Effectiveness and Limitations of Hand Hygiene Promotion on Decreasing HealthcareAssociated Infections

Yee-Chun Chen,1,2,3,* Wang-Huei Sheng,1,2 Jann-Tay Wang,1,2 Shan-Chwen Chang,2,3 Hui-Chi Lin,2 Kuei-Lien Tien,2 Le-Yin Hsu,2 and Keh-Sung Tsai1,3 Author information Article notes Copyright and License information This article has been cited by other articles in PMC. Go to:

Abstract
Background
Limited data describe the sustained impact of hand hygiene programs (HHPs) implemented in teaching hospitals, where the burden of healthcare-associated infections (HAIs) is high. We use a quasi-experimental, before and after, study design with prospective hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs.

Methods and Findings

A 4-year hospital-wide HHP, with particular emphasis on using an alcohol-based hand rub, was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan. Compliance was measured by direct observation and the use of hand rub products. Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods. The economic impact was estimated based on a case-control study in Taiwan. We observed 8,420 opportunities for hand hygiene during the study period. Compliance improved from 43.3% in April 2004 to 95.6% in 2007 (p<.001), and was closely correlated with increased consumption of the alcohol-based hand rub (r = 0.9399). The disease severity score (Charlson comorbidity index)

increased (p = .002) during the intervention period. Nevertheless, we observed an 8.9% decrease in HAIs and a decline in the occurrence of bloodstream, methicillinresistant Staphylococcus aureus, extensively drug-resistant Acinetobacter baumannii, and intensive care unit infections. The intervention had no discernable impact on HAI rates in the hematology/oncology wards. The net benefit of the HHP was US$5,289,364, and the benefit-cost ratio was 23.7 with a 3% discount rate.

Conclusions

Implementation of a HHP reduces preventable HAIs and is cost effective. Go to:

Introduction
Healthcare-associated infections (HAIs) cause significant concern regarding the safety and quality of healthcare quality worldwide [1], [2]. The World Health Organization launched the World Alliance for Patient Safety in October 2004 [2]. HAIs have been identified as a fundamental priority, and were selected as the topic of the first Global Patient Safety Challenge. Hand hygiene was identified as the core component of this strategy because it is a simple, standardized, low-cost measure based on solid scientific evidence. The major barrier is poor compliance by healthcare providers, regardless of available resources [1][3]. Following the SARS epidemic in 2003, we reviewed the strengths and weaknesses of infection control strategies at the National Taiwan University Hospital in anticipation of other infectious diseases emerging [4], [5]. We decided to focus first on compliance with hand hygiene. An unannounced hand hygiene audit by infection control nurses was conducted of hospital wards in December 2003. We found that of the 226 opportunities presented, hospital staff washed their hands for only 16.6%. This finding led us to introduce alcohol-based hand rubs, and implement a hospital-wide program promoting hand hygiene through using alcohol-based hand rubs. Facing an increase in overall HAIs and infections caused by multidrug-resistant organisms [6], the goal of this initiative was to decrease HAIs by blocking the transmission of microorganisms via the hands of healthcare workers (HCW). We used a quasi-experimental, before and after, study design [7] with prospective hospital-wide surveillance of HAIs to assess the effectiveness of hand hygiene. We found that the sustained improvement of hand hygiene compliance reduces HAIs and is cost effective. Go to:

Methods
Hospital and study population
National Taiwan University Hospital (NTUH) is a 2,200-bed major teaching hospital in Taiwan that provides both primary and tertiary medical care. Approximately one third of the hospital's house staff on the floor are replaced each year. The distribution and time trends of HAIs and infection control programs during 1981 to 2007 have been described previously [6]. An antimicrobial stewardship program was not conducted during the study period.

Baseline evaluation

We conducted a baseline evaluation in December 2003 [8]. At that time, hands-free washing facilities with unmedicated liquid soap (not refilled) and paper towels were located in every room of the wards and by every intensive care unit (ICU) bed. However, alcohol-based hand rubs were unavailable. The baseline evaluation included direct observation of hand hygiene compliance by infection control nurses, a survey of knowledge and the reasons or factors affecting hand hygiene adherence using a structured, self-administered questionnaire, and suggestions to improve hand hygiene performance. Accordingly, we introduced accessible alcohol-based hand rubs to improve compliance.

Hospital-wide hand hygiene program

With substantial support from the hospital superintendent, the hospital-wide hand hygiene promotion program began in April 2004. A multidisciplinary approach involving cognition, equipment, and behavior was designed based on literature, the baseline evaluation, and the concept of total quality improvement [9]. Disposable alcohol-based hand rub sanitizers (75% isopropyl alcohol in plastic hand-compressing dispensers) (So Easy liquid, PBF, Taiwan) were wall mounted between every two beds in general wards, by each bed in special units (such as intensive care units), and affixed to trolleys (including treatment trolleys and resuscitation trolleys) to ensure accessibility near or at the point of care [2]. Promotion consisted of lectures and/or web-based self-learning with a post test, reminders located near points of care, use of hand hygiene compliance as a quality indicator, observation and verbal reminders by infection control nurses, periodic audits and performance feedback provided to units and departments, and incentives of US$160.00 for an outstanding performance (unit and department level). A fine of US$3.00 for compliance failures (individual level) was implemented in 2007 in highly specific situations, that is, individuals not modify their behavior even after face-to-face communication. The hand hygiene program was announced and promoted hospitalwide for one month every year while preparing for pandemic influenza (typically during November). The program was reviewed, revised, and promoted annually according to the plan-do-check-act cycle [8]. The target hand hygiene compliance rate was determined based on the performance in the preceding year.

Determination of hand hygiene compliance

Hand hygiene compliance was assessed by direct observation during day shifts (8 a.m. to 5 p.m.) on weekdays according to the U.S.A. CDC criteria [10], using a standardized case report form. Emergency procedures were excluded. Direct observation was performed by infection control nurses (ICN) after training and consensus development [11]. The site audit period was announced, though healthcare workers were not informed of the specific observation time. The hand hygiene compliance rates recorded for comparison between hospital services or between years were limited to the opportunities before and after patient contact to maintain consistency during the study period. Six surveys were conducted during the implementation period. To avoid the

Hawthorne effect [12], the duration and number of opportunities for hand hygiene monitoring were increased gradually for the six surveys (Fig. 1A). The annual consumption of liquid soap, antiseptics, and alcohol hand rub (product volume use per 1,000 patient-days) was used as a surrogate marker of hand hygiene over time.

Figure 1 Trends in compliance with the hand hygiene during 6 consecutive hospital-wide surveys conducted from May 2004 to December 2007.

