Features of educational interventions that lead to compliance with hand hygiene in healthcare professionals within a hospital care setting. A BEME systematic review: BEME Guide No. 22

Figures & data

Table

Practice points

Taking part in any structured educational intervention designed to improve hand hygiene compliance in a hospital environment is likely to be effective in improving practice. Combining an educational intervention with other components (reminders, incentives, checklists, surveillance, audit and feedback) is the most effective way of reinforcing the educational message. Repeated sessions feed into daily practice will maintain compliance. The first step to improving hand hygiene compliance should be to target educational interventions in areas where compliance to best-practice is poorest. Consider using performance feedback when educating healthcare professionals. Performance feedback in the form of performance reports or the use of UV technology is likely to increase hand hygiene compliance. Ensure that hand washing practices become intrinsic within professional practice by using internal teams to deliver interventions rather than external sources.

Table 1.  Inclusion criteria

Study design	All study designs considered. Studies conducted and published from 1995 onwards included.
Population	Healthcare professional participants OR Contained one or more of the above groups for which results were recorded separately.
Educational intervention	Content documentable and repeatable. Run over defined time period. Structured and educational Interventions designed to change staff behaviour with regards to compliance of one or more facet of hand hygiene.
Comparator	Any, including but not limited to use of a control group, a differing educational intervention and use of differing healthcare groups.
Outcome measures	At least one outcome measure of aseptic hand hygiene. Study reports pre and post intervention data relating to either patient outcomes or staff behavioural change Reports adequate descriptive statistics to evaluate the effectiveness of an intervention
Setting of study	Studies carried out within a hospital care setting settings considered.
Follow-up period	At least 6 months

Table 2.  Krkpatrick's Hierarchy (1967)

Level 1: Reaction This covers learner's views on the delivery and content of the educational intervention. This may take the form of verbal or written feedback immediately after the delivery of the intervention, and includes learner's views on presentation, organisation, content, teaching methods, time-tabling, materials used and quality of teaching. Level 2a: Modification of attitudes and perceptions This relates to any changes in reciprocal attitudes or perceptions between participant groups. This includes any changes in perceptions or attitudes by participants towards the value and/or use of the taught approach to caring for patients, and their condition, circumstances, care and treatment. Level 2b: Acquisition of knowledge and skills For knowledge, this relates to the acquisition of concepts, procedures and principles of hand hygiene as a direct result of the delivery of the educational intervention.For skills, this relates to the acquisition of thinking/problem-solving, psychomotor and social skills linked to hand hygiene as a direct result of the delivery of the educational intervention.

Level 3: Behavioural change This relates to the transfer of principles of aseptic hand hygiene to the workplace, such as support for change in behaviour in the workplace, or willingness of learners to apply knowledge and skills about hand hygiene, obtained as a direct result of the delivery of the educational intervention, to their practice style. Level 4a: Change in organisational practice This relates to wider changes in the organisation/delivery of care, attributable to the delivery of an education intervention. These changes may be financial or organisational. Level 4b: Benefits to patients/clients, families and communities This relates to any improvements in the health and well being of patients as a direct result of the delivery of an educational intervention. Where possible, objectively measured or self reported outcomes will be used, including but not limited to health status measures, infection incidence, duration or cure rates, mortality rates, complication rates, readmission rates, continuity of hand hygiene and costs to carer or patient. These outcomes will be further determined by the literature found.

