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Comparison of hand hygiene compliance among healthcare workers in Intensive care units and wards of COVID-19: A large scale multicentric study in India

Published:October 09, 2022DOI:https://doi.org/10.1016/j.ajic.2022.09.028

      Highlights

      • This multicentric study is first of its kind to involve COVID care locations from various types of institutions from different zones of India.
      • Overall data on hand hygiene compliance in various locations across the country provides national bench mark data.
      • Hand hygiene total adherence rate (HHCAR) and Hand hygiene complete adherence rate (HHCAR) was found higher in COVID wards compared to COVID ICU.
      • There was month wise improvement in HHTAR from month 1 to month-6 in COVID ICU, but fluctuating trend was recorded for COVID wards.

      Abstract

      Background

      Hand hygiene is a significant component involved in preventing transmission of health care associated infections including COVID-19. Compliance to hand hygiene among the health care workers (HCWs) requires evaluation and timely feedback. “You can't improve what you can't measure” is a famous saying and this multicentric study was designed to measure hand hygiene compliance and have birds eye view on hand hygiene compliance in COVID Intensive care units (ICUs) and wards across India.

      Methods

      A prospective multicentric observational study was conducted for a period of 6 months in 92 health care facility across India which included varied type of public and private hospitals. Hand hygiene audit was conducted in COVID ICU and COVID non-ICU wards in all these facilities by their HCWs using the IBHAR mobile application based on WHO's hand hygiene audit tool. Hand hygiene total adherence rate (HHTAR) and hand hygiene complete adherence rate (HHCAR) were analyzed and compared between 2 locations. Adherence rates were analyzed based on the zones, institute type, profession and for each WHO moments.

      Results

      A total of 1,61,056 hand hygiene opportunities were documented and adherence rates were recorded higher in COVID wards (HHTAR-61.4%; HHCAR-28.8%) than COVID ICUs (HHTAR-57.8%; HHCAR-25.6%). Overall, the adherence rates were observed higher in COVID wards (HHTAR- 68.1%; HHCAR-38.3%) of private hospitals, COVID wards of the west zone (HHTAR- 70.2%; HHCAR-36.8%), cleaning staffs of the COVID ward scores better compliance than all other professions in COVID ICUs and COVID wards. HHTAR was found to be the higher in moment 3 (After body fluid exposure-76.3%) followed by moment 4 (after touching patient-73.7%) done in COVID wards compared to moments done in ICUs.

      Conclusions

      This study highlights the practice of hand hygiene in COVID care locations across India. Effective strategies need to be implemented in COVID ICUs across the facilities to improve the compliance.

      Key Words

      Introduction

      Hand hygiene is considered as one of the significant components of hospital infection control. By improving hand hygiene adherence, health care associated infections can be significantly reduced.
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      The good side of COVID-19 pandemic is enormous public health messages are made available through various sources which substantially has increased the awareness of hand hygiene among general public as well.
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      The effect of hand hygiene audit in COVID intensive care units in a tertiary care hospital in South India.
      The degree of illness of the patients and nature of workload among health care workers are different in intensive care units (ICU) and non-ICU setup. The admitted patients stay for longer duration in ICU due to severity of their disease and they are more likely to be colonized with multidrug resistant organism (MDROs).
      • Karaaslan A
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      Compliance of healthcare workers with hand hygiene practices in neonatal and pediatric intensive care units: overt observation.
      The ICU protocol for admission of patients varies across the hospitals and it is changing from time to time due to fluctuating case load in hospitals during the pandemic. Patients with respiratory distress and risk factors are directly shifted to ICUs. Non-ICU patients are shifted to ICUs based on risk categorization, considering factors like worsening of clinical condition, radiological, and laboratory parameters. During the peak times of pandemic, some patient may not have access to ICUs because of unavailability of beds and they may be continued to be monitored in wards. When standard and transmission-based precautions are inappropriately followed in any health care unit including ICUs and non-ICU wards, transmission of hospital acquired infections (HAI) occurs at higher pace. Such infections can worsen the condition of patients admitted in non-ICU wards and those patients finally gets shifted to ICUs for more vigilant monitoring. Therefore, non-ICU wards should be considered as high-risk locations and hand hygiene compliance should be monitored by conducting regular hand hygiene audits. A large-scale data in hand hygiene compliance in COVID care location and comparison of adherence in ICUs and non-ICU wards are not available in India. Therefore, the hand-hygiene compliance in ICU and wards of COVID care locations was evaluated in this multicentric study, which was conducted across 92 health care facilities of India, with Jawaharlal Institute of Post-graduate Medical Education and Research (JIPMER), Puducherry being the nodal center.

