7/21/2019 Bmj.h3728.Full http://slidepdf.com/reader/full/bmjh3728full 1/14 thebmjBMJ 2015; 351:h3728 doi: 10.1136/bmj.h3728 RESEARCH 1 OPEN ACCESS Mahidol-Oxord Tropical Medicine Research Unit, Faculty o Tropical Medicine, Mahidol University, Bangkok, Thailand School o Public Health, Queensland University o Technology, Brisbane, Australia Department o Tropical Hygiene, Faculty o Tropical Medicine, Mahidol University, Bangkok, Thailand Centre or Tropical Medicine and Global Health, Nuffield Department o Clinical Medicine, University o Oxord, Oxord, UK Inection Control Program, University o Geneva Hospitals and Faculty o Medicine, Geneva , Switzerland Departments o Inectious Diseases and Microbiology, Royal Prince Alred Hospital, Sydney , Australia Institute o Health and Biomedical Innovation, Queensland University o Technology, Brisbane, Australia Correspondence to: N Luangasanatip, Mahidol-Oxord Tropical Medicine Research Unit, / th Anniversary Chalermprakiat Building; rd Floor, Rajvithi Road, Bangkok Thailand [email protected]Additional material is published online only. To view please visit the journal online (ht tp://dx.doi. org/./bmj.h) Cite this as: BMJ ;:h doi: ./bmj.h Accepted: June Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis Nantasit Luangasanatip, , Maliwan Hongsuwan, Direk Limmathurotsakul, , Yoel Lubell, , Andie S Lee, , Stephan Harbarth, Nicholas P J Day, , Nicholas Graves, , Ben S Cooper , ABSTRACT OBJECTIVE To evaluate the relative efficacy o the World Health Organization campaign (WHO-) and other interventions to promote hand hygiene among healthcare workers in hospital settings and to summarize associated inormation on use o resources. DESIGN Systematic review and network meta-analysis. DATA SOURCES Medline, Embase, CINAHL, NHS Economic Evaluation Database, NHS Centre or Reviews and Dissemination, Cochrane Library, and the EPOC register (December to February ); studies selected by the same search terms in previous systematic reviews (-). REVIEW METHODS Included studies were randomised controlled trials, non-randomised trials, controlled beore-afer 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 perormed on studies reporting directly observed compliance with hand hygiene when they were considered sufficiently homogeneous with regard to interventions and participants. Inormation on resources required or interventions was extracted and graded into three levels. RESULTS O studies retrieved, met the inclusion criteria (six randomised controlled trials, interrupted time series, one non-randomised trial, and two controlled beore-afer studies). Meta-analysis o two randomised controlled trials showed the addition o goal setting to WHO- was associated with improved compliance (pooled odds ratio ., % confidence interval . to .; I =%). O pairwise comparisons rom interrupted time series, showed stepwise increases in compliance with hand hygiene, and all but our showed a trend or increasing compliance afer the intervention. Network meta-analysis indicated considerable uncertainty in the relative effectiveness o interventions, but nonetheless provided evidence that WHO- is effective and that compliance can be urther improved by adding interventions including goal setting, reward incentives, and accountability. Nineteen studies reported clinical outcomes; data rom these were consistent with clinically important reductions in rates o inection resulting rom improved hand hygiene or some but not all important hospital pathogens. Reported costs o interventions ranged rom to (-; - ) per bed days. CONCLUSION Promotion o hand hygiene with WHO- is effective at increasing compliance in healthcare workers. Addition o goal setting, reward incentives, and accountability strategies can lead to urther improvements. Reporting o resources required or such interventions remains inadequate. Introduction At any point in time more than . million patients around the world experience healthcare associated infections. Such infections cause excess morbidity and are associated with increased mortality. Direct contact between patients and healthcare workers who are transiently contaminated with nosocomial patho- gens is believed to be the primary route of transmission for several organisms and can lead to patients becom- ing colonised or infected. Although hand hygiene is widely thought to be the most important activity for the prevention of nosocomial infections, a review of hand hygiene studies by the World Health Organization (WHO) found that baseline compliance with hand hygiene among healthcare workers was on average only .% (range -%). In , the WHO World Alliance for Patient Safety launched a campaign, the First Global Patient Safety Challenge—“Clean Care is Safer Care”—aiming to improve hand hygiene in healthcare. This campaign WHAT IS ALREADY KNOWN ON THIS TOPIC Hand hygiene among healthcare workers is possibly one o the most effective measures to reduce healthcare associated inections, but compliance remains poor in many hospital settings In WHO launched a campaign to improve hand hygiene in healthcare settings by promoting a multimodal strategy consisting o five components: system change, training and education, observation and eedback, reminders in the hospital, and a hospital saety climate WHAT THIS STUDY ADDS These meta-analyses provide evidence that the WHO campaign is effective at increasing compliance with hand hygiene in healthcare workers There is evidence that additional interventions (used in conjunction with the WHO campaign elements), including goal setting, reward incentive, and accountability, can lead to urther improvements Reporting on resource implications o such interventions is limited
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RESEARCH
1
OPEN ACCESS
983089Mahidol-Oxord TropicalMedicine Research Unit Facultyo Tropical Medicine MahidolUniversity Bangkok Thailand983090School o Public HealthQueensland University oTechnology Brisbane Australia983091Department o TropicalHygiene Faculty o TropicalMedicine Mahidol UniversityBangkok Thailand983092Centre or Tropical Medicineand Global Health NuffieldDepartment o Clinical Medicine
University o Oxord Oxord UK983093Inection Control ProgramUniversity o Geneva Hospitalsand Faculty o MedicineGeneva 983089983090983089983089 Switzerland983094Departments o InectiousDiseases and MicrobiologyRoyal Prince Alred HospitalSydney 983090983088983093983088 Australia983095Institute o Health andBiomedical InnovationQueensland University oTechnology Brisbane Australia
Correspondence toN Luangasanatip Mahidol-OxordTropical Medicine Research Unit983092983090983088983094 983094983088th Anniversary
Additional material is publishedonline only To view please visit
the journal online (ht tpdxdoiorg983089983088983089983089983091983094bmjh983091983095983090983096)
Cite this as BMJ 983090983088983089983093983091983093983089h983091983095983090983096doi 983089983088983089983089983091983094bmjh983091983095983090983096
Accepted 983090983090 June 983090983088983089983093
Comparative efficacy of interventions to promote hand hygiene
in hospital systematic review and network meta-analysis
Nantasit Luangasanatip983089 983090 Maliwan Hongsuwan983089 Direk Limmathurotsakul983089 983091 Yoel Lubell983089 983092 Andie S Lee983093 983094 Stephan Harbarth983093 Nicholas P J Day983089 983092 Nicholas Graves983090 983095 Ben S Cooper 983089 983092
ABSTRACT
OBJECTIVE
To evaluate the relative efficacy o the World Health
Organization 983090983088983088983093 campaign (WHO-983093) and other
interventions to promote hand hygiene among
healthcare workers in hospital settings and to
summarize associated inormation on use o
resources
DESIGN
Systematic review and network meta-analysis
DATA SOURCES
Medline Embase CINAHL NHS Economic EvaluationDatabase NHS Centre or Reviews and Dissemination
Cochrane Library and the EPOC register (December
983090983088983088983097 to February 983090983088983089983092) studies selected by the
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 perormed
on studies reporting directly observed compliance
with hand hygiene when they were considered
sufficiently homogeneous with regard to
interventions and participants Inormation on
resources required or interventions was extracted
and graded into three levels
RESULTS
O 983091983094983091983097 studies retrieved 983092983089 met the inclusion criteria
(six randomised controlled trials 983091983090 interrupted time
series one non-randomised trial and two controlled
beore-afer studies) Meta-analysis o two randomised
controlled trials showed the addition o goal setting to
WHO-983093 was associated with improved compliance
(pooled odds ratio 983089983091983093 983097983093 confidence interval 983089983088983092
to 983089983095983094 I983090=983096983089) O 983090983090 pairwise comparisons rom
interrupted time series 983089983096 showed stepwise increases
in compliance with hand hygiene and all but our
showed a trend or increasing compliance afer the
intervention Network meta-analysis indicatedconsiderable uncertainty in the relative effectiveness
o interventions but nonetheless provided evidence
that WHO-983093 is effective and that compliance can be
urther improved by adding interventions including
goal setting reward incentives and accountability
Nineteen studies reported clinical outcomes data
rom these were consistent with clinically important
reductions in rates o inection resulting rom
improved hand hygiene or some but not all important
hospital pathogens Reported costs o interventions
ranged rom 983076983090983090983093 to 983076983092983094983094983097 (983203983089983092983094-983203983091983088983091983093 991404983090983088983092-
991404983092983090983090983097) per 983089983088983088983088 bed days
CONCLUSIONPromotion o hand hygiene with WHO-983093 is effective at
increasing compliance in healthcare workers Addition
o goal setting reward incentives and accountability
strategies can lead to urther improvements Reporting
o resources required or such interventions remains
inadequate
Introduction
At any point in time more than 983089983092 million patients
around the world experience healthcare associated
infections983089 983090 Such infections cause excess morbidity
and are associated with increased mortality983090 983091 Direct
contact between patients and healthcare workers whoare transiently contaminated with nosocomial patho-
gens is believed to be the primary route of transmission
for several organisms and can lead to patients becom-
ing colonised or infected Although hand hygiene is
widely thought to be the most important activity for the
prevention of nosocomial infections a review of hand
hygiene studies by the World Health Organization
(WHO) found that baseline compliance with hand
hygiene among healthcare workers was on average only
before and after the intervention from at least two inter-
vention and two comparable control sites) and inter-rupted time series (with a clearly defined point in time
for the intervention and outcome measures from at least
three time points in both baseline and intervention
periods)983089983090 983089983091
Patient involvement
No patients were involved in setting the research ques-
tion or the outcome measures nor were they involved in
the design and implementation of the study There are
no plans to involve patients in dissemination
Data extraction and assessment o quality
Two reviewers (NL and BSC) independently screenedthe titles and abstracts of the citations obtained from
the search to assess the eligibility Consensus was
reached by discussion if initial assessments differed NL
evaluated the full text and abstracted data which was
checked by BSC
The reviewers abstracted data including study design
and duration population activities to promote hand
hygiene in both intervention and comparison groups
hand hygiene outcomes clinical and microbiological
outcomes measurement methods and settings When
possible we classified hand hygiene promotion activi-
ties according to WHO guidelines on hand hygiene in
healthcare983092 We grouped activities into eight compo-nents system change education feedback reminders
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RESEARCH
3
safety climate incentives goal setting and account-
ability (table 983089) Results and raw compliance data from
each study were extracted for further re-analyses In
addition we extracted the costs of hand hygiene inter-
ventions or data on use of resources (materials and time
spent on interventions) when appropriate Additional
information was obtained from the authors if it was not
clear from the manuscript For all included studies we
used prespecified definitions to record the level of infor-
mation (high moderate or low) about resources used
for promotion of hand hygiene (see appendix 983090)
Assessment o risk o bias in included studies
We used the Cochrane Collaborationrsquos tool to assess risk
of bias983089983092 Nine standard criteria for randomised con-
trolled trials non-randomised trials and controlled
before-after studies and seven standard criteria forinterrupted time series were applied and used to clas-
sify each studyrsquos risk of bias as low high or unclear
Data synthesis and statistical analysis
Data synthesis was performed separately for different
study designs The primary evidence synthesis was
based on studies that used direct observation to mea-
sure compliance with hand hygiene We restricted our
analysis to this outcome because it reflects the opportu-
nities for hand hygiene
For randomised controlled trials we used Cochrane
Review Manager (RevMan version 983093983089) to calculate the
natural logarithm of the odds ratio and associated vari-ance to estimate the pooled odds ratio with a random
effects model983089983093 The same method was applied to
non-randomised trials and controlled before-after
studies if applicable Heterogeneity between studies
was assessed with the I983090 statistic Risk of publication
bias was evaluated with an enhanced contour funnel
plot983089983094 983089983095
For interrupted time series if re-analysis was
required we used a generalised linear segmented
regression analysis to estimate the stepwise change in
level and change in trend associated with the interven-
tion983089983096 This approach is similar to that proposed by
Ramsey and colleagues983089983097 and Vidanapathirana and col-leagues983090983088 except that it accounts for the binomial
nature of the data appropriately weighting each data
point by the number of observations We accounted for
any evidence of autocorrelation by using Newey-West
standard errors983090983089 Analysis was performed with Stata 983089983091
(Statacorp LP College Station TX) We then estimated
two summary measures that combined both stepwise
and trend changes Firstly we calculated the mean nat-
ural logarithm of the odds ratio for hand hygiene asso-
ciated with the intervention a measure of relative
improvement Secondly we calculated the mean per-
centage change in compliance in the period after the
intervention (compared with that expected if there had
been no intervention) an absolute measure of improve-
ment in compliance Standard errors were derived with
the delta method by using the emdbook package in
R983090983090 983090983091 Appendix 983091 provides full details
Network meta-analysis
Network meta-analysis aims to combine all of the
evidence both direct and indirect to estimate the
comparative efficacy of all the interventions983090983092 Each
intervention strategy is represented by a node in the
network If a study directly compares two interventions
they are directly connected by a link on the network and
a direct comparison is possible If two interventions are
connected indirectly (for example if there are studies
