title: The Feedback Intervention Trial (FIT)--improving hand-hygiene compliance in UK healthcare workers: a stepped wedge cluster randomised controlled trial.
abstract: BACKGROUND
  Achieving a sustained improvement in hand-hygiene compliance is the WHO's first global patient safety challenge. There is no RCT evidence showing how to do this. Systematic reviews suggest feedback is most effective and call for long term well designed RCTs, applying behavioural theory to intervention design to optimise effectiveness.
  
  
  METHODS
  Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals (16 Intensive Therapy Units [ITU]; 44 Acute Care of the Elderly [ACE] wards) routinely implementing a national cleanyourhands campaign). Intervention-based on Goal & Control theories. Repeating 4 week cycle (20 mins/week) of observation, feedback and personalised action planning, recorded on forms. Computer-generated stepwise entry of all hospitals to intervention. Hospitals aware only of own allocation.
  
  
  METHODS
  direct blinded hand hygiene compliance (%).
  
  
  RESULTS
  All 16 trusts (60 wards) randomised, 33 wards implemented intervention (11 ITU, 22 ACE). Mixed effects regression analysis (all wards) accounting for confounders, temporal trends, ward type and fidelity to intervention (forms/month used). INTENTION TO TREAT ANALYSIS: Estimated odds ratio (OR) for hand hygiene compliance rose post randomisation (1.44; 95% CI 1.18, 1.76;p<0.001) in ITUs but not ACE wards, equivalent to 7-9% absolute increase in compliance. PER-PROTOCOL ANALYSIS FOR IMPLEMENTING WARDS: OR for compliance rose for both ACE (1.67 [1.28-2.22]; p<0.001) & ITUs (2.09 [1.55-2.81]; p<0.001) equating to absolute increases of 10-13% and 13-18% respectively. Fidelity to intervention closely related to compliance on ITUs (OR 1.12 [1.04, 1.20]; p = 0.003 per completed form) but not ACE wards.
  
  
  CONCLUSIONS
  Despite difficulties in implementation, intention-to-treat, per-protocol and fidelity to intervention, analyses showed an intervention coupling feedback to personalised action planning produced moderate but significant sustained improvements in hand-hygiene compliance, in wards implementing a national hand-hygiene campaign. Further implementation studies are needed to maximise the intervention's effect in different settings.
  
  
  BACKGROUND
  Controlled-Trials.com ISRCTN65246961.
authors.affiliation: Royal Free Campus, University College London Medical School, University College, London, United Kingdom.
authors.forename: Christopher
authors.initials: C
authors.lastname: Fuller
authors.forename: Susan
authors.initials: S
authors.lastname: Michie
authors.forename: Joanne
authors.initials: J
authors.lastname: Savage
authors.forename: John
authors.initials: J
authors.lastname: McAteer
authors.forename: Sarah
authors.initials: S
authors.lastname: Besser
authors.forename: Andre
authors.initials: A
authors.lastname: Charlett
authors.forename: Andrew
authors.initials: A
authors.lastname: Hayward
authors.forename: Barry D
authors.initials: BD
authors.lastname: Cookson
authors.forename: Ben S
authors.initials: BS
authors.lastname: Cooper
authors.forename: Georgia
authors.initials: G
authors.lastname: Duckworth
authors.forename: Annette
authors.initials: A
authors.lastname: Jeanes
authors.forename: Jenny
authors.initials: J
authors.lastname: Roberts
authors.forename: Louise
authors.initials: L
authors.lastname: Teare
authors.forename: Sheldon
authors.initials: S
authors.lastname: Stone
mesh_terms: D003187:Compliance; D003428:Cross Infection / Q000517:prevention & control; D019983:Guideline Adherence; D006235:Hand Disinfection; D063373:Hand Hygiene / Q000592:standards* / Q000706:statistics & numerical data*; D006282:Health Personnel / Q000706:statistics & numerical data*; D006801:Humans; D006113:United Kingdom