      Methodology

      This was a prospective multicentric observational study conducted for a period of 6 months in 92 health care facility in India. The study included 4 different types of health care settings such as government teaching, government non-teaching, private teaching and private nonteaching institutes. The study was initiated after receiving approval from JIPMER ethics committee which is the nodal center for this multicentric study and also from the individual centers where institute ethics committee was established. Government and private sector hospitals are near equally participated—33 government and 58 private sector hospitals. Multiple awareness and motivational sessions were conducted to create interest among the government sector hospitals to participate in the study. Initially the hand hygiene auditors from each center were trained in direct observation method using hand hygiene audit application developed by IBHAR technologies in collaboration with JIPMER.
      • Hygiene H.
      Measuring hand hygiene adherence: overcoming the challenges.
      The training was done through virtual mode by project principal investigator covering the basics of hand hygiene from various guidelines such as World Health Organization (WHO) and Centre for disease Control (CDC).
      • Safety WP
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      The auditors were initially monitored using dummy audit programs with model case scenario for recording the following information such as date and time of audit, profession of the health care workers (HCWs) posted in COVID ICU/wards, Hand Hygiene opportunities (HH moments) available, duration for which the HH is performed, the steps of HH followed and presence of gloves when the HH is performed. Following a series of virtual meetings with nodal center and training of auditors by investigators of individual centers, certificate was issued to the trained auditors before initiating the study. The HH audit was conducted by those trained auditors for an observation period of 20 min/d, until a daily minimum of 20 HH opportunities were recorded. The HH event were marked as “completely followed” when 4 WHO steps of HH were performed, for the recommended duration (20 seconds for hand rub and 40 seconds for hand wash). When 3 WHO's HH steps were missed and/or the duration of HH, if less than recommended, such HH events were marked as “partially followed.” We have compared Hand hygiene complete adherence rate (HHCAR), and Hand hygiene total adherence rate (HHTAR) between COVID ICU and COVID wards for the study period using below mentioned formula.
      HH Complete Adherence rate (HHCAR): Number of times HH followed completely (≥4 steps and ≥20 seconds duration))/No. of opportunities of HH available X 100
      HH Total Adherence rate (HHTAR): Number of times HH followed completely+ partially/No. of opportunities of HH available X 100
      Profession-specific HHAR: HH performed by each profession / total opportunities available for that profession X 100
      Month-wise trend analysis was performed to observe significant improvement in HH adherence rate across the study period. The rates were compared for all 5 moments of hand hygiene between these 2 locations. Profession specific adherence rates were compared for 4 different types of health care workers such as doctors, nurses, cleaning staffs and allied staffs/others in these 2 locations. The institutions participated in this study were divided into 4 zones based on geographic location such as East, west, North and South and adherence rates were compared.

      Results

      A total of 161,056 opportunities were recorded during the study period. As shown in the Figure 1A, maximum number of opportunities was recorded in COVID ICUs (136,786) during the study period compared to COVID wards (24,270). However, as shown in the Figure 1B, adherence rates such as HHTAR and HHCAR were higher in COVID wards compared to COVID ICUs. Figure 2 represents increasing trend in monthly HHTAR of COVID ICUs during the study period which increased from 53.1% in the first month to 65.6% in the 6th month. However, HHCAR in COVID ICUs and wards was at increasing pace from the first month till 5th month but it was decreased in the 6th month of the study. The statistical analysis was done by chi-square test. There is no statistically significant difference in adherence rate across months (P value -.937). HHTAR in COVID wards showed fluctuating trends throughout the study period. Overall, the highest HHTAR (72.2%) and HHCAR (39.6%) was recorded in COVID ward during month-5.
      Fig 1
      Fig 1Hand hygiene audit analysis of COVID Intensive care units and COVID wards of 92 health care facilities.
      ICUs, intensive care units; HHCAR, hand hygiene complete adherence rate; HHTAR. hand hygiene total adherence rate.
      Fig 2
      Fig 2Month wise HH audit analysis of COVID ICU and COVID wards of 92 HCFs.
      HH, hand hygiene; HCFs, health care facilities; ICUs, intensive care units; HHCAR, hand hygiene complete adherence rate; HHTAR, hand hygiene total adherence rate.

      Zone-wise hand hygiene adherence

      The institutes participated in this multicentric study was divided into 4 zones according to geographic location namely, east, west, north, and south zones. In ICUs, a greater number of opportunities were recorded by South zone institutes (77,327) followed by East (26,295) and in COVID wards, a greater number of opportunities were recorded by East zone institutes (9,158) followed by South (8,378). West zone institutes recorded the least opportunities in ICUs (15,570) as well as wards (3,042). HHTAR was best documented in COVID wards of west zone (83.3%), followed by COVID ward of south zone (64.4%). There is statistically significant difference in the distribution of HHCAR across the months (P value-.006). Figure 3 shows zone wise HH adherence in COVID ICUs and wards.
      Fig 3
      Fig. 3Zone wise HHTAR and HHCAR of COVID ICU and COVID wards.
      ICU, intensive care units; HHCAR, hand hygiene complete adherence rate; HHTAR, hand hygiene total adherence rate.

      Institution type HHAR

      As shown in the Figure 4, HHAR was higher in private sector health care in both ICUs (HHTAR-65.1%; HHCAR-33.2%) and wards (HHTAR-68.1%; HHCAR-38.3%) than public sector health care locations. Adherence was higher in non-teaching hospitals compared to teaching hospitals. Overall, hand hygiene adherence (HHTAR and HHCAR) was best observed in COVID wards (HHTAR-73%; HHCAR-42.2%) of private non-teaching hospitals. The HHCAR between ICU and ward in private institutes was not found to be statistically significant (P value-.744). The HHCAR between ICU and ward in public institutes was found to be statistically significant (P value- <.001)
      Fig 4
      Fig 4Institution type wise HH audit analysis of COVID ICU and wards of 92 HCFs.
      ICUs, intensive care units; HHCAR, hand hygiene complete adherence rate; HHTAR, hand hygiene total adherence rate.

