Asssigment

Special articles (or Research methods)

Evidence-based practices to increase hand hygiene compliance in health care facilities: An integrated review

Jun Rong Jeffrey Neo BS a,*, Rana Sagha-Zadeh MArch, PhD a, Ole Vielemeyer MD b, Ella Franklin RN, BSN c

a Department of Design and Environmental Analysis, Cornell University, Ithaca, NY b Division of Infectious Disease, Weill Cornell Medical College, New York, NY c National Center for Human Factors in Healthcare, MedStar Health, Washington, DC

Background: Hand hygiene (HH) in health care facilities is a key component to reduce pathogen trans- mission and nosocomial infections. However, most HH interventions (HHI) have not been sustainable. Aims: This review aims to provide a comprehensive summary of recently published evidence-based HHI designed to improve HH compliance (HHC) that will enable health care providers to make informed choices when allocating limited resources to improve HHC and patient safety. Methods: The Medline electronic database (using PubMed) was used to identify relevant studies. English language articles that included hand hygiene interventions and related terms combined with health care environments or related terms were included. Results: Seventy-three studies that met the inclusion criteria were summarized. Interventions were cat- egorized as improving awareness with education, facility design, and planning, unit-level protocols and procedures, hospital-wide programs, and multimodal interventions. Past successful HHIs may not be as effective when applied to other health care environments. HH education should be interactive and engaging. Electronic monitoring and reminders should be implemented in phases to ensure cost- effectiveness. To create hospitalwide programs that engage end users, policy makers should draw expertise from interdisciplinary fields. Before implementing the various components of multimodal interven- tions, health care practitioners should identify and examine HH difficulties unique to their organizations. Conclusions: Future research should seek to achieve the following: replicate successful HHI in other health care environments, develop reliable HHC monitoring tools, understand caregiver-patient-family interactions, examine ways (eg, hospital leadership, financial support, and strategies from public health and infection prevention initiatives) to sustain HHC, and use simulated lab environments to refine study designs. © 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier

Inc. All rights reserved.

BACKGROUND

Despite many efforts, health care-associated infections (HAI) con- tinue to be a threat to hospital patients. Whereas various factors account for HAIs,1 contact transmission is a key pathway.2 Thus, hand hygiene (HH) with soap andwater or alcohol-based handrub (ABHR) is regarded as among the most important interventions to prevent HAI.3 As far as 150 years ago, Ignaz Semmelweis described a sub- stantial drop in mortality rates with simple HH.4

In complex modern health care environments, health care workers (HCWs) are constantly on the move and respond to stressful and time-sensitivework demands. Thus, sustaining HH com- pliance (HHC) remains a challenge.5 In fact, public health authorities have rated HHC among HCWs to be unacceptably poor.6 In one review, for example, HHC only reached 30%-40% in intensive care units (ICUs).7,8 According to the World Health Organization (WHO), several types of microbes (eg, Staphylococcus aureus, Streptococcus pyogenes, and vancomycin-resistant Enterococcus) can be spread through the hands of HCWs due to lapses in HH. HCW hands can be contaminated even after various “clean” procedures (eg, taking a pulse). Several studies have suggested that contaminated hands can increase the spread of microbes and HAI, which are a threat to patients.9 According to the Centers for Disease Control and Preven- tion (CDC), in 2011, the total number of HAI cases in the United States

* Address correspondence to Jun Rong Jeffrey Neo, BS, 2425Martha Van Rensselaer Hall, Ithaca, New York 14850.

E-mail address: [email protected] (J.R.J. Neo). Conflicts of Interest: None to report.

0196-6553/© 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.ajic.2015.11.034

American Journal of Infection Control 44 (2016) 691-704

Contents lists available at ScienceDirect

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alonewas estimated to be 721,800 and cost the US health care system $35 billion.10 In 2000, Pitiet et al11 noted that “HHC level does not rely on individual factors alone, and [that] the same can be said for its promotion.” For example, besides personal variables, environ- ment conditions, social norms, and organizational policies are some factors that may affect HHC.

HH is defined as the act of handwashing with soap and water or disinfectionwith an antiseptic agent.6,7 Accordingly, HHC refers to the extent to which HH behavior matches or conforms to recommen- dations or guidelines.12,13 An HH intervention (HHI) is defined as a hand sanitization program implemented by an organization to in- creaseHHC. It canrange indesign fromsimple (eg, increasedavailability of cleaning agents) to complex (eg, multimodal intervention [MMI] program involving education, facility design, and performance feed- back). In addition, HHI could also be studied to reduce HAI.14

Given that the behavior change process is multifaceted and complex, an HHI that targets only a specific user or area often fail to yield positive results.11 Although some evidence-based HHIs have been developed, sustaining HHC among HCWs remains difficult, ul- timately threatening health care quality and safety.15 That being said, several government agencies have provided guideline and/or tools to improve HHC in health care systems. In 2002, the CDC pro- duced guidelines for HH in health-care settings.16 The guideline provides HCWs with a data review for handwashing and hand an- tisepsis in health care environments. The review also provides in- depth recommendations to improve HHC and reduce pathogenic microorganism transmissions in health care environments.16 In 2005, the Institute for Healthcare Improvement, in collaboration with the CDC, the Association for Professionals in Infection Control and Epi- demiology, and the Society of Healthcare Epidemiology of America produced “How-to Guide: Improving Hand Hygiene.”17 The guide includes a description of the case for improving HH and use of gloves among HCWs, recommended evidence-based HH that will result in improved HH, steps to improve HHC in health care organizations, and measurement support tools.17 According to The Joint Commis- sion, HH is the most critical intervention for preventing HAI. The Joint Commission provides resources that include HH solutions avail- able from the Center for Transforming Healthcare, and a monograph on measuring hand hygiene adherence, among others.18

Recently, with increased public awareness and robust research activity in this area, a growing number of articles and reviews have been published. The latter mostly focus on documenting and sum- marizing various kinds of HHI. In 2008, Backman, Zoutman, and Marck14 reviewed 35 publications that examined the effectiveness of various HHIs and called for more rigorous studies to provide ev- idence on the influence of specific HHIs on HAI prevention.

More recently, Marra and Edmond19 discussed new technolo- gies to monitor HHC among HCWs. They concluded that before making significant investments, more analyses are needed to assess the effectiveness of these HH technologies. As new technologies to

monitor HHC are constantly developed, interdisciplinary teams need to collaborate in the planning phase.

Our review provides a comprehensive summary of recently pub- lished HHIs aimed at improving HHC, paying special attention to capture and discuss the full breadth of HHI types. It also provides a useful framework to enable health care providers to make in- formed choices when allocating limited resources to improve HHC and patient safety.

