Eur J Clin Microbiol Infect Dis DOI 10.1007/s10096-015-2313-1
REVIEW
Efficacy of interventions to improve hand hygiene compliance in neonatal units: a systematic review and meta-analysis N. Ofek Shlomai & S. Rao & S. Patole
Received: 22 October 2014 / Accepted: 7 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Healthcare-associated infections (HCAIs) cause significant morbidity and mortality in neonatal intensive care units (NICUs). Meticulous hand hygiene is the most effective strategy to prevent HCAI. However, hand hygiene compliance (HHC) is low, especially in ICUs. Hence, we aimed to evaluate the efficacy of strategies for improving HHC in NICUs. A systematic review of the literature and metaanalysis were carried out. PubMed, EMBASE, Cochrane CENTRAL and CINAHL were searched in October 2013. PRISMA guidelines were followed. The quality of included studies was assessed by the Newcastle–Ottawa scale (NOS). Sixteen eligible non-randomised studies were included. A total of 27,155 hand hygiene moments were observed. Metaanalysis using a random effects model indicated that a range of strategies, such as educational campaigns, musical parodies, reminders, easy access to hand hygiene sanitisers, UV sensors and performance feedback, improved HHC [odds ratio (OR) 2.04; 95 % confidence interval (CI) 1.40, 2.97]. Significant statistical heterogeneity was noted. Studies which specifically provided performance feedback at either the individual or group levels reported a more significant improvement in HHC compared to those that did not (OR 2.81; 95 % CI N. Ofek Shlomai : S. Rao : S. Patole Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia N. Ofek Shlomai (*) Department of Neonatology, Hadassah and Hebrew University Medical Center, Mount Scopus, P.O. Box 12000, Jerusalem, Israel e-mail: [email protected] S. Rao Department of Neonatology, Princess Margaret Hospital for Children, Perth, Australia S. Rao : S. Patole Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
1.32, 5.96 vs. OR 1.55; 95 % CI 1.13–2.11). Strategies to improve HHC in NICUs seem to be more effective when they include performance feedback at the personal or group levels. Randomised controlled trials (RCTs) specifically assessing the benefits of performance feedback in improving HHC are needed.
Introduction Healthcare-associated infections (HCAIs) are one of the most serious patient safety issues in healthcare. The World Health Organization (WHO) estimates that hundreds of millions of patients suffer from HCAIs each year worldwide. HCAIs occur in 5–10 % of hospitalised patients, with a high prevalence (20–30 %) in those in an intensive care unit (ICU) [1]. HCAI rates are generally higher (up to 48.7 %) in resource-limited countries [2]. The significance of HCAI in neonatal intensive care units (NICUs) cannot be overemphasised [3, 4]. Lateonset sepsis (LOS), developing after the first 72 h of life, is a major cause of morbidity and mortality in NICUs [5]. In hospitalised infants, these are considered HCAIs and their incidence ranges from 3.8 to 60/1,000 patient days [6]. Neonatal LOS is associated with a significant increase in early and late mortality [7, 8], with almost 50 % of deaths beyond 2 weeks of age being attributed to infection [9]. HCAIs have been reported to prolong hospital stay by several weeks [9] and are associated with a greater risk of neurodevelopmental impairment (NDI), including cerebral palsy [8, 10]. The economic burden of LOS is significant [9], with hospital costs up to 1.4-fold greater in affected infants [11]. Various strategies have been developed to reduce neonatal HCAI [4, 12–14]. These range from early preferential feeding with breast milk and minimising prolonged exposure to parenteral nutrition, to judicious use of venous catheters and antibiotics and
Eur J Clin Microbiol Infect Dis
prophylactic bovine lactoferrin supplementation. However, it is accepted that meticulous hand hygiene is the single most effective strategy to reduce HCAIs [15–17]. Hand hygiene includes hand degerming, maintaining good skin and nail condition, and banning artificial nails and jewellery [18]. In order to promote hand hygiene practices among healthcare workers (HCWs) at a global level, the WHO initiated the ‘Clean Care is Safer Care’ programme [19] in 2005. As per its guidelines, when working with patients, hand hygiene should be performed at five key moments, preferably by using an alcoholbased rub or by hand washing with soap and water if the hands are visibly dirty. The five moments for hand hygiene are: before touching a patient; before clean and aseptic procedures (e.g. catheter insertion); after contact with body fluids; after touching a patient; and after touching patient surroundings. Prior to the WHO programme, various organisations had provided guidelines on hand hygiene practices among HCWs [18]. The WHO reported that, as of May 2013, over 15,700 healthcare facilities have committed to improving hand hygiene. This represents approximately 9 million HCWs and more than 3.9 million patient beds [18]. However, hand hygiene compliance (HHC) has been reported to be low throughout the health system [20], with mean baseline rates ranging from 5 to 89 % [17]. ICUs have been reported to have even lower HHC, with an average of 30–40 % [17]. Strategies to improve HHC are, therefore, important. The WHO’s ‘Clean Care is Safer Care’ programme has provided various strategies to enhance HHC [19]. They are: 1. Ensuring HCWs have access to alcohol-based hand rub at the point of patient care; 2. Training and education of HCWs on the most important times in patient care for hand hygiene; 3. Monitoring and feedback on compliance; 4.Visual reminders at the point of care in the workplace; and 5. Creation of a culture of attention to patient and HCW safety within the institution [19]. Considering that HHC is as crucial in NICUs as in adult care settings [7, 21, 22], we aimed to conduct a systematic review of studies evaluating the efficacy of strategies to improve HHC in NICUs. It is a commonly held belief that healthcare professionals are prompted to modify their practice when given performance feedback. A recent large systematic review found that audit and feedback generally leads to potentially important improvements in professional practice and healthcare outcomes [23]. The role of performance feedback in improving HHC in the context of NICUs is not clear. Hence, we aimed to separately analyse the studies in which performance feedback was given.
Materials and methods Guidelines from the PRISMA statement [24] were followed for reporting this systematic review.
The search strategy and study selection criteria were as follows: PUBMED (1946 to October 2013), EMBASE (1980 to October 2013), CINAHL (until October 2013) and Cochrane CENTRAL (October 2013) were searched independently by two authors (SR and NO). Studies reporting on interventions aimed to improve HHC in neonatal setups were eligible for inclusion in the review. Studies conducted during an outbreak of HCAI were excluded. Both randomised as well as ‘before and after intervention’ design studies were eligible for inclusion. No language restrictions were applied. Two authors performed the final selection of studies for inclusion in the review independently. Differences of opinion were resolved by discussion among all authors (SR, NO and SP). Details of the search terminology and yield are given in Table 1. Details of the process for selecting studies are given in Fig. 1. Data extraction and synthesis Using a pre-specified proforma, the following data were collected independently by two authors (SR and NO): year and Table 1
Literature search
Search terms used
EMBASE (via Ovid) (October 2013
• Hand washing • Hygiene • Newborn • Care • Hand washing • Hygiene • Intensive • Intensive care units, neonatal • Neonatal • Neonatal intensive care unit • Newborn intensive care unit • Compliance • Hand washing • Hygiene After removing overlapping articles CINAHL (via EBSCOHost) (October, 2013) Search terminology “Hand hygiene” AND “neonatal intensive care unit or newborn infant” Hand hygiene and intensive care unit PUBMED (October 2013 ((“Infant, Newborn”[Mesh]) OR “Intensive Care Units, Neonatal”[Mesh]) AND “Hand Hygiene”[Mesh] ((“Hand Hygiene”[Mesh]) AND “Guideline Adherence”[Mesh]) AND “Intensive Care Units”[Mesh] hand hygiene compliance and newborn infant hand hygiene and newborn nursery hand washing and neonatal intensive care unit After removing overlapping articles
865
303
57
851 Yield 0 142 Yield 216
102
26 34 158 356
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Results
Fig. 1 Study selection process