      Profession specific HHAR

      Profession specific HHTAR and HHCAR are depicted in the Table 1, Overall analysis of HHTAR shows that this rate was high in cleaning staffs employed in COVID wards (68.3%) followed by nurse in COVID wards (60.8%) and doctors in COVID wards (59.2%). In COVID ICU, nurses recorded high compliance compared to other professionals. Cleaning staffs in COVID wards showed highest compliance (68.3 % [2,657/3,893]). However, cleaning staffs employed in the COVID ICUs recorded the least (55.1% [9,605/17,419]).
      Table 1Profession-specific HH total adherence rate (HHTAR) % (n/N)
      MonthDoctorNurseCleaning staffsAllied staffs/others
      Covid ICUCOVID wardCovid ICUCovid wardCovid ICUCovid wardCovid ICUCovid ward
      Month-154.4 (7,096/13,041)56.0 (592/1,058)53.8 (15,820/29,414)63.7 (1,895/2,973)50.2 (2,994/5,964)71.2 (616/865)50.2 (3,465/6,903)61.7 (348/564)
      Month-259.7 (4,373/7,319)51.8 (536/1,035)55.8 (7,072/12,676)50.5 (1,586/3,143)57.6 (2,112/3,665)59.0 (496/841)60.4 (2,471/4,089)54.1 (338/625)
      Month-363.6 (3,458/5,438)60.1 (591/983)66.0 (6,680/10,128)59.2 (1,786/3,016)60.3 (1,821/3,021)65.1 (501/769)61.2 (2,117/3,459)54.8 (267/487)
      Month-456.8 (2,616/4,602)68.3 (529/774)65.2 (4,855/7,447)67.6 (1,160/1715)54.4 (1,387/2,548)72.8 (402/552)55.7 (1,286/2,309)63.5 (261/411)
      Month-561.3 (2,235/3,644)66.9 (407/608)67.2 (4,016/5,977)72.4 (917/1,266)57.4 (1,152/2,008)81.7 (405/496)62.7 (929/1,482)66.3 (193/291)
      Month-657.3 (286/499)55.6 (245/441)71.4 (535/749)62.9 (501/796)65.3 (139/213)64.1 (237/370)64.4 (123/191)50.3 (96/191)
      Total58.1 (20,064/34,543)59.2 (2,900/4,899)58.7 (38,978/66,391)60.8 (7,845/12,909)55.1 (9,605/17,419)68.3 (26,57/3,893)56.4 (10,391/18,433)58.5 (1,503/2,569)
      HH, hand hygiene; ICUs, intensive care units; HHCAR, hand hygiene complete adherence rate.

      Moment specific HHTAR

      Figure 5 shows the comparison of moment specific HHTAR between COVID ICUs and wards. HHTAR was found to be the highest in moment 3 (After body fluid exposure-76.3%) followed by moment 4 (after touching patient-73.7%) done in COVID wards compared to moments done in ICUs. HHTAR was recorded high for moment 2 (before aseptic procedure) in ICUs compared to other moments. Moment 5(after touching patients’ environment) has been least followed in both ICUs (42.3%) and in wards (45.2 %).
      Fig 5
      Fig. 5Moment specific HHTAR of COVID ICU and COVID wards of 92 HCFs
      HH, hand hygiene; HCFs, Health care facilities; ICUs, intensive care units; HHCAR, hand hygiene complete adherence rate; HHTAR, hand hygiene total adherence rate.

      Discussion

      The present study is a large-scale multicentric study involving 92 centers, with about 1.6 lakh number of hand hygiene opportunities. To the best of our knowledge, no other published literature on hand hygiene involved such a huge number of centers worldwide. The prime novelty in the present study was to conduct HH audit inside COVID care locations as very limited research has been carried out till date. Monitoring hand -hygiene adherence by direct observation method is the simplest and cost-effective method which involves designated hand hygiene auditors to be available in the health care location for a particular time period and requires standard method of data collection.
      • Sastry AS
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      Impact of a hand hygiene audit on hand hygiene compliance in a tertiary care public sector teaching hospital in South India.
      Direct observation method remains gold standard method in monitoring hand hygiene compliance.
      • Chavali S
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      Hand-hygiene audit mobile based applications are available which replaces conventional observation form-based auditing and further reduces the difficulty of data collection by auditors and also reduces intensive final analysis by infection control team. WHO recommends adequate training of HCWs before involving them in audit process. To ensure uniformity of data collection auditors from various health care settings involved in this multicentric study were uniformly trained about opportunities of hand hygiene, understanding my 5 moments of hand hygiene, indications and use of IBHAR hand hygiene tool making them a validated observer to participate in this multicentric study.
      This multicentric study is first of its kind to involve various types of institution from different zones of India, so that we will have an overall picture on hand hygiene compliance in various locations, based on which various interventions can be planned to improve the same. Most of the hand hygiene audit studies available were carried out during pre-COVID time and fewer studies which were performed during COVID times involved non-COVID location only. Anguraj S et al conducted similar hand hygiene compliance study in only COVID ICU of single institution.
      • Anguraj S
      • Ketan P
      • Sivaradjy M
      • et al.
      The effect of hand hygiene audit in COVID intensive care units in a tertiary care hospital in South India.
      The overall data showed that HHTAR and HHCAR was found higher in COVID wards compared to COVID ICU. This may be attributed to less emergency procedures being conducted in wards, However, remarkably the number of opportunities recorded in COVID ICU was less. There was month wise improvement in HHTAR from month 1 to month-6 in ICU, but fluctuating trend was recorded for wards. This may be due to extensive importance given to outcomes of COVID ICU patients where deaths are frequent and the concern of ICU HCWs to improve their adherence to hand hygiene may be noticed according to the feedback given by infection control team. Significant monthly improvement in HH compliance has been observed in many studies done by Mu X al, Anguraj et al.
      • Anguraj S
      • Ketan P
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      ,
      • Mu X
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      Improving hand hygiene compliance among healthcare workers: an intervention study in a Hospital in Guizhou Province.
      HHCAR in ICU and ward improved from month 1 to month-5 but decreased in month 6. This decrease in complete adherence in final months of the study may be related to reduced number of COVID-19 cases in India and probably due to loosened surveillance during this period.
      Profession specific HHTAR was recorded highest in cleaning staffs of COVID wards whereas cleaning staffs of COVID ICUs recorded the least HHTAR among all the profession. The reason may be due to cleaning staffs were allotted only cleaning work in their wards and better supervised by their higher rank staffs, therefore may have better done the hand hygiene in most of the institutions. In COVID ICU, compliance of nurses was maximum compared to other health care workers. This is similar to most of the available studies in non-COVID era where profession specific HHTAR was highest in nurses by AS Sastry et al, Lohiya et al, Karaaslan et al. However, doctors showed high HHTAR in COVID care location study by Anguraj S et al. HH adherence rate improved over study period among nurses, cleaning staffs and allied staffs working in COVID ICUs except doctors which were decreased in the last month of the study.
      The moment specific HHTAR is maximum for “after moments” such as after body fluid exposure(moment-3) and after touching patient(moment-4). This shows the health care workers may be more concerned to reduce contracting COVID-19 from the patients by performing hand-hygiene for after moments. “Before moments” should also be emphasized equally and adequate education to be done to health care workers to prevent the transmission of hospital acquired infection through the gloved/nongloved hands of the health care workers to the patients. These results are similar to study done by Rodrigues et al, Naglaa et al, AS sastry et al and AM Laskar et al which are done during pre-COVID period.
      • Sastry AS
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      Impact of a hand hygiene audit on hand hygiene compliance in a tertiary care public sector teaching hospital in South India.
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      Our study results slightly differ from study by Anguraj S et al which was done during pandemic times in COVID ICU where HHTAR is higher for moment 2 and 3.
      • Anguraj S
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      Frequent educational programme including display of visual reminders, knowledge attitude practice study to understand the lacunae in the system are absolutely essential to emphasize the importance of before moments also. A study done by Teker et al showed improvement in adherence for “before moments” was observed after extensive educational interventions on hand hygiene and nosocomial infections.
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      Limitations of the study

