Impact of a multimodal hand hygiene improvement intervention in a 1000-bed hospital in Thailand: a stepped wedge cluster randomized controlled trial

BackgroundGood hand hygiene compliance amongst healthcare workers is critical for patient safety and plays a central role in preventing healthcare-associated infections. The World Health Organization (WHO) recommends a multimodal strategy to improve healthcare worker hand hygiene. We aimed to evaluate the effectiveness of this strategy in a middle-income country using a stepped-wedge cluster randomized trial. MethodsThe trial was conducted between 2013 and 2015 in 58 wards in a 1000-bed hospital in Thailand. The intervention was adapted from the WHOs Hand Hygiene Improvement Strategy and implemented by the hospitals infection control team. The primary outcome was observed hand hygiene compliance among healthcare workers in the study wards. This study was registered at ClinicalTrials.gov (NCT01933087). FindingsDuring 4,230 observation sessions, 54,073 hand hygiene opportunities were identified. Hand hygiene compliance increased from 10.0% (2,660/26,482) to 11.0% (3,048/27,591) after the intervention (odds ratio [OR] 1.12; 95% CI: 1.01-1.24). Among the five moments for hand hygiene, the greatest improvement in compliance was observed in hand hygiene before patient contact (OR 1.52; 95% CI: 1.21, 1.91). InterpretationWhile hand hygiene compliance improved slightly, the intervention failed to achieve the substantial improvements that were needed. There is a need for new strategies to ensure that all hospitals in low and middle-income countries can achieve and maintain acceptable levels of hand hygiene. FundingOak Foundation, MRC