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Study flow diagram.
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Figure 1

Study flow diagram.

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Risk of bias graph for non‐ITS studies (RCTs, NRCTs, and CBAs)
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Figure 2

Risk of bias graph for non‐ITS studies (RCTs, NRCTs, and CBAs)

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Risk of bias summary for non‐ITS studies (RCTs, NRCTs, and CBAs)
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Figure 3

Risk of bias summary for non‐ITS studies (RCTs, NRCTs, and CBAs)

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Risk of bias graph for ITS studies
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Figure 4

Risk of bias graph for ITS studies

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Risk of bias summary for ITS studies
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Figure 5

Risk of bias summary for ITS studies

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Overview: interventions compared with different or no interventions for improving hand hygiene compliance in healthcare workers or reducing infection or colonisation rates

Patient or population: Healthcare workers

Settings: Hospitals, nursing homes and long‐term care facilities

Intervention: Strategies varied by study

Comparison: Varied by study

Types of Interventions1

Impact

Outcomes and Certainty of the evidence (GRADE) 2

Hand Hygiene Compliance3

Change in infection rates4

Change in colonisation rates4

Multimodal, not WHO‐based5: contains some strategies recommended by WHO

Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance and may slightly reduce infection rates (low certainty of evidence).

⊕⊕⊝⊝
low

(5 studies)

⊕⊕⊝⊝
low

(3 studies)

‐‐‐

Multimodal, WHO‐based: contains all strategies recommended by WHO

It is uncertain whether multimodal interventions that include all strategies recommended in the WHO guidelines improve hand hygiene compliance or reduces infection because the certainty of this evidence is very low. Such multimodal interventions may slightly reduce colonization rates (low certainty of evidence)

⊕⊝⊝⊝
very low

(5 studies)

⊕⊝⊝⊝
very low

(2 studies)

⊕⊕⊝⊝
low

(2 studies)

Multimodal, WHO‐enhanced: contains all strategies recommended by WHO and additional ones

Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (low certainty of evidence). It is uncertain whether such multimodal interventions reduce infection rates because the certainty of this evidence is very low

⊕⊕⊝⊝
low

(6 studies)

⊕⊝⊝⊝
very low

(1 study)

‐‐‐

Performance feedback

Performance feedback may improve hand hygiene compliance (low certainty of evidence) and probably slightly reduces infection and colonisation rates

⊕⊕⊝⊝
low

(6 studies)

⊕⊕⊕⊝
moderate

(1 study)

⊕⊕⊕⊝
moderate

(1 study)

Education

Education may improve hand hygiene compliance (low certainty of evidence)

⊕⊕⊝⊝
low

(2 studies)

‐‐‐

‐‐‐

Cues

Cues such as signs or scent may slightly improve hand hygiene compliance (low certainty of evidence)

⊕⊕⊝⊝
low

(3 studies)

‐‐‐

‐‐‐

Placement of ABHR

Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (moderate certainty of evidence).

⊕⊕⊕⊝
moderate

(1 study)

‐‐‐

‐‐‐

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.
Abbreviations: ABHR: alcohol‐based hand rub; WHO: World Health Organization

1Studies evaluated different strategies or combinations of strategies.
2See individual 'Summary of findings' tables (by intervention type) for specific impact and rationale for downgrading evidence.
3Hand hygiene compliance: measured through direct observation or a proxy indicator such as product use.
4Rates: infection or colonisation rates, or both, were reported for different micro‐organisms.
5Multiple strategies were used but were not consistent with WHO guidelines.

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Multimodal interventions (not WHO‐based) compared with no intervention for promotion of hand hygiene or reduction of infection or colonisation rates

Patient or population: Healthcare workers

Settings: Long‐term care, primary care, hospital

Intervention: Multimodal with some but not all of the strategies recommended by WHO; strategies varied by study

Comparison: No hand hygiene promotion

Outcomes

Impact

Studies

Certainty of the evidence
(GRADE)

Hand hygiene compliance

In the RCTs, the absolute differences in hand hygiene compliance compared to baseline ranged from 1.9 to 37.7 percentage points in intervention groups and from 0.3 to 11.9 in control groups. The ITS reported an adjusted OR of 1.19, 95% CI 1.01 to 1.42 favouring the intervention

4 RCTs, 1 ITS

24 long‐term care facilities, 10 hospitals, 11 ICUs and 11 primary healthcare units

⊕⊕⊝⊝
low1

Infection rates

1 RCT reported reduced respiratory outbreaks and MRSA infections requiring hospitalisation (IRR 0.12 to 0.61) favouring the intervention, while 1 ITS study reported no reduction in MRSA clinical isolates or infection. 1 RCT reported reductions of 0.27 to 0.77 cases per 1000 resident‐days in serious infections, pneumonia and death in the intervention group compared to no change or an increase of 0.57 cases per 1000 resident‐days in the control group

2 RCT, 1 ITS

24 long‐term care facilities, 10 hospitals,

⊕⊕⊝⊝
low2

Colonisation rates

Not reported

‐

‐

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.
Abbreviations: CI: confidence interval; ICU: intensive care unit; IRR: incidence rate ratio; ITS: interrupted time series; MRSA: methicillin‐resistant Staphylococcus aureus; OR: odds ratio; RCT: randomised (controlled) trial; WHO: World Health Organization

1Evidence downgraded from high to low due to non‐randomised evidence (one of five studies); high risk of bias (all studies have two or more sources of bias), and inconsistency in effect sizes between studies and within multi‐unit studies.
2Evidence downgraded from high to low due to non‐randomised evidence (one of three studies), high risk of bias (all studies have two or more sources of high risk of bias), and (inconsistency in results with some studies reporting changes for some micro‐organisms but not others and 1 reporting no change.