      The main limitation of this study is that there is no data on month-wise device associated infections (DAI) rates in these locations. Increase or reduction of DAIs serves as good indicator of hand hygiene practice in any location. Variation of HHAR in different shifts of health care workers, its distribution based on years of experience, gender variation, were not analyzed as the observation periods were based on convenience sampling and were not randomized.

      HHAC Study Group (contributor list including main authors)

      Dr Apurba Sankar Sastry, Additional Professor of Microbiology and Officer in-charge, HICC, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Dr Ketan Priyadarshi, Senior Resident & Fellowship in HIC, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Dr Deepashree Rajshekar, Assistant Professor, Department of Microbiology and Assistant Surveillance Officer, HIC, JSS Medical College, Mysore; Dr Sivanantham Krishnamoorthi, Assistant Professor, Department of Microbiology and Officer in-charge, Infection Control, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab; Dr Raja Sundaramurthy, Assistant Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Bibinagar Hyderabad; Dr Haritha Madigubba, Consultant Microbiologist and Infection Control Officer, Yashoda Hospital, Malakpet, Hyderabad; Dr Sarumathi, Senior Resident & Fellowship in HIC, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Dr Anusha Cherian, Professor of Anaesthesiology and critical care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry; Dr Chetak K B, Assistant Professor, Department of Paediatrics and Surveillance Officer, HIC, JSS Medical College, Mysore; Dr Geethu Joe, Consultant Microbiologist, Jupiter Lifeline Hospitals, Pune; Dr Raksha K, Head of Department, Consultant Microbiologist and Infection Control Officer, St. Martha's Hospital, Bangalore; Dr Archana Nagarajan, Associate Consultant & Infection Control Officer, MGM Healthcare, Chennai; Dr Manisha Subrao Mane, Professor & Head, Dept of Microbiology, ESIC Medical College and PGIMSR, KK Nagar, Chennai; Dr Premalatha P, Senior Resident, Dept of Microbiology, ESIC Medical College and PGIMSR, KK Nagar, Chennai; Dr Arcy Billoria, Consultant Microbiologist and Infection Control Officer, Lotus Hospitals, Hyderabad; Dr Tessa Antony, Assistant Professor of Microbiology and Infection Control officer Sri Ramachandra Hospital, Sri Ramachandra Institute of Higher Education and Research; Dr M.K. Renuka, Professor & HOD of Critical Care Medicine, Sri Ramachandra Institute of Higher Education and Research; Dr K. Sneha Jigisha, Assistant Professor of Microbiology and Infection Control Officer, Telangana Institute of Medical Sciences and Research, Hyderabad; Dr Abhilasha Korani, Assistant Professor of Microbiology and Infection Control Officer, Telangana Institute of Medical Sciences and Research, Hyderabad; Dr Abiroo Jan, Assistant Professor of microbiology, Government Medical College, Anantnag; Dr Roopika Berry, Consultant Microbiology and Secretary HICC, Narayana Multispeciality Hospital, Ahmedabad; Dr Deepti Chaurasia, Professor and Head of Microbiology, Gandhi Medical College, Bhopal; Dr Simmi Dubey, Professor and Head of Medicine, Gandhi Medical College, Bhopal; Dr Lokendra Dave, Professor, Pulmonary Medicine, Gandhi Medical College, Bhopal; Dr Archa Sharma, Assistant Professor, Microbiology, Gandhi Medical College, Bhopal; Dr Jaya Lalwani, Associate Professor and OIC, HICC, Gandhi Medical College, Bhopal; Dr Shahzad Mirza, Associate Professor of Microbiology and Hospital Infection Control Officer, DR D Y Patil Medical College Hospital And Research Centre, Pune; Dr Amber Prasad, Assistant Professor and Hospital Infection Control Officer, All India Institute of Medical Sciences (AIIMS), Rishikesh; Dr Pratima Gupta, Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Rishikesh; Dr Prasan Kumar Panda, Associate Professor of Medicine, All India Institute of Medical Sciences (AIIMS), Rishikesh; Dr Smita Sinha, Associate Professor, All India Institute of Medical Sciences (AIIMS), Rishikesh; Dr Biswajeet Sahoo, Assistant Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Rishikesh; Dr Vanya Singh, Senior Resident, All India Institute of Medical Sciences (AIIMS), Rishikesh; Dr Suneeta Sahu, Senior Consultant, and HOD Clinical Microbiology and Immunoserology, Chairperson HICC, Apollo Hospitals, Bhubaneswar; Dr Rani Sahu, Associate Consultant Clinical Microbiology and Immunoserology, Apollo Hospitals, Bhubaneswar; Dr Shyamala R, Associate Professor, Infection Control Officer, Department of Microbiology, Quality Assurance Nodal Officer, Kodagu Institute of Medical Sciences, Madikeri; Dr Rangineni Jayaprada, Associate Professor of Microbiology, HICC Incharge, Department of Microbiology, Sri Venkateswara Institute of Medical Sciences, Tirupathi; Dr N.Ramakrishna, Assistant Professor, Department of Microbiology, Sri Venkateswara Institute of Medical Sciences, Tirupathi; Dr Mamta bhatt, Consultant Microbiologist, Utkal Institute of Medical Sciences, Bhubaneswar; Dr Mini P N, Additional Professor of Microbiology and HICC Officer, Government Medical College, Kozhikode; Dr