Interventions to improve hand hygiene compliance in patient care.

Healthcare-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as the most effective method of prevention but is poorly performed by health workers. We report a systematic review identifying studies which investigated the effectiveness of interventions to increase hand hygiene compliance short and longer term and to determine their success in terms of hand hygiene compliance and subsequent effect on rates of healthcare-associated infection. We employed the inclusion criteria employed by the Cochrane Effective Practice and Organisation of Care Group. Forty-eight studies and one thesis were identified. Only two met the stringent inclusion criteria. Overall studies remain small scale, poorly controlled and follow-up data collection is abandoned too soon to establish impact longer term. Furthermore, designs are insufficiently robust to attribute any observed changes to the intervention. Studies lack theoretical focus and seldom describe the intervention in sufficient detail, the change management process or contextual information about the organisation in the depth necessary to explain success or lack of it. The review concludes that interrupted time-series studies may offer the most rigorous approach to assessing the impact of interventions to increase hand hygiene compliance. In such study designs the number of new cases of healthcare-associated infection should be taken as an outcome measure, with data collection points at least 12 months before intervention and afterwards to allow for seasonal trends. Contextual factors at national and at local level should be carefully documented to take into consideration the influence of secular trends.