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WHO‐based multimodal interventions compared with some or no interventions for promotion of hand hygiene or reduction of infection or colonisation rates

Patient or population: Healthcare workers

Settings: Acute care hospitals

Intervention: Multimodal with all five strategies recommended by WHO: ABHR at point of care, education, performance feedback, reminders, and administrative support.

Comparison: Varied by study

Outcomes

Impact

Studies

Certainty of the evidence
(GRADE)

Hand hygiene compliance

The absolute difference in hand hygiene compliance between intervention and control group was 6.3 percentage points in the RCT. One ITS reported a difference of 17 percentage points in hand hygiene compliance compared to baseline, while another ITS reported no change on medicine units and a RR of 1.56, 95% CI 1.29 to 1.89 in IDUs favouring intervention. One ITS in a multistate system reported an increase of 27.45 ounces of ABHR per adjusted bed‐day. One ITS did not report estimates of change

1 RCT, 4 ITS

1 multistate system with 166 hospitals, 5 hospitals and 13 ICUs

⊕⊝⊝⊝
very low1

Infection rates

1 ITS reported a decrease in blood stream infections of 0.191 cases per 1000 line‐days and a decrease in ventilator‐associated pneumonia of 0.538 cases per 1000 ventilator days. 1 ITS reported that MRSA decreased by 0.03 clinical isolates for each litre of ABHR per 100 patient‐days but there was no change in C. difficile

2 ITS

3 hospitals and 13 ICUs

⊕⊝⊝⊝
very low2

Colonisation rates

1 RCT reported no difference in MRSA colonisation. 1 ITS reported a slight decrease in MRSA acquisition (IRR 0.976 favouring intervention) but no change in VRE or HRE acquisition.

1 RCT, 1 ITS

1 multistate system with 166 hospitals, 1 hospital

⊕⊕⊝⊝
low3

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very certainty: We are very uncertain about the estimate.
Abbreviations: ABHR: alcohol‐based hand rub; C. difficile: Clostridium difficile; CI: confidence interval; HRE: highly‐resistant Enterobacteriaceae; ICU: intensive care unit; IDU: immunisation and diagnosis unit; ; ITS: interrupted time series; MRSA: methicillin‐resistant Staphylococcus aureus; RCT: randomised (controlled) trial; RR: risk ratio; VRE: vancomycin‐resistant enterococci; WHO: World Health Organization

1Evidence downgraded from high to very low due to non‐randomised evidence (four of five studies); high risk of bias (four of five studies have two or more sources of high risk of bias), and inconsistency in effect sizes between studies and within multi‐unit studies.
2Evidence downgraded from high to very low due to non‐randomised evidence (two studies), high risk of bias (studies have two or more sources of high risk of bias), and inconsistency in effect sizes between studies and within multi‐unit studies.
3Evidence downgraded from high to low due to non‐randomised evidence (one of two studies), high risk of bias (both studies have two or more sources of high risk of bias), and inconsistency in results with one study reporting changes for some microorganisms but not others and the other reporting no change.

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WHO‐enhanced multimodal interventions compared with some or no interventions for promoting hand hygiene

Patient or population: Healthcare workers

Settings: Acute care hospitals

Intervention: Multimodal with all of the strategies recommended by WHO, plus additional interventions.

Comparison: Varied by study

Outcomes

Impact

Studies

Certainty of the evidence
(GRADE)

Hand hygiene compliance

1 RCT and one ITS reported an increase in hand hygiene compliance with RR of 1.48 to 1.64 favouring intervention. 1 RCT reported increases in hand hygiene compliance of 20.1 to 28.4 percentage points in the intervention group compared to a decrease of 0.7 to 3.1 in the control. 1 ITS reported an increase in hand hygiene compliance of 2% per month during the intervention compared to < 1% a month before and after the intervention, while another ITS reported hand hygiene compliance of 83% ‐ 95% post‐intervention compared to 38% ‐ 100% at baseline, with variation by unit. 1 ITS did not report estimates of change

2 RCTs, 4 ITS

15 hospitals

⊕⊕⊝⊝
low1

Infection rates

1 ITS reported no change in MRSA clinical isolates or in C. difficile

1 ITS

1 hospital

⊕⊝⊝⊝
very low2

Colonisation rates

Not reported

‐

‐

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

Abbreviations:C. difficile: Clostridium difficile; ITS: interrupted time series; MRSA: methicillin‐resistant Staphylococcus aureus; RCT: randomised (controlled) trial; RR: risk ratio; WHO: World Health Organization

1Evidence downgraded from high to low due to non‐randomised evidence (four of six studies; high risk of bias (five of six studies have two or more sources of high risk of bias), and inconsistency in effect sizes between studies and within multi‐unit studies.