Fairoz CP, Assistant professor, Government Medical College, Kozhikode; Dr Vishnu k, Assistant Professor, Government Medical College, Kozhikode; Dr Asfia Sultan, Assistant Professor, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University (AMU), Aligarh; Dr Fatima Khan, Associate Professor, Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University (AMU), Aligarh; Dr Atanu Chakravarty, Associate Professor of Microbiology and Secretary, HICC, Jorhat Medical College and Hospital, Jorhat; Dr Rajib Hazarika, Professor and Head of Anesthesiology, Jorhat Medical College and Hospital, Jorhat; Dr Binita Bhuyan, Demonstrator of Microbiology and Infection Control Officer, HICC, Jorhat Medical College and Hospital, Jorhat; Dr K V Leela, Head of Department of Microbiology and Hospital Infection Control Officer, SRM Medical College Hospital and Research Centre, Chengalpattu; Dr Anusha Gopinathan, Associate Professor, Department of Microbiology, SRM Medical
      College Hospital and Research Centre, Chengalpattu; Dr Lavanya Sriramajayam, Associate Professor of Microbiology and Secretary, Infection control Officer - HICC, PSG Institute of Medical Sciences and Research, Coimbatore; Dr M. Mohamadiya Rizwana, Assistant Professor of Microbiology, PSG Institute of Medical Sciences and Research, Coimbatore; Dr Rupali Ashok Akude, Senior Specialist & Hospital Infection Control Officer, ESIC Medical College & Hospital, Hyderabad; Dr Mahamad Wajid, Associate Professor, Department of Microbiology ESIC Medical College Sanath Nagar Hyderabad, ESIC Medical College & Hospital, Hyderabad; Dr Shazia Naaz, Assistant Professor of Microbiology, ESIC Medical College & Hospital, Hyderabad; Dr Deepthi Karumanchi, Infection control officer, Microbiology, Krishna Institute of Medical Sciences Limited, Hyderabad; Dr Avula Renuka Devi, Professor and Nodal officer IPC & HICC, Kurnool Medical College, Kurnool; Dr Kammineni Chakrapani, Assistant Professor, In-charge HICC, IPC, Kurnool Medical College, Kurnool; Dr Poonam Gupta, Laboratory director, Consultant microbiologist and Infection Control, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai; Dr Bharat Jagiasi, Director, Critical Care, Kokilaben Dhirubhai Ambani Hospital, Navi Mumbai; Dr Jaya Banerjee, Consultant Microbiologist and Infection Control Officer, Yashoda Hospital, Secunderabad; Dr Anuradha Gopalkrishna Tolpadi, Professor of Microbiology and In-charge Infection Control, Bharati Vidyapeeth (Deemed to be University) Medical College Hospital & Research Centre, Pune; Dr Abhijeet Kantilal Mane, Associate Professor of Microbiology and Coordinator - Infection Control Department, Bharati Vidyapeeth (Deemed to be University) Medical College Hospital & Research Centre, Pune; Dr Lakshmi Jyothi Tadi, Additional Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Bibinagar Hyderabad; Dr Rahul Narang, Professor and Head of Microbiology, All India Institute of Medical Sciences (AIIMS), Bibinagar Hyderabad; Dr Sunil Kumar D Chavan, Assistant Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Bibinagar Hyderabad; Dr. Ujjwala Nitin Gaikwad, Additional Professor of Microbiology and Infection Control Officer, All India Institute of Medical Sciences (AIIMS), Raipur; Dr Moonis Mirza, Assistant Professor, Department of Hospital Administration and Member, HICC, All India Institute of Medical Sciences (AIIMS), Bathinda, Punjab; Dr Manisha Khandait, Professor and Head Department of Microbiology, Shree Guru Gobind Singh Tricentary Medical College, Hospital and Research Institute, Budhera, Gurgaon, Haryana; Dr Mukesh Sharma, In charge of HICC, Shree Guru Gobind Singh Tricentary Medical College, Hospital and Research Institute, Budhera, Gurgaon, Haryana; Dr Kavya P, Head of the Department of Microbiology and Officer-in-charge, HICC, Daya General Hospital and speciality surgical centre, Thrissur; Dr Aboobacker Siddiq, Physician (Internal Medicine), Daya General Hospital and speciality surgical centre, Thrissur; Dr Penmetcha Uma, Professor And HOD of Microbiology and ICO, HICC, NRI Medical College & GH, Chinakakani, Guntur; Dr Padmaja Yarlagadda, Professor of Microbiology, NRI Medical College & GH, Chinakakani, Guntur; Dr Prudhivi Sumana, Professor of Microbiology, NRI Medical College & GH, Chinakakani, Guntur; Dr Naseema Shaik, Assistant Professor, NRI Medical College & GH, Chinakakani, Guntur; Dr Sheela Devi Chandrakesan, Professor of Microbiology, Pondicherry Institute of Medical Sciences, Puducherry; Dr Sujitha Elan Seralathan, Associate Professor, Pondicherry Institute of Medical Sciences, Puducherry; Dr Arthi E, Associate Professor, Pondicherry Institute of Medical Sciences, Puducherry; Vidya J, Assistant Professor- College of Nursing and Infection Control Nurse, Pondicherry Institute of Medical Sciences, Puducherry; Dr Divya Suguna Jayakar, Associate Professor of Microbiology, PK DAS Institute of Medical Sciences, Ottapalam; Dr Balaram Padala, Associate Professor of Anaesthesia, PK DAS Institute of Medical Sciences, Ottapalam; Dr Rajive Kumar Sureka, Professor & HOD of Microbiology, Mediciti Institute of Medical Sciences, Medchal, Hyderabad; Dr Kiranmai Sannithi, Associate