Effectiveness Of Hand Hygiene Compliance Interventions In Hospitals

Methodology

In hospital patients it is quite common to have infections from the bad condition of the hand hygiene of the health care workers (HCW) and it has become a global challenge to combat against this infection associated with the hand hygiene. The prevalence rate of health care associated infections (HAIs) are comparatively higher in undeveloped countries than that of the developed countries (Chassin, Mayer & Nether, 2015). In US, almost 2 million of infections were reported and it also contributed in increasing hospital staying among the patients. The improvement of hand hygiene behavior among the health care professionals is considered as an effective practice to reduce the risk of disease transmission in hospitals. In practice of hygiene, the use of alcohol is very much common and this hand rubbing technique is strongly supported by WHO and Centers for Disease Control and Prevention. From the studies, it was seen that, using of alcohol based rubbing technique had lowered the rate of infections (japan). Measurement of hand hygiene practice is done by direct observation method in which human auditors directly observe the hand hygiene compliance of the HCW who are directly related to the clinical care plans of the patients (Gould et al., 2017). However this method is not completely correct as this method is associated with the Hawthorne effect which is the biased behavior of the observer (Srigley et al., 2014). The direct contact between the patients and the HCW who are directly exposed to the contaminations of nosocomial pathogens and this is assumed as the primary root of infections in the patients. WHO had launched a campaign named ‘Clean Care is Safe Care’ in order to improve the hand hygiene among in hospitals. This program was launched in 2005 and the main objective of this program is to global promotion of best hand hygiene policy (“Background to Clean Care is Safer Care”, 2018). Therefore, in this study, five article have been selected and critical assessment was performed on them to find relevance on the question: “How effective are hand hygiene compliance interventions in improving hand hygiene behaviors (thus reducing the risk of transmitting disease) in hospitals?” in the following sections.

Five articles published recently were selected for this critical assessment study. Amongst them, two are systematic review, one experimental study, one quasi-experimental study and one is cohort study. The publication time duration for these articles were all within 2013 – 2018.

Google scholar (https://scholar.google.co.in/) was used as a searching database to find these articles by customizing the publication year from 2013 to 2018.

Keywords were used to narrow down the articles from online database. Four keywords have been used and these key words are: ‘Hand hygiene’, ‘Hand hygiene behaviours’, ‘interventions’, and ‘hospital’.

Selected article were appraised and graded on the basis of their quality. As stated by Rychetnik et al. (2002), MERGE or Method for Evaluating Research and Guideline Evidence was used for the assessment of these articles. For MERGE analysis, one descripted information about the study and one evaluation criterion were used for the appraisal of these articles. Each of the criterion includes different parameters which are mentioned in the results section of this article. FORM framework guidelines were used for the gradation of these articles. The FORM framework mentioned in this study was followed framework as cited by the (Hillier et al., 2011). For the gradation of these articles, five parameters were used namely generalizability, evidence based practice, consistency, clinical impact, and applicability. Four different grading mark were used for gradation and these are poor, satisfactory, good and execellent.

Results

MERGE or Method for Evaluating Research and Guideline Evidence is used for the assessment of the articles included in this study. Assessment table for each article have been illustrated here within.

Appraisal of Article 1:

Study information	Description
Documentation of the review	Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane database of systematic reviews, (9)
Review type	Systematic review
Type of studies which have been considered in this review	controlled before-after studies, non-randomised trials, randomised trials, and interrupted time series analyses (ITS)
Kind of outcomes measured in this review	Primary and secondary outcomes were considered.
Whether interferences were directed at individuals or populations?	Interferences directed at individuals

Assessment criterion for the review	Comments
Does all appropriate articles were satisfactorily and thoroughly considered?	Yes
Whether the study considered all the possible benefits and problems related to the topic?	Yes, all the possible outcomes were considered.
Whether only RCTs (Randomised controlled trials) were considered?	Yes
Presentation of information – whether presented in organised manner to deduce effect estimation and CI (confidence intervals)?	Confidence level were not mentioned in the study
Whether the included articles were assessed for quality?	Yes, authors screened every included article individually.