METHODS

Search strategy

The electronic database Medline (using PubMed) was used. A search included articles in English with the MESH headings: handwash*, hand hygiene, intervention*, program*, technique*, tech- nology*, protocol*, compliance*, and observance. These words were combined with 1 of the following terms: hospital*, and healthcare environment*. An asterisk is used as a truncation symbol that allow us to search the “root” of a word to find all its different endings. For example, technology* finds technologies, technological, and the like. Table A1 provides the full list of search terms. Of the 151 ar- ticles retrieved, 73 articles met the inclusion criteria.

Two reviewers (JN and RZ) independently evaluated the 151 re- trieved articles. Following the initial round of independent reviews, the reviewers (JN and RZ) discussed the rationale as to why some articles were included or excluded from the review, based on the inclusion and exclusion criteria.

Inclusion and exclusion criteria

The findings were analyzed based on targeted participant groups (HCW, physicians, registered nurses, nursing students, families and visitors, and patients), health care settings (eg, ICU, inpatient unit, entire facility, and long-term-care facility), intervention types (im- proving awareness with education, facility design and planning [FDP], unit-level protocols and procedures, institution-wide programs, and MMI), study rigor (P value, study design, and comments on study design), and effectiveness and sustainability of HHC. They are re- ported in Table 1.

Study rigor

Several past studies related to HHC considered a P value < .05 to be significant.20-22 In this review, a P value < .05 would be con- sidered to be a clinically significant increase in HHC, following past studies with similar assumptions.23 The study design (pre- and postintervention with/without control group or nonrandomized/ randomized controlled trial) for each study was also included in the results table (Table A2).

Table 1 Inclusion and exclusion criteria

Inclusion Exclusion

Date of publication January 1, 2002-September 30, 2015 Before January 1, 2002, after October 1, 2015 Location or context Health care environments (eg, entire facility, intensive care unit, inpatient units,

long-term care facility) in developed countries All other settings (eg, education spaces, workspaces, public spaces)

Intervention Various forms of hand hygiene interventions Antibiotics or therapeutic drugs Precautionary isolation measures

Outcome Measurements of improvement in hand hygiene compliance Any other studies that do not measure improvement in hand hygiene compliance

Study design Experimental: Randomized controlled trial and nonrandomized controlled trial Observational: Pre- and postintervention design with a control group and pre- and postintervention design without a control group

Any other publications (eg, commentary, outbreak reports)

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SEARCH RESULTS

Seventy-three of 151 studies were retrieved fromMEDLINE and met the inclusion criteria.

Participant groups The results table (Table A2) shows the list of HHI classified ac-

cording to study participants: 51 (70%) HCW (not otherwise specified); 17 (23%) registered nurses, nursing assistants, and stu- dents; 5 (7%) families and visitors; 3 (4%) physicians; and 1 (1%) patients. As some studies examined different participant groups in the same study, the sum of studies is >73, and thus the total per- centages are >100%.

Health care settings The results table (Table A2) shows a list of HHIs sorted accord-

ing to the general facility type where HHI was conducted: 16 (22%) entire facility, 28 (38%) ICU, 27 (37%) non-ICU inpatient units, 5 (7%) long-term facility, and 4 (5%) reported data from other locations.

Intervention types Five key categories of HHI emerged: improving awareness with

education (knowledge transfer, evaluation, mentoring, and feed- back), FDP, unit-level protocols and procedures, institution-wide programs, and MMIs.

Intervention 1: Improving awareness with education (knowledge transfer, evaluation, mentoring, and feedback)

A host of interventions emerged that involved knowledge trans- fer and knowledge retention for HHC for HCWs, families, visitors, and/or patients. Educational interventions included knowledge trans- fer via hands-on or online training; problem-based education; education with gaming technology, conferences, newsletters, bro- chures, videos, posters, visual cues with inputs from staff, and simple visual illustrations to families and visitors; verbal reminders; voice messages; electronic alerts and displays; e-mail; screen savers; signs; prominent visual cues; and getting patients to remind HCWs onHHC; monitoring using cameras to record HH; electronic monitoring; eval- uation using performance feedback; and use of fluorescent gel to evaluate HH technique; and engaging student mentors in monitor- ing students’ HH.

Thirty-three of 34 studies found improvedHHCbetween 4%31 and 70%.52 Several studies indicated that unit-level education interven- tionsareeffective. Education thatengagesusersappearsmoreeffective. Some interventions are enhanced by technology and/or games.

Intervention 2: FDP

A group of HHI involved interventions at the FDP and manage- ment level. FDP interventions included installation of new ABHR dispensers in the units in strategic locations, repositioning of ex- isting ABHR, and increasing sink numbers. FDP can be effective in improving HH. Seven of the 8 studies found improved HHC of 14%61-60%.60

Intervention 3: Unit-level protocols and procedures

A group of studies included unit-level operational interven- tions that have to do with procedures, practices, and protocols. Unit- level protocols and procedures included enforcements, protocols, standard operating procedures, guidelines, and Six Sigma pro- cesses to identify, implement, and sustain changes in the areas of HH, infection control, and isolation, decontamination, and clean- ing of clinical instruments. Unit-level protocols and procedures with

direct relevance to HH are effective to improve HH. Six of the 7 studies found improved HHC between 16%71 and 59%.70

Intervention 4: Institution-wide programs

Some studies introduced HHI that required policy implemen- tations at the institutional level by administrators. Institution- wide programs included infection control programs, patient safety programs, and enforcement of the CDC HH guideline. Programs that engage users are effective to enforce HHC. Two of 3 studies found improved HHC of 20%73 and 43%.74

Intervention 5: MMIs

If the HHI consists of various interventions, it was categorized into intervention 5. MMIs included education delivered via knowl- edge transfer (problem-based and task-oriented training, WHO 5 moments of HH, health talks, videos, and posters), reminders (in- structions), monitoring (mentoring), and evaluation (performance feedback); FDP by installing new ABHR, ABHR racks, and pull reels in the units in strategic locations, and repositioning of existing ABHR dispensers; leadership engagement and commitment, leader- directed strategies, HH initiatives championed by physicians and nurses, guiding nurses in a welcoming manner, adopting an open communication approach, role modeling, and social influence; and protocols and procedures using regular HH audit, HAI surveil- lance, clinical improvements, enhanced minimal handling protocol, clustering of nursing care, compliance assessments, and financial incentives. For example, Harbarth et al80 combined knowledge trans- fer, FDP and leadership, rolemodels, and empowerment in theirMMI.

Study rigor Among studies that reported the P value, 59 out of 63 pro-

duced a statistically significant increase in HHC (P < .05) and 4 did not.26,65,69,85 Ten studies did not report the P value.36,38-40,42,47,74,79,89,94

As for study design, 37 (51%) pre- and postinterventions without a control group, 21 (29%) pre- and postinterventions with a control group, 9 (12%) nonrandomized controlled trials, and 6 (8%) ran- domized controlled trials.

DISCUSSION

This integrated review identified, classified, and summarized re- cently published multidisciplinary evidence-based HHIs to increase HHC. Studies were analyzed based on targeted participant groups, health care settings, intervention types, study rigor, effectiveness, and sustainability of HHC.

