Effectiveness and limitations of hand hygiene promotion on decreasing healthcare-associated infections

Abstract

Background: Limited data describe the sustained impact of hand hygiene programs (HHPs) implemented in teaching hospitals, where the burden of healthcare-associated infections (HAIs) is high. We use a quasi-experimental, before and after, study design with prospective hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs.

Methods and findings: A 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. Compliance was measured by direct observation and the use of hand rub products. Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. The economic impact was estimated based on a case-control study in Taiwan. We observed 8,420 opportunities for hand hygiene during the study period. Compliance improved from 43.3% in April 2004 to 95.6% in 2007 (p<.001), and was closely correlated with increased consumption of the alcohol-based hand rub (r = 0.9399). The disease severity score (Charlson comorbidity index) increased (p = .002) during the intervention period. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillin-resistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. The net benefit of the HHP was US$5,289,364, and the benefit-cost ratio was 23.7 with a 3% discount rate.

Conclusions: Implementation of a HHP reduces preventable HAIs and is cost effective.

Figure 1. Trends in compliance with the hand hygiene during 6 consecutive hospital-wide surveys conducted from May 2004 to December 2007.

Panel A shows significant increases in percent of adherence to hand hygiene before and after patient contact for all healthcare workers in in-patient service units (p<0.001), by doctors (p<0.001), nurses (p<0.001), and other healthcare workers (p<0.001). Panel B shows significant increases in the annual consumption of alcohol-based hand rub (p = 0.001), antiseptics (p = 0.04), and liquid soap (p = 0.03).

Figure 2. Time trends of monthly cumulative incidences of overall healthcare-associated infection before (January 1999 to March 2004) and during the hand hygiene program (April 2004 through December 2007).

(A) hospital-wide (change in levels, p = 0.02; change in trends, p = 0.04); (B) intensive care units (change in levels, p = 0.26; change in trends, p<0.001); (C) hematology ward (p = 0.21, p = 0.38, respectively). Observed incidences, black solid line, —; mean, red dash line, ---; green and blue shadow, 95% confidence interval of observed incidences; yellow shadow, 95% confidence interval (CI) of predicted incidences. The vertical dashed lines (- - -) separate the preintervention and intervention periods.

Figure 3. Time trends of monthly cumulative incidences by pathogen.

(A) methicillin-resistant S. aureus (MRSA) (change in level, p = 0.03; change in trend, p = 0.04); (B) extensively drug-resistant Acinetobacter (XDRAB) (p = 0.78; p<0.001, respectively); (C) Escherichia coli (p = 0.89; p = 0.33, respectively). Infection control measures for XDRAB were intensified during June 2001 to June 2002. These efforts resulted in only a transient reduction in the rates of infection for XDRAB and MRSA. Observed incidences, black solid line, —; mean, red dash line, ---; green and blue shadow, 95% confidence interval of observed incidences; yellow shadow, 95% confidence interval (CI) of predicted incidences. The vertical dashed lines (- - -) separate the preintervention and intervention periods.