comparing each with a third intervention) then indi-
rect comparison is possible
We used network meta-analysis to compare the rela-
tive effectiveness of four different strategies no promo-tion of hand hygiene single component interventions
WHO-983093 and WHO-983093 and others (table 983090 ) We included in
the network meta-analysis those studies that included
only these strategies and permitted a segmented regres-
sion analysis and directly observed compliance with
hand hygiene983090983093 983090983094
The effect sizes obtained from each comparison were
combined in a network meta-analysis with a random
effects model983090983093 Effect sizes were taken as the mean of
the natural logarithm of the odds ratio for the hand
hygiene intervention as estimated with the segmented
regression model Intervention rankings and associ-
ated credible intervals were obtained Model fitting forthe meta-analysis was carried out within a Bayesian
Table 983089 | Description o eight components o interventions to promote hand hygiene in healthcare workers
Component Description
System change Ensuring necessary inrastructure is available including access to water soap and towels and alcohol basedhandrub at point o care
Education and training Providing training or educational programme on importance o hand hygiene and correct procedures orhand hygiene or healthcare workers
Feedback Monitor ing hand hygiene pract ices among healthcare workers whi le providing compliance eedback to staff
Reminders at workplace Prompting healthcare workers either through printed material verbal reminders electronic communications orother methods to remind them about impor tance o hand hygiene and appropriate indications and procedures
Institutional saety climate Active participation at institutional level creating environment allowing prioritisation o hand hygiene
Goal setting Setting o specific goals aimed at improving compliance with hand hygiene which can both apply atindividual and group level and can include healthcare associated inection rates
Reward incentives Interventions providing any reward incentive or participants completing a particular task or reaching acertain level o compliance Both non-financial and financial rewards are included
Accountability Interventions involved with improving healthcare workersrsquo accountability both at individual and unit level
I the intervention period included changing the location or ormulation o alcohol based handrub or installing more handrub dispensers the baselineintervention was counted as no intervention or standard practice (no system change component) even i alcohol based handrub had been used duringthe baseline period
rupted time series and two controlled before and after
studies) Clinical outcomes were reported in 983089983097 stud-ies983090983096-983091983088 983091983093 983092983090 983092983094-983093983090 983093983093-983093983095 983093983097 983094983090 983094983091 983094983094 983094983095 983094983097 Appendix 983094 provides full
study characteristics including study design setting
intervention and comparison groups
Examination of funnel plots (appendix 983095) did not pro-
vide any clear evidence of publication bias though evi-
dence for or against such bias was limited by the fact
that there were no more than four studies for any pair-
wise comparison of strategies
Quality assessment
Ten studies were considered to have a high risk of bias
Thirty one had either low or unclear risk High risk of
bias was present in all three non-randomised trials orcontrolled before-after studies but only in seven out of
Table 983090 | Mean odds ratios with 983097983093 credible intervals or interventions strategies topromote hand hygiene Results are rom random effects network meta-analysis model
Strategies Description Mean OR (983097983093 credible interval)
Nonecurrent pract ice No intervention or current pract ice Reerence
Single intervention Single intervention (system changeor education)
983092983091983088 (983088983092983091 to 983092983094983093983095)
WHO-983093dagger WHO-983093 components 983094983093983089 (983089983093983096 to 983091983089983097983089)
WHO-983093 + others WHO-983093 plus incentives goal settingor accountability
983089983089983096983091 (983090983094983095 to 983093983091983095983097)
Model fit statistic posterior mean residual deviance=983089983088983092983088 and deviance inormation criterion (DIC)=983090983091983096983094daggerContained five components system change education eedback reminders and institutional saety climate(see table 983089 or details)
Studies identified by Gould et al orHuis et al and meeting EPOC criteria
(1980 to Nov 2009) (n=10 studies)
Potentially relevant citations identifiedafter searching from electronic database(Dec 2009 to Feb 2014) (n= 7615 records)
Records screened after duplicates removed (n=3639)
Relevant studies included in systematic review (n=41) Randomised controlled trials (n=6) Interrupted time series (n=32)
Studies included in quantitative synthesis (n=10) Randomised controlled trials (n=2) Interrupted time series studies (n=8)
Non-randomised trials (n=1)Controlled before and after trials (n=2)
Full text articles assessed for eligibility (n=202)
Studies met initial inclusion criteria of these 41 studies met EPOC inclusion criteria (n=142)
Full text articles excluded (n=60) No hand hygiene outcome (n=21) No intervenion or not hand hygiene promotion (n=15) Not healthcare workers (n=1) Not hospital settings (n=5) Not intervention studies not peer reviewed (review protocol conference proceeding economic evaluation (n=12)
Non-English literature (n=6)
Records excluded by title and abstract screening (n=3437)
Records excluded by EPOC inclusion criteria (n=101) Controlled before and after with appropriate control (n=3) Uncontrolled before and after design (n=80) Interrupted time series trials with inadequate data collection points (n=18)
Fig 983089 | Flow chart o study identification in systematic review o interventions to promotehand hygiene in healthcare workers
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RESEARCH
5
983091983090 interrupted time series No randomised controlled
trials or cluster randomised controlled trials were
thought to have a high risk of bias (fig 983090)
The two controlled before-after studies983094983095 983094983096 had high
risks for inadequate allocation sequence and conceal-
ment while one non-randomised trial983094983094 had high risk of
dissimilarity in baseline outcome between experimen-
tal and control groups
Fourteen studies (983091983092) had a low risk of bias due to
the knowledge of allocated intervention as these stud-
ies either measured objective outcomes (such as alco-
hol consumption or output from electronic counting
devices) or stated that the observers were blinded to
the intervention The rest of the studies had unclear
risk as they did not report whether the observers were
blinded
Risk of selective outcome reporting was unclear in 983091983091
studies as pre-specified protocols were reported only in
three randomised controlled trials983091983090 983091983092 983091983093 Two of the
interrupted time series had a high risk of selective out-
come reporting as they reported on a non-periodical
basis983090983096 983093983097 Among the interrupted time series six had a
high risk that outcomes were affected by other interven-
tions such as a universal chlorhexidine body washing
programme983092983090 983094983091 reinforcement of standard precau-
tions983092983090 screening and decolonisation for multidrug-re-
983091983090983095 (983097983093 confidence interval 983089983093983094 to 983092983097983095) for
opportunities before contact with patients and 983090983088983092
(983093983094 to 983091983093983090) for opportunities after contact (baseline
compliance before and after contact was about 983090983093 and
983091983095 respectively in both arms)983091983091 In Canada a cluster
randomised trial of a bundle of education performance
feedback and visual reminders in 983091983088 hospital units
where alcohol hand rub was available at point of care in
both arms (but with no other interventions in the con-
trol arm) reported a higher adherence after the interven-
tion in the intervention arm (mean difference 983094983091
983097983093 confidence interval 983092983091 to 983096983092)983091983093 In both arms
baseline compliance was low (983089983094)
Fisher and colleagues randomised individuals to
either a control group where hand hygiene was not
actively promoted or an intervention arm that used
audio reminders and individual feedback983091983089 They
assessed compliance using an automated system at
entry to and exit from patientsrsquo rooms The interven-
tion was associated with a 983094983096 (983097983093 confidence
interval 983090983093 to 983089983089983089) improvement in complianceSalamati and colleagues randomised nursing person-
nel to either a motivational interviewing intervention
(a behaviour modification approach initially devel-
oped to treat patients with alcoholism) or a control
group983091983094 Both arms also received an educational inter-
vention The outcome measure was a composite hand
hygiene score which was found to increase in the
intervention arm The scoring details however were
unclear
Interrupted time series
Of 983091983090 interrupted time series 983090983093 measured hand
hygiene compliance Only 983089983096 studies with directobservation however reported the number of obser-
vations at each time point making them eligible for
re-analysis983090983096-983091983088 983091983095 983091983096 983092983088-983092983094 983092983096 983093983088 983093983092 983093983094 983094983088 983094983092 983094983093 As some of these
studies were conducted at multiple sites983092983096 or had multi-
The baseline compliance ranged from 983095983094 to 983097983089983091
Twelve of 983090983090 comparisons showed a declining trend in
compliance during the period before intervention
seven of these did not report any activities to promote
hand hygiene before intervention while another fourused only education or reminders Fifteen pairwise
contrasts showed a positive change in trend for com-
pliance with hand hygiene after the intervention
(table 983091 ) All but four contrasts showed both stepwise
increases in compliance with hand hygiene associated
with the intervention and increases in mean compli-
ance in the period after intervention compared with
that expected in the absence of the intervention The
range was wide the mean change in hand hygiene
attributed to the intervention varied between a
decrease of 983089983092983096 and an increase of 983096983091983091 (table 983091 )
Two studies had an intervention period lasting at least
two years neither showed evidence for any decline in
compliance over this period983092983088 983092983089 In only one study was
there a net trend for decreasing compliance after the
intervention (fig 983092)983092983093
Non-randomised trials and controlled beore-afer
studies
Mayer and colleagues compared WHO-983093 and reward
incentives (WHO-983093+) with a combination of system
change education and feedback using a staggeredintroduction of an intervention bundle across four out
of six patient units983094983094 The WHO-983093+ intervention was
associated with improved compliance which increased
from 983092983088 to 983094983092 in one two-unit cohort and from 983091983092
to 983092983097 in the other
Benning and colleagues reported a hospital-wide
trend of increased soap and alcohol consumption in
both intervention (package of system change remind-
ers and safety climate) and control (no intervention)
groups but found no evidence of an increased effect in
the intervention group983094983095 Gould and colleagues found
no evidence of improvement in frequency of hand
decontamination in surgical intensive care wardsresulting from a series of educational lectures com-
pared with no intervention (control)983094983096
Analysis o interrupted time series and network
meta-analysis
Among the 983090983090 pairwise comparisons from interrupted
time series 983089983096 had clear details about interventions and
similar indications for compliance with hand hygiene
among qualified healthcare workers In 983089983094 of these the
intervention period included additional intervention
components alongside measures to promote hand
hygiene used in the baseline period and all outcome
data favoured the intervention (fig 983093 ) In the two com-parisons where there was no improvement in hand
Fuller 2012 (acute care of elderly wards)
Fuller 2012 (intensive care units)
Huis
Total (95 CI)
Test for heterogeneityτ2=004
χ2=1063 df=2 P=0005 I2=81
Test for overall effect z=227 P=002
106 (088 to 127)
144 (118 to 176)
164 (133 to 202)
135 (104 to 176)
343
331
326
1000
Author Mean odds ratio(95 CI)
Weight()
0058
0365
0495
Log(odds ratio)
0092
0102
0106
Standarderror
02 05 1 2 5
Favourscontrol
Favoursexperimental
Mean odds ratio(95 CI)
Fig 983091 | Forest plot o the associations between WHO-983093 and goal setting compared with WHO-983093 alone and compliance withhand hygiene rom randomised controlled trials using intention to treat results
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7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
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983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
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RESEARCH
13
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983089983091 Cochrane Effective Practice and Organisation o Care Review Group
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Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
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983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
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Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
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983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
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hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
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983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
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983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
before and after the intervention from at least two inter-
vention and two comparable control sites) and inter-rupted time series (with a clearly defined point in time
for the intervention and outcome measures from at least
three time points in both baseline and intervention
periods)983089983090 983089983091
Patient involvement
No patients were involved in setting the research ques-
tion or the outcome measures nor were they involved in
the design and implementation of the study There are
no plans to involve patients in dissemination
Data extraction and assessment o quality
Two reviewers (NL and BSC) independently screenedthe titles and abstracts of the citations obtained from
the search to assess the eligibility Consensus was
reached by discussion if initial assessments differed NL
evaluated the full text and abstracted data which was
checked by BSC
The reviewers abstracted data including study design
and duration population activities to promote hand
hygiene in both intervention and comparison groups
hand hygiene outcomes clinical and microbiological
outcomes measurement methods and settings When
possible we classified hand hygiene promotion activi-
ties according to WHO guidelines on hand hygiene in
healthcare983092 We grouped activities into eight compo-nents system change education feedback reminders
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3
