Hand Hygiene Compliance Interventions: A Critical Assessment Report

This report critically assesses the effectiveness of hand hygiene compliance interventions in reducing disease transmission risks within hospital settings. It analyzes five articles, including systematic reviews, experimental, quasi-experimental, and cohort studies, published between 2013 and 2018. The methodology involves selecting articles from Google Scholar using keywords such as 'hand hygiene' and 'interventions,' followed by appraisal using the MERGE framework, and grading based on the FORM framework. The results section provides detailed assessments of each article, evaluating their strengths and limitations. The discussion synthesizes the findings, highlighting the effectiveness of various interventions and the importance of hand hygiene compliance among healthcare workers. The report emphasizes the need for improved hand hygiene practices to minimize hospital-acquired infections, referencing WHO guidelines and campaigns.

Running head: CRITICAL ASSESSMENT ON HAND HYGIENE
Critical Assessment on Hand Hygiene
Name of the Student
Name of the University
Author’s Note:

1CRITICAL ASSESSMENT ON HAND HYGIENE
Topic
How effective are hand hygiene compliance interventions in improving hand hygiene
behaviours (thus reducing the risk of transmitting disease) in hospitals?
Introduction
In hospital patients it is quite common to have infections from the bad condition of
the hand hygiene of the health care workers (HCW) and it has become a global challenge to
combat against this infection associated with the hand hygiene. The prevalence rate of health
care associated infections (HAIs) are comparatively higher in undeveloped countries than that
of the developed countries (Chassin, Mayer & Nether, 2015). In US, almost 2 million of
infections were reported and it also contributed in increasing hospital staying among the
patients. The improvement of hand hygiene behavior among the health care professionals is
considered as an effective practice to reduce the risk of disease transmission in hospitals. In
practice of hygiene, the use of alcohol is very much common and this hand rubbing technique
is strongly supported by WHO and Centers for Disease Control and Prevention. From the
studies, it was seen that, using of alcohol based rubbing technique had lowered the rate of
infections (japan). Measurement of hand hygiene practice is done by direct observation
method in which human auditors directly observe the hand hygiene compliance of the HCW
who are directly related to the clinical care plans of the patients (Gould et al., 2017).
However this method is not completely correct as this method is associated with the
Hawthorne effect which is the biased behavior of the observer (Srigley et al., 2014). The
direct contact between the patients and the HCW who are directly exposed to the
contaminations of nosocomial pathogens and this is assumed as the primary root of infections
in the patients. WHO had launched a campaign named ‘Clean Care is Safe Care’ in order to
improve the hand hygiene among in hospitals. This program was launched in 2005 and the
main objective of this program is to global promotion of best hand hygiene policy

2CRITICAL ASSESSMENT ON HAND HYGIENE
("Background to Clean Care is Safer Care", 2018). Therefore, in this study, five article have
been selected and critical assessment was performed on them to find relevance on the
question: “How effective are hand hygiene compliance interventions in improving hand
hygiene behaviors (thus reducing the risk of transmitting disease) in hospitals?" in the
following sections.
Methodology
Selection of article
Five articles published recently were selected for this critical assessment study.
Amongst them, two are systematic review, one experimental study, one quasi-experimental
study and one is cohort study. The publication time duration for these articles were all within
2013 – 2018.
Searching database for article selection
Google scholar (https://scholar.google.co.in/) was used as a searching database to find
these articles by customizing the publication year from 2013 to 2018.
Keywords
Keywords were used to narrow down the articles from online database. Four
keywords have been used and these key words are: ‘Hand hygiene’, ‘Hand hygiene
behaviours’, ‘interventions’, and ‘hospital’.
Tool for grading and assessment
Selected article were appraised and graded on the basis of their quality. As stated by
Rychetnik et al. (2002), MERGE or Method for Evaluating Research and Guideline Evidence
was used for the assessment of these articles. For MERGE analysis, one descripted
information about the study and one evaluation criterion were used for the appraisal of these
articles. Each of the criterion includes different parameters which are mentioned in the results