Selected publications examined HHIs across various partici- pant groups: families, visitors, patients, and all types of HCW. Although 70% of the studies were conducted among HCWs, signifi- cantly more studies were conducted on nurses than on physicians.

Five types of HHI to improve HHC in health care environments were identified: improving awareness with education (knowledge transfer, evaluation, mentoring, and feedback), influencing HHwith FDP, use of unit-level protocols and procedures, and effects seenwith institution-wide programs. A fair number of studies targeted >1 intervention type (ie, MMI).

Health care settings

HH studies were examined across 5 facility types ranging from specialized units to entire facilities. However, study locations were unequally distributed, with 38% of HH studies conducted in ICUs alone, contrasted with only 7% of studies in long-term-care facili- ties. Because many infection control programs have an incentive to

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reduce HAI and pathogen transmission with improved HH, data are routinely collected only from ICUs but not hospitalwide. Only 16 (22%) studies took place within the entire health care facility. Ten (14%) out of 73 studies reported the inability to generalize their findings to other health care facilities as a research limitation.21,22,30,42,48,50,57,58,66,68 HH behaviors can differ vastly de- pending on the health care setting, and there is no 1-size-fits-all solution to improve HH across every health care delivery system. Thus, to determine the generalizability of successful HHI, future re- search needs to replicate results in other health care facility types,24,34,69,80,88 and allow other researchers to apply the design of successful HH studies onto other facility types by providing de- tailed descriptions of the HHI and the health care facility type examined.82 Given the relatively higher HAI and mortality rates in ICUs, such acute care units may benefit most from HH research advancements.63,83,89 Also, there is a need to understand the effect of the social context, social networking, and positive deviance on HH behavior.11

Intervention 1: Improving awareness with education (knowledge transfer, evaluation, mentoring, and feedback)

Several studies combined knowledge transfer, monitoring, and evaluation and feedback at the unit or institutional level. Most train- ing programs were effective for all occupants.

Interactive HH training needs to target the right audience. Train- ing that provided HCWs with constant interactive engagements and learning opportunities produced greater improvements.47,54 In Zingg et al,26 the 4-phase training programmay be overly informative and cognitively demanding. Thus, training should not exert excessive cog- nitive load onHCW in addition to their hectic work schedule. Training should be fun, engaging, and should fit well into the daily workflow.54

Also, an HHI focused on 1 of the WHO 5 moments of HH im- proved HHC by 9.1% among nurses but −14% among physicians.78

In this study, nurses received more HH training on proper hand- washing technique as part of the standard training activities between observation periods.78 Each nurse was encouraged to participate at least once during the training.78 However, physicians did not receive the same level of reinforcement and learning opportunities on good HH, and that may be why the WHO intervention produced posi- tive improvements among nurses, but not physicians.78

Evaluation, monitoring, and feedback can be enhanced with technology.34-41 Several studies indicated that unit-level educa- tion, campaigns, evaluation, mentoring, and feedback in hospitals are effective.34,36-39,41,43,46,47 Some technological interventions were enhanced by gaming.54 An HHI focused on HH e-mail, bulletins, posters, and verbal reminders improved HHC by 11% after 1month.31

However, HHC returned to baseline after 3 months. Findings from this study support past evidence that HHC tends to return to base- line unless sustainedwith continued audit and reinforcement.31 Thus, HHI involving technology and gaming may improve HHC over sus- tained durations because these HHIs may provide continued audit and reinforcement.34,36-39,41,43,46,47,54

Routine actions like HH can often be overlooked by busy HCWs, and technology-assisted evaluation, monitoring, and performance feedback might be a powerful reminder.76 Although this type of HHI generally produces greater improvements in HHC, it often costs more (due to the need for installation, operations, and maintenance) and may not detect all HH opportunities.36,37,39

Automated HH monitoring systems34-40 would ideally improve monitoring capabilities at reduced costs and resolve some of the current monitoring problems. However, their widespread application remains limited. Such technology should be applied to areas where HHC appear most crucial such as in neonatal ICUs.

The relatively high cost of automated monitoring may require im- plementation in phases.

Accurate and meaningful HH evaluation, monitoring, and feed- back remain critical for patient care and safety.40,41 Future research should determine optimal locations for important visual remind- ers such as signs to prevent users’ “information saturation.”42,45,46

In addition, it should focus on a better understanding of human be- havior in various contexts or health care environments, and draw expertise from the fields of psychology, human factors, and ergo- nomics to improve and sustain proper HH behavior through better monitoring systems11 that incorporate HH opportunities as defined by WHO Healthcare Infection Control Practices Advisory Commit- tee as the denominator.96

Intervention 2: FDP

FDP, environmental psychology, behavioral economics, human factors, and ergonomics are important for the proper design of HH products, processes, and physical environments to improve HHC. Such interventions have been used to study issues such as patient safety, handoffs, and patient–caregiver communications. Yet, without an understanding of the processes involved and barriers due to human behavior, simply having more HH products available in more places would likely not improve and sustain HHC.65 For example, a study65 that examined the influence of increased sink numbers on HHC confirmed that the availability of sinks alone does not improve HHC among HCWs. Thus, instead of just providing HH re- sources, additional HHIs or MMIs may be required.65 More research should be devoted to understanding human behavior when it comes to HHC, and apply novel interventions from nonclinical fields to reduce infection transfer.65 The Systems Engineering Initiative for Patient Safety model, a framework for understanding the influ- ence of work system design on safety and organizational outcomes, may support the integration of these external disciplines within future HHIs.97

Optimizing research resources will allow for examining more targeted HHIs in health care environments.64 Simulated lab envi- ronments may allow researchers to refine their study designs and HHIs before applying these HHIs into actual health care environments.64 Because busy work schedules and perceptions of HH, among other issues, are often limitations, it is particularly im- portant for study designs and interventions to be refined before applying them to field settings.64

Intervention 3: Unit-level protocols and procedures

Six studies implemented unit-level protocols and procedures that considered the unique HH challenges at their hospital and found that adapting them to their units successfully increased HHC.66-68,70-72

The 1 study that did not produce increased HHC simply added the requirement of gown use.69 In situations where gown compliance is good, users may instead have a false assurance that the re- quired measures for infection control have been taken, thus undermining the importance of HH.69 This may also indicate the im- portance of implementing interventions that allow behavior change to be paired with unit-level protocols and procedures.66,71

Intervention 4: Institution-wide programs

The 2 studies that improved HHC through an institution-wide program also engaged participants.73,74 They implemented pro- grams that incorporated unique issues and challenges for their respective hospitals.73,74 Rossenthal et al74 described a program (Measure to Achieve Patient Safety) at the University of California, Los Angeles, Medical Center to allow undergraduate student

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volunteers to conduct HH observations in the hospital. In the study by Ebnöther et al,73 the infection control program required addi- tional staff for infection control.

