Title

Author(s)

Factors affecting hand hygiene compliance in intensive care

units: a systematic review

Lau, Chun-ling.; .

Citation

Issued Date

URL

Rights

2012

http://hdl.handle.net/10722/179908

The author retains all proprietary rights, (such as patent rights)

and the right to use in future works.

Factors Affecting Hand Hygiene

Compliance in Intensive Care Units:
A Systematic Review
Submitted by

Lau Chun Ling

MPH Project
The University of Hong Kong
2012

A project submitted in partial fulfillment of the requirements for

the Degree of Master of Public Health
at The University of Hong Kong

August 2012

Abstract of project entitled

Factors Affecting Hand Hygiene Compliance in Intensive Care Units:

A Systematic Review
Submitted by

Lau Chun Ling

for the degree of Master of Public Health
at The University of Hong Kong
in August 2012

Abstract
Hospital-acquired, or nosocomial infections (HAIs) are the major source of mortality and
morbidity for hospitalized patients. It is estimated that 7-10% patients developed HAIs during
their hospital stays, with most patients got infected from intensive care units (ICU) [1,2].
Hand hygiene (HH) is recognized as the most easy and effective way to prevent HAIs. However,
the observed hand hygiene compliance rates among healthcare workers (HCWs) have been
regarded as unacceptably low, especially in ICU [3]. This literature review is to discuss the
factors influencing the hand hygiene compliance among HCWs in ICU, in both the individual
and institutional level, and suggest which factor was important in both levels. Recommendations
in comprehensive approach on hand hygiene practices will also be included.

Declaration
I declare that the project and the research work thereof represents my own work, except where
due acknowledgement is made, and that it has not been previously included in a thesis,
dissertation or report submitted to this University or to any other institution for a degree,
diploma or other qualification.

Signed
Lau Chun Ling

Acknowledgements
I would like to express my sincere appreciation and heartfelt thanks to my supervisor, Dr.
Dennis Ip, for his patient guidance and expert advice on the direction and completion of my
project. This work would not have been possible without his kind comments and support.
I owe the biggest debt of gratitude to my family and friends, especially Mrs. Janet Lau, Miss
Kathy Lau and Big Four, for their endless love and understanding, to support me come across all
the hard time in both my work and study during this master program.
A special acknowledgement and sincere thanks go to Mr. Sammy Tsang, for his continuous
support and encouragement, and for always being my motivation.

Table of Contents
Abstract ................. 1
Declaration.................... 2
Acknowledgements.................................................... 3
Table of Contents ..................... 4

Chapter 1 Introduction..................... 6
1.1 Impact of Hospital-acquired Infections................ 6
1.2 Definitions of Hand Hygiene Compliance............... 6
1.3 Importance of Hand Hygiene Practice and its poor compliance.............. 7
1.4 Current Literature Gaps............... 8
1.5 Objectives..................... 8

Chapter 2 Methods.............................................................................................................. 10
2.1 Search process.................... 10
2.2 Inclusion and exclusion criteria..............10
2.3 Citation assessments...............11

Chapter 3 Results.................13
3.1 Selection of Articles................13
3.2 Individual Factors Affecting the Hand Hygiene Compliance.................19
3.3 Institutional Factors Affecting the Hand Hygiene Compliance..................22

Chapter 4 Discussion...............24
4.1 Summary of Findings..................24
4.2 Recommendations on Hand Hygiene Practice................25
4.3 Future Researches Directions..................28
4.4 Limitations..................29

Chapter 5 Conclusion..............30
References................31
List of diagrams and tables:
Figure1: Inclusion and exclusion process in the systematic review.....................14
Table 1: Summary of the description of studies on factors affecting hand hygiene
compliance................15
Table 2: Summary of the reported impact of HAIs..................39

Chapter 1 Introduction
1.1 Impact of Hospital-acquired Infections
Hospital-acquired infections (HAIs) or nosocomial infections are major global health problems
and are identified as the first priority for Global Patient Safety Challenge by WHO [4]. The
prevalence of HAIs is estimated to be 1.4 million worldwide. It leads to 50,000 attributable
mortality and 2 million attributable morbidity in developed countries every year [5,6], as well as
resulting in an extra 14 days hospital stays and an additional of 3154 annual healthcare
expenses [7,Table 2]. Eliminating HAIs can save millions of treatment costs and relieved its
associated socio-economic burden [8].

1.2 Definitions of Hand Hygiene Compliance

Hand Hygiene practice refers to any action of hand cleansing to decrease hand colonization with
transient flora. According to Centers for Disease Control and Prevention and the hand hygiene
guidelines from WHO (2009), hand hygiene (HH) compliance includes hand washing, hand
antisepsis, and the use of gloves followed with hand washing at the Five moments for hand
hygiene, i.e. before touching a patient, before a procedure, after a procedure or body fluid
exposure, after touching a patient and after touching a patient's surroundings [9].

1.3 Importance of Hand Hygiene Practice and its poor compliance

HAIs result from cross-contamination. Studies show that the hands of healthcare workers
(HCWs) are the major route of bacteria transmission between patients [10]. HH is regarded as
the most important and simplest measure to prevent HAIs [11], one third of HAIs cases are
preventable

[12]

by

proper

hand

hygiene

practice,

including

those

caused

by

methicillin-resistant Staphylococcus aureus and drug-resistant Acinetobacter baumannli [13].

The US Centers for Disease Control and Disease Prevention proposed that hand washing
remains the single most important prevention strategy that reduces the risk of HCWs
transmitting micro-organisms from one patient to another [14].
HH is very cost-effective as it can prevent additional health care expenses spent on treating
HAIs, and the savings can exceed any incremental costs for promoting or improving HH
practice [9].
Although HH practice is both effective and cost-effective in preventing HAIs, many studies had
highlighted the poor compliance to recommended hand hygiene guidelines in general hospital
settings, with an overall average of only 40% [9]. The major risk factors affecting HH
compliance as documented in hospital wide survey were professional category, type of hospital
ward, workload, knowledge and attitude, patients risk of infection, feedback and role model,
skin irritation to hand hygiene agents [15,16].