place where the study was conducted, details of the intervention, overall HHC rates before and after intervention. Similar information was intended to be collected for randomised controlled trials (RCTs) for intervention versus no intervention groups. The authors of all studies were contacted by email for additional information or for clarification of reported information. Pooling of the data, where possible, was done using RevMan 5.2 software provided by the Cochrane Library (http://ims.cochrane.org/revman). If studies had given HHC rates at different time points after the implementation of intervention strategies, such results were added. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using a random effects model in the meta-analysis to derive pooled estimates of effect size. Studies wherein performance feedback was included were analysed separately from those where there was no performance feedback. p-Values 1/shift 2. Artistic information posters 3. Phrases on hand hygiene, by hospital radio 1. Posters 2. Training 3. Performance feedback. Not clear if it was at a personal level or group feedback 4. Provision of alcohol-based hand rub
Interventions
Mukerji et al. [42], 2013
1. E-Learning package 2. Posters 3. Screen savers Mazi et al. [41], 2013 1. Lectures 2. Hands-on workshop 3. Exhibitions 4. Three-monthly audit and feedback to team leaders and hospital director Helder et al. [43], 1. Computer screen saver displays instead of 2012 static poster. Messages included images of hands, germs and disinfection methods 2. Screen saver message designs changed every 2 weeks to avoid desensitisation van den Hoogen et al. 1. Questionnaire regarding unit’s hand washing [29], 2011 protocol 2. Direct feedback from observer to the observed person. After observation, the HCW had to fill in a questionnaire and received immediate feedback 3. Informing HCWs of baseline hand washing rates 4. Informing HCWs of nosocomial infection rates 5. Videos of common mistakes on all computers in the unit 6. Posters with cartoons showing correct hand washing, changing every 3 weeks 7. Special attention to hand hygiene in new staff orientation Helder et al. [32], Education programme including: 2010 1. Overview of nosocomial infections and prevention 2. Instructions for optimal hand hygiene procedures 3. Performance feedback on hand washing was received automatically by the HCW because only sufficiently rubbed parts will glow in UV light 4. Senior healthcare professionals were encouraged to serve as role models Gill et al. [38], 2009 1. Alcohol hand rub at each bassinet 2. Preparatory workshops for key staff 3. Lectures on hand hygiene and infection control 4. Interactive case discussions Picheansathian et al. 1. Training session [35], 2008 2. Regular performance feedback at both individual and group levels 3. Reminder poster displays 4. Bedside alcohol-based solution 5. Supply of individual bottles of alcohol-based rub and hand towels Raskind et al. [30], 2007
Table 2 (continued)
Ongoing promotion programme, illustrations and written information regarding correct techniques: 1. E-mailed brochure 2. Prominently displayed bulletins 3. Posters 4. Verbal reminders
das Neves et al. [39], 2006
Danchaivijitr et al. [27], 2005 (MNMC Hospital, Bangkok)
Danchaivijitr et al. 1. Posters [27], 2005 (Siriraj 2. Leaflets hospital, Bangkok) 3. Rewarding HCWs who suggest the most attractive name for the alcohol gel and a hand washing slogan, parade to boost hand hygiene practice 4. Not clear if performance feedback was given Won et al. [36], 2004 1. Formal lectures on correct hand washing and importance of hand washing 2. Hand washing as part of orientation to all new staff 3. Labels with slogans placed throughout the nursery 4. Group feedback as well as private discussions with individual HCWs on errors in technique 5. Financial rewards and penalties according to hand washing performance 6. Public praise to good hand washers Lam et al. [37], 2004 1. Education sessions focusing on hand hygiene importance and techniques, plus face-to-face training sessions 2. Hand hygiene protocols 3. Pictures of correct step-by-step hand washing placed on sinks 4. Alcohol-based hand rub available on each incubator 5. Clustering of handling and procedures Brown et al. [34], 1. Provision of alcohol-based hand rub, free2003 standing dispensers (stage 1) 2. Single mandatory education session 3. Personalised instruction in hand washing technique Sharek et al. [40], 1. Educational sessions 2002 2. Notices 3. Reminder stickers on patient isolettes Raju and Kobler [28], Educational sessions+clinical rounds: 1991 1. Sharing baseline observation results with staff 2. Hand washing methods 3. Nosocomial infections 4. Handing out literature
2.81; 95 % CI 1.32, 5.96; HHC moments: 15,417), whereas studies that did not include the provision of performance feedback resulted in improvement of HHC to a lesser degree (OR
d
c
b
a
* * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * *
NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
* * * * * * * * * * * * * * * *
The final score is out of 8 instead of 9 because ‘Outcome not present at start’ is not applicable to non-RCTs of HHC
Follow-up length≥6 months was considered adequate
In none of the studies were the outcome assessors blinded to the fact that an intervention had been implemented
Studies that used logistic regression analysis or subgroup analysis to control for confounders received an additional star
NA not applicable
Danchaivijitr et al. [27], 2005 Brown et al. [34], 2003 das Neves et al. [39], 2006 Won et al. [36], 2004 van den Hoogen et al. [29], 2011 Raskind et al. [30], 2007 Picheansathian et al. [35], 2008 Pessoa-Silva et al. [33], 2007 Lam et al. [37], 2004 Helder et al. [32], 2010 Helder et al. [43], 2012 Raju and Kobler [28], 1991 Sharek et al. [40], 2002 Mukherjee et al. [42], 2013 Mazi et al. [41], 2013 Gill et al. [38], 2009
* * * 0 * * 0 * * * * 0 * * * 0
Additional factorsa
Main factor
Outcome not present at start
Representativeness of exposed
Ascertainment of exposure
Selection
Study ID Representativeness of non-exposed
Comparability
Quality of included studies (Newcastle–Ottawa Scale, NOS)
Table 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Assessmentb
Outcome
* 0 0 * * 0 * * * * 0 * * * * *
Follow-up lengthc
* * * * * * * * * * * * * * * *
Adequacy of follow-up 7 6 6 6 7 6 6 7 7 7 6 6 7 7 7 6
Final score, out of 8d^
Eur J Clin Microbiol Infect Dis
10 m
May 2010 to March 2011, Saudi Arabia
2007, level 3 NICU, the Netherlands 2006–2007, level 3 NICU, the Netherlands
2003–2006, level 3 NICU, the Netherlands
Helder et al. [43], 2012 van den Hoogen et al. [29], 2011
Helder et al. [32], 2010
Unit secretaries Two trained observers
3m 9m
1998–2001 Level 3 NICU, Taiwan
Year: N/A, level 3 NICU, Hong Kong
2000, level 3 NICU, Saint Petersburg (Russia)
Lam et al. [37], 2004
Brown et al. [34], 2003
4m
6m
NICU 1: 38 m NICU 2: 6 m 24 m
Danchaivijitr et al. [27], 2005 Won et al. [36], 2004
2001–2004, NICU, Thailand
2m
das Neves et al. [39], 2003–2004, level 2 2006 NICU/PICU, Brazil
Two trained graduate students
Trained observer under guise of medical student
NICU nurses
Trained observers
Trained observers
Trained nurses
7m
June 2004 to February 2005, NICU, Thailand Year: not clear, level 3 NICU, USA 2001–2004, levels 2 and 3 NICU, Geneva (Switzerland)
Picheansathian et al. [35], 2008 Raskind et al. [30], 2007 Pessoa-Silva et al. [33], 2007
Trained observers
NICU 1: 10 m NICU 2: 5 m
Researchers. Adequacy of hand rub, using UV light
Trained members of infection control department Electronic dispensers and medical students Five trained NICU nurses
Trained volunteer students
Method of monitoring HHC
Gill et al. [38], 2009 2003–2004, two level 3 NICUs, the Philippines
18 m
9m
2m
24 m
2009–2012, Canada
Mukerji et al. [42], 2013 Mazi et al. [41], 2013
Duration of follow-up
Year, setting
Characteristics of the included studies and their findings
Study ID
Table 4
248 patients, 1,027 moments
312 scheduled observational periods, number of moments: not clear 913 moments
4,182 moments
1,358 moments
1,114 patients, 5,325 moments
497 moments
1,245 moments
1,827 patients; 5,432 moments
703 patients, 1,360 moments
269 patients, 584 moments 1,604 moments
3,422 patients; 1,184 moments 686 moments
Number of hand hygiene moments
124/283 (44 %)
266/666 (40 %)
43 %
Before procedure: 188/314 (60 %) After procedure: 172/314 (55 %) 344/2,094 (16.5 %)
386/919 (42 %) Alcohol hand rub use: 66.6 L/1,000 patients
168/189 (89 %)
20/320 (6 %)
Global: 129/688 (19 %) Before procedure: 65/267 After procedure: 65/227 Before procedure: 352/512 (69 %) After procedure: 327/512 (64 %) 560/2,583
