Helping hands: a cluster randomised trial to evaluate the effectiveness of two different strategies for promoting hand hygiene in hospital nurses

The Effectiveness of Interventions in Improving Hand Hygiene Compliance: A Meta-Analysis and Logic Model

Background

Despite the availability of various guidelines, rules, and strategies, hand hygiene adherence rates among healthcare workers are reported significantly lower than expected. The aim of this meta-analysis is to determine the most effective interventions to improve hand hygiene and to develop a logic model based on the characteristics of the most effective interventions.

Methods

A literature search was conducted on PubMed, ProQuest, Web of Knowledge, Scopus, Cochrane Library, and ScienceDirect databases up to December 21, 2019, with no time limit. Randomized clinical trials which had designed interventions to improve hand hygiene were reviewed. Data were extracted independently by two authors. All statistical analyses were performed using Comprehensive Meta-Analysis (CMA) software (version 2.0). A random-effects model was used to estimate odds ratios.

Results

Although 14 studies were initially reviewed, only 12 studies entered the meta-analysis, since they had identified percentage rates of hand hygiene compliance. The most effective intervention (odds ratio 18.4, 95% CI (13.6–24.8)) was a multilevel strategy that influenced the determinants of hand hygiene behavior at individual, interpersonal, and organizational levels. Following this, a theory-driven logic model was mapped out to promote hand hygiene, based on situational analysis.

Conclusion

This study suggests that designing integrated interventions based on a multilevel socioecological approach has the greatest potential to improve hand hygiene compliance in healthcare workers. The logical model proposed in this study can thus provide a useful guide for designing and conducting future experimental research.

Infection control link nurse programs in Dutch acute care hospitals; a mixed-methods study

Background

Infection control link nurse programs show considerable variation. We report how Dutch link nurse programs are organized, how they progress, and how contextual factors may play a role in the execution of these programs.

Methods

This mixed-methods study combined a survey and semi-structured interviews with infection control practitioners, based on items of the Template for Intervention Description and Replication (TIDieR) checklist.

Results

The Netherlands has 74 hospitals; 72 infection control practitioners from 72 different hospitals participated in the survey. Four of these infection control practitioners participated in interviews. A link nurse program was present in 67% of the hospitals; responsibility for 76% of these programs lied solely with the infection prevention and control team. The core component of most programs (90%) was education. Programs that included education on infection prevention topics and training in implementation skills were perceived as more effective than programs without such education or programs where education included only infection prevention topics.

The interviews illustrated that these programs were initiated by the infection prevention team with the intention to collaborate with other departments to improve practice. Content for these programs was created at the time of their implementation. Infection control practitioners varied in their ability to express program goals and to engage experts and key stakeholders.

Conclusions

Infection control link nurse programs vary in content and in set up. Programs with a clear educational content are viewed as more successful by the infection control practitioners that implement these programs.

Hand hygiene-related clinical trials reported since 2010: a systematic review

Considerable emphasis is currently placed on reducing healthcare-associated infection through improving hand hygiene compliance among healthcare professionals. There is also increasing discussion in the lay media of perceived poor hand hygiene compliance among healthcare staff. Our aim was to report the outcomes of a systematic search for peer-reviewed, published studies - especially clinical trials - that focused on hand hygiene compliance among healthcare professionals. Literature published between December 2009, after publication of the World Health Organization (WHO) hand hygiene guidelines, and February 2014, which was indexed in PubMed and CINAHL on the topic of hand hygiene compliance, was searched. Following examination of relevance and methodology of the 57 publications initially retrieved, 16 clinical trials were finally included in the review. The majority of studies were conducted in the USA and Europe. The intensive care unit emerged as the predominant focus of studies followed by facilities for care of the elderly. The category of healthcare worker most often the focus of the research was the nurse, followed by the healthcare assistant and the doctor. The unit of analysis reported for hand hygiene compliance was 'hand hygiene opportunity'; four studies adopted the 'my five moments for hand hygiene' framework, as set out in the WHO guidelines, whereas other papers focused on unique multimodal strategies of varying design. We concluded that adopting a multimodal approach to hand hygiene improvement intervention strategies, whether guided by the WHO framework or by another tested multimodal framework, results in moderate improvements in hand hygiene compliance.

