Infection Control & Hospital Epidemiology
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Fig. 1. Overview of the study population, which illustrates a hierarchical overview with 3 levels: healthcare organizations, wards, and observed opportunities. Level 3 illustrates the number of observed opportunities that hand hygiene should have been applied.
multivariable multilevel logistic regressions were performed to investigate the association between hand hygiene compliance and different time points, ward types, and type of HCW. The outcome variable of ward type and type of HCW in the multilevel analyses was the average compliance of all 5 time points for all 10 healthcare organizations. Associations were considered statistically significant at P<.20
for univariable analyses and P<.05 for multivariable analyses. Furthermore, the outcome resulted in odds ratios (OR) with a corresponding confidence interval (95% CI). All data were ana- lyzed using SPSS software version 21 or 24 (IBM, Armonk, NY).
Results Hand hygiene compliance
Figure 2 shows the mean hand hygiene compliance in all 10 healthcare organizations as well as the implemented (optional) interventions. The compliance at time point 1, the start of the study, was 42.9% (95% CI, 41.4–44.4). After implementing e-learning in 5 organizations and a workshop in 1 organization (between time points 1 and 2), compliance increased by 2.2% to 45.1% (95% CI, 43.4–46.8), but it decreased to 41.2% (95% CI, 39.7–42.7) at time point 3. During this period, 3 organizations implemented a workshop. Hand hygiene compliance increased to 53.9% (95% CI, 52.3–55.5) after the implementation of observer training (in 7 organizations) and team training (in 2 organiza- tions) between time points 3 and 4. One organization imple- mented observer training after time point 4. At the end of the study, the mean hand hygiene compliance of all organizations was 51.4% (95% CI, 49.8–53.0), a significant (P<.001) increase of 8.5% between time points 1 and 5.
χ 2 analyses
Tables 1, 2, and 3 show the χ2 analyses and the changes in hand hygiene compliance over time by ward type, type of HCW, and
healthcare organization. Table 1 shows significant increases in hand hygiene compliance on 5 of the 9 ward types, but 3 of the 9 ward types (ie, pediatric, neonatal, and mixed) showed a sig- nificant decrease between time points 1 and 5. Concerning the type of HCW, only nurses showed a significant improvement of 9.2% for hand hygiene compliance (P<.001). Table 3 shows great diversity among organizations in hand hygiene compliance change between time point 1 and time point 5 (ranging from −11.5% to +33.3%).
Multilevel logistic regression
Table 4 shows the outcome of univariable and multivariable multilevel logistic regressions. The regression analysis shows that all variables are significant in the univariable model. Therefore, all variables are included in the multivariable model. The multivariable model shows that for the variable ‘ward,’ the
neonatal ward has highest odds of being compliant in performing hand hygiene (OR, 3.96; 95% CI, 3.99–5.25) compared to the internal ward. This result contrasts with the emergency ward, which had the lowest odds of being compliant (OR, 0.58; 95% CI, 0.50– 0.67). Furthermore, a significant increase in hand hygiene com- pliance was observed for almost all time points, with time point 4 (OR, 1.61; 95% CI, 1.47–1.76) and 5 (OR, 1.44; 95% CI, 1.32–1.57) showing the highest increase. For the last variable, type of HCW, only ‘other HCWs’ shows a significant difference in the multi- variable analysis (OR, 0.62; 95% CI, 0.45–0.86) compared to physicians.
Discussion
The main aim of this study was to investigate the effects of a multimodal, friendly competition intervention on hand hygiene compliance. The core element of the intervention program was the monitoring and feedback of hand hygiene compliance in an existing collaboration of 10 healthcare organizations. Hand hygiene was observed during a period of 2 years at 6-month
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