1.4 Current Literature Gaps

Among different hospital specialties, intensive care units (ICU) are consistently found to have
the highest prevalence rate of HAIs, ranging from 13-26% [17-20], when compared to the usual
figure of 5-10% reported in other units in the hospitals, [21-24]. Yet, HCWs in intensive care
units were also having the lowest HH compliance rate (36%, median=40%-50%) when
compared with staffs working in other specialties (median=50-60%) [16].
Hand hygiene compliance is influenced by both individual and institutional factors [15].
Although existing evidence-based researches and systematic reviews have identified many
factors affecting the HH compliance among HCWs in general hospital settings, there isnt any
systematic review exploring specifically the factors affecting the HH compliance in an intensive
care setting, at both the individual and institutional levels, which is having the lowest HH
compliance rate and the highest risk of HAIs.

1.5 Objectives
To systematically review aims to address the following research questions:
(1) What are the individual factors that affect the hand hygiene compliance in intensive care
units?
(2) What are the institutional factors that affect the hand hygiene compliance in intensive care
units?

(3) What recommendations on hand hygiene practices can be formulated basing on the above
evidence?

Chapter 2 Methods
2.1 Search process
In order to identify the individual and institutional levels factors affecting the hand hygiene
compliance in a systematic way, relevant literatures are retrieved from databases Medline(Ovid),
PubMed, EBSOHost. The following medical subject headings (MeSH) are used under 3 key
categories that addressing the research topic: i) Factors-improving OR increasing OR
factor OR determinant AND ii) Hand hygiene-hand hygiene OR hand washing OR
hand disinfection OR hand sanitization OR infection control OR alcohol-based hand rub
OR hand $ OR hand hygiene $ AND iii) compliance- compliance OR non-compliance
OR adherence OR non-adherence OR better compliance OR better tolerance.
The search is then limited to journals. Reference list of the retrieved articles are also manually
screened to identify all related published studies. Search was being done on 10th Aug, 2012. Any
papers published before 10 Aug 2012 that were being picked up by the search and fitting the
inclusion and exclusion criteria were being included.

2.2 Inclusion and exclusion criteria

In this study, hand hygiene practice refers to either hand washing or hand disinfection, which
can be done by washing hands with detergents and water, or water alone, or antiseptic agent
alone like alcohol-based hand rub. Surgical hand scrub, using gloves with no following hand

10

washing, were not identified as hand hygiene practice in this paper. The duration and
appropriate steps of hand hygiene practice were also not considered here since the aim of this
paper is to review the factors affecting the HH compliance but not to assess the adequacy of HH
skills and technique among HCWs.
The inclusion and exclusion criteria were set in prior to select the most relevant journals from
those retrieved. The inclusion criteria were: a) Subjects studied were health care workers who
work in the intensive care unit (both adult, pediatric, neonatal, cardiac, medical and surgical); b)
Factors of hand hygiene compliance were mentioned; c) Original studies were included; d)
Sample and setting were carried in ICU, if discrete data for HH compliance factors can be
retrieved for ICU, even studies in general hospital setting can also be included.
The exclusion criteria were: a) Conference papers, abstracts, protocols, guidelines, unpublished
results, reviews articles. b) Results of effect cannot be separated from other infection control
interventions e.g. gown use, single isolation room. c) Interventional studies were also excluded
since this paper aims at reviewing the underlying factors affecting HH compliance but not the
effectiveness of an intervention on the enhancement or improvement of HH practice.

2.3 Citation assessments

The identified articles were screened by the inclusion and exclusion criteria, content of every
article was further evaluated in relation to the two three research questions and followed the

11

international guideline STROBE (observational studies) [25]. The critical appraisal was based
on: a) Methods (describe the study design, setting, location and period of data collection), b)
Sample size (enough sample size?), c) Descriptive data (statistical methods, characteristics of
study participants and inclusion criteria, statistical information on factors affecting HH
compliance and potential bias and confounders).
The overall quality of the selected articles was assessed by using the STROBE checklist and
rank in A (good), B (average), and C (unsatisfactory).

12

Chapter 3 Results
3.1 Selection of Articles
In the initial search, 1206 related articles were obtained in PubMed, 936 in Medline(Ovid) and
466 in EBSOHost after conducting the MeSH search term mentioned above (i AND ii AND iii).
The search was then limited to original articles and journals and NOT interventional studies. 383
potential papers were retrieved in PubMed, 357 in Medline(Ovid) and 60 in EBSOHost. These
citations were then further evaluated by screening on the title and abstract. Those studies which
were not related to the factors affecting HH compliance among HCWs, not confined in ICU
settings were excluded. The inclusion and exclusion process is summarized in Figure 1. There
were 14 published studies remained for this systematic review. The summary and results of
these studies were listed in Table 1.

13

Figure 1: Inclusion and exclusion process in the systematic review

1206 potentially relevant

papers were identified from
PubMed, MEDLINE and
EBSOHost

383 potentially papers were

screened

68 papers were selected for

further evaluation

823 papers were excluded as

they were interventional
studies/not original
articles/not journals

315 papers were excluded after screening of

the title and abstract:
-184 papers were not relevant to the
research questions or not confined in ICU
settings
-55 papers compared different hand washing
or hand antisepsis agents
-48 papers included other infection control
measures e.g. single isolation room, gown
use, universal gloving
-28 papers did not mention factors affecting
HH compliance

54 papers were excluded after further

evaluation:
-29 papers were analyzing hand hygiene
compliance rate only without details on
factors affecting compliance
-25 papers cannot retrieve discrete data for
factors affecting HH compliance in ICU from
other specialties
14 papers were used for this
systematic review

14

Table 1: Summary of the description of Studies on factors affecting hand hygiene compliance
Reference

Year

Study design

Sample size

Demographics

Settings

Individual factors

Institutional factors

Harbarth et.al

2001

Observational,

2811 hand

Nurses (2031 opportunities),

1 PICU and 1 CICU and

Professional category

Type of ICU

prospective cohort study

hygiene

physicians (426 opportunities),

1 NICU at a tertiary care

(being a respiratory

(working in

opportunities

respiratory therapist (251

childrens hospital in

therapist-OR=5.1);

NICU-OR=1.6);

opportunities), aids/medical

Boston

Type of patient-care

Grade
A

[26]

student/radiology technician (103

activities(before

opportunities)

contact with body fluid

secretions-OR=11.5);
Disrupted workflow
(OR=0.15)

