Clinical governance is important for providing safe care to patients and is essential to continuous improvement in patient safety.(vicgov) One of the key components in relation to this safety and quality issue in health care is preventing and controlling healthcare associated infections(HAI) which plays a significant role in poor outcomes of patients.(sahealth) To prevent transmission of HAI, Hand Hygiene should be done which is one of the most effective ways. Clinical professionals, especially nurses who have high risk of HAI transmission to patients, need to review the effects and great importance of Hand Hygiene to minimize the risk of HAI. Also, study tells that a number of infections can be prevented by adherence to established infection control practices.(sahealth) However, when accessing articles, they need to know the review methods such as a systematic review and randomized control trial, to satisfy evidence based practice with having analysing skills for quality resources. Five articles were reviewed to practice this.


Larson et al did research to examine the impact of the new practice Guideline on HAI and this compared the infection rates of pre- and post-Guideline implementation in a sample of US hospitals in different time. The problem is the result can be affected by time. Some components, such as how surveillance is conducted, how infections are defined and other concurrent infection prevention activities over time, might play a significant role in the result. Also, there were no control groups in this research so that the outcome of this research cannot be compared with the control group’s infection rates in the same time of post-Guideline implementation. And there was only 2 days observation which is unlikely to be an accurate reflection of practice.

Monistrol et al used no control group as well. And Hand Hygiene compliance, the consumption of alcohol-based hand rub (AHR), HAIs and MRSA hospital acquisition incidence were measured. Hand Hygiene compliance was measured by direct observation of health care workers during daily work routine. Observations covered all the 8 hour shifts on weekdays, which is more acceptable than Larson et al’s only 2 days observation. However, infection control nurses undertook the observers and also part of the educator. This could explain the high Hand Hygiene compliance in all periods due to the presence of observers.

Meanwhile, Allegranzi et al assessed the effectiveness of the World Health Organization hand hygiene improvement strategy in a low-income African country, evaluating hand hygiene infrastructure, compliance, healthcare workers’ knowledge and perceptions, and handrub consumption.

The ideal design for these researches would be Randomized Clinical Trial (RCT), because the research outcomes can be compared by control groups for more exact data in a same time. However, those cannot be done properly with RCT and this is the reason why they did not choose RCT for the research strategy. Once the new practice