Abstract

Objective

To verify adherence and quality of hand hygiene techniques performed by health professionals at recommended times and identify impacting factors.

Methods

This is an observational study, with 41 professionals from the Adult Intensive Care Unit of a Brazilian teaching hospital. Data collection took place from September to December 2021, using a sociodemographic questionnaire and observation form from the World Health Organization. Statistical tests of binomial analysis and mixed-effects logistic regression model were applied, and a significance level of 0.05 was adopted.

Results

A total of 1,055 hand hygiene opportunities were observed; the adherence rate was 23.98%; and it can be seen that professionals did not perform the recommended technique. The binomial test verified greater adherence to moments “after” when compared to moments “before” (p< 0.001) and a negative impact of using gloves was found (p< 0.001). The logistical model reinforced greater adherence in moments “after”. Even though adherence is low among all professional categories, the logistical model demonstrated more chances of hand hygiene by nurses.

Conclusion

Adherence to hand hygiene was considerably low, especially considering the appropriate technique. A negative impact of using gloves on hand hygiene adherence was verified. Professionals demonstrated greater chances of adhering to hand hygiene in the moments “after” when compared to moments “before”.

Hand hygiene; Health personnel; Infection control; Patient safety; Intensive Care Units

Resumo

Objetivo

Verificar a adesão e a qualidade da técnica de higiene das mãos realizada por profissionais de saúde nos momentos preconizados e identificar os fatores impactantes.

Métodos

Estudo observacional, com 41 profissionais de Unidade de Terapia Intensiva Adulto de um hospital de ensino brasileiro. A coleta de dados foi de setembro a dezembro de 2021, utilizando questionário sociodemográfico e formulário de observação da Organização Mundial da Saúde. Foram aplicados testes estatísticos de análise binomial e modelo de regressão logística de efeitos mistos e adotou-se nível de significância de 0,05.

Resultados

Um total de 1.055 oportunidades de Higiene das Mãos foram observadas, a taxa de adesão foi de 23,98% e pode-se verificar que os profissionais não executaram a técnica preconizada. O teste binomial verificou maior adesão aos momentos “após” quando comparados aos momentos “antes” (p< 0,001) e foi constatado impacto negativo do uso de luvas (p< 0,001). O modelo logístico reforçou a maior adesão nos momentos “após”. Ainda que a adesão esteja baixa entre todas as categorias profissionais, o modelo logístico demonstrou mais chances de higiene das mãos pelos enfermeiros.

Conclusão

A adesão à higiene das mãos foi consideravelmente baixa principalmente considerando a técnica adequada. Foi verificado impacto negativo do uso de luvas na adesão higiene das mãos. Os profissionais demonstraram maiores chances de aderirem a higiene das mãos nos momentos “após” quando comparados aos momentos “antes”.

Higiene das mãos; Pessoal de saúde; Controle de infecções; Segurança do paciente; Unidades de Terapia Intensiva

Resumen

Objetivo

Verificar la adhesión y la calidad de la técnica de higiene de manos realizada por profesionales de la salud en los momentos recomendados e identificar los factores impactantes.

Métodos

Estudio observacional con 41 profesionales de una unidad de cuidados intensivos adulta de un hospital universitario brasileño. La recopilación de datos se realizó de septiembre a diciembre de 2021, mediante un cuestionario sociodemográfico y un formulario de observación de la Organización Mundial de la Salud. Se aplicaron pruebas estadísticas de análisis binominal y el modelo de regresión logística de efectos mixtos, y se adoptó un nivel de significación de 0,05.

Resultados

Se observó un total de 1.055 oportunidades de higiene de manos. El índice de adhesión fue del 23,98 % y se pudo verificar que los profesionales no ejecutan la técnica recomendada. La prueba binominal verificó una mayor adhesión en los momentos “después” comparado con los momentos “antes” (p<0,001) y se constató un impacto negativo del uso de guantes (p<0,001). El modelo logístico reforzó la mayor adhesión en los momentos “después”. Aunque la adhesión sea baja en todas las categorías profesionales, el modelo logístico demostró mayor probabilidad de higiene de manos por parte de los enfermeros.

Conclusión

La adhesión a la higiene de manos fue considerablemente baja, sobre todo si se considera la técnica adecuada. Se verificó un impacto negativo del uso de guantes en la adhesión a la higiene de manos. Los profesionales demostraron mayores probabilidades de adhesión a la higiene de manos en los momentos “después” comparado con los momentos “antes”.