Nobile et.al

2002

Survey

413 nurses and

Physicians(151), nurses (249) and

19 and 5 randomly

Gender

Type of ICU

physicians

head nurse (12), with similar

selected hospitals in

(female-OR=1.69);

(NICU=9.94);

numbers in both sex

Campania and

Self-protection (96.5%)

Availability of hand

A
[27]

Calabria(Italy)

hygiene products
(93.9%)

Pessoa-Silva

2005

Questionnaire

61 neonatal

et.al

(based on the theory of

HCWs

[28]

planned behavior)

12 physicians and 49 nurses

NICU of the University

Attitude (OR=3.32);

of Geneva Hospital

Perception of control

(Switzerland)

(OR=3.1);

Perception of being a
model (OR=2.9)
Skin irritation (57.4%);
Use of gloves (53.3%);
Forgot to wash hand
(50.8%)
15

Cohen et.al

2003

Direct observations

1472 touches

All HCWs

2 university- affiliated

Level of contact

Use of alcohol-based

(visitors can be excluded)

NICUs in New York

(P<0.03);

hand rubs (p<0.01)

B
[29]

Professional category
(55.1% for physicians,
46.2% for nurses)
Sharma et.al

2011

Cross-sectional

114 HCWs

18 attending physicians, 8

42-bed MICU of a

Professional category

Activity index

intensivists, 9 senior residents, 10

tertiary care teaching

(50.8% for physicians,

(38.2% for higher

Postgraduate residents, 4 non

hospital in Punjab

41.3% for nurses);

activity index, 52.1%

postgraduate residents, 65 nurses

(Pakistan)

Age

for lower activity

(40.4% for 21-30 years

index);

old, 65.1% for 31-40

Risk of

years old)

cross-transmission

Attitude;

(38.8% for high risk,

Skin irritation

43.8% for medium

A
[30]

risk, 44.7% for low

risk);
Administrative
apathy;
Lack of motivation
De Wandel et.al

2010

Questionnaire

108 nurses

72% female and 27% male nurses

40-bed ICU of the Ghent

Attitude (p<0.001);

(based on behavior

with various number of years of

University Hospital

Self-efficacy

theory model)

working experience

(Belgium)

(p=0.001);

14-bed MICU

Awareness of being

B
[31]

Maury et.al

2006

4-phase Observational

1064 for phase 1;

Nurses, aids, physicians,

study

1045 for phase 2;

residents, students

B
[32]

observed (p<0.05)

1038 for phase 3;

and 995 for phase
4

16

Duggan et.al

2008

Covert observation

975 hand hygiene

Attending physician, nurses,

SICU and MICU of a

Awareness of being

opportunities

therapist, technician and medical

319-bed teaching

observed (p<0.001)

resident, student

hospital in University of

B
[33]

Toledo (Spain)
Kaplan et.al

1986

Observation

42 HCWs

8 physicians, 30 nurses, 2

MICU and SICU at an

Professional category

Sink accessibility

radiology technicians and 2

university affiliated

(p<0.001)

(p<0.001);

respiratory technicians

teaching hospital

727 hand hygiene

Nurses (593), doctors(70) and

31-bed ICU of a Belgium

Professional category

opportunities

physiotherapists(64)

University hospital

(p<0.0001);

B
[34]

Noritomi et.al

2007

Prospective observation

B
[35]

Level of working
experience (p=0.56);
Gender(p=0.02);
Type of patient-care
activities (p<0.0001);
Contagious status of
patient (p<0.0001)
Rumbaua et.al

2001

Point-in-time observation

88 HCWs

53 physicians, 21 nurses, 14

ICU of St. Lukes

Professional category

Risk of

aids/medical technologists,

Medical Center (US)

(19% for physicians,

cross-transmission/

43% for nurses)

Workload

B
[36]

radiology technicians and

respiratory therapists

(25% for high risk,

50 % for low risk)

Mathai et.al

2011

Observational

105 HCWs

24 nurses, 36 resident trainee, 8

A 13-bed mixed

Professional category

High density

consultants, 31 physiotherapists

medical-surgical AICU

(17% for physicians,

activities/too busy

and 6 ICU technicians

of a tertiary care hospital

45% for nurses);

(33.7%)

in northern India

Forgot to wash hand

B
[37]

(~27%)

17

Van de Mortel

2001

Covert observation

~214 HCWs

~70 nurses, 44 ward persons, 17

16-bed critical care unit

et.al

physiotherapists, 68 doctors and

at city hospital in

[38]

15 X-ray technicians

Australia

Gender (p=0.0001)
C

(inclusion criteria for participants

was not mentioned)
Karabey et.al.

2002

Direct observation

32 HCWs

6 doctors, 23 nurses, 2 laboratory

ICU in Istanbul (Turkey)

Professional category;

Lack of sinks,

technicians, 1 physiotherapist

Excessive use of gloves

washing and drying

(inclusion criteria for participants

(statistics not

products

not mentioned)

mentioned)

(statistics not

C
[39]

mentioned)
HCW, health care workers. AICU, adult intensive care unit. SICU, surgical intensive care unit. MICU, medical intensive care unit. PICU, pediatric intensive care unit. NICU,
neonatal intensive care unit. CICU, coronary intensive care unit.

Hand hygiene opportunities, any potential hand hygiene action for patient care as recommended by

standard guidelines. Hand hygiene touches, any contact by the hands of HCW with a patients skin or the surrounding environment. Phase 1,3, periods of non-announced
observation. Phase 2,4, periods of announced observation.

18

In general, 9 out of 14 retrieved papers [26,27,28,29,31,33,35,36,38] were done in developed

countries, 3 in developinged countries [30,37,39] while 2 papers did not mention the place
where it was being done [32,34]. Of the 14 studies, 11 were observational studies
[16,29,30,32,33,34,35,36,37,38,39] while 3 were questionnaire surveys [27,28,31]. The
overall quality of the studies were average, with eight of the fourteen studies graded
average, four studies graded good and two studies graded satisfactory.