A study that examined the influence of enforcement of the CDC HH guideline did not improve HHC.72 The authors suggested that widely disseminated policies, procedures, and programs, and pro- vision of HH resources alone might be insufficient to improve HHC in clinical environments.72 Thus, practitioners should seek to explore MMIs that incorporate additional input from staff before imple- menting these HH programs.72 Effective administrative policies should be adapted to HH issues and challenges unique to each health care environment and be paired with physical, operational, and cul- tural HHIs to create and sustain behavior change.72 It is important to engage users during the policy-making process.72 We also propose that future HH research apply implementation science competen- cies to create generalizable knowledge that can be applied to various types of health care environment.

Intervention 5: MMIs

In recent years, MMIs have beenwidely studied and later adopted routinely by health care organizations to improve HHC. However, due to low-quality study design, previous research examining the influence of MMIs on HHC are largely inconclusive.98

Of the 73 selected manuscripts, 21 (29%) examined the influ- ence of MMIs on HHC and included the following components: education (knowledge transfer, evaluation, monitoring, and feedback); FDP; leadership, role modeling, and empowerment; and unit-level protocols and procedures.

Education was a component in each of the 21 MMI studies, sug- gesting the importance of education for improved HH. Future research may examine how improving awareness with education can enhance the overall effectiveness of MMIs.

Granted, the HHIs were implemented in various health care fa- cilities across various participant groups. Thus, it is difficult to make relative comparisons between percentage improvements. Because there was a wide range of improvements, the relevance and effi- cacy of existing MMI components should be questioned. Although MMIs are commonly used to improve HHC, it is important for health care practitioners to enforce implementation of these MMI com- ponents in a selective and prudent manner.85 For example, inWhitby et al,85 the Liquid-soap Substitution and the Geneva Program failed to increase HHC. An HHI with past success (eg, in a neonatal ICU) may not have the same results in other health care environments.85

Thus, it is important to consider past successful MMIs in totality before implementing them.85

The mixed results generated from recent MMIs suggest that new and innovative components should be examined in future MMI studies.89 In Won et al,89 financial rewards or penalties were applied to the nursing staff based on HH levels. A percentage of total neo- natal ICU profit was given to nurses as a monthly bonus. HCWs who performed HH incorrectly had points deducted.89 Bonuses were cal- culated by dividing each nurse’s points by the total points of all nurses in the neonatal ICU that month.67 Also, strong leadership, role modeling, and empowerment emerged as a new category, ex- clusive to the MMI, but only as 1 component.76-79,88

In summary, MMIsmay address the issue of poor HHC on a global level (eg, HH education and products). Understanding the role of individual MMI components would ensure optimal manpower and resource allocations.

Study rigor

Only 6 (8%) studies were randomized controlled trials. The lack of randomized controlled trials in HH studies could be due to various

reasons (eg, clinical equipoises). However, for some types of HH studies (eg, the use of mock-up architectural simulation to study HH behaviors and preferences), study design in the form of ran- domized controlled trials would be possible and should be looked into for future HH research.

Sustainability of HHC

Besides increasing HHC, sustaining HHC in health care environ- ments remains a key challenge. HHI needs to be continually reinforced.43 In an observational trial by Raskind et al,48 results support past evidence that, without ongoing audit and continual reinforcement, HHC tends to return to baseline.

Frequent performance feedback and focused training pro- grams might produce sustained HHC.83,95 Fifty-two out of 73 (71%) current studies have short follow-up without effective measures of sustained HHC.86 Future studies should incorporate follow-up studies83 or have longer durations.86 There is a critical need to provide measurement and feedback over a sustained duration.74,89 However, conducting periodic measurement over an extended duration with effective performance feedback across an entire health care facili- ty remains challenging.

Son et al47 described a novel approach to measure, monitor, and increase HHC. WHO guidelines were introduced and incorporated into the workflow of front-line staff to create a more sustainable program with peer-based direct observations of HHC throughout multiple locations within the health care facility.47 HHC improved from 65%-97% and was sustained for almost 3 years.47 However, Rosenthal et al74 suggested that peer-based observations might be inaccurate and impractical due to the hectic work schedule of HCWs. Third-party remote video auditing with real-time feedback pro- duced sustained improvements in HHC.41,49

Rupp et al59 found that sustained HHC is strongly related to ABHR availability. However, Whitby et al85 suggest that the availability of ABHR alone, without an associated behavior change program, is in- effective. Behavior change among users is important to sustain HHC.72

Sustained behavior changemay require cultural change via a bottom- up approach.46 HHI needs to be well received43 and engaging.54

Detailed personnel-oriented planning together with a continuous commitment from opinion leaders and interdisciplinary teams are essential for sustained HHC.80 An HH campaign should fit the ho- spital’s culture, and have strong support from senior leadership.88

In Huis et al,87 the 2 hospitals that produced sustained HHC speci- fied HH as a hospitalwide priority. The third hospital was less explicit and distinct in addressing the goal of HH as an organizational priority.87 Thus, hospital culture might influence HHC and its sustainability.87

Limitations

The key limitations of this reviewwere that only 1 search engine (Medline) was used, the search only included studies with the terms hand hygiene and hand wash due to the large amount of studies avail- able in this area, and only studies published in English and conducted in a developed countries were included for better comparison of the results.

CONCLUSIONS

Our review showed that different HHI types require different fea- tures to be effective:

1. HHI with past reported success in 1 specific settingmay not have the same positive results when applied to other health care environments.

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2. Even with improved HHC during the study duration, sustain- ing HHC over an extended period remains challenging.

3. HH education will likely have minimal benefit unless it is in- teractive and engaging. Such education must not be overly informative and cognitively demanding, and must fit well into the hectic work schedule of HCWs.

4. Phased use of high-cost HH monitoring and electronic remind- ers may reduce costs.

5. Visual cues and signs are a low-cost form of HHI, suited better for low-risk health care environments, but are more fre- quently used with other types of HHI (eg, MMIs).

6. Policy-making processes must address each health care env- ironment’s unique challenges, engage users, and draw on expertise from interdisciplinary fields, compared with generic policies.

7. Health care practitioners should always examine HH issues unique to their organizations before deciding which MMI com- ponents to implement.

8. Strong leadership and commitment are needed.

Future research in the field of HH should seek to:

1. Replicate successful HHI strategies in other health care facili- ty types.

2. Better understand caregiver-patient-family interactions. 3. Examine new ways to sustain HHC over an extended duration. 4. Examine how incorporating HH training into physical environ-

ments, products, procedures, and policies might help sustain or reinforcement HH behavior improvements.

5. Incorporate new innovative components such as environmen- tal psychology, behavioral economics, and financial rewards to better understand and catalyze improved behavioral change in various contexts and environments to improve HH.