Higiene de las manos; Personal de salud; Control de infecciones; Seguridad del paciente; Unidades de Cuidados Intensivos

Introduction

Healthcare-associated infections (HAIs) are adverse events present in health services that affect millions of people around the world, presenting themselves as a global challenge for patient safety.(¹1. Valim MD, Rocha IL, Souza TP, Cruz YA, Bezerra TB, Baggio E, et al. Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review. Rev Bras Enferm. 2019;72(2):578-92.,²2. Bezerra TB, Valim MD, Bortolini J, Ribeiro RP, Marcon SR, Moura ME. Adherence to hand hygiene in critical sectors: Can we go on like this? J Clin Nurs. 2020;29:2691-8.) Every day around the world, more than 1.4 million people are affected by preventable HAIs. In Brazil, around 3 to 15% of people admitted to hospital develop some type of HAI, which can complicate the patient’s health situation, expose them to contamination, require longer hospital admission, increase costs with medications and tests and cause death. Furthermore, HAIs are related to the emergence of multidrug-resistant microorganisms.(³3. World Health Organization (WHO). Global report on infection prevention and control Executive summary. Geneva: WHO; 2022 [cited 2023 May 17]. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/ipc/ipc-global-report/who_ipc_global-report_executive-summary.pdf?sfvrsn=9bdb205f_7&download=true
https://cdn.who.int/media/docs/default-s... )

Evidence shows that low adherence to hand hygiene (HH) is one of the main factors for the increase in HAIs, increasing costs related to patient care.(⁴4. Leoncio JM, Almeida VF, Ferrari RA, Capobiango JD, Kerbauy G, Tacla MT. Impacto das infecções relacionadas à assistência à saúde nos custos da hospitalização de crianças. Rev Esc Enferm USP. 2019;53:e03486.,⁵5. Leal MA, Freitas-Vilela AA. Custos das infecções relacionadas à assistência em saúde em uma Unidade de Terapia Intensiva. Rev Bras Enferm. 2021;74(1):e20200275.) Faced with this worrying scenario, the World Health Organization (WHO), which was included in the World Alliance for Patient Safety, adopted HH as the first challenge to promote patient safety since 2004.(³3. World Health Organization (WHO). Global report on infection prevention and control Executive summary. Geneva: WHO; 2022 [cited 2023 May 17]. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/ipc/ipc-global-report/who_ipc_global-report_executive-summary.pdf?sfvrsn=9bdb205f_7&download=true
https://cdn.who.int/media/docs/default-s... )

HH is a simple, low-cost measure with proven effectiveness in preventing HAIs, as it reduces the microbial load present on the hands and prevents the spread of pathogenic agents.(⁶6. Custódio GO, Santos FS, Rabello RD, Querido SM, Cesário PS, Salgado JS, et al. Avaliação microbiológica e da higiene das mãos de profissionais de enfermagem: uma abordagem investigativa. Braz J Hea Rev. 2022;5(6):23571-83.,⁷7. Gurgel MC, Luz SM, Lima AP, Veras LM. Hand hygienization and its relevance for the prevention of health care infections: an integrative review. Res Soc Deve. 2022;11(15):e303111537103.) However, even with scientific evidence that proves its effectiveness, low adherence to HH practice is still a problem faced worldwide, which challenges professionals and managers of health institutions.(²2. Bezerra TB, Valim MD, Bortolini J, Ribeiro RP, Marcon SR, Moura ME. Adherence to hand hygiene in critical sectors: Can we go on like this? J Clin Nurs. 2020;29:2691-8.,⁸8. Chang NC, Reisinger HS, Schweizer ML, Jones I, Chrischilles E, Chorazy M, et al. Hand Hygiene Compliance at Critical Points of Care. Clin Infect Dis. 2021;72(5):814–20.,⁹9. Costa JG, Araújo LD, Neiva M, Abreu MB, Lacerda RP, Silva TW. Fatores impactantes na prática da higienização das mãos. Rev Cient Enfermagem. 2022;12(38):278-91.)

In this regard, infection control programs need to monitor not only adherence rates based on opportunities, but also the HH technique quality, which consists of following the steps and time recommended for the appropriate action of the antiseptic.(¹⁰10. Toney-Butler TJ, Gasner A, Carver N. Hand Hygiene. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 May 17]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470254/
https://www.ncbi.nlm.nih.gov/books/NBK47... ) Recent studies propose that the rationalized 3-step technique is as effective as the 6-step technique recommended by the WHO,(¹¹11. Tschudin-Sutter S, Rotter ML, Frei R, Nogarth D, Hausermann P, Stranden A, et al. Simplifying the WHO ‘how to hand rub’ technique: three steps are as effective as six-results from an experimental randomized crossover trial. Clin Microbiol Infect. 2017;23(6):409.e1.,¹²12. Tschudin-Sutter S, Sepulcri D, Dangel M, Ulrich A, Frei R, Widmer AF. Simplifying the World Health Organization Protocol: 3 steps versus 6 steps for performance of hand hygiene in a cluster-randomized trial. Clin Infect Dis. 2019;69(4):614-20.) whose rationalization of steps follows: 1- covering all surfaces of the hands; (2) rotational rubbing of the fingertips in the palm of the alternate hand; and (3) rotational rubbing of both thumbs. Regarding time, recent studies have shown that reducing the time from 30 to 15 seconds with alcoholic preparations was effective in reducing bacterial counts on hands.(¹³13. Harnoss JC, Dancer SJ, Kaden CF, Baguhl R, Kohlmann T, Papke R, et al. Hand antisepsis without decreasing efficacy by shortening the rub-in time of alcohol-based handrubs to 15 seconds. J Hosp Infect. 2020;104(4):419-24.,¹⁴14. Suchomel M, Fritsch F, Kampf G. Bactericidal efficacy of two modified WHO-recommended alcohol-based hand rubs using two types of rub-in techniques for 15s. J Hosp Infect. 2021;111:47-9.)

