Effectiveness of Handwashing in Preventing Nosocomial Infections: A Systematic Review

1. Systematic Review on the Effectiveness of Handwashing-interim report- Hiroshi Ikai Stephanie Smith Allison McGeer Department of Infection Control, Mount Sinai Hospital

2. 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.

3. 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.

4. Objective • 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

5. 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)

6. 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 Methods (2): Search Terms 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

7. 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

8. 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

9. Search results

10. Variations of study design / results

11. Sample meta-analysis

12. 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%.

13. 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.