Professor of Microbiology, Mediciti Institute of Medical Sciences, Medchal, Hyderabad; Dr T. Ashita Singh, Assistant Professor of Microbiology, Mediciti Institute of Medical Sciences, Medchal, Hyderabad; Dr Pragathi Kottapalli, Consultant Microbiologist and Infection Control Officer, Asian Institute of Gastroenterology AIG, Gachibowli, Hyderabad; Dr. Ashit Bhusan Xess, Consultant Microbiologist, Ispat General Hospital, Rourkela; Dr Rajeev Kumar Seth, Consultant Microbiologist, Ispat General Hospital, Rourkela; Dr Rajya Bardhan Pattanaik, Additional Chief Medical Officer, Ispat General Hospital, Rourkela; Dr Narayan Prasad Sahoo, Chief Medical Officer, Ispat General Hospital, Rourkela; Dr Bijayini Behera, Additional Professor, Department Of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar; Dr Ashoka Mahapatra, Additional Professor, Department Of Microbiology, All India Institute of Medical Sciences (AIIMS), Bhubaneswar; Dr Varsha Gupta, Professor, Microbiology and In-charge HICC, Government Medical College and Hospital sector -32. Chandigarh; Dr Preeti Chaudhary, Assistant Professor Microbiology, Government Medical College and Hospital sector -32. Chandigarh; Dr J Gerard Rakesh, Associate Professor, Sri Venkateswaraa Medical College Hospital and Research Centre, Pondicherry; Dr J Margaret Theresa, Assistant Professor of Pathology, Sri Venkateswaraa Medical College Hospital and Research Centre, Pondicherry; Dr Kala Yadav M L, Professor and HOD Microbiology and Member secretary HICC, Bowring lady Curzon Medical College and Research Institute, Bangalore, Karnataka; Dr Chetana G S, Assistant Professor and Infection control officer, Bowring lady Curzon Medical College and Research Institute, Bangalore, Karnataka; Dr Ashok Kumar Sharma, Associate Professor & HOD, Microbiology, Rajendra Institute of Medical Sciences, Ranchi; Dr Kumari Seema, Assistant Professor, Rajendra Institute of Medical Sciences, Ranchi; Dr Manju Boipai, Assistant Professor of Microbiology, Rajendra Institute of Medical Sciences, Ranchi; Dr Abhay Kumar, Assistant Professor of Microbiology, Rajendra Institute of Medical Sciences, Ranchi; Dr Rajendra Bhanudas Surpam, Professor and Head of Microbiology, Government Medical College, Chandrapur; Dr Virendra Kolhe, Assistant Professor of Microbiology and In-charge HICC, Government Medical College, Chandrapur; Dr Abiramasundari V K, Assistant Professor of Microbiology and Infection Control Officer, HICC, Saveetha Medical College and Hospital, Chennai; Dr Tuhina Banerjee, Professor, Department of Microbiology and Infection Control Officer, HICC, Institute of Medical Sciences, Banaras Hindu University (BHU), Varanasi; Dr Neha Rathor, Senior Consultant (Microbiology) and Infection Control officer, Marengo QRG Hospital, Faridabad; Dr Vinitha Mary Joy, Senior Resident, Amala Institute of Medical Sciences, Thrissur; Dr Subi Das, Associate Professor, Amala Institute of Medical Sciences, Thrissur; Dr Mohammed Khaleel, Professor, Microbiology, Deccan College of Medical Sciences, Hyderabad; Dr Shalini Akunuri, Consultant Paediatrician, Pediatric Intensive Care Unit, Deccan College of Medical Sciences, Hyderabad; Dr Shashikala Shivaprakash, Consultant Microbiology, Seven Hills Hospital- Reliance Covid beds, Mumbai; Swapna Pawar, Infection Control Manager, Seven Hills Hospital- Reliance Covid beds, Mumbai; Dr Nipa Singh, Associate Professor of Microbiology and Infection Control Officer, Kalinga Institute of Medical Sciences, Bhubaneswar; Dr Subhra Snigdha Panda, Associate Professor, Kalinga Institute of Medical Sciences, Bhubaneswar; Dr Nirav Pandya, Consultant Microbiologist & Chairperson - HICC, Bhailal Amin General Hospital, Vadodara; Dr Swathi. CM, Associate professor, Microbiology, ICO, Mallareddy Narayana Multispeciality Hospital, Hyderabad; Dr Gunturu Sowjanya, Assistant professor, ICO, Mallareddy Narayana Multispeciality Hospital, Hyderabad; Dr P.Swathi Prakasham, Consultant Microbiologist and Infection control officer, Yashoda hospital Somajiguda, Hyderabad; Dr Geetarani Purohit, Associate Consultant Microbiology and Infection Control Officer, Vikash Multi-Speciality Hospital, Bargarh; Dr Uday Hembram, Associate Consultant Microbiology, Vikash Multi-Speciality Hospital, Bargarh; Dr Tupili Ramya, Assistant professor of microbiology, Government Medical College, Nizamabad; Dr Kasawar Darahasa, Associate professor, Government Medical College, Nizamabad; Dr Syeda Amtul Moqueeth, Professor, Government Medical College, Nizamabad; Shiva Kumar, Postgraduate, Government Medical College, Nizamabad; Spandana.T, Postgraduate, Government Medical College, Nizamabad; Dr Namita Srivastava, Assistant professor, Microbiology, Maharani Laxmi bai Medical College, Jhansi; Singh Neeraj, Pathologist, Maharani Laxmi bai Medical College, Jhansi; Dr Anshul Jain, Professor of anaesthesia and nodal officer covid, Maharani Laxmi bai Medical College, Jhansi; Dr Mandavi Agarwal, Associate professor of medicine, Maharani Laxmi bai Medical College, Jhansi; Dr A. Mohan Kumar, Assistant Professor of Microbiology and ICO, HICC, All India Institute of Medical Sciences (AIIMS), Mangalagiri; Dr