Systematic Review on the
Effectiveness of Handwashing
-interim reportHiroshi Ikai
Stephanie Smith
Allison McGeer
Department of Infection Control,
Mount Sinai Hospital
Background (1)
• Hand hygiene is historically one of the
most simple yet effective component of
infection control activity.
• Guideline for hand hygiene was published
in 2002 by HICPAC/SHEA/APIC/IDSA,
where the efficacy of hand hygiene is
discussed as removal of microorganisms
from hand.
Background (2)
• Clinical effectiveness of hand hygiene for
the prevention of nosocomial infections
(NI) varies in quantity (effect size) and
quality (study design) among studies.
Objective
(1) To quantify the preventable portion of
nosocomial infections by the implementation /
reinforcement of handwashing in hospital
settings
-And its variation across different categories of infection
(2) To quantify the impact of handwashing to the
society and the health economy
-through the systemic review of previous studies
Methods(1): data source
• Systematic database search
– Data source
•
•
•
•
MEDLINE
EMBASE
Cochrane Database of Systematic Reviews
CINAHL
• Secondary citations from
• above articles
• Textbook (Mandell, Mayhall)
• Guidelines (WHO/SHEA/HICPAC)
Methods (2): Search Terms
Handwashing
Handwashing [MeSH]
hand was*
hand hygiene
hand scrub*
hand clean*
Nosocomial infections
Cross infection [MeSH]
bloodstream infection
surgical site infection
urinary tract infection
gastrointestinal tract infection
CNS infection / meningitis
vertical/horizontal transmission
Absenteeism
absenteeism [MeSH]
sick leave
leave of absence
absen* AND work
Length of Hospitalization
length of:
stay/hospitalization/admission
time until discharge
hospital days
Health economics
Economics, Medical [MeSH]
Health Care Costs [MeSH]
Cost of Illness [MeSH]
burden of illness
economic loss
Methods (3): Title / abstracts review
• Titles and abstracts are reviewed by at least two people
• Inclusion criteria:
– Comparative studies before and after handwashing program
OR
reviews that may mention about such studies
– Hospital setting
– Either retrospective or prospective design
– Peer reviewed journals
• Exclusion criteria:
– Article type
• Short (1-3 pages) review with no original data
• Editorials
• Single case reports
Methods (4): Data collection
• Two independent reviewers extract data on:
– Study design
• Before-after / Cohort study / etc.
– Patient population
• Adults / pediatrics / post-surgical
– Care setting
• Ward / ICU / NICU
– Target caregivers
• Physician / nurse / all HCWs +/- visitor / family
– Type / content of handwashing program
• Education program / monitoring / overall process improvements
– Outcomes
• Improvement of adherence to hand hygiene practice
• Incidence / absenteeism / economics / length of stay
Search results
Nosocomial
infections
Absenteeism
Economics
Length of
stay
HH-PubMed
2181
43
38
170
HH-EMBASE
791
25
74
59
HH-CINAHL
339
13
11
24
HH-CDSR
184
211
48
102
# titles
reviewed
2935
244
166
311
# abstracts
reviewed
1405
12
66
110
# articles in
review
320
4
10
29
Adding
Adding
Adding
Adding
Secondary
citations
Variations of study design / results
A uthor/Year Study design Setting
Zafar 1998
Before-after 1 acute-care hospital HCW
7 acute-care
Hospitals
7 acute-care
Pittet 2000 Before-after
Hospitals
1 acute-care hospital
Tomic 2004 Before-after
> general ward and
Pittet 2000
Won 2004
Before-after
Before-after NICU
(subgroup)
Before-after NICU
1 acute-care hospital
Rosenthal
Before-after > med-surg ICU and
2005
coronary ICU
1 Acute-care hospital
Marena 2002 Before-after
> vascular surgery
1 Acute-care hospital
> neurosurgery ward
Lam 2004
Brown 2003 Before-after NICU
Hilburn 2003 Before-after
Prospective
cohort study
Prospective
Fendler 2002
cohort study
Makris 2000
Swoboda
2004
Target of
intervention
Quasiexperimental
(subgroup)
Dr, Ns,
Ns assitant
Dr, Ns,
Ns assitant
Type of
intervention
C linical
outcom e
Multi-modal
C.difficile
diarrhea
Multi-modal
NI
Multi-modal
MRSA
isolation
MRSA
isolation
HH
HH
Incidence
P reventable
Incidence (after) R elative
adherence adherence (before)
portion of
(cases/pt*days) risk
(before) (after)
(cases/pt*days)
N Is (%)
.
.
47.6%
66.2%
47.6%
66.2%
.
.
43%
162 cases/yr
45 cases/yr 0.27778
72%
16.9%
9.9% prevalence 0.0585
prevalence
94%
2.16 / 10000
0.93/10000
0.43056
57%
26 / 78108
3 / 70423
0.12798
87%
80%
15.13 / 1000
10.69 / 1000
0.70654
29%
HCW
Multi-modal
Dr, Ns,
other HCW
Multi-modal
NI
Dr, Ns
Multi-modal
NI
39-40%
53-59%
3.35 / 1000
20 / 1764
1.06 / 1000
11 / 1776
0.31642
0.54628
68%
45%
Dr, Ns,
Multi-modal
ancillary staff
NI
23.10%
64.50%
104 / 2187
207 / 7409
0.58752
41%
Dr, Ns,
Education
paramedicals
NI
6.6 cases /
100 admission
7.3 cases /
100 admission
5.7 cases /
0.86364
100 admission
6.2 cases /
0.84932
100 admission
21.5 / 1000
3.2 / 1000
0.14884
85%
40 / 4868
49 / 9242
0.64524
35%
Test
0.70556
621/149639,
29%
(RTI)
HCW
Dr, Ns,
1 acute-care hospital patients,
visitors
all
8 LTCFs
employees
1 extended care
nursing staff
facility
1 acute-care hospital Dr, Ns,
> surgical
ancillary
intermediate care
staff,
Alcohol, audit with K.pneumoniae
feedback
infection
44.20%
48%
Alcohol sanitizer,
NI
education
15%
Antimicrobial
soap, education
NI
.
.
Alcohol sanitizer
NI
.
.
552/172897
184 / 81036
0.71119
29%
Multi-modal
NI
19.10%
24.40%
100 / 1616
97 / 1933
0.81093
19%
51 / 81036
87 / 81036
0.81814
0.78321
18%
22%
(UTI)
(RTI)
.
.
Test
743/117377,
14%
. 133 / 172897
. 237 / 172897
Sample meta-analysis
Hilburn 2003
Swobada 2004
Lam 2004
Rosenthal 2005
Summary
• Most of current data on the effectiveness
of hand hygiene are based on before-after
studies.
• Most studies show effectiveness of hand
hygiene for prevention of nosocomial
infections.
• Effect size are variable, with relative risk
ranging from 14% to 94%.
Next step
• Systematic review should also be completed for
other outcomes, i.e. absenteeism, length of
hospital stay, and health economics.
• There may be a guideline for reporting
observational studies in infection control, so that
each data can contribute to future policy making.
• Controlled study design maybe preferred in the
future, if ethically appropriate.