could therefore
be possible if the annual hand-hygiene

Table 1. Hand-hygiene observations and compliance, handrub use, and health-care-associated infections, Finland, 2013–2018

Year No. of
observations

No. of observations
where compliance
with hand hygiene

was recorded

Hand-hygiene
compliance, %

(95% CI)

Litres of
handrub used/

1000 patient-days

No. of health-
care-associated

infections

No. of health-care-asso-
ciated infections/ 1000
patient-days (95% CI)

2013 3617 2762 76.4 (74.8–77.6) 57 2 012 14.2 (13.4–14.9)
2014 7906 6479 82.0 (81.1–82.8) 68 2 003 13.6 (13.0–14.2)
2015 8599 7358 85.6 (84.8–86.3) 63 1 987 13.2 (12.7–13.8)
2016 11 346 9522 83.9 (83.2–84.6) 67 2 005 13.0 (12.4–13.6)
2017 10 436 9087 87.1 (86.4–87.7) 73 1 901 12.2 (11.6–12.7)
2018 10 211 9034 88.5 (87.8–89.1) 74 1 831 11.7 (11.2–12.2)
Total 52 115 44 242 84.9 (84.6–85.2) 67 11 739 12.9 (12.7–13.1)

CI: confidence interval.

478 Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, Finland Helena Ojanperä et al.

compliance rate at the hospital were
raised above 90.0%.

We think that the increased com-
pliance with hand hygiene is the most
plausible explanation for the reduced in-
cidence in health-care-associated infec-
tions in our study because the infection
control practices applied at the hospital
had remained largely unchanged in the
years before the study. Although we can-
not completely exclude the possibility
that other factors may have contributed
to the decline in health-care-associated
infection rates, no other hospital-wide
infection prevention strategies were
introduced during the study period.
However, the negative correlation be-
tween health-care-associated infections
and hand-hygiene compliance was rela-
tively weak (r2 = 0.23), suggesting that
only 23% of the observed variation in
the incidence of health-care-associated
infections was related to changes in
hand-hygiene practices. Therefore, some
unidentified confounding factors could
have contributed to the decrease in
health-care-associated infections.

Previous reports have emphasized
the need for multimodal approaches to
achieve and sustain permanent improve-
ments in hand-hygiene compliance.1 We
believe that this is probably true when
starting a hand-hygiene programme in a
hospital with a low level of hand-hygiene
compliance, as was demonstrated in
an earlier hospital-wide compliance
project.2 However, our results indicate
that direct observation and immediate
feedback on hand-hygiene procedures
can induce a sustained increase in
hand-hygiene compliance even when
the annual compliance rate is relatively
high to begin with (76.4% in our case).
This relatively high initial compliance
rate was a result of years of intensive
efforts to improve hand-hygiene prac-
tices. Before this survey, four of the five
components of the WHO’s multimodal
hand-hygiene guideline1,23 had already
been implemented at the hospital. How-
ever, this policy by itself did not reduce
the incidence of health-care-associated
infections to the levels observed after
introducing regular observation and
feedback. The important role of perfor-
mance feedback in promoting and sus-
taining good hand-hygiene behaviour
in hospital health-care workers has also
been highlighted in previous reports.24

Direct observation makes it pos-
sible to assess compliance rates for all
of the WHO hand-hygiene moments,

Table 2. Hand-hygiene observations and compliance, by month, Finland, 2013–2018

Month, year Total no. of
observations

Observations where compliance with hand
hygiene recorded, no. (%)