Outcome assessment and data collection

We measured the overall HAI rates, HAI rates by site of infection, and HAI rates by selected pathogen to assess the effectiveness of HHP. We chose methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, and extensively drug-resistant A. baumannii (XDRAB) as marker organisms because our previous study showed a significant increase in HAI incidences, and outbreaks of these infections occurred during the study period [6]. Conversely, the incidences of HAIs by methicillin-susceptible S. aureus (MSSA) and Escherichia coli, which were chosen as control organisms, were relatively stable or decreased. Prospective, hospital-wide on-site surveillance of HAIs at NTUH began in 1981, and were conducted through weekly visits from full-time ICN to all patient units [6]. Data were collected on standardized data collection forms and inputted into the computer database manually. The severity of underlying diseases, comprising a maximum of six diseases, was scored using the Charlson comorbidity index [13]. The patient population, bed occupancy rate, age, gender, severity of underlying diseases, length of hospital stay, cumulative incidence of HAI, and outcome at discharge were determined during the preintervention (January 1999 to March 2004) and intervention (April 2004 to December 2007) periods.

Definitions
HAIs were classified according to definitions provided by the Centers for Disease Control and Prevention, U.S.A. [6], [14]. The cumulative incidence of HAIs was defined as episodes per 1,000 patient-days. Extensively drug-resistant A. baumannii (XDRAB) was defined as isolates that were resistant to five or more classes of antibacterial agents [6]. Compliance with hand hygiene is the ratio of the number of performed actions using correct technique to the number of opportunities [2], [11].

Statistical evaluation
To investigate the impact of the intervention on the levels and trends of cumulative HAI incidence over time, we adopted the generalized autoregressive Poisson regression analyses [15], [16]. This model autocorrelates the HAI cases in successive periods by

incorporating the autoregressive order j term and number of HAI cases at an earlier time t-j [17]. The factors considered by the model (see Text S1) include the levels and trends in the preintervention period, the changes in levels and trends during the intervention period, and autoregressive terms. Because the SARS epidemic occurred during the later part of the preintervention period (April 2003 to July 2003), an additional variable was added to the model to assess the effect of SARS. To account for possible seasonal and other event variations, such as the lengthy Chinese New Year holiday during January and February, the old guy effect during April and May, and the new staff effect during June to July, the model defined spring as March to May, summer as June to August, autumn as September to November, and winter as December to February. The analysis was further stratified by the site of infection, such as bloodstream, urinary tract, and surgical site infections, by the pathogens, such as MSSA, MRSA, Acinetobacter, XDRAB, and E. coli, and by ward units, such as ICUs, oncology wards, and hematology wards. Heterogeneity factors were calculated by dividing the deviance with the degrees of freedom, and used as an indicator to assess whether an extra-Poisson variation (overdispersion) was present. The difference in patient population during the two periods was examined using Student's t-test (continuous variables) and a chi-squared test (categorical variables). Time trends in the consumption of alcohol-based hand rubs, soap, and antiseptics were examined using simple linear regression. To investigate improvements to hand hygiene compliance during the six consecutive hospital-wide surveys, Pearson's chi-squared test for trend was performed. Correlation between hand hygiene compliance and the consumption of alcohol-based hand rubs, soap, and antiseptics, was examined using the Spearman method. All statistical tests were considered two-tailed and were significant at p<.05.

Economic evaluation
The relevant parameters used in the economic evaluation are shown in Table S2. The cost-effectiveness of the program was evaluated by calculating the extra cost required to prevent one episode of HAI from a hospital perspective. The number of expected episodes of HAI averted by the program was derived using the generalized autoregressive Poisson regression model. The costs considered in the analysis included alcohol-based hand hygiene products and promotional efforts (posters, wall displays, rewards, and other expenses) over the 4-year intervention period. The cost of personnel involved in the program (including planning, training, and auditing) was not considered in the base-case analysis (Table S2), because the program did not incur any increases in staff or manpower costs. However, the opportunity costs of personnel were considered in the sensitivity analysis by converting the number of working hours that infection control nurses spent on the program to their salary (Table S3). Cost-benefit analyses were also conducted to examine the net benefit and benefit-cost ratio of the program. The benefit was measured by subtracting the cost savings from the extra costs caused by HAIs, which was determined by a case-control study conducted in our hospital [18]. All future costs, number of HAI episodes, and benefits were discounted to the present value at an annual rate of 3% [19], [20]. One-way sensitivity analyses were

performed to explore the influence of the uncertainty of several parameters, such as discount rates, cost of alcohol hand rub, campaign expenses, extra cost per HAI episode, and the number of averted HAIs. The ranges used for the sensitivity analysis were a 50% increase or decrease to the base-case estimates of alcohol hand rub costs and campaign expenses, the twenty-fifth and seventy-fifth percentile of the estimated additional costs of each HAI episode, and a 95% confidence interval for the modelpredicted number of averted HAIs.

Ethics statement
We followed the principles expressed in the Declaration of Helsinki. This study was approved by the Institutional Ethics Review Board of the National Taiwan University Hospital (No. NTUH-200805033R). Go to:

Results
Patient population
The patient population characteristics during the preintervention and intervention periods are summarized in Table 1. During the intervention period, the total patient days (p = .004), mean Charlson comorbidity index (p = .002), and frequency of underlying illnesses, such as hematological malignancies and solid tumors ( p<.001), increased significantly.

Table 1 Characteristics of the Patient Population.

Hand hygiene compliance

During the six surveys conducted during the intervention period, 8,420 opportunities to observe hand hygiene were presented, as shown in Fig. 1A. Overall compliance improved from 43.3% in 2004 to 95.6% in 2007 (p<.001). Compliance improved significantly for all professional categories of HCW (p<.001), in both general wards and intensive care units (p<.001). We also observed an increased use of alcohol-based hand rubs (p = .001), liquid soap (p = .03), and antiseptics (p = 0.04), as shown in Fig. 1B. The overall improvement in hand hygiene compliance was significantly correlated with the increased consumption of alcohol-based hand rub (correlation coefficient r = 0.9399, p = .005), but less correlated with the

consumption of antiseptics (r 0.7686, p = .07).

0.7930, p

.06) and soap (r

Outcome assessment
The predicted monthly cumulative incidence of HAI using the full and most parsimonious segmented regression models are shown in Table S1. Before intervention, HAI increased gradually, and the impact of SARS and seasons were significant. After implementation of the hand hygiene program, the levels and trends of HAIs changed significantly (p = .02, p = .04, respectively), as shown in

Fig. 2A. Bloodstream (p<.001), urinary tract (trend, p = .03), and skin and soft tissue infections (trend, p<.001) decreased significantly. Additionally, though surgical site infections showed a downward trend, the incidence rate did not differ significantly. No significant changes in the respiratory tract and gastrointestinal tract infection rates were observed during the intervention. The time trends of HAI significantly decreased in ICUs (p<.001) during the intervention period, as shown in Fig. 2B; however, no significant changes in the HAI rates of oncology and hematological wards was noted, as shown in Fig. 2C.