safety climate incentives goal setting and account-
ability (table 983089) Results and raw compliance data from
each study were extracted for further re-analyses In
addition we extracted the costs of hand hygiene inter-
ventions or data on use of resources (materials and time
spent on interventions) when appropriate Additional
information was obtained from the authors if it was not
clear from the manuscript For all included studies we
used prespecified definitions to record the level of infor-
mation (high moderate or low) about resources used
for promotion of hand hygiene (see appendix 983090)
Assessment o risk o bias in included studies
We used the Cochrane Collaborationrsquos tool to assess risk
of bias983089983092 Nine standard criteria for randomised con-
trolled trials non-randomised trials and controlled
before-after studies and seven standard criteria forinterrupted time series were applied and used to clas-
sify each studyrsquos risk of bias as low high or unclear
Data synthesis and statistical analysis
Data synthesis was performed separately for different
study designs The primary evidence synthesis was
based on studies that used direct observation to mea-
sure compliance with hand hygiene We restricted our
analysis to this outcome because it reflects the opportu-
nities for hand hygiene
For randomised controlled trials we used Cochrane
Review Manager (RevMan version 983093983089) to calculate the
natural logarithm of the odds ratio and associated vari-ance to estimate the pooled odds ratio with a random
effects model983089983093 The same method was applied to
non-randomised trials and controlled before-after
studies if applicable Heterogeneity between studies
was assessed with the I983090 statistic Risk of publication
bias was evaluated with an enhanced contour funnel
plot983089983094 983089983095
For interrupted time series if re-analysis was
required we used a generalised linear segmented
regression analysis to estimate the stepwise change in
level and change in trend associated with the interven-
tion983089983096 This approach is similar to that proposed by
Ramsey and colleagues983089983097 and Vidanapathirana and col-leagues983090983088 except that it accounts for the binomial
nature of the data appropriately weighting each data
point by the number of observations We accounted for
any evidence of autocorrelation by using Newey-West
standard errors983090983089 Analysis was performed with Stata 983089983091
(Statacorp LP College Station TX) We then estimated
two summary measures that combined both stepwise
and trend changes Firstly we calculated the mean nat-
ural logarithm of the odds ratio for hand hygiene asso-
ciated with the intervention a measure of relative
improvement Secondly we calculated the mean per-
centage change in compliance in the period after the
intervention (compared with that expected if there had
been no intervention) an absolute measure of improve-
ment in compliance Standard errors were derived with
the delta method by using the emdbook package in
R983090983090 983090983091 Appendix 983091 provides full details
Network meta-analysis
Network meta-analysis aims to combine all of the
evidence both direct and indirect to estimate the
comparative efficacy of all the interventions983090983092 Each
intervention strategy is represented by a node in the
network If a study directly compares two interventions
they are directly connected by a link on the network and
a direct comparison is possible If two interventions are
connected indirectly (for example if there are studies
comparing each with a third intervention) then indi-
rect comparison is possible
We used network meta-analysis to compare the rela-
tive effectiveness of four different strategies no promo-tion of hand hygiene single component interventions
WHO-983093 and WHO-983093 and others (table 983090 ) We included in
the network meta-analysis those studies that included
only these strategies and permitted a segmented regres-
sion analysis and directly observed compliance with
hand hygiene983090983093 983090983094
The effect sizes obtained from each comparison were
combined in a network meta-analysis with a random
effects model983090983093 Effect sizes were taken as the mean of
the natural logarithm of the odds ratio for the hand
hygiene intervention as estimated with the segmented
regression model Intervention rankings and associ-
ated credible intervals were obtained Model fitting forthe meta-analysis was carried out within a Bayesian
Table 983089 | Description o eight components o interventions to promote hand hygiene in healthcare workers
Component Description
System change Ensuring necessary inrastructure is available including access to water soap and towels and alcohol basedhandrub at point o care
Education and training Providing training or educational programme on importance o hand hygiene and correct procedures orhand hygiene or healthcare workers
Feedback Monitor ing hand hygiene pract ices among healthcare workers whi le providing compliance eedback to staff
Reminders at workplace Prompting healthcare workers either through printed material verbal reminders electronic communications orother methods to remind them about impor tance o hand hygiene and appropriate indications and procedures
Institutional saety climate Active participation at institutional level creating environment allowing prioritisation o hand hygiene
Goal setting Setting o specific goals aimed at improving compliance with hand hygiene which can both apply atindividual and group level and can include healthcare associated inection rates
Reward incentives Interventions providing any reward incentive or participants completing a particular task or reaching acertain level o compliance Both non-financial and financial rewards are included
Accountability Interventions involved with improving healthcare workersrsquo accountability both at individual and unit level
I the intervention period included changing the location or ormulation o alcohol based handrub or installing more handrub dispensers the baselineintervention was counted as no intervention or standard practice (no system change component) even i alcohol based handrub had been used duringthe baseline period
rupted time series and two controlled before and after
studies) Clinical outcomes were reported in 983089983097 stud-ies983090983096-983091983088 983091983093 983092983090 983092983094-983093983090 983093983093-983093983095 983093983097 983094983090 983094983091 983094983094 983094983095 983094983097 Appendix 983094 provides full
study characteristics including study design setting
intervention and comparison groups
Examination of funnel plots (appendix 983095) did not pro-
vide any clear evidence of publication bias though evi-
dence for or against such bias was limited by the fact
that there were no more than four studies for any pair-
wise comparison of strategies
Quality assessment
Ten studies were considered to have a high risk of bias
Thirty one had either low or unclear risk High risk of
bias was present in all three non-randomised trials orcontrolled before-after studies but only in seven out of
Table 983090 | Mean odds ratios with 983097983093 credible intervals or interventions strategies topromote hand hygiene Results are rom random effects network meta-analysis model
Strategies Description Mean OR (983097983093 credible interval)
Nonecurrent pract ice No intervention or current pract ice Reerence
Single intervention Single intervention (system changeor education)
983092983091983088 (983088983092983091 to 983092983094983093983095)
WHO-983093dagger WHO-983093 components 983094983093983089 (983089983093983096 to 983091983089983097983089)
WHO-983093 + others WHO-983093 plus incentives goal settingor accountability
983089983089983096983091 (983090983094983095 to 983093983091983095983097)
Model fit statistic posterior mean residual deviance=983089983088983092983088 and deviance inormation criterion (DIC)=983090983091983096983094daggerContained five components system change education eedback reminders and institutional saety climate(see table 983089 or details)
Studies identified by Gould et al orHuis et al and meeting EPOC criteria
(1980 to Nov 2009) (n=10 studies)
Potentially relevant citations identifiedafter searching from electronic database(Dec 2009 to Feb 2014) (n= 7615 records)
Records screened after duplicates removed (n=3639)
Relevant studies included in systematic review (n=41) Randomised controlled trials (n=6) Interrupted time series (n=32)
Studies included in quantitative synthesis (n=10) Randomised controlled trials (n=2) Interrupted time series studies (n=8)
Non-randomised trials (n=1)Controlled before and after trials (n=2)
Full text articles assessed for eligibility (n=202)
Studies met initial inclusion criteria of these 41 studies met EPOC inclusion criteria (n=142)
Full text articles excluded (n=60) No hand hygiene outcome (n=21) No intervenion or not hand hygiene promotion (n=15) Not healthcare workers (n=1) Not hospital settings (n=5) Not intervention studies not peer reviewed (review protocol conference proceeding economic evaluation (n=12)
Non-English literature (n=6)
Records excluded by title and abstract screening (n=3437)
Records excluded by EPOC inclusion criteria (n=101) Controlled before and after with appropriate control (n=3) Uncontrolled before and after design (n=80) Interrupted time series trials with inadequate data collection points (n=18)
Fig 983089 | Flow chart o study identification in systematic review o interventions to promotehand hygiene in healthcare workers
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RESEARCH
5
983091983090 interrupted time series No randomised controlled
trials or cluster randomised controlled trials were
thought to have a high risk of bias (fig 983090)
The two controlled before-after studies983094983095 983094983096 had high
risks for inadequate allocation sequence and conceal-
ment while one non-randomised trial983094983094 had high risk of
dissimilarity in baseline outcome between experimen-
tal and control groups
Fourteen studies (983091983092) had a low risk of bias due to
the knowledge of allocated intervention as these stud-
ies either measured objective outcomes (such as alco-
hol consumption or output from electronic counting
devices) or stated that the observers were blinded to
the intervention The rest of the studies had unclear
risk as they did not report whether the observers were
blinded
Risk of selective outcome reporting was unclear in 983091983091
studies as pre-specified protocols were reported only in
three randomised controlled trials983091983090 983091983092 983091983093 Two of the
interrupted time series had a high risk of selective out-
come reporting as they reported on a non-periodical
basis983090983096 983093983097 Among the interrupted time series six had a
high risk that outcomes were affected by other interven-
tions such as a universal chlorhexidine body washing
programme983092983090 983094983091 reinforcement of standard precau-
tions983092983090 screening and decolonisation for multidrug-re-
983091983090983095 (983097983093 confidence interval 983089983093983094 to 983092983097983095) for
opportunities before contact with patients and 983090983088983092
(983093983094 to 983091983093983090) for opportunities after contact (baseline
compliance before and after contact was about 983090983093 and
983091983095 respectively in both arms)983091983091 In Canada a cluster
randomised trial of a bundle of education performance
feedback and visual reminders in 983091983088 hospital units
where alcohol hand rub was available at point of care in
both arms (but with no other interventions in the con-
trol arm) reported a higher adherence after the interven-
tion in the intervention arm (mean difference 983094983091
983097983093 confidence interval 983092983091 to 983096983092)983091983093 In both arms
baseline compliance was low (983089983094)
Fisher and colleagues randomised individuals to
either a control group where hand hygiene was not
actively promoted or an intervention arm that used
audio reminders and individual feedback983091983089 They
assessed compliance using an automated system at
entry to and exit from patientsrsquo rooms The interven-
tion was associated with a 983094983096 (983097983093 confidence
interval 983090983093 to 983089983089983089) improvement in complianceSalamati and colleagues randomised nursing person-
nel to either a motivational interviewing intervention
(a behaviour modification approach initially devel-
oped to treat patients with alcoholism) or a control
group983091983094 Both arms also received an educational inter-
vention The outcome measure was a composite hand
hygiene score which was found to increase in the
intervention arm The scoring details however were
unclear
Interrupted time series
Of 983091983090 interrupted time series 983090983093 measured hand
hygiene compliance Only 983089983096 studies with directobservation however reported the number of obser-
vations at each time point making them eligible for
re-analysis983090983096-983091983088 983091983095 983091983096 983092983088-983092983094 983092983096 983093983088 983093983092 983093983094 983094983088 983094983092 983094983093 As some of these
studies were conducted at multiple sites983092983096 or had multi-
The baseline compliance ranged from 983095983094 to 983097983089983091
Twelve of 983090983090 comparisons showed a declining trend in
compliance during the period before intervention
seven of these did not report any activities to promote
hand hygiene before intervention while another fourused only education or reminders Fifteen pairwise
contrasts showed a positive change in trend for com-
pliance with hand hygiene after the intervention
(table 983091 ) All but four contrasts showed both stepwise
increases in compliance with hand hygiene associated
with the intervention and increases in mean compli-
ance in the period after intervention compared with
that expected in the absence of the intervention The
range was wide the mean change in hand hygiene
attributed to the intervention varied between a
decrease of 983089983092983096 and an increase of 983096983091983091 (table 983091 )
Two studies had an intervention period lasting at least
two years neither showed evidence for any decline in
compliance over this period983092983088 983092983089 In only one study was
there a net trend for decreasing compliance after the
intervention (fig 983092)983092983093
Non-randomised trials and controlled beore-afer
studies
Mayer and colleagues compared WHO-983093 and reward
incentives (WHO-983093+) with a combination of system
change education and feedback using a staggeredintroduction of an intervention bundle across four out
of six patient units983094983094 The WHO-983093+ intervention was
associated with improved compliance which increased
from 983092983088 to 983094983092 in one two-unit cohort and from 983091983092
to 983092983097 in the other
Benning and colleagues reported a hospital-wide
trend of increased soap and alcohol consumption in
both intervention (package of system change remind-
ers and safety climate) and control (no intervention)
groups but found no evidence of an increased effect in
the intervention group983094983095 Gould and colleagues found
no evidence of improvement in frequency of hand
decontamination in surgical intensive care wardsresulting from a series of educational lectures com-
pared with no intervention (control)983094983096
Analysis o interrupted time series and network
meta-analysis
Among the 983090983090 pairwise comparisons from interrupted
time series 983089983096 had clear details about interventions and
similar indications for compliance with hand hygiene