6. Use simulated lab environments to refine study designs and HHI before actual studies.

7. Apply implementation and dissemination science competen- cies to future HH research.

8. Evaluate opportunities to apply successful influence and im- plementation strategies from other public health and infection prevention initiatives.

9. Develop reliable HHCmonitoring tools that incorporate HH op- portunities as defined by WHO/Healthcare Infection Control Practices Advisory Committee as the denominator.

10. Study the importance of committed hospital leadership (and financial support) for sustained improvement in HHC.

From our review, 5 HHI types were found to be effective. The rate of effectiveness could be increased by systems and MMIs, adapta- tion of the interventions to unit-level conditions and issues, and adaptations of novel approaches such as environmental psycholo- gy, behavioral economics, human factors and ergonomics, and financial rewards to catalyze behavior change.

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55. Mcguckin M, Taylor A, Martin V, Porten L, Salcido R. Evaluation of a patient education model for increasing hand hygiene compliance in an inpatient rehabilitation unit. Am J Infect Control 2004;32:235-8.

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57. Eveillard M, Raymond F, Guilloteau V, Pradelle M-T, Kempf M, Zilli-Dewaele M, et al. Impact of a multi-faceted training intervention on the improvement of hand hygiene and gloving practices in four healthcare settings including nursing homes, acute-care geriatric wards and physical rehabilitation units. J Clin Nurs 2011;20:2744-51.

58. Mody L, Mcneil SA, Sun R, Bradley SF, Kauffman CA. Introduction of a waterless alcohol-based hand rub in a long-term–care facility. Infect Control Hosp Epidemiol 2003;24:165-71.

59. Rupp ME, Fitzgerald T, Puumala S, Anderson JR, Craig R, Iwen PC, et al. Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol 2008;29:8-15.

60. Munoz-Price LS, Patel Z, Banks S, Arheart K, Eber S, Lubarsky DA, et al. Randomized crossover study evaluating the effect of a hand sanitizer dispenser on the frequency of hand hygiene among anesthesiology staff in the operating room. Infection Control and Hospital Epidemiology. Infect Control Hosp Epidemiol 2014;36:717-20.

61. Yeung WK, Tam WSW, Wong TW. Clustered randomized controlled trial of a hand hygiene intervention involving pocket-sized containers of alcohol-based hand rub for the control of infections in long-term care facilities. Infect Control Hosp Epidemiol 2011;32:67-76.

62. Babiarz LS, Savoie B, McGuire M, McConnell L, Nagy P. Hand sanitizer-dispensing door handles increase hand hygiene compliance: a pilot study. Am J Infect Control 2014;42:443-5.

63. Thomas BW, Berg-Copas GM, Vasquez DG, Jackson BL, Wetta-Hall R. Conspicuous vs customary location of hand hygiene agent dispensers on alcohol-based hand hygiene product usage in an intensive care unit. J Am Osteopath Assoc 2009;109:263-7.

64. Birnbach DJ, Nevo I, Scheinman SR, Fitzpatrick M, Shekhter I, Lombard JL. Patient safety begins with proper planning: a quantitative method to improve hospital design. Qual Saf Health Care 2010;19:462-5.

65. Whitby M, Mclaws M-L. Handwashing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect 2004;58:247-53.

66. Creedon SA. Health care workers’ hand decontamination practices: an Irish study. Clin Nurs Res 2006;15:6-26.

67. Eldridge NE, Woods SS, Bonello RS, Clutter K, Ellingson L, Harris MA, et al. Using the six sigma process to implement the centers for disease control and prevention guideline for hand hygiene in 4 intensive care units. J Gen Intern Med 2006;21:S35-42.

68. Chassin M, Mayer C. Nether, K. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Jt Comm J Qual Patient Saf 2015;41:4-12.

69. Golan Y, Doron S, Griffith J, Gamal HE, Tanios M, Blunt K, et al. The impact of gown-use requirement on hand hygiene compliance. Clin Infect Dis 2006;42:370-6.

70. Howard DPJ, Williams C, Sen S, Shah A, Daurka J, Bird R, et al. A simple effective clean practice protocol significantly improves hand decontamination and infection control Measures in the acute surgical setting. Infection 2009;37:34-8.

71. Erasmus V, Kuperus M, Richardus J, Vos M, Oenema A, Beeck EV. Improving hand hygiene behaviour of nurses using action planning: a pilot study in the intensive care unit and surgical ward. J Hosp Infect 2010;76:161-4.

72. Scheithauer S, Eitner F, Mankartz J, Haefner H, Nowicki K, Floege J, et al. Improving hand hygiene compliance rates in the haemodialysis setting: more than just more hand rubs. Nephrol Dial Transplant 2010;27:766-70.

73. Ebnöther C, Tanner B, Schmid F, La Rocca V, Heinzer I, Bregenzer T. Impact of an infection control program on the prevalence of nosocomial infections at a tertiary care center in Switzerland. Infect Control Hosp Epidemiol 2008;29:38- 43.

74. Rosenthal T, Erbeznik M, Padilla T, Zaroda T, Nguyen DH, Rodriguez M. Observation and Measurement of hand hygiene and patient identification improve compliance with patient safety practices. Acad Med 2009;84:1705-12.

75. Larson EL, Quiros D, Lin SX. Dissemination of the CDC’s hand hygiene guideline and impact on infection rates. Am J Infect Control 2007;35:666-75.

76. Aboumatar H, Ristaino P, Davis RO, Thompson CB, Maragakis L, Cosgrove S, et al. Infection prevention promotion program based on the PRECEDE model: improving hand hygiene behaviors among healthcare personnel. Infect Control Hosp Epidemiol 2012;33:144-51.

77. Tromp M, Huis A, Guchteneire ID, Meer JVD, Achterberg TV, Hulscher M, et al. The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement program. Am J Infect Control 2012;40:732-6.

78. Martino PD, Ban KM, Bartoloni A, Fowler KE, Saint S, Mannelli F. Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation. Am J Infect Control 2011;39:14-8.

79. Walker J, Sistrunk W, Higginbotham MA, Burks K, Halford L, Goddard L, et al. Hospital hand hygiene compliance improves with increased monitoring and immediate feedback. Am J Infect Control 2014;42:1074-8.

80. Harbarth S, Pittet D, Grady L, Zawacki A, Potter-Bynoe G, Samore MH, et al. Interventional study to evaluate the impact of an alcohol-based hand gel in improving hand hygiene compliance. Pediatr Infect Dis J 2002;21:489-95.

81. Lam BC. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 2004;114:e565- 71.

82. Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162:1037-43.

83. Hussein R, Khakoo R, Hobbs G. Hand hygiene practices in adult versus pediatric intensive care units at a university hospital before and after intervention. Scand J Infect Dis 2007;39:566-70.

84. Johnson L, Grueber S, Schlotzhauer C, Phillips E, Bullock P, Basnett J, et al. A multifactorial action plan improves hand hygiene adherence and significantly reduces central line–associated bloodstream infections. Am J Infect Control 2014;42:1146-51.