2Evidence downgraded from high to very low due to non‐randomised evidence and high risk of bias (two sources of high risk of bias).

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Performance feedback compared with some or no interventions for promoting hand hygiene

Patient or population: Healthcare workers

Settings: Acute care hospitals

Intervention: Feedback with additional strategies such as focus on leadership; varied by study

Comparison: Varied by study

Outcomes

Impact

Studies

Certainty of the evidence
(GRADE)

Observed hand hygiene compliance

1 RCT and 1 NRCT reported increases in hand hygiene compliance of 0 ‐ 61 percentage points in intervention groups compared to no changes or a slight decrease of 4 percentage points in control groups. 2 RCTs reported ORs of 1.61 to 2.09 favouring intervention. 1 ITS reported a weekly increase in hand hygiene compliance of 4% after an initial increase of 17.5%, while 1 ITS reported an increase of 37 percentage points during the active accountability phase of the study

3 RCTs, 1 NRCT, 2 ITS

21 hospitals

⊕⊕⊝⊝
low1

Infection rates

1 RCT reported reduced primary bloodstream infection in the enhanced feedback group (0.71, 95% CI 0.54 to 0.95) and control group (0.57, 95% CI 0.40 to 0.80) with little change in the enhanced feedback + patient participation group (1.02, 95% CI 0.78 to 1.34). Period prevalence of HCAIs was also reduced in the enhanced feedback group (0.91, 95% CI 0.68 to 1.23), with little change in the enhanced feedback + patient participation group (1.05, 95% CI 0.78 to 1.40) and an increase in the control group (1.33, 95% CI 0.94 to 1.88)

1 RCT

1 hospital

⊕⊕⊕⊝
moderate2

Colonisation rates

1 RCT reported reduced colonisation with MRSA in the enhanced feedback group (0.79, 95% CI 0.66 to 0.95) and the enhanced feedback + patient participation group (0.82, 95% CI 0.67 to 0.99), as well as in the control group (0.92, 95% CI 0.77 to 1.13)

1 RCT

1 hospital

⊕⊕⊕⊝
moderate2

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

Abbreviations: CI: confidence interval; HCAIs: healthcare‐associated infections; ITS: interrupted time series; MRSA: methicillin‐resistant Staphylococcus aureus; NRCT: non‐randomised (controlled) trial; OR: odds ratio; RCT: randomised (controlled) trial

1Evidence downgraded from high to low due to non‐randomised evidence (three of six studies); high risk of bias (two or more sources in all studies), and inconsistency in effect sizes between studies and within multi‐unit studies.
2Evidence downgraded from high to moderate due to high risk of bias (two sources), and inconsistency in effect sizes within the study.

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Education compared with no education for promotion of hand hygiene

Patient or population: Healthcare workers

Settings: Acute care hospitals

Intervention: Education; content and delivery methods varied by study

Comparison: No education

Outcomes

Impact

Studies

Certainty of the evidence
(GRADE)

Observed hand hygiene compliance

1 RCT reported increases of 16.3 to 24.5 percentage points in the proportion of nurses in the intervention group who complied with recommendations for hand hygiene, depending on moment of hand hygiene evaluated, compared to no changes or a decrease of 4.1 percentage points in the control group. 1 ITS reported an increase in hand hygiene compliance as a proportion of opportunities of 42 percentage points

1RCT and 1 ITS

2 hospitals

⊕⊕⊝⊝
low1

Infection rates

Not reported.

‐

‐

Colonisation rates

Not reported.

‐

‐

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

Abbreviations: ITS: interrupted time series; RCT: randomised (controlled) trial

1Evidence downgraded from high to low due to non‐randomised evidence (one of two studies); and risk of bias (high and unclear).

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Cues compared with no cue or different cue for promotion of hand hygiene

Patient or population: Healthcare workers

Settings: Acute care hospitals

Intervention: Signs or scent as cue

Comparison: No cue or different signs

Outcomes

Impact

No of Participants
(studies)

Certainty of the evidence
(GRADE)

Observed hand hygiene compliance

1 RCT reported an increase in hand hygiene of 8.51 percentage points for the patient consequences sign compared to a slight decrease of 0.29 percentage points for the personal consequences sign. 1 RCT reported increases in hand hygiene compliance of 31.9 and 6.7 percentage points for the scent cue and sign of stern male eyes respectively, and a decrease of 5 percentage points for the sign with female eyes. One NRCT reported an increase of 7 percentage points in hand hygiene compliance with the light cue on day 2 compared to 9 percentage points with no light cue, whereas on day 3 compared to day 1 there was no difference with the light cue and an increase of 16 percentage points with no light cue

2 RCTs, 1 NRCT

3 hospitals

⊕⊕⊝⊝
low1

Infection rates

Not reported

‐

‐

Colonisation rates

Not reported

‐

‐

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

Abbreviations: NRCT: non‐randomised (controlled) trial; RCT: randomised (controlled) trial

1Evidence downgraded from high to low due to non‐randomised evidence (one of three studies); risk of bias (all studies have two or more sources of high risk of bias), and inconsistency in effect sizes between studies.

