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Am Fam Physician. 2001;63(8):1625-1626

The importance of simple, basic routines such as handwashing is underappreciated by many health care professionals. Hand hygiene is the single most important measure to prevent or reduce nosocomial infections, including methicillin-resistant Staphylococcus aureus (MRSA). Pittet and colleagues demonstrated the effectiveness of a promotional program to reduce hospital infection rates and transmission of MRSA through emphasis on effective hand hygiene.

The program began in 1995 after a baseline survey of hand hygiene, and introduced an intensive publicity campaign, including bedside availability of chlorhexidine hand-rub solution. All health care workers were provided with a convenient, flat, pocket-sized container of chlorhexidine for personal use. Publicity materials, most prominently posters, were strategically displayed in more than 250 sites within the hospital. The content of the posters was individualized to each unit or ward location, and posters were changed regularly. Senior administrators and managers made the campaign an institutional priority and arranged for internal and external publicity.

Compliance was monitored through surveys and a systematic program of observation by infection-control nurses. Feedback was provided through newsletters distributed with pay slips. An additional measure of compliance was the actual number of handwashing and handrubbing episodes. The rate of nosocomial infections was monitored continuously on the basis of standardized routines that did not change during the study.

Results were based primarily on more than 20,000 observations of opportunities for hand hygiene. Overall compliance improved significantly, from 47.6 percent in 1994 to 66.2 percent in 1997. Simple handwashing rates remained nearly stable during this period, but there was a significant increase in the use of hand disinfectant. Although compliance differed, all areas improved, with the most significant gains occurring in the medical, surgical and intensive-care departments. The greatest compliance increases were achieved by nurses and nursing assistants. By the end of the study, these groups had from 70 to 80 percent compliance with hand hygiene guidelines. Physicians showed low rates of compliance with no significant gains over time. Physician compliance remained about 30 percent; however, physicians did exchange handwashing for disinfecting as their predominant hand hygiene method. Among other health care workers, compliance remained stable at about 40 percent. The prevalence of nosocomial infections decreased during the campaign from 16.9 percent in 1994 to 9.9 percent in 1998, and the incidence of MRSA decreased from 2.16 to 0.93 episodes per 10,000 patient-days. During the same time period, the calculated rate of hospital-acquired MRSA bacteremia decreased significantly, from 0.74 to 0.24 episodes per 10,000 patient-days.

The authors conclude that the program produced a measurable, sustained improvement in hand hygiene, but this improvement was limited largely to nursing staff. Nevertheless, the program was associated with a significant decrease in the incidence of nosocomial infections and MRSA transmission. They attribute the success of the program largely to the bedside availability of antiseptic hand rubs.

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