85. Whitby M, Mclaws M-L, Slater K, Tong E, Johnson B. Three successful interventions in health care workers that improve compliance with hand hygiene: is sustained replication possible? Am J Infect Control 2008;36:349-55.

86. Dierssen-Sotos T, Brugos-Llamazares V, Robles-García M, Rebollo-Rodrigo H, Fariñas-Álvarez C, Antolín-Juarez FM, et al. Evaluating the impact of a hand hygiene campaign on improving adherence. Am J Infect Control 2010;38:240-3.

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APPENDIX A

Table A1 Search strategy and review period: January 1, 2002, to October 1, 2015

S/N PubMed S/N PubMed

1 handwashing 2 hand wash 3 handwash 4 hand hygiene 5 hand hygiene 6 Any 1 term from 1 to 5 7 intervention 8 interventions 9 program 10 programs 11 activity 12 activities 13 technique 14 techniques 15 technology 16 technologies 17 protocol 18 protocols 19 Any 1 term from 1 to 5 + 1

term from 7 to 18 20 compliance

21 compliances 22 observance 23 Any 1 term from 1 to 5 + 1

term from 7 to 18 + 1 term from 20 to 22

24 hospital

25 hospitals 26 healthcare 27 health care 28 healthcare environment 29 healthcare environments 30 health care environment 31 health care environments 32 Any 1 term from 1 to 5 + 1 term

from 7 to 18 + 1 term from 20 to 22 + 1 term from 24 to 31

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APPENDIX B

Table A2 Summary of hand hygiene (HH) interventions and outcomes

Primary author (y) Design Participants Location Intervention

Outcome (% improvement in HH) P value Comments on study design

Improving awareness with education (Knowledge transfer) Zerr (2005)24 PPWOC HCW Pediatric unit Conferences, employee newsletters, signs 19 <.001 Observer effect

Data collection: Inability to track HHC of individual HCW

Chen (2007)25 NRCT Families and visitors

Pediatric ICU Simple visual illustration to teach HH 26 <.0001 Relatively short study duration Inability to obtain baseline data for comparison

Zingg (2009)26 PPWOC HCW Medical ICU Education program that taught HH (handwashing and hand rubbing technique) and catheter care standards

6 .466 HHC compliance rate did not improve significantly. Other interventions may be necessary for a facility with relatively high HHC during preintervention period

The disparity in study population highlights limitations of pre–post HHI study in a single facility

Helder (2010)27

PPWOC HCW Neonatal ICU Problem-based HH education 23 <.001 Observer effect

El-Kafrawy (2013)28

PPWOC Families and visitors

Neonatal ICU Video showing HH information and standards 21 .002 Inability to capture all HH attempts

Alemagno (2010)29

PPWOC HCW Children’s hospital Community hospital

Three online training session 26 No data A convenient sample size of volunteer HCWs Only self-assessed HHC. Did not have measures to validate responses. Did not conduct direct observations of HHC

Hautemaniere (2010)30

PPWC HCW Teaching hospital 30-min training on good HH practice using florescent gel

62 <10^-8 Observer effect

Didiodato (2013)31

PPWC RNs, assistants, students

Community hospital Education program: “Just Clean Your Hands” Before patient contact: 6 After patient contact: 4 (sustained)

<.0001 <.0001

Relatively small sample size. Potential confounder: Program may potentially contaminate the control group

Huang (2008)32 PPWOC RN, assistants, students

Long-term-care facility In-service class (1 h), hands-on training (30 min) 21 <.001 Small sample size and study duration

Improving awareness with education (knowledge transfer, evaluation, monitoring, and feedback) Reich (2015)33 PPWOC Physicians Teaching hospital Physician report cards and comparative rankings

for medical and surgical subspecialty 27 (sustained) <.0001 Study was conducted only in 1 ICU without a control

group. The entire sampling method is based on the reliability of one observer. No specific reliability test was carried out

Swoboda (2004)34

NRCT HCW Surgical unit Electronic monitoring device and computer voice prompts

44 <.05 Observer effect Relatively small sample size

Conway (2014)35

PPWOC HCW Inpatient: Childbirth, critical care, joint center, medical/surgical, psychiatry, step-down, telemetry.

outpatient: computerized tomography, emergency, endoscopy, lab/ phlebotomy, magnetic resonance imaging, mammography

Electronic monitoring and automated feedback Inpatient units: Hand hygiene increased on average by 0.17 events/ patient-hour.

Outpatient units: HH performance did not change significantly

.008 Relatively small sample size

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Table A2 Continued

Primary author (y) Design Participants Location Intervention

Outcome (% improvement in HH) P value Comments on study design

Storey (2014)36 PPWOC HCW Cardiovascular unit Electronic monitoring and automated feedback 45 No data The device could not capture other forms of HHC (eg, use of soap and water)

Levchenko (2014)37

PPWC HCW Continuing care unit Electronic monitoring and automated feedback 30 .004 The device could not capture other forms of HHC (eg, use of soap and water)

Venkatesh (2008)38

PPWOC HCW Hematology unit Electronic alerts 34 No data The study was conducted over different periods Thus, staff population might be different.

The device has occasional sensing issues The device could not capture the duration of HHC during patient care and other forms of HHC (eg, use of soap and water)

Levchenko (2011)39

PPWOC RNs, assistants, students

General/unspecified unit Electronic monitors 53 No data HHC performed with wall-mount soap dispensers were not captured

Al Salman (2015)40

PPWC HCW Cardiovascular unit Electronic monitors 15-37 No data Relatively small sample size and short study duration

Armellino (2012)41

PPWOC HCW Medical ICU Cameras to record HH compliance 78 (sustained) .0019 HH data from remote video audit cannot be compared with HHC rates from human observations

Single study site without a control group Thomas (2005)42

PPWOC RNs, assistants, students

Medical, pediatric, surgical, trauma ICU

Emergency unit

Visual cues produced with input from staff 17 No data Potential confounding variables might be present during the move to the new ICU during phase I of study

McGuckin (2006)43

PPWOC HCW Medical, surgical ICU HH voice message by ICU staff 60 <.001 Did not track if HH product was used by visitors

Pessoa-Silva (2007)44

PPWOC HCW Neonatal unit Posters, focus groups, performance, and infection-rate feedback

10 (sustained) <.001 Observer effect

D’Egidio (2014)45

PPWC HCW, families, and visitors

Hospital entrance Flashing red light attached to ABHR 11 <.0001 Relatively small sample size and short study duration

Davis (2010)46 PPWC HCW Surgical unit Bright red tap along corridors leading to ward entrances, arrowheads pointing at ABHR, and instructional posters

38 (sustained) <.0001 Low number of staff entering the ward Potential confounder: Other infection control programs may increase HHC