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Placement of ABHR on cart compared with placement of ABHR on wall for promotion of hand hygiene

Patient or population: Anaesthesiologists and CRNAs

Settings: Acute care surgical

Intervention: Placement of ABHR on anaesthesia cart

Comparison: Placement of ABHR on wall of anaesthesia room

Outcomes

Impact

No of Participants
(studies)

Certainty of the evidence
(GRADE)

Observed hand hygiene compliance

1 RCT reported an increase of 0.3 hand hygiene events an hour in the intervention group compared to the control group

1 RCT

1 hospital

⊕⊕⊕⊝
moderate1

Infection rates

Not reported

‐

‐

Colonisation rates

Not reported

‐

‐

GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

Abbreviations: ABHR: alcohol‐based hand rub; CRNA: certified registered nurse anaesthetist; RCT: randomised (controlled) trial

1Evidence downgraded from high to moderate due to high risk for bias (two sources of high risk and two sources of unclear risk ).

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Table 1. Results from studies evaluating multimodal interventions

Study

Comparison

Estimate of compliance

Measure of difference or change

Intervention: Multimodal, not WHO

Ho 2012

Cluster‐randomised trial

Intervention:

Multimodal not WHO

· Also had study arms with powdered or powderless gloves

Control: 2‐hour health talk

Outcome: Hand hygiene compliance

Inappropriate analysis:

GEE but did not compare changes between arms

Observed mean hand hygiene compliance:

Intervention with powdered gloves:

· Baseline: 27.0%

· 1 month post: 59.2%

· 4 months post: 60.6%

Intervention with powderless gloves:

· Baseline: 22.2%

· 1 month post: 59.9%

· 4 months post: 48.6%

Control:

· Baseline: 19.5%

· 1 month post: 19.8%

· 4 months post: 21.6%

Not reported by researchers

Calculated differences1 in percentage points between baseline and 1 month:

· intervention with powdered gloves: 32.2

· intervention with powderless gloves: 37.7

· control: 0.3

Calculated differences1 in percentage points between baseline and 4 months:

· intervention with powdered gloves: 33.6

· intervention with powderless gloves: 26.4

· control: 2.1

Lee 2013

ITS

· 6 ‐ 7 month baseline

· Intervention:

Multimodal not WHO

· 12 month intervention phase

· 6‐month washout period

· Control wards: no hand hygiene promotion

Outcome: Hand hygiene compliance

Intervention wards

· Baseline: 49.3% (95% CI 47.2% to 51.4%)

· Intervention phase: 63.8% (95% CI 62.3% to 64.4%)

Control wards:

· Baseline: 30.5% (95% CI 28.7% to 32.4%)

· Washout period: 23.9% (95% CI 22.0% to 25.9%)

Segmented regression analysis:

· Increase after start of hand hygiene promotion: adjusted OR 1.19, 95% CI 1.01 to 1.42

· Decrease of 9% per month in washout period after campaign ended: adjusted OR 0.91, 95% CI 0.85 to 0.97

Martin‐Madrazo 2012

Cluster‐randomised trial

Intervention:

Multimodal not WHO

Control: No intervention

Outcome: Hand hygiene compliance

Inappropriate analysis:

Analysed at level of individual not cluster; inappropriate correction for missing data

Mean observed hand hygiene compliance:

Intervention group:

Baseline: 7.98%, 95% CI 4.5 to 10.2

6 months post: 32.74 (no CI reported)

Control group:

Baseline: 8.26% (95% CI: 6.2‐11.6)

6 months post: 11.86 (no CI reported)

Not reported by researchers

Calculated differences1 in percentage points between baseline and 6 months

post‐intervention:

· intervention group: 24.76

· control group: 3.6

Rodriguez 2015

Stepped wedge RCT

Intervention: Multimodal Not WHO

Control: No intervention

Outcome: Hand hygiene compliance

Variation by site:

· Pre: 47.2% to 79.8%

· Post: 57.0% to 93.9%

Absolute difference range: 1.9 to 26.7

Intervention effect: OR 1.17, 95% CI 1.13 to 1.22

Intervention effect adjusted by time: OR 1.08, 95% CI 1.03 to 1.14

Yeung 2011

Cluster‐randomised trial

Intervention:

Multimodal not WHO

Control: Basic life support workshop

Outcome: Hand hygiene compliance

Inappropriate analysis:

Analysed at level of individual not cluster

Mean observed hand hygiene compliance (handwashing or ABHR use):

Intervention group:

Baseline: 25.8%

Post‐intervention: 33.3%

7 months post: 36.7%

Control group:

Baseline: 25.8%

Post‐intervention: 30.0%

7 months post: 37.7%

Not reported by researchers

Calculated differences1 in percentage points between baseline and post intervention:

· intervention group: 7.5

· control group: 4.2

Calculated differences1 in percentage points between baseline and 7 months post‐intervention:

· intervention group: 10.9

· control group: 11.9

Intervention: Multimodal, WHO based

Derde 2014

ITS

Intervention: WHO based multimodal

Outcome: Observed mean hand hygiene compliance:

· Baseline: 52%

· Optimised hand hygiene plus CHG bathing: 69%

· Addition of MRSA screening and contact precautions: 77%

Inappropriate analysis:

No statistical analysis done

Calculated difference1 in percentage points:

· between baseline and optimised hand hygiene plus CHG bathing: 17

· between baseline and addition of MRSA screening and contact precautions: 25

Mertz 2010

Cluster‐randomised trial

Intervention: WHO based multimodal

Control: addition of ABHR

Outcome: Hand hygiene compliance

Intervention:

· Pre: 15.8%

· Post: 48.2%

Control:

· Pre: 15.9%

· Post 42.6%

Mean difference between groups at post‐test:

· 6.3%, 95% CI 4.3% to 8.4%

Perlin 2013

ITS

Intervention: WHO‐based multimodal

Outcome: Mean ounces of ABHR per adjusted pt‐day

· Pre intervention: 21.3

· Post intervention: 48.75

Inappropriate analysis:

No statistical analysis done

Calculated difference1 between pre and post intervention: 27.45 ounces of ABHR per adjusted patient‐day

Interventions: Multimodal, WHO‐enhanced and WHO based

Vernaz 2008

ITS

VigiGerme campaign:WHO‐enhanced multimodal

Clean Care is Safer Care campaign: WHO‐based multimodal

Outcome: ABHR in litres per 100 patient‐days

Did not report actual volume

Increases in both VigiGerme and Clean Care campaigns via ARIMA modelling; no estimates of effect reported

Overall increase in ABHR from 1.303 L/100 patient days to 2.016 L/patient days, but did not report by programme

Whitby 2008

ITS

Washington programme: WHO‐enhanced multimodal

Geneva programme: WHO based multimodal

Outcome: Electronic count of hand hygiene measured number of times ABHR dispensed from count

Actual counts were not reported

Noted that initial compliance was high in IDU

GEE analysis:

Washington program: increase in hand hygiene relative to baseline: RR 1.48 (95% CI: 1.2‐1.81)

Geneva on medicine units: no increase in hand hygiene

Geneva in IDU: increase in hand hygiene relative to baseline: RR 1.56, 95% CI 1.29 to 1.89

Intervention: Multimodal, WHO‐enhanced

Huis 2013

Cluster‐randomised trial

Intervention: WHO‐enhanced multimodal

Control: State of the art multimodal

Outcome: Observed mean hygiene compliance

Intervention:

· Pre: 20%

· Post: 53%

· 6 months: 53%

Control:

· Pre: 23%

· Post: 42%

· 6 months: 46%

OR of 1.64, 95% CI 1.33 to 2.02 in favour of team leader support

Midturi 2015

ITS

· 9‐month baseline

Intervention: Multimodal WHO‐enhanced

· 10‐month intervention period

· 22‐month post‐intervention

Outcome: Hand hygiene compliance

· Baseline: 72.7% (range: 62.5% to 86.2%)

· Intervention period: 79.7% (range not reported)

· Post: 93.2% (range 7.9% to 97.7%)

Inappropriate reporting of analysis for ITS

· During intervention, average increase was 2% per month

· Before‐after intervention, average increase was < 1% a month

Rosenbluth 2015

ITS

· 2‐year baseline

Intervention: Multimodal WHO‐enhanced

· 3‐year intervention period

· 10‐month post‐intervention

Outcome: Hand hygiene compliance

Inappropriate analysis for ITS

All healthcare workers:

· During intervention: 85% to 92%

· Pre‐intervention: variation (38% ‐ 100% but < 80% most months)

· Post‐intervention: 83% ‐ 95% but most > 85%

MDs:

· During intervention: 75% ‐ 83%

· Not reported for other time periods

Not reported by researchers

Because of the considerable variation by unit, it was not possible for the review authors to calculate a difference1 in percentage points between pre‐ and post‐intervention

Stevenson 2014

Cluster‐randomised trial

Intervention: WHO‐enhanced multimodal

Control:

Usual activities

Outcome: Observed mean hand hygiene compliance

Actual compliance rates were not reported

Hand hygiene before and after patient contact, mean difference per group:

Intervention:

· 20.1% (range: 7.8% ‐ 35.5%)

Control:

· ‐3.1% (range: ‐6.3% ‐ +5.9%)

Hand hygiene before or after patient contact,

mean difference per group:

Intervention:

· 28.4% (range: 17.8% ‐ 38.2%)

Control:

· ‐0.7% (range: ‐16.7% ‐ +20.7%)

1 Where researchers did not report differences, the review authors calculated the differences based on the data reported by the researchers and summarised in the column "estimate of compliance".
ABHR: alcohol‐based hand rub; ARIMA: autoregressive integrated moving average; CHG: chlorhexidine gluconate; CI: confidence interval; GEE: generalised estimating equation; IDU: immunisation and diagnosis unit; ITS: interrupted time series; MDs: physicians; MRSA: methicillin‐resistant Staphylococcus aureus; OR: odds ratio; RCT: randomised (controlled) trial; RR: risk ratio; WHO: World Health Organizaiton