V. Mangayarkarasi, Additional Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Mangalagiri; Dr Rakesh Kakkar, Professor of CFM, All India Institute of Medical Sciences (AIIMS), Mangalagiri; Dr Vamshidhar Chamala, Assistant Professor of Anaesthesia, All India Institute of Medical Sciences (AIIMS), Mangalagiri; Dr Urvi Kamat, Consultant Microbiologist and Infection Control Team Member, South Goa district hospital; Dr Prajay Naik, Consultant Microbiologist, South Goa district hospital; Dr Reena Sachan, Assistant Professor of Microbiology, Moti Lal Nehru Medical College Prayagraj; Dr Abhishek Singh, Assistant Professor of Pulmonary Medicine, Moti Lal Nehru Medical College Prayagraj; Dr Smriti Singh, Associate Professor of Medicine, Moti Lal Nehru Medical College Prayagraj; Dr Sarika Prabhakar Kombade, Associate Professor of Microbiology, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Vibhor Tak, Associate Professor of microbiology and infection control officer, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Naveen Dutt, Additional Professor and head of pulmonary medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Pradeep Kumar Bhatia, Professor of department of Anasthesiology and critical medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Naresh Midha, Assistant Professor of department of general medicine, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Ashok Kumar, Additional Professor college of nursing and CNO, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Himanshu, Associate Professor college of nursing, All India Institute of Medical Sciences (AIIMS), Jodhpur; Dr Sweta shah, Consultant Microbiologist and Infection Prevention, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Mumbai; Dr Pooja Suresh Thakkar, Consultant Microbiology, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Mumbai; Havovi Fouzdar, General Manager - Nursing, HIPC member, Kokilaben Dhirubhai Ambani Hospital and Research Institute, Mumbai; Sapna Malik, Professor of Microbiology, K.J. Somaiya Hospital & Research Center, Mumbai; Vidya Shetty, Associate Professor of Microbiology, K.J. Somaiya Hospital & Research Center, Mumbai; Dr Shelley Sharma Ganguly, Consultant Microbiologist and in-charge HICC, HOD, Dept. of Laboratory Medicine, AMRI Hospitals-Salt Lake, Kolkata; Dr Sathyajith Ramvihar, Head, Laboratory Services & Infection Control, KIMS Alshifa Super Speciality Hospital, Perinthalmanna; Dr Shreshtha Tiwari, Consultant Microbiologist & Infection Control Officer, Balco Medical Centre, Raipur; Manisa Sahu, Head Lab Services & HICC, Balco Medical Centre, Raipur; Dr Bhaskar Narayan Chaudhuri, Chief Microbiologist and Senior Consultant, Dept. of Microbiology and Molecular Biology, and Infection Control Officer, Peerless Hospitex Hospital and Research Center Ltd., Kolkata; Dr Partha Guchhait, Associate Consultant, Dept. of Microbiology and Molecular Biology, Peerless Hospitex Hospital and Research Center Ltd., Kolkata; Santa Mukherjee, Deputy Nursing Superintendent, Peerless Hospitex Hospital and Research Center Ltd., Kolkata; Dr M.S.Ratnamani, Head and Senior Consultant Microbiologist,Infection Control Officer, Apollo Hospitals, Jubilee hills, Hyderabad; Dr J. Prathiba, Consultant Microbiologist, Member IPCC, Apollo Hospitals, Jubilee hills, Hyderabad; Dr Sneha Chunchanur, Assistant Professor and Infection control officer-HICC, Department of Microbiology, Bangalore Medical College and Research Institute (Victoria Hospital) Bengaluru; Dr Shwetha J V, Assistant Professor and Infection control officer- HICC, Department of Microbiology, Bangalore Medical College and Research Institute (Victoria Hospital) Bengaluru; Dr Ambica R, Professor and HOD of Microbiology, Member Secretary, HICC, Bangalore Medical College and Research Institute (Victoria Hospital) Bengaluru; Dr Pravin Kumar Nair, Consultant Infection control, Bethany Hospital,Thane, Maharashtra; Dr Ranjeeta Adhikary, Consultant Microbiogist and Infection Control Officer, Manipal Hospital, HAL airport road, Bangalore; Dr Sunil Karanth, Consultant Intensivist Critical Care Medicine, Manipal Hospital, HAL airport road, Bangalore; Dr Venkatesha Gupta K V, Consultant Critical Care Medicine, Manipal Hospital, HAL airport road, Bangalore; Dr Akshith Thimmaiah, Head of laboratory services and Head of HIC, Dr. Mehta's Hospitals, Chennai; Dr Ravi Shankar Reddy Anukolu, Professor, Member Secretary, HICC, Kamineni Academy of Medical Sciences & Research Centre; Dr Ruturaj M Kolhapuri, Associate Professor, Infection Control Officer, HICC, Kamineni Academy of Medical Sciences & Research Centre; Dr Naveena Jagadeesan, Professor of Microbiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore; Dr Kavitha Karur, Assistant Professor, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore; Dr Nandini Puttamasthi Gowda, Assistant Professor, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore; Dr Vithiya Ganesan, Associate Professor of Microbiology and Officer in-charge, HICC, Velammal Medical College Hospital and Research Institute, Madurai; Dr Jhansi Charles, Professor and Head of Microbiology, Chairperson Hospital Infection Control Committee, Velammal Medical College Hospital and Research