Intervention Review

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Interventions to improve hand hygiene compliance in patient care

  1. Dinah J Gould1,*,
  2. Donna Moralejo2,
  3. Nicholas Drey1,
  4. Jane H Chudleigh3

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 8 SEP 2010

Assessed as up-to-date: 2 AUG 2010

DOI: 10.1002/14651858.CD005186.pub3


How to Cite

Gould DJ, Moralejo D, Drey N, Chudleigh JH. Interventions to improve hand hygiene compliance in patient care. Cochrane Database of Systematic Reviews 2010, Issue 9. Art. No.: CD005186. DOI: 10.1002/14651858.CD005186.pub3.

Author Information

  1. 1

    School of Community and Health Sciences, City University, Adult Nursing Department, London, UK

  2. 2

    Memorial University, School of Nursing, St. John's, Newfoundland, Canada

  3. 3

    ICH/GOSH, Portex Unit, London, UK

*Dinah J Gould, Adult Nursing Department, School of Community and Health Sciences, City University, 24 Chiswell Street, London, EC1 4TY, UK. d.gould@city.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 8 SEP 2010

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Characteristics of included studies [ordered by study ID]
Gould 1997

MethodsDesign: CBA
Duration: 3 months baseline and 3 months post-intervention


ParticipantsUK
Nurses on 4 general surgical wards


InterventionsSingle teaching session: hand hygiene, universal precautions


Outcomes% frequency of hand washes after high risk activities


NotesIntervention not successful at 3 months

Also evaluated knowledge of infection control, observed glove use, and observed handling of used needles


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)High riskCBA study, not done

Allocation concealment (selection bias)High riskCBA study, not done

Blinding (performance bias and detection bias)
All outcomes
Low riskUnclear in paper, but confirmed through personal communication with author

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskData was only collected from 31 of 50 nurses; attrition or lost to follow-up rates were similar in both groups but not specified if characteristics of dropouts were similar

Selective reporting (reporting bias)Unclear riskNo published protocol, unable to determine

Other biasLow riskNo other biases identified

Baseline outcomesLow riskData reported as similar between 2 groups

Baseline characteristicsUnclear riskCharacteristics mentioned as similar in text but no data were presented

Protection from contaminationUnclear riskControl group likely did not get intervention but intervention group members did not receive all intended education

Huang 2002

MethodsDesign: RCT
Duration: 4 months post-intervention


ParticipantsPeople's Republic of China
Nurses throughout a hospital


InterventionsEducation, mainly universal precautions


Outcomes% of nurses washing hands before and after patient contact


NotesIntervention successful after 4 months

Also evaluated knowledge scores, prevalence of Hepatitis B immunization, self reported behaviours related to bloodborne pathogens and universal precautions, self reported needlestick and sharps injury, and observed behaviours related to handling used needles.


Risk of bias

BiasAuthors' judgementSupport for judgement

Random sequence generation (selection bias)Unclear riskNot specified

Allocation concealment (selection bias)Unclear riskNot specified

Blinding (performance bias and detection bias)
All outcomes
Unclear riskNot specified

Incomplete outcome data (attrition bias)
All outcomes
Low risk98% follow-up achieved

Selective reporting (reporting bias)Unclear riskNo published protocol

Other biasUnclear riskThe outcome measure, percent of nurses who performed hand hygiene during the 30 minutes of observation, was not clearly described in terms of whether hand hygiene was performed each time it was required or if it was just performed at any time during the observation period. It is possible that actual adherence was overestimated, although this would apply equally to both groups and not affect the difference between the groups. 