3CRITICAL ASSESSMENT ON HAND HYGIENE
section of this article. FORM framework guidelines were used for the gradation of these
articles. The FORM framework mentioned in this study was followed framework as cited by
the (Hillier et al., 2011). For the gradation of these articles, five parameters were used namely
generalizability, evidence based practice, consistency, clinical impact, and applicability. Four
different grading mark were used for gradation and these are poor, satisfactory, good and
execellent.
Results
MERGE or Method for Evaluating Research and Guideline Evidence is used for the
assessment of the articles included in this study. Assessment table for each article have been
illustrated here within.
Appraisal of Article 1:
Study information Description
Documentation of the review
Gould, D. J., Moralejo, D., Drey, N., Chudleigh, J. H.,
& Taljaard, M. (2017). Interventions to improve hand
hygiene compliance in patient care. Cochrane database
of systematic reviews, (9)
Review type Systematic review
Type of studies which have been
considered in this review
controlled before-after studies, non-randomised trials,
randomised trials, and interrupted time series analyses
(ITS)
Kind of outcomes measured in
this review Primary and secondary outcomes were considered.
Whether interferences were
directed at individuals or
populations?
Interferences directed at individuals
Assessment criterion for the review Comments
Does all appropriate articles were Yes

4CRITICAL ASSESSMENT ON HAND HYGIENE
satisfactorily and thoroughly considered?
Whether the study considered all the
possible benefits and problems related to the
topic?
Yes, all the possible outcomes were
considered.
Whether only RCTs (Randomised
controlled trials) were considered? Yes
Presentation of information – whether
presented in organised manner to deduce
effect estimation and CI (confidence
intervals)?
Confidence level were not mentioned in the
study
Whether the included articles were assessed
for quality?
Yes, authors screened every included article
individually.
Appraisal of Article 2:
Study information Description
Documentation of the review
Luangasanatip, N., Hongsuwan, M., Limmathurotsakul,
D., Lubell, Y., Lee, A. S., Harbarth, S., ... & Cooper, B.
S. (2015). Comparative efficacy of interventions to
promote hand hygiene in hospital: systematic review
and network meta-analysis. bmj, 351, h3728.
Review type Systematic review and network meta- analysis
Type of studies which have been
considered in this review
Non-randomised trials, randomised controlled trials,
interrupted time series studies and controlled before-
after trials
Kind of outcomes measured in
this review
Both strengths and limitations of the study were
discussed.
Whether interferences were
directed at individuals or
populations?
Interferences were directed at individuals.
Assessment criterion for the review Comments

5CRITICAL ASSESSMENT ON HAND HYGIENE
Does all appropriate articles were
satisfactorily and thoroughly considered? Yes
Whether the study considered all the
possible benefits and problems related to the
topic?
The article has considered both benefits and
harmful effects.
Whether only RCTs (Randomised
controlled trials) were considered? Yes
Presentation of information – whether
presented in organised manner to deduce
effect estimation and CI (confidence
intervals)?
Data were organised in thorough and
presentable manner with CI (confidence
intervals)
Whether the included articles were assessed
for quality?
Yes, the studies were quality assessed
against EPOC checklist.
Appraisal of Article 3:
Study information Description
Documentation of the article
Chassin, M. R., Mayer, C., & Nether, K. (2015).
Improving hand hygiene at eight hospitals in the United
States by targeting specific causes of
noncompliance. The Joint Commission Journal on
Quality and Patient Safety, 41(1), 4-12.
Category of the considered
investigation Experimental study
Type of interferences and
interventions measured and
applied in this article
Six sigma, change management method and lean were
used to measure the outcome.
Whether interferences or
interventions were directed at
individuals or populations?
Interferences were directed at individuals.
Assessment criterion for the study Comments

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Category of the article Experimental study
Whether the subjects considered in this
article were adequately defined clearly with
respect to time, person or place?
Yes, it was clearly defined.
Whether standard, credible and effective
method were applied to detect the
interferences or interventions exposure?
Methods applied to determine outcomes
were all standard, credible and effective.
Whether identical methodology was applied
to both the test and control group? Yes
Whether standard, credible and effective
method were applied to determine the
outcomes?
Yes
Whether identical methodology was applied
to determine the outcome for both the test
and control group?
Yes
Whether any risk factors or limitations were
considered during the study?
Yes, limitations were considered in this
study.
Whether the intended purpose of the study
was to interfere? Yes
Appraisal of Article 4:
Study information Description
Documentation of the article
Allegranzi, B., Gayet-Ageron, A., Damani, N.,
Bengaly, L., McLaws, M. L., Moro, M. L., ... &
Donaldson, L. (2013). Global implementation of
WHO's multimodal strategy for improvement of hand
hygiene: a quasi-experimental study. The Lancet
infectious diseases, 13(10), 843-851.
Category of the considered
investigation Quasi- experimental study
Type of interferences and
interventions measured and
WHO’s strategy were implemented in 3 to 6 months