May, 2013 423 328 (77.5)
June, 2013 347 257 (74.1)
July, 2013 426 314 (73.7)
August, 2013 496 376 (75.8)
September, 2013 527 406 (77.0)
October, 2013 563 440 (78.2)
November, 2013 493 367 (74.4)
December, 2013 342 274 (80.1)
January, 2014 297 220 (74.1)
February, 2014 908 701 (77.2)
March, 2014 731 585 (80.0)
April, 2014 677 544 (80.4)
May, 2014 763 621 (81.4)
June, 2014 516 457 (88.6)
July, 2014 436 366 (83.9)
August, 2014 599 483 (80.6)
September, 2014 828 670 (80.9)
October, 2014 823 699 (84.9)
November, 2014 905 771 (85.2)
December, 2014 423 362 (85.6)
January, 2015 460 383 (83.3)
February, 2015 468 406 (86.8)
March, 2015 598 507 (84.8)
April, 2015 701 634 (90.4)
May, 2015 988 837 (84.7)
June, 2015 637 534 (83.8)
July, 2015 494 438 (88.7)
August, 2015 815 726 (89.1)
September, 2015 725 640 (88.3)
October, 2015 893 734 (82.2)
November, 2015 742 621 (83.7)
December, 2015 1078 898 (83.3)
January, 2016 680 584 (85.9)
February, 2016 1351 1130 (83.6)
March, 2016 1028 823 (80.1)
April, 2016 816 709 (86.9)
May, 2016 1093 871 (79.7)
June, 2016 745 648 (87.0)
July, 2016 594 510 (85.9)
August, 2016 612 525 (85.8)
September, 2016 1005 828 (82.4)
October, 2016 1117 949 (85.0)
November, 2016 1295 1075 (83.0)
December, 2016 1010 870 (86.1)
January, 2017 746 641 (85.9)
February, 2017 982 836 (85.1)
March, 2017 1072 942 (87.9)
April, 2017 1189 1033 (86.9)
May, 2017 583 528 (90.6)
June, 2017 779 644 (82.7)
July, 2017 583 518 (88.9)
August, 2017 791 713 (90.1)
September, 2017 746 650 (87.1)

(continues. . .)

479Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, FinlandHelena Ojanperä et al.

and is seen as the gold standard for
monitoring hand-hygiene compliance.
However, direct observation is time- and
resource-intensive, and can only be done
in a small proportion of hand-hygiene
opportunities.14 Furthermore, the risk of
bias due to the Hawthorne effect can oc-
cur as health workers may improve their
practices when under observation.25,26
Regardless of any possible Hawthorne
effect, to improve your behaviour when
you are observed, the infection-control
link nurses made regular hand-hygiene
observations in their own wards in a
similar way over several years and gave
feedback to their co-workers. We think
that the Hawthorne effect might have
had a positive influence on our results;
it has earlier been shown that the Haw-
thorne effect can be used to encourage

hand-hygiene compliance. In an ideal
situation, the Hawthorne effect would be
sustained with continuous observations
improving hand-hygiene compliance
and decreasing numbers of health-care-
associated infections.27

Our study has several limitations.
First, it is a non-randomized real-world
internal audit survey conducted in a
single university hospital in Finland.
Further studies in other types of hos-
pitals and countries will be needed to
test the generalizability of these find-
ings. Second, the link nurses only made
hand-hygiene observations during the
day shifts on week days, so the findings
may not apply to night and weekend
shifts. Third, our analysis is based only
on hand-rubbing time, without the
evaluation of rubbing technique. The

observed median rubbing time of 21 s
is acceptable because WHO recom-
mends rubbing for 20–30 s.1 However,
some of the staff observed did not spend
enough time on rubbing because the
25th centile rubbing time was only 13 s.
In addition, in the last year of the study
(2018), no handrubbing was done at all
in 11.5% (1177/10 211) of the occasions
when hand hygiene was needed. Fourth,
our survey did not assess whether the
hand-hygiene technique was properly
performed or if gloves were used. Fifth,
we cannot rule out possible confound-
ing factors (e.g. seasonal influenza,
norovirus outbreaks in the commu-
nity or holiday periods of health-care
workers) that may have affected hand-
hygiene compliance or the incidence
of health-care-associated infections.
Sixth, because we were interested only in
hospital-level changes, we do not know
which health-care-associated infections
(e.g. surgical site infections or hospital-
acquired pneumonia) decreased more af-
ter increased hand-hygiene compliance.
We also did not compare hand-hygiene
compliance between doctors and nurses
or in different hospital wards.

