192
Table 4. Hand Hygiene Compliance With Multilevel Logistic Regression Analysis Variable
Hand Hygiene Opportunities, No. (%)
Time point Time point 1 Time point 2 Time point 3 Time point 4 Time point 5 Ward
Internal ward Surgical ward
Intensive care ward Pediatric ward Neonatal ward Emergency ward
Gynecology–obstetrics Mixed ward Other wardb
Type of HCW Physicians Nurses
Other HCWc
4,285 (21.1) 3,497 (17.2) 4,432 (21.8) 3,941 (19.4) 4,131 (20.4)
6,845 (33.7) 4,977 (24.5) 1,939 (9.6) 543 (2.7) 266 (1.3) 970 (4.8) 922 (4.5)
1,901 (9.4) 1,923 (9.5)
2,197 (10.8) 17,910 (88.3) 179 (0.9)
Compliance %
42.9 45.1 41.2 53.9 51.4
46.4 46.7 41.9 57.8 72.6 35.4 42.0 54.4 47.5
45.8 47.0 33.5
Note. HCW, healthcare worker. aSignificant if P<.20 in univariable analysis and if P<.05 in multivariable analysis. bOutpatient clinic and cardiology, cardiac catheterization, and ENT wards. cNutritionists, physiotherapists, laboratory staff, etc.
hygiene opportunities without bias to specific opportunities (eg, before or after care). Furthermore, the number and variation in type (eg, academic teaching, rural, revalidation) of participating healthcare organizations and HCWs, as well as hand hygiene opportunities, provides a good representation of healthcare organizations in general. Additionally, the same method is used at all time points, which resulted in a constant number of obser- vations of hand hygiene opportunities over time, which led to less fluctuation in our results. The first limitation of this study is the uncontrolled, non-
randomized design, whichmakes it impossible to determine a causal relation between the interventions of “Roll Up Your Sleeves” and hand hygiene compliance. On the other hand, these results provide a better estimate of how hand hygiene could be improved in daily practice outside of a strict study setting. The healthcare organiza- tions were allowed to use other interventions in addition to the interventions offered by “Roll Up Your Sleeves” due to the obser- vational nature of the study. However, it was difficult tomonitor the extent of these other interventions, which makes it difficult to esti- mate how many HCWs were exposed to the interventions within each organization. Another limitation is the long time interval between feedback reports, which might have limited the impact of the intervention. However, due to the continuous attention for hand
hygiene compliance between the reports, we expect that this effect was minimal. Furthermore, although the multilevel analyses cor- rected the effect of the intervention for the type of wards within organizations, other variables, such as hospital size, might have influenced the hand hygiene compliance of HCWs. Lastly, although directly observing hand hygiene behavior is considered the gold standard, it can change the behavior of those being observed (ie, the Hawthorne effect), which could lead to socially desirable behavior (ie, better hand hygiene) or altered behavior. Better hand hygiene behavior only occurs if the observed HCW is aware of the correct opportunities, which would then lead to an overestimation of hand hygiene compliance.28 To decrease the possibility of a Hawthorne effect, the observers mentioned to the HCWs that they were observing patient safety in general instead of hand hygiene com- pliance specifically. Even though the Hawthorne effect may have contributed to an increase in hand hygiene compliance, the increase is mostly attributable to the 5 rounds of observations and the suc- cessful interventions of the “Roll Up Your Sleeves” project. Our results show that the multimodal intervention program of
“Roll Up Your Sleeves” in a friendly competition setting was accompanied by a significant overall increase of hand hygiene compliance between the start and the end of the program. Future research is needed to investigate the long-term effects of the
Manon D. van Dijk et al
Odds Ratio (95% CI) in Univariable Analysis
1.00
1.13 (1.03–1.24)a 0.97 (0.89–1.06) 1.62 (1.48–1.77)a 1.46 (1.34–1.59)a
1.00
1.00 (0.93–1.08) 0.87 (0.78–0.96)a 1.64 (1.37–1.97)a 4.02 (3.04–5.32)a 0.60 (0.52–0.69)a 0.81 (0.70–0.94)a 1.30 (1.16–1.45)a 0.96 (0.85–1.07)
1.00
1.11 (1.02–1.22)a 0.57 (0.41–0.79)a
Odds Ratio (95% CI) in Multivariable Analysis 1.00
1.12 (1.02–1.23)a 0.96 (0.88–1.05) 1.61 (1.47–1.76)a 1.44 (1.32–1.57)a
1.00
1.00 (0.93–1.08) 0.88 (0.79–0.97)a 1.69 (1.41–2.02)a 3.96 (2.99–5.25)a 0.58 (0.50–0.67)a 0.83 (0.72–0.96)a 1.29 (1.15–1.44)a 0.95 (0.85–1.07)
1.00
1.05 (0.95–1.15) 0.62 (0.45–0.86)a
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