Table 3.  Characteristics of included studies

Author	Country of study	Study period	Main outcome measure	Preintervention	Postintervention	Length of follow-up (months)	Type of intervention	Study setting	Participant gro up	Alcohol gel included in intervention	Any additional component	Kirkpatrick level	Quality assessment score
Benton 2007	USA	January 2004–January 2005	Compliance with hand hygiene	17%	78.1%	6	Education, multimodal with self-study	Hospital wound care centre	Doctors	Y		3	71
Bhutta et al. 2007	USA	1998–2005	CVC primary bloodstream infections	9.7/1000 CVC days	3.0/1000 CVC days	36	Education, multimodal with video	One paediatric ICU (19 beds)	Not specified	Y	Interventions designed for CVC insertion and maintenance. Stepwise introduction of interventions, including maximal barrier precautions, change in skin disinfectant and use of antibiotic impregnated catheters.	3 and 4b	60
Buffet-Bataillon et al. 2010	France	2006–2007	Compliance with hand hygiene	44.9	58.0	12	Education, multimodal with demonstration	Tertiary hospital	All healthcare professionals	Y	Compliance improved in nursing staff but decreased in doctors and nursing auxiliary workers	3	82
Conrad et al. 2010	Germany	January 2003–July 2008	MRSA rates	0.19/1000 patient days	0.12/1000 patient days	37	Education, multimodal	Various departments in a tertiary hospital	Nurses and doctors	Y		4b	71
Danchaivijitr et al. 2005	Thailand	January 2004–July 2004	Compliance with hand hygiene	4.5%	13.4%	34	Education, multimodal	Neonatal ICU	All healthcare professionals	Y	Data only taken from the one hospital that had a longer follow-up than 6 months	3	75
Dierssen-Sotos et al. 2010	Spain	October 2006–October 2007	Compliance with hand hygiene	40.5%	46.1%	12	Education, multimodal	Three hospitals	All healthcare professionals	Y		3	71
Doron et al. 2011	USA	September 2007–February 2009	Compliance with hand hygiene	90%	96%	11	Education, multimodal	Hospital	All healthcare professionals	N	Ward culture was considered when developing intervention. Feedback included within intervention.	3 and 4b	60
Gill et al. 2009	The Philippines	May 2003–August 2004	Risk of death	Risk of death per 1000 admissions: 290	Risk of death per 1000 admissions: 144	10	Education, multimodal with video	Two NICUs	All healthcare professionals	Y		3 and 4b	86
Grayson et al. 2008	Australia	October 2004–September 2006 (pilot) March 2006–March 2007 (secondary)	Compliance with hand hygiene	20%	49%	12	Education, multimodal with demonstration and video	Pilot- 6 healthcare institutions, secondary all public hospitals in Victoria	All healthcare professionals	N		3 and 4b	68
Helder et al. 2010	Netherlands	June 2003–December 2006	Nosocomial infection rate	17.3/1000 patient days	13.5/1000 patient days	18	Educational, multimodal with self-study	Level IIID NICU	Nurses and doctors	Y		4b	71
Helms et al. 2010	USA	July 2007–June 2008	Compliance with hand hygiene	66%	93%	12	Educational, multimodal with self study	All departments of 1 hospital	All healthcare professionals	Y		3	79
Huang et al. 2002	China	September 2000–January 2001	Compliance with hand hygiene.	40%	60%	24	Education, multimodal with demonstration	General hospital- nurses form all departments including medical and surgical wards, operating rooms, central supply room, ICU, dialysis centre, OBGYN.	Nursing staff	N	Educational intervention also looked at needle stick and sharps injuries training	2 and 3	96
Johnson et al. 2005	Australia	May 2001–May 2004	Compliance with hand hygiene	21%	42%	12	Education, multimodal with online elements	6 acute-surgical wards, ICU, renal unit and spinal injuries unit, then expanding to whole hospital	All healthcare professionals	N	In response to an outbreak of MRSA. Stepwise introduction of interventions	3 and 4b	79
Lam et al. 2004	China	19 months (duration not specified)	Compliance with hand hygiene	40%	53%	6	Education, multimodal with self-study	Neonatal ICU (12 bed)	All health professionals	Y		3 and 4b	82
Larson et al. 2000	USA	August 1997–December 1998	MRSA rates	0.464/1000 patient days	0.309/1000 patient days	6	Education, multimodal	Two hospitals	All health professionals	Y	Uses academic detailing to disseminate intervention	3 and 4b	85