193/303 (64 %)
Phase 1: 142/162 (88 %)
388/509 (76 %)
HHC before intervention
Stage 1: 176/421 (42 %) Stage 2: 155/323 (48 %)
168/317 (53 %)
74 % in the 1st year; 80 % in the 2nd year
1 month: 212/212 (100 %) 3 months: 85/96 (88.5 %) Phase 2: 1142/2,539 (45 %); alcohol hand rub use 77.9 L/1,000 patients Phase 3: 1,026/1,867 (55 %); alcohol hand rub use 89.2 L/1,000 patients Before procedure: 298/496 (60 %) After procedure: 299/495 (60 %) 654/2,088 (31.3 %)
Global: 437/889 (49 %) Before procedure: 180/297 After procedure: 158/272 Before procedure: 599/689 (87 %) After procedure: 579/689 (84 %) 936/2,849 Compared to the before intervention rates, HHC improved in both NICUs; NICU 1: RR 1.3 (1.15–1.49); NICU 2: RR 1.61 (1.40–1.86) 751/925 (81 %)
Phase 2: 307/457 (67 %) Phase 3: 165/218 (76 %) Phase 2: 145/160 (90 %) Phase 3: 94/104 (90 %) Phase 4: 177/260 (68 %) 201/281 (96 %)
HHC after intervention
Colonisation 21.5/1,000
17.2/100 admissions; 11.3/1,000 patient days
15.3+/− 0.98
Not reported
Not reported
11.1/1,000 patient days
Not reported
9.7/1,000 patient days
NICU 1: 382.5/1,000 days NICU 2: 816.8/1,000 days
191/429
13.40 %
Not reported
Not reported
40/1,077
HCAI before intervention
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Culture-positive CONS: 6.1±2.3 patient days
Not reported
Compliance for this subgroup improved to 85.4 % (41 of 48) after the intervention was introduced (p=0.001) Surgeons: 50 % Nurse practitioners/house staff: 91 % X-ray technicians: 94 %
62.5 % met the proper hand washing criteria
Subgroup of house staff/ neonatal nurse practitioners, surgeons and X- ray technicians had a combined ‘between-patient compliance of 47.4 % (9 of 19) at baseline’ Surgeons: 33 % Nurse practitioners/house staff: 43 % X-ray technicians: 56 % 28 % met the proper hand washing criteria
Table 5
HHC hand hygiene compliance; HCAI healthcare-associated infection; NICU neonatal intensive care unit; CONS coagulase-negative staphylococcus; PICU paediatric intensive care unit
9m
NICU nurses
654
Study ID
Raju and Kobler [28],1988–1989, level 3 NICU, 1991 Chicago, USA
Trained staff nurses 1998–1999, level 3 NICU, Stanford University Hospital, California, USA Sharek et al. [40], 2002
6m
2,685 patients, 46 healthcare professionals HHC moments: not given
HCAI before intervention HHC after intervention Method of monitoring HHC Duration of follow-up Year, setting Study ID
Table 4 (continued)
Number of hand hygiene moments
HHC before intervention
Eur J Clin Microbiol Infect Dis Studies in which performance feedback was provided Type of performance feedback
Mazi et al. [41], 2013 Three-monthly audit and feedback to team leaders and hospital director van den Hoogen et al. Direct feedback from observer to the observed [29], 2011 person. After observation, the HCW had to fill in a questionnaire and received immediate feedback Helder et al. [32], Performance feedback on hand washing was 2010 received automatically by the HCW because only sufficiently rubbed parts will glow in UV light Picheansathian et al. Regular performance feedback at both the [35], 2008 individual and the group levels Pessoa-Silva et al. Group feedback during discussions by superiors [33], 2007 Danchaivijitr et al. Performance feedback was given (MNMC [27], 2005 Hospital, Bangkok). Not clear if it was at a personal level or group feedback Won et al. [36], 2004 Group feedback as well as private discussions with individual HCWs on errors in technique
1.55; 95 % CI 1.13–2.11; HHC moments: 11,738) (Fig. 2). The funnel plot [26] suggested that publication bias was unlikely (Fig. 3). Studies that could not be included in the meta-analysis because of lack of data in the required format also showed improved HHC with intervention [36, 40]. Won et al. [36] reported that, before intervention, the baseline HHC rate was 43 %, whereas it improved to 74 % during the first year of the programme and 80 % in the second year (Table 4). Sharek et al. [40] reported that the subgroup of house staff/neonatal nurse practitioners, surgeons and X-ray technicians had a combined ‘between-patient compliance of 47.4 % (9 of 19) at baseline.’ Compliance for this subgroup improved to 85.4 % (41 of 48) after the intervention was introduced (p= 0.001). They also reported that each subgroup improved compliance from baseline (surgeons from 33 % to 50 %, neonatal nurse practitioners/house staff from 43 % to 91 % and X-ray technicians from 56 % to 94 %. Nine of the included studies reported on blood culturepositive HCAIs [29, 32–38] or colonisation by pathogens [34]; seven of these reported a decrease in the incidence of HCAI following implementation of interventions to improve HHC. However, Picheansathian et al. [35] and Gill et al. [38] reported no improvement in HCAI, but mortality was reduced in the study by Gill et al. [38]. Won et al.[36] reported an improvement in the total infection rate (bloodstream, surgical, urinary tract, gastrointestinal tract, skin and respiratory tract) from 15.13±0.98 to 10.69±0.88 (p=0.003). Pooling of the data for these outcomes was not possible due to different measures for reporting (e.g. odds ratio, rate per admission or patient days, percentage).
Eur J Clin Microbiol Infect Dis
Fig. 2 Forrest plot of efficacy of interventions to improve hand hygiene compliance (HHC)
Discussion The results of our systematic review and meta-analysis, which included 27,155 hand hygiene moments from 16 studies, indicate that a range of strategies, such as educational campaigns, musical parodies, reminders, easy access to hand
Fig. 3 Funnel plot
hygiene sanitisers and UV sensors, can improve HHC in NICUs. They also suggest that the provision of performance feedback in addition to other measures has the potential to improve HHC significantly. Gould and co-workers conducted a Cochrane review (2010) to assess the short- and longer-term success of
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strategies to improve HHC and to determine whether a sustained increase in HHC can reduce rates of HCAI. The review was not restricted to NICU setups. The authors were able to identify only four studies (all non-neonatal) that met the criteria for their review. Hence, they concluded that there was insufficient evidence to draw a firm conclusion regarding the efficacy of education, substitution of cleaning products and promotion campaigns in increasing HHC [44]. Helder et al. systematically evaluated studies (n = 15) reporting on non-pharmacological interventions for the prevention of bloodstream infections (HCAIs) in NICUs. The interventions analysed were research on hand hygiene promotion, use of IV bundles, closed IV sets/patches/filters and surveillance. They found three studies which had reported on the effects of intervention on improving HHC [32, 33, 37]. They concluded that hand hygiene promotion increases hand hygiene among HCWs, but there is inconclusive evidence that this intervention subsequently reduces bloodstream infection in infants. They also concluded that future studies must be well designed, with standardised outcome measures [31]. Erasmus et al. conducted a systematic review of 96 studies assessing HHC across various healthcare settings (ICU, general ward, surgical ward etc.). They found that the most important factors influencing HHC were the type of procedure (i.e. clean vs. dirty tasks), the introduction of alcohol-based hand rub or gel, accessibility of materials and performance feedback [1]. Only 3/16 neonatal studies included in our review were included in their review [28, 33, 40]. They did not include any neonatal studies that were not included in our review. A variety of methods of performance feedback was used in the included studies in our review (Table 5). Some of them were individual feedback from supervisors to HCWs, whereas some provided group feedback in the form of discussions. The benefits of performance feedback in improving the practice of HCWs in various areas are supported by other studies. A recent Cochrane review assessed RCTs (n=140) of audit and feedback that reported objectively measured health professionals’ practice [23]. In the case of multi-faceted interventions, only the trials with audit and feedback as an essential aspect of at least one intervention arm were included. The weighted median adjusted risk difference was a 4.3 % [interquartile range (IQR) 0.5 % to 16 %] absolute increase in health professional’s compliance with the desired practice. The weighted median adjusted precent change relative to controls was 1.3 % (IQR1.3 % to 28.9 %). Multi-variable meta-regression indicated that feedback may be more effective when the baseline performance is low, the source is a supervisor or colleague, it is provided more than once in both verbal and written formats, and when it includes both explicit targets and an action plan. Additionally, the effect size varied based on the clinical behaviour targeted by the intervention. The reviewers pointed out that, although the median effect of performance
