Hand Hygiene Intervention Improves Compliance

Troy Brown, RN

September 03, 2013

A World Health Organization (WHO) hand hygiene program increased hand hygiene compliance in healthcare workers from 51.0% to 67.2%, according to the results of a quasi-experiment conducted at 6 pilot sites (55 departments in 43 hospitals) in Costa Rica, Italy, Mali, Pakistan, and Saudi Arabia.

Benedetta Allegranzi, MD, from First Global Patient Safety Challenge, WHO Patient Safety Programme, Geneva, Switzerland, and colleagues report their findings in an article published online August 23 in the Lancet Infectious Disease.

Healthcare-associated infections affect hundreds of millions of patients each year and cause significant morbidity, mortality, and financial losses for health systems, according to WHO estimates.

"Our findings represent powerful support for decision and policy makers to enforce implementation of WHO's strategy, which is recommended by both the US Centers for Disease Control and Prevention and the European Centre for Disease Prevention and Control, Joint Commission International and accredited bodies, most professional organisations, and many governments worldwide, including 50 national hand-hygiene campaigns," the authors write.

The WHO's hand hygiene program has 5 primary components: ensuring system change, particularly healthcare worker access to an alcohol-based hand rub at the point of patient care, so they can use hand-rubbing as the preferred method for hand hygiene; healthcare worker training and education; monitoring of practices and provision of feedback regarding performance; visual workplace reminders; and establishing a safety climate within the institution.

All sites in the current study used a stepwise implementation strategy conducted in 4 phases lasting 3 to 6 months: preparedness, baseline assessment, intervention, and follow-up assessment.

The primary outcome was compliance, which was assessed by direct observation. The secondary outcome was healthcare workers' knowledge about microbial transmission of healthcare and hand hygiene best practices, which was assessed by questionnaire.

Before the intervention, there were 21,884 hand hygiene opportunities during 1423 sessions; after the intervention, there were 23,746 opportunities during 1784 sessions.

Overall compliance rose from 51.0% before the intervention (95% confidence interval [CI], 45.1% - 56.9%) to 67.2% after (95% CI, 61.8% - 72.2%).

There was an independent association between compliance and gross national income per head, with a larger intervention effect in low-and middle-income countries (odds ratio, 4.67; 95% CI, 3.16 - 6.89; P < .0001) than in high-income countries (2.19; 95% CI, 2.03 - 2.37; P < .0001).

Implementation of the intervention had a strong effect on healthcare worker compliance across all sites (odds ratio, 2.15; 95% CI, 1.99 - 2.32) after adjustment for main confounders, including professional category, hand hygiene indications, country income level according to the 2008 World Bank classification, availability of alcohol-based hand rub before the study intervention, and day of the week.

The knowledge of healthcare workers improved at all sites, with an average score that increased from 18.7 (95% CI, 17.8 - 19.7) to 24.7 (95% CI, 23.7 - 25.6), out of a maximum of 37, after training sessions.

"Similar to other reports, nurses had the highest compliance across all pilot sites before the intervention and doctors the lowest, apart from in Costa Rica and Mali.... After the intervention, compliance remained higher in nurses than in doctors across all test sites, apart from Mali," the authors write.

After 2 years, all sites reported continued hand hygiene activities or further improvement, including national scale-up.

In an accompanying editorial, Enrique Castro-Sánchez, an academic research nurse at the Centre for Infection Prevention and Management at Imperial College in London, United Kingdom, and Alison Holmes, MD, MPH, professor of infectious diseases, lead for hospital epidemiology and infection prevention at Imperial College London, director of infection prevention and control for the Imperial College Academic Health Science Centre, and codirector of the Centre for Infection Prevention and Management at Imperial College London, United Kingdom, write, "That we do not protect vulnerable individuals in health-care settings from preventable harm inflicted by treatments or clinical procedures is unacceptable."

The study is an international step toward addressing this problem, Castro-Sánchez and Dr. Holmes write, but research should also examine economic issues related to hand hygiene.

"Although we agree that complex hand-hygiene interventions have shown positive returns on investment, useful economic evidence should be generated for public health practitioners, service commissioners, and government officials who, to implement WHO's strategy (akin to a vertical programme), might divert resources from other important issues," the editorialists conclude.

This study was funded by WHO, University of Geneva Hospitals, the Swiss National Science Foundation, and the Swiss Society of Public Health Administration and Hospital Pharmacists. The authors and editorialists have disclosed no relevant financial relationships.

Lancet. Published online August 23, 2013. Article abstract, Editorial extract


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