Figure 2 Time trends of monthly cumulative incidences of overall healthcare-associated infection before (January 1999 to March 2004) and during the hand hygiene program (April 2004 through December 2007). The cumulative incidence of HAIs caused by MRSA, Acinetobacter, and XDRAB decreased substantially during the intervention period, as shown in Figs. 3A and 3B. This was associated with a decrease in the annual consumption of glycopeptides, antiPseudomonas fluoroquinolones, and carbapenems (data not shown). Finally, no significant change in the trends or levels of infections caused by MSSA and E. coli during the intervention period was observed, as shown in Fig. 3C.

Figure 3 Time trends of monthly cumulative incidences by pathogen.

Economic evaluation
The hand hygiene program was associated with an estimated reduction of 1,504 (95% confidence interval: 526 to 2,544) HAI episodes (8.9%) during the intervention period without discounting (Table 2). Results of the economic analysis with a 3% discount rate

are shown in Table 3. From a hospital perspective, the discounted additional cost of preventing one HAI episode was US$163.6. However, the net benefit of the hand hygiene program is US$5,289,364, which indicates that the benefits from savings to the additional costs of HAI could outweigh the program costs. The benefit-cost ratio shows that every US$1 spent on the program could result in a US$23.7 benefit. The results of one-way sensitivity analysis (Table S3) show that the cost of alcohol hand rub and the number of averted HAI episodes are the two factors influencing the additional cost of preventing one HAI episode; extra cost per HAI episode and the number of averted HAI episodes significantly impact the net benefit and benefit-cost ratio.

Table 2 Decrease in Healthcare-associated Infections and Cost Savings Attributed to the Hand Hygiene Program. Table 3 Results of Cost-effectiveness Analysis and Cost-benefit Analysis of the Hand Hygiene Programa. Go to:

Discussion
This study demonstrates that excellent compliance with hand hygiene by HCW was achieved and maintained over 4 years through an intensive hospital-wide program. The program was associated with significant decreasing trends for all HAIs and HAIs caused by MRSA and XDRAB, and was cost effective. However, we were unable to demonstrate a reduction in the HAIs of hematology and oncology services. We were also unable to demonstrate a reduction in HAIs caused by MSSA and E. coli. This result was unsurprising because of the relatively greater importance of endogenous infections in immune and structurally compromised hosts. To provide consistent care and protect patient safety throughout the hospital, a hand hygiene program requires multidisciplinary efforts and encompasses all hospital units. However, conducting a randomized, controlled trial in such a large and complex situation is difficult. According to a recent, comprehensive review of literature published as a Cochrane Review [21], the quality of intervention studies intended to increase hand hygiene compliance remains disappointing. We chose to superimpose the hand hygiene program on a well-established infection control program using standardized surveillance methods. This enabled us to determine the differences in HAI incidences over 4-year preintervention and postintervention periods, and conduct numerous observations while adjusting to changes in the frequency and severity of underlying diseases. We elected to use Poisson regression analysis with an interrupted time series [22], [23] to assess the efficacy of the hospital-wide hand hygiene intervention over time, and

determine whether factors other than the intervention could explain the change. In the interrupted time series, the level and trend of the preintervention segment served as the controls for the postintervention segment, providing a methodologically acceptable design for measuring the intervention effect [22], [23]. This method requires data of the continuous or counted outcome measures, summarized at regular, evenly spaced intervals. Thus, evaluation of the longitudinal effect of a hospital-wide hand hygiene program is only feasible in limited healthcare settings. Although evidence exists that improved adherence to hand hygiene is linked to reduced infection rates [24][26], other studies failed to report these effects [27][30]. In addition, the impact of hand hygiene improvement on HAI incidence varied [31], [32]. Several potentially confounding factors are relevant to this study. First, although direct observation is the criterion standard for measuring HH compliance, the method is subject to observation bias, selection bias, and the Hawthorne effect [2], [12], which may result in an overestimated HH rate. Second, the HH compliance rate was limited to the opportunities before and after patient contact to maintain consistency during the study period. Our recent survey demonstrated that the HH rate for 5 moments was only approximately 60%; whereas the HH rate for two moments exceeded 90% (unpublished data). Third, the hand hygiene programs in this study focused only on HCWs. Patients, patients' family, and other caregivers may contaminate the environment and/or transfer organisms. Fourth, not all HAIs of exogenous origin can be prevented by hand hygiene [33], [34]. Augmenting other infection control measures, such as multimodal implementation strategies (bundle care), environment cleanliness, appropriate use of antimicrobial agents, and active microbial surveillance of multidrug-resistant organisms is also necessary [33][38]. Finally, not all HAI were preventable. Our data failed to support the effects of HHP on decreasing HAIs among hemato-oncology patients and patients with infections caused by MSSA and E. coli. Endogenous infection may be reduced through improvements in host immunity. The economic impact of effective hand hygiene programs on decreasing HAIs was first evaluated by Pittet et al. [2], [24]. Pittet and colleagues [24] estimated the program costs to be less than US$57,000 per year for a 2,600-bed hospital, an average of US$1.42 per admitted patient. Supplementary costs associated with the increased use of alcoholbased hand rub averaged US$6.07 per 100 patient-days. Based on conservative estimates, US$100 was saved per averted infection. The economic evaluation in this study produced similar results. In addition, this study showed that the cost of alcohol hand rub and the number of averted HAI episodes are the two factors influencing the additional costs of preventing one HAI episode, which subsequently influences the net benefit and benefit-cost ratio. However, in the model used in this study, the cost of manpower was underestimated, and the indirect costs related to HAIs were not included. Several studies have demonstrated a temporal relationship between improved hand hygiene practices and a reduction in HAI incidence and multidrug resistant microorganisms [2], [25]; however, few have been able to sustain a lasting impact [2], [26]. Demonstrating to hospital administrators that these programs are cost-effective, relatively inexpensive, improve patient safety, and require long-term and stable investment is essential [2], [24]. This is particularly required by teaching hospitals where

the house staff and attending physicians change periodically [25]. Interest in pay-forperformance and other funding schemes is growing, which should further strengthen financial incentives to foster hand hygiene [39][41]. In conclusion, this study demonstrates that implementing a hospital-wide hand hygiene program is feasible. The program was associated with a reduction in the HAIs of most hospital units and HAIs caused by MRSA and XDRAB. This effect was achieved and confirmed using a before and after study design combined with a prospective HAI surveillance program and hospital-wide annual promotion, which resulted in sustained effects and high-quality HH observation. The costs of implementing the program were low compared to the costs saved by reducing the HAI incidence. The impact may be even greater with full adherence to the five moments for hand hygiene. However, hand hygiene programs are only one component of hospital infection control. They must be supplemented with measures directed at device-associated and endogenous infections in compromised hosts, and augmented by antimicrobial stewardship. Go to:

Supporting Information
Text S1 The generalized autoregressive Poisson model. (DOC) Click here for additional data file.(40K, doc) Table S1 Parameter estimates, standard errors and p values from the full and most parsimonious segmented regression models predicting monthly incidence density (episodes per 1000 patient-days) over time. (DOC) Click here for additional data file.(896K, doc) Table S2 Base-case estimates and ranges used in sensitivity analyses of parameters. (DOC) Click here for additional data file.(48K, doc)