feedback might be perceived as small, the 75th percentile effect size was much larger (16 %), suggesting that audit and feedback, when optimally designed and used in the right context, can play an important role in improving professional practice [23]. Sullivan et al. [45] reported that a narcotic prescribing error feedback programme in the NICU reduced the errors by 83 % and also increased the time between errors from 3.94 to 22.63 days. They provided group feedback as well as individualised feedback to the clinicians who had prescribed the errors. Whilst our meta-analysis found that studies where feedback was provided improved HHC, one needs to be careful and not rely on it alone. Additionally, feedback, if not given constructively, has the potential to affect staff morale. Changing physician behaviour is a challenge, even when RCTs demonstrate an intervention to be effective [46, 47]. A combination of methods, including the broad context of social norms [48], education of both physicians and patients, and feedback, has been reported to be effective in changing physician behaviour [46]. A systematic review of barriers to change in physician behaviour has reported lack of awareness and familiarity, lack of agreement and complicated guidelines to be the main issues [49]. Performance feedback is expected to facilitate change in healthcare professionals’ behaviour by improving awareness. The results of a recent systematic review (2012) indicate that only a strategy targeting barriers to change will achieve a long-lasting improvement in hand hygiene behaviour [50]. Currently, it is standard practice to audit HHC in each and every hospital in many countries. While such audits have increased awareness regarding the importance of hand hygiene, they have not really translated into improved HHC rates. This is most likely because of the impersonal nature of the audit reports, wherein a monthly or quarterly statement is produced, which is then circulated electronically via emails, which end up being ignored by all concerned. The audits also cost an enormous amount of money to the system [20]. A recent analysis of Australian data showed poor HHC rates, especially among medical staff [20]. The authors suggested that it was time to move from the obsession with auditing to the next phase—targeting practice and HCWs to effect change. They specifically emphasised the importance of immediate feedback [20]. While it is reassuring that our meta-analysis showed that the implementation of new interventions improved HHC, it is important to note that the follow-up duration was under 1 year in 12 of the 16 included studies. For any improvement in HHC to be sustained in the long run, ongoing audit, education and feedback are essential. We believe that the ongoing poor HHC rates are most likely because of the impersonal nature of the audit reports, wherein a monthly or quarterly statement is produced, which is then circulated electronically via emails, which end up being
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ignored by all concerned, resulting in a waste of resources. The five stages of an audit cycle are preparing for the audit, selecting criteria, measuring performance level, making improvements and sustaining them [51]. While the first three stages have been successfully achieved, the last two stages for HHC seem to have received insufficient attention. Our systematic review has shown that one way of making improvements in HHC and sustaining them is providing effective feedback to HCWs at an individual or a group level. The strengths of our review include a large sample size (16 studies with 27,155 hand hygiene moments), consistent benefits across different strategies to improve HHC, different setups (developed as well as developing countries) and time periods (1991–2013). The main limitation of our review was that all included studies were of non-RCT design and the fact that there was significant statistical heterogeneity. In addition, the duration of follow-up was inadequate in the majority of the studies. In summary, our results indicate that a range of strategies are effective in improving HHC in NICUs. Provision of performance feedback has the potential to further enhance HHC. Considering the benefits of hand hygiene, every effort should be undertaken to improve compliance with this simple procedure to reduce the burden of HCAIs in NICUs. The importance of promoting the habit for meticulous hand hygiene cannot be overemphasised in this context. Acknowledgements We thank Onno Helder (2010), Christopher Gill, Waleed Mazi, Wilawan Picheansathian, Onno Helder (2012) and Agnes van den Hoogen for providing additional information from their published studies or clarifying existing information.
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Conflict of interest The authors declare no conflict of interest. 15.
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infections in the NICU: observing and implementing meaningful differences in process between high and low acquired infection rate centers. J Perinatol 23(6):489–492. doi:10.1038/sj.jp.7210981 Hornik CP, Fort P, Clark RH, Watt K, Benjamin DK Jr, Smith PB, Manzoni P, Jacqz-Aigrain E, Kaguelidou F, Cohen-Wolkowiez M (2012) Early and late onset sepsis in very-low-birth-weight infants from a large group of neonatal intensive care units. Early Hum Dev 88(Suppl 2):S69–S74. doi:10.1016/S0378-3782(12)70019-1 Bassler D, Stoll BJ, Schmidt B, Asztalos EV, Roberts RS, Robertson CM, Sauve RS; Trial of Indomethacin Prophylaxis in Preterms Investigators (2009) Using a count of neonatal morbidities to predict poor outcome in extremely low birth weight infants: added role of neonatal infection. Pediatrics 123(1):313–318. doi:10.1542/peds.2008-0377 Polin RA, Saiman L (2003) Nosocomial infections in the neonatal intensive care unit. NeoReviews 4(3):e81–e89 van der Ree M, Tanis JC, Van Braeckel KN, Bos AF, Roze E (2011) Functional impairments at school age of preterm born children with late-onset sepsis. Early Hum Dev 87(12):821–826. doi:10.1016/j. earlhumdev.2011.06.008 Johnson TJ, Patel AL, Jegier BJ, Engstrom JL, Meier PP (2013) Cost of morbidities in very low birth weight infants. J Pediatr 162(2):243– 249.e1. doi:10.1016/j.jpeds.2012.07.013 Manzoni P, Rizzollo S, Decembrino L, Ruffinazzi G, Rossi Ricci A, Gallo E, Stolfi I, Mostert M, Stronati M, Farina D (2011) Recent advances in prevention of sepsis in the premature neonates in NICU. Early Hum Dev 87(Suppl 1):S31–S33. doi:10.1016/j. earlhumdev.2011.01.008 O’Grady NP, Alexander M, Dellinger EP, Gerberding JL, Heard SO, Maki DG, Masur H, McCormick RD, Mermel LA, Pearson ML, Raad II, Randolph A, Weinstein RA; Healthcare Infection Control Practices Advisory Committee (2002) Guidelines for the prevention of intravascular catheter-related infections. Infect Control Hosp Epidemiol 23(12):759–769. doi:10.1086/502007 Stoll BJ, Hansen N, Fanaroff AA, Wright LL, Carlo WA, Ehrenkranz RA, Lemons JA, Donovan EF, Stark AR, Tyson JE, Oh W, Bauer CR, Korones SB, Shankaran S, Laptook AR, Stevenson DK, Papile LA, Poole WK (2002) Late-onset sepsis in very low birth weight neonates: the experience of the NICHD Neonatal Research Network. Pediatrics 110(2 Pt 1):285–291 Kilpatrick C, Murdoch H, Storr J (2012) Importance of hand hygiene during invasive procedures. Nurs Stand 26(41):42–46 Simmons B, Bryant J, Neiman K, Spencer L, Arheart K (1990) The role of handwashing in prevention of endemic intensive care unit infections. Infect Control Hosp Epidemiol 11(11):589–594 Pittet D, Allegranzi B, Boyce J; World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts (2009) The World Health Organization Guidelines on Hand Hygiene in Health Care and their consensus recommendations. Infect Control Hosp Epidemiol 30(7):611–622. doi:10.1086/600379 Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force (2002) Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol 23(12 Suppl):S3–S40. doi:10.1086/503164 World Health Organization (WHO) (2009) WHO guidelines on hand hygiene in health care. WHO, Geneva McLaws ML, Azim S (2014) Doctor, do you have a moment? National Hand Hygiene Initiative compliance in Australian hospitals. Med J Aust 201(5):265