The need to balance merits and limitations from different disciplines when considering the stepped wedge cluster randomized trial design

Background

Various papers have addressed pros and cons of the stepped wedge cluster randomized trial design (SWD). However, some issues have not or only limitedly been addressed. Our aim was to provide a comprehensive overview of all merits and limitations of the SWD to assist researchers, reviewers and medical ethics committees when deciding on the appropriateness of the SWD for a particular study.

Methods

We performed an initial search to identify articles with a methodological focus on the SWD, and categorized and discussed all reported advantages and disadvantages of the SWD. Additional aspects were identified during multidisciplinary meetings in which ethicists, biostatisticians, clinical epidemiologists and health economists participated. All aspects of the SWD were compared to the parallel group cluster randomized design. We categorized the merits and limitations of the SWD to distinct phases in the design and conduct of such studies, highlighting that their impact may vary depending on the context of the study or that benefits may be offset by drawbacks across study phases. Furthermore, a real-life illustration is provided.

Results

New aspects are identified within all disciplines. Examples of newly identified aspects of an SWD are: the possibility to measure a treatment effect in each cluster to examine the (in)consistency in effects across clusters, the detrimental effect of lower than expected inclusion rates, deviation from the ordinary informed consent process and the question whether studies using the SWD are likely to have sufficient social value. Discussions are provided on e.g. clinical equipoise, social value, health economical decision making, number of study arms, and interim analyses.

Conclusions

Deciding on the use of the SWD involves aspects and considerations from different disciplines not all of which have been discussed before. Pros and cons of this design should be balanced in comparison to other feasible design options as to choose the optimal design for a particular intervention study.

Uniform presentation of process evaluation results facilitates the evaluation of complex interventions: development of a graph

RATIONALE, AIMS AND OBJECTIVES

Process evaluation is a highly essential element for the increasing number of studies regarding multi-component interventions. Yet, researchers are challenged to collect and present appropriate process outcomes in such way that it is easy and valuable to be used by other researchers and policy makers in interpreting and comparing intervention effects because of the absence of standards for conducting and publishing process evaluation. This article describes the development of a method to concisely summarize the results of process evaluations of complex multi-component interventions.

METHODS

Development of a graph with the aim to facilitate the reporting of process evaluation's results, based on a narrative review of the literature for process measures used in complex interventions for elderly people.

RESULTS

Seventeen articles of process evaluations alongside effect studies of complex interventions were reviewed. From these articles, it was found that process evaluations should address whether the intervention (1) was implemented successfully; (2) was evaluated properly; and (3) can be continued in the future. A flow chart based on the essential components of an adequate process evaluation was developed. A simplified but highly informative figure reporting a summary of the results of the process evaluation is proposed and its use is explained by administering the figure to two studies including a process and effect evaluation of a complex intervention.

CONCLUSION

A graphical approach - which includes the core results of process evaluation and can be used directly in reporting effectiveness studies - will help researchers and policy makers to interpret and compare effects of complex multi-component interventions.

Implementation of a children's hospital-wide central venous catheter insertion and maintenance bundle

BACKGROUND

Central venous catheter-associated bloodstream infections in children are an increasingly recognized serious safety problem worldwide, but are often preventable. Central venous catheter bundles have proved effective to prevent such infections. Successful implementation requires changes in the hospital system as well as in healthcare professionals' behaviour. The aim of the study is to evaluate process and outcome of implementation of a state-of-the-art central venous catheter insertion and maintenance bundle in a large university children's hospital.

METHODS/DESIGN

An interrupted time series design will be used; the study will encompass all children who need a central venous catheter. New state-of-the-art central venous catheter bundles will be developed. The Pronovost-model will guide the implementation process. We developed a tailored multifaceted implementation strategy consisting of reminders, feedback, management support, local opinion leaders, and education. Primary outcome measure is the number of catheter-associated infections per 1000 line-days. The process outcome is degree of adherence to use of these central venous catheter bundles is the secondary outcome. A cost-effectiveness analysis is part of the study. Outcomes will be monitored during three periods: baseline, pre-intervention, and post-intervention for over 48 months.

