Comparative efficacy of interventions to promote hand hygiene in hospital: systematic review and network meta-analysis [医院促进手部卫生干预措施的比较疗效：系统综述和网络荟萃分析]

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BMJ 2015; 351 doi: http://dx.doi.org/10.1136/bmj.h3728 (Published 28 July 2015)

Cite this as: BMJ 2015;351:h3728

Authors
Nantasit Luangasanatip, health economist and PhD student, Maliwan Hongsuwan, research nurse and PhD student, Direk Limmathurotsakul, head of microbiology department and assistant professor of epidemiology, Yoel Lubell, health economist and lecturer, Andie S Lee, research fellow and infectious diseases physician and microbiologist, Stephan Harbarth, associate professor of internal medicine, Nicholas P J Day, director and professor of tropical medicine, Nicholas Graves, professor of health economics, Ben S Cooper, senior research fellow and associate professor of infectious disease epidemiology 

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; I2=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.