3.2. Individual Factors Affecting the Hand Hygiene Compliance

Individual factors affecting the hand hygiene compliance in intensive care units were
identified in those studies, including:
Professional category: Eight studies assessed effect of professional category on HH
compliance [26,29,30,34,35,36,37,39]. Four of the eight studies [34,36,37,39] mentioned
that being a physician or a nursing aids rather than a nurse is a perceived barrier to hand
hygiene compliance, only 17-19% physicians adhered to HH guidelines [36,37].
Compliance with hand hygiene protocols was significantly higher for nurses than doctors
(p<0.001) [34], ranging from 43-45% [36,37]. In contrast, the other four studies
[26,29,30,35] have rather opposite findings in which higher compliance was observed in
doctors (50.8%-55.1%) than nurses (41.3%-46.2%) [29,30]. Furthermore, doctors of
different specialties also exhibited different compliance rate, with the highest HH
compliance rate observed in respiratory therapist (OR=5.1) [26].
Age [30]: Only one study assessed the effect of age on HH compliance. It stated that the
hang hygiene compliance was the highest in the age group of 31-40 years old (65.1%)
while at the lowest in the age group of 21-30 years old in doctors (40.4%) [30].
Gender [27,38]: Two studies examined the effect of gender on HH compliance. Both of
them presented that female health care workers tend to wash hand more often than male

19

ones (OR=1.69) [16]. The gender difference is more significant in the disciplines of
doctors (p=0.047) and ward persons (p=0.0001) [38].
Behavior determinants including self-efficacy, attitude and perception of control
[28,30,31]: Three studies demonstrated the effect of behavior determinants on HH
compliance. They all found that for those who reported higher self-efficacy
(OR=2.9-3.37) , more positive attitudes toward HH practice guidelines (OR=3.32) and
higher perception of control (OR=3.1), were associated with a significantly higher
compliance to the HH practice guidelines (p=0.02, p=0.01) [28,31], probably because of
the belief that adhering to the practice guidelines could improve patient outcomes.
Hand irritation and dryness [28,30]: Two studies assessed the effect of hand irritation and
dryness on HH compliance. Both of them showed that the use of drying and irritating hand
antisepsis products were associated with a decreased HH compliance rate among health
care workers. 57.4% HCWs believed that the products they were using for hand
disinfection and routine hand disinfection would cause skin irritation; hence, and thus less
likely to wash their hands [28].
Disrupted workflow [26]: Only one study examined the effect of disrupted workflow on
HH compliance. It observed that interruption of patient care activities would affect HH
compliance (9%), for example when the HCW left a patient to contact with another patient
or surfaces such as the medication dispenser, telephone and then go back to touch the first
patient [26].
Level of working experience [35]: Only one paper studied the effect of level of working
experience on HH compliance. It stated that the level of working experience was
uncorrelated with hand hygiene adherence rates (p=0.56).
Level of contact/Contagious status of patient/ Type of patient care activity/Self-protection
[26,27,29,35]: Four studies assessed the effect of contagious status of patient on HH

20

compliance. One showed that hand hygiene compliance (50.3%) increased with the level
of contact with neonates, HCWs were more likely to wash their hands when they need to
directly touching the neonates [29]. Moreover, the others also exhibited that 77% HCWs
would wash their hands when they have to do with dirty tasks such as before contact with
body fluid secretions [26], as well as for those procedures associated with patients under
isolation or contact precaution due to their contagious status (p<0.0001) [35], this
confirmed with the finding that almost all (96.5%) HCWs perceived HH practice as a
means of self-protection [27].
Excessive use of gloves [28,39]: Two studies examined the effect of use of gloves on HH
compliance. Karabey observed that HCWs were more unwilling to wash their hands when
they wore gloves. The use of gloves provided them with a sense of self-protection, thus,
lowered their HH compliance [39]. 53.3% HCWs reported that they prefer to use gloves
rather than washing their hands [28].
Perception of being a model [28]: Only one study assessed the effect of perception of
being a model on HH compliance. When a HCW was aware that he/she became a role
model to other colleagues, they would be more committed and adhered to the HH practice
guidelines. The perception of being a model or superiors was independently associated
with the HH compliance (p=0.035) [28].
Awareness of being observed [32,33]: Two studies examined the effect of awareness of
being observed on HH compliance. It is a strong indicator of higher HH compliance as the
one being observed believed that they set a positive role model (p<0.001, p<0.05) [32,33].
The social influence and peer pressure also affected the compliance rate.
Forgetful in wash hands [28,37]: Two studies assessed the effect of forgetfulness on HH
compliance. Approximately 27%-50.8% HCWs said they failed to remember that they
have to perform HH [28,37], and it was also the second most common reason for HH

21

non-compliance reported by HCWs from a questionnaire [37].

3.3 Institutional Factors Affecting the Hand Hygiene Compliance

Workload/Activity index/ High density activities/ Risk of cross-transmission [30,36,37]:
Three studies assessed the effect of workload on HH compliance. Mathai [37] stated that
the most common reason for the HH non-compliant was that HCWs were too busy
(33.7%). When the workload was heavy or the activity index was higher (>20), there was
higher demand for hand hygiene and leads to higher HH opportunities [36]; hence, lower
compliance rate (38.2%) would be resulted [30]. The hand hygiene compliance for low
risk of cross-transmission, varied from 44.7%-50%, was significantly higher than that of
high risk of cross-transmission, ranged from 25%-38.8% [30,36]. The urgent patients
need in critical care units outweighs the importance of HH practice and attributed to
non-adherence to HH guidelines [30].
Type of ICU [26,27]: Two studies examined the effect of type of ICU on HH compliance.
They both reported that the staff in neonatal ICU has the highest HH compliance rate
(OR=1.6-9.94) while HH compliance rate in cardiac ICU was the lowest when compared
to other types of ICU (OR=0.7, p<0.001).
Promotion for the use of alcohol-based hand hygiene product [29]: Only one study
assessed the effect of use of alcohol-based hand hygiene product on HH compliance. It
confirmed that HH was significantly improved when HCWs used alcohol-based product
rather than using antiseptic detergent to clean their hands (p<0.01). Therefore, administers
should encourage the use of alcohol-based product.
Lack of sinks, washing and drying products/poor accessibility [27,34,39]: Three studies
assessed the effect of poor accessibility on HH compliance. The observation from Karabey
[39] was that the lack of sinks, washing and drying products such as not fixing the paper

22

towels on the wall and not enough number of sinks in ward can be a significant indicator
for poor HH compliance. 93.9% HCWs believed that HH can be supported by the
availability of HH products [27] and poor accessibility of sinks would decrease the HH
compliance rate in ICU (p<0.01) [34].
Administrative apathy [30]: Only one study stated the effect of administrative apathy on
HH compliance. HCWs claimed that one of the reasons for their low compliance was
attributed to the administrative apathy and the low institutional priority for hand hygiene
support [30].

