Blog | Wednesday, December 11, 2013

Searching for an optimal hand hygiene bundle


One of the things we frequently discuss is the central role that hand hygiene compliance plays in preventing the horizontal transmission of resistant bacterial pathogens. We’ve written 16 “hand hygiene” posts so far in 2013. Hand hygiene compliance is consistently lower than we wish for and it’s common that health care workers are blamed for poor compliance.

I’ve often mentioned the 2011 Cochrane Review of “Interventions to Improve Hand Hygiene Compliance in Patient Care” and how only 4 papers made the cut, as it struck me that the inclusion criteria were too restrictive. We then wondered if expanding the number of studies included would offer any additional guidance for developing a standardized hand hygiene improvement program.

With the support of the VA National Center for Occupational Health and Infection Control (COHIC) and VA Office of Public Health, Marin Schweizer and our group at Iowa City have completed an extensive meta-analysis of interventions (and bundles) targeting hand hygiene compliance (just published in CID). The review included all studies published from 2000-2012; the year 2000 was selected since ABHR became more widely utilized around that time. 8,148 articles were identified and 46 studies were reviewed and included with one-third from the U.S. and one-third from from Europe.

There were several important findings:

1) Only 46 studies from 45 populations have been completed in over a decade. For a critical intervention, this is an unacceptably low number of studies. Funding agencies (and folks that blame health care workers for poor compliance) should take note.

2) Meta-analyses of single interventions could not be performed because there were too few studies. It’s surprising that we are building bundles without examining individual components first.

3) Increasing the number of interventions included in a bundle was not associated with greater improvements in compliance. For example, bundles with only 1 or 2 interventions were associated with more than a 3-fold increase in hand hygiene compliance while bundles of 3-4 or >5 interventions were associated with a smaller 2-fold improvement in compliance.

4) Several bundles were frequently studied and deemed effective. One bundle that included education, reminders, feedback, administrative support, and access to alcohol-based hand rub was associated with improved hand hygiene compliance (pooled odds ratio [OR], 1.82) and another bundle that included education, reminders, and feedback was also associated with improved compliance (pooled OR, 1.47).

There’s more work to do!

Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands). This post originally appeared at the blog Controversies in Hospital Infection Prevention.