Research for infection protection
  • germs
  • Adenovirus
  • Aspergillus niger
  • Bovine virus diarrhea
  • Clostridium difficile
  • Candida albicans
  • Candida albicans
  • Coronavirus
  • Corynebacterium
  • Escherichia coli
  • Helicobacter pylori

Author: Luangasanatip, N. / Hongsuwan, M. / Limmathurotsakul, D. / Lubell, Y. / Lee, A. S. / Harbarth, S. / Day, N. P. J. / Graves, N. / Cooper, B. S. (2015) Source: Luangasanatip,N. et al. BMJ. 2015; 351:h3728. Doi: 10.1136/bmj.h3728


Luangasanatip, N. / Hongsuwan, M. / Limmathurotsakul, D. / Lubell, Y. / Lee, A. S. / Harbarth, S. / Day, N. P. J. / Graves, N. / Cooper, B. S. (2015)

Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis

Background: Hand disinfection is the most important individual measure to prevent nosocomial infection. Worldwide, the compliance however is only 38.7 per cent. In 2005, WHO therefore started the “Clean Care is Safer Care” campaign. In addition to the multi-modal campaign’s five elements (system change; training/education; evaluation and feedback; reminders; and an institutional safety climate) there are meanwhile other approaches with the aim to improve the hand hygiene behaviour of healthcare workers (e.g. setting targets, incentives, strengthening accountability). In their review, Luangasanatip et al. assessed how successful the WHO campaign (WHO-5) and other compliance-promoting interventions are, what effect the interventions have on the rate of nosocomial infections, and what costs such programmes involve.

Method: For the review, the authors conducted a systematic literature research of studies published between 1980 and 2014. On the basis of pre-defined quality criteria, the researchers then selected the studies to be further analysed. The analysis was done when the study was available in English, peer reviewed and met the following initial criteria:

  • Compliance: During the study, interventions to improve hand hygiene compliance among healthcare workers were introduced.
  • Type of measurement: The study either measured the compliance directly or used comparative indicators to evaluate compliance (e.g. measurement of consumption).
  • Study design: The study was a randomised controlled trial, a non-randomised trial, a controlled before-after study, or used an interrupted time series design. In the case of the latter two, repeated compliance measurements are done before and after the intervention at pre-defined intervals.

From the analysed studies the authors obtained data on, for example, the extent of increase in compliance and which measures were conducted (e.g. training or feedback in the study and control groups). In addition, Luangasanatip et al. collected data on the rates of nosocomial infection and antimicrobial resistances as well as information on the associated costs.

Results: 41 of the 3 639 identified studies met the requirements. 34 of these studies observed the hand hygiene behaviour of healthcare workers with patient contact. The other 7 studies considered the compliance of nursing staff, nursing assistants and nursing students only.

In 14 of the analysed studies, the average compliance increased by up to 83.3 per cent. Overall, the studies showed that the five WHO measures improve the compliance among healthcare workers. With additional compliance targets, incentives and emphasis on the accountability for the patients and their health the employees’ hand hygiene behaviour even further improved.

A total of 19 studies demonstrated that an increased compliance rate reduces the rate of nosocomial infection or antimicrobial resistance. The costs associated with the differing interventions were between $225 and $4 669 per 1 000 patient days.

Conclusion: According to the authors, the five elements of the WHO “Clean Care is Safer Care” campaign can cause a considerable and sustainable increase in compliance among healthcare workers. Additional measures beyond the WHO-5 can even further increase the compliance. Such additional measures include setting targets, incentivising good hand hygiene behaviour and emphasising responsibility for the patient. Luangasanatip et al. conclude that future studies should more intensively collect information on costs and use of resources during interventions. It should also be considered to evaluate the long-term effect (sustainability) of compliance interventions.

Luangasanatip,N. et al. BMJ. 2015; 351:h3728. Doi: 10.1136/bmj.h3728

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Additional information on hand hygiene programmes is available under CENTER.