However, another problem found worldwide is the poor quality in the HH technique execution, with low levels of friction on the tips of fingers and thumbs as well as reduced time for the antiseptic to act.(¹⁵15. Yehouenou CL, Dohou AM, Fiogbe AD, Esse M, Degbey C, Simon A, et al. Hand hygiene in surgery in Benin: opportunities and challenges. Antimicrob Resist Infect Control. 2020;9(1):85.,¹⁶16. Feng G, Jun H, Elaine G, Haitao S. Powdered Activated Charcoal Tracing in Hand Hygiene Training and Compliance Assessment During the COVID-19 Pandemic. Risk Manag Healthc Policy. 2021;14:675-83.)

Considering the above, this study aimed to verify the adherence and quality of the HH technique performed by health professionals at recommended times and identify the impacting factors.

Methods

This is an observational, analytical study. Data collection was carried out in the Intensive Care Unit (ICU) of the Hospital Universitário Júlio Muller (HUJM), municipality of Cuiabá, Mato Grosso, Brazil, from September to December 2021, in the morning, afternoon and night shifts, during all days of the week. The hospital is considered medium-sized and offers tertiary care to the state’s population. The study population was made up of professionals who had been carrying out care activities in the adult ICU for at least three months. At the time, there were 93 health professionals, distributed between morning, afternoon and night shifts. Of these, 48 were excluded due to termination of their employment contract or were reassigned to another sector and four because they were on sick leave or on vacation, which totaled a final sample of 41 health professionals. In order to minimize the Hawthorne effect, health professionals received the study information and signed the Informed Consent Form (ICF) at least one month before the beginning of observations.

The dependent variable was adherence to HH based on the moments recommended by the WHO.(³3. World Health Organization (WHO). Global report on infection prevention and control Executive summary. Geneva: WHO; 2022 [cited 2023 May 17]. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/ipc/ipc-global-report/who_ipc_global-report_executive-summary.pdf?sfvrsn=9bdb205f_7&download=true
https://cdn.who.int/media/docs/default-s... ,¹⁷17. Organização Pan-Americana da Saúde (OPAS). Agência Nacional de Vigilância Sanitária. Manual para observadores: estratégia multimodal da OMS para a melhoria da higienização das mãos. Brasília (DF): OPAS; 2008 [citado 2023 Maio 17]. Disponível em: https://proqualis.fiocruz.br/sites/proqualis.fiocruz.br/files/MANUAL%20PARA%20OBSERVADORES.pdf
https://proqualis.fiocruz.br/sites/proqu... ) Independent variables were professional category, sex, observation period, moments recommended for HH,(³3. World Health Organization (WHO). Global report on infection prevention and control Executive summary. Geneva: WHO; 2022 [cited 2023 May 17]. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/ipc/ipc-global-report/who_ipc_global-report_executive-summary.pdf?sfvrsn=9bdb205f_7&download=true
https://cdn.who.int/media/docs/default-s... ,¹⁷17. Organização Pan-Americana da Saúde (OPAS). Agência Nacional de Vigilância Sanitária. Manual para observadores: estratégia multimodal da OMS para a melhoria da higienização das mãos. Brasília (DF): OPAS; 2008 [citado 2023 Maio 17]. Disponível em: https://proqualis.fiocruz.br/sites/proqualis.fiocruz.br/files/MANUAL%20PARA%20OBSERVADORES.pdf
https://proqualis.fiocruz.br/sites/proqu... ) HH technique quality (steps performed and time spent), glove use and unit infrastructure. Sociodemographic and work variables were collected using a self-administered questionnaire, containing closed-ended and multiple-choice questions about age, sex, education level and professional category. Adherence to HH was collected by direct observation using the observation form validated by the WHO.(¹⁷17. Organização Pan-Americana da Saúde (OPAS). Agência Nacional de Vigilância Sanitária. Manual para observadores: estratégia multimodal da OMS para a melhoria da higienização das mãos. Brasília (DF): OPAS; 2008 [citado 2023 Maio 17]. Disponível em: https://proqualis.fiocruz.br/sites/proqualis.fiocruz.br/files/MANUAL%20PARA%20OBSERVADORES.pdf
https://proqualis.fiocruz.br/sites/proqu... ,¹⁸18. World Health Organization (WHO). Guide to implementation: a guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: WHO; 2009 [cited 2023 May 17]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... )