Table S3 Results of one-way sensitivity analysis. (DOC) Click here for additional data file.(49K, doc) Go to:

Acknowledgments
We are grateful to members of the NTUH Center for Infection Control and Center for Quality Control for their support of the hand hygiene program and the hospital staff for their commitment to improve patient safety and reduce healthcare-associated infections. We appreciate members of the Biostatistics Laboratory of the College of Public Health, National Taiwan University, and Dr. Grace Hui-Min Wu for their assistance and suggestions regarding the statistical analysis; they received no compensation for their contribution. Additionally, the authors are grateful to Prof. Calvin Kunin and Prof. WeiChuan Hsieh for their suggestions and critical review of the manuscript. Go to:

Footnotes
Competing Interests: None of the authors declared a conflict of interest. Funding: Dr. Chen received grants (DOH96-DC-1010, DOH97-DC-1005) from the Center for Disease Control, Department of Health, and a grand (DOH99-TD-B-111-001) from the Department of Health, Taiwan. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Go to:

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Efektivitas dan Keterbatasan Promosi Kebersihan Tangan pada Penurunan KesehatanAssociated Infeksi Yee-Chun Chen, 1,2,3, * Wang Sheng-Huei, 1,2 Jann-Tay Wang, 1,2 Shan-Chwen Chang, 2,3 Hui Lin Chi-, 2 Kuei-Lien Tien, 2 Le- yin Hsu, 2 dan Keh-Sung Tsai1, 3 Penulis Informasi Pasal catatan Hak Cipta dan Lisensi Informasi Artikel ini telah dikutip oleh artikel lainnya di PMC. Pergi ke: Abstrak Latar belakang Data yang terbatas menggambarkan dampak berkelanjutan dari program kebersihan tangan (HHPs) dilaksanakan di rumah sakit pendidikan, di mana beban kesehatan terkait infeksi (hais) yang tinggi. Kami menggunakan kuasi-eksperimental, sebelum dan sesudah, belajar desain dengan calon rumah sakit-lebar pengawasan hais untuk menilai efektivitas biaya HHPs. Metode dan Temuan Sebuah rumah sakit-lebar 4-tahun HHP, dengan penekanan khusus pada menggunakan menggosok tangan berbasis alkohol, dilaksanakan pada bulan April 2004 di sebuah rumah sakit pendidikan 2.200 tempat tidur di Taiwan. Kepatuhan diukur dengan pengamatan langsung dan penggunaan produk menggosok tangan. Analisis regresi Poisson yang digunakan untuk mengevaluasi kepadatan dan kecenderungan hais selama preintervention ini (Januari 1999 sampai Maret 2004) dan intervensi (April 2004 sampai Desember 2007) periode. Dampak ekonomi diperkirakan berdasarkan pada studi kasus-kontrol di Taiwan. Kami mengamati 8.420 peluang untuk kebersihan tangan selama masa studi. Kepatuhan meningkat dari 43,3% pada April 2004 sampai 95,6% pada tahun 2007 (p <.001), dan berhubungan erat dengan peningkatan konsumsi menggosok tangan berbasis alkohol (r = 0,9399). Tingkat keparahan penyakit skor (Charlson indeks komorbiditas) meningkat (p = .002) selama periode intervensi. Namun demikian, kami mengamati penurunan 8,9% pada hais dan penurunan terjadinya aliran darah, methicillin-resistant Staphylococcus aureus, luas resistan terhadap obat Acinetobacter baumanii, dan infeksi perawatan intensif unit. Intervensi tidak berdampak pada tingkat discernable HAI di hematologi / onkologi bangsal. Manfaat bersih HHP adalah US $ 5.289.364, dan rasio manfaat-biaya adalah 23,7 dengan tingkat diskonto 3%. Kesimpulan Pelaksanaan HHP yang mengurangi hais dicegah dan biaya yang efektif. Pergi ke: Pengantar Kesehatan terkait infeksi (hais) menimbulkan keprihatinan yang signifikan mengenai keselamatan dan kualitas pelayanan kesehatan berkualitas di seluruh dunia [1], [2]. Organisasi Kesehatan Dunia meluncurkan Aliansi Dunia untuk Keselamatan Pasien pada Oktober 2004 [2]. Hais telah diidentifikasi sebagai prioritas mendasar, dan dipilih sebagai topik Challenge Patient Safety Global pertama. Kebersihan tangan diidentifikasi sebagai komponen inti dari strategi ini karena itu adalah sederhana, standar, murah ukuran berdasarkan bukti ilmiah yang kuat. Hambatan utama adalah kepatuhan miskin oleh penyedia layanan kesehatan, terlepas dari sumber daya yang tersedia [1] - [3]. Setelah wabah SARS pada tahun 2003, kami meninjau kekuatan dan kelemahan strategi pengendalian infeksi di National Taiwan University Hospital dalam mengantisipasi penyakit

menular lainnya yang muncul [4], [5]. Kami memutuskan untuk fokus pertama pada kepatuhan kebersihan tangan. Sebuah kebersihan Audit tangan tanpa pemberitahuan oleh perawat pengendalian infeksi dilakukan dari bangsal rumah sakit pada bulan Desember 2003. Kami menemukan bahwa dari 226 peluang yang disajikan, staf rumah sakit mencuci tangan mereka hanya 16,6%. Temuan ini mendorong kami untuk memperkenalkan berbasis alkohol Pembersih tangan, dan menerapkan program rumah sakit-lebar mempromosikan kebersihan tangan melalui menggunakan alkohol Pembersih tangan berdasar. Menghadapi peningkatan hais keseluruhan dan infeksi yang disebabkan oleh organisme-MDR [6], tujuan dari inisiatif ini adalah untuk mengurangi hais dengan menghalangi transmisi mikroorganisme melalui tangan para pekerja kesehatan (HCW). Kami menggunakan kuasieksperimental, sebelum dan sesudah, desain penelitian [7] dengan calon rumah sakit-lebar pengawasan hais untuk menilai efektivitas kebersihan tangan. Kami menemukan bahwa peningkatan berkelanjutan kepatuhan kebersihan tangan mengurangi hais dan biaya yang efektif. Pergi ke: Metode Rumah Sakit dan populasi penelitian National Taiwan University Hospital (NTUH) adalah 2.200 tempat tidur rumah sakit pendidikan utama di Taiwan yang menyediakan perawatan medis baik primer dan tersier. Sekitar sepertiga dari staf rumah sakit di lantai diganti setiap tahun. Kecenderungan distribusi dan waktu hais dan program pengendalian infeksi selama 1981-2007 telah dijelaskan sebelumnya [6]. Program pelayanan antimikroba tidak dilakukan selama masa studi. Dasar evaluasi Kami melakukan evaluasi awal pada Desember 2003 [8]. Pada saat itu, hands-free fasilitas mencuci dengan sabun cair tanpa pengobatan (tidak diisi ulang) dan handuk kertas yang terletak di setiap kamar bangsal dan oleh setiap unit perawatan intensif (ICU) tempat tidur. Namun, alkohol Pembersih tangan berdasar tidak tersedia. Evaluasi awal termasuk pengamatan langsung kepatuhan kebersihan tangan oleh perawat pengendalian infeksi, survei pengetahuan dan alasan atau faktor yang mempengaruhi kepatuhan kebersihan tangan menggunakan, terstruktur dikelola sendiri kuesioner, dan saran untuk meningkatkan kinerja kebersihan tangan. Oleh karena itu, kami memperkenalkan diakses berbasis alkohol Pembersih tangan untuk meningkatkan kepatuhan. Rumah sakit-lebar kebersihan tangan Program Dengan dukungan besar dari pengawas rumah sakit, rumah sakit-lebar kebersihan tangan program promosi dimulai pada bulan April 2004. Sebuah pendekatan multidisiplin yang melibatkan kognisi, peralatan, dan perilaku yang dirancang berdasarkan literatur, evaluasi awal, dan konsep peningkatan kualitas total [9]. Pembersih menggosok pakai alkohol berbasis tangan (75% isopropil alkohol dalam plastik tangan-mengompresi dispenser) (cairan Jadi Mudah, PBF, Taiwan) yang dinding terpasang antara setiap dua tempat tidur di bangsal umum, oleh setiap tempat tidur di unit khusus (seperti perawatan intensif unit), dan ditempelkan troli (termasuk perawatan troli dan resusitasi troli) untuk menjamin aksesibilitas dekat atau pada titik perawatan [2]. Promosi terdiri dari kuliah dan / atau berbasis web belajar mandiri dengan post test, pengingat terletak dekat tempat-tempat perawatan, penggunaan kepatuhan kebersihan tangan sebagai

