Resources, implementation and performance of hand hygiene practices and their impact on hospital care: A multicenter cross-sectional survey in Greece

Our latest research study was published in the American Journal of Infection Control (Association for Professionals in Infection Control and Epidemiology, Inc), July 31, 2025.

Resources, implementation and performance of hand hygiene practices and their impact on hospital care: A multicenter cross-sectional survey in Greece

by 

Eirini Astrinaki, Evangelos I. Kritsotakis, Efsevia Vitsaxaki, Stamatina Saplamidou, Panagiotis Skevakis, Emmanouil Bolikas, Despoina Christofaki, Apostolia Salvaraki, Christos Kleovoulou, Styliani Papathanasaki, Chrisanthi Markopoulou, Evagelia Magouli, Diamantis Kofteridis, Petros Ioannou

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Abstract

Background

Limited data exist on hand hygiene practices in Greek hospitals. This study assessed hand hygiene resources, implementation, and compliance in eight public hospitals and their impact on healthcare-associated bloodstream infections (BSIs).

Methods

The World Health Organization's "Ward Infrastructure Survey", "Hand Hygiene Self-Assessment Framework" (HHSAF) and the "5 Moments" concept were employed. Hand hygiene indicators and BSI rates were assessed using Poisson regression.

Results

Hand washing facilities were provided in 87% of patient room toilets. Νearly all sinks (96%) had soap, but disposable paper towels availability was 51%.Alcohol-based hand rub (ABHR) availability at the point of care was 41.8%. Hospitals scored at "Basic" (n=5; 62%) or "Inadequate" (n=3; 38%) hand hygiene implementation level with a mean HHSAF score of 140. Compliance was 58.8% (95% CI 56.9%-60.6%) in one surveyed tertiary hospital but only 9.8% (95% CI: 8.7%-11%) in one secondary. BSI rates in the wards were higher with higher ABHR availability (incidence rate ratio (IRR) 1.09 per 10% increase in ABHR p=0.002) and when powdered gloves were not used (IRR 2.09, p<0.001).

Conclusion

Significant hand hygiene compliance discrepancies and ineffective implementation strategies within surveyed hospitals were determined. Improving hand hygiene infrastructure, education and feedback could foster current scores.

Statistical analysis

All analyses of the hand hygiene survey data were cross-sectional and ecological, and the unit of analysis was the hospital (n = 8), the ward (n = 80), or the patient care area (n = 512). Hand hygiene compliance was quantified as a proportion by dividing the number of correct hand hygiene moments by the total number of observed hand hygiene moments, and 95% confidence intervals were calculated using Wilson's score method. Frequency counts and proportions were compared between different groups of independent observations using Pearson's χ² test, whereas mean differences were compared using linear regression. The occurrence of BSIs was quantified as an annual incidence density rate (per 1,000 patient-days) at the ward level. Multivariable Poisson regression was applied to estimate incidence rate ratios of BSIs for the absence, as opposed to the presence, of hand hygiene structures and resources at the wards. The models were adjusted for main ward-level covariates (ward specialty, numbers of nurses, physicians, and cleaning staff) and the annual number of patient-days (log-transformed offset). Poisson regression was performed for hand hygiene indicators with sufficient variation across the surveyed wards (when the absence of a structure or resource was observed for at least 20% of the wards [ie, n > 15]). In addition, univariate ward-level associations between hand hygiene compliance proportions and BSI rates were visualized by scatterplots and quantified by Pearson's correlation coefficient. No multivariable analysis was attempted for the latter due to the small number of data points available.Two-sided 95% confidence intervals and p values were reported for all analyses. Statistical significance was considered when P < .05. Stata version 18 was used.

Figure 1. Box-and-whisker plot of overall and component hand hygiene scores based on the Hand Hygiene Self-Assessment Framework survey (N = 8 hospitals)

Table 2. Hand hygiene infrastructure in patient care areas

Table 3. Associations between bloodstream infection rates and ward-level indicators of hand hygiene structures and resources

Notes. Relative incidence rates (IRR) for bloodstream infections were estimated by Poisson regression adjusting for ward specialty (ICU, medical, surgical, other), numbers of nurses, physicians and cleaning staff, and the annual number of patient days in the wards. Only hand hygiene indicators with sufficient variation in at least 20% of the wards (n>15) were examined.

Figure 2. Associations between hand hygiene compliance proportions and bloodstream infection rates in n = 17 high-risk wards at two hospitals