Baseline outcomesLow riskSimilar scores for both groups

Baseline characteristicsLow riskSimilar scores for both groups

Protection from contaminationUnclear riskNo description of protection against contamination

Vernaz 2008

MethodsDesign: ITS

Duration: February 2000 to September 2006


ParticipantsSwitzerland

Healthcare workers throughout hospital


InterventionsSocial marketing campaign (VigiGerme®) in 2003 and Clean Care is Safer Care campaign in 2005


OutcomesVolume of hand hygiene products (litres per 100 patient-days)


NotesBoth interventions successful for short-term increase in hand hygiene

Also measured new MRSA isolates per 100 patient-days, new C. difficile isolates per 100 patient-days, defined daily dose of antibiotics per 100 patient-days


Risk of bias

BiasAuthors' judgementSupport for judgement

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNumber of subjects not specified

Selective reporting (reporting bias)Unclear riskNo protocol published, unable to determine

Other biasLow riskNo other biases identified

Intervention independentHigh riskMRSA/C. difficile control policies and Contact Precautions were implemented at the same time

Shape of effect pre-specifiedLow riskPoint of analysis same as point of intervention

Intervention had no effect on data collectionLow riskData collection not associated with intervention

Protection from contaminationHigh riskSubjects were aware of intervention

Whitby 2008

MethodsDesign: ITS

Duration: Each intervention took place over a 2 year period


ParticipantsAustralia

All healthcare workers in multiple units


Interventions3 separate interventions:

1) Simple substitutions: ABHR for soap, and one type of ABHR for another

2) Geneva campaign

3) Washington campaign


OutcomesProduct use (hand hygiene events per occupied-bed days)


NotesIntervention successful for Geneva and Washington campaigns


Risk of bias

BiasAuthors' judgementSupport for judgement

Incomplete outcome data (attrition bias)
All outcomes
Unclear riskNumber of subjects not specified

Selective reporting (reporting bias)Unclear riskNo evidence of protocol published, unable to determine

Other biasUnclear riskUnclear how group differences (e.g. characteristics of patients) may have impacted outcome for wards receiving Geneva intervention

Intervention independentLow riskNo other changes identified

Shape of effect pre-specifiedLow riskPoint of analysis same as point of intervention

Intervention had no effect on data collectionLow riskData collection not associated with intervention

Protection from contaminationHigh riskSubjects aware of intervention

 
Characteristics of excluded studies [ordered by study ID]

StudyReason for exclusion

Apisarnthananarak 2008Uncontrolled before and after design

Assanasen 2008Interrupted time series study, inadequate data collection points

Avila-Aguero 1998Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Baker 1998Uncontrolled before and after study design

Barchitta 2008No hand hygiene outcome data presented

Bellis 2006Interrupted time series study, inadequate data collection points

Berg 1995Uncontrolled before and after study design

Berhe 2006Uncontrolled before and after design

Bhojani 2008Uncontrolled before and after design

Bhutta 2007No hand hygiene outcome data presented

Bischoff 2000Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Bittner 2002Controlled before and after study design with one nonequivalent control group.

Brown 2003Uncontrolled before and after study design

Cantrell 2009Uncontrolled before and after design

Capretti 2008No hand hygiene outcome data presented

Chan 2007Uncontrolled before and after design, no baseline data

Chimango 2009Uncontrolled before and after design

Christiaens 2009Interrupted time series design with less than three data entry points after the intervention.

Coghill 2009Uncontrolled before and after design

Coignard 1998Uncontrolled before and after study design

Colombo 2002Controlled before and after study design with one nonequivalent control group.

Conly 1989Interrupted time series design with less than three data entry points before/after each intervention.

Creedon 2005Uncontrolled before and after study design

Creedon 2006Uncontrolled before and after design

Cromer 2008Uncontrolled before and after design

das Neves 2006Uncontrolled before and after design

Diekema 1995Uncontrolled before and after study design

Diersson-Sotos 2008Uncontrolled before and after design

Donowitz 1986Interrupted time series design with less than three data entry points before/after each intervention.

