Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis

Abstract

Objective: To evaluate the relative efficacy of the World Health Organization 2005 campaign (WHO-5) and other interventions to promote hand hygiene among healthcare workers in hospital settings and to summarize associated information on use of resources.

Design: Systematic review and network meta-analysis.

Data sources: Medline, Embase, CINAHL, NHS Economic Evaluation Database, NHS Centre for Reviews and Dissemination, Cochrane Library, and the EPOC register (December 2009 to February 2014); studies selected by the same search terms in previous systematic reviews (1980-2009).

Review methods: Included studies were randomised controlled trials, non-randomised trials, controlled before-after trials, and interrupted time series studies implementing an intervention to improve compliance with hand hygiene among healthcare workers in hospital settings and measuring compliance or appropriate proxies that met predefined quality inclusion criteria. When studies had not used appropriate analytical methods, primary data were re-analysed. Random effects and network meta-analyses were performed on studies reporting directly observed compliance with hand hygiene when they were considered sufficiently homogeneous with regard to interventions and participants. Information on resources required for interventions was extracted and graded into three levels.

Results: Of 3639 studies retrieved, 41 met the inclusion criteria (six randomised controlled trials, 32 interrupted time series, one non-randomised trial, and two controlled before-after studies). Meta-analysis of two randomised controlled trials showed the addition of goal setting to WHO-5 was associated with improved compliance (pooled odds ratio 1.35, 95% confidence interval 1.04 to 1.76; I(2)=81%). Of 22 pairwise comparisons from interrupted time series, 18 showed stepwise increases in compliance with hand hygiene, and all but four showed a trend for increasing compliance after the intervention. Network meta-analysis indicated considerable uncertainty in the relative effectiveness of interventions, but nonetheless provided evidence that WHO-5 is effective and that compliance can be further improved by adding interventions including goal setting, reward incentives, and accountability. Nineteen studies reported clinical outcomes; data from these were consistent with clinically important reductions in rates of infection resulting from improved hand hygiene for some but not all important hospital pathogens. Reported costs of interventions ranged from $225 to $4669 (£146-£3035; €204-€4229) per 1000 bed days.

Conclusion: Promotion of hand hygiene with WHO-5 is effective at increasing compliance in healthcare workers. Addition of goal setting, reward incentives, and accountability strategies can lead to further improvements. Reporting of resources required for such interventions remains inadequate.

Fig 1 Flow chart of study identification in systematic review of interventions to promote hand hygiene in healthcare workers

Fig 2 Assessment of risk of bias in included studies of interventions to promote hand hygiene in healthcare workers

Fig 3 Forest plot of the associations between WHO-5 and goal setting compared with WHO-5 alone and compliance with hand hygiene from randomised controlled trials using intention to treat results

Fig 4 Re-analysis of studies involving interrupted time series where the outcome was hand hygiene compliance. Points represent observations, solid lines show expected values from fitted segmented regression models, and broken lines represent extrapolated trends before intervention. SYS=system change; EDU=education; FED=feedback; REM=reminders; SAF=institutional safety climate; INC=incentives; GOAL=goal setting; ACC=accountability; WHO-5=combined intervention strategies including SYS, EDU, FED, REM, and SAF

Fig 5 Forest plot showing effect size as mean log odds ratios for hand hygiene compliance for all direct pairwise comparisons from interrupted time series studies. Lee and colleagues was a multi-centre study. In hospitals 8 and 9 baseline strategy was already equivalent to WHO-5. SYS=system change; EDU=education; FED=feedback; REM=reminders; SAF=institutional safety climate; INC=incentives; GOAL=goal setting; ACC=accountability; WHO-5=combined intervention strategies including SYS, EDU, FED, REM, and SAF

Fig 6 Network structure for network meta-analysis of four hand hygiene intervention strategies from interrupted time series studies. Intervention strategies were: none (no intervention); single intervention; WHO-5; and WHO-5+ (WHO-5 with incentives, goal-setting, or accountability)

Fig 7 Box-and-whiskers plot showing relative efficacy of different hand hygiene intervention strategies compared with standard of care estimated by network meta-analysis from interrupted time series studies. Lower and upper edges represent 25th and 75th centiles from posterior distribution; central line median. Whiskers extend to 5th and 95th centiles. Intervention strategies were single intervention; WHO-5; and WHO-5+ (WHO-5 with incentives, goal-setting, or accountability). Appendix 9 shows results from sensitivity analysis that excluded studies where interventions were implemented as multiple time points

Fig 8 Rankograms showing probabilities of possible rankings for each intervention strategy (rank 1=best, rank 4=worst)