DISCUSSION

This model-based implementation strategy will reveal the challenges of implementing a hospital-wide safety program. This work will add to the body of knowledge in the field of implementation. We postulate that healthcare workers' willingness to shift from providing habitual care to state-of-the-art care may reflect the need for consistent care improvement. Trial registration: Dutch trials registry, trial # 3635.

TRIAL REGISTRATION

Dutch trials registry (http://www.trialregister.nl), trial # 3635.

Automated measures of hand hygiene compliance among healthcare workers using ultrasound: validation and a randomized controlled trial

OBJECTIVE

The primary objective of this study was to validate a novel method of assessing hand hygiene compliance using ultrasound transmitters in patient zones and staff tagged with receivers. The secondary objective was to assess the impact of audio reminders and quantified individual feedback.

DESIGN

An observational comparison against manual assessment followed by assessment using an open-label randomized control method.

SETTING

Patient zones were established in 3 wards of 2 large teaching hospitals, including 88 general and 18 intensive care unit ward beds.

PARTICIPANTS

Consented regular ward nursing, medical, and allied health staff.

METHODS

Concordance between 40 hours of manual observation using trained hand hygiene auditors and automated measures of opportunities and compliance. Subsequent measured interventions were reminder beeps and written individual feedback.

RESULTS

When compared with manual observations, ultrasound monitoring underestimated percentage compliances by a nonsignificant mean (95% confidence interval [CI]) difference of 5.2% (-20.1% to 9.8%; [Formula: see text]). After the intervention, adjusted multivariate analysis showed mean (95% CI) overall compliance in the intervention arm was 6.8% (2.5%-11.1%; [Formula: see text]) higher than in the control arm. Results stratified by compliance at entry and exit showed that the effect of intervention was stronger for compliance at exit than at entry.

CONCLUSIONS

Our automated measure of hand hygiene compliance is valid when compared with the traditional gold standard of manual observations. As an interventional tool, ultrasound-based automated hand hygiene audits have significant benefit that can be built upon with enhancements and find increasing acceptance with time.

Explaining the effects of two different strategies for promoting hand hygiene in hospital nurses: a process evaluation alongside a cluster randomised controlled trial

Background

There is only limited understanding of why hand hygiene improvement strategies are successful or fail. It is therefore important to look inside the ‘black box’ of such strategies, to ascertain which components of a strategy work well or less well. This study examined which components of two hand hygiene improvement strategies were associated with increased nurses’ hand hygiene compliance.

Methods

A process evaluation of a cluster randomised controlled trial was conducted in which part of the nursing wards of three hospitals in the Netherlands received a state-of-the-art strategy, including education, reminders, feedback, and optimising materials and facilities; another part received a team and leaders-directed strategy that included all elements of the state-of-the-art strategy, supplemented with activities aimed at the social and enhancing leadership. This process evaluation used four sets of measures: effects on nurses’ hand hygiene compliance, adherence to the improvement strategies, contextual factors, and nurses’ experiences with strategy components. Analyses of variance and multiple regression analyses were used to explore changes in nurses’ hand hygiene compliance and thereby better understand trial effects.

Results

Both strategies were performed with good adherence to protocol. Two contextual factors were associated with changes in hand hygiene compliance: a hospital effect in long term (p < 0.05), and high hand hygiene baseline scores were associated with smaller effects (p < 0.01). In short term, changes in nurses’ hand hygiene compliance were positively correlated with experienced feedback about their hand hygiene performance (p < 0.05). In the long run, several items of the components ‘social influence’ (i.e., addressing each other on undesirable hand hygiene behaviour p < 0.01), and ‘leadership’ (i.e., ward manager holds team members accountable for hand hygiene performance p < 0.01) correlated positively with changes in nurses’ hand hygiene compliance.