Dorsey 1996Uncontrolled before and after study design

Dubbert 1990Uncontrolled before and after study design

Duerink 2006Controlled before and after study, inadequate control, no baseline

Duggan 2008Uncontrolled before and after design, no baseline data

Earl 2001Uncontrolled before and after study design

Ebnother 2008Uncontrolled before and after design

Eckmanns 2006Uncontrolled before and after design

Eldridge 2006Interrupted time series study, inadequate data collection points

Elola-Vicente 2008Hand hygiene was assessed during simulation and in an artificial setting not involving real patients

Giannitsioti 2009Controlled clinical trial, inadequate control

Golan 2006Crossover trial with only one intervention group and one control group

Gopal Rao 2009No hand hygiene outcome data presented

Graham 1990Uncontrolled before and after study design

Grayson 2008Interrupted time series study, inadequate data collection points

Haas 2008Uncontrolled before and after design

Harbarth 2002Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Harrington 2007Uncontrolled before and after design

Hon 2008Hand hygiene was assessed in an artificial setting not involving real patients

Howard 2009Uncontrolled before and after design, no baseline data

Huang 2006Interrupted time series study, inadequate data collection points

Huang 2008Interrupted time series study, inadequate data collection points

Hughes 1986Uncontrolled before and after study design

Hugonnet 2002Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Hussein 2007Uncontrolled before and after study

Khatib 1999Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Kohli 2009Controlled clinical trial, inadequate control

Kusachi 2006No hand hygiene outcome data presented

Lam 2004Uncontrolled before and after study design

Larson 1991Controlled before and after study design with one nonequivalent control group.

Larson 1997Controlled before and after study design with one nonequivalent control group.

Larson 2000Controlled before and after study design with one nonequivalent control group.

Larson 2007No clear intervention

Lausten 2009aUncontrolled before and after design

Lausten 2009bUncontrolled before and after design

Lee 2009Uncontrolled before and after design

Macdonald 2006Hand hygiene was assessed during simulation

Madani 2006Interrupted time series study, inadequate data collection points

Marena 2002No control group for intervention of interest

Marra 2008Controlled clinical trial, no baseline data, inadequate control

Maury 2000Limited or no baseline data

Mayer 1986Controlled before and after study design with one nonequivalent control group.

McDonald 2007No hand hygiene outcome data presented

McGuckin 1999Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

McGuckin 2004Uncontrolled before and after study design

McGuckin 2006Uncontrolled before and after design

McLaws 2009Interrupted time series study, inadequate data collection points

Milward 2007Hand hygiene was assessed in an artificial setting not involving real patients

Miyachi 2007Interrupted time series study, inadequate data collection points

Moongtui 1999Data pertaining to hand hygiene were not presented separately from data related to universal precautions

Moore 1980No data were presented

Muto 2000Uncontrolled before and after study design

Muto 2007Uncontrolled before and after design, no baseline data

Nouira 2008Uncontrolled before and after design

Panhotra 2004Limited or no baseline data

Pessoa-Siilva 2007Uncontrolled before and after design

Picheansathian 2008Interrupted time series study, inadequate data collection points

Pittet 2000Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Prieto 2005Uncontrolled before and after study design

Raju 1991Interrupted time series design with less than three data entry points before/after each intervention.

Randle 2006Uncontrolled before and after design, no baseline data

Raskind 2009Uncontrolled before and after design

Roberts 2009No hand hygiene outcome data presented

Rose 2009Uncontrolled before and after design

Rosenthal 2003Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Rosenthal 2008Uncontrolled before after design; amalgamated data from 18 countries, no control groups

Rummukainen 2009Uncontrolled before and after design

Rupp 2008Crossover trial with only one intervention group and one control group

Rykkje 2007Hand hygiene data collected by self-report

Sacar 2006Uncontrolled before and after design

Salemi 2002Uncontrolled before and after study design

Sanchez-Paya 2007Uncontrolled before and after design

Santana 2007Uncontrolled before and after design

Schneider 2009Uncontrolled before and after design

Shaw 2003Uncontrolled before and after study design

Siegel 2007Uncontrolled before and after design

Simmons 1990Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Snow 2006No clear intervention

