Hand Washing- The Poka-Yoke for Cross Infection Control


Executive Summary

Healthcare is changing. Over the years, there has been a clear shift from treatment to prevention. Patient safety forms a large aspect of prevention, and preventing cross infections forms a large aspect of patient safety.

Needless to mention that hand hygiene is the gold standard for cross infection control. It is a measure so powerful that it can even prevent spread of most dreaded multi resistant microbes. But, when it comes to following a simple 5-steps of hand washing, it is neglected even in critical and intensive care settings.

Every hospital around the globe has been trying to get their staff specially doctors and nurses to become 100% compliant to hand hygiene, however, they haven’t succeeded yet.

What could be reason? What are these training programs lacking? Do they lack in imparting the knowledge or are they unable to cultivate a culture of motivation around hand washing?

We tried to find the answer through a survey conducted with 48 large hospitals participating in it. And the answer we found was that the compliance rate around hand hygiene is low due to ‘forgetfulness and lenient attitude’. Which means that we need to realign our approach while training our doctors and nurses.

With technologies such as virtual reality (VR) showing promising results in behavioural therapies, we suggest, VR should be used as a part of these training programs. Where training could be imparted with the traditional mode and sensitization and behavioural remodelling could be done with VR.


Health Care Associated infections (HCAI) or cross infections due to poor hand hygiene compliance are a major cause of increasing morbidity, mortality, and health care costs among hospitalized patients worldwide1. They are a leading cause of Anti-microbial resistance around the globe. Those in ICU and critically ill patients are even more susceptible to it.

According to centre for disease control and prevention, on any given day, about one in 31 hospital patients has at least one healthcare-associated infection.

Cross infections are infections that occur while receiving health care, developed in a hospital or other health care facility that first appear 48 hours or more after hospital admission, or within 30 days after having received health care. According to USCDC, 1 in 17 patients admitted to a hospital die due to these, that is more than 98000 patients a year.

Many studies suggest that simple infection-control measures such as hand hygiene protocol (handwashing) with an antimicrobial before and after contacting a patient, can go a long way in preventing HAIs, saving lives, reducing morbidity, and minimising health care costs.

Routine trainings and educational interventions for health care professionals wherever done, are having little effect in changing their hand-hygiene practices to prevent the spread of infection.

Prevalence and brief outline of cross infections

A survey conducted in 183 hospitals in US with 11,282 patients reported that 4% of patients had at least one Health care acquired Infection.

Health care or hospital acquired infections are also problematic elsewhere in the world. For example, a similar study in Singapore reported 11.9% (646) patients had acquired such infections.

A recent European study found that 2,609,911 new patients were identified as having hospital acquired infections annually in the European Union and European Economic Area. This study reported that for every 20 patients hospitalized, at least one acquired an infection which was preventable.

In Greece, the cross-infection prevalence rate reaches 9.1%. Another study (systematic review and meta-analysis) regarding health care acquired infections in Southeast Asian countries (Brunei, Myanmar, Cambodia, East Timor, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand, and Vietnam) found an overall prevalence rate of 9.1%

In India, the state is even more worrying, with incidence rate of 25% to 50%.8 According to a study done in one part of the country, the incidence rate of hospital acquired infections ranged between 11 to 83%.

Current practices and their effectiveness

Hand hygiene contributes significantly in the safety of patients. It is a simple, low-cost method to prevent the spread of various microbes that cause a hospital acquired infections. While hand washing is not the only measure to counter these infections, compliance with it alone can dramatically enhance patient safety, because there is much scientific evidence proving that micro-organisms causing hospital acquired infections are most frequently spread between patients by the hands of health-care workers.

According to a study to assess the knowledge and practice of hand washing among health professionals (Related to doctors and nurses training on infection control practices), the result found that majority of healthcare professionals had poor practice of hand washing.

Another study reported an overall hand hygiene compliance rate of 78%. Nurses had an adherence rate of 63%; allied staff adherence was 86.5%. Compliance was 93% after patient contact versus 63% before patient contact. Nurses’ compliance before aseptic procedures was lowest at 39%. 92% staff was aware of the facts viz. hospital acquired infections prevented
by hand washing, ideal duration of hand washing, reduction of health care associated infections and costs, etc.

Similar studies suggest an Overall, low levels of adherence to best hygiene practices. Non-compliance of hand washing protocols by Doctors and Nurses.

