Factors affecting hand hygiene adherence among critical care healthcare workers: a systematic review

Abstract Background Hand hygiene (HH) is the most effective and cost-efficient measure to prevent healthcare-associated infections. However, compliance remains suboptimal, particularly in intensive care units (ICUs) and emergency departments (EDs), where organizational and operational barriers hinder adherence. We aimed to analyse the main factors affecting hand hygiene compliance among critical settings healthcare workers (HCW). Methods We conducted a systematic review according to the PRISMA statement, searching PubMed, SCOPUS, Web Of Science for studies evaluating barriers and obstacles encountered by ED and ICU healthcare workers in pursuing hand hygiene adherence. Main findings were described through a narrative synthesis. PROSPERO registration CRD420251020343. Results Twenty-eight studies published between 1994 and 2024 were included (nineteen quantitative and five qualitative, two mixed), eleven were from European Countries, with a study population of 25 to 300 HCWs. Methods used to assess barriers and other factors associated with poor adherence to HH included surveys, interviews, direct and retrospective observation. The main barriers to reduced hand hygiene compliance included structural and organizational factors (scarcity of available materials and time, poor visibility of sinks, high work rhythms, overcrowding - especially in medical, cardiac and pediatric ICUs) and personal factors (skin irritation, use of gloves). Coworkers’ attitudes were also associated to poor HH. Conclusions Health care personnel in ICUs and EDs, even when properly trained, face structural and organizational barriers that prevent proper adherence to hand hygiene practices. In addition, personal beliefs and work group attitude are very influential in determining compliance with HH standards. Continuous staff training is critical to maintaining proper compliance, but it is also important to provide the right support from the hospital facility in terms of logistics and architecture. Key messages • Organizational barriers like lack of time, resources, and overcrowding, along with personal factors, hinder hand hygiene compliance in ICUs and EDs. • Proper training and facility support are crucial to improve hand hygiene adherence, alongside addressing structural, organizational, and personal barriers.