23

Chapter 4 Discussion
4.1 Summary of Findings
Individual factors
Our result suggested that a number of important individual factors were affecting HH
compliance in the ICU setting. These included professional category, age, gender, behavior
determinants, hand irritation and dryness, disrupted workflow, contagious status of patients,
use of gloves, perception of being a model, awareness of being observed and forgetfulness.
Among all the factors being studied, the contrasting result regarding the different patterns of
HH compliance among different professional groups probably served to highlight the
existence of fundamental differences in conception and attitude regarding HH practice and in
consequence underlying reasons sharping their degree of compliance among different
professional groups. Despite this controversy, a number of studies had reported the highest
HH compliance rate among nurses in comparison with other HCWs in ICU due to their higher
number of HH opportunities in patient care, which was in accordance with landmark studies
about hospital wide predictors for HH compliance [15,40]. Couple of studies in the review
also indicated that disrupted workflow and forgetfulness would affect the HH compliance,
probably related to the high workload in ICU setting [26,28,37]. This also confirmed with the
findings in general hospital setting about that the inverse correlation between the intensity of
patient care and rate of HH compliance [41-52]. In other words, the higher the demand for
hand hygiene, the lower the compliance rate, possibly related to the lack of time due to the
amount of workload. This may explain why ICU always have the lowest HH compliance rate
when compared to elsewhere [53].
Institutional factors
For the institutional factors, workload, type of ICU, use of alcohol-based hand hygiene
products, poor accessibility to sinks and HH products and administrative climate were all

24

definitively related to the HH compliance. The higher observed HH compliance rate in NICU
(39-56%) than the other type of ICU can also be explained by the lower intensity of patient
care in NICU, which was allied with the finding in a WHO study [4]. Other perceived
institutional factors affecting HH compliance have been assessed in this paper also remained
accordant with other observational studies [54-60].
In comparison to the systematic reviews about the factors affecting the hand hygiene
compliance among HCWs in general hospital settings [15,16], we found consistent results
with those in ICU in our papers. One interesting finding was that the level of working
experience was not associated with HH compliance in ICU [35] but a positive result was
found in general hospital settings [15,16]. Further prudent research is necessary to explore the
underlying reason for this finding. As high workload in ICU is the common factor attributing
to lower HH compliance in both the individual and institutional level, it may reflect that the
amount of workload is an important factor affecting HH compliance in ICU setting.

4.2 Recommendations on Hand Hygiene Practice

Full compliance to HH guidelines is unrealistic. However, targeting the barriers and
implementing associated interventions could effectively improve HH compliance.
i) Education with performance feedback
Education with performance feedback has been demonstrated by systematic reviews to be a
very effective approach in modifying HH compliance [15,61]. Although a number of
important factors, including gender and age were not being modifiable [27,30,38], these do
represent important direction to guide educational efforts. Our findings suggested that
education together with performance feedback in order to improve their adherence to HH
practice should better be targeted more on young and male groups who were having much
lower observed compliance rate in most studies.

25

ii) Tailor-made interventions for different professional categories

Moreover, although controversy remained regarding the effect of professional category in HH
compliance, it does serve to highlight the fact that there may be fundamental conceptual
differences regarding HH practice and in consequence underlying reasons sharping their
compliance may be very different among different professional groups, remained was found
to be a definitive factor for HH compliance in ICU. Interventions should also be tailor made
for different professional disciplines as the reason for HH non-compliance was different for
each professional category. For instance, reason for the lower HH compliance rate among
doctors was their skeptical attitude and mistrust of the HH guidelines on the improvement of
patient outcomes [62,63]. Their attitude should be adjusted so that HH guidelines can be put
in practice comprehensively. Role models set from senior or emphasis on the importance of
HH guidelines given by influential doctors, which was an important factor for HH compliance
found in this review [28], can significantly increase doctors positive attitudes towards HH
practice [62]. One interventional study in ICU proved that if the role models washed their
hands during the doctors round, all other doctors would apt to follow suit [64].
iii) Decrease workload
On the other hand, the major reason for the lower HH compliance rate for nurses found in the
review was the higher number of HH opportunity when compared with other professional
disciplines. In other words, it represented a higher activity index and hence heavier workload
that decreased the HH compliance rate among nurses. To solve this, the use of alcohol-based
HH products should be encouraged among nursing discipline since significant evidence
showed that easier access of alcohol-based hand rubs at the point of patient care can save
much more time than that of traditional hand washing [43,57,65]. This can target the busyness
which was a significant barrier for HH compliance in ICU.
iv) Tackle hand irritation and dryness

26

Another factor affecting HH compliance was the problem of hand irritation and dryness
associated with hand rubs, despite the fact that many nurses still believed that alcohol-based
hand rubs would cause more harm to their skins than hand washing agents, studies show that
they caused less irritation and dryness to skin, and applying hand rubs after hand washing can
even reduce the irritation caused by the washing [66]. These concepts should be effectively
communicated in promotional programs that were particularly targeted on nurses. Hospitals
have to ensure the easy access to alcohol-based hand rubs with emollients, and distributing
pocket size hand rub to each HCWs can also be considered [44,67]. Furthermore,
interventions proved that providing hand cream to HCWs can minimize irritant contact
dermatitis that resulted from HH practice [68], hand lotions or creams are thus indispensable
items in ICU. Possibility to place hand creams next to hand rubs and sinks should be assessed
locally. Good accessibility to hand rubs and hand creams should both be guaranteed as they
were pivotal factors affecting HH compliance.
v) Keep HCWs alert
Apart from coping with an ever-expanding workload, being oblivious in washing hands was
another reason for HH non-compliance reported by HCWs in ICU. Posters and warning signs
about hand hygiene such as Hand hygiene practice at five moments or Wash hands after use
gloves can be put on ventilators, doors and walls to continuously remind HCWs to wash their
hands [69].
vi) Enhance behavior determinants
Behavior determinant was another factor for HH compliance. It should be targeted and
enhanced by the aid of interventions. Attitude can be improved by increasing ones knowledge
via education program while self-efficacy can be enhanced by social learning from role
models or providing positive performance feedback and rewards. A compliment or positive
feedback from senior staff or peers can invoke more positive attitude and better self-efficacy;