Conclusion

This study illustrates the use of a process evaluation to uncover mechanisms underlying change in hand hygiene improvement strategies. Our study results demonstrate the added value of specific aspects of social influence and leadership in hand hygiene improvement strategies, thus offering an interpretation of the trial effects.

Trial registration

The study is registered in ClinicalTrials.gov, dossier number: NCT00548015.

Cost-effectiveness of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial

BACKGROUND

Many strategies have been designed and evaluated to address poor hand hygiene compliance. Unfortunately, well-designed economic evaluations of hand hygiene improvement strategies are lacking.

OBJECTIVE

To compare the cost-effectiveness of two successful implementation strategies for improving nurses' hand hygiene compliance and reducing hospital acquired infections (HAI's).

DESIGN AND SETTING

A cost-effectiveness analysis alongside a cluster randomised controlled trial was conducted in 67 nursing wards of three hospitals in the Netherlands. The evaluation used a hospital perspective.

PARTICIPANTS

All affiliated nurses of the nursing wards. Wards were randomly assigned to either the control group (n=30) or the experimental group (n=37).

METHODS

The control group received a state-of-the-art strategy including education, reminders feedback and optimising materials and facilities. The experimental group received a team and leaders-directed strategy which included all elements of the state-of-the-art strategy supplemented with interventions aimed at the social context of teams and enhancing leadership. The most efficient implementation strategy was determined by the incremental cost-effectiveness ratio per extra percentage of hand hygiene compliance gained and the incremental cost-effectiveness ratio per additional percentage reduction in the HAI rate. Bootstrap methods were used to determine confidence intervals for these incremental cost-effectiveness ratio's. Two scenarios of 15 and 30% were used to express the association between increased hand hygiene compliance and the reduction in HAIs.

RESULTS

The team and leaders-directed strategy was significantly more effective in improving hand hygiene compliance. The mean difference effect was 8.91% (95% CI, 0.75-17.06). This extra increase was achieved at an average cost of €5497 per ward. The incremental cost per extra percentage of hand hygiene gained on ward level was €622. The incremental cost per additional percentage reduction in the HAI rate on ward level was €2074 (30% scenario) and €4125 (15% scenario). Within the 30% scenario, there is a probability of 90% that the team and leaders-directed strategy is cost-effective and within the 15% scenario, there is a probability of 70% that the team and leaders-directed strategy is cost-effective.

CONCLUSIONS

Optimising hand hygiene compliance through a team and leaders-directed strategy is cost-effective as compared to a state-of-the-art strategy.

The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program

BACKGROUND

Although hand hygiene (HH) compliance has been an important issue for years, the compliance rate is still a problem in health care today.

METHODS

This was an observational, prospective, before-and-after study. We measured HH knowledge and HH compliance before (baseline), directly after (poststrategy), and 6 months after the performance of HH team strategies (follow-up). The study was composed of employed nurses and physicians working in the department of internal medicine of a university hospital. We performed a multifaceted improvement program including HH education, feedback, reminders, social influence activities including the use of role models, and improvement of HH facilities.

RESULTS

Ninety-two nurses and physicians were included. Compared with baseline, there was a significant improvement in the overall mean HH knowledge score at poststrategy (from 7.4 to 8.4) and follow-up (from 7.4 to 8.3). The overall HH compliance was 27% at baseline, 83% at poststrategy, and 75% at follow-up. At baseline, the compliance rate was 17% in nurses and 43% in physicians and significantly improved to 63% in nurses and 91% in physicians at follow-up.

CONCLUSION

Our multifaceted HH improvement program resulted in a sustained improvement of HH knowledge and compliance in nurses as well as physicians.

A systematic review of hand hygiene improvement strategies: a behavioural approach

BACKGROUND

Many strategies have been designed and evaluated to address the problem of low hand hygiene (HH) compliance. Which of these strategies are most effective and how they work is still unclear. Here we describe frequently used improvement strategies and related determinants of behaviour change that prompt good HH behaviour to provide a better overview of the choice and content of such strategies.