indikator kualitas, observasi dan pengingat secara verbal oleh perawat pengendalian infeksi, audit berkala dan kinerja umpan balik yang diberikan untuk unit dan departemen, dan insentif dari US $ 160.00 untuk performa yang luar biasa (unit dan tingkat departemen). Denda US $ 3,00 untuk kegagalan kepatuhan (tingkat individu) dilaksanakan pada tahun 2007 dalam situasi yang sangat spesifik, yaitu, individu tidak mengubah perilaku mereka bahkan setelah tatap muka komunikasi. Program kebersihan tangan diumumkan dan dipromosikan di rumah sakitlebar untuk satu bulan setiap tahun sambil mempersiapkan pandemi influenza (biasanya selama bulan November). Program ini telah ditinjau, direvisi, dan dipromosikan setiap tahun sesuai dengan siklus rencana-do-check-bertindak [8]. Tangan Target kebersihan tingkat kepatuhan ditentukan berdasarkan kinerja pada tahun sebelumnya. Penentuan kepatuhan kebersihan tangan Tangan kepatuhan kebersihan dinilai dengan pengamatan langsung selama shift hari (08:005:00) pada hari kerja sesuai dengan kriteria CDC Amerika Serikat [10], dengan menggunakan formulir laporan kasus standar. Prosedur darurat dikeluarkan. Pengamatan langsung dilakukan oleh infeksi kontrol perawat (ICN) setelah pelatihan dan pengembangan konsensus [11]. Periode audit situs diumumkan, meskipun petugas kesehatan tidak diberitahu waktu pengamatan tertentu. Tingkat kepatuhan kebersihan tangan direkam untuk perbandingan antara layanan rumah sakit atau antara tahun terbatas pada kesempatan sebelum dan sesudah kontak dengan pasien untuk menjaga konsistensi selama masa studi. Enam survei dilakukan selama periode pelaksanaan. Untuk menghindari efek Hawthorne [12], durasi dan jumlah peluang untuk memantau kebersihan tangan meningkat secara bertahap untuk enam survei (Gambar 1A). Konsumsi tahunan sabun cair, antiseptik, dan alkohol gosok tangan (volume produk penggunaan per 1.000 pasien-hari) digunakan sebagai penanda pengganti dari kebersihan tangan dari waktu ke waktu. Gambar 1 Tren sesuai dengan kebersihan tangan selama 6 kali berturut-turut rumah sakit-lebar survei yang dilakukan dari bulan Mei 2004 sampai Desember 2007. Hasil penilaian dan pengumpulan data Kami mengukur tingkat HAI keseluruhan, tingkat HAI oleh situs infeksi, dan tingkat HAI oleh patogen dipilih untuk menilai efektivitas HHP. Kami memilih methicillin-resistant Staphylococcus aureus (MRSA), Acinetobacter, dan ekstensif resistan terhadap obat A. baumanii (XDRAB) sebagai organisme penanda karena penelitian kami sebelumnya menunjukkan peningkatan yang signifikan dalam insiden HAI, dan wabah infeksi ini terjadi selama masa studi [ 6]. Sebaliknya, insiden hais oleh methicillin-rentan S. aureus (MSSA) dan Escherichia coli, yang terpilih sebagai organisme kontrol, relatif stabil atau menurun. Calon, rumah sakit-lebar di tempat pengawasan hais di NTUH dimulai pada tahun 1981, dan dilakukan melalui kunjungan mingguan dari penuh-waktu ICN untuk semua unit pasien [6]. Data dikumpulkan pada bentuk pengumpulan data standar dan dimasukkan ke dalam database komputer secara manual. Tingkat keparahan penyakit yang mendasari, terdiri dari maksimal enam penyakit, yang mencetak gol dengan menggunakan indeks Charlson komorbiditas [13]. Populasi pasien, tempat tidur tingkat hunian, umur, jenis kelamin, tingkat keparahan penyakit yang mendasari, lama tinggal di rumah sakit, kejadian kumulatif HAI, dan hasil pada debit ditentukan selama preintervention (Januari 1999 sampai Maret 2004) dan intervensi (April 2004