A strength of this survey is the fact
that observations of hand-hygiene com-
pliance and health-care-associated in-
fection surveillance were done regularly
on a monthly basis over several years in a
real-life setting. Health-care-associated
infections were followed using a semi-
automate d el e c t ron i c su r ve i l l anc e
system.20 Implementation of electronic
surveillance is considered a feasible
way to identify health-care-associated
infections.28 Importantly, the frequency
of health-care-associated infections in

Month, year Total no. of
observations

Observations where compliance with hand
hygiene recorded, no. (%)

October, 2017 1003 854 (85.1)
November, 2017 1153 1009 (87.5)
December, 2017 809 719 (88.9)
January, 2018 1053 924 (87.7)
February, 2018 713 659 (92.4)
March, 2018 862 778 (90.3)
April, 2018 995 850 (85.4)
May, 2018 1157 1059 (91.5)
June, 2018 974 848 (87.1)
July, 2018 553 487 (88.1)
August, 2018 737 624 (84.7)
September, 2018 703 589 (83.8)
October, 2018 1037 927 (89.4)
November, 2018 944 833 (88.2)
December, 2018 483 456 (94.4)

(. . .continued)

Fig. 1. Monthly incidence of health-care-associated infections and hand-hygiene compliance, Finland, 2013–2018

No
. o

f i
nf

ec
tio

ns
p

er
1

00
0

pa
tie

nt
-d

ay
s 18

16

14

12

10

8

6

4

2

0

%
co

m
pl

yi
ng

w
ith

h
an

d
hy

gi
en

e

100
90
80
70
60

50
40
30
20
10
0

Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct Jan Apr Jul Oct
2013 2014 2015 2016 2017 2018

Month, Year
Incidence of health-care-associated infections Hand-hygiene compliance

480 Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, Finland Helena Ojanperä et al.

patients discharged from the wards had
remained steady in the 2 years before
the study: the number of health-care-
associated infections per discharged

patient was 5.0% (1328/26 714) in 2011
and 5.0% (1266/25 457) in 2012.20 We
were not able to obtain the number
of discharged patients as in this ear-

lier study, so could report incidence of
health-care-associated infections per
1000 patients-days. These health-care-
associated infections were recorded us-
ing the same semi-automated electronic
surveillance system used during the sur-
vey. The introduction of the eRub-tool
made easier to observe hand-hygiene
and saved the link nurses time. Similarly,
positive outcomes have been achieved
using mobile tools for hand-hygiene
observation in other studies.5,29

Further studies are needed to evalu-
ate the contribution of hand-hygiene
techniques to reducing the incidence of
health-care-associated infections and to
determine which health-care-associated
infections are most effectively prevented
by improving hand-hygiene compli-
ance. â– 

Acknowledgements
We thank Pasi Ohtonen.

Competing interests: None declared.

摘要
芬兰医院工作人员的手部卫生合规性以及卫生保健相关性感染的发生率
目的 在直接观察医生和护士的手部卫生习惯之后确定
手部卫生合规性的变化,并且评估这些变化与卫生保
健相关性感染发生率之间的关系。
方法 从 2013 年至 2018 年,我们在芬兰的一家三级医
院进行了内部审核调查。感染控制专科护士根据世界
卫生组织的手部卫生策略观察了手部卫生习惯。我们

计算手部卫生合规性的方法为 :采取了必要手部卫生
措施的观察次数除以需要保持手部卫生的观察总数。
我们使用半自动化的电子发生率监测程序来确定卫生
保健相关性感染的发生率。我们计算了皮尔逊相关系
数 (r),以评估卫生保健相关性感染发生率与手部卫生
合规性之间的关系。

ملخص
االلتزام بنظافة اليدين لدى فرق العمل باملستشفيات وحدوث العدوى املرتبط بالرعاية الصحية، فنلندا