27

and thus, adhere to HH practice on a long-term basis [70].

vii) Increase awareness of being observed
The review confirmed that awareness of being observed was associated with HH compliance.
To increase the awareness of being observed, accreditation visits or audits are needed to
prompt HCWs regularly and renewed them with periodically updated HH recommendations
[32].
viii) System level initiative
System level initiative is crucial to generate staff motivation for the change of HH practice.
For example, implementing morning huddles, which is an organizational tool to enhance
multi-disciplinary communication and allow the frontline staff to raise their concerns about
the barriers to poor HH practice directly to the administrators, reinforce individuals to adhere
to HH guidelines via peer influence and feedback [15, 71]. Study indicated that units with
morning huddle reported significantly higher HH compliance rate [71].
ix) External motivator and compatible hospital policies
External motivator such as furnishing with adequate HH products, setting up role models
from key staff, providing encouragement or incentive via monthly rewards with positive
performance feedback are also effective strategies to improve HH compliance in
administrative level [72-75]. Hospital policies should ensure administrative sanctions for a
better culture and higher priority for HH compliance and avoid understaffing and
overwhelming workload [3].

4.3 Future Researches Directions

To facilitate future learning, there is a need to standardize the measuring instrument in order
to analyze the effect of those factors affecting HH compliance. Moreover, interventions
implemented in ICU could be systematically reviewed so as to investigate the reasons of

28

successes and failures. They could be definite contributions to improve patient safety.
Furthermore, this paper does not include appropriate duration and steps of hand hygiene
practice which are important factors attributed to proper hand hygiene practice. Further
research should be thoroughly undertaken so as to review this part.
An interventional study conducted in Hong Kong stated that the HH compliance in a neonatal
ICU among HCWs was 40% in general [76]. Another cross-sectional study conducted in four
acute Hong Kong hospitals explored cognitive factors affecting HH compliance and some
effective interventions to improve the compliance rate [77]. However, local data about HH
compliance rate in ICU are still scarce and factors affecting the local HH compliance are also
inconclusive.

4.4 Limitations
As most of studies were being conducted in developed countries with a Western culture, some
of the results may have limited generalizability to the local situation in Hong Kong, especially
regarding factors that may be more culturally sensitive such as gender, workload.
As most of the studies form this systematic review were based either on direct observation or
self-reporting, there may be inherent limitation on validity due to the Hawthorne effect,
observer bias and sampling bias. As different methods were used for the indicators of HH
compliance in different studies, such as hand hygiene opportunities, touches, it is difficult to
compare them and draw a conclusion on the effect size of each variables and hence to explore
the most determinant factor of HH compliance in ICU.
Another area of limitation is that some HCWs groups such as occupational therapists may not
have been underrepresented as nurses being the predominant sample in most of the studies of
this review.

29

Chapter 5 Conclusion
ICU has the highest prevalence rate of HAIs but the lowest HH compliance rate. It is
important to understand the root cause of the lowest HH compliance rate.
This review has reported a number of important underlying factors affecting the HH
compliance in ICU, in both the individual and institutional level, and suggested that the
amount of workload may be an important factor contributing to HH compliance as it was
reflected in both levels.
This review also highlighted the fact that probably no single approach for improving HH
compliance can be adequately successful and fit all HCWs. Most effective interventions
should be adopting a comprehensive approach for addressing both the individual factors and
institutional factors, targeting different problems and barriers, with continual reinforcement,
in order to achieve lasting changes in HH practices. A real change following guideline
dissemination cannot be achieved unless individual efforts and explicit institutional
administrative support are fostered.

30

References
1. Jarvis WR. Selected aspects of the socioeconomic impact of nosocomial infections:
morbidity, mortality, cost, and prevention. Infect Control Hosp Epidemiol. 1996
Aug;17(8):552-7.
2. Olaechea PM, Ulibarrena MA, Alvarez-Lerma F, Insausti J, Palomar M, De la Cal MA;
ENVIN-UCI Study Group. Factors related to hospital stay among patients with
nosocomial infection acquired in the intensive care unit. Infect Control Hosp Epidemiol.
2003 Mar;24(3):207-13.
3. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach.
Emerg Infect Dis. 2001 Mar-Apr;7(2):234-40.
4. World Health Organization. WHO guidelines on hand hygiene in health care. First global
patient safety challenge: clean care is safe care: WHO, 2009. Available from:
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf [Accessed 9th May
2012]
5. Astagneau P, Rioux C, Golliot F, Brucker G; INCISO Network Study Group. Morbidity
and mortality associated with surgical site infections: results from the 1997-1999 INCISO
surveillance. J Hosp Infect. 2001 Aug;48(4):267-74.
6. Garcia-Martin M, Lardelli-Claret P, Jimenez-Moleon JJ, Bueno-Cavanillas A,
Lunadel-Castillo JD, Galvez-Vargas R. Proportion of hospital deaths potentially
attributable

to

nosocomial

infection.

Infect

Control

Hosp

Epidemiol.

2001

Nov;22(11):708-14.
7. Freeman, J., Rosner, B.A. and McGowan, J.E. Adverse effects of nosocomial infection.
Journal of Infectious Diseases. 1979 Aug; 140(5);732-740.
8. Plowman R. The socio-economic burden of hospital acquired infection. Euro Surveill.
2000 Apr;5(4):49-50.

31

9. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Health-Care
Settings: CDC, 2011. Available from:
http://www.cdc.gov/handhygiene/Guidelines.html [Accessed 4th Feb 2012].
10. Bauer TM, Ofner E, Just HM, Just H, Daschner FD. An epidemiological study assessing
the relative importance of airborne and direct contact transmission of microorganisms in a
medical intensive care unit. J Hosp Infect. 1990 May;15(4):301-9.
11. Nystrom B. Impact of handwashing on mortality in intensive care: examination of the
evidence. Infect Control Hosp Epidemiol. 1994 Jul;15(7):435-6.
12. Haley RW, Culver DH, White JW, Morgan WM, Emori TG, Munn VP, Hooton TM. The
efficacy of infection surveillance and control programs in preventing nosocomial
infections in US hospitals. Am J Epidemiol. 1985 Feb;121(2):182-205.
13. Chen YC, Sheng WH, Wang JT, Chang SC, Lin HC, Tien KL, Hsu LY, Tsai KS.
Effectiveness

and

limitations

of

hand

hygiene

promotion

on

decreasing

healthcare-associated infections. PLoS One. 2011;6(11):e27163. Epub 2011 Nov 16.