The observation form recommended by the WHO makes it possible to calculate the adherence rate to HH by health professionals based on the actions carried out in relation to the total number of opportunities verified.(¹⁷17. Organização Pan-Americana da Saúde (OPAS). Agência Nacional de Vigilância Sanitária. Manual para observadores: estratégia multimodal da OMS para a melhoria da higienização das mãos. Brasília (DF): OPAS; 2008 [citado 2023 Maio 17]. Disponível em: https://proqualis.fiocruz.br/sites/proqualis.fiocruz.br/files/MANUAL%20PARA%20OBSERVADORES.pdf
https://proqualis.fiocruz.br/sites/proqu... ,¹⁸18. World Health Organization (WHO). Guide to implementation: a guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: WHO; 2009 [cited 2023 May 17]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... ) It is a checklist containing initial identification of observer, date, start and end time of observations, period of observation, professional category, opportunities and recommendations for HH in accordance with the five moments recommended by the WHO:(¹⁷17. Organização Pan-Americana da Saúde (OPAS). Agência Nacional de Vigilância Sanitária. Manual para observadores: estratégia multimodal da OMS para a melhoria da higienização das mãos. Brasília (DF): OPAS; 2008 [citado 2023 Maio 17]. Disponível em: https://proqualis.fiocruz.br/sites/proqualis.fiocruz.br/files/MANUAL%20PARA%20OBSERVADORES.pdf
https://proqualis.fiocruz.br/sites/proqu... ) 1- before touching a patient, 2- before clean/aseptic procedures, 3- after body fluid exposure/risk, 4- after touching a patient, 5- after contact with patient surroundings. Two moments for HH were added, following the WHO recommendation during the COVID-19 pandemic: 6- before putting PPE and 7- after removing PPE.(³3. World Health Organization (WHO). Global report on infection prevention and control Executive summary. Geneva: WHO; 2022 [cited 2023 May 17]. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/ipc/ipc-global-report/who_ipc_global-report_executive-summary.pdf?sfvrsn=9bdb205f_7&download=true
https://cdn.who.int/media/docs/default-s... )

This form allows observers to quantify the total number of HH opportunities, the number of times professionals performed the HH technique and, when performed, whether it was performed with alcohol-based products or soap and water. To meet the study objectives, a question was added to the form about glove use by professionals when the opportunity for HH was verified and, once HH was performed, a question was added with the aim of assessing the technique quality, recording the time of the steps performed:(¹¹11. Tschudin-Sutter S, Rotter ML, Frei R, Nogarth D, Hausermann P, Stranden A, et al. Simplifying the WHO ‘how to hand rub’ technique: three steps are as effective as six-results from an experimental randomized crossover trial. Clin Microbiol Infect. 2017;23(6):409.e1.,¹²12. Tschudin-Sutter S, Sepulcri D, Dangel M, Ulrich A, Frei R, Widmer AF. Simplifying the World Health Organization Protocol: 3 steps versus 6 steps for performance of hand hygiene in a cluster-randomized trial. Clin Infect Dis. 2019;69(4):614-20.) 1- covering all surfaces of the hands; 2- rotational rubbing of the fingertips in the palm of the alternate hand; and 3- rotational rubbing of both thumbs. The recommended time of 15 seconds for HH with alcoholic preparations and 40 to 60 seconds for HH with soap and water was considered correct. A digital chronometer tested and approved by the Brazilian Institute of Metrology, Quality and Technology (INMETRO - Instituto Brasileiro de Metrologia, Qualidade e Tecnologia) was used.

Data were collected by two trained observers. In order to verify whether the two observers were satisfactorily trained to observe the moments recommended for HH and assess the level of agreement between them, a total of 42 HH opportunities were observed and the Kappa coefficient was calculated. Observations were carried out in a ward belonging to the medical clinic of the aforementioned hospital with seven health professionals during their work activities, in three 20-minute sessions and were not part of the study. The researcher in charge acted as the gold standard (judge). The Kappa coefficient found was 0.84, therefore classified as almost perfect agreement.(¹⁹19. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74.)