among qualified healthcare workers In 983089983094 of these the
intervention period included additional intervention
components alongside measures to promote hand
hygiene used in the baseline period and all outcome
data favoured the intervention (fig 983093 ) In the two com-parisons where there was no improvement in hand
Fuller 2012 (acute care of elderly wards)
Fuller 2012 (intensive care units)
Huis
Total (95 CI)
Test for heterogeneityτ2=004
χ2=1063 df=2 P=0005 I2=81
Test for overall effect z=227 P=002
106 (088 to 127)
144 (118 to 176)
164 (133 to 202)
135 (104 to 176)
343
331
326
1000
Author Mean odds ratio(95 CI)
Weight()
0058
0365
0495
Log(odds ratio)
0092
0102
0106
Standarderror
02 05 1 2 5
Favourscontrol
Favoursexperimental
Mean odds ratio(95 CI)
Fig 983091 | Forest plot o the associations between WHO-983093 and goal setting compared with WHO-983093 alone and compliance withhand hygiene rom randomised controlled trials using intention to treat results
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7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1414
RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
analysis
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safety climate incentives goal setting and account-
ability (table 983089) Results and raw compliance data from
each study were extracted for further re-analyses In
addition we extracted the costs of hand hygiene inter-
ventions or data on use of resources (materials and time
spent on interventions) when appropriate Additional
information was obtained from the authors if it was not
clear from the manuscript For all included studies we
used prespecified definitions to record the level of infor-
mation (high moderate or low) about resources used
for promotion of hand hygiene (see appendix 983090)
Assessment o risk o bias in included studies
We used the Cochrane Collaborationrsquos tool to assess risk
of bias983089983092 Nine standard criteria for randomised con-
trolled trials non-randomised trials and controlled
before-after studies and seven standard criteria forinterrupted time series were applied and used to clas-
sify each studyrsquos risk of bias as low high or unclear
Data synthesis and statistical analysis
Data synthesis was performed separately for different
study designs The primary evidence synthesis was
based on studies that used direct observation to mea-
sure compliance with hand hygiene We restricted our
analysis to this outcome because it reflects the opportu-
nities for hand hygiene
For randomised controlled trials we used Cochrane
Review Manager (RevMan version 983093983089) to calculate the
natural logarithm of the odds ratio and associated vari-ance to estimate the pooled odds ratio with a random
effects model983089983093 The same method was applied to
non-randomised trials and controlled before-after
studies if applicable Heterogeneity between studies
was assessed with the I983090 statistic Risk of publication
bias was evaluated with an enhanced contour funnel
plot983089983094 983089983095
For interrupted time series if re-analysis was
required we used a generalised linear segmented
regression analysis to estimate the stepwise change in
level and change in trend associated with the interven-
tion983089983096 This approach is similar to that proposed by
Ramsey and colleagues983089983097 and Vidanapathirana and col-leagues983090983088 except that it accounts for the binomial
nature of the data appropriately weighting each data
point by the number of observations We accounted for
any evidence of autocorrelation by using Newey-West
standard errors983090983089 Analysis was performed with Stata 983089983091
(Statacorp LP College Station TX) We then estimated
two summary measures that combined both stepwise
and trend changes Firstly we calculated the mean nat-
ural logarithm of the odds ratio for hand hygiene asso-
ciated with the intervention a measure of relative
improvement Secondly we calculated the mean per-
centage change in compliance in the period after the
intervention (compared with that expected if there had
been no intervention) an absolute measure of improve-
ment in compliance Standard errors were derived with
the delta method by using the emdbook package in
R983090983090 983090983091 Appendix 983091 provides full details
Network meta-analysis
Network meta-analysis aims to combine all of the
evidence both direct and indirect to estimate the
comparative efficacy of all the interventions983090983092 Each
intervention strategy is represented by a node in the
network If a study directly compares two interventions
they are directly connected by a link on the network and
a direct comparison is possible If two interventions are
connected indirectly (for example if there are studies
comparing each with a third intervention) then indi-
rect comparison is possible
We used network meta-analysis to compare the rela-
tive effectiveness of four different strategies no promo-tion of hand hygiene single component interventions
WHO-983093 and WHO-983093 and others (table 983090 ) We included in
the network meta-analysis those studies that included
only these strategies and permitted a segmented regres-
sion analysis and directly observed compliance with
hand hygiene983090983093 983090983094
The effect sizes obtained from each comparison were
combined in a network meta-analysis with a random
effects model983090983093 Effect sizes were taken as the mean of
the natural logarithm of the odds ratio for the hand
hygiene intervention as estimated with the segmented
regression model Intervention rankings and associ-
ated credible intervals were obtained Model fitting forthe meta-analysis was carried out within a Bayesian
Table 983089 | Description o eight components o interventions to promote hand hygiene in healthcare workers
Component Description
System change Ensuring necessary inrastructure is available including access to water soap and towels and alcohol basedhandrub at point o care
Education and training Providing training or educational programme on importance o hand hygiene and correct procedures orhand hygiene or healthcare workers
Feedback Monitor ing hand hygiene pract ices among healthcare workers whi le providing compliance eedback to staff
Reminders at workplace Prompting healthcare workers either through printed material verbal reminders electronic communications orother methods to remind them about impor tance o hand hygiene and appropriate indications and procedures
Institutional saety climate Active participation at institutional level creating environment allowing prioritisation o hand hygiene
Goal setting Setting o specific goals aimed at improving compliance with hand hygiene which can both apply atindividual and group level and can include healthcare associated inection rates
Reward incentives Interventions providing any reward incentive or participants completing a particular task or reaching acertain level o compliance Both non-financial and financial rewards are included
Accountability Interventions involved with improving healthcare workersrsquo accountability both at individual and unit level
I the intervention period included changing the location or ormulation o alcohol based handrub or installing more handrub dispensers the baselineintervention was counted as no intervention or standard practice (no system change component) even i alcohol based handrub had been used duringthe baseline period
rupted time series and two controlled before and after
studies) Clinical outcomes were reported in 983089983097 stud-ies983090983096-983091983088 983091983093 983092983090 983092983094-983093983090 983093983093-983093983095 983093983097 983094983090 983094983091 983094983094 983094983095 983094983097 Appendix 983094 provides full
study characteristics including study design setting
intervention and comparison groups
Examination of funnel plots (appendix 983095) did not pro-
vide any clear evidence of publication bias though evi-
dence for or against such bias was limited by the fact
that there were no more than four studies for any pair-
wise comparison of strategies
Quality assessment
Ten studies were considered to have a high risk of bias
Thirty one had either low or unclear risk High risk of
bias was present in all three non-randomised trials orcontrolled before-after studies but only in seven out of
Table 983090 | Mean odds ratios with 983097983093 credible intervals or interventions strategies topromote hand hygiene Results are rom random effects network meta-analysis model
Strategies Description Mean OR (983097983093 credible interval)
Nonecurrent pract ice No intervention or current pract ice Reerence
Single intervention Single intervention (system changeor education)
983092983091983088 (983088983092983091 to 983092983094983093983095)
WHO-983093dagger WHO-983093 components 983094983093983089 (983089983093983096 to 983091983089983097983089)
WHO-983093 + others WHO-983093 plus incentives goal settingor accountability
983089983089983096983091 (983090983094983095 to 983093983091983095983097)
Model fit statistic posterior mean residual deviance=983089983088983092983088 and deviance inormation criterion (DIC)=983090983091983096983094daggerContained five components system change education eedback reminders and institutional saety climate(see table 983089 or details)
Studies identified by Gould et al orHuis et al and meeting EPOC criteria
(1980 to Nov 2009) (n=10 studies)
Potentially relevant citations identifiedafter searching from electronic database(Dec 2009 to Feb 2014) (n= 7615 records)
Records screened after duplicates removed (n=3639)
Relevant studies included in systematic review (n=41) Randomised controlled trials (n=6) Interrupted time series (n=32)
Studies included in quantitative synthesis (n=10) Randomised controlled trials (n=2) Interrupted time series studies (n=8)
Non-randomised trials (n=1)Controlled before and after trials (n=2)
Full text articles assessed for eligibility (n=202)
Studies met initial inclusion criteria of these 41 studies met EPOC inclusion criteria (n=142)
Full text articles excluded (n=60) No hand hygiene outcome (n=21) No intervenion or not hand hygiene promotion (n=15) Not healthcare workers (n=1) Not hospital settings (n=5) Not intervention studies not peer reviewed (review protocol conference proceeding economic evaluation (n=12)
Non-English literature (n=6)
Records excluded by title and abstract screening (n=3437)
Records excluded by EPOC inclusion criteria (n=101) Controlled before and after with appropriate control (n=3) Uncontrolled before and after design (n=80) Interrupted time series trials with inadequate data collection points (n=18)
Fig 983089 | Flow chart o study identification in systematic review o interventions to promotehand hygiene in healthcare workers
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RESEARCH
5
983091983090 interrupted time series No randomised controlled
trials or cluster randomised controlled trials were
thought to have a high risk of bias (fig 983090)
The two controlled before-after studies983094983095 983094983096 had high
risks for inadequate allocation sequence and conceal-
ment while one non-randomised trial983094983094 had high risk of
dissimilarity in baseline outcome between experimen-
tal and control groups
Fourteen studies (983091983092) had a low risk of bias due to
the knowledge of allocated intervention as these stud-
ies either measured objective outcomes (such as alco-
hol consumption or output from electronic counting
devices) or stated that the observers were blinded to
the intervention The rest of the studies had unclear
risk as they did not report whether the observers were
blinded
Risk of selective outcome reporting was unclear in 983091983091
studies as pre-specified protocols were reported only in
three randomised controlled trials983091983090 983091983092 983091983093 Two of the
interrupted time series had a high risk of selective out-
come reporting as they reported on a non-periodical
basis983090983096 983093983097 Among the interrupted time series six had a
high risk that outcomes were affected by other interven-
tions such as a universal chlorhexidine body washing
programme983092983090 983094983091 reinforcement of standard precau-
tions983092983090 screening and decolonisation for multidrug-re-
983091983090983095 (983097983093 confidence interval 983089983093983094 to 983092983097983095) for
opportunities before contact with patients and 983090983088983092
(983093983094 to 983091983093983090) for opportunities after contact (baseline
compliance before and after contact was about 983090983093 and
983091983095 respectively in both arms)983091983091 In Canada a cluster
randomised trial of a bundle of education performance
feedback and visual reminders in 983091983088 hospital units
where alcohol hand rub was available at point of care in
both arms (but with no other interventions in the con-
trol arm) reported a higher adherence after the interven-
tion in the intervention arm (mean difference 983094983091
983097983093 confidence interval 983092983091 to 983096983092)983091983093 In both arms
baseline compliance was low (983089983094)
Fisher and colleagues randomised individuals to
either a control group where hand hygiene was not
actively promoted or an intervention arm that used
audio reminders and individual feedback983091983089 They
assessed compliance using an automated system at
entry to and exit from patientsrsquo rooms The interven-
tion was associated with a 983094983096 (983097983093 confidence
interval 983090983093 to 983089983089983089) improvement in complianceSalamati and colleagues randomised nursing person-
nel to either a motivational interviewing intervention
(a behaviour modification approach initially devel-
oped to treat patients with alcoholism) or a control
group983091983094 Both arms also received an educational inter-
vention The outcome measure was a composite hand
hygiene score which was found to increase in the
intervention arm The scoring details however were
unclear
Interrupted time series
Of 983091983090 interrupted time series 983090983093 measured hand
hygiene compliance Only 983089983096 studies with directobservation however reported the number of obser-
vations at each time point making them eligible for
re-analysis983090983096-983091983088 983091983095 983091983096 983092983088-983092983094 983092983096 983093983088 983093983092 983093983094 983094983088 983094983092 983094983093 As some of these
studies were conducted at multiple sites983092983096 or had multi-
The baseline compliance ranged from 983095983094 to 983097983089983091
Twelve of 983090983090 comparisons showed a declining trend in
compliance during the period before intervention
seven of these did not report any activities to promote
hand hygiene before intervention while another fourused only education or reminders Fifteen pairwise
contrasts showed a positive change in trend for com-
pliance with hand hygiene after the intervention
(table 983091 ) All but four contrasts showed both stepwise
increases in compliance with hand hygiene associated
with the intervention and increases in mean compli-
ance in the period after intervention compared with
that expected in the absence of the intervention The
range was wide the mean change in hand hygiene
attributed to the intervention varied between a
decrease of 983089983092983096 and an increase of 983096983091983091 (table 983091 )
Two studies had an intervention period lasting at least
two years neither showed evidence for any decline in
compliance over this period983092983088 983092983089 In only one study was
there a net trend for decreasing compliance after the
intervention (fig 983092)983092983093
Non-randomised trials and controlled beore-afer
