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. 16 "hand hygiene" posts so far in 2013. Hand hygiene compliance is consistently lower than we wish for and it's common that healthcare 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. 8148 articles were identified and 46 studies were reviewed and included with 1/3 from the US and 1/3 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 HCW 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, Group B below) and another bundle that included education, reminders, and feedback was also associated with improved compliance (pooled OR, 1.47 - Group A below). See the figure below.

More work to do!

Reference: Schweizer ML, Reisinger HS, Ohl M, Formanek MB, Blevins A, Ward MA, Perencevich EN. Clin Infect Dis; 2013.


  1. Will check this out when I can get the Journal issue or PDF . Looking forward to it.

  2. Wondering why this one (I'm first author) wasnt included. When it was published in 2006 I think it had more observations (over 4000) than any other paper. Google scholar says it's been cited 61 times so far... There's even a YouTube video, and it's about the VA implantation mentioned in the article...

    1. Can you explain the exact interventions that were not present in the before period and were present in the after period? Were they the same in all units? For the meta-analysis, we would have to be sure that the exact bundle was implemented in a specific defined fashion in all units at a specific time. Given the provided checklist, it doesn't appear that this was the case. It appears that some parts of the bundle may have been present in the before period in some locations and not others. Is that the case?

  3. I will have to go back and retread my own paper and the attachments to answer your question! It was a long time ago. I've also posted the VHA Directive that existed 6 years prior to the one posted in the paper. That was the first one that was part of so many of the changes that were made in VA. This is the link... I think the site must be malfunctioning because it says that over 150 people looked at it tonight.

  4. I went back and did some rereading (not retreading!). It seems to me that everyone at a JCAHO (that was the name then)-accredited hospital was required as of 2004 to follow the stronger evidence parts of the 2002 CDC Hand Hygiene Guideline. In VA we wrote a special 1-page summary for the Under Secretary for Health in 2003 and had it sent out systemwide as a sort of shortcut (see page 2 of the first below). So really everything in VA after that was at all related to hand-hygiene: "my" 6 sigma study published in JGIM, Marta Render's paper on CLABSI reduction, Jain's paper on MRSA (and C diff and other infections), etc., were all confounded by this intervention to get folks to actually act on the CDC Guideline and JCAHO requirement. The memo and the newsletter guidance to VA Medical Centers are referred to at these links (I don't think I have the USH's memo anymore): and Trying to prevent adverse events and studying why they do or don't continue to happen is not a physics experiment that can be isolated from external forces. That said, I understand your reasons for excluding out paper. But I think it's sad because I think it contains some pretty nifty and effective tools and methods. I had major surgery this year (2013) and some of the posters we developed so many years ago for the VA were posted on the walls and doors at Johns Hopkins University Hospital. My room, almost incredibly, had one on it that I had written myself. It only occurred to me tonight that maybe my wife had set that up. But I don't think so and hope not... Our paper is at: and it shows the checklist right after the fulltext of the paper - with our "nifty" not-yet-obsolete bundle - posting this version since it was excluded from your study... In general I think the premise for your study doesn't make sense in the real world. There is no optimum hand hygiene bundle. There are good ones. A good one that is actually implemented and stuck with is better than a more-perfect one than is ignored or dropped. I would defy anyone to come up with one better than the one shown in our Appendix Figure A. It's not impossible to to make a better list, but it would be hard. The downside of it is that there's a lot to do, and it's not trivial to maintain. But you don't get something for nothing...

  5. One other thing about our goofy little paper. It was among (just barely) the top 20 most-downloaded papers in that general medicine journal (we didn't put it in a specialty journal on purpose - we wanted regular docs and nurses to read it). This was despite the fact that we sent it all over VA to PSMs and others as an attachment...


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