METHODS

Systematic searches of experimental and quasi-experimental research on HH improvement strategies were conducted in Medline, Embase, CINAHL, and Cochrane databases from January 2000 to November 2009. First, we extracted the study characteristics using the EPOC Data Collection Checklist, including study objectives, setting, study design, target population, outcome measures, description of the intervention, analysis, and results. Second, we used the Taxonomy of Behavioural Change Techniques to identify targeted determinants.

RESULTS

We reviewed 41 studies. The most frequently addressed determinants were knowledge, awareness, action control, and facilitation of behaviour. Fewer studies addressed social influence, attitude, self-efficacy, and intention. Thirteen studies used a controlled design to measure the effects of HH improvement strategies on HH behaviour. The effectiveness of the strategies varied substantially, but most controlled studies showed positive results. The median effect size of these strategies increased from 17.6 (relative difference) addressing one determinant to 49.5 for the studies that addressed five determinants.

CONCLUSIONS

By focussing on determinants of behaviour change, we found hidden and valuable components in HH improvement strategies. Addressing only determinants such as knowledge, awareness, action control, and facilitation is not enough to change HH behaviour. Addressing combinations of different determinants showed better results. This indicates that we should be more creative in the application of alternative improvement activities addressing determinants such as social influence, attitude, self-efficacy, or intention.

Impact of a team and leaders-directed strategy to improve nurses' adherence to hand hygiene guidelines: a cluster randomised trial

BACKGROUND

Improving hand hygiene compliance is still a major challenge for most hospitals. Innovative approaches are needed.

OBJECTIVE

We tested whether an innovative, theory based, team and leaders-directed strategy would be more effective in increasing hand hygiene compliance rates in nurses than a literature based state-of-the-art strategy.

DESIGN AND SETTING

A cluster randomised controlled trial called HELPING HANDS was conducted in 67 nursing wards of three hospitals in the Netherlands.

PARTICIPANTS

All affiliated nurses of the nursing wards. Wards were randomly assigned to either the team and leaders-directed strategy (30 wards) or the state-of-the-art strategy (37 wards).

METHODS

The control arm received a state-of-the-art strategy including education, reminders, feedback and targeting adequate products and facilities. The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership, comprising specific team and leaders-directed activities. Strategies were delivered during a period of six months. We monitored nurses' HH compliance during routine patient care before and directly after strategy delivery, as well as six months later. Secondary outcomes were compliance with each type of hand hygiene opportunity, the presence of jewellery and whether the nurses wore long-sleeved clothes. The effects were evaluated on an intention-to-treat basis by comparing the post-strategy hand hygiene compliance rates with the baseline rates. Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques.

RESULTS

During the study, we observed 10,785 opportunities for appropriate hand hygiene in 2733 nurses. The compliance in the state-of-the-art group increased from 23% to 42% in the short term and to 46% in the long run. The hand hygiene compliance in the team and leaders-directed group improved from 20% to 53% in the short term and remained 53% in the long run. The difference between both strategies showed an Odds Ratio of 1.64 (95% CI 1.33-2.02) in favour of the team and leaders-directed strategy.

CONCLUSIONS

Our results support the added value of social influence and enhanced leadership in hand hygiene improvement strategies. The methodology of the latter also seems promising for improving team performance with other patient safety issues.

TRIAL REGISTRATION

ClinicalTrials.gov [NCT00548015].

Taking power, politics, and policy problems seriously: the limits of knowledge translation for urban health research

Knowledge translation (KT) is a growing movement in clinical and health services research, aimed to help make research more relevant and to move research into practice and policy. This paper examines the conventional model of policy change presented in KT and assesses its applicability for increasing the impact of urban health research on urban health policy. In general, KT conceptualizes research utilization in terms of the technical implementation of scientific findings, on the part of individual decision-makers who can be "targeted" for a KT intervention, in a context that is absent of political interests. However, complex urban health problems and interventions infrequently resemble this single decision, single decision-maker model posited by KT. In order to clarify the conditions under which urban health research is more likely or not to have an influence on public policy development, we propose to supplement the conventional model with three concepts drawn from the social science: policy stages, policy networks, and a discourse analysis approach for theorizing power in policy-making.