sampai Desember 2007) periode. Definisi Hais diklasifikasikan menurut definisi yang diberikan oleh Pusat Pengendalian dan Pencegahan Penyakit, Amerika Serikat [6], [14]. Insiden kumulatif hais didefinisikan sebagai episode per 1.000 pasien-hari. Luas resistan terhadap obat A. baumanii (XDRAB) didefinisikan sebagai isolat yang resisten terhadap lima atau lebih kelas agen antibakteri [6]. Kepatuhan terhadap kebersihan tangan adalah rasio jumlah tindakan yang dilakukan dengan menggunakan teknik yang benar untuk jumlah peluang [2], [11]. Evaluasi statistik Untuk mengetahui dampak dari intervensi pada tingkat dan kecenderungan kejadian HAI kumulatif dari waktu ke waktu, kami mengadopsi autoregressive analisis regresi Poisson umum [15], [16]. Model ini autocorrelates kasus HAI di periode berturut-turut dengan memasukkan j jangka urutan autoregressive dan jumlah kasus HAI pada waktu sebelumnya tj [17]. Faktorfaktor yang dipertimbangkan oleh model (lihat S1 Text) meliputi tingkat dan tren pada periode preintervention, perubahan tingkat dan tren selama periode intervensi, dan istilah autoregressive. Karena epidemi SARS terjadi selama bagian akhir dari periode preintervention (April 2003 sampai Juli 2003), variabel tambahan ditambahkan ke model untuk menilai efek dari SARS. Untuk menjelaskan kemungkinan variasi musiman dan event lainnya, seperti liburan Tahun Baru Imlek panjang selama bulan Januari dan Februari, "orang tua" berlaku selama bulan April dan Mei, dan efek staf baru selama Juni sampai Juli, model semi didefinisikan sebagai Maret sampai Mei, musim panas sebagai Juni sampai Agustus, musim gugur bulan September hingga November, dan musim dingin bulan Desember sampai Februari. Analisis ini lebih lanjut dikelompokkan berdasarkan tempat infeksi, seperti aliran darah, saluran kemih, dan infeksi situs bedah, oleh patogen, seperti MSSA, MRSA, Acinetobacter, XDRAB, dan E. coli, dan oleh unit bangsal, seperti ICU , onkologi bangsal, dan bangsal hematologi. Heterogenitas faktor dihitung dengan membagi penyimpangan dengan derajat kebebasan, dan digunakan sebagai indikator untuk menilai apakah variasi ekstra-Poisson (overdispersion) hadir. Perbedaan populasi pasien selama dua periode telah diteliti dengan menggunakan Student ttest (variabel kontinyu) dan tes chi-kuadrat (variabel kategori). Waktu tren konsumsi alkohol berbasis menggosok tangan, sabun, dan antiseptik diperiksa menggunakan regresi linier sederhana. Untuk menyelidiki perbaikan kepatuhan kebersihan tangan selama enam berturutturut rumah sakit-lebar survei, chi-kuadrat uji Pearson untuk tren dilakukan. Korelasi antara kepatuhan kebersihan tangan dan konsumsi alkohol berbasis menggosok tangan, sabun, dan antiseptik, diperiksa dengan menggunakan metode Spearman. Semua uji statistik dianggap dua-ekor dan signifikan pada p <.05. Ekonomi Evaluasi Parameter yang relevan digunakan dalam evaluasi ekonomi ditunjukkan pada Tabel S2. Efektivitas biaya program dievaluasi dengan menghitung biaya tambahan yang diperlukan untuk mencegah satu episode HAI dari perspektif rumah sakit. Jumlah episode diharapkan HAI dihindari oleh program ini berasal menggunakan model regresi autoregressive umum Poisson. Biaya dipertimbangkan dalam analisis termasuk alkohol berbasis produk kebersihan tangan dan upaya promosi (poster, menampilkan dinding, penghargaan, dan biaya lainnya) selama periode intervensi 4 tahun. Biaya personil yang terlibat dalam program (termasuk perencanaan, pelatihan, dan audit) tidak dipertimbangkan dalam analisis kasus dasar (Tabel S2), karena

program tersebut tidak menimbulkan kenaikan biaya karyawan atau tenaga kerja. Namun, biaya kesempatan dari personel dipertimbangkan dalam analisis sensitivitas dengan mengubah jumlah jam kerja perawat bahwa infeksi kontrol dihabiskan untuk program untuk gaji mereka (Tabel S3). Analisis biaya-manfaat juga dilakukan untuk menguji keuntungan bersih dan keuntungan-biaya rasio program. Manfaat diukur dengan mengurangi penghematan biaya dari biaya tambahan yang disebabkan oleh hais, yang ditentukan oleh sebuah studi kasus-kontrol yang dilakukan di rumah sakit kami [18]. Semua biaya masa depan, jumlah episode HAI, dan manfaat yang didiskontokan ke nilai sekarang pada tingkat tahunan sebesar 3% [19], [20]. Satucara analisis sensitivitas dilakukan untuk menyelidiki pengaruh ketidakpastian beberapa parameter, seperti tingkat diskonto, biaya menggosok tangan beralkohol, biaya kampanye, biaya tambahan per episode HAI, dan jumlah hais dihindari. Rentang yang digunakan untuk analisis sensitivitas adalah kenaikan 50% atau penurunan ke basis-kasus perkiraan biaya menggosok tangan beralkohol dan biaya kampanye, persentil puluh lima dan tujuh puluh seperlima dari biaya tambahan estimasi setiap episode HAI, dan 95% confidence interval untuk model-prediksi jumlah hais dihindari. Etika Pernyataan Kami mengikuti prinsip-prinsip yang dinyatakan dalam Deklarasi Helsinki. Penelitian ini telah disetujui oleh Dewan Etika Kelembagaan Ulasan dari National Taiwan University Hospital (No NTUH-200805033R). Pergi ke: Hasil Pasien populasi Karakteristik populasi pasien selama preintervention dan periode intervensi diringkas dalam Tabel 1. Selama periode intervensi, hari total pasien (p = .004), berarti Charlson Indeks komorbiditas (p = .002), dan frekuensi penyakit yang mendasari, seperti keganasan hematologi dan tumor padat (p <.001), meningkat secara signifikan. Tabel 1 Karakteristik Penduduk Pasien. Kepatuhan kebersihan tangan Selama enam survei yang dilakukan selama periode intervensi, 8420 peluang untuk mengamati kebersihan tangan yang disajikan, seperti ditunjukkan pada Gambar. 1A. Kepatuhan keseluruhan meningkat dari 43,3% pada tahun 2004 menjadi 95,6% pada tahun 2007 (p <.001). Kepatuhan meningkat secara signifikan untuk semua kategori profesional LPK (p <.001), baik di bangsal umum dan unit perawatan intensif (p <.001). Kami juga mengamati peningkatan penggunaan alkohol Pembersih tangan berdasar (p = .001), sabun cair (p = .03), dan antiseptik (p = 0,04), seperti ditunjukkan pada Gambar. 1B. Peningkatan keseluruhan sesuai kebersihan tangan secara signifikan berkorelasi dengan peningkatan konsumsi alkohol berbasis menggosok tangan (koefisien korelasi r = 0,9399, p = .005), tetapi kurang berkorelasi dengan konsumsi antiseptik (r = 0,7930, p = .06 ) dan sabun (r = 0,7686, p = .07). Hasil penilaian Prediksi kejadian kumulatif bulanan HAI menggunakan model penuh dan paling pelit regresi tersegmentasi ditunjukkan pada Tabel S1. Sebelum intervensi, HAI meningkat secara bertahap, dan dampak SARS dan musim yang signifikan. Setelah pelaksanaan program kebersihan