studies
Mayer and colleagues compared WHO-983093 and reward
incentives (WHO-983093+) with a combination of system
change education and feedback using a staggeredintroduction of an intervention bundle across four out
of six patient units983094983094 The WHO-983093+ intervention was
associated with improved compliance which increased
from 983092983088 to 983094983092 in one two-unit cohort and from 983091983092
to 983092983097 in the other
Benning and colleagues reported a hospital-wide
trend of increased soap and alcohol consumption in
both intervention (package of system change remind-
ers and safety climate) and control (no intervention)
groups but found no evidence of an increased effect in
the intervention group983094983095 Gould and colleagues found
no evidence of improvement in frequency of hand
decontamination in surgical intensive care wardsresulting from a series of educational lectures com-
pared with no intervention (control)983094983096
Analysis o interrupted time series and network
meta-analysis
Among the 983090983090 pairwise comparisons from interrupted
time series 983089983096 had clear details about interventions and
similar indications for compliance with hand hygiene
among qualified healthcare workers In 983089983094 of these the
intervention period included additional intervention
components alongside measures to promote hand
hygiene used in the baseline period and all outcome
data favoured the intervention (fig 983093 ) In the two com-parisons where there was no improvement in hand
Fuller 2012 (acute care of elderly wards)
Fuller 2012 (intensive care units)
Huis
Total (95 CI)
Test for heterogeneityτ2=004
χ2=1063 df=2 P=0005 I2=81
Test for overall effect z=227 P=002
106 (088 to 127)
144 (118 to 176)
164 (133 to 202)
135 (104 to 176)
343
331
326
1000
Author Mean odds ratio(95 CI)
Weight()
0058
0365
0495
Log(odds ratio)
0092
0102
0106
Standarderror
02 05 1 2 5
Favourscontrol
Favoursexperimental
Mean odds ratio(95 CI)
Fig 983091 | Forest plot o the associations between WHO-983093 and goal setting compared with WHO-983093 alone and compliance withhand hygiene rom randomised controlled trials using intention to treat results
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7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
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RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
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983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
rupted time series and two controlled before and after
studies) Clinical outcomes were reported in 983089983097 stud-ies983090983096-983091983088 983091983093 983092983090 983092983094-983093983090 983093983093-983093983095 983093983097 983094983090 983094983091 983094983094 983094983095 983094983097 Appendix 983094 provides full
study characteristics including study design setting
intervention and comparison groups
Examination of funnel plots (appendix 983095) did not pro-
vide any clear evidence of publication bias though evi-
dence for or against such bias was limited by the fact
that there were no more than four studies for any pair-
wise comparison of strategies
Quality assessment
Ten studies were considered to have a high risk of bias
Thirty one had either low or unclear risk High risk of
bias was present in all three non-randomised trials orcontrolled before-after studies but only in seven out of
Table 983090 | Mean odds ratios with 983097983093 credible intervals or interventions strategies topromote hand hygiene Results are rom random effects network meta-analysis model
Strategies Description Mean OR (983097983093 credible interval)
Nonecurrent pract ice No intervention or current pract ice Reerence
Single intervention Single intervention (system changeor education)
983092983091983088 (983088983092983091 to 983092983094983093983095)
WHO-983093dagger WHO-983093 components 983094983093983089 (983089983093983096 to 983091983089983097983089)
WHO-983093 + others WHO-983093 plus incentives goal settingor accountability
983089983089983096983091 (983090983094983095 to 983093983091983095983097)
Model fit statistic posterior mean residual deviance=983089983088983092983088 and deviance inormation criterion (DIC)=983090983091983096983094daggerContained five components system change education eedback reminders and institutional saety climate(see table 983089 or details)
Studies identified by Gould et al orHuis et al and meeting EPOC criteria
(1980 to Nov 2009) (n=10 studies)
Potentially relevant citations identifiedafter searching from electronic database(Dec 2009 to Feb 2014) (n= 7615 records)
Records screened after duplicates removed (n=3639)
Relevant studies included in systematic review (n=41) Randomised controlled trials (n=6) Interrupted time series (n=32)
Studies included in quantitative synthesis (n=10) Randomised controlled trials (n=2) Interrupted time series studies (n=8)
Non-randomised trials (n=1)Controlled before and after trials (n=2)
Full text articles assessed for eligibility (n=202)
Studies met initial inclusion criteria of these 41 studies met EPOC inclusion criteria (n=142)
Full text articles excluded (n=60) No hand hygiene outcome (n=21) No intervenion or not hand hygiene promotion (n=15) Not healthcare workers (n=1) Not hospital settings (n=5) Not intervention studies not peer reviewed (review protocol conference proceeding economic evaluation (n=12)
Non-English literature (n=6)
Records excluded by title and abstract screening (n=3437)
Records excluded by EPOC inclusion criteria (n=101) Controlled before and after with appropriate control (n=3) Uncontrolled before and after design (n=80) Interrupted time series trials with inadequate data collection points (n=18)
Fig 983089 | Flow chart o study identification in systematic review o interventions to promotehand hygiene in healthcare workers
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RESEARCH
5
983091983090 interrupted time series No randomised controlled
trials or cluster randomised controlled trials were
thought to have a high risk of bias (fig 983090)
The two controlled before-after studies983094983095 983094983096 had high
risks for inadequate allocation sequence and conceal-
ment while one non-randomised trial983094983094 had high risk of
dissimilarity in baseline outcome between experimen-
tal and control groups
Fourteen studies (983091983092) had a low risk of bias due to
the knowledge of allocated intervention as these stud-
ies either measured objective outcomes (such as alco-
hol consumption or output from electronic counting
devices) or stated that the observers were blinded to
the intervention The rest of the studies had unclear
risk as they did not report whether the observers were
blinded
Risk of selective outcome reporting was unclear in 983091983091
studies as pre-specified protocols were reported only in
three randomised controlled trials983091983090 983091983092 983091983093 Two of the
interrupted time series had a high risk of selective out-
come reporting as they reported on a non-periodical
basis983090983096 983093983097 Among the interrupted time series six had a
high risk that outcomes were affected by other interven-
tions such as a universal chlorhexidine body washing
programme983092983090 983094983091 reinforcement of standard precau-
tions983092983090 screening and decolonisation for multidrug-re-
983091983090983095 (983097983093 confidence interval 983089983093983094 to 983092983097983095) for
opportunities before contact with patients and 983090983088983092
(983093983094 to 983091983093983090) for opportunities after contact (baseline
compliance before and after contact was about 983090983093 and
983091983095 respectively in both arms)983091983091 In Canada a cluster
randomised trial of a bundle of education performance
feedback and visual reminders in 983091983088 hospital units
where alcohol hand rub was available at point of care in
both arms (but with no other interventions in the con-
trol arm) reported a higher adherence after the interven-
tion in the intervention arm (mean difference 983094983091
983097983093 confidence interval 983092983091 to 983096983092)983091983093 In both arms
baseline compliance was low (983089983094)
Fisher and colleagues randomised individuals to
either a control group where hand hygiene was not
actively promoted or an intervention arm that used
audio reminders and individual feedback983091983089 They
assessed compliance using an automated system at
entry to and exit from patientsrsquo rooms The interven-
tion was associated with a 983094983096 (983097983093 confidence
interval 983090983093 to 983089983089983089) improvement in complianceSalamati and colleagues randomised nursing person-
nel to either a motivational interviewing intervention
(a behaviour modification approach initially devel-
oped to treat patients with alcoholism) or a control
group983091983094 Both arms also received an educational inter-
vention The outcome measure was a composite hand
hygiene score which was found to increase in the
intervention arm The scoring details however were
unclear
Interrupted time series
Of 983091983090 interrupted time series 983090983093 measured hand
hygiene compliance Only 983089983096 studies with directobservation however reported the number of obser-
vations at each time point making them eligible for
re-analysis983090983096-983091983088 983091983095 983091983096 983092983088-983092983094 983092983096 983093983088 983093983092 983093983094 983094983088 983094983092 983094983093 As some of these
studies were conducted at multiple sites983092983096 or had multi-
The baseline compliance ranged from 983095983094 to 983097983089983091
Twelve of 983090983090 comparisons showed a declining trend in
compliance during the period before intervention
seven of these did not report any activities to promote
hand hygiene before intervention while another fourused only education or reminders Fifteen pairwise
contrasts showed a positive change in trend for com-
pliance with hand hygiene after the intervention
(table 983091 ) All but four contrasts showed both stepwise
increases in compliance with hand hygiene associated
with the intervention and increases in mean compli-
ance in the period after intervention compared with
that expected in the absence of the intervention The
range was wide the mean change in hand hygiene
attributed to the intervention varied between a
decrease of 983089983092983096 and an increase of 983096983091983091 (table 983091 )
Two studies had an intervention period lasting at least
two years neither showed evidence for any decline in
compliance over this period983092983088 983092983089 In only one study was
there a net trend for decreasing compliance after the
intervention (fig 983092)983092983093
Non-randomised trials and controlled beore-afer
studies
Mayer and colleagues compared WHO-983093 and reward
incentives (WHO-983093+) with a combination of system
change education and feedback using a staggeredintroduction of an intervention bundle across four out
of six patient units983094983094 The WHO-983093+ intervention was
associated with improved compliance which increased
from 983092983088 to 983094983092 in one two-unit cohort and from 983091983092
to 983092983097 in the other
Benning and colleagues reported a hospital-wide
trend of increased soap and alcohol consumption in
both intervention (package of system change remind-
ers and safety climate) and control (no intervention)
groups but found no evidence of an increased effect in
the intervention group983094983095 Gould and colleagues found
no evidence of improvement in frequency of hand
decontamination in surgical intensive care wardsresulting from a series of educational lectures com-
pared with no intervention (control)983094983096
Analysis o interrupted time series and network
meta-analysis
Among the 983090983090 pairwise comparisons from interrupted
time series 983089983096 had clear details about interventions and
similar indications for compliance with hand hygiene
among qualified healthcare workers In 983089983094 of these the
intervention period included additional intervention
components alongside measures to promote hand
hygiene used in the baseline period and all outcome
data favoured the intervention (fig 983093 ) In the two com-parisons where there was no improvement in hand
Fuller 2012 (acute care of elderly wards)
Fuller 2012 (intensive care units)
Huis
Total (95 CI)
Test for heterogeneityτ2=004
χ2=1063 df=2 P=0005 I2=81
Test for overall effect z=227 P=002
106 (088 to 127)
144 (118 to 176)
164 (133 to 202)
135 (104 to 176)
343
331
326
1000
Author Mean odds ratio(95 CI)
Weight()
0058
0365
0495
Log(odds ratio)
0092
0102
0106
Standarderror
02 05 1 2 5
Favourscontrol
Favoursexperimental
Mean odds ratio(95 CI)
Fig 983091 | Forest plot o the associations between WHO-983093 and goal setting compared with WHO-983093 alone and compliance withhand hygiene rom randomised controlled trials using intention to treat results
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7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
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983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
analysis
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RESEARCH
5
983091983090 interrupted time series No randomised controlled
trials or cluster randomised controlled trials were
thought to have a high risk of bias (fig 983090)
The two controlled before-after studies983094983095 983094983096 had high
risks for inadequate allocation sequence and conceal-
ment while one non-randomised trial983094983094 had high risk of
dissimilarity in baseline outcome between experimen-
tal and control groups
Fourteen studies (983091983092) had a low risk of bias due to
the knowledge of allocated intervention as these stud-
ies either measured objective outcomes (such as alco-
hol consumption or output from electronic counting
devices) or stated that the observers were blinded to
the intervention The rest of the studies had unclear
risk as they did not report whether the observers were
blinded
Risk of selective outcome reporting was unclear in 983091983091
studies as pre-specified protocols were reported only in
three randomised controlled trials983091983090 983091983092 983091983093 Two of the
interrupted time series had a high risk of selective out-
come reporting as they reported on a non-periodical
basis983090983096 983093983097 Among the interrupted time series six had a
high risk that outcomes were affected by other interven-
tions such as a universal chlorhexidine body washing
programme983092983090 983094983091 reinforcement of standard precau-
tions983092983090 screening and decolonisation for multidrug-re-
983091983090983095 (983097983093 confidence interval 983089983093983094 to 983092983097983095) for
opportunities before contact with patients and 983090983088983092
(983093983094 to 983091983093983090) for opportunities after contact (baseline
compliance before and after contact was about 983090983093 and
983091983095 respectively in both arms)983091983091 In Canada a cluster
randomised trial of a bundle of education performance
feedback and visual reminders in 983091983088 hospital units
where alcohol hand rub was available at point of care in
both arms (but with no other interventions in the con-
trol arm) reported a higher adherence after the interven-
tion in the intervention arm (mean difference 983094983091
983097983093 confidence interval 983092983091 to 983096983092)983091983093 In both arms
baseline compliance was low (983089983094)
Fisher and colleagues randomised individuals to
either a control group where hand hygiene was not
actively promoted or an intervention arm that used