تطبيق بعد اليدين بنظافة االلتزام يف التغريات حتديد الغرض
املالحظة املبارشة ملامرسات نظافة اليدين لدى األطباء واملمرضات،
املرتبطة العدوى حاالت وحدوث التغريات بني العالقة وتقييم

بالرعاية الصحية.
رعاية مستشفى يف داخيل تدقيقي مسح بإجراء قمنا الطريقة
قام .2018 إىل 2013 من الفرتة خالل فنلندا يف الثانوي فوق
بناًء اليدين نظافة ممارسات بمالحظة العدوى مكافحة ممرضو
عىل اسرتاتيجية منظمة الصحة العاملية اخلاصة بنظافة اليدين. قمنا
باحتساب االلتزام بنظافة اليدين بعدد املالحظات حيث تم ممارسة
املالحظات عدد إمجايل عىل مقسوًما الرضورية، اليدين نظافة
حدوث قررنا لقد اليدين. نظافة إىل حاجة هناك كانت حيث
برنامج باستخدام الصحية بالرعاية املرتبطة العدوى حاالت
معامل بحساب قمنا العدوى. حلدوث آيل شبه إلكرتوين مراقبة
ارتباط Pearson (r) لتقييم العالقة بني حدوث حاالت العدوى

املرتبطة بالرعاية الصحية، وااللتزام بنظافة اليدين.

النتائج سجلت املمرضات 52115 مالحظة بخصوص نظافة
اليدين يف الفرتة ما بني عامي 2013 و2018. زاد االلتزام السنوي
يف (3617/2762) 76.4% من ملحوظ بشكل اليدين بنظافة
عام 2013، إىل %88.5 (10211/9034) يف عام 2018 (نسبة
عدد انخفض الفرتة، نفس خالل .(0.0001 من أقل االحتامل
حاالت العدوى املرتبطة بالرعاية الصحية من 2012 إىل 1831،
إىل 14.0 من مريض/يوم 1000 لكل حدوثها معدل وانخفض
عالقة اكتشفنا لقد .(0.0001 من أقل االحتامل (نسبة 11.7
الشهري املعدل بني سلبية، إحصائية داللة ذات ولكنها ضعيفة،
حلدوث العدوى املرتبطة بالرعاية الصحية، وااللتزام بنظافة اليدين

(معامل االرتباط r = -0.48؛ نسبة االحتامل أقل من 0.001).
بمامرسات واملمرضات األطباء التزام حتسن االستنتاج
التغيري هذا وارتبط والتقييم، املبارشة املالحظة مع اليدين نظافة
الصحية. بالرعاية املرتبطة العدوى حاالت حدوث يف بانخفاض
هناك حاجة إىل مزيد من الدراسات لتقييم مسامهة نظافة اليدين يف

احلد من حاالت العدوى املرتبطة بالرعاية الصحية.

Fig. 2. Correlation between monthly incidence of health-care-associated infections and
hand-hygiene compliance, Finland, 2013–2018

No
. o

f h
ea

lth
-c

ar
e-

as
so

ci
at

ed
in

fe
ct

io
ns

pe

r 1
00

0
pa

tie
nt

-d
ay

s

20

18

16

14

12

10

8

6

4

2

0

Hand-hygiene compliance %
70 75 80 85 90 95 100

481Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, FinlandHelena Ojanperä et al.