Institute, Madurai; Dr Krithika Varshini, Postgraduate of Microbiology, Velammal Medical College Hospital and Research Institute, Madurai; Dr Shaily R, Postgraduate of Microbiology, Velammal Medical College Hospital and Research Institute, Madurai; Dr. Kalyani.M, Professor and Head, Panimalar Medical College Hospital and Research Institute, Varadharajapuram, Poonamallee, Chennai 600123; Dr. Jayanthi.S, Professor, Panimalar Medical College Hospital and Research Institute, Varadharajapuram, Poonamallee, Chennai 600123; Dr. Shifa Meharaj S H, Associate Professor, Panimalar Medical College Hospital and Research Institute, Varadharajapuram, Poonamallee, Chennai 600123; Dr Ekta Agrawal, Associate Consultant, Dept of Microbiology and Infection Control Officer, Apollo Hospital Bilaspur; Dr Manoj Rai, Senior Consultant, Dept .of Internal Medicine, Apollo Hospital Bilaspur; Dr Chithra Valsan, Professor & HOD of Microbiology and Officer in Charge, HICC, Jubilee Mission Medical College&RI, Thrissur; Dr Ardra M, Associate Professor of Microbiology, Jubilee Mission Medical College&RI, Thrissur; Dr Champa Hemachandra, Professor and HOD, Department of Microbiology, Infection Control Officer, Dr. Moopen's Medical College, Meppadi; Dr Cherlopalli Sunil Kumar, ENT Head and Neck Consultant, Dr. Moopen's Medical College, Meppadi; Dr Lakshmikanth BM, Professor and HOD of Anatomy, Dr. Moopen's Medical College, Meppadi; Dr Aruna Poojary, Professor and HOD Microbiology, Breach Candy Hospital, Mumbai; Dr Priyanka Patil, Senior Infection Control Officer, Breach Candy Hospital, Mumbai; Dr. Archana G.J, Assistant professor, Department of Microbiology, Gandhi Medical College and Hospital, Hyderabad; Dr. Navneetha Ch, Associate Professor of Microbiology, Gandhi Medical College and Hospital, Hyderabad; Dr.K. Raja Rao, Superintendent, Gandhi Hospital, General Medicine, Gandhi Medical College and Hospital, Hyderabad; Dr. Rajeshwar Rao, Professor and HOD, Department of Microbiology, Gandhi Medical College and Hospital, Hyderabad; Dr.K. Nagamani, Professor, Microbiology, Gandhi Medical College and Hospital, Hyderabad; Dr T Mangaiyarkarasi, Professor of Microbiology and Infection Control Officer, HICC, Sri Manakula Vinayagar Medical College and Hospital, Puducherry; Dr S. Sunil Shivekar, Associate Professor of Microbiology, Sri Manakula Vinayagar Medical College and Hospital, Puducherry; Dr.K. Deepika, Assistant professor of Microbiology, KMCH IHSR, KMCH Institute of Health Sciences and Research, Coimbatore; Dr.J. Jayalakshmi, Professor and Head of Microbiology, KMCH IHSR, KMCH Institute of Health Sciences and Research, Coimbatore; Dr. Selvarajan N, ICU incharge, Critical care consultant, KMCH Institute of Health Sciences and Research, Coimbatore; Dr Avantika Shukla, Consultant Microbiologist, Thunga Hospital, Mumbai; Dr HB Veena Kumari, Professor, Microbiology, NIMHANS (National Institute of Mental Health and Neuro Sciences, Bengaluru; Dr Nagarathna S, Professor, NIMHANS (National Institute of Mental Health and Neuro Sciences, Bengaluru; Dr Jayasree Shivadasan, Consultant Microbiology, Apollo Hospital, Bannerghatta Road, Bangalore; Dr Chandana Devaraj, Registrar, Apollo Hospital, Bannerghatta Road, Bangalore; Dr Subha S, Consultant Microbiologist and Infection Control Officer, Dr Rela institute and medical Centre, Chennai; Dr Vidhyalakshmi PR, Consultant ID Physician, Dr Rela institute and medical Centre, Chennai; Dr Jyoti S Kabbin, Professor of Microbiology, Bangalore Medical college and research institute (Super speciality Hospital PMSSY); Dr Amrita Gupta, Consultant Microbiologist, Metro Heart Institute with Multispecility, Faridabad

      Conclusion

      This study was conducted in large scale to highlight the practice of hand hygiene in COVID care locations across India. Thorough analysis of this kind of multicentric studies can result in drastic improvement in infection control behavior among health care workers. Large pan India data of this sort enlightens us regrading HH practices in various zones of India and local authorities can take action on escalating education on hand hygiene practices. Prompt feedback, effective educational intervention, multidisciplinary campaigns supported by hospital administration are mandatory to consistently have good hand hygiene adherence. As there is no such large-scale multicentric study conducted so far in India and globally, the results of this study can be considered as national benchmark data to compare the hand hygiene compliance data of other health care facilities.

      Acknowledgments

      The authors thank Dr Anuj Sharma, Acting Team Lead – Communicable Diseases, Technical officer – Antimicrobial Resistance | Health Laboratories | Infection Prevention and Control, World Health Organization Country Office for India for their technical support and Ibhar Technologies Pvt Ltd. which provided Ibhar mobile application for hand hygiene electronic audit tool and data cloud storage. We also thank Dr.Sathish Rajaa, Assistant Professor, ESIC Medical College and PGIMSR, Chennai for performing statistical analysis for this study.

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