To verify the study’s infrastructure for HH, a questionnaire validated by the WHO was used.(¹⁸18. World Health Organization (WHO). Guide to implementation: a guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: WHO; 2009 [cited 2023 May 17]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... ) The instrument was filled out by observers. It is a checklist containing 27 items referring to the physical resources for HH existing in the units, such as availability of water, existence of alcoholic preparation within reach in perfect working order and/or refilled, types of dispensers, availability and stock of procedure gloves, number of beds, number of sinks stocked with water, soap and paper towels available, presence/location of illustrative posters about HH, number of health professionals in the sector, participation in training on HH and presence of audit on adherence to HH in the institution.(¹⁸18. World Health Organization (WHO). Guide to implementation: a guide to the implementation of the WHO multimodal hand hygiene improvement strategy. Geneva: WHO; 2009 [cited 2023 May 17]. Available from: https://apps.who.int/iris/bitstream/handle/10665/70030/WHO_IER_PSP_2009.02_eng.pdf?sequence=1&isAllowed=y
https://apps.who.int/iris/bitstream/hand... )

The HH adherence rate was determined by the total number of HH opportunities in which professionals performed HH divided by the total number of opportunities. The rate of adherence to HH with correct technique was calculated by the number of HH opportunities in which professionals performed HH with appropriate technique divided by the total number of HH opportunities performed. The number of times health professionals were wearing gloves during unexecuted HH opportunities was also calculated by the total number of unexecuted HH opportunities in order to estimate the percentage of unexecuted opportunities that could be associated with glove use.

In descriptive data analysis, frequency distributions, medians, means, standard deviation, minimum and maximum were estimated for the numerical variables. Confidence intervals for proportions, bivariate analysis for calculating differences between two proportions and mixed-effects logistic regression were calculated to verify the association between the adherence rate to HH and gender, period, profession and moments recommended for HH with the size of the effect of the association calculated by Odds Ratio. For use of glove response, a mixed-effects logistic regression model was estimated with the same specifications as the previous model, except for recommended moments, for which categories from 1 to 5 were considered. The significances of Odds Ratios were verified by the Wald test. The R 4.3.1 (2023) software was used for all statistical analyzes and a significance level of 0.05 was adopted.

This study was approved by the Research Ethics Committee (REC) of HUJM, under Opinion 2.442.333 (Certificate of Presentation for Ethical Consideration (Certificado de Apresentação para Apreciação Ética): 75169317.0.0000.5541). After being informed about the research procedures, all professionals who agreed to take part in the study signed the ICF.

Results

Of the 41 health professionals who participated in the study, 58.5% (24) were nursing technicians, 14.6% (6) nurses, 14.6% (6) physical therapists and 12.2% (5) were physicians. Professionals’ mean age was 42.22 years (SD = 8.07 years) with a minimum of 27 and a maximum of 60 years. A total of 73.2% (30) of professionals were female, 37.5% (15) had completed specialization and 35% (14) had completed higher education. A total of 1055 opportunities were observed. The general adherence rate to HH was 23.98% (253), 1.80% of actions were carried out according to the correct recommended technique. Nurses and physicians were the professionals who most adhered to HH (40.17% and 33.33%, respectively). As for technique quality, it can be seen that the recommended technique was not performed by the professionals (Table 1). Health professionals’ adherence to HH was higher in the moments “before removing PPE” (82.65%), “after touching patient surroundings” (39.76%) and “after touching a patient” (33.15%). When considering using the appropriate HH technique in these moments, professionals’ adherence decreased considerably (10.20% and 2.41%, respectively) (Table 1). In the binomial test, there was a statistical difference in the proportions of adherence to HH between the moments “before” (7.05%) and the moments “after” (23.82%), (p<0.001).

The highest frequency of glove use for HH actions not performed was found in the moments “before clean/aseptic procedures”, “before touching a patient” and “after body fluid exposure/risk”. Of the total number of HH actions not carried out, 60.14% were related to glove use, and the binomial test verified a significant impact of using gloves on health professionals’ non-adherence to HH (p<0.001) (Table 2).

In the mixed-effects logistic model for HH adherence, the variables that showed significance were professional category (X²= 8.549, df = 3 and p = 0.036) and recommendation (X²= 172.570 df = 6 and p < 0.001). The regression model’s success rate was 75.7%. Table 3 presents the Odds Ratios for HH for each level of independent variables compared with their references. Adherence to HH was significantly higher in moments “after” when compared to moments “before touching a patient”, “after removing PPE” (OR 68.44, p<0.001), “after touching patient surroundings” (OR 7.18, p<0.001) and “after touching a patient” (OR 5.34, p<0.001). Nurses were more likely to clean their hands when compared to nursing technicians (p=0.010) and physical therapists (p=0.014). Sex did not present statistical significance. Regarding HH with the use of alcoholic preparations or the use of soap and water, in the binomial test, there was a significant difference (p < 0.001) between the rates of adherence to HH when performed with alcohol (23.70%; CI (95%): 0.186; 0.294) and soap and water (76.30%; CI (95%): 0.706; 0.814) (Table 3).

