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Author: Kirkland, K. B. / Homa, K. A. / Lasky, R. A. / Ptak, J. A. / Taylor, E. A. / Splaine, M. E. (2012) Source: BMJ Qual Saf 2012; 21: 1019 - 1026


Kirkland, K. B. / Homa, K. A. / Lasky, R. A. / Ptak, J. A. / Taylor, E. A. / Splaine, M. E. (2012)

Impact of a hospital-wide hand hygiene initiative on healthcare-associated infections: results of an interrupted time series

Background: Despite the knowledge that targeted hand hygiene reduces the rate of nosocomial infection, healthcare workers’ hand hygiene compliance is still too low. Hence, Kirkland et al. developed a hospital-wide and multimodal hand hygiene programme with the aim of improving hand hygiene compliance sustainably and reducing the rates of nosocomial infection.

Method: In January 2006, the programme was introduced to a 383-bed hospital, and then progressively complemented by additional interventions until the end of 2008. There were five areas of intervention:

  • involvement of the management level and emphasis of responsibility

  • audits and feedback

  • accessibility to hand disinfectants

  • education and training including certification

  • marketing and communication (campaigns).

To determine the compliance rates by occupational group and ward, monthly covert, direct observations were conducted in all hospital wards. These observations lasted until December 2009, i.e. one year beyond the last intervention had been introduced.

Additionally, the incidence of nosocomial infections per patient-day was recorded on a monthly basis and comprised several categories to identify infections due to, for example, Staphylococcus aureus. S. aureus infections were subdivided into two categories: infections that occurred in wards and infections attributable to surgeries. The authors expected the latter to be less influenceable by the intervention programme. Furthermore, Kirkland et al. collected data on conducted hygiene audits, consumption of hand disinfectant and the number of campaign activities (posters, articles, etc.).

Results: Hand hygiene compliance increased from an initial 41 % to 64 % at the end of 2006. During the summer 2007, it reached 79 %, and was 87 % in the spring of 2008. In the first year after the initiative (2009), the compliance further increased to 91 %.

The number of nosocomial infections decreased from 538 cases in 2006 to 394 cases in 2009. In 2008, 374 patients acquired a nosocomial infection. In 2007, the authors observed a significant and sudden reduction in infection rates from 4.8 to 3.3 per 1 000 patient-days. The rate of infection due to S. aureus also dropped significantly from 2.5 to 1.6 infections per 1 000 inpatient days. S. aureus infections attributable to surgeries, however, did not fall.

Conclusions: Multimodal interventions may increase compliance rates significantly and sustainably and may reduce the incidence of nosocomial infection. Kirkland et al. suspect that the key to their initiative’s success was that they linked hand hygiene compliance to the incidence of nosocomial infection. However, they note that the number of nosocomial infection did not decline until after some time the compliance had increased. One possible explanation may be that a minimum threshold of compliance is required to have an effect. Kirkland et al. furthermore emphasise that various influencing factors need to be observed when planning and implementing compliance programmes. These include the differing occupational groups, the types of ward and the associated types of risks of infection, dispenser placement, and the medical discipline.

BMJ Qual Saf 2012; 21: 1019 - 1026

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Additional information on hand hygiene programmes is available under CENTER.