This study investigated HH compliance (in terms of hygienic hand disinfection as recommended by WHO-5) in the surgical area of a specialized orthopedic hospital. Overall, a compliance of approximately 41% was observed. Thus, while in line with findings from other studies [5, 6]—which sometimes have reported lower compliance levels [12]—HH compliance clearly merits improvement in the present setting. There might be different explanations for this finding. First, the workload in a specialized orthopedic facility with high patient turnover and multitasking (especially for the anesthesia staff) may be relevant, as described before in another setting [9]. Second, lack of time might also be an issue (as observed in intensive care [13]).
While we, like others [1, 2], did observe higher compliance for nurses than for physicians, the differences across the medical specialties involved, i.e., anesthesia versus surgery, were considerably larger. Anesthesia staff had higher compliance than surgical staff, especially among physicians. These patterns are notable, especially since previous studies in the surgery setting have often focused on the hand hygiene performance of anesthesia staff only [7]. One explanation might be that surgeons associate hand hygiene in the surgical area predominantly with surgical hand disinfection immediately prior to the operative procedure and tend to overlook indications for hygienic hand disinfection.
In the study clinic, multimodal surgical site infection-preventive interventions have taken place since 2007 [14]. These included hand hygiene education for nurses and physicians in the wards. Since 2017, anesthesia staff (nurses and physicians) in the surgical area has been trained yearly with respect to hand hygiene. Future interventions to increase hand hygiene should also be directed at surgeons and explicitly address the immediate perioperative setting.
Considering the overall level of HH compliance of approximately 41% in the present study, the impact of the abovementioned interventions remains disillusioning. This underlines that more research on sustainable interventions is urgently needed. Using behavioral change principles for these interventions might be a promising concept but further research is needed as stated in a systematic review by Srigley et al. [15]. In this context, Clancy et al. state in a systemic review of HH related clinical trials that future research should also focus on which intervention types work best for different professional groups [1]. Furthermore, studies should find ways to initiate or maintain collection and evaluation of HH compliance data at regular and long-term follow-up intervals [1].
Looking at different medical specialties, varying hand hygiene compliance (e.g. surgical: 72%, medical: 71%, pediatric: 78%, rehabilitation: 66%) in non-intensive care units have been reported within the reference data of the national hand hygiene campaign in Germany [10].The overall median compliance in the aforementioned study was 73%, which is higher than the observed 41% in our study setting. This again underlines the need to assess and address hand hygiene within an operating area of hospitals. Nonetheless, we are aware that different settings (such as intensive care units, non-intensive care units, and operating theatres) are only comparable to a limited extent due to different conditions, including staffing and workload. Moreover, hand hygiene compliance might be measured differently depending on the respective setting.
In the present study, compliance was higher in the operation theatre for pediatric patients. Healthcare workers in pediatric patient care settings are known to have higher HH compliance [10, 16]. One reason may be that pediatric patient populations rely greatly on hands-on-care [17]. Healthcare workers involved in pediatrics are aware of this and use good HH to protect their vulnerable patients. In fact, surgical site infections following, for instance, pediatric spinal deformity surgery represent a severe complication [18], with possibly consequential lifelong damage starting at a comparatively young age. This might be another reason for the comparatively high HH compliance in this setting.
The study has potential limitations and strengths. It is a single-center study in a highly specialized patient care setting of an orthopedic university clinic. Thus, our findings might not apply to other settings. However, nearly all operative procedures observed were elective, which may imply some transferability to comparable institutions providing elective orthopedic surgery (such as knee and hip arthroplasty). While possibly overestimating compliance through the Hawthorne effect [19], this does not necessarily invalidate specific comparisons between subgroups such as occupational groups or medical specialties. Observation took place in late summer 2020 after the first wave of the coronavirus disease 2019 (COVID-19) pandemic in Germany. On the one hand, this might have influenced the hand hygiene performance in our study, as reported previously by others [20]. On the other hand, in our experience, elective orthopedic surgery was not a clinical hotspot of the COVID-19 pandemic. Moreover, improvements of hand hygiene compliance during the first wave of the COVID-19 pandemic were not always sustained [21]. Thus, the impact may have been not so substantial. Finally, we did not track single observation events (i.e., hand hygiene opportunities) to specific physicians or nurses. Thus, multilevel analysis taking into account the individual level was not viable. However, the observer was instructed to observe as many different healthcare workers as possible in order to reduce bias due to consistent behavior of individual persons. In our study clinic, alcoholic liquid hand-rub solution is used for HH purposes, which is in very widespread use in Germany. Of note, other formulations of alcoholic hand rub solution (such as gels or foams) have been positively evaluated in terms of high acceptance, which may also have affected compliance in our study [22].
Regarding strengths, most importantly, patients were followed continuously, i.e., during their entire stay in the surgical area. Our results reflect a comprehensive and probably realistic approximation of the “true” number of hand hygiene opportunities in this specific setting, with the number of missed opportunities probably in the lower single digit range. Furthermore, the inclusion of surgical staff in a study located within the specific setting of the surgical area itself addresses a relevant stakeholder group whose role in infection prevention has tended to be under-researched and potentially underestimated [23].
In conclusion, this study emphasizes that there is a clear need for improvement of HH compliance in the immediate pre, intra- and postoperative patient care setting in orthopedics. Efforts are particularly needed to increase compliance among surgeons. However, the anesthesia care team also needs to be addressed, as it is responsible for the majority of aseptic tasks. Given the abovementioned previous intervention efforts in the present setting, more strictly tailored interventions (e.g., strategies addressing different occupational groups’ needs empirically assessed beforehand [24, 25]), may be a promising option in orthopedic surgery.