Observer effect Son (2011)47 PPWOC RNs, assistants,

students Oncology unit Small-group discussion about HH barriers 27 No data Observer effect

Raskind (2007)48

PPWC HCW, families, and visitors

Neonatal ICU HH e-mails bulletins, posters, and verbal reminders

1 mo: 11% 3 mo: 0%

<.0001 Observer effect No attempt to limit the number of HH opportunities by an individual. If many subjects washed their hands for several times, the final data might be skewed

Sampling bias: Observations may not be comprehensive due to disrupted and convenient sampling method

Taylor (2012)49 PPWOC Families and visitors

Neonatal ICU Infection control reminders in video form 21 (sustained) <.0016 Intervention may have short-term effects

Helder (2012)50

NRCT HCW Neonatal ICU HH information on computer screensavers 8 <.001 Relatively short study duration Study design: The effects of confounding variables remains unknown due to the absence of the control group

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Table A2 Continued

Primary author (y) Design Participants Location Intervention

Outcome (% improvement in HH) P value Comments on study design

Kim (2013)51 PPWOC Patients Tertiary hospital Antibiotic stewardship and HH program that emphasized the importance of HH by promoting infection control program with posters, electronic display, and screen savers

40 .043 Relatively small sample size and short study duration Potential confounder: The influence of infection control programs on the reduction in Methicillin- resistant Staphylococcus aureus rates is not well understood

Snow (2006)52 NRCT RNs, assistants, students

Unspecified Influence of mentors’ HH on HH among nursing students on various clinical rotations

70 <.01 Observer effect

Monsalve (2014)53

PPWC HCW Medical ICU Peer effects: Presence and proximity of other HCW on HH of peers

7 <.01 HH opportunities only limited to in-and-out of the room

Only collected HHC data that occurs outside patient’s room (and not inside)

Higgins (2013)54

NRCT HCW Tertiary hospital Gaming technology that allowed users to learn and practice HH with an audit tool

42 <.0001 Potential confounder: Extra ABHR in clinical areas had a confounding effect on the increased use of ABHR

Observer effect Improving awareness with education (evaluation, monitoring, and feedback) McGuckin (2004)55

PPWOC HCW Community hospital Patient education model: 1) brochures and videos to educate patients on HH importance, particularly among HCW, 2) before patient contact, patients were asked to check with HCW if “they had wash/sanitized your hands,” and 3) patients had a HH reminder banner to stick on their hospital gowns to remind HCW

22 <.001 Relatively small sample size Potential confounder: 5 sinks were spoilt, 11 patients who were discharged early

Mertz (2010)56 RCT RNs, assistants, students

General/unspecified unit Small group seminars, posters, and feedback 6 <.001 Potential confounder: Potential contamination of the program to the control group.

Only pooled unit-specific feedback was provided to the HCW

Eveillard (2011)57

PPWOC HCW Long-term-care facility Knowledge transfer and performance feedback 20 <10^-5 Relatively small sample size and duration Unequal sample proportion: Only 5% of observed samples were physicians

FDP Mody (2003)58 PPWC HCW Long-term-care facility New ABHR installation in strategic locations 35 .002 Self-reported HH data Rupp (2008)59 PPWC RNs, assistants,

students Medical ICU New ABHR installation in strategic locations 31 (sustained) <.001 Patients were only followed up after 48-h transfer

from ICU Inability to draw an association between improved HHC and HAI rates: Might be due to the limited power of the study or the lack of HHC

Munoz-Price (2014)60

PPWC HCW Operating room Using a hand sanitizer dispenser on the anesthesia machine in addition to the standard wall-mounted dispensers

60 .01 The study was only conducted in 1 location

Yeung (2011)61 RCT HCW Long-term-care facility Pocket-sized ABHR 14 .001 Snowball sampling method Generalizability of findings: May not be applicable to other long-term-care facilities

Babiarz (2014)62

PPWC HCW Ultrasound area Novel sanitizer-dispensing door handle device 53 <.001 Study only examined a small number of exam rooms at a single study site

Relatively short study duration

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Table A2 Continued

Primary author (y) Design Participants Location Intervention

Outcome (% improvement in HH) P value Comments on study design

Thomas (2009)63

PPWC HCW Medical ICU Moving the ABHR to more prominent locations and closer to the patient

56 <.001 Potential confounding variables might be present during the move to the new ICU during phase I of the study.

Birnbach (2010)64

RCT Physicians Mock-up simulation Relocation of ABHR 42 .0011 Relatively small sample size

Whitby (2004)65

PPWOC RNs, assistants, students

Medical ICU infectious disease, urology unit

Increased sink numbers Did not improve .95 Potential confounder: Methicillin-resistant Staphylococcus aureus outbreak in study 1

Unit-level protocols and procedures Creedon (2006)66

NRCT HCW Medical, surgical ICU Enabled, reinforced, and predisposed HCW to observe HH guidelines

32 <.001 Lack of a follow-up period after the initial observation Observer effect

Eldridge (2006)67

PPWC HCW Medical, surgical ICU Six Sigma Process: Focus—Identify, implement, and sustain changes

33 (sustained) <.001 Observer effect

Chassin (2015)68

PPWOC HCW 8 hospitals Six Sigma Process: Focus—Identify, implement, and sustain changes

Change management

33 (sustained) <.001 Cannot determine if HHI was the sole reason behind increased HHC

Golan (2006)69 PPWC HCW Medical ICU Enforcing gown use requirements Did not improve .85 A large number of observers: Data collection may not be consistent. Did not account for interrater reliability

Howard (2009)70

PPWOC HCW Surgical ICU, breast, cardiovascular, gastrointestinal, urology unit

Clean practice protocol: Hand decontamination, glove and gown use, patient infective isolation, notes and garments contamination, and cleaning of clinical instruments

59 <.00001 Duration between audit cycles: Relatively short interval

Further studies that examine long-term effects is necessary

Erasmus (2010)71

PPWOC RNs, assistants, students

Surgical ICU surgery unit

Action planning: If–then plans that relate an environmental cue with an intended action

16 <.001 Relatively small sample size and short study duration Observer effect

Scheithauer (2012)72

PPWOC HCW RNs, assistants, students

Hemodialysis unit Optimized HH standard operating procedures for dialysis connections and disconnections

32 <.001 Observer effect Potential confounder: The influence of patient outcome on improving HHC was not explored

Institution-wide programs Ebnöther (2008)73

PPWOC HCW Tertiary hospital Infection control program: Addition of infection control staff, repeated HH instructions, new guidelines for preoperative antibiotic prophylaxis, patient isolation

20 .01 The specific influence of a particular HHI is unclear

Rosenthal (2009)74

PPWC RNs, assistants, students

Teaching hospital Patient safety program that engages student volunteers to conduct HH observations

43 (sustained) No data Interrater reliability Observer effect HH data for night shifts are not systematically measured