结果 在 2013 年至 2018 年之间,护士进行了 52,115
次 手 部 卫 生 观 察。 年 度 手 部 卫 生 合 规 性 从 2013 年
的 76.4 % (2762/3617) 显 著 提 升 至 2018 年 的 88.5 %
(9034/10 211) (P < 0.0001)。同时,卫生保健相关性感染
数量从 2012 例降至 1831 例,观察对象每 1000 个入院
日的发生率从 14.0 降至 11.7 (P < 0.0001)。我们发现每
月卫生保健相关性感染的发生率与手部卫生合规性之

间存在微弱但在统计学上呈显著的负相关性 (r = −0.48;
P < 0.001)。
结论 通过直接观察和反馈改善了医生与护士在手部卫
生习惯方面的合规性,并且这种变化与医疗保健相关
性感染的发生率降低相关。需要进一步的研究来评估
手部卫生对减少卫生保健相关性感染的有利因素。

Résumé

Respect de l’hygiène des mains par le personnel hospitalier et nombre d’infections liées aux soins de santé en Finlande
Objectif Identifier les changements dans l’application des mesures
d’hygiène des mains après l’introduction d’un système d’observation
directe des pratiques en la matière chez les médecins et infirmiers.
Évaluer le rapport entre ces changements et le nombre d’infections
liées aux soins de santé.
Méthodes Nous avons effectué un audit interne au sein d’un hôpital de
soins tertiaires en Finlande entre 2013 et 2018. Les infirmières chargées
du contrôle des infections ont jugé les pratiques d’hygiène en se basant
sur la stratégie d’hygiène des mains de l’Organisation mondiale de la
Santé. Nous avons défini dans quelle mesure le personnel respectait
les consignes d’hygiène des mains en divisant le nombre de cas où le
niveau d’hygiène requis était respecté par le nombre total de cas où
l’hygiène des mains était nécessaire. Nous avons également déterminé le
nombre d’infections liées aux soins de santé à l’aide d’un programme de
surveillance électronique semi-automatique. Enfin, nous avons calculé
le coefficient de corrélation de Pearson (r) afin d’évaluer le rapport
entre le nombre d’infections liées aux soins de santé et le respect de
l’hygiène des mains.

Résultats Les infirmières ont observé 52 115 cas d’hygiène des mains
entre 2013 et 2018. La moyenne annuelle du respect des mesures a
considérablement augmenté, passant de 76,4% (2762/3617) en 2013
à 88,5% (9034/10 211) en 2018 (P < 0,0001). Durant la même période,
le nombre d’infections liées aux soins de santé a diminué, passant de
2012 à 1831, et leur fréquence sur 1000 jours-patients a chuté, de 14,0
à 11,7 (P < 0,0001). Nous avons détecté une corrélation négative faible
mais statistiquement significative entre le taux d’incidence mensuel
d’infections liées aux soins de santé et le respect de l’hygiène des mains
(r = −0,48; P < 0,001).
Conclusion Les observations directes et retours ont encouragé les
médecins et infirmiers à mieux respecter les consignes d’hygiène des
mains. Ce changement a entraîné une baisse du nombre d’infections
liées aux soins de santé. D’autres études sont cependant nécessaires pour
évaluer l’impact de l’hygiène des mains sur la diminution des infections
liées aux soins de santé.

Резюме

Соблюдение сотрудниками больниц правил гигиены рук и заболеваемость внутрибольничными
инфекциями в Финляндии
Цель Выявить изменения в соблюдении правил гигиены
рук с момента введения непосредственного наблюдения за
гигиеной рук для врачей и медицинских сестер и оценить
взаимосвязь между данными изменениями и заболеваемостью
внутрибольничными инфекциями.
Методы Авторы проводили опросы во время внутренних
проверок в больнице третичной медицинской помощи
в Финляндии в период с 2013 по 2018 год. Медицинские
сестры отделения инфекционного контроля наблюдали за
осуществлением на практике гигиены рук в соответствии
с правилами, определенными Всемирной организацией
здравоохранения. Авторы рассчитали коэффициент соответствия
требованиям гигиены рук как соотношение количества
наблюдений, в ходе которых правила гигиены рук соблюдались,
к общему количеству наблюдений, в ходе которых соблюдение
таких правил было необходимо. Авторы также определили
показатель заболеваемости внутрибольничными инфекциями
с применением полуавтоматической программы электронного
надзора за заболеваемостью. Был рассчитан коэффициент
корреляции Пирсона (r) для оценки взаимосвязи меж ду
з а б о л е в а е м о с ть ю в ну тр и б о л ь н ич н ы м и и н ф е к ц и я м и и
соблюдением правил гигиены рук.

