John: Hello, I'm John Hilton, editor of the Cochrane Editorial unit. Healthcare-associated infection is a major problem for health systems, causing concern, unnecessary illness and death for patients. It is receiving further priority from policy-makers because it contributes to the global threat of antimicrobial resistance. Hand hygiene is regarded as an effective preventative measure and the September 2017 update of a Cochrane Review provides evidence on the effects of various interventions. Lead author, Dinah Gould from the School of Healthcare Sciences at Cardiff University in Wales brings us up to date in this podcast.

Dinah: International recommendations to encourage hand hygiene compliance recommend multimodal strategies, which typically include use of an alcohol-based handrub or gel, education about the importance of hand hygiene, training to use the alcohol-based product, and written and verbal reminders to use it along with performance feedback and administrative support.
We have updated our review to continue our investigation of the short and longer-term success of these strategies to improve hand hygiene compliance and their ability to reduce rates of healthcare-associated infection. This, our second update now includes 26 studies, four of which were randomised trials and ten were interrupted time series studies. Most were conducted in hospitals or long-term care facilities, with one having been done in primary care. However, for most of our analyses, we were only able to use five or fewer studies and, in general, we rated the certainty of the evidence as low.
Fourteen studies assessed different combinations of strategies recommended by the World Health Organisation, WHO. Six assessed different types of performance feedback, two evaluated education, three evaluated cues such as signs or scent and one assessed positioning of the alcohol-based product in the clinical area. Hand hygiene compliance was measured by direct observation in 23 of the 26 studies, with the other three basing their findings on product consumption. Eight studies reported rates of infection or colonisation.
We found that multimodal interventions that include some but not all the strategies recommended by the WHO can slightly improve hand hygiene compliance and may slightly reduce infection rates. When the multimodal interventions included additional strategies to those recommended in the WHO guidelines, we found that they may slightly improve hand hygiene compliance, but it’s unclear whether this approach can reduce infection or colonisation rates.
Performance feedback may improve hand hygiene compliance and probably slightly reduces infection. Also, when tested separately both education and cues such as signs or scent, may slightly improve hand hygiene compliance; while, placing alcohol-based products close to the point of use probably slightly improves hand hygiene compliance.
In summary, our review shows that multimodal interventions to increase hand hygiene compliance and single interventions based on individual components of these multimodal strategies probably lead to a modest increase in hand hygiene compliance. They may also slightly reduce infection and colonisation rates, but the quality of the evidence needs to be improved. There is an urgent need to conduct methodologically robust research to explore the effectiveness of multimodal interventions compared with simpler interventions and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.

John: If you would like to read more about the various interventions that Dinah and her colleagues were able to review, and to watch for further updates of this review should more evidence become available, just go to Cochrane Library dot com and search 'hand hygiene and patient care' to find the full review.