Larson (2007)75 PPWOC HCW Entire facility/unspecified area

Enforcement of the Centers for Disease Control and Prevention HH guideline

Did not improve <.001 Potential confounder: Unstandardized surveillance of HH opportunities

Assessment of HHC: Only 2 days Observer effect

Multimodal Interventions Aboumatar (2012)76

NRCT HCW General/unspecified unit Education: Feedback FDP: Environmental changes Leadership: Leadership engagement

200 (sustained) <.001 Observer effect HHC between specific opportunities cannot be determined

Study design limited by quasiexperimental design Lack of data: How increased HHC from program could improve patient outcome

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Table A2 Continued

Primary author (y) Design Participants Location Intervention

Outcome (% improvement in HH) P value Comments on study design

Tromp (2012)77 PPWC RNs, assistants, students

Internal medicine unit Education: Training, feedback, mentoring FDP: Introduction of ABHR Leadership: Role model, social influence, mentoring

48 (sustained) <.05 Rather low response rate (60%) HHC was lower in nonobservational setting (ie, outpatient clinic)

Martino (2011)78

PPWOC RNs, assistants, students

Emergency unit Education: Sessions emphasizing ABHR over soap and water, presentation of baseline HH rates to all units to show the need to improve compliance

FDP: Introduction of pocket-size ABHR Leadership: Physician and nurse champions were selected to promote HH

Nurses: 9 Physicians: −14

.03

.008 Observer effect The study was only conducted in 1 department

Walker (2014)79

PPWC HCW Surgical unit Education: Continuous education FDP: Conspicuous and visible monitors Leadership: Dissemination of HH information to leaders

Experiment 1: 41 Experiment 2: 36 (Sustained)

No data Due to the presence of various confounders, the relationship between HHI, and improved HHC cannot be ascertained

Harbarth (2002)80

PPWC HCW Pediatric ICU Education: Training, feedback FDP: Introduction of ABHR

8 <.001 Long-term impact was not assessed Observer effect

Lam (2004)81 PPWC HCW Neonatal ICU Education: Problem-based and task-oriented HH training

FDP: Addition of ABHR Protocols and procedures: Revised minimal handling protocol, clustering of nursing care, regular HH audit, hospital-associated infection surveillance

Before patient contact: 13 After patient contact: 20

.0002 <.0001

Observer effect

Hugonnet (2002)82

PPWOC HCW Medical, neonatal, pediatric, surgical ICU

Education: Training, monitoring, feedback FDP: Introduction of ABHR

16 (sustained) <.001 Observer effect Inability to estimate the relative efficacy of the different multimodal intervention components

Hussein (2007)83

PPWOC HCW Medical ICU Education: Training using posters and shirt buttons sponsored by the Centers for Disease Control and Prevention

FDP: Improved ABHR accessibility

42 <.0001 The observed number of HH opportunities is different between the 2 study periods

Johnson (2014)84

PPWOC Physicians RNs, assistants, students

Teaching hospital Education: Reeducate importance of HH through newsletters, screen savers, posters, in-person education, and computer-based training modules

Education: HH education was provided to medical students before they began clinical clerkships and to resident physicians during orientation. Patients and their families were engaged in improvement efforts, given standard information as to when to expect HCW to perform HH and instructed to speak up when HCW did not perform HH

FDP: Use and relocation of ABHR to more convenient locations

40 <.001 Observer effect

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Table A2 Continued

Primary author (y) Design Participants Location Intervention

Outcome (% improvement in HH) P value Comments on study design

Whitby (2008)85

PPWOC HCW Medical ICU infectious disease, urology unit

Studied 3 HHIs that had past success: Liquid- soap substitution, the Geneva Program, and the Washington Program. Only the Washington Program sustainably improved HH

Program 1 and 2: Did not improve Program 3: 48% (sustained)

.238

.328 <.001

HHI replicated in this study may not be entirely similar to those from previous studies

Dierssen-Sotos (2010)86

PPWOC HCW Medical ICU emergency unit

Education: Education strategy, feedback FDP: Addition of ABHR

16.6 (sustained) <.005 Observer effect There might be other confounding factors in the before–after study design

Mayer (2011)15 NRCT HCW Medical ICU emergency, oncology unit

Education: Monitoring, feedback FDP: Introduction of ABHR

Cohort 1: 24 Cohort 2: 15 (sustained)

<.001 Observer effect HHC rate may be inflated

Huis (2013)87 RCT HCW Nursing unit Education: Knowledge transfer, feedback Leadership: Leaders directed strategies

(−) 2-70 <.01 Low response rate (48%) Psychometric properties in the survey were not tested

Doron (2011)88 PPWOC HCW General/unspecified unit Education: Marketing, monitoring, feedback Leadership: Strong commitment from hospital leadership

22 <.0001 Relatively short study duration

Won (2004)89 NRCT HCW Neonatal ICU Education: Lecture, posters, instructions, feedback

Protocols and procedures: Financial incentive

37 No data Observer effect

Bouadma (2010)90

PPWOC HCW Medical ICU Education: Interdisciplinary task force, training, feedback

Protocols and procedures: Compliance assessment

68 (sustained) <.0001 Some major recommendations were not evaluated Observer effect Observer bias

Trick (2007)91 PPWC RNs, assistants, students

Entire facility/unspecified area

Education: Knowledge transfer, reminder poster FDP: Addition of ABHR

15 (sustained) .002 Potential confounder: Data compared across groups was not matched by the type of care provided in each hospital unit. Did not control for workload; that is, nurse to patient ratio was not recorded

Observer effect Martin- Madrazo (2012)92

RCT HCW Children’s hospital Education: Knowledge transfer, reminder posters FDP: Installation of ABHR

21 <.001 Potential confounder: The HHI may contaminate the control group. Time of study coincided with H1N1 pandemic

Ho (2012)93 RCT HCW Long-term-care facility Education: Knowledge transfer, reminders, health talks, videos, training, feedback

FDP: Introduction of ABHR racks, pull reels

Arm 1: 34 Arm 2: 27

<.001 Selection bias: Homes that participated could be more inclined toward HHC

Observer bias Lederer (2009)94

PPWOC RNs, assistants, students

Entire facility/unspecified area

Education: Marketing protocols and procedures; clinical improvements

49 (sustained) No data Observer effect

Oh (2012)95 PPWOC HCW Outpatient clinic Education: 5 moments of HH FDP: Appropriate ABHR placement Leadership: Guiding nurses in a welcoming manner, adopting an open communication approach

73 <.0001 Observer bias Relatively small sample size collected from 1 location

ABHR, alcohol-based handrub; FDP, facility design and planning; HCW, health care workers; HH, hand hygiene; HHC, hand hygiene compliance; HHI, hand hygiene intervention; ICU, intensive care unit; NRCT, nonrandomized controlled trial; PPWC, pre- and postintervention with control group; PPWOC, pre- and postintervention without control group; RCT, randomized controlled trial; RN, registered nurse.

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