Souweine 2009Uncontrolled before and after design

Stone 2007Reported only baseline data, no follow-up data

Suchitra 2007Uncontrolled before and after design

Suresh 2007No hand hygiene outcome data presented

Swoboda 2004Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Swoboda 2007Uncontrolled before and after study design, reanalysis of previous data

Tenias 2009Uncontrolled before and after design

Thomas 2005Limited or no baseline data

Thomas 2009Uncontrolled before and after design

Thu 2007No hand hygiene outcome data presented

Tibbals 1996Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Traore 2007Uncontrolled before and after design

Trick 2007Controlled before and after study, inadequate control

Van de Mortel 1995Uncontrolled before and after study design

Van de Mortel 2000Uncontrolled before and after study design

Van de Mortel 2006Interrupted time series study, inadequate data collection points

Venkatesh 2008Uncontrolled before and after design

Wharton 2006Uncontrolled before and after design

Whitby 2004Uncontrolled before and after study design with sequential addition of new intervention(s) but limited data collection after each addition.

Widmer 2007Uncontrolled before and after design

Won 2004Uncontrolled before and after study design

Xue 2008Uncontrolled before and after design

Zingg 2009Uncontrolled before and after design

 
Table 1. Summary of Results

StudyMeasurement PeriodComparisonsMain Effect: Hand hygiene (HH)Effect: Infection ratesNotes

Huang 2002Baseline vs. 4 months post-interventionEducation group vs. control groupPercentage of 49 nurses who used appropriate HH before patient contact:

Education group:

- pre : 51%

- post 85.7%

Control group

- pre 53.1%

- post 53.1%

 

Percentage of 49 nurses who used appropriate HH after patient contact:

Education group:

- pre : 75.5%

- post 91.8%

Control group

- pre 75.5%

- post 71.4%
Not assessedSignificant increase in education group at post test for both before patient contact (p <.001) and after patient contact (P<.05) compared to control and baseline

 

No confidence intervals reported

Gould 1997Baseline vs. 3 months post interventionEducation group vs. control groupPercentage of essential hand

decontamination:

Education group:

- pre : 54.5%

- post 58.6%

Control group

- pre 54.4%

- post 64.1%

 
Not assessedNo significant difference between education and control groups

 

No confidence intervals reported

Vernaz 2008Monthly observations:

-  Baseline: February 2000 to spring 2003

-  VigiGerme campaign: spring 2003 to summer 2005

WHO campaign: summer 2005 to September 2006
Monthly use of litres of ABHR:

Baseline (2001): 1.303 litres per 100 patient-days increased to 2.016 litres in 2006 with ARIMA model showing effect after both promotions
Significant association found between ABHR use and decreased MRSA but no association found for C. difficile

 

No change in use of antibiotics over time
Significant increases in ABHR use in both periods compared to baseline (P<.0001 after VigiGerme and P =.0013 after WHO)

Whitby 2008Monthly observations: 4 or 5 months at baseline2 years post-intervention: monthly observations‘Geneva’ intervention: increased product use by 56% in the infectious diseases unit (IRR=1.56, 95% CI = 1.29 to 1.89 P<0.001), but not the medical wards (IRR=1.14, 95% CI = 0.93 to 1.39; p = 0.204).

’Washington’ intervention: 48% increase in product use (IRR=1.48, 95% CI = 1.20 to 1.81 P<0.001) which was sustained over two years.

No differences in product use for simple replacements.
Not assessedSignificant increase in one ward for Geneva intervention but not for other ward.

 

Significant increase for Washington intervention

 ABHR: alcohol-based hand rub
ARIMA: autoregressive integrated moving average
C: clostridium
CI: confidence interval
HH: hand hygiene
IRR: incidence rate ratio
MRSA: methicillin-resistant Staphylococcus aureus  
WHO: World Health Organization