Figuras y tablas -
Table 1. Results from studies evaluating multimodal interventions
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Table 2. Results from studies evaluating interventions other than multimodal interventions

Study

Comparison

Estimate of compliance

Measure of difference or change

Intervention: Performance feedback

Armellino 2012

ITS

· 16‐week baseline

· Intervention: video recording and feedback of hand hygiene rates

· 16‐week post

· 75‐week maintenance

Outcome: Observed mean hand hygiene compliance:

Baseline: 6.5% (weekly range: 3.5% to 9.8%)

Post‐feedback period: 81.6% (weekly range: 30.8% to 91.2%)

Maintenance phase: 87.9%

(weekly range: 83.5% to 91.6%)

Segmented regression analysis:

· In week after start of intervention, estimated increase in compliance of 17.5% with additional 4% increase in each following week

· In maintenance period, small weekly decrease of ‐0.04%

Fisher 2013a

Cluster‐randomised trial

Intervention: wireless monitoring and feedback

Control: No intervention

Outcome: Mean hand hygiene compliance on entry as recorded by electronic monitor:

Intervention group:

· Baseline: 28% (21% ‐ 37%)

· Phase 2: real time reminders: 33% (25% ‐ 41%)

· Phase 3: feedback: 28% (16% ‐ 40%)

Control group:

· Baseline: 28% (21% ‐ 37%)

· Phase 2: real time reminders: 26% (22% ‐ 32%)

· Phase 3: feedback: 24% (19% ‐ 33%)

Similar increases in compliance on exit

Variation by study ward, professional category and opportunity load

Unclear reporting of regression

Not reported by researchers

Calculated differences1 in percentage points between baseline and phase 2 real time reminders:

· intervention group: 5

· control group: ‐2

Calculated differences1 in percentage points between baseline and phase 3 feedback:

· intervention group: 0

· control group: ‐4

Fuller 2012

Stepped‐wedge RCT

Intervention: feedback and personalised action planning

Control: Clean Your Hands campaign

Outcomes reported:

· Estimated relative change in liquid soap procurement

· Hand hygiene compliance

Estimates of volume of soap use or observed hand hygiene compliance were not reported

Estimated relative change in liquid soap:

ACE: 1.133, 95% CI 0.987 to 1.3)

ITU: 1.314, 95% CI 1.114 to 1.548

Absolute increase in compliance:

ACE wards:

· 13% if pre‐hand hygiene compliance was 50%

· 10% if pre‐hand hygiene compliance was 70%

ITU wards

· 18% if pre‐hand hygiene compliance was 50%

· 13% if pre‐hand hygiene compliance was 70%

OR (compared to baseline)

ACE wards:

· 1.67, 95% CI 1.26 to 2.22

ITU wards:

· 2.09, 95% CI 1.55 to 2.81

Moghnieh 2016

NRCT

Intervention 1: Incentive

Intervention 2: Audit and feedback

Control: Usual hand hygiene campaign

Outcome: Hand hygiene compliance

Variation by week:

· Baseline all groups: 16% ‐ 20%

· During intervention 1: 60% at week 8 and 77% at week 14

· During intervention 2: 43% at week 8 and 51% at week 14

· Control group: unchanged from baseline

Decreased post‐intervention at week 21:

· Intervention 1: 34%

· Intervention 2: 48%

· Control: unchanged

Not reported by researchers

Calculated differences1 in percentage points between baseline and week 8:

· intervention 1: 40 ‐ 44

· intervention 2: 23 ‐ 27

· control group: unchanged

Calculated differences1 in percentage points between baseline and week 14:

· intervention 1: 57 ‐ 61

· intervention 2: 31 ‐ 35

· control group: unchanged

Stewardson 2016

Cluster‐randomised trial

Intervention 1: Enhanced performance feedback

Intervention 2: Enhanced performance feedback plus patient participation

Control: Usual WHO‐based hand hygiene campaign

Outcome: Hand hygiene compliance

Performance feedback:

· Baseline: 65%

· Intervention period:75%

· Follow‐up:72%

Feedback plus patient participation:

· Baseline: 66%

· Intervention period: 77%

· Follow‐up: 72%

Control:

· Baseline: 66%

· Intervention period: 73%

· Follow‐up: 70%

Absolute change for performance feedback:

· Intervention period: 10% with OR 1.61, 95% CI 1.41 to 1.84

· Follow‐up:7% with OR 1.38, 95% CI 1.19 to 1.60

Absolute change for feedback plus patient participation:

· Intervention period: 11% with OR 1.73, 95% CI 1.51 to 1.98

· Follow‐up: 6% with OR 1.36, 95% CI 1.18 to 1.57

Absolute change for Control:

· Intervention period: 7% with OR 1.41, 95% CI 1.21 to 1.63

· Follow‐up: 4% with OR 1.21, 95% CI 1.00 to 1.47

Talbot 2013

ITS

· Baseline: 2004 ‐ 2009

· Intervention 2009 ‐ 10: feedback, leadership and incentives

· Active accountability: 2010 ‐ 2012

Outcome: observed hand hygiene compliance

Baseline: 52%

Intervention: 75%

Active accountability phase: 89%

Segmented regression analysis done but no estimates of effect reported:

· Increase in adherence in each phase

· Changes in slope associated with each time period

Calculated differences1 in percentage points between baseline and

· intervention phase: 23

· active accountability phase 37

Intervention: Education

Higgins 2013

ITS

Intervention: Education: E‐learning hand hygiene game

Outcome: Observed mean hand hygiene compliance:

· in 12 months pre‐e‐learning game: 42%

· in 12 months post‐e‐learning game: 84%

Appropriateness of analysis unclear: Did not specify statistical analysis done but only reported mean hand hygiene compliance

Calculated differences1 in percentage points between pre and post: 42

Huang 2002

RCT

Intervention:

Education sessions on hand hygiene and UP

Control: No intervention

Outcome: % of nurses who performed hand hygiene

Before patient contact:

Intervention

· Pre: 51.0%

· Post: 85.7%

Control

· Pre: 53.1%

· Post:53.1%

After patient contact:

Intervention

· Pre: 75.5%

· Post: 91.8%

Control

· Pre: 75.5%

· Post: 71.4%

Not reported by researchers

Calculated differences1 in percentage points for before pt contact:

· intervention: 24.5

· control group: no change

Calculated differences1 in percentage points for after patient contact:

· intervention: 16.3

· control group: 4.1

Intervention: Cues

Diegel‐Vacek 2016

NRCT

Intervention: Light cue over sink

Comparison: no light cue

Outcome: Hand hygiene compliance

Light cue:

· Day 1: 23%

· Day 2: 30%

· Day 3: 23%

No light cue:

· Day 1: 7%

· Day 2: 16%

· Day 3: 23%

Not reported by researchers

Calculated differences1 in percentage points between day 1 and day 2:

· light cue: 7

· no light cue: 9

Calculated differences1 in percentage points between day 1 and day 3:

· light cue: 0

· no light cue: 16

Grant 2011

Pair‐matched cluster‐randomised trial

Compared 2 signs: personal vs patient consequences as message

Outcome: Observed mean hand hygiene compliance:

Personal consequences sign:

Pre‐test: 80.0%

Post‐test: 79.71%

Patient consequences sign:

Pre‐test: 80.69%

Post‐test: 89.2%

Variation by type of practitioner but all had greater increase in hand hygiene in response to patient consequences sign

Inappropriate analysis : Did not do a matched analysis

Not reported by researchers

Calculated differences1 in percentage points between pre and post test:

· Personal consequences sign: ‐0.29

· Patient consequences sign: +8.51

King 2016

RCT

Intervention: Olfactory cue (scent) or signs with male or female eyes

Comparison: baseline without cues

Outcome: Hand hygiene compliance

· Baseline: 15.0%

· Scent cue: 46.9%

· Male eyes cue: 21.7%

· Female eyes cue: 10.0%

Some differences women vs men

Not reported by researcher

Calculated differences1 in percentage points between pre‐ and post‐test:

· Scent cue: +31.9

· Stern male eyes: +6.7

· Female eyes: ‐5

Intervention: Placement of ABHR

Munoz‐Price 2014

RCT with cross‐over

Intervention: placement of ABHR on cart

Control: ABHR on wall

Outcome: hand hygiene events per hour:

Intervention: 0.84

Control: 0.54

Difference was an increase of 0.3 events per hour

1 Where researchers did not report differences, the review authors calculated the differences based on the data reported by the researchers and summarized in the column "estimate of compliance".
ABHR: alcohol‐based hand rub; ACE: acute care of the elderly; CI: confidence interval; ITS: interrupted time series; ITU: intensive care unit; NRCT: non‐randomised (controlled) trial; OR: odds ratio; RCT: randomised (controlled) trial

Figuras y tablas -
Table 2. Results from studies evaluating interventions other than multimodal interventions
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Table 3. Comparison of multimodal interventions

Study/

Category*

Education

Feedback

Posters/

signs

ABHR

Admin

Staff

Other

Intervention: Multimodal, not WHO

Ho 2012

Yes

(detailed)

Individual and unit

Yes

Individual and point of care

No

No

Gloves with and without powder

Lee 2013

Yes

No

Yes

Yes

Yes

No

‐‐‐

Martin‐Madrazo 2012

Yes (details)

No

Yes

Yes

‐‐‐

No

‐‐‐

Rodriguez 2015

Yes

Unit level

Yes

Yes

Yes

No

Role modelling

Direct MD encouragement

Incentives for MDs

Yeung 2011

Yes (details)

1 session to both groups at 3 months

Yes

Individual

No

No

Pens as reminder

Intervention: Multimodal, WHO based

Mertz 2010

WHO‐based

Yes

Unit level

Yes

Yes

Yes

Yes

‐‐‐

Perlin 2013

WHO‐based

Yes

Yes (at discretion)