audio reminders and individual feedback983091983089 They
assessed compliance using an automated system at
entry to and exit from patientsrsquo rooms The interven-
tion was associated with a 983094983096 (983097983093 confidence
interval 983090983093 to 983089983089983089) improvement in complianceSalamati and colleagues randomised nursing person-
nel to either a motivational interviewing intervention
(a behaviour modification approach initially devel-
oped to treat patients with alcoholism) or a control
group983091983094 Both arms also received an educational inter-
vention The outcome measure was a composite hand
hygiene score which was found to increase in the
intervention arm The scoring details however were
unclear
Interrupted time series
Of 983091983090 interrupted time series 983090983093 measured hand
hygiene compliance Only 983089983096 studies with directobservation however reported the number of obser-
vations at each time point making them eligible for
re-analysis983090983096-983091983088 983091983095 983091983096 983092983088-983092983094 983092983096 983093983088 983093983092 983093983094 983094983088 983094983092 983094983093 As some of these
studies were conducted at multiple sites983092983096 or had multi-
The baseline compliance ranged from 983095983094 to 983097983089983091
Twelve of 983090983090 comparisons showed a declining trend in
compliance during the period before intervention
seven of these did not report any activities to promote
hand hygiene before intervention while another fourused only education or reminders Fifteen pairwise
contrasts showed a positive change in trend for com-
pliance with hand hygiene after the intervention
(table 983091 ) All but four contrasts showed both stepwise
increases in compliance with hand hygiene associated
with the intervention and increases in mean compli-
ance in the period after intervention compared with
that expected in the absence of the intervention The
range was wide the mean change in hand hygiene
attributed to the intervention varied between a
decrease of 983089983092983096 and an increase of 983096983091983091 (table 983091 )
Two studies had an intervention period lasting at least
two years neither showed evidence for any decline in
compliance over this period983092983088 983092983089 In only one study was
there a net trend for decreasing compliance after the
intervention (fig 983092)983092983093
Non-randomised trials and controlled beore-afer
studies
Mayer and colleagues compared WHO-983093 and reward
incentives (WHO-983093+) with a combination of system
change education and feedback using a staggeredintroduction of an intervention bundle across four out
of six patient units983094983094 The WHO-983093+ intervention was
associated with improved compliance which increased
from 983092983088 to 983094983092 in one two-unit cohort and from 983091983092
to 983092983097 in the other
Benning and colleagues reported a hospital-wide
trend of increased soap and alcohol consumption in
both intervention (package of system change remind-
ers and safety climate) and control (no intervention)
groups but found no evidence of an increased effect in
the intervention group983094983095 Gould and colleagues found
no evidence of improvement in frequency of hand
decontamination in surgical intensive care wardsresulting from a series of educational lectures com-
pared with no intervention (control)983094983096
Analysis o interrupted time series and network
meta-analysis
Among the 983090983090 pairwise comparisons from interrupted
time series 983089983096 had clear details about interventions and
similar indications for compliance with hand hygiene
among qualified healthcare workers In 983089983094 of these the
intervention period included additional intervention
components alongside measures to promote hand
hygiene used in the baseline period and all outcome
data favoured the intervention (fig 983093 ) In the two com-parisons where there was no improvement in hand
Fuller 2012 (acute care of elderly wards)
Fuller 2012 (intensive care units)
Huis
Total (95 CI)
Test for heterogeneityτ2=004
χ2=1063 df=2 P=0005 I2=81
Test for overall effect z=227 P=002
106 (088 to 127)
144 (118 to 176)
164 (133 to 202)
135 (104 to 176)
343
331
326
1000
Author Mean odds ratio(95 CI)
Weight()
0058
0365
0495
Log(odds ratio)
0092
0102
0106
Standarderror
02 05 1 2 5
Favourscontrol
Favoursexperimental
Mean odds ratio(95 CI)
Fig 983091 | Forest plot o the associations between WHO-983093 and goal setting compared with WHO-983093 alone and compliance withhand hygiene rom randomised controlled trials using intention to treat results
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RESEARCH
7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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RESEARCH
9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1414
RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
983091983090983095 (983097983093 confidence interval 983089983093983094 to 983092983097983095) for
opportunities before contact with patients and 983090983088983092
(983093983094 to 983091983093983090) for opportunities after contact (baseline
compliance before and after contact was about 983090983093 and
983091983095 respectively in both arms)983091983091 In Canada a cluster
randomised trial of a bundle of education performance
feedback and visual reminders in 983091983088 hospital units
where alcohol hand rub was available at point of care in
both arms (but with no other interventions in the con-
trol arm) reported a higher adherence after the interven-
tion in the intervention arm (mean difference 983094983091
983097983093 confidence interval 983092983091 to 983096983092)983091983093 In both arms
baseline compliance was low (983089983094)
Fisher and colleagues randomised individuals to
either a control group where hand hygiene was not
actively promoted or an intervention arm that used
audio reminders and individual feedback983091983089 They
assessed compliance using an automated system at
entry to and exit from patientsrsquo rooms The interven-
tion was associated with a 983094983096 (983097983093 confidence
interval 983090983093 to 983089983089983089) improvement in complianceSalamati and colleagues randomised nursing person-
nel to either a motivational interviewing intervention
(a behaviour modification approach initially devel-
oped to treat patients with alcoholism) or a control
group983091983094 Both arms also received an educational inter-
vention The outcome measure was a composite hand
hygiene score which was found to increase in the
intervention arm The scoring details however were
unclear
Interrupted time series
Of 983091983090 interrupted time series 983090983093 measured hand
hygiene compliance Only 983089983096 studies with directobservation however reported the number of obser-
vations at each time point making them eligible for
re-analysis983090983096-983091983088 983091983095 983091983096 983092983088-983092983094 983092983096 983093983088 983093983092 983093983094 983094983088 983094983092 983094983093 As some of these
studies were conducted at multiple sites983092983096 or had multi-
The baseline compliance ranged from 983095983094 to 983097983089983091
Twelve of 983090983090 comparisons showed a declining trend in
compliance during the period before intervention
seven of these did not report any activities to promote
hand hygiene before intervention while another fourused only education or reminders Fifteen pairwise
contrasts showed a positive change in trend for com-
pliance with hand hygiene after the intervention
(table 983091 ) All but four contrasts showed both stepwise
increases in compliance with hand hygiene associated
with the intervention and increases in mean compli-
ance in the period after intervention compared with
that expected in the absence of the intervention The
range was wide the mean change in hand hygiene
attributed to the intervention varied between a
decrease of 983089983092983096 and an increase of 983096983091983091 (table 983091 )
Two studies had an intervention period lasting at least
two years neither showed evidence for any decline in
compliance over this period983092983088 983092983089 In only one study was
there a net trend for decreasing compliance after the
intervention (fig 983092)983092983093
Non-randomised trials and controlled beore-afer
studies
Mayer and colleagues compared WHO-983093 and reward
incentives (WHO-983093+) with a combination of system
change education and feedback using a staggeredintroduction of an intervention bundle across four out
of six patient units983094983094 The WHO-983093+ intervention was
associated with improved compliance which increased
from 983092983088 to 983094983092 in one two-unit cohort and from 983091983092
to 983092983097 in the other
Benning and colleagues reported a hospital-wide
trend of increased soap and alcohol consumption in
both intervention (package of system change remind-
ers and safety climate) and control (no intervention)
groups but found no evidence of an increased effect in
the intervention group983094983095 Gould and colleagues found
no evidence of improvement in frequency of hand
decontamination in surgical intensive care wardsresulting from a series of educational lectures com-
pared with no intervention (control)983094983096
Analysis o interrupted time series and network
meta-analysis
Among the 983090983090 pairwise comparisons from interrupted
time series 983089983096 had clear details about interventions and
similar indications for compliance with hand hygiene
among qualified healthcare workers In 983089983094 of these the
intervention period included additional intervention
components alongside measures to promote hand
hygiene used in the baseline period and all outcome
data favoured the intervention (fig 983093 ) In the two com-parisons where there was no improvement in hand
Fuller 2012 (acute care of elderly wards)
Fuller 2012 (intensive care units)
Huis
Total (95 CI)
Test for heterogeneityτ2=004
χ2=1063 df=2 P=0005 I2=81
Test for overall effect z=227 P=002
106 (088 to 127)
144 (118 to 176)
164 (133 to 202)
135 (104 to 176)
343
331
326
1000
Author Mean odds ratio(95 CI)
Weight()
0058
0365
0495
Log(odds ratio)
0092
0102
0106
Standarderror
02 05 1 2 5
Favourscontrol
Favoursexperimental
Mean odds ratio(95 CI)
Fig 983091 | Forest plot o the associations between WHO-983093 and goal setting compared with WHO-983093 alone and compliance withhand hygiene rom randomised controlled trials using intention to treat results
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7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
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983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
analysis
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RESEARCH
7
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Lee et al 2013 hospital 4No intervention v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 7WHO-5 v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 8SYS v WHO-5
0 5 10 15 20
Time (months)
Lee et al 2013 hospital 9WHO-5 v WHO-5
0 5 10 15 200
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Higgins et alNo intervention v WHO-5+INC
0 10 20 30
Time (months)
0 10 20 30
Time (months)
Chou et al
No intervention v WHO-5+INC+GOAL
0 20 40 60
Time (months)
0 20 40 60
Time (months)
Marra et al
No intervention v WHO-5
0 5 10 15
Time (months)
0 5 10 15
Time (months)
0 5 10 15
Time (months)
Helms et al
No intervention v WHO-5
0 5 10 150
02
04
06
08
10
Time (months)
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Kirkland et alNo intervention v WHO-5
0 10 20 30 40 50
Time (months)
0 1 2 3 4 5
Time (months)
0 10 20 30 40 50
Time (months)
0 05 10 15 20 25
Time (months)
0 05 10 15 20 25
Al-Tawfiq et alNo intervention v WHO-5+GOAL
Time (months)
Talbot et al phase I-IIEDU v WHO-5+INC+GOAL
0 10 20 20 40
Talbot et al phase II-IIIWHO-5+INC+GOALv WHO-5+INC+GOAL+ACC
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Derde et alREM v EDU+FED+REM
Time (months)
Doron et alSYS+EDU+FED+REMv WHO-5
0 5 10 15 20
Crews et alEDU v SYS+EDU+FED+REM+INC+GOAL
Dubbert et alNo intervention v EDU+FED
0
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Tibballs et alSYS v SYS+EDU
Time (months)
Khatib et alEDU v EDU+FED
0 05 10 15 20
Time (months)
Jaggi et alUnclear interventions
0 10 20 30 40
Time (months)
Armellino et al 2012No intervention v FED+GOAL
0 2 4 6 80
02
04
06
08
10
P r o b a b i l i t y o f h a n d
h y g i e n e c o m p l i a n c e
Armellino et al 2013No intervention v FED+GOAL
Salmon et alNo intervention v EDU
0
02
04
06
08
10
Fig 983092 | Re-analysis o studies involving interrupted time series where the outcome was hand hygiene compliance Points represent observations solidlines show expected values rom fitted segmented regression models and broken lines represent extrapolated trends beore intervention SYS=system
change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountabilityWHO-983093=combined intervention strategies including SYS EDU FED REM and SAF
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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RESEARCH
9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
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RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
Fig 983093 | Forest plot showing effect size as mean log odds ratios or hand hygiene compliance or all direct pairwise comparisonsrom interrupted time series studies Lee and colleagues983092983096 was a multi-centre study In hospitals 983096 and 983097 baseline strategy wasalready equivalent to WHO-983093 SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety
climate INC=incentives GOAL=goal setting ACC=accountability WHO-983093=combined intervention strategies including SYSEDU FED REM and SAF
Table 983091 | Results o re-analysis o studies using interrupted time series to assess compliance with hand hygiene
Armellino983091983096dagger No intervention v FED+GOAL 983095983094 minus983090983092983097983091 (983088983089983093) minus983088983088983096 983096 (983088983089983091983091) 983088983096983092983097 (983088983090983091983093) 983091983088983092983094 (983088983094983096) 983092983093983092 (983091983096983093 to 983093983090983091)
Armellino983091983095dagger No intervention v FED+GOAL 983090983097983088 minus983088983096983097983093 (983088983088 983092) 983088983089983090983090 (983088983089983088) minus983088983089983088983097 (983088983088983096) 983090983090983094983095 (983088983089983092) 983095983092983097 (983094983093983093 to 983096983092983092)
Salmon983093983092Dagger No inter vention v EDU 983092983090983095 minus983088983090983097983093 (983088983089983095) 983088983088983088983091 (983088983088983090) 983088983088983090983089 (983088983088983090) 983088983092983096983093 (983088983090983090) 983089983095983097 ( minus983088983091 to 983091983094983090)
SYS=system change EDU=education FED=eedback REM=reminders SAF =institutional saety climate INC=incentives GOAL=goal setting ACC=accountability WHO -983093=combinedintervention strategies including SYS EDU FED REM and SAFMean change in hand hygiene compliance during period afer intervention period attributed to intervention accounting or baseline trends (see appendix 983091 or details)daggerEvidence o autocorrelation Newey-West standard errors reportedDaggerHand hygiene compliance measured in student nurses
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RESEARCH
9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
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RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
analysis
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RESEARCH
9