Eur J Clin Microbiol Infect Dis 21. Borghesi A, Tzialla C, Decembrino L, Manzoni P, Stronati M (2011) New possibilities of prevention of infection in the newborn. J Matern Fetal Neonatal Med 24(Suppl 2):28–30. doi:10.3109/14767058.2011.604934 22. Toltzis P, Walsh M (2010) Recently tested strategies to reduce nosocomial infections in the neonatal intensive care unit. Expert Rev Anti Infect Ther 8(2):235–242. doi:10.1586/eri.09.129 23. Ivers N, Jamtvedt G, Flottorp S, Young JM, Odgaard-Jensen J, French SD, O’Brien MA, Johansen M, Grimshaw J, Oxman AD (2012) Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev 6:CD000259. doi:10.1002/14651858.CD000259.pub3 24. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. J Clin Epidemiol 62(10):1006–1012. doi:10.1016/j.jclinepi.2009.06.005 25. Stang A (2010) Critical evaluation of the Newcastle–Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol 25(9):603–605. doi:10.1007/s10654-010-9491-z 26. Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315(7109): 629–634 27. Danchaivijitr S, Pichiensatian W, Apisarnthanarak A, Kachintorn K, Cherdrungsi R (2005) Strategies to improve hand hygiene practices in two university hospitals. J Med Assoc Thai 88(Suppl 10):S155– S160 28. Raju TN, Kobler C (1991) Improving handwashing habits in the newborn nurseries. Am J Med Sci 302(6):355–358 29. van den Hoogen A, Brouwer AJ, Verboon-Maciolek MA, Gerards LJ, Fleer A, Krediet TG (2011) Improvement of adherence to hand hygiene practice using a multimodal intervention program in a neonatal intensive care. J Nurs Care Qual 26(1):22–29. doi:10.1097/NCQ.0b013e3181ea86e9 30. Raskind CH, Worley S, Vinski J, Goldfarb J (2007) Hand hygiene compliance rates after an educational intervention in a neonatal intensive care unit. Infect Control Hospit Epidemiol 28(9):1096–1098. doi:10.1086/519933 31. Helder O, van den Hoogen A, de Boer C, van Goudoever J, VerboonMaciolek M, Kornelisse R (2013) Effectiveness of nonpharmacological interventions for the prevention of bloodstream infections in infants admitted to a neonatal intensive care unit: A systematic review. Int J Nurs Stud 50(6):819–831. doi:10.1016/j. ijnurstu.2012.02.009 32. Helder OK, Brug J, Looman CW, van Goudoever JB, Kornelisse RF (2010) The impact of an education program on hand hygiene compliance and nosocomial infection incidence in an urban neonatal intensive care unit: an intervention study with before and after comparison. Int J Nurs Stud 47(10):1245–1252. doi:10.1016/j.ijnurstu.2010.03.005 33. Pessoa-Silva CL, Hugonnet S, Pfister R, Touveneau S, Dharan S, Posfay-Barbe K, Pittet D (2007) Reduction of health care associated infection risk in neonates by successful hand hygiene promotion. Pediatrics 120(2):e382–e390. doi:10.1542/peds.2006-3712 34. Brown SM, Lubimova AV, Khrustalyeva NM, Shulaeva SV, Tekhova I, Zueva LP, Goldmann D, O’Rourke EJ (2003) Use of an alcoholbased hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit. Infect Control Hosp Epidemiol 24(3):172–179. doi:10.1086/502186 35. Picheansathian W, Pearson A, Suchaxaya P (2008) The effectiveness of a promotion programme on hand hygiene compliance and
nosocomial infections in a neonatal intensive care unit. Int J Nurs Pract 14(4):315–321. doi:10.1111/j.1440-172X.2008.00699.x 36. Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, Tsao PN (2004) Handwashing program for the prevention of nosocomial infections in a neonatal intensive care unit. Infect Control Hosp Epidemiol 25(9):742–746. doi:10.1086/502470 37. Lam BC, Lee J, Lau YL (2004) Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection. Pediatrics 114(5):e565–e571. doi:10.1542/peds.2004-1107 38. Gill CJ, Mantaring JB, Macleod WB, Mendoza M, Mendoza S, Huskins WC, Goldmann DA, Hamer DH (2009) Impact of enhanced infection control at 2 neonatal intensive care units in the Philippines. Clin Infect Dis 48(1):13–21. doi:10.1086/594120 39. das Neves ZC, Tipple AF, Silva e Souza AC, Pereira MS, Melo Dde S, Ferreira LR (2006) Hand hygiene: The impact of incentive strategies on adherence among healthcare workers from a newborn intensive care unit. Rev Lat Am Enfermagem 14(4):546–552 40. Sharek PJ, Benitz WE, Abel NJ, Freeburn MJ, Mayer ML, Bergman DA (2002) Effect of an evidence-based hand washing policy on hand washing rates and false-positive coagulase negative staphylococcus blood and cerebrospinal fluid culture rates in a level III NICU. J Perinatol 22(2):137–143. doi:10.1038/sj.jp.7210661 41. Mazi W, Senok AC, Al-Kahldy S, Abdullah D (2013) Implementation of the world health organization hand hygiene improvement strategy in critical care units. Antimicrob Resist Infect Control 2(1):15. doi:10.1186/2047-2994-2-15 42. Mukerji A, Narciso J, Moore C, McGeer A, Kelly E, Shah V (2013) An observational study of the hand hygiene initiative: a comparison of preintervention and postintervention outcomes. BMJ Open 3(5). pii: e003018. doi:10.1136/bmjopen-2013-003018 43. Helder OK, Weggelaar AM, Waarsenburg DC, Looman CW, van Goudoever JB, Brug J, Kornelisse RF (2012) Computer screen saver hand hygiene information curbs a negative trend in hand hygiene behavior. Am J Infect Control 40(10):951–954. doi:10.1016/j.ajic.2011.12.003 44. Gould DJ, Moralejo D, Drey N, Chudleigh JH (2010) Interventions to improve hand hygiene compliance in patient care. Cochrane Database Syst Rev 9:CD005186. doi:10.1002/14651858. CD005186.pub3 45. Sullivan KM, Suh S, Monk H, Chuo J (2013) Personalised performance feedback reduces narcotic prescription errors in a NICU. BMJ Qual Saf 22(3):256–262. doi:10.1136/bmjqs-2012-001089 46. Greco PJ, Eisenberg JM (1993) Changing physicians’ practices. N Engl J Med 329(17):1271–1273. doi:10.1056/NEJM199310213291714 47. Fineberg HV (1987) Clinical evaluation: how does it influence medical practice? Bull Cancer 74(3):333–346 48. Bauchner H, Simpson L, Chessare J (2001) Changing physician behaviour. Arch Dis Child 84(6):459–462 49. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR (1999) Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 282(15): 1458–1465 50. Huis A, van Achterberg T, de Bruin M, Grol R, Schoonhoven L, Hulscher M (2012) A systematic review of hand hygiene improvement strategies: a behavioural approach. Implement Sci 7: 92. doi:10.1186/1748-5908-7-92 51. Benjamin A (2008) Audit: how to do it in practice. BMJ 336(7655): 1241–1245. doi:10.1136/bmj.39527.628322.AD
REVIEW
Efficacy of interventions to improve hand hygiene compliance in neonatal units: a systematic review and meta-analysis N. Ofek Shlomai & S. Rao & S. Patole
Received: 22 October 2014 / Accepted: 7 January 2015 # Springer-Verlag Berlin Heidelberg 2015
Abstract Healthcare-associated infections (HCAIs) cause significant morbidity and mortality in neonatal intensive care units (NICUs). Meticulous hand hygiene is the most effective strategy to prevent HCAI. However, hand hygiene compliance (HHC) is low, especially in ICUs. Hence, we aimed to evaluate the efficacy of strategies for improving HHC in NICUs. A systematic review of the literature and metaanalysis were carried out. PubMed, EMBASE, Cochrane CENTRAL and CINAHL were searched in October 2013. PRISMA guidelines were followed. The quality of included studies was assessed by the Newcastle–Ottawa scale (NOS). Sixteen eligible non-randomised studies were included. A total of 27,155 hand hygiene moments were observed. Metaanalysis using a random effects model indicated that a range of strategies, such as educational campaigns, musical parodies, reminders, easy access to hand hygiene sanitisers, UV sensors and performance feedback, improved HHC [odds ratio (OR) 2.04; 95 % confidence interval (CI) 1.40, 2.97]. Significant statistical heterogeneity was noted. Studies which specifically provided performance feedback at either the individual or group levels reported a more significant improvement in HHC compared to those that did not (OR 2.81; 95 % CI N. Ofek Shlomai : S. Rao : S. Patole Department of Neonatal Paediatrics, KEM Hospital for Women, Perth, Australia N. Ofek Shlomai (*) Department of Neonatology, Hadassah and Hebrew University Medical Center, Mount Scopus, P.O. Box 12000, Jerusalem, Israel e-mail: [email protected] S. Rao Department of Neonatology, Princess Margaret Hospital for Children, Perth, Australia S. Rao : S. Patole Centre for Neonatal Research and Education, University of Western Australia, Perth, Australia
1.32, 5.96 vs. OR 1.55; 95 % CI 1.13–2.11). Strategies to improve HHC in NICUs seem to be more effective when they include performance feedback at the personal or group levels. Randomised controlled trials (RCTs) specifically assessing the benefits of performance feedback in improving HHC are needed.