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applied in this article phase for four times.
Whether interferences or
interventions were directed at
individuals or populations?
Interferences were directed at individuals
Assessment criterion for the study Comments
Category of the article Quasi- experimental study
Whether the subjects considered in this
article were adequately defined clearly with
respect to time, person or place?
Yes, it was clearly defined.
Whether standard, credible and effective
method were applied to detect the
interferences or interventions exposure?
Yes, the methods were standard, credible
and effective
Whether identical methodology was applied
to both the test and control group? Yes
Whether standard, credible and effective
method were applied to determine the
outcomes?
Yes
Whether identical methodology was applied
to determine the outcome for both the test
and control group?
Yes
Whether any risk factors or limitations were
considered during the study? No, limitations were discussed for this study
Whether the intended purpose of the study
was to interfere? yes
Appraisal of Article 5:
Study information Description
Documentation of the article Srigley, J. A., Furness, C. D., Baker, G. R., & Gardam,
M. (2014). Quantification of the Hawthorne effect in
hand hygiene compliance monitoring using an

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electronic monitoring system: a retrospective cohort
study. BMJ Qual Saf, 23(12), 974-980.
Category of the considered
investigation Cohort study
Type of interferences and
interventions measured and
applied in this article
A RTLS or real-time location system were applied.
Whether interferences or
interventions were directed at
individuals or populations?
Interferences were directed at individuals.
Assessment criterion for the study Comments
Category of the article Cohort study
Whether the subjects considered in this
article were adequately defined clearly with
respect to time, person or place?
Yes, it was clearly defined.
Whether standard, credible and effective
method were applied to detect the
interferences or interventions exposure?
Yes
Whether identical methodology was applied
to both the test and control group? Yes
Whether standard, credible and effective
method were applied to determine the
outcomes?
Yes
Whether identical methodology was applied
to determine the outcome for both the test
and control group?
Yes
Whether any risk factors or limitations were
considered during the study?
Limitations have been discussed in the
study.
Whether the intended purpose of the study
was to interfere? Yes

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FORM framework for gradation:
Gradation for each studies according to the FORM framework is provided below:
Study or
Review name
Parameters
Generaliz-
ability
Evidence
based
practice
Clinical
impact
Consistency Applicability
Gould et al.,
2017 Excellent Satisfactory Good Satisfactory Good
Luangasanatip
et al., 2015 Good Excellent Excellent Excellent Excellent
Chassin,
Mayer &
Nether, 2015
Good Satisfactory Excellent Excellent Good
Allegranzi et
al., 2013 Excellent Good Excellent Excellent Good
Srigley et al.,
2014 Good Satisfactory Good Excellent Satisfactory
Discussion
In a nutshell, from the above findings, it can be deduced that all the experimental
studies and review articles were dedicated to the compliance regarding hand hygiene amongst
health workers and to improve the hand hygiene behaviours amongst health workers. Gould
et al. (2017) have focussed their review article on the compliance amongst health worker
regarding hand hygiene in long and short term basis and whether improvement in hand
hygiene is effective against the reduction of infection. However, the study is little bit limited
regarding the reproducibility of the accumulated data. On the contrary, the systematic review
published by Luangasanatip et al. (2015) have directed their aim on the evaluation of the

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promotion performed by WHO and other promotional campaign regarding hand hygiene
among health workers. Their published work is excellent in terms of clinical impact,
applicability, consistency and evidence based practice. In track with the previous author,
Allegranzi et al. (2013) have evaluated the implementation of WHO’s promotional strategy
regarding hand hygiene amongst health workers. These study have excellent strengths in
terms of clinical impact and consistency. However, evidence accumulated in this article is
little less strong compared to the other parameters. On the other hand, Chassin, Mayer &
Nether (2015) have performed an experimental study with the aim of improving hand
hygiene among eight USA based hospitals. Interestingly, Srigley et al. (2014) have
investigated in the area which any of the previous articles have not enquired. They have
studied the Hawthorne effect amongst the health workers with regards to hand hygiene and
compliance. Their article is interesting and explored in to a research area which the article
have enquired but the article leaves a lot to be desired in terms of applicability and evidence
based practice. Finally, from the FORM matrix framework it can be deduced that the research
paper published by Luangasanatip et al. (2015) is the best published paper in terms of
gradation.
Conclusion
Henceforth, from the above conclusion, it can be concluded that hand hygiene
behaviours by the health workers plays a significant role in the prevention of infection in
health care institution like hospitals. Additionally, there is many multi- modal strategy like
strategy implemented by WHO is present in this area. Studies have shown that multi- modal
strategies like this can be implemented in the healthcare industry across the globe but a
simpler intervention method might be more effective. Interestingly, scientific phenomenon
like Hawthorne effect has modified the behaviour of health care workers. To conclude, it can
be said that a further objective specific research is needed in this area for a robust and simpler

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intervention method for compliance regarding health care workers in the area of hand
hygiene, so that infection from this area can be prevented.