Thus, it would not be incorrect to state that the current practices and doctor-nurses’ trainings are not effective enough. Healthcare administrators need to evaluate their approach and adopt newer practices to increase the compliance rate.

It is important to understand that the hands of doctors and nurses can become contaminated even after seemingly ‘clean’ procedures such as;
1. Taking a pulse
2. Taking blood pressure readings
3. Taking a temperature
4. Touching a patient’s hand, shoulder or groin.
Furthermore, several studies have presented dramatic evidence that microbes have an
impressive ability to survive on the hands, sometimes for hours, if hands are not cleaned.

Aims and objectives of the study

A study involving 48 large sized hospitals was conducted to understand various means to increase the compliance rate among the ICUs and CCUs. The participants mainly involved were ICU registrars, ICU medical officers, nurse heads and Infection control department heads.

The study was aimed at understanding the reason (s) for the traditional teaching and training methods to not yield satisfying results in improving hand hygiene compliance among healthcare workforce.

Result- current compliance monitoring methods

55% of participating hospital ICUs rely on observatory methods to monitor hand hygiene practices, and 19% of them rely on demonstrations, both of which are very subjective, and the results are often misleading. There is even a scope of partiality, personal benefits and wrong judgement as a human error.

Current teachings are typically classroom based or demo- based. Both of which have lose memory retention. Thus, the observations, however subjective, shows the rate of compliance is rarely beyond 50 to 60%. Which is undoubtedly a worrying number.

Result- Causes of non-compliance

56% of the participants, stated that forgetfulness and Lenient attitude are the top reasons for non- compliance.

The result shows that knowledge gap is not a hindrance to compliance here, the problem is much deeply rooted when there is a lenient attitude and forgetfulness attached to it.

A good behaviour modification program or a sensitization program would change the approach of the caregivers towards compliance on hand hygiene.

Also, to address the forgetfulness as a problem, digitally enabled reminder systems could be used, which whenever interacts with the digital interface of one patient, starts to beep/vibrate, if hand washing has not been followed before and after the interaction.

Conclusion and suggestions

The study was aimed at understanding the gaps between the traditional doctor and nurse’s training approaches and their results. And, with the results, it is evident that the current training methodologies are not yielding satisfying results. Because, these are aimed at closing a knowledge gap, which is not as big an issue. However, there is a gap in behavioural and
sensitization aspect of it.

While virtual reality (VR) maybe comparatively new for healthcare, it is showing promising usability in number of areas. Many studies have demonstrated and used VR for behaviour modification in psychology and other therapies. We are currently testing a VR based sensitization module for hand hygiene compliance in multiple hospitals.

It has been proven with various studies that VR has a much higher knowledge retention and for a longer duration than traditional methods. The retention of procedural trainings such as hand hygiene, is even more.

Digitally enabled bands that remind the staff members to follow hand hygiene before and after every patient interaction can tackle forgetfulness as a hurdle.

If a simple digital intervention can significantly improve hand hygiene compliance, it can save multiple lives and result in huge healthcare cost savings. Since hand hygiene is the Poka-yoke for cross infection control in all healthcare settings, especially critical care and intensive care settings.


  1. https://www.hindawi.com/journals/apm/2018/5290797/
  2. https://www.cdc.gov/hai/data/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov
  3. Health care-associated infections – an overview
  4. Multistate point-prevalence survey of health care-associated infections
  5. Prevalence of Healthcare-Associated Infections and Antimicrobial Use Among Adult Inpatients in Singapore Acute-Care Hospitals: Results From the First National Point Prevalence Survey.
  6. Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study.
  7. Burden of Six Healthcare-Associated Infections on European Population Health: Estimating Incidence-Based Disability-Adjusted Life Years through a Population Prevalence-Based Modelling Study.
  8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3657861/
  9. A Study on Hospital Acquired Infections among Patients in a Tertiary Care Hospital of Darjeeling District, West Bengal
  10. https://www.who.int/gpsc/tools/faqs/evidence_hand_hygiene/en/
  11. Knowledge and Practices of Hand Washing among Health Professionals in Dubti Referral Hospital, Dubti, Afar, Northeast Ethiopia.
  12. Hand hygiene compliance among healthcare workers in an accredited tertiary care hospital
  13. Assessing hand hygiene compliance among healthcare workers in six Intensive Care Units
  14. Hand Hygiene Practices in a Neonatal Intensive Care Unit: A Multimodal Intervention and Impact on Nosocomial Infection

Pin It on Pinterest

Share This