Introduction Healthcare-associated infections (HCAIs) are one of the most serious patient safety issues in healthcare. The World Health Organization (WHO) estimates that hundreds of millions of patients suffer from HCAIs each year worldwide. HCAIs occur in 5–10 % of hospitalised patients, with a high prevalence (20–30 %) in those in an intensive care unit (ICU) [1]. HCAI rates are generally higher (up to 48.7 %) in resource-limited countries [2]. The significance of HCAI in neonatal intensive care units (NICUs) cannot be overemphasised [3, 4]. Lateonset sepsis (LOS), developing after the first 72 h of life, is a major cause of morbidity and mortality in NICUs [5]. In hospitalised infants, these are considered HCAIs and their incidence ranges from 3.8 to 60/1,000 patient days [6]. Neonatal LOS is associated with a significant increase in early and late mortality [7, 8], with almost 50 % of deaths beyond 2 weeks of age being attributed to infection [9]. HCAIs have been reported to prolong hospital stay by several weeks [9] and are associated with a greater risk of neurodevelopmental impairment (NDI), including cerebral palsy [8, 10]. The economic burden of LOS is significant [9], with hospital costs up to 1.4-fold greater in affected infants [11]. Various strategies have been developed to reduce neonatal HCAI [4, 12–14]. These range from early preferential feeding with breast milk and minimising prolonged exposure to parenteral nutrition, to judicious use of venous catheters and antibiotics and
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prophylactic bovine lactoferrin supplementation. However, it is accepted that meticulous hand hygiene is the single most effective strategy to reduce HCAIs [15–17]. Hand hygiene includes hand degerming, maintaining good skin and nail condition, and banning artificial nails and jewellery [18]. In order to promote hand hygiene practices among healthcare workers (HCWs) at a global level, the WHO initiated the ‘Clean Care is Safer Care’ programme [19] in 2005. As per its guidelines, when working with patients, hand hygiene should be performed at five key moments, preferably by using an alcoholbased rub or by hand washing with soap and water if the hands are visibly dirty. The five moments for hand hygiene are: before touching a patient; before clean and aseptic procedures (e.g. catheter insertion); after contact with body fluids; after touching a patient; and after touching patient surroundings. Prior to the WHO programme, various organisations had provided guidelines on hand hygiene practices among HCWs [18]. The WHO reported that, as of May 2013, over 15,700 healthcare facilities have committed to improving hand hygiene. This represents approximately 9 million HCWs and more than 3.9 million patient beds [18]. However, hand hygiene compliance (HHC) has been reported to be low throughout the health system [20], with mean baseline rates ranging from 5 to 89 % [17]. ICUs have been reported to have even lower HHC, with an average of 30–40 % [17]. Strategies to improve HHC are, therefore, important. The WHO’s ‘Clean Care is Safer Care’ programme has provided various strategies to enhance HHC [19]. They are: 1. Ensuring HCWs have access to alcohol-based hand rub at the point of patient care; 2. Training and education of HCWs on the most important times in patient care for hand hygiene; 3. Monitoring and feedback on compliance; 4.Visual reminders at the point of care in the workplace; and 5. Creation of a culture of attention to patient and HCW safety within the institution [19]. Considering that HHC is as crucial in NICUs as in adult care settings [7, 21, 22], we aimed to conduct a systematic review of studies evaluating the efficacy of strategies to improve HHC in NICUs. It is a commonly held belief that healthcare professionals are prompted to modify their practice when given performance feedback. A recent large systematic review found that audit and feedback generally leads to potentially important improvements in professional practice and healthcare outcomes [23]. The role of performance feedback in improving HHC in the context of NICUs is not clear. Hence, we aimed to separately analyse the studies in which performance feedback was given.
Materials and methods Guidelines from the PRISMA statement [24] were followed for reporting this systematic review.
The search strategy and study selection criteria were as follows: PUBMED (1946 to October 2013), EMBASE (1980 to October 2013), CINAHL (until October 2013) and Cochrane CENTRAL (October 2013) were searched independently by two authors (SR and NO). Studies reporting on interventions aimed to improve HHC in neonatal setups were eligible for inclusion in the review. Studies conducted during an outbreak of HCAI were excluded. Both randomised as well as ‘before and after intervention’ design studies were eligible for inclusion. No language restrictions were applied. Two authors performed the final selection of studies for inclusion in the review independently. Differences of opinion were resolved by discussion among all authors (SR, NO and SP). Details of the search terminology and yield are given in Table 1. Details of the process for selecting studies are given in Fig. 1. Data extraction and synthesis Using a pre-specified proforma, the following data were collected independently by two authors (SR and NO): year and Table 1
Literature search
Search terms used
EMBASE (via Ovid) (October 2013
• Hand washing • Hygiene • Newborn • Care • Hand washing • Hygiene • Intensive • Intensive care units, neonatal • Neonatal • Neonatal intensive care unit • Newborn intensive care unit • Compliance • Hand washing • Hygiene After removing overlapping articles CINAHL (via EBSCOHost) (October, 2013) Search terminology “Hand hygiene” AND “neonatal intensive care unit or newborn infant” Hand hygiene and intensive care unit PUBMED (October 2013 ((“Infant, Newborn”[Mesh]) OR “Intensive Care Units, Neonatal”[Mesh]) AND “Hand Hygiene”[Mesh] ((“Hand Hygiene”[Mesh]) AND “Guideline Adherence”[Mesh]) AND “Intensive Care Units”[Mesh] hand hygiene compliance and newborn infant hand hygiene and newborn nursery hand washing and neonatal intensive care unit After removing overlapping articles
865
303
57
851 Yield 0 142 Yield 216
102
26 34 158 356
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Results
Fig. 1 Study selection process
place where the study was conducted, details of the intervention, overall HHC rates before and after intervention. Similar information was intended to be collected for randomised controlled trials (RCTs) for intervention versus no intervention groups. The authors of all studies were contacted by email for additional information or for clarification of reported information. Pooling of the data, where possible, was done using RevMan 5.2 software provided by the Cochrane Library (http://ims.cochrane.org/revman). If studies had given HHC rates at different time points after the implementation of intervention strategies, such results were added. Odds ratios (ORs) and 95 % confidence intervals (CIs) were calculated using a random effects model in the meta-analysis to derive pooled estimates of effect size. Studies wherein performance feedback was included were analysed separately from those where there was no performance feedback. p-Values 1/shift 2. Artistic information posters 3. Phrases on hand hygiene, by hospital radio 1. Posters 2. Training 3. Performance feedback. Not clear if it was at a personal level or group feedback 4. Provision of alcohol-based hand rub
Interventions
Mukerji et al. [42], 2013
1. E-Learning package 2. Posters 3. Screen savers Mazi et al. [41], 2013 1. Lectures 2. Hands-on workshop 3. Exhibitions 4. Three-monthly audit and feedback to team leaders and hospital director Helder et al. [43], 1. Computer screen saver displays instead of 2012 static poster. Messages included images of hands, germs and disinfection methods 2. Screen saver message designs changed every 2 weeks to avoid desensitisation van den Hoogen et al. 1. Questionnaire regarding unit’s hand washing [29], 2011 protocol 2. Direct feedback from observer to the observed person. After observation, the HCW had to fill in a questionnaire and received immediate feedback 3. Informing HCWs of baseline hand washing rates 4. Informing HCWs of nosocomial infection rates 5. Videos of common mistakes on all computers in the unit 6. Posters with cartoons showing correct hand washing, changing every 3 weeks 7. Special attention to hand hygiene in new staff orientation Helder et al. [32], Education programme including: 2010 1. Overview of nosocomial infections and prevention 2. Instructions for optimal hand hygiene procedures 3. Performance feedback on hand washing was received automatically by the HCW because only sufficiently rubbed parts will glow in UV light 4. Senior healthcare professionals were encouraged to serve as role models Gill et al. [38], 2009 1. Alcohol hand rub at each bassinet 2. Preparatory workshops for key staff 3. Lectures on hand hygiene and infection control 4. Interactive case discussions Picheansathian et al. 1. Training session [35], 2008 2. Regular performance feedback at both individual and group levels 3. Reminder poster displays 4. Bedside alcohol-based solution 5. Supply of individual bottles of alcohol-based rub and hand towels Raskind et al. [30], 2007
Table 2 (continued)
Ongoing promotion programme, illustrations and written information regarding correct techniques: 1. E-mailed brochure 2. Prominently displayed bulletins 3. Posters 4. Verbal reminders
das Neves et al. [39], 2006
Danchaivijitr et al. [27], 2005 (MNMC Hospital, Bangkok)