Lederer et al. 2009a, b	USA	January 2006–December 2008	Compliance with hand hygiene	50%	>95%	35	Education, multimodal	Seven acute care facilities	All health professionals	N	Uses ‘compliance monitors’ and feedback in addition to education.	3 and 4b	60
Lobo et al. 2010	Brazil	January 2005–January 2007	Compliance with hand hygiene and Central venous catheter bloodstream infection rates (CVC-BSI)	6% (hand hygiene compliance lowest figure) 16.2 CVC-BSI rate (highest)	48% (hand hygiene compliance lowest figure) 13.7 CVC-BSI rate (highest)	9	Education, multimodal	Two medicals ICUs	All healthcare professionals	Y	Interventions were designed to reduce CVC-BSI rate by education of the whole procedure of CVC insertion including compliance with hand hygiene	3 and 4b	100
Lobo et al. 2005	Brazil	2002	CVC primary bloodstream infections	20/1000 CVC days	11/1000 CVC days	8	Education, multimodal with demonstration	One medical ICU	Medical residents and nurses	N	Intervention designed for CVC insertion and maintenance	3 and 4b	92
Muto et al. 2000	USA	2 months (duration not specified)	Compliance with hand hygiene	60%	52%	60	Education, multimodal	One medical ICU and one step-down unit	13 physicians,42 nurses, 17 technicians and 2 housekeepers	N		3	79
Picheansathian et al. 2008	Thailand	June 2004–February 2005	Compliance with hand hygiene	6.3%	81.2%	7	Education, multimodal	One paediatric ICU	26 nurses	N	Increase in NI. Doctors and other staff were not involved in study. Initial rating of compliance based on 20 observations only.	3 and 4b	70
Pittet et al. 2000	Switzerland	December 1994–December 1997	Compliance with hand hygiene	32%	63%	36	Education, multimodal with demonstration	Teaching hospital- all wards and departments	All healthcare professionals	N		3 and 4b	75
Rosenthal et al. 2009	USA	January 2006–May 2008	Compliance with hand hygiene	50%	93%	30	Education, multimodal	All departments of hospital	All healthcare professionals	Y		3	79
Rosenthal et al. 2003	Argentina	July 1998–July 2002	Compliance with hand hygiene	Hospital B: 24% Hospital C: 23.1%	Hospital B: 67.1% Hospital C: 69.4%	Hospital B: 24 months Hospital A: 15 months	Education, multimodal	Three hospitals, one public and two private	All healthcare professionals	Y	Performance feedback was also included	3	79
Salemi et al. 2002	USA	April 1998–September 2000	Compliance with hand hygiene	19%	68%	23	Education, multimodal with video	One medical surgical ICU and one CCU	Doctors	Y		3 and 4b	61
Schelenz et al. 2005	UK	September 2000–May 2003	MRSA rates	11.16/1000 patients	2.09/1000 patients	16	Education, multimodal with demonstration	Adult cardiac surgical unit	All healthcare professionals	N	Intervention carried out in response to MRSA outbreak. Other components were involved, such as MRSA screening and isolation of MRSA patients.	4b	72
Sharek et al. 2002	USA	January 1998–November 1999	Compliance with hand hygiene	47.7%	85.4%	6	Education, multimodal	Paediatric ICU	All healthcare professionals	Y	Very small group of participants, so chose to report on those who had changed the most	3	79
Trautmann et al. 2007	Germany	2002–2006	MRSA rates	6.7/1000 patient days (SICU), 5.8/1000 patient days (MICU)	7.5/1000 patient days (SICU), 1.7/1000 patient days (MICU)	48	Education, multimodal	Community teaching hospital	All healthcare professionals	N	Intervention had multiple components, such as a written MRSA standard, use of surveillance, gowns and carts and feedback to staff about infection rates. MRSA screening policy.	4b	72
Trick et al. 2007	USA	October 1999–December 2002	Compliance with hand hygiene	23% (hospital A), 30% (hospital B), 35% (hospital C)	46% (hospital A), 50% (hospital B), 435 (hospital C)	24	Education, multimodal with self-study	Four hospitals (ICUs medical/surgical units, skilled care units, rehab unit)	All healthcare professionals	N		3 and 4b	82
Won et al. 2004	Taiwan	January 1997–August 2000	Compliance with hand hygiene	43%	80% (after education alone), 81% (after education and feedback)	40	Education, multimodal	Neonatal ICU	All healthcare professionals	N		3	70
Zhang et al 2010	China	May 2000–May 2008	Nosocomial infection rate	>12%	6%	96	Education, multimodal	Paediatric Nephrology unit	Nurses and doctors	Y		4b	71