Discussion

This is a study that allowed expanding scientific knowledge about HH adherence by health professionals and the quality of the technique used as well as discussing the factors that impact adherence. Even with solid evidence of HH effectiveness in reducing infection rates, length of hospital stay, costs related to treatment and transmission of multi-resistant microorganisms,(⁶6. Custódio GO, Santos FS, Rabello RD, Querido SM, Cesário PS, Salgado JS, et al. Avaliação microbiológica e da higiene das mãos de profissionais de enfermagem: uma abordagem investigativa. Braz J Hea Rev. 2022;5(6):23571-83.,⁷7. Gurgel MC, Luz SM, Lima AP, Veras LM. Hand hygienization and its relevance for the prevention of health care infections: an integrative review. Res Soc Deve. 2022;11(15):e303111537103.,²⁰20. Boyce JM. Current issues in hand hygiene. Am J Infect Control. 2019;47s:A46–52.) low adherence to HH by health professionals is still a global concern as it presents an imminent threat to patient safety in health institutions.(³3. World Health Organization (WHO). Global report on infection prevention and control Executive summary. Geneva: WHO; 2022 [cited 2023 May 17]. Available from: https://cdn.who.int/media/docs/default-source/integrated-health-services- (ihs)/ipc/ipc-global-report/who_ipc_global-report_executive-summary.pdf?sfvrsn=9bdb205f_7&download=true
https://cdn.who.int/media/docs/default-s... )

Several factors may be related to low adherence to HH by professionals, such as forgetfulness, carrying out care activities with a higher risk of infection, glove use and other personal protective equipment (PPE), high workload, lack of knowledge, distance from the washbasin and also aspects related to mental health, such as anxiety, depression, impaired sleep, among others.(²¹21. Teixeira CF, Soares CM, Souza EA, Lisboa ES, Pinto IC, Andrade LR, et al. A saúde dos profissionais de saúde no enfrentamento da pandemia de Covid-19. Cien Saude Colet. 202025(9):3465–74.) There is evidence in the international literature that these factors can constitute barriers for professionals to adhere to HH.(²²22. Casas I, Castellà L, Gimenez M, Pulido A, Sopena N, Ciércoles A, et al. Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital. Med Clin (Ed Impr). 2022;159(9):426-31.,²³23. Al-Maani A, Wahaibi AA, Al-Zadjali N, Al-Sooti J, AlHinai M, Badawi AA, et al. The impact of the hand hygiene role model project on improving healthcare workers’ compliance: a quasi-experimental observational study. J Infect Public Health. 2022;15(3):324-30.)

The study showed that adherence to HH by health professionals was considerably low in all categories, even among those who performed the correct technique. Failure to use the appropriate HH technique is the main cause of HAI.(²⁴24. Valencia-Martín R, Gonzalez-Galan V, Alvarez-Marín R, Cazalla-Foncueva AM, Aldabó T, Gil-Navarro MV, Alonso-Araujo I, Martin C, Gordon R, García-Nuñez EJ, Perez R, Peñalva G, Aznar J, Conde M, Cisneros JM; In representation of A. baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital. Antimicrob Resist Infect Control. 2019;8:199.) Researchers verified a decrease in the incidence of colonization of patients with multidrug-resistant bacteria after the implementation of health interventions aimed at improving the HH technique,(²⁴24. Valencia-Martín R, Gonzalez-Galan V, Alvarez-Marín R, Cazalla-Foncueva AM, Aldabó T, Gil-Navarro MV, Alonso-Araujo I, Martin C, Gordon R, García-Nuñez EJ, Perez R, Peñalva G, Aznar J, Conde M, Cisneros JM; In representation of A. baumannii eradication program. A multimodal intervention program to control a long-term Acinetobacter baumannii endemic in a tertiary care hospital. Antimicrob Resist Infect Control. 2019;8:199.) especially those that included team training, with real-time feedback on failures to execute the correct technique.(²⁵25. Goodsell DS, Jenkinson J. Molecular illustration in research and education: past, present, and future. J Mol Biol. 2018;430(21):3969–81.)

In inferential analysis, nurses were more likely to clean their hands when compared to nursing technicians and physical therapists. The lack of HH by these professionals is worrying, as it compromises the safety of the care provided, leading to a greater risk of spreading HAIs.(²⁶26. Oliveira ES, Cardoso MV, Bezerra CM, Barbosa LP, Nobre KS, Carneiro TA. Hand hygiene rate in a Neonatal Intensive Care Unit. Acta Paul Enferm. 2022;35:eAPE00497.) A possible explanation regarding the nursing team can be attributed to the greater workload directed to mid-level professionals in that profession, when it comes to the high demand for care assistance procedures. The findings obtained in this study reinforce the need for educational actions and incentives for HH adherence by all team professionals,(²²22. Casas I, Castellà L, Gimenez M, Pulido A, Sopena N, Ciércoles A, et al. Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital. Med Clin (Ed Impr). 2022;159(9):426-31.,²³23. Al-Maani A, Wahaibi AA, Al-Zadjali N, Al-Sooti J, AlHinai M, Badawi AA, et al. The impact of the hand hygiene role model project on improving healthcare workers’ compliance: a quasi-experimental observational study. J Infect Public Health. 2022;15(3):324-30.) especially the nursing team, as they provide direct care to patients.

