Major article
Impact of hand hygiene on the infectious risk in nursing home residents: A systematic review

https://doi.org/10.1016/j.ajic.2015.05.043Get rights and content

Highlights

  • We review 56 studies dealing with hand hygiene and infections in nursing homes.

  • The number and methodologic quality of studies on this issue increase with time.

  • Overall, 63% of studies suggest that hand hygiene helps control the infectious risk.

  • Only 25% of randomized trials conclude in favor of hand hygiene interventions.

  • More evidence is needed.

Background

In nursing homes, the infectious risk is high, making infection control using approaches such as hand hygiene (HH) a major issue. However, the effectiveness of HH in these settings is not well documented, and HH compliance is low.

Methods

We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for studies in nursing homes that either described a HH-related intervention or assessed HH compliance and included a measured infectious outcome. Two reviewers independently performed the study selection.

Results

Fifty-six studies met the inclusion criteria and were reviewed. Most were outbreak reports (39%), followed by observational studies (23%), controlled trials (23%), and before-after intervention studies (14%). Thirty-five studies (63%) reported results in favor of HH on at least one of their outcome measures; in addition, the infection control success rate was higher when at least one HH-related intervention (eg, staff education on HH, increased availability of handrub solution) was included (70% vs 30% for no intervention). However, only 25% of randomized trials concluded that HH-related interventions led to a reduction in the infectious risk.

Conclusion

The results of this systematic review suggest that more evidence on HH effectiveness in nursing homes is needed. Future interventional studies should enhance methodologic rigor using clearly defined outcome measures, standardized reporting of findings, and a relevant HH observation tool.

Section snippets

Methods

Our systematic review was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement.9 We systematically searched PubMed, Scopus, Web of Science, and Cochrane Clinical Trials for articles published through April 1, 2015. The search strategy was developed using key words, standardized key words, and Medical Subject Headings terms, depending on the database. Search terms for hygiene and long-term facilities were combined with search terms for health care settings

Study selection

The database search retrieved 790 unique articles, to which we added 8 additional articles identified through other means, such as reference lists. These 798 articles were independently assessed by 2 reviewers (M.N.H. and L.T.) based on the inclusion and exclusion criteria. After the initial round of independent reviews, the 2 reviewers discussed their findings. In case of disagreement regarding the inclusion of a specific study, each reviewer provided the rationale for their conclusion, and a

Discussion

Fifty-six studies were included in this systematic review, evaluating a total of 22 outbreak reports, 13 observational studies, 8 before-after-intervention studies, 8 randomized trials, and 5 nonrandomized trials. Although our analysis suggests that interventions based on HH may help control the infectious risk in nursing home settings, it also demonstrates that the precise impact of HH on infectious outcomes remains poorly documented. In particular, the proportion of studies in favor of HH

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      Despite their effectiveness,20,21 adoption of proper HH practices among HCWs is still grossly insufficient, generally ranging from 30% to 50%.8,22–25 In NHs specifically, HH has a major role in infection prevention,26,27 leading to up to 80% decrease of respiratory infections and influenza (80%), 76% for infections caused by gram-positive bacteria, and 44% for infections caused by gram-negative bacteria.29,28 Formal policies for monitoring staff compliance are often lacking.

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      To prevent and control the infection in nursing home, several measures including surveillance, hand hygiene, isolation precautions, education, and antibiotic stewardship are developed. Among these intervention, hand hygiene is the essential and the most important infection control measure in nursing homes.1,4 In a France study,5 the implementation a bundle of hand hygiene-related measures in nursing home over one years was associated with significantly lower mortality (2.10 vs 2.65 per 100 residents per month, respectively; P = 0.003) and antibiotic prescriptions (5.0 vs 5.8 defined daily doses per 100 resident days, respectively; P < 0.001).

    • Impact of a multicomponent hand hygiene–related intervention on the infectious risk in nursing homes: A cluster randomized trial

      2018, American Journal of Infection Control
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      In this randomized controlled trial, a multifaceted HH intervention was associated with a short-term decreased mortality in NHs, but not with morbidity. Based on a recent review, there are very few randomized trials on HH in NHs.15 However, another trial was performed in France in 2010.23

    • Infection Control in Alternative Health Care Settings: An Update

      2016, Infectious Disease Clinics of North America
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      HH remains the most effective and least expensive measure to prevent transmission of pathogenic organisms in health care settings. Despite calls from numerous local, national, and international organizations and infection prevention societies, compliance with HH remains dismal, averaging only 30% to 50%.19–26 Reasons frequently reported for poor compliance with HH measures by HCWs include skin irritation from frequent washing, too little time due to a high workload, and simply forgetting.

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    Conflicts of interest: None to report.

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