Danchaivijitr et al. 1. Posters [27], 2005 (Siriraj 2. Leaflets hospital, Bangkok) 3. Rewarding HCWs who suggest the most attractive name for the alcohol gel and a hand washing slogan, parade to boost hand hygiene practice 4. Not clear if performance feedback was given Won et al. [36], 2004 1. Formal lectures on correct hand washing and importance of hand washing 2. Hand washing as part of orientation to all new staff 3. Labels with slogans placed throughout the nursery 4. Group feedback as well as private discussions with individual HCWs on errors in technique 5. Financial rewards and penalties according to hand washing performance 6. Public praise to good hand washers Lam et al. [37], 2004 1. Education sessions focusing on hand hygiene importance and techniques, plus face-to-face training sessions 2. Hand hygiene protocols 3. Pictures of correct step-by-step hand washing placed on sinks 4. Alcohol-based hand rub available on each incubator 5. Clustering of handling and procedures Brown et al. [34], 1. Provision of alcohol-based hand rub, free2003 standing dispensers (stage 1) 2. Single mandatory education session 3. Personalised instruction in hand washing technique Sharek et al. [40], 1. Educational sessions 2002 2. Notices 3. Reminder stickers on patient isolettes Raju and Kobler [28], Educational sessions+clinical rounds: 1991 1. Sharing baseline observation results with staff 2. Hand washing methods 3. Nosocomial infections 4. Handing out literature
2.81; 95 % CI 1.32, 5.96; HHC moments: 15,417), whereas studies that did not include the provision of performance feedback resulted in improvement of HHC to a lesser degree (OR
d
c
b
a
* * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * *
* * * * * * * * * * * * * * * *
NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA
* * * * * * * * * * * * * * * *
The final score is out of 8 instead of 9 because ‘Outcome not present at start’ is not applicable to non-RCTs of HHC
Follow-up length≥6 months was considered adequate
In none of the studies were the outcome assessors blinded to the fact that an intervention had been implemented
Studies that used logistic regression analysis or subgroup analysis to control for confounders received an additional star
NA not applicable
Danchaivijitr et al. [27], 2005 Brown et al. [34], 2003 das Neves et al. [39], 2006 Won et al. [36], 2004 van den Hoogen et al. [29], 2011 Raskind et al. [30], 2007 Picheansathian et al. [35], 2008 Pessoa-Silva et al. [33], 2007 Lam et al. [37], 2004 Helder et al. [32], 2010 Helder et al. [43], 2012 Raju and Kobler [28], 1991 Sharek et al. [40], 2002 Mukherjee et al. [42], 2013 Mazi et al. [41], 2013 Gill et al. [38], 2009
* * * 0 * * 0 * * * * 0 * * * 0
Additional factorsa
Main factor
Outcome not present at start
Representativeness of exposed
Ascertainment of exposure
Selection
Study ID Representativeness of non-exposed
Comparability
Quality of included studies (Newcastle–Ottawa Scale, NOS)
Table 3
0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Assessmentb
Outcome
* 0 0 * * 0 * * * * 0 * * * * *
Follow-up lengthc
* * * * * * * * * * * * * * * *
Adequacy of follow-up 7 6 6 6 7 6 6 7 7 7 6 6 7 7 7 6
Final score, out of 8d^
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10 m
May 2010 to March 2011, Saudi Arabia
2007, level 3 NICU, the Netherlands 2006–2007, level 3 NICU, the Netherlands
2003–2006, level 3 NICU, the Netherlands
Helder et al. [43], 2012 van den Hoogen et al. [29], 2011
Helder et al. [32], 2010
Unit secretaries Two trained observers
3m 9m
1998–2001 Level 3 NICU, Taiwan
Year: N/A, level 3 NICU, Hong Kong
2000, level 3 NICU, Saint Petersburg (Russia)
Lam et al. [37], 2004
Brown et al. [34], 2003
4m
6m
NICU 1: 38 m NICU 2: 6 m 24 m
Danchaivijitr et al. [27], 2005 Won et al. [36], 2004
2001–2004, NICU, Thailand
2m
das Neves et al. [39], 2003–2004, level 2 2006 NICU/PICU, Brazil
Two trained graduate students
Trained observer under guise of medical student
NICU nurses
Trained observers
Trained observers
Trained nurses
7m
June 2004 to February 2005, NICU, Thailand Year: not clear, level 3 NICU, USA 2001–2004, levels 2 and 3 NICU, Geneva (Switzerland)
Picheansathian et al. [35], 2008 Raskind et al. [30], 2007 Pessoa-Silva et al. [33], 2007
Trained observers
NICU 1: 10 m NICU 2: 5 m
Researchers. Adequacy of hand rub, using UV light
Trained members of infection control department Electronic dispensers and medical students Five trained NICU nurses
Trained volunteer students
Method of monitoring HHC
Gill et al. [38], 2009 2003–2004, two level 3 NICUs, the Philippines
18 m
9m
2m
24 m
2009–2012, Canada
Mukerji et al. [42], 2013 Mazi et al. [41], 2013
Duration of follow-up
Year, setting
Characteristics of the included studies and their findings
Study ID
Table 4
248 patients, 1,027 moments
312 scheduled observational periods, number of moments: not clear 913 moments
4,182 moments
1,358 moments
1,114 patients, 5,325 moments
497 moments
1,245 moments
1,827 patients; 5,432 moments
703 patients, 1,360 moments
269 patients, 584 moments 1,604 moments
3,422 patients; 1,184 moments 686 moments
Number of hand hygiene moments
124/283 (44 %)
266/666 (40 %)
43 %
Before procedure: 188/314 (60 %) After procedure: 172/314 (55 %) 344/2,094 (16.5 %)
386/919 (42 %) Alcohol hand rub use: 66.6 L/1,000 patients
168/189 (89 %)
20/320 (6 %)
Global: 129/688 (19 %) Before procedure: 65/267 After procedure: 65/227 Before procedure: 352/512 (69 %) After procedure: 327/512 (64 %) 560/2,583
193/303 (64 %)
Phase 1: 142/162 (88 %)
388/509 (76 %)
HHC before intervention
Stage 1: 176/421 (42 %) Stage 2: 155/323 (48 %)
168/317 (53 %)
74 % in the 1st year; 80 % in the 2nd year
1 month: 212/212 (100 %) 3 months: 85/96 (88.5 %) Phase 2: 1142/2,539 (45 %); alcohol hand rub use 77.9 L/1,000 patients Phase 3: 1,026/1,867 (55 %); alcohol hand rub use 89.2 L/1,000 patients Before procedure: 298/496 (60 %) After procedure: 299/495 (60 %) 654/2,088 (31.3 %)
Global: 437/889 (49 %) Before procedure: 180/297 After procedure: 158/272 Before procedure: 599/689 (87 %) After procedure: 579/689 (84 %) 936/2,849 Compared to the before intervention rates, HHC improved in both NICUs; NICU 1: RR 1.3 (1.15–1.49); NICU 2: RR 1.61 (1.40–1.86) 751/925 (81 %)
Phase 2: 307/457 (67 %) Phase 3: 165/218 (76 %) Phase 2: 145/160 (90 %) Phase 3: 94/104 (90 %) Phase 4: 177/260 (68 %) 201/281 (96 %)
HHC after intervention
Colonisation 21.5/1,000
17.2/100 admissions; 11.3/1,000 patient days
15.3+/− 0.98
Not reported
Not reported
11.1/1,000 patient days
Not reported
9.7/1,000 patient days
NICU 1: 382.5/1,000 days NICU 2: 816.8/1,000 days
191/429
13.40 %
Not reported
Not reported
40/1,077
HCAI before intervention
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Culture-positive CONS: 6.1±2.3 patient days
Not reported
Compliance for this subgroup improved to 85.4 % (41 of 48) after the intervention was introduced (p=0.001) Surgeons: 50 % Nurse practitioners/house staff: 91 % X-ray technicians: 94 %
62.5 % met the proper hand washing criteria
Subgroup of house staff/ neonatal nurse practitioners, surgeons and X- ray technicians had a combined ‘between-patient compliance of 47.4 % (9 of 19) at baseline’ Surgeons: 33 % Nurse practitioners/house staff: 43 % X-ray technicians: 56 % 28 % met the proper hand washing criteria
Table 5
HHC hand hygiene compliance; HCAI healthcare-associated infection; NICU neonatal intensive care unit; CONS coagulase-negative staphylococcus; PICU paediatric intensive care unit
9m
NICU nurses
654
Study ID
Raju and Kobler [28],1988–1989, level 3 NICU, 1991 Chicago, USA
Trained staff nurses 1998–1999, level 3 NICU, Stanford University Hospital, California, USA Sharek et al. [40], 2002
6m
2,685 patients, 46 healthcare professionals HHC moments: not given
HCAI before intervention HHC after intervention Method of monitoring HHC Duration of follow-up Year, setting Study ID
Table 4 (continued)
Number of hand hygiene moments
HHC before intervention
Eur J Clin Microbiol Infect Dis Studies in which performance feedback was provided Type of performance feedback
Mazi et al. [41], 2013 Three-monthly audit and feedback to team leaders and hospital director van den Hoogen et al. Direct feedback from observer to the observed [29], 2011 person. After observation, the HCW had to fill in a questionnaire and received immediate feedback Helder et al. [32], Performance feedback on hand washing was 2010 received automatically by the HCW because only sufficiently rubbed parts will glow in UV light Picheansathian et al. Regular performance feedback at both the [35], 2008 individual and the group levels Pessoa-Silva et al. Group feedback during discussions by superiors [33], 2007 Danchaivijitr et al. Performance feedback was given (MNMC [27], 2005 Hospital, Bangkok). Not clear if it was at a personal level or group feedback Won et al. [36], 2004 Group feedback as well as private discussions with individual HCWs on errors in technique
1.55; 95 % CI 1.13–2.11; HHC moments: 11,738) (Fig. 2). The funnel plot [26] suggested that publication bias was unlikely (Fig. 3). Studies that could not be included in the meta-analysis because of lack of data in the required format also showed improved HHC with intervention [36, 40]. Won et al. [36] reported that, before intervention, the baseline HHC rate was 43 %, whereas it improved to 74 % during the first year of the programme and 80 % in the second year (Table 4). Sharek et al. [40] reported that the subgroup of house staff/neonatal nurse practitioners, surgeons and X-ray technicians had a combined ‘between-patient compliance of 47.4 % (9 of 19) at baseline.’ Compliance for this subgroup improved to 85.4 % (41 of 48) after the intervention was introduced (p= 0.001). They also reported that each subgroup improved compliance from baseline (surgeons from 33 % to 50 %, neonatal nurse practitioners/house staff from 43 % to 91 % and X-ray technicians from 56 % to 94 %. Nine of the included studies reported on blood culturepositive HCAIs [29, 32–38] or colonisation by pathogens [34]; seven of these reported a decrease in the incidence of HCAI following implementation of interventions to improve HHC. However, Picheansathian et al. [35] and Gill et al. [38] reported no improvement in HCAI, but mortality was reduced in the study by Gill et al. [38]. Won et al.[36] reported an improvement in the total infection rate (bloodstream, surgical, urinary tract, gastrointestinal tract, skin and respiratory tract) from 15.13±0.98 to 10.69±0.88 (p=0.003). Pooling of the data for these outcomes was not possible due to different measures for reporting (e.g. odds ratio, rate per admission or patient days, percentage).