Результаты В период с 2013 по 2018 год медицинские сестры
выполнили 52 115 наблюдений за гигиеной рук. Ежегодный
показатель соблюдения правил гигиены рук значительно
вырос: с 76,4% (2762 случая из 3617) в 2013 году до 88,5% (9034
из 10 211 случаев) в 2018 году (P < 0,0001). В тот же период
количество случаев внутрибольничных инфекций сократилось
с 2012 до 1831, а заболеваемость на 1000 пациенто-дней упала
с 14,0 до 11,7 (P < 0,0001). Авторы обнаружили слабую, но
статистически значимую отрицательную корреляцию между
ежемесячной заболеваемостью внутрибольничными инфекциями
и соблюдением правил гигиены рук (r = –0,48; P < 0,001).
Вывод Соблюдение врачами и медицинскими сестрами
правил гигиены рук улучшилось с момента введения прямого
наблюдения и отчетов о результатах, и это изменение связано
со снижением показателей заболеваемости внутрибольничными
инфекциями. Для оценки роли гигиены рук в снижении
заболеваемости внутрибольничными инфекциями необходимо
проведение дальнейших исследований.

482 Bull World Health Organ 2020;98:475–483| doi: http://dx.doi.org/10.2471/BLT.19.247494

Research
Hand-hygiene compliance and health-care-associated infections, Finland Helena Ojanperä et al.

Resumen

Cumplimiento de la higiene de las manos entre el personal de los hospitales y la incidencia de las infecciones relacionadas con
la atención médica, Finlandia
Objetivo Determinar los cambios del cumplimiento de la higiene de las
manos tras las observaciones directas en las prácticas de higiene de las
manos que realizan los médicos y las enfermeras, además de evaluar la
relación entre los cambios y la incidencia de las infecciones relacionadas
con la atención médica.
Métodos Se realizó una encuesta de auditoría interna en un hospital
de atención terciaria en Finlandia de 2013 a 2018. Las enfermeras
de control de infecciones observaron las prácticas de higiene de las
manos según la estrategia de la Organización Mundial de la Salud para
la higiene de las manos. Se estimó que el cumplimiento de la higiene
de las manos equivalía a dividir el número de las observaciones en las
que era necesario practicar la higiene de las manos por el número total
de observaciones en las que se requería la higiene de las manos. Se
determinó la incidencia de las infecciones relacionadas con la atención
médica mediante un programa semiautomatizado y electrónico de
vigilancia de la incidencia. Se calculó la correlación de Pearson (r) para
evaluar la relación entre la incidencia de las infecciones relacionadas
con la atención médica y el cumplimiento de la higiene de las manos.

Resultados Las enfermeras realizaron 52 115 observaciones de higiene
de las manos entre 2013 y 2018. El cumplimiento anual de la higiene de
las manos aumentó significativamente del 76,4 % (2762/3617) en 2013
al 88,5 % (9034/10 211) en 2018 (P < 0,0001). Durante el mismo tiempo,
el número de infecciones relacionadas con la atención médica disminuyó
de 2012 a 1831, y su incidencia por cada 1000 días de pacientes se redujo
de 14,0 a 11,7 (P < 0,0001). Se encontró una correlación negativa débil
pero estadísticamente significativa entre la incidencia mensual de las
infecciones relacionadas con la atención médica y el cumplimiento de
la higiene de las manos (r = -0,48; P < 0,001).
Conclusión El cumplimiento de las prácticas de higiene de las manos
que realizan los médicos y las enfermeras mejoró con la observación
directa y la retroalimentación, lo que se asoció a una disminución de
la incidencia de las infecciones relacionadas con la atención médica.
Se requieren más estudios para evaluar la contribución de la higiene
de las manos a la reducción de las infecciones relacionadas con la
atención médica.

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