hygiene all components of the intervention were
already in place in the baseline period983092983096
Twelve pairwise comparisons met the criteria for net-
work meta-analysis and included direct comparisons
between all pairs of strategies except WHO-983093 versus
WHO-983093+ and no intervention versus single intervention
(fig 983094 ) The network meta-analysis showed that
although there was large uncertainty in effect sizes
among the pairwise comparisons point estimates for
all intervention strategies indicated an improvement in
compliance with hand hygiene compared with no inter-
vention (fig 983095 ) When two strategies WHO-983093 and WHO-
983093+ were compared with no intervention there was
strong evidence that they were effective (table 983090 ) The
WHO983093+ strategy also showed additional improvement
compared with single intervention strategies and
WHO-983093 alone For the latter comparison which
depended only on indirect comparisons the estimated
effect size was similar to that seen in the randomised
controlled trials though uncertainty was much larger
(odds ratio for WHO-983093 versus WHO-983093+ was 983089983096983090 983097983093
credible interval 983088983090 to 983089983090983090) WHO-983093+ had the highest
probability (983094983095) of being the best strategy in improv-
ing compliance (fig 983096)
After we excluded studies with multiple stepwise
interventions in the sensitivity analysis there was a
decrease in the effect size of all intervention strategies
(appendix 983092)
Clinical outcomes
Nineteen studies reported clinical or microbiological
outcomes alongside hand hygiene outcomes Six of
these were multicentre studies983091983093 983092983090 983092983096 983093983093 983094983090 983094983095 and 983089983091 were
based in a single hospital983090983096-983091983088 983092983094 983092983095 983092983097 983093983090 983093983094 983093983095 983093983097 983094983091 983094983094 983094983097 Allreported that improvements in hand hygiene were asso-
ciated with reductions in at least one measure of hospi-
tal acquired infection andor resistance rates In most
WHO-5
WHO-5+
None Single
Fig 983094 | Network structure or network meta-analysis o ourhand hygiene intervention strategies rom interrupted timeseries studies Intervention strategies were none (nointervention) single intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentives goal-setting or accountability)
Intervention strategies
O
s r a t i o
Singleintervention
WHO-5 WHO-5+0
1
2
5
20
100
Fig 983095 | Box-and-whiskers plot showing relative efficacy odifferent hand hygiene intervention strategies comparedwith standard o care estimated by network meta-analysisrom interrupted time series studies Lower and upperedges represent 983090983093th and 983095983093th centiles rom posteriordistribution central line median Whiskers extend to 983093thand 983097983093th centiles Intervention strategies were single
intervention WHO-983093 and WHO-983093+ (WHO-983093 with incentivesgoal-setting or accountability) Appendix 983097 shows resultsrom sensitivity analysis that excluded studies whereinterventions were implemented as multiple time points
P r o b a b i l i t y
WHO-5+
1
0
02
04
06
08
10
2 3 4
WHO-5
1 2 3 4
P r o b a b i l i t y
Single intervention
0
02
04
06
08
10
No interventioncurrent practice
Fig 983096 | Rankograms showing probabilities o possible rankings or each intervention strategy (rank 983089=best rank 983092=worst)
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1414
RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
data has also been proposed983095983094 Cost effectiveness anal-
ysis of promotion of hand hygiene is required to assess
under what circumstances these initiatives represent
good value for money and when resources might be bet-
ter directed at supplemental interventions including
care bundles983095983095 ward cleaning983095983096 and screening and
decolonisation983095983097 to complement well maintained com-
pliance with hand hygiene
Strengths and limitations o study
A particular strength of our study is that the network
meta-analysis allowed us to quantify the relative effi-
cacy among a series of different intervention strategies
with different baseline interventions even where the
direct head-to-head comparisons were absent
This study also has several limitations Firstly
details on implementation of components of the inter-
vention varied substantially For example personal
feedback and group feedback were classified together
but in practice the impacts of these strategies can
vary Moreover different studies might implement the
same programme with different quality of delivery and
level of adherence so called intervention fidelity or
type III error983096983088 Both issues are common to many inter-
ventions to improve the quality of care in hospital set-
tings and are likely to be responsible for much of the
unexplained heterogeneity between studies983096983089 983096983090 Sec-
ondly direct observation of compliance with hand
hygiene might induce an increase in compliance unre-
lated to the intervention (the Hawthorne effect)
Recent research suggests that such Hawthorne effects
can lead to substantial overestimation of compli-
ance983096983091 983096983092 Such effects however should not bias esti-
mates of the relative efficacy of different interventionsfrom randomised controlled trials and interrupted
time series unless the effects vary between study arms
intervention periods Thirdly it is possible that it is the
novelty of the intervention itself that leads to improve-
ments in compliance and that any sufficiently novel
intervention would do the same regardless of the com-
ponents used This clearly cannot be ruled out and is
not necessarily inconsistent with our findings that
interventions with more components tend to perform
better At present however there are too few high
quality studies to evaluate whether individual compo-
nents of interventions show consistent differences
that cannot be explained by novelty alone Fourthresults might be distorted by publication bias Fifth
there might also be a low level of language bias
because we excluded studies in languages other than
English The magnitude of such bias however is likely
to be small983096983093 983096983094
Finally linking improved compliance to clinical out-
comes such as number of infections prevented would
provide more direct evidence about the value of such
interventions983089983088 Such direct evidence is still limited in
hospital settings although the association is supported
by a growing body of indirect evidence as well as bio-
logical plausibility Moreover findings from studies
included in our review that reported clinical or microbi-ological outcomes are consistent with substantial
reductions in infections for some pathogens such as
MRSA resulting from large improvements in hand
hygiene983096983095 983096983096 The lack of a measureable effect of
improved hand hygiene on MSSA infections might seem
paradoxical but can be partly explained by the fact that
MSSA infections are much more likely to be of endoge-
nous origin whereas MRSA is more often linked to nos-
ocomial cross transmission Moreover predictions from
modelling studies that hand hygiene will have a dispro-
portionate effect on the prevalence of resistant bacteria
in hospitals (provided resistance is rare in the commu-
nity) seem to have been borne out in practice983096983097
Conclusions
While there is some evidence that single component
interventions lead to improvements in hand hygiene
there is strong evidence that the WHO-983093 intervention
can lead to substantial rapid and sustained improve-
ments in compliance with hand hygiene among health-
care workers in hospital settings There is also evidence
that goal setting reward incentives and accountability
provide additional improvements beyond those
achieved by WHO-983093 Important directions for future
work are to improve reporting on resource implications
for interventions increasingly focus on strong study
designs and evaluate the long term sustainability and
cost effectiveness of improvements in hand hygiene
We are grateul to all authors o the literature included in this reviewwho responded to requests or additional inormation We also thankthe inection control staff o Sappasithiprasong Hospital or technicalsupport and Cecelia Favede or help in editing
Contributors NL BSC YL DL NG and ND contributed to the studyconception and design NL and BSC extracted data and NL perormedthe data analysis NL wrote the first draf DL YL MH ASL SH NG ND
and BSC critically revised the manuscript or important intellectualcontent All authors read and approved the final manuscript NL andBSC are guarantors
Funding This research was part o the Wellcome Trust-MahidolUniversity-Oxord Tropical Medicine Research Programme supportedby the Wellcome Trust o Great Britain (983088983096983097983090983095983093Z983088983097Z) BSC wassupported by the Oak Foundation and the Medical Research Counciland Department or International Development (grant No MRK983088983088983094983097983090983092983089)
Competing interests All authors have completed the ICMJE uniormdisclosure orm at httpwwwicmjeorgcoi_disclosurepd anddeclare no financial relationships with any organisations that mighthave an interest in the submitted work in the previous three years noother relationships or activities that could appear to have inluencedthe submitted work
Ethical approval Not required
Data sharing The relevant data and code used in this study areavailable rom the authors
Transparency The lead author affirms that this manuscript is anhonest accurate and transparent account o the study being reportedthat no important aspects o the study have been omitted and thatany discrepancies rom the study as planned (and i relevantregistered) have been explained
This is an Open Access article distributed in accordance with the termso the Creative Commons Attribution (CC BY 983092983088) license whichpermits others to distribute remix adapt and build upon this work orcommercial use provided the original work is properly cited Seehttpcreativecommonsorglicensesby983092983088
983089 Weinstein RA Nosocomial inection update Emerg Infect Dis 983089983097983097983096983092983092983089983094-983090983088
983090 Jarvis WR Selected aspects o the socioeconomic impact onosocomial inections morbidity mortality cost and preventionInfect Control Hosp Epidemiol 983089983097983097983094983089983095983093983093983090-983095
983091 Rosenthal VD Maki DG Jamulitrat S et al International NosocomialInection Control Consortium (INICC) report data summary or983090983088983088983091-983090983088983088983096 issued June 983090983088983088983097 Am J Infect Control 983090983088983089983088983091983096983097983093-983089983088983092e983090
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
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RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
analysis
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1314thebmj 983164 BMJ 2015351h3728 983164 doi 101136bmjh3728
RESEARCH
13
983092 WHO guidelines on hand hygiene in health care (First global patientsaety challenge clean care is saer care) WHO 983090983088983088983097
983093 Gould DJ Moralejo D Drey N Chudleigh JH Interventions to improvehand hygiene compliance in patient care Cochrane Database SystRev 983090983088983089983089983097CD983088983088983093983089983096983094
983094 Huis A van Achterberg T de Bruin M et al A systematic review ohand hygiene improvement strategies a behavioural approachImplement Sci 983090983088983089983090983095983097983090
983095 Schweizer ML Reisinger HS Ohl M et al Searching or an optimal
hand hygiene bundle a meta-analysis Clin Infect Dis 983090983088983089983092983093983096983090983092983096-983093983097983096 Naikoba S Haryeard A The effectiveness o interventions aimed at
983097 Drummond MF Sculpher MJ Torrance GW OrsquoBrien BJ Stoddart GLMethods or the economic evaluation o health care programmesOxord University Press 983090983088983088983093
983089983088 Graves N Halton K Page K Barnett A Linking scientific evidence anddecision making a case study o hand hygiene interventions InfectControl Hosp Epidemiol 983090983088983089983091983091983092983092983090983092-983097
983089983089 Moher D Liberati A Tetzlaff J Altman DG The PRISMA Group (983090983088983088983097)preerred reporting items or systematic reviews and meta-analysesthe PRISMA statement PLoS Med 983090983088983088983097983094e983089983088983088983088983088983097983095
983089983090 Effective Practice and Organisation o Care (EPOC) What study designsshould be included in an EPOC review EPOC Resources or reviewauthors Norwegian Knowledge Centre or the Health Services 983090983088983089983091httpepoccochraneorgepoc-specific-resources-review-authors
983089983091 Cochrane Effective Practice and Organisation o Care Review Group
Data Collection Checklist EPOC Resources or review author sNorwegian Knowledge Centre or the Health Services 983090983088983089983091 httpepoccochraneorgsitesepoccochraneorgfilesuploadsdatacollectionchecklistpd
983089983092 Higgins JPT Green S Cochrane handbook or systematic reviews ointerventions Version 983093983089983088 [updated March 983090983088983089983089] The CochraneCollaboration 983090983088983089983089 wwwcochrane-handbookorg
983089983093 DerSimonian R Laird N Meta-analysis in clinical trials Control ClinTrials 983089983097983096983094983095983089983095983095-983096983096
983089983094 Borenstein M Hedges LV Higgins JPT Rothstein HR Identiying andquantiying heterogeneity Part 983092 Heterogeneity In Introduction tometa-analysis John Wiley 983090983088983088983097983089983088983095-983090983093
983089983095 Peters JL Sutton AJ Jones DR Abrams KR Rushton L Contour-enhanced meta-analysis unnel plots help distinguish publicationbias rom other causes o asymmetry J Clin Epidemiol 983090983088983088983096983094983089983097983097983089-983094
983089983096 Taljaard M McKenzie JE Ramsay CR Grimshaw JM The use osegmented regression in analysing interrupted time seriesstudies an example in pre-hospital ambulance care Implement Sci
983090983088983089983092983097983095983095983089983097 Ramsay CR Matowe L Grilli R Grimshaw JM Thomas RE Interruptedtimeseries designs in health technology assessment lessons romtwo systematic reviews o behavior change strategies Int J Technol
Assess Health Care 983090983088983088983091983089983097983094983089983091-983090983091983090983088 Vidanapathirana J Abramson M Forbes A Fairley C Mass media
interventions or promoting HIV testing Cochrane Database Syst Rev 983090983088983088983093983091CD983088983088983092983095983095983093
983090983089 Newey WK West KD A simple positive semi-definiteheteroskedasticity and autocorrelation consistent covariance matrixEconometrica 983089983097983096983095983093983093983095983088983091-983096
983090983090 Bolker BM Ecological models and data in R Princeton UniversityPress 983090983088983088983096
983090983091 R Core Team R A language and environment or statisticalcomputing R Foundation or Statistical Computing 983090983088983089983092wwwR-projectorg
983090983092 Lu G Ades AE Combination o direct and indirect evidence in mixedtreatment comparisons Stat Med 983090983088983088983092983090983091983091983089983088983093-983090983092
983090983093 Sutton A Ades AE Cooper N Abrams K Use o indirect and mixed
treatment comparisons or technology assessmentPharmacoeconomics 983090983088983088983096983090983094983095983093983091-983094983095
983090983094 Spiegelhalter DJ Thomas A Best N Lunn D WinBUGS user manualVersion 983089983092 January 983090983088983088983091 wwwmrc-bsucamacukbugs