tangan, tingkat dan kecenderungan hais berubah secara signifikan (p = .02, p = .04, masingmasing), seperti ditunjukkan pada Gambar. 2A. Aliran darah (p <.001), saluran kemih (trend, p = .03), dan infeksi kulit dan jaringan lunak (trend, p <.001) menurun secara signifikan. Selain itu, meskipun infeksi situs bedah menunjukkan tren menurun, tingkat kejadian tidak berbeda secara signifikan. Tidak ada perubahan signifikan dalam saluran pernapasan dan saluran pencernaan tingkat infeksi yang diamati selama intervensi. Tren waktu dari HAI menurun secara bermakna di ICU (p <.001) selama periode intervensi, seperti ditunjukkan pada Gambar. 2B, namun, tidak ada perubahan signifikan dalam tingkat HAI bangsal onkologi dan hematologi tercatat, seperti ditunjukkan pada Gambar. 2C. Gambar 2 Waktu tren insiden kumulatif bulanan keseluruhan kesehatan terkait infeksi sebelum (Januari 1999 sampai Maret 2004) dan selama program kebersihan tangan (April 2004 sampai Desember 2007). Insiden kumulatif hais disebabkan oleh MRSA, Acinetobacter, dan XDRAB menurun secara substansial selama periode intervensi, seperti yang ditunjukkan pada Gambar. 3A dan 3B. Hal ini terkait dengan penurunan konsumsi tahunan glycopeptides, anti-Pseudomonas fluoroquinolones, dan carbapenems (data tidak ditampilkan). Akhirnya, tidak ada perubahan signifikan dalam tren atau tingkat infeksi yang disebabkan oleh MSSA dan E. coli selama periode intervensi diamati, seperti ditunjukkan pada Gambar. 3C. Gambar 3 Waktu tren insiden kumulatif bulanan oleh patogen. Ekonomi Evaluasi Program kebersihan tangan dikaitkan dengan pengurangan diperkirakan 1.504 (95% confidence interval: 526 sampai 2.544) HAI episode (8,9%) selama periode intervensi tanpa diskon (Tabel 2). Hasil dari analisis ekonomi dengan tingkat diskonto 3% ditunjukkan pada Tabel 3. Dari perspektif rumah sakit, biaya tambahan diskon untuk mencegah satu episode HAI adalah US $ 163,6. Namun, keuntungan bersih dari program kebersihan tangan adalah US $ 5.289.364, yang menunjukkan bahwa manfaat dari tabungan untuk biaya tambahan HAI bisa lebih besar daripada biaya program. Rasio manfaat-biaya menunjukkan bahwa setiap US $ 1 yang dihabiskan pada program bisa menghasilkan keuntungan US $ 23,7. Hasil dari satu arah analisis sensitivitas (Tabel S3) menunjukkan bahwa biaya menggosok tangan beralkohol dan jumlah episode HAI dihindari adalah dua faktor yang mempengaruhi biaya tambahan mencegah satu episode HAI, biaya tambahan per episode HAI dan jumlah episode HAI dihindari secara signifikan berdampak pada keuntungan bersih dan keuntungan-biaya rasio. Tabel 2 Penurunan Kesehatan terkait Infeksi dan Tabungan Biaya dikaitkan dengan Program Kebersihan Tangan. Tabel 3 Hasil Analisis efektivitas biaya dan Biaya-manfaat Analisis Programa Kebersihan Tangan. Pergi ke:

Diskusi Studi ini menunjukkan bahwa kepatuhan kebersihan tangan dengan baik oleh LPK dicapai dan dipertahankan selama 4 tahun melalui program rumah sakit-lebar intensif. Program ini terkait dengan tren penurunan signifikan untuk semua hais hais dan yang disebabkan oleh MRSA dan XDRAB, dan biaya yang efektif. Namun, kami tidak dapat menunjukkan penurunan hais layanan hematologi dan onkologi. Kami juga tidak dapat menunjukkan penurunan hais disebabkan oleh MSSA dan E. coli. Hasil ini tidak mengherankan karena pentingnya relatif lebih besar dari infeksi endogen dalam host kekebalan tubuh dan struktural dikompromikan. Untuk memberikan perawatan yang konsisten dan melindungi keselamatan pasien di seluruh rumah sakit, program kebersihan tangan memerlukan upaya multidisiplin dan meliputi semua unit rumah sakit. Namun, melakukan uji coba, acak terkontrol dalam situasi yang besar dan kompleks sulit. Menurut review, baru-baru ini komprehensif literatur yang diterbitkan sebagai Cochrane Review [21], kualitas studi intervensi dimaksudkan untuk meningkatkan kepatuhan kebersihan tangan tetap mengecewakan. Kami memilih untuk superimpose program kebersihan tangan pada program mapan pengendalian infeksi menggunakan metode surveilans yang baku. Hal ini memungkinkan kita untuk menentukan perbedaan dalam insiden HAI lebih dari 4 tahun preintervention dan periode pasca-intervensi, dan melakukan sejumlah pengamatan sementara menyesuaikan diri dengan perubahan dalam frekuensi dan tingkat keparahan penyakit yang mendasari. Kami memilih untuk menggunakan analisis regresi Poisson dengan time series terganggu [22], [23] untuk menilai efektivitas intervensi kebersihan rumah sakit-lebar tangan dari waktu ke waktu, dan menentukan apakah faktor-faktor lain selain intervensi dapat menjelaskan perubahan. Dalam serial waktu terganggu, tingkat dan trend dari segmen preintervention menjabat sebagai kontrol untuk segmen postintervention, menyediakan desain metodologis diterima untuk mengukur efek intervensi [22], [23]. Metode ini memerlukan data dari ukuran hasil terus menerus atau dihitung, dirangkum pada teratur, interval merata spasi. Dengan demikian, evaluasi efek longitudinal program kebersihan rumah sakit-lebar tangan hanya layak dalam pengaturan kesehatan yang terbatas. Meskipun ada bukti bahwa kepatuhan ditingkatkan untuk kebersihan tangan terkait dengan tingkat infeksi berkurang [24] - [26], penelitian lain gagal untuk melaporkan efek [27] - [30]. Selain itu, dampak peningkatan kebersihan tangan pada insiden HAI bervariasi [31], [32]. Faktor pembaur Beberapa relevan dengan penelitian ini. Pertama, meskipun pengamatan langsung adalah standar kriteria untuk mengukur kepatuhan HH, metode ini dipengaruhi bias pengamatan, bias seleksi, dan efek Hawthorne [2], [12], yang dapat mengakibatkan tingkat HH berlebihan. Kedua, tingkat kepatuhan HH terbatas pada kesempatan sebelum dan sesudah kontak dengan pasien untuk menjaga konsistensi selama masa studi. Survei terbaru kami menunjukkan bahwa tingkat HH selama 5 saat itu hanya sekitar 60%, sedangkan tingkat HH untuk dua momen melebihi 90% (data tidak dipublikasikan). Ketiga, program kebersihan tangan dalam penelitian ini difokuskan hanya pada petugas kesehatan. Pasien, keluarga pasien, dan pengasuh lainnya dapat mencemari lingkungan dan / atau organisme transfer. Keempat, tidak semua hais asal eksogen dapat dicegah dengan kebersihan tangan [33], [34]. Dengan meningkatkan langkah-langkah pengendalian infeksi lainnya, seperti strategi implementasi multimodal (perawatan bundel), kebersihan lingkungan, penggunaan yang tepat dari agen antimikroba, dan pengawasan mikroba aktif multidrug-resistant organisme juga diperlukan [33] -