Yes

Yes

Yes

No

‐‐‐

Whitby 2008 :

Geneva

Intervention

WHO‐based

Yes

Yes

Yes

Yes

Yes

No

‐‐‐

Intervention: Multimodal, WHO‐enhanced

Huis 2012

Yes

Individual

Yes

Yes

Yes

Yes

Adequate supplies

Midturi 2015

Yes

Individual and unit level

Yes

Yes

Yes

No

Rewards, alerts to immediate supervisor

Rosenbluth 2015

No

Unit level

Yes

Yes

Yes

No

‐‐‐

Stevenson 2014

Yes

Yes at unit level (variable)

Yes

Yes

Yes

Yes

Recognition and rewards programme (e.g. candy, buttons)

Whitby 2008 : Washington

Intervention

Yes

Informal

Yes

Yes

Yes (walk around by exec)

Yes

‐‐‐

Note: Vernaz 2008 and Derde 2014 did not describe their multimodal campaigns and are not included in this table.
Category: WHO‐based = included the 5 types of interventions recommended by WHO; WHO‐enhanced = included the 5 types of interventions recommended by WHO plus additional strategies; Not WHO = did not include at least the 5 types of interventions recommended by WHO.
ABHR: alcohol‐based hand rub; MDs: physicians; WHO: World Health Organization

Figuras y tablas -
Table 3. Comparison of multimodal interventions
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Table 4. Results from studies reporting microbiological data

Study

Design/

Intervention

Results

Intervention: Multimodal, not WHO

Ho 2012

RCT

· Reduced respiratory outbreaks: IRR 0.12, 95% CI 0.01 to 0.93

· Reduced MRSA infections requiring hospitalisation: IRR 0.61, 95% CI 0.38 to 0.97

Lee 2013

ITS

No reduction related to the hand hygiene promotion campaign alone in:

· MRSA in clinical isolates: IRR 1.44, 95% CI 0.96 to 2.15

· MRSA infections: IRR 1.28, 95% CI 0.79 to 2.06

Yeung 2011

RCT

Reduced serious infections (cases per 1000 resident‐days):

· Intervention group: pre: 1.42; post: 0.65 (difference: ‐0.77)

· Control groups: pre: 0.49; post: 1.05 (difference: 0.56)

Reduced pneumonia (cases per 1000 resident‐days)

· Intervention group: pre: 0.91; post: 0.28 (difference: ‐0.63)

· Control group: no change

Reduced deaths per 1000 resident‐days:

· Intervention group: pre: 0.37; post: 0.10 (difference: ‐0.27)

· Control group: no change

Intervention: Multimodal, WHO based

Derde 2014

ITS

· Trend in MRSA acquisition following hand hygiene campaign: IRR 0.976, 95% CI 0.954 to 0.999;

· No changes in acquisition of VRE or HRE

Mertz 2010

RCT

No difference in MRSA colonisation (cases per 1000 patient‐days):

· Intervention group: 0.30

· Control group: 0.31

Perlin 2013

ITS

MRSA CLABSI per 1000 line days:

· Pre: .497 (difference: ‐0.191)

· Post: .306

MRSA VAP per 1000 ventilator days:

· Pre: 1.088 (difference: ‐0.538)

· Post: 0.550

Vernaz 2008

ITS

· MRSA decreased by 0.03 clinical isolates per 100 patient‐days for each litre of ABHR per 100 patient‐days

· No change in C. difficile

Intervention: Multimodal, WHO‐enhanced

Vernaz 2008

ITS

· No change in MRSA clinical isolates

· No change in C. difficile

Intervention: Performance feedback

Stewardson 2016

RCT

Primary bloodstream infection

· Enhanced feedback: IRR 0.71, 95% CI 0.54 to 0.95

· Enhanced feedback + patient participation: IRR 1.02, 95% CI 0.78 to 1.34

· Control: IRR 0.57, 95% CI 0.40 to 0.80

Period prevalence of HCAIs

· Enhanced feedback: IRR 0.91, 95% CI 0.68 to 1.23

· Enhanced feedback + patient participation: IRR 1.05, 95% CI 0.78 to 1.40

· Control: IRR 1.33, 95% CI 0.94 to 1.88

Colonisation with MRSA

· Enhanced feedback: IRR 0.79, 95% CI 0.66 to 0.95

· Enhanced feedback + patient participation: IRR 0.82, 95% CI 0.67 to 0.99

· Control: IRR 0.92, 95% CI 0.77 to 1.13

AHBR: alcohol‐based hand rub; C. difficile: Clostridium difficile; CLABSI: central line‐associated blood stream infections; CI: confidence interval; HCAI: healthcare‐associated infection; HRE: highly‐resistant Enterobacteriaceae; IRR: incidence rate ratio; ITS: interrupted time series; MSRA: methicillin‐resistant Staphylococcus aureus; RCT: randomised (controlled) trial; VAP: ventilator‐associated pneumonia; VRE: vancomycin‐resistant enterococci; WHO: World Health Organization

Figuras y tablas -
Table 4. Results from studies reporting microbiological data
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