14. Conly JM, Hill S, Ross J, Lertzman J, Louie TJ. Handwashing practices in an intensive
care unit: the effects of an educational program and its relationship to infection rates. Am
J Infect Control. 1989 Feb; 17(3):330339.
15. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp
Epidemiol. 2000 Jun;21(6):381-6.
16. Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, van Beeck EF.
Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
Infect Control Hosp Epidemiol. 2010 Mar;31(3):283-94.
17. Daschner FD, Frey P, Wolf G, et al. Nosocomial infections in intensive care wards: A
multicenter prospective study. Intensive Care Med 1982; 8:5-9.

32

18. Donowitz LG, Wenzel RP, Hoyt JW. High risk of hospital acquired infections in the ICU
patient. Crit Care Med 1982; 10:355- 357.
19. Potgieter PD, Linton DM, Oliver SO, Forder AA. Nosocomial infections in respiratory
intensive care, unit. Crit Care Med 1987; 15:495-498.
20. Donowitz LG. High risk of nosocomial infections in the pediatric critical care patient.
Crit Care Med 1986;14:26-28.
21. Graig GB, Connelly S. Effect of intensive care unit in nosocomial pneumonia on
duration of stay and mortality. Am J Infect Control 1984; 12:233-238.
22. MeLaws ML, Gold J, King K, et al. The prevalence of nosocomial and community
acquired infections in Australian hospitals. Med J Aust 1988; 149: 582-590.
23. Meers PD, Ayliffe GAJ, Emmerson AM, et al. Report on the national survey of
infection in hositals, 1980. J Hosp Infect 1981; 2 (Suppl): 13-17.
24. Haley RW, Culver DH, White JW, et al. The nationwide nosocomial infection rate. A
new need for vital statistics. Am J Epidemiol 1985; 21:159-167.
25. Strobe Statement. Strengthening the Reporting of Observational studies in Epidemiology:
Strobe checklist, 2007. Available from:
http://www.strobe-statement.org/index.php?id=available-checklists [Accessed 17th Apr
2012].
26. Harbarth S, Pittet D, Grady L, Goldmann DA. Compliance with hand hygiene practice in
pediatric intensive care. Pediatr Crit Care Med. 2001 Oct;2(4):311-4.
27. Nobile CG, Montuori P, Diaco E, Villari P. Healthcare personnel and hand
decontamination in intensive care units: knowledge, attitudes, and behaviour in Italy. J
Hosp Infect. 2002 Jul;51(3):226-32.

33

28. Pessoa-Silva CL, Posfay-Barbe K, Pfister R, Touveneau S, Perneger TV, Pittet D.

Attitudes and perceptions toward hand hygiene among healthcare workers caring for
critically ill neonates. Infect Control Hosp Epidemiol. 2005 Mar;26(3):305-11.
29. Cohen B, Saiman L, Cimiotti J, Larson E. Factors associated with hand hygiene practices
in two neonatal intensive care units. Pediatr Infect Dis J. 2003 Jun;22(6):494-9.
30. Sarit Sharma, Shruti Sharma, Sandeep Puri, Jagdeep Whig. Hand Hygiene Compliance
in the Intensive Care Units of a Tertiary Care Hospital. Indian J Community Med. 2011
Jul-Sep; 36(3): 217221.
31. De Wandel D, Maes L, Labeau S, Vereecken C, Blot S. Behavioral determinants of hand
hygiene compliance in intensive care units. Am J Crit Care. 2010 May;19(3):230-9.
32. Maury E, Moussa N, Lakermi C, Barbut F, Offenstadt G. Compliance of health care
workers to hand hygiene: awareness of being observed is important. Intensive Care Med.
2006 Dec;32(12):2088-9. Epub 2006 Oct 13.
33. Duggan JM, Hensley S, Khuder S, Papadimos TJ, Jacobs L. Inverse correlation between
level of professional education and rate of handwashing compliance in a teaching hospital.
Infect Control Hosp Epidemiol. 2008 Jun;29(6):534-8.
34. Kaplan LM, McGuckin M. Increasing handwashing compliance with more accessible
sinks. Infect Control. 1986 Aug;7(8):408-10.
35. Noritomi DT, Chierego M, Byl B, Menestrina N, Carollo T, Struelens M, Vincent JL. Is
compliance with hand disinfection in the intensive care unit related to work experience?
Infect Control Hosp Epidemiol. 2007 Feb;28(3):362-4.
36. Rumbaua RO, Yu CT, Pena AC. A Point-in-Time Observational Study of Hand Washing
Practices of Healthcare Workers in the Intensive Care Unit of St. Lukes Medical Center.
PSMID. 2001 Feb;30(1): 1-5.

34

37. Mathai AS, George SE, Abraham J. Efficacy of a multimodal intervention strategy in
improving hand hygiene compliance in a tertiary level intensive care unit. Indian J Crit
Care Med. 2011 Jan;15(1):6-15.
38. Van de Mortel T, Bourke R, McLoughlin J, Nonu M, Reis M. Gender influences
handwashing rates in the critical care unit. Am J Infect Control. 2001 Dec;29(6):395-9.
39. Karabey S, Ay P, Derbentli S, Nakipoglu Y, Esen F. Handwashing frequencies in an
intensive care unit. J Hosp Infect. 2002 Jan;50(1):36-41.
40. Pittet D, Mourouga P, Perneger TV. Compliance with hand washing in a teaching
hospital. Infection Control Program. Ann Intern Med. 1999; 130:126-30.
41. Kampf G, Ostermeyer C. Influence of applied volume on efficacy of 3-minute surgical
reference

disinfection

method

prEN

12791.

Appl

EnvirMicrobiology.