[38]. Akhirnya, tidak HAI semua itu dapat dicegah. Data kami gagal untuk mendukung efek HHP pada penurunan hais antara hemato-onkologi pasien dan pasien dengan infeksi yang disebabkan oleh MSSA dan E. coli. Infeksi endogen dapat dikurangi melalui peningkatan imunitas host. Dampak ekonomi dari program kebersihan tangan efektif pada hais penurunan pertama kali dievaluasi oleh Pittet et al. [2], [24]. Pittet dan rekan [24] memperkirakan biaya program menjadi kurang dari US $ 57.000 per tahun untuk rumah sakit 2.600 tempat tidur, rata-rata AS $ 1,42 per pasien mengaku. Tambahan biaya yang terkait dengan peningkatan penggunaan alkohol berbasis menggosok tangan rata-rata US $ 6,07 per 100 pasien-hari. Berdasarkan perkiraan konservatif, US $ 100 per diselamatkan infeksi dihindari. Evaluasi ekonomi dalam penelitian ini menghasilkan hasil yang sama. Selain itu, studi ini menunjukkan bahwa biaya menggosok tangan beralkohol dan jumlah episode HAI dihindari adalah dua faktor yang mempengaruhi biaya tambahan mencegah satu episode HAI, yang kemudian mempengaruhi keuntungan bersih dan keuntungan-biaya rasio. Namun, dalam model yang digunakan dalam penelitian ini, biaya tenaga kerja yang diremehkan, dan biaya tidak langsung yang berkaitan dengan hais tidak dimasukkan. Beberapa studi telah menunjukkan hubungan temporal antara praktik kebersihan tangan peningkatan dan penurunan kejadian HAI dan mikroorganisme resisten multidrug [2], [25], namun beberapa telah mampu mempertahankan dampak yang langgeng [2], [26]. Menunjukkan kepada administrator rumah sakit bahwa program ini biaya-efektif, relatif murah, meningkatkan keselamatan pasien, dan memerlukan investasi jangka panjang dan stabil sangat penting [2], [24]. Hal ini sangat dibutuhkan oleh rumah sakit pendidikan di mana staf rumah dan dokter menghadiri berubah secara berkala [25]. Bunga di bayar kinerja untukdan skema pendanaan lainnya berkembang, yang selanjutnya harus memperkuat insentif keuangan untuk mendorong kebersihan tangan [39] - [41]. Sebagai kesimpulan, penelitian ini menunjukkan bahwa pelaksanaan program rumah sakit-lebar kebersihan tangan layak. Program ini dikaitkan dengan penurunan dalam hais unit rumah sakit yang paling dan hais disebabkan oleh MRSA dan XDRAB. Efek ini dicapai dan dikonfirmasi menggunakan sebelum dan sesudah desain studi dikombinasikan dengan program surveilans HAI prospektif dan rumah sakit-lebar promosi tahunan, yang mengakibatkan efek berkelanjutan dan berkualitas tinggi pengamatan HH. Biaya pelaksanaan program ini rendah dibandingkan dengan biaya diselamatkan dengan mengurangi kejadian HAI. Dampaknya mungkin lebih besar dengan kepatuhan penuh terhadap lima momen untuk kebersihan tangan. Namun, tangan program kebersihan hanya salah satu komponen pengendalian infeksi rumah sakit. Mereka harus dilengkapi dengan langkah-langkah diarahkan pada infeksi perangkat-terkait dan endogen dalam host dikompromikan, dan ditambah dengan kepengurusan antimikroba. Pergi ke: Pendukung Informasi Teks S1 The autoregressive umum Poisson model. (DOC) Klik di sini untuk file data tambahan (40K, doc). Tabel S1 Parameter estimasi, kesalahan standar dan nilai-nilai p dari model penuh dan paling pelit regresi tersegmentasi memprediksi kepadatan kejadian bulanan (episode per 1000 pasien-hari)

dari waktu ke waktu. (DOC) Klik di sini untuk file data tambahan. (896K, doc) Tabel S2 Base-kasus perkiraan dan rentang yang digunakan dalam analisis sensitivitas parameter. (DOC) Klik di sini untuk file data tambahan. (48k, doc) Tabel S3 Hasil satu arah analisis sensitivitas. (DOC) Klik di sini untuk file data tambahan. (49K, doc) Pergi ke: Ucapan Terima Kasih Kami berterima kasih kepada para anggota dari Pusat Pengendalian Infeksi NTUH dan Pusat Pengendalian Mutu untuk dukungan mereka terhadap program kebersihan tangan dan staf rumah sakit untuk komitmen mereka untuk meningkatkan keselamatan pasien dan mengurangi infeksi kesehatan terkait. Kami menghargai anggota Laboratorium biostatistik dari College of Public Health, National Taiwan University, dan Dr Grace Hui-Min Wu atas bantuan dan saran mengenai analisis statistik, mereka tidak menerima kompensasi atas kontribusi mereka. Selain itu, penulis berterima kasih kepada Prof Calvin Kunin dan Prof Wei-Chuan Hsieh atas saran dan tinjauan kritis naskah. Pergi ke: Catatan kaki Minat Bersaing: Tak satu pun dari para penulis menyatakan konflik kepentingan. Pendanaan: Dr Chen menerima hibah (DOH96-DC-1010, DOH97-DC-1005) dari Pusat Pengendalian Penyakit, Departemen Kesehatan, dan besar (DOH99-TD-B-111-001) dari Departemen Kesehatan , Taiwan. The penyandang dana tidak memiliki peran dalam desain penelitian, pengumpulan data dan analisis, keputusan untuk mempublikasikan, atau penyusunan naskah. Pergi ke: Referensi 1. Burke JP. Pengendalian Infeksi - Sebuah masalah bagi keselamatan pasien. N Engl J Med. 2003; 348:651-656. [PubMed] 2. Organisasi Kesehatan Dunia. Pedoman WHO mengenai kebersihan tangan dalam perawatan kesehatan. 2009. Pertama pasien tantangan keamanan global: perawatan bersih adalah perawatan yang aman. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf. Diakses 5 Mei 2010. 3. Saint S, Howell JD, Krein SL. Implementasi Sains: Bagaimana untuk Langsung-Mulai Pencegahan Infeksi. Menginfeksi Kontrol Hosp Epidemiol. 2010, 31: S14-S17. [PMC bebas Artikel] [PubMed] 4. Chen YC, Chen PJ, Chang SC, Kao CL, Wang SH, et al. Pengendalian infeksi dan penularan SARS di kalangan pekerja kesehatan, Taiwan. Pgl Infect Dis. 2004; 10:895-898. [PMC bebas Artikel] [PubMed] 5. Chen YC, Huang LM, Chan CC, Su CP, Chang SC, et al. SARS di kamar rumah sakit

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