Given the present scenario, the multimodal strategy must be implemented in health establishments with the aim of reducing barriers to adherence to HH and valuing adequate technique, favoring the change and maintenance of behavior aimed at promoting patient safety.(²²22. Casas I, Castellà L, Gimenez M, Pulido A, Sopena N, Ciércoles A, et al. Impact of a multimodal intervention on compliance with hand hygiene among health care workers of a tertiary hospital. Med Clin (Ed Impr). 2022;159(9):426-31.,²³23. Al-Maani A, Wahaibi AA, Al-Zadjali N, Al-Sooti J, AlHinai M, Badawi AA, et al. The impact of the hand hygiene role model project on improving healthcare workers’ compliance: a quasi-experimental observational study. J Infect Public Health. 2022;15(3):324-30.) Another relevant aspect for the multimodal strategy effectiveness is the need to involve management, both intersectoral and institutional, in order to assist in establishing a favorable safety climate with a view to achieving satisfactory levels of adherence to HH.(¹1. Valim MD, Rocha IL, Souza TP, Cruz YA, Bezerra TB, Baggio E, et al. Efficacy of the multimodal strategy for Hand Hygiene compliance: an integrative review. Rev Bras Enferm. 2019;72(2):578-92.)

The greater adherence to HH in the moments “after touching a patient” or “after touching patient surroundings” compared to the moment “before touching a patient” may be related to the culture of self-protection, i.e., professionals realize that practicing HH is a way of protecting themselves, feeling more motivated to carry it out as a way of protecting their own health.(²⁷27. Graveto JM, Rebola RI, Fernandes EA, Costa PJ. Hand hygiene: nurses’ adherence after training. Rev Bras Enferm. 2018;71(3):1189-93.

28. Silva BR, Carreiro MA, Simões BF, Paula DG. Monitoramento da adesão à higiene das mãos em uma unidade de terapia intensiva. Rev Enferm UERJ. 2018;26:e33087.-²⁹29. Paula DG, Francisco MR, Freitas JD, Levachof RC, Fonseca BO, Simões BF, et al. Hand hygiene in high-complexity sectors as an integrating element in the combat of Sars-CoV-2. Rev Bras Enferm. 2020;73(Suppl 2):e20200316.)

It can be inferred that glove use was a factor that had a negative impact on adherence to HH by professionals, as there was a significant impact of using gloves on non-adherence to HH. It is believed that some health professionals have the false impression that using gloves before contact with patients keeps their hands protected, replacing, therefore, HH practice,(³⁰30. Alvim AL, Reis LC, Couto BR, Starling CE, Vaz R. Avaliação das práticas de higienização das mãos em três unidades de terapia intensiva. Rev Epidemiol Controle Infecç. 2019;9(1):55-9.

31. Korb JP, Jezewski G, Aozane F, Feldhaus C, Kolankiewicz AC, Loro MM. Conhecimento sobre higienização das mãos na perspectiva de profissionais de enfermagem em um pronto atendimento. Rev Pesqu Cuid Fundam (Online). 2019;11(2):517-23.-³²32. Bezerra TB, Valim MD, Bortolini J, Ferreira AM, Almeida WA, Rigotti MA, et al. Influencing factors of hand hygiene in critical sections of a brazilian hospital. J Infect Dev Ctries. 2021;15(6):840-6.)incurring a serious error.

Regarding adherence to the HH technique, it was observed in this study that it is considerably low, even internationally, which recommends a minimum of three steps in 15 seconds to guarantee the technique effectiveness, which is worrying given that HH is the main strategy to reduce and prevent HAIs.

As can be identified in a randomized clinical trial that aimed to compare adherence and microbiological efficacy between the two HH techniques (WHO six steps and the three-step technique), it concluded that the 3-step technique achieved greater adherence in both in relation to the moments regarding the appropriate HH technique.(¹²12. Tschudin-Sutter S, Sepulcri D, Dangel M, Ulrich A, Frei R, Widmer AF. Simplifying the World Health Organization Protocol: 3 steps versus 6 steps for performance of hand hygiene in a cluster-randomized trial. Clin Infect Dis. 2019;69(4):614-20.) In a study carried out with 60 professionals from a Brazilian ICU with the objective of observing the adherence rate to HH with the 3-step technique, it was identified that 13.69% of these workers performed the simplified technique. During microbiota analysis on the hands of these professionals after performing HH, no growth of potentially pathogenic microorganisms was identified when compared to the others, which reinforces that this technique, when carried out correctly and within the recommended time, is effective in controlling HAIs.(³³33. Valim MD, Correa ER, Machado AP, Correa LV, Morais RB, Teixeira RF, et al. The impact of an effective 3-step hand hygiene technique in reducing potentially pathogenic microorganisms found on nursing professionals’ hands. J Infect Dev Ctries. Forthcoming. 2023;17(8):1088-98)