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Fig. 2 Forrest plot of efficacy of interventions to improve hand hygiene compliance (HHC)
Discussion The results of our systematic review and meta-analysis, which included 27,155 hand hygiene moments from 16 studies, indicate that a range of strategies, such as educational campaigns, musical parodies, reminders, easy access to hand
Fig. 3 Funnel plot
hygiene sanitisers and UV sensors, can improve HHC in NICUs. They also suggest that the provision of performance feedback in addition to other measures has the potential to improve HHC significantly. Gould and co-workers conducted a Cochrane review (2010) to assess the short- and longer-term success of
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strategies to improve HHC and to determine whether a sustained increase in HHC can reduce rates of HCAI. The review was not restricted to NICU setups. The authors were able to identify only four studies (all non-neonatal) that met the criteria for their review. Hence, they concluded that there was insufficient evidence to draw a firm conclusion regarding the efficacy of education, substitution of cleaning products and promotion campaigns in increasing HHC [44]. Helder et al. systematically evaluated studies (n = 15) reporting on non-pharmacological interventions for the prevention of bloodstream infections (HCAIs) in NICUs. The interventions analysed were research on hand hygiene promotion, use of IV bundles, closed IV sets/patches/filters and surveillance. They found three studies which had reported on the effects of intervention on improving HHC [32, 33, 37]. They concluded that hand hygiene promotion increases hand hygiene among HCWs, but there is inconclusive evidence that this intervention subsequently reduces bloodstream infection in infants. They also concluded that future studies must be well designed, with standardised outcome measures [31]. Erasmus et al. conducted a systematic review of 96 studies assessing HHC across various healthcare settings (ICU, general ward, surgical ward etc.). They found that the most important factors influencing HHC were the type of procedure (i.e. clean vs. dirty tasks), the introduction of alcohol-based hand rub or gel, accessibility of materials and performance feedback [1]. Only 3/16 neonatal studies included in our review were included in their review [28, 33, 40]. They did not include any neonatal studies that were not included in our review. A variety of methods of performance feedback was used in the included studies in our review (Table 5). Some of them were individual feedback from supervisors to HCWs, whereas some provided group feedback in the form of discussions. The benefits of performance feedback in improving the practice of HCWs in various areas are supported by other studies. A recent Cochrane review assessed RCTs (n=140) of audit and feedback that reported objectively measured health professionals’ practice [23]. In the case of multi-faceted interventions, only the trials with audit and feedback as an essential aspect of at least one intervention arm were included. The weighted median adjusted risk difference was a 4.3 % [interquartile range (IQR) 0.5 % to 16 %] absolute increase in health professional’s compliance with the desired practice. The weighted median adjusted precent change relative to controls was 1.3 % (IQR1.3 % to 28.9 %). Multi-variable meta-regression indicated that feedback may be more effective when the baseline performance is low, the source is a supervisor or colleague, it is provided more than once in both verbal and written formats, and when it includes both explicit targets and an action plan. Additionally, the effect size varied based on the clinical behaviour targeted by the intervention. The reviewers pointed out that, although the median effect of performance
feedback might be perceived as small, the 75th percentile effect size was much larger (16 %), suggesting that audit and feedback, when optimally designed and used in the right context, can play an important role in improving professional practice [23]. Sullivan et al. [45] reported that a narcotic prescribing error feedback programme in the NICU reduced the errors by 83 % and also increased the time between errors from 3.94 to 22.63 days. They provided group feedback as well as individualised feedback to the clinicians who had prescribed the errors. Whilst our meta-analysis found that studies where feedback was provided improved HHC, one needs to be careful and not rely on it alone. Additionally, feedback, if not given constructively, has the potential to affect staff morale. Changing physician behaviour is a challenge, even when RCTs demonstrate an intervention to be effective [46, 47]. A combination of methods, including the broad context of social norms [48], education of both physicians and patients, and feedback, has been reported to be effective in changing physician behaviour [46]. A systematic review of barriers to change in physician behaviour has reported lack of awareness and familiarity, lack of agreement and complicated guidelines to be the main issues [49]. Performance feedback is expected to facilitate change in healthcare professionals’ behaviour by improving awareness. The results of a recent systematic review (2012) indicate that only a strategy targeting barriers to change will achieve a long-lasting improvement in hand hygiene behaviour [50]. Currently, it is standard practice to audit HHC in each and every hospital in many countries. While such audits have increased awareness regarding the importance of hand hygiene, they have not really translated into improved HHC rates. This is most likely because of the impersonal nature of the audit reports, wherein a monthly or quarterly statement is produced, which is then circulated electronically via emails, which end up being ignored by all concerned. The audits also cost an enormous amount of money to the system [20]. A recent analysis of Australian data showed poor HHC rates, especially among medical staff [20]. The authors suggested that it was time to move from the obsession with auditing to the next phase—targeting practice and HCWs to effect change. They specifically emphasised the importance of immediate feedback [20]. While it is reassuring that our meta-analysis showed that the implementation of new interventions improved HHC, it is important to note that the follow-up duration was under 1 year in 12 of the 16 included studies. For any improvement in HHC to be sustained in the long run, ongoing audit, education and feedback are essential. We believe that the ongoing poor HHC rates are most likely because of the impersonal nature of the audit reports, wherein a monthly or quarterly statement is produced, which is then circulated electronically via emails, which end up being
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ignored by all concerned, resulting in a waste of resources. The five stages of an audit cycle are preparing for the audit, selecting criteria, measuring performance level, making improvements and sustaining them [51]. While the first three stages have been successfully achieved, the last two stages for HHC seem to have received insufficient attention. Our systematic review has shown that one way of making improvements in HHC and sustaining them is providing effective feedback to HCWs at an individual or a group level. The strengths of our review include a large sample size (16 studies with 27,155 hand hygiene moments), consistent benefits across different strategies to improve HHC, different setups (developed as well as developing countries) and time periods (1991–2013). The main limitation of our review was that all included studies were of non-RCT design and the fact that there was significant statistical heterogeneity. In addition, the duration of follow-up was inadequate in the majority of the studies. In summary, our results indicate that a range of strategies are effective in improving HHC in NICUs. Provision of performance feedback has the potential to further enhance HHC. Considering the benefits of hand hygiene, every effort should be undertaken to improve compliance with this simple procedure to reduce the burden of HCAIs in NICUs. The importance of promoting the habit for meticulous hand hygiene cannot be overemphasised in this context. Acknowledgements We thank Onno Helder (2010), Christopher Gill, Waleed Mazi, Wilawan Picheansathian, Onno Helder (2012) and Agnes van den Hoogen for providing additional information from their published studies or clarifying existing information.
7.
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9. 10.
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Conflict of interest The authors declare no conflict of interest. 15.
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