 Appraisal of Article 2:

Study information	Description
Documentation of the review	Luangasanatip, N., Hongsuwan, M., Limmathurotsakul, D., Lubell, Y., Lee, A. S., Harbarth, S., … & Cooper, B. S. (2015). Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. bmj, 351, h3728.
Review type	Systematic review and network meta- analysis
Type of studies which have been considered in this review	Non-randomised trials, randomised controlled trials, interrupted time series studies and controlled before-after trials
Kind of outcomes measured in this review	Both strengths and limitations of the study were discussed.
Whether interferences were directed at individuals or populations?	Interferences were directed at individuals.

Assessment criterion for the review	Comments
Does all appropriate articles were satisfactorily and thoroughly considered?	Yes
Whether the study considered all the possible benefits and problems related to the topic?	The article has considered both benefits and harmful effects.
Whether only RCTs (Randomised controlled trials) were considered?	Yes
Presentation of information – whether presented in organised manner to deduce effect estimation and CI (confidence intervals)?	Data were organised in thorough and presentable manner with CI (confidence intervals)
Whether the included articles were assessed for quality?	Yes, the studies were quality assessed against EPOC checklist.

Appraisal of Article 3:

Study information	Description
Documentation of the article	Chassin, M. R., Mayer, C., & Nether, K. (2015). Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. The Joint Commission Journal on Quality and Patient Safety, 41(1), 4-12.
Category of the considered investigation	Experimental study
Type of interferences and interventions measured and applied in this article	Six sigma, change management method and lean were used to measure the outcome.
Whether interferences or interventions were directed at individuals or populations?	Interferences were directed at individuals.

Assessment criterion for the study	Comments
Category of the article	Experimental study
Whether the subjects considered in this article were adequately defined clearly with respect to time, person or place?	Yes, it was clearly defined.
Whether standard, credible and effective method were applied to detect the interferences or interventions exposure?	Methods applied to determine outcomes were all standard, credible and effective.
Whether identical methodology was applied to both the test and control group?	Yes
Whether standard, credible and effective method were applied to determine the outcomes?	Yes
Whether identical methodology was applied to determine the outcome for both the test and control group?	Yes
Whether any risk factors or limitations were considered during the study?	Yes, limitations were considered in this study.
Whether the intended purpose of the study was to interfere?	Yes

Appraisal of Article 4:

Study information	Description
Documentation of the article	Allegranzi, B., Gayet-Ageron, A., Damani, N., Bengaly, L., McLaws, M. L., Moro, M. L., … & Donaldson, L. (2013). Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. The Lancet infectious diseases, 13(10), 843-851.
Category of the considered investigation	Quasi- experimental study
Type of interferences and interventions measured and applied in this article	WHO’s strategy were implemented in 3 to 6 months phase for four times.
Whether interferences or interventions were directed at individuals or populations?	Interferences were directed at individuals

Assessment criterion for the study	Comments
Category of the article	Quasi- experimental study
Whether the subjects considered in this article were adequately defined clearly with respect to time, person or place?	Yes, it was clearly defined.
Whether standard, credible and effective method were applied to detect the interferences or interventions exposure?	Yes, the methods were standard, credible and effective
Whether identical methodology was applied to both the test and control group?	Yes
Whether standard, credible and effective method were applied to determine the outcomes?	Yes
Whether identical methodology was applied to determine the outcome for both the test and control group?	Yes
Whether any risk factors or limitations were considered during the study?	No, limitations were discussed for this study
Whether the intended purpose of the study was to interfere?	yes

Appraisal of Article 5:

Study information	Description
Documentation of the article	Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam, M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf, 23(12), 974-980.
Category of the considered investigation	Cohort study
Type of interferences and interventions measured and applied in this article	A RTLS or real-time location system were applied.
Whether interferences or interventions were directed at individuals or populations?	Interferences were directed at individuals.

Assessment criterion for the study	Comments
Category of the article	Cohort study
Whether the subjects considered in this article were adequately defined clearly with respect to time, person or place?	Yes, it was clearly defined.
Whether standard, credible and effective method were applied to detect the interferences or interventions exposure?	Yes
Whether identical methodology was applied to both the test and control group?	Yes
Whether standard, credible and effective method were applied to determine the outcomes?	Yes
Whether identical methodology was applied to determine the outcome for both the test and control group?	Yes
Whether any risk factors or limitations were considered during the study?	Limitations have been discussed in the study.
Whether the intended purpose of the study was to interfere?	Yes

FORM framework for gradation:

Gradation for each studies according to the FORM framework is provided below:

Study or Review name			Parameters
Generaliz-ability	Evidence based practice	Clinical impact	Consistency	Applicability
Gould et al., 2017	Excellent	Satisfactory	Good	Satisfactory	Good
Luangasanatip et al., 2015	Good	Excellent	Excellent	Excellent	Excellent
Chassin, Mayer & Nether, 2015	Good	Satisfactory	Excellent	Excellent	Good
Allegranzi et al., 2013	Excellent	Good	Excellent	Excellent	Good
Srigley et al., 2014	Good	Satisfactory	Good	Excellent	Satisfactory

In a nutshell, from the above findings, it can be deduced that all the experimental studies and review articles were dedicated to the compliance regarding hand hygiene amongst health workers and to improve the hand hygiene behaviours amongst health workers. Gould et al. (2017) have focussed their review article on the compliance amongst health worker regarding hand hygiene in long and short term basis and whether improvement in hand hygiene is effective against the reduction of infection. However, the study is little bit limited regarding the reproducibility of the accumulated data. On the contrary, the systematic review published by Luangasanatip et al. (2015) have directed their aim on the evaluation of the promotion performed by WHO and other promotional campaign regarding hand hygiene among health workers. Their published work is excellent in terms of clinical impact, applicability, consistency and evidence based practice. In track with the previous author, Allegranzi et al. (2013) have evaluated the implementation of WHO’s promotional strategy regarding hand hygiene amongst health workers. These study have excellent strengths in terms of clinical impact and consistency. However, evidence accumulated in this article is little less strong compared to the other parameters. On the other hand, Chassin, Mayer & Nether (2015) have performed an experimental study with the aim of improving hand hygiene among eight USA based hospitals. Interestingly, Srigley et al. (2014) have investigated in the area which any of the previous articles have not enquired. They have studied the Hawthorne effect amongst the health workers with regards to hand hygiene and compliance. Their article is interesting and explored in to a research area which the article have enquired but the article leaves a lot to be desired in terms of applicability and evidence based practice. Finally, from the FORM matrix framework it can be deduced that the research paper published by Luangasanatip et al. (2015) is the best published paper in terms of gradation.

Conclusion

Henceforth, from the above conclusion, it can be concluded that hand hygiene behaviours by the health workers plays a significant role in the prevention of infection in health care institution like hospitals. Additionally, there is many multi- modal strategy like strategy implemented by WHO is present in this area. Studies have shown that multi- modal strategies like this can be implemented in the healthcare industry across the globe but a simpler intervention method might be more effective. Interestingly, scientific phenomenon like Hawthorne effect has modified the behaviour of health care workers. To conclude, it can be said that a further objective specific research is needed in this area for a robust and simpler intervention method for compliance regarding health care workers in the area of hand hygiene, so that infection from this area can be prevented.

References

Allegranzi, B., Gayet-Ageron, A., Damani, N., Bengaly, L., McLaws, M. L., Moro, M. L., … & Donaldson, L. (2013). Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. The Lancet infectious diseases, 13(10), 843-851.

Background to Clean Care is Safer Care. (2018). Retrieved from https://www.who.int/gpsc/background/en/

Chassin, M. R., Mayer, C., & Nether, K. (2015). Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. The Joint Commission Journal on Quality and Patient Safety, 41(1), 4-12.

Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H., & Taljaard, M. (2017). Interventions to improve hand hygiene compliance in patient care. Cochrane database of systematic reviews, (9).

Hillier, S., Grimmer-Somers, K., Merlin, T., Middleton, P., Salisbury, J., Tooher, R., & Weston, A. (2011). FORM: an Australian method for formulating and grading recommendations in evidence-based clinical guidelines. BMC medical research methodology, 11(1), 23.

Luangasanatip, N., Hongsuwan, M., Limmathurotsakul, D., Lubell, Y., Lee, A. S., Harbarth, S., … & Cooper, B. S. (2015). Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis. bmj, 351, h3728.

Rychetnik, L., Frommer, M., Hawe, P., & Shiell, A. (2002). Criteria for evaluating evidence on public health interventions. Journal of Epidemiology & Community Health, 56(2), 119-127.

Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam, M. (2014). Quantification of the Hawthorne effect in hand hygiene compliance monitoring using an electronic monitoring system: a retrospective cohort study. BMJ Qual Saf, 23(12), 974-980.