title: 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.
  
  
  METHODS
  Systematic review and network meta-analysis.
  
  
  METHODS
  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).
  
  
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand School of Public Health, Queensland University of Technology, Brisbane, Australia nantasit@tropmedres.ac.
authors.forename: Nantasit
authors.initials: N
authors.lastname: Luangasanatip
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
authors.forename: Maliwan
authors.initials: M
authors.lastname: Hongsuwan
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Department of Tropical Hygiene, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.
authors.forename: Direk
authors.initials: D
authors.lastname: Limmathurotsakul
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
authors.forename: Yoel
authors.initials: Y
authors.lastname: Lubell
authors.affiliation: Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva 1211, Switzerland Departments of Infectious Diseases and Microbiology, Royal Prince Alfred Hospital, Sydney 2050, Australia.
authors.forename: Andie S
authors.initials: AS
authors.lastname: Lee
authors.affiliation: Infection Control Program, University of Geneva Hospitals and Faculty of Medicine, Geneva 1211, Switzerland.
authors.forename: Stephan
authors.initials: S
authors.lastname: Harbarth
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
authors.forename: Nicholas P J
authors.initials: NP
authors.lastname: Day
authors.affiliation: School of Public Health, Queensland University of Technology, Brisbane, Australia Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Australia.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Graves
authors.affiliation: Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.
authors.forename: Ben S
authors.initials: BS
authors.lastname: Cooper
mesh_terms: D003362:Cost-Benefit Analysis; D003428:Cross Infection / Q000517:prevention & control*; D063373:Hand Hygiene / Q000592:standards*; D007722:Health Knowledge, Attitudes, Practice; D006282:Health Personnel; D006293:Health Promotion; D006295:Health Resources / Q000600:supply & distribution; D006761:Hospitals; D006801:Humans; D017757:Infectious Disease Transmission, Professional-to-Patient / Q000517:prevention & control*; D065186:Interrupted Time Series Analysis; D009042:Motivation