Sustained improvement in hand hygiene at a children's hospital

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

BACKGROUND

Direct observation of hand hygiene compliance is the "gold standard" despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance amongst physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

AIM

This review aimed to explore differences in compliance between physicians and nurses further, and to analyse if compliance estimates differed when observations were covert rather than overt.

METHODS

A systematic search of databases PubMed, EMBASE, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

FINDINGS

The weighted pooled compliance rate for nurses was 52% (95% CI 47% to 57%) and for doctors was 45% (95% CI 40% to 49%). Heterogeneity was considerable (I²=99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%, 95% CI for the difference 0.8% to 13.5%, p=0.027) and covert (difference of 7%, 95% CI 3% to 11%, p=0.0002) observation. Considerable heterogeneity was found in all analyses.

CONCLUSION

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

Sustaining compliance with hand hygiene when resources are low: A quality improvement report

Background

Sustainability of hand hygiene is challenging in low resource settings. Adding ownership and goal setting to the WHO-5 multimodal intervention may help sustain high compliance.

Aim

To increase and sustain compliance of nursing and medical staff with hand hygiene in a tertiary referral center with limited resources.

Methods

A quality improvement initiative was conducted over two years (2016–2018). After determining baseline compliance rates, the WHO-5 multimodal intervention was implemented with staff education and training, system change, hospital reminders, direct observation and feedback, and hospital safety climate. Additionally, the medical staff was responsible for continuous surveillance of compliance (ownership) until rates above 90% were achieved and sustained (goal setting).

Results

Of 2987 observations collected between August 2016 and April 2018, 1630 (54.5%) were before, and 1357 (45.5%) were after patient encounters. The average overall compliance with hand hygiene was sustained at 94% for nursing and medical staff. Two instances of drops below 90% were associated with incidence of nosocomial Rotavirus infections. There were no similar infections during intervention periods with compliance rates above the set goal. Analysis using p-charts revealed significant improvement in compliance rates from baseline (χ² (1) = 7.94, p = 0.005).

Conclusion

Adding ownership and goal setting to the WHO-5 multimodal intervention may help achieve, and sustain high rates of compliance with hand hygiene. Involving health care workers in quality improvement initiatives is feasible, durable, reliable, and cheap, especially in settings with limited financial resources.

Interventions to improve hand hygiene compliance in patient care

BACKGROUND

Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.

OBJECTIVES

To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.

SEARCH METHODS

We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.

SELECTION CRITERIA

We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.

MAIN RESULTS

This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.

AUTHORS' CONCLUSIONS

With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

Acute care nurses' responses and recommendations for improvement of hand hygiene compliance: A cross-sectional factorial survey research study

BACKGROUND

Hand hygiene is promoted as an effective practice to counter health care-acquired infections; however, compliance is less than optimal. Nurses have many patient contact opportunities and therefore are frequent participants in intervention research. The optimal combination of efficient and effective intervention components has not been conclusively identified.

METHODS

A factorial survey research design offers an efficient method to assess multiple factors simultaneously by combining elements into vignettes. This article describes a process, grounded in the framework of Bandura's social cognitive theory, that explored environmental and individual factors that potentially influence nurses' hand hygiene behavior in acute care settings. Survey respondents consisted of nurses employed in patient care; respondents also could address an open response item.

RESULTS

A total of 466 participants scored a total of 3,685 vignettes. Statistically significant parameters included goal, supervisor priority, electronic monitoring, and rewards. The most frequently mentioned open response item was the need to keep hand hygiene product dispensers refilled. Participants also suggested that culture and intrinsic motivation influenced hand hygiene behavior.

CONCLUSIONS

Researchers might consider assessing promising factors, especially use of goal setting, as an intervention rather than as components of an intervention. Further research is indicated to better understand how nurses define and view hand hygiene culture.

Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis

OBJECTIVE

To evaluate the relative efficacy of the World Health Organization 2005 campaign (WHO-5) and other interventions to promote hand hygiene among healthcare workers in hospital settings and to summarize associated information on use of resources.

DESIGN

Systematic review and network meta-analysis.

DATA SOURCES

Medline, Embase, CINAHL, NHS Economic Evaluation Database, NHS Centre for Reviews and Dissemination, Cochrane Library, and the EPOC register (December 2009 to February 2014); studies selected by the same search terms in previous systematic reviews (1980-2009).

REVIEW METHODS

Included studies were randomised controlled trials, non-randomised trials, controlled before-after trials, and interrupted time series studies implementing an intervention to improve compliance with hand hygiene among healthcare workers in hospital settings and measuring compliance or appropriate proxies that met predefined quality inclusion criteria. When studies had not used appropriate analytical methods, primary data were re-analysed. Random effects and network meta-analyses were performed on studies reporting directly observed compliance with hand hygiene when they were considered sufficiently homogeneous with regard to interventions and participants. Information on resources required for interventions was extracted and graded into three levels.

RESULTS

Of 3639 studies retrieved, 41 met the inclusion criteria (six randomised controlled trials, 32 interrupted time series, one non-randomised trial, and two controlled before-after studies). Meta-analysis of two randomised controlled trials showed the addition of goal setting to WHO-5 was associated with improved compliance (pooled odds ratio 1.35, 95% confidence interval 1.04 to 1.76; I(2)=81%). Of 22 pairwise comparisons from interrupted time series, 18 showed stepwise increases in compliance with hand hygiene, and all but four showed a trend for increasing compliance after the intervention. Network meta-analysis indicated considerable uncertainty in the relative effectiveness of interventions, but nonetheless provided evidence that WHO-5 is effective and that compliance can be further improved by adding interventions including goal setting, reward incentives, and accountability. Nineteen studies reported clinical outcomes; data from these were consistent with clinically important reductions in rates of infection resulting from improved hand hygiene for some but not all important hospital pathogens. Reported costs of interventions ranged from $225 to $4669 (£146-£3035; €204-€4229) per 1000 bed days.

CONCLUSION

Promotion of hand hygiene with WHO-5 is effective at increasing compliance in healthcare workers. Addition of goal setting, reward incentives, and accountability strategies can lead to further improvements. Reporting of resources required for such interventions remains inadequate.