Table 4.  Format of education used

Educational delivery	Studies using this form of education
Multimodal education with a demonstration	Buffet-Bataillon et al. (2010); Huang et al. (2002); Lobo et al. (2005); Pittet et al. (2000); Schelenz et al. (2005)
Multimodal education with no demonstration	Conrad et al. (2010); Danchaivijitr et al. (2005); Dierssen-Sotos et al. (2010); Doron et al. (2011); Larson et al. (2000); Lederer et al. (2009a, b); Lobo et al. (2010); Muto et al. (2000); Picheansathian et al. (2008); Rosenthal et al. (2003, 2009); Sharek et al. (2002); Trautmann et al. (2007); Won et al. (2004); Zhang et al. (2010)
Multimodal education with a self-study module	Benton (2007); Helder et al. (2010); Helms et al. (2010); Lam et al. (2004); Trick et al. (2007)
Multimodal education with a video	Bhutta et al. (2007); Gill et al. (2009); Salemi et al. (2002)
Multimodal education with demonstration and a video	Grayson et al. (2008)
Multimodal education with an online element	Johnson et al. (2005)

Table 5.  Summary of outcomes

Educational intervention type	Kirkpatrick level	Outcome measures used	Number of studies reporting statistically significant results	Statistical significance value range	Other findings
1. Education, multimodal with demonstration	3	Compliance with hand hygiene policy	4/4	0.001 to 0.05	In one study compliance rates increased for nursing staff but decreased for doctors and auxiliary nursing staff.
	4	Change in MRSA rates. Change in catheter-related bloodstream infection rates	3/3	0.001 to 0.05
2. Education, multimodal without demonstration	3	Compliance with hand hygiene policy	10/12	0.0001 to 0.05	No improvement in hand hygiene compliance in two studies
	4	Reduction in MRSA rate. Reduction in nosocomial infection rates. Reduction in central venous catheter bloodstream infection (CVC-BSI) rates.	7/10	0.001 to 0.94	Reduction in central venous catheter bloodstream infection (CVC-BSI) rates decreased but only in one of the units in the study. One study showed an increase in nosocomial infection rates.
3. Education, multimodal, with self-study	3	Compliance with hand hygiene policy.	4/4	0.0001 to 0.002	There was no significant finding in two of the hospitals monitored in one of the studies.
	4	Reduction in antimicrobial resistant hospital acquired bacteraemia. Decreased rate of nosocomial infection.	3/3	0.0002 to 0.03
4. Education, multimodal with video	3	Compliance with hand hygiene policy.	1/3	Not specified
	4	Risk of death per 1000 ICU admissions. CVC-BSI rate.	3/3	0.001
5. Multimodal education with demonstration and video	3	Compliance with hand hygiene policy	1/1	>0.001
	4	Decrease in MRSA rates post intervention.	1/1	0.035
6. Multimodal education with an online element	3	Compliance with hand hygiene policy.	1/1	>0.001
	4	Decrease in clinical MRSA rates post intervention.	1/1	0.001	MRSA rates remained static 12 months post intervention.

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