983090983095 Dias S Welton NJ Caldwell DM Ades AE Checking consistency inmixed treatment comparison meta-analysis Stat Med 983090983088983089983088983090983097983097983091983090-983092983092
983090983096 Al-Tawfiq JA Abed MS Al-Yami N Promoting and sustaining ahospital-wide multiaceted hand hygiene program resulted insignificant reduction in health care-associated inections
Am J Infect Control 983090983088983089983091983092983089983092983096983090-983094983090983097 Kirkland KB Homa KA Lasky RA et al Impact o a hospital-wide hand
hygiene initiative on healthcare-associated inections results o aninterrupted time series BMJ Qual Saf 983090983088983089983090983090983089983089983088983089983097-983090983094
983091983088 Helms B Dorval S Laurent P Winter M Improving hand hygienecompliance a multidisciplinary approach Am J Infect Control 983090983088983089983088983091983096983093983095983090-983092
983091983089 Fisher DA Seetoh T Oh May-Lin H et al Automated measures o handhygiene compliance among healthcare workers using ultrasoundvalidation and a randomized controlled trial Infect Control HospEpidemiol 983090983088983089983091983091983092983097983089983097-983090983096
983091983090 Fuller C Michie S Savage J et al The Feedback Intervention Trial(FIT)mdashimproving hand-hygiene compliance in UK healthcare workersa stepped wedge cluster randomised controlled trial PLoS ONE 983090983088983089983090983095e983092983089983094983089983095
983091983091 Huang J Jiang D Wang X et al Changing knowledge behavior andpractice related to universal precautions among hospital nurses inChina J Contin Educ Nurs 983090983088983088983090983091983091983090983089983095-983090983092
983091983092 Huis A Schoonhoven L Grol R et al Impact o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983092983094983092-983095983092983091983093 Mertz D Daoe N Walter SD Brazil K Loeb M Effect o a multiaceted
intervention on adherence to hand hygiene among healthcareworkers a cluster-randomized trial Infect Control Hosp Epidemiol 983090983088983089983088983091983089983089983089983095983088-983094
983091983094 Salamati P Poursharifi H Rahbarimanesh AA Koochak HE Najfi ZEffectiveness o motivational interviewing in promoting hand hygieneo nursing personnel Int J Prev Med 983090983088983089983091983092983092983092983089-983095
983091983095 Armellino D Trivedi M Law I et al Replicating changes in handhygiene in a surgical intensive care unit with remote video auditingand eedback Am J Infect Control 983090983088983089983091983092983089983097983090983093-983095
983091983096 Armellino D Hussian E Schilling ME et al Using high-technology toenorce low-technology saety measures the use o third-partyremote video auditing and real-time eedback in healthcare ClinInfect Dis 983090983088983089983090983093983092983089-983095
983091983097 Chan BP Homa K Kirkland KB Effect o varying the number andlocation o alcohol-based hand rub dispensers on usage in a generalinpatient medical unit Infect Control Hosp Epidemiol 983090983088983089983091983091983092983097983096983095-983097
983092983088 Chou T Kerridge J Kulkarni M Wickman K Malow J Changing theculture o hand hygiene compliance using a bundle that includes aviolation letter Am J Infect Control 983090983088983089983088983091983096983093983095983093-983096
983092983089 Crews JD Whaley E Syblik D Starke J Sustained improvement in handhygiene at a childrenrsquos hospital Infect Control Hosp Epidemiol 983090983088983089983091983091983092983095983093983089-983091
983092983090 Derde LPG Cooper BS Goossens H et al Interventions to reducecolonisation and transmission o antimicrobial-resistant bacteria inintensive care units an interrupted time series study and clusterrandomised trial Lancet Infect Dis 983090983088983089983092983089983092983091983089-983097
983092983091 Doron SI Kiuji K Hynes BT et al A multiaceted approach toeducation observation and eedback in a successul hand hygienecampaign Jt Comm J Qual Patient Saf 983090983088983089983089983091983095983091-983089983088
983092983092 Helder OK Weggelaar AM Waarsenburg DCJ et al Computer screensaver hand hygiene inormation curbs a negative trend in handhygiene behavior Am J Infect Control 983090983088983089983090983092983088983097983093983089-983092
983092983093 Higgins A Hannan M Improved hand hygiene technique andcompliance in healthcare workers using gaming technology
J Hosp Infect 983090983088983089983091983096983092983091983090-983095983092983094 Jaggi N Sissodia P Multimodal supervision programme to reducecatheter associated urinary tract inections and its analysis to enableocus on labour and cost effective inection control measures in atertiary care hospital in India J Clin Diagn Res 983090983088983089983090983094983089983091983095983090-983094
983092983095 Koff MD Corwin HL Beach ML Surgenor SD Lofus RW Reduction inventilator associated pneumonia in a mixed intensive care unit aferinitiation o a novel hand hygiene program J Crit Care 983090983088983089983089983090983094983092983096983097-983097983093
983092983096 Lee AS Cooper BS Malhotra-Kumar S et al Comparison o strategiesto reduce meticillin-resistant Staphylococcus aureus rates in surgicalpatients a controlled multicentre intervention trial BMJ Open 983090983088983089983091983091e983088983088983091983089983090983094
983092983097 Lee YT Chen SC Lee MC et al Time-series analysis o the relationshipo antimicrobial use and hand hygiene promotion with the incidenceo healthcare-associated inections J Antibiot (Tokyo) 983090983088983089983090983094983093983091983089983089-983094
983093983088 Marra AR Noritomi DT Westheimer Cavalcante AJ et al A multicenterstudy using positive deviance or improving hand hygienecompliance Am J Infect Control 983090983088983089983091983092983089983097983096983092-983096
983093983089 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviancea program or sustained improvement in hand hygiene compliance
Am J Infect Control 983090983088983089983089983091983097983089-983093983093983090 Mestre G Berbel C Tortajada P et al ldquoThe 983091983091 strategyrdquo a successul
multiaceted hospital wide hand hygiene intervention based on WHOand continuous quality improvement methodology PLoS One 983090983088983089983090983095e983092983095983090983088983088
983093983091 Morgan DJ Pineles L Shardell M et al Automated hand hygienecount devices may better measure compliance than humanobservation Am J InfectControl 983090983088983089983090983092983088983097983093983093-983097
983093983092 Salmon S Wang XB Seetoh T Lee SY Fisher DA A novel approach toimprove hand hygiene compliance o student nurses AntimicrobResist Infect Control 983090983088983089983091983090983089983094
983093983093 Stone SP Fuller C Savage J et al Evaluation o the nationalCleanyourhands campaign to reduce Staphylococcus aureusbacteraemia and Clostridium difficile inection in hospitals in Englandand Wales by improved hand hygiene our year prospectiveecological interrupted time series study BMJ 983090983088983089983090983091983092983092e983091983088983088983093
983093983094 Talbot TR Johnson JG Fergus C et al Sustained improvement in handhygiene adherence utilizing shared accountability and financialincentives Infect Control Hosp Epidemiol 983090983088983089983091983091983092983089983089983090983097-983091983094
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1414
RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity
analysis
7212019 Bmjh3728Full
httpslidepdfcomreaderfullbmjh3728full 1414
RESEARCH
983093983095 Vernaz N Sax H Pittet D et al Temporal effects o antibiotic use andhand rub consumption on the incidence o MRSA and Clostridiumdifficile J Antimicrob Chemother 983090983088983088983096983094983090983094983088983089-983095
983093983096 Whitby M McLaws ML Slater K Tong E Johnson B Three successulinterventions in health care workers that improve compliance withhand hygiene is sustained replication possible Am J Infect Control 983090983088983088983096983091983094983091983092983097-983093983093
983093983097 Yngstrom D Lindstrom K Nystrom K et al Healthcare-associatedinections must stop a breakthrough project aimed at reducing
healthcare-associated inections in an intensive-care unit BMJ QualSaf 983090983088983089983089983090983088983094983091983089-983094983094983088 Dubbert PM Dolce J Richter W Miller M Chapman SW Increasing ICU
staff handwashing effects o education and group eedback InfectControl Hosp Epidemiol 983089983097983097983088983089983089983089983097983089-983091
983094983089 Eldridge NE Wood SS Bonello RS et al Using the six sigma processto implement the Centers or Disease Control and Preventionguideline or hand hygiene in 983092 intensive care units J Gen Intern Med 983090983088983088983094983090983089(suppl 983090)S983091983093-983092983090
983094983090 Grayson ML Jarvie LJ Martin R et al Significant reductions inmethicillin-resistant Staphylococcus aureus bacteraemia and clinicalisolates associated with a multisite hand hygiene culture-changeprogram and subsequent successul statewide roll-out Med J Aust 983090983088983088983096983090983089983096983096983094983091983091-983092983088
983094983091 Johnson PD Martin R Burrell LJ et al Efficacy o an alcoholchlorhexidine hand hygiene program in a hospital with high rates onosocomial methicillin-resistant Staphylococcus aureus (MRSA)inection Med J Aust 983090983088983088983093983089983096983091983093983088983097-983089983092
983094983092 Khatib M Jamaleddine G Abdallah A Ibrahim Y Hand washing and
use o gloves while managing patients receiving mechanicalventilation in the ICU Chest 983089983097983097983097983089983089983094983089983095983090-983093
983094983093 Tibballs J Teaching hospital medical staff to handwash Med J Aust 983089983097983097983094983089983094983092983091983097983093-983096
983094983094 Mayer J Mooney B Gundlapalli A et al Dissemination andsustainability o a hospital-wide hand hygiene program emphasizingpositive reinorcement Infect Control Hosp Epidemiol 983090983088983089983089983091983090983093983097-983094983094
983094983095 Benning A Dixon-Woods M Nwulu U et al Multiple componentpatient saety intervention in English hospitals controlled evaluationo second phase BMJ 983090983088983089983089983091983092983090d983089983097983097
983094983096 Gould D Chamberlain A The use o a ward-based educationalteaching package to enhance nursesrsquo compliance with inectioncontrol procedures J Clin Nurs 983089983097983097983095983094983093983093-983094983095
983094983097 Marra AR Guastelli LR de Arauacutejo CM et al Positive deviance a newstrategy or improving hand hygiene compliance Infect Control HospEpidemiol 983090983088983089983088983091983089983089983090-983090983088
983095983088 Huis A Hulscher M Adang E et al Cost-effectiveness o a team andleaders-directed strategy to improve nursesrsquo adherence to hand
hygiene guidelines a cluster randomised trial Int J Nurs Stud 983090983088983089983091983093983088983093983089983096-983090983094983095983089 Mestre G Berbel G Tortajada P et al Monitoratge periogravedic retroaccioacute
immediata i treball en equip claus de lrsquoegravexit i sostenibilitat delrsquoestrategravegia 983091983091 drsquohigiene de mans Annals de Medicina 983090983088983089983091983097983094983089-983095
983095983090 Ansari F Grey K Nathwani D et al Outcomes o an intervention toimprove hospital antibiotic prescribing interrupted time series withsegmented regression analysis J Antimicrob Chemother 983090983088983088983091983093983090983096983092983090-983096
983095983091 Davey P Brown E Charani E et al Interventions to improve antibioticprescribing practices or hospital inpatients Cochrane Database SystRev 983090983088983089983091983091983088CD983088983088983091983093983092983091
983095983092 Marwick CA Guthrie B Pringle JEC et al A multiaceted interventionto improve sepsis management in general hospital wards withevaluation using segmented regression o interrupted time seriesBMJ Qual Saf 983090983088983089983092983090983091e983090
983095983093 Graves N Halton K Lairson D Economics and preventinghospital-acquired inection broadening the perspective InfectControl Hosp Epidemiol 983090983088983088983095983090983096983089983095983096-983096983092
983095983094 Page K Graves N Halton K Barnett AG Humans ldquothingsrdquo and spacecosting hospital inection control interventions J Hosp Infect 983090983088983089983091983096983092983090983088983088-983093
983095983095 Aboelela SW Stone PW Larson EL Effectiveness o bundledbehavioural interventions to control healthcare-associated inectionsa systematic review o the literature J Hosp Infect 983090983088983088983095983094983094983089983088983089-983096
983095983097 Harbarth S Fankhauser C Schrenzel J et al Universal screening or
methicillin-resistant Staphylococcus aureus at hospital admission andnosocomial inection in surgical patients JAMA 983090983088983088983096983090983097983097983089983089983092983097-983093983095983096983088 Carroll C Patterson M Wood S et al A conceptual ramework or
implementation fidelity Implement Sci 983090983088983088983095983091983088983092983088983096983089 Dijkstra R Wensing M Thomas R et al The relationship between
organisational characteristics and the effects o clinical guidelines onmedical perormance in hospitals a meta-analysis BMC Health ServRes 983090983088983088983094983090983096983093983091
983096983090 Turner RM Spiegelhalter DJ Smith GC Thompson SG Bias modellingin evidence synthesis J R Stat Soc Ser A Stat Soc 983090983088983088983097983089983095983090983090983089-983092983095
983096983091 Hagel S Reischke J Kesselmeier M et al Quantiying the HawthorneEffect in hand hygiene compliance through comparing directobservation with automated hand hygiene monitoring Infect ControlHosp Epidemiol 983090983088983089983093Apr 983090983091983089-983094
983096983092 Srigley JA Furness CD Baker GR Gardam M Quantification o theHawthorne effect in hand hygiene compliance monitoring using anelectronic monitoring system a retrospective cohort study BMJ QualSaf 983090983088983089983092983090983091983097983095983092-983096983088
983096983093 Juumlni P Holenstein F Sterne J Bartlett C Egger M Direction and impact
o language bias in meta-analyses o controlled trials empirical studyInt J Epidemiol 983090983088983088983090983091983089983089983089983093-983090983091
983096983094 Morrison A Polisena J Husereau D et al The effect o English-language restriction on systematic review-based meta-analysesa systematic review o empirical studies Int J Technol Assess HealthCare 983090983088983089983090983090983096983089983091983096-983092983092
983096983095 Bauer TM Oner E Just HM Just H Daschner F An epidemiologicalstudy assessing the relative importance o airborne and directcontact transmission o microorganisms in a medical intensive careunit J Hosp Infect 983089983097983097983088983089983093983091983088983089-983097
983096983096 Hugonnet S Pittet D Hand hygiene-belies or science Clin MicrobiolInfect 983090983088983088983088983094983091983093983088-983094
983096983097 Lipsitch M Bergstrom CT Levin BR The epidemiology o antibioticresistance in hospitals paradoxes and prescriptions Proc Natl AcadSci USA 983090983088983088983088983097983095983089983097983091983096-983092983091
copy BMJ Publishing Group Ltd 983090983088983089983093
Appendix 983089 Complete search strategy
Appendix 983090 Classification for level of information on
resources use
Appendix 983091 Analysis of interrupted time series data
Appendix 983092 WINBUGs code for network meta-analysis
Appendix 983093 Excluded studies with reason by EPOC
criteria
Appendix 983094 Details of included studies
Appendix 983095 Funnels plots figs A-D
Appendix 983096 Details of extracted intervention
components and level of information on resource use
Appendix 983097 Supplementary results from sensitivity