Regarding the recommended time for performing the technique, evidence suggests that 15 seconds of hand rubbing can be as effective as 30 seconds in reducing the microbial load on the hands.(¹³13. Harnoss JC, Dancer SJ, Kaden CF, Baguhl R, Kohlmann T, Papke R, et al. Hand antisepsis without decreasing efficacy by shortening the rub-in time of alcohol-based handrubs to 15 seconds. J Hosp Infect. 2020;104(4):419-24.,¹⁴14. Suchomel M, Fritsch F, Kampf G. Bactericidal efficacy of two modified WHO-recommended alcohol-based hand rubs using two types of rub-in techniques for 15s. J Hosp Infect. 2021;111:47-9.)

The results of this study reinforce the need to implement health education that disseminates the rationalized HH technique, as it is more simplified, has high microbiological efficacy and greater adherence by health professionals when compared to the 6-step technique.(¹¹11. Tschudin-Sutter S, Rotter ML, Frei R, Nogarth D, Hausermann P, Stranden A, et al. Simplifying the WHO ‘how to hand rub’ technique: three steps are as effective as six-results from an experimental randomized crossover trial. Clin Microbiol Infect. 2017;23(6):409.e1.,¹²12. Tschudin-Sutter S, Sepulcri D, Dangel M, Ulrich A, Frei R, Widmer AF. Simplifying the World Health Organization Protocol: 3 steps versus 6 steps for performance of hand hygiene in a cluster-randomized trial. Clin Infect Dis. 2019;69(4):614-20.) The proposition of this technique has been encouraged worldwide and consists of executing 3 steps, which are: 1) covering all surfaces of the hands; 2) rotational rubbing of the fingertips in the palm of the alternate hand; and 3) rotational rubbing of both thumbs.(¹¹11. Tschudin-Sutter S, Rotter ML, Frei R, Nogarth D, Hausermann P, Stranden A, et al. Simplifying the WHO ‘how to hand rub’ technique: three steps are as effective as six-results from an experimental randomized crossover trial. Clin Microbiol Infect. 2017;23(6):409.e1.,¹²12. Tschudin-Sutter S, Sepulcri D, Dangel M, Ulrich A, Frei R, Widmer AF. Simplifying the World Health Organization Protocol: 3 steps versus 6 steps for performance of hand hygiene in a cluster-randomized trial. Clin Infect Dis. 2019;69(4):614-20.,¹⁴14. Suchomel M, Fritsch F, Kampf G. Bactericidal efficacy of two modified WHO-recommended alcohol-based hand rubs using two types of rub-in techniques for 15s. J Hosp Infect. 2021;111:47-9.)

Among the limitations of this study, the fact that it was carried out with health professionals from a single ICU, from a single teaching and research hospital, stands out. Research in different health institutions and care sectors focused on identifying the factors that interfere with HH practice are necessary to support future interventions aimed at improving HH adherence behavior. The Hawthorne effect also stands out, which occurs due to possible changes in workers’ behavior, when observers are present. However, the literature reinforces that techniques such as discreet and/or frequent observation can minimize this effect and should be assessed according to the object and study setting.(³⁴34. Gould DJ, Creedon S, Jeanes A, Drey NS, Chudleigh J, Moralejo D. Impact of observing hand hygiene in practice and research: a methodological reconsideration. J Hosp Infect. 2017;95(2):169-74.)

Conclusion

A low rate of adherence to HH by health professionals was found, especially when considering the execution of appropriate HH technique. Professionals demonstrated greater chances of adhering to HH in moments “after” when compared to moments “before”, denoting low adherence to the aforementioned technique in moments and opportunities that aim to reduce and prevent HAIs. Professional nurses were more likely to clean their hands when compared to nursing technicians and physical therapists. Glove use had a negative impact on professionals’ adherence to HH. The results infer that low adherence to HH may be related to the erroneous perception that glove use replaces HH. It is essential that the infection control service works together with sectoral and institutional management through multimodal strategies, in order to provide favorable conditions for patient safety and sensitize health professionals and management to adopt actions to prevent and control HAIs. Experimental studies are encouraged in order to implement multimodal strategies using educational and instrumental technologies, with the aim of making HH viable as the best strategy to combat HAIs and their serious consequences.

Acknowledgments

To the Mato Grosso Research Support Foundation (FAPEMAT - Fundação de Amparo à Pesquisa do Estado de Mato Grosso) for the financial assistance granted to carry out the study.

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