2004

Mar;49(1):345-349.
42. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel.
Am J Infect Control. 1982 Aug;10(70):70667069.
43. Suchitra JB, Lakshmi Devi N. Impact of education on knowledge, attitudes and practices
among various categories of health care workers on nosocomial infections. Indian J Med
Microbio. 2007 Mar; 25:181187.
44. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S. Effectiveness
of a hospital-wide programme to improve compliance with hand hygiene. Lancet
2000;356:130712.
45. Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with
hand hygiene in intensive care units. Arch Intern Med. 2002;162(9):10371043.
46. Pittet D et al. Hand hygiene among physicians: performance, beliefs, and perceptions.
Ann Intern Med. 2004;141:18.

35

47. Traore O et al. Liquid versus gel handrub formulation: a prospective intervention study.
Criti Care. 2007;11:R52.
48. Gould D. Nurses hand decontamination practice: results of a local study. J Hosp Infect.
1994;28:1530.
49. Pittet D et al. Hand-cleansing during postanesthesia care. Anes. 2003;99:530535.
50. Arenas MD et al. A multicentric survey of the practice of hand hygiene in haemodialysis
units:

factors

affecting

compliance.

Nephrology,

Dialysis,

Transplantation.

2005;20:11641171.
51. OBoyle CA, Henly SJ, Larson E. Understanding adherence to hand hygiene
recommendations: the theory of planned behavior. AmJ Infect Control. 2001;29:352360.
52. Lipsett PA, Swoboda SM. Handwashing compliance depends on professional status.
Surg Infect. 2001;2:241245.
53. Qushmaq IA, Heels-Ansdell D, Cook DJ, Loeb MB, Meade MO. Hand hygiene in the
intensive care unit: prospective observations of clinical practice. Pol Arch Med Wewn.
2008 Oct;118(10):543-7.
54. Larson E, Killien M. Factors influencing handwashing behavior of patient care personnel.
Am J Infect Control. 1982;10:9399.
55. Conly JM et al. Handwashing practices in an intensive care unit: the effects of an
educational program and its relationship to infection rates. AmJ Infect Control.
1989;17:330339.
56. Dubbert PM et al. Increasing ICU staff handwashing: effects of education and group
feedback. Infect Control Hosp Epidemio. 1990;11:191193.
57. Boyce JM. It is time for action: improving hand hygiene in hospitals. Ann Intern Med.
1999;130:153155.

36

58. Larson E, Kretzer EK. Compliance with handwashing and barrier precautions. J Hosp
Infect. 1995;30(Suppl.):88106.
59. Sproat LJ, Inglis TJ. A multicentre survey of hand hygiene practice in intensive care
units. J Hosp Infect. 1994;26:137148.
60. Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices.
Am J Infect Control. 1998;26:245253.
61. Dubbert PM, Dolce J, Richter W, Miller M, Chapman SW. Increasing ICU staff hand
washing:

effects

of

education

and

group

feedback.

Infect

Control

Hosp

Epidemiol.1990;11 :191 193

62. Quiros D, Lin S, Larson EL. Attitudes toward practice guidelines among intensive care
unit

personnel:

cross-sectional

anonymous

survey.

Heart

Lung.

2007

Jul-Aug;36(4):287-97.
63. Pittet D et al. Hand hygiene among physicians: performance, beliefs, and perceptions.
Ann Intern Med. 2004;141:18.
64. Muto CA, Sistrom MG, Farr BM. Hand hygiene rates unaffected by installation of
dispensers of a rapidly acting hand antiseptic. Am J Infect Control 2000; 28: 273-6.
65. Voss A, Widmer AF. No time for handwashing? Handwashing versus alcoholic rub: can
we afford 100% compliance? Infect Control Hosp Epidemiol. 1997;18:205-8.
66. Gnter Kampf, Harald Lffler, Petra Gastmeier. Hand Hygiene for the Prevention of
Nosocomial Infections. Dtsch Arztebl Int. 2009 October; 106(40): 649655.
67. Pittet D. Compliance with hand disinfection and its impact on hospital-acquired
infections. J Hosp Infect 2001;48(suppl A):S40S46.
68. Kampf G, Lffler H. Prevention of irritant contact dermatitis among health care workers
by using evidence-based hand hygiene practices: a review. Ind Health. 2007
Oct;45(5):645-52.

37

69. Khatib M, Jamaleddine G, Abdallah A, Ibrahim Y. Hand washing and use of gloves while
managing patients receiving mechanical ventilation in the ICU. Chest. 1999
Jul;116(1):172-5.
70. Bischoff WE, Reynolds TM, Sessler CN, Edmond MB, Wenzel RP. Handwashing
compliance by health care workers: The impact of introducing an accessible,
alcohol-based hand antiseptic. Arch Intern Med. 2000 Apr 10;160(7):1017-21.
71. Dunn-Navarra AM, Cohen B, Stone PW, Pogorzelska M, Jordan S, Larson E.
Relationship Between Systems-Level Factors and Hand Hygiene Adherence. J Nurs Care
Qual. 2010 May.
72. Kretzer EK, Larson EL. Behavioral interventions to improve infection control practices.
Am J Infect Control 1998;26:24553.
73. Larson EL, Early E, Cloonan P, Sugrue S, Parides M. An organizational climate
intervention associated with increased handwashing and decreased nosocomial infections.
Behav Med 2000;26:1422.
74. Ward MM, Doebbeling BN, Vaughn TE, et al. Effectiveness of a nationally implemented
smoking cessation guideline on provider and patient practices. Prev Med 2003;36:26571.
75. Vaughn TE, Ward MM, Doebbeling BN, Uden-Holman T, Clarke WT, Woolson RF.
Organizational and provider characteristics fostering smoking cessation practice guideline
adherence: an empirical look. J Ambul Care Manage 2002;25:1731.
76. Lam BC, Lee J, Lau YL. Hand hygiene practices in a neonatal intensive care unit: a
multimodal intervention and impact on nosocomial infection. Pediatrics. 2004
Nov;114(5):e565-71.
77. Tai JW, Mok ES, Ching PT, Seto WH, Pittet D. Nurses and physicians' perceptions of the
importance and impact of healthcare-associated infections and hand hygiene: a

38

multi-center exploratory study in Hong Kong. Infection. 2009 Aug;37(4):320-33. Epub

2009 Jul 27.

Table 2: Summary of the reported impact of HAIs

Costs and consequences of hospital acquired infection
No HAI HAI

HAI effect

Mean costs ( )

1628

4782 3154

Mean stay (days)

22

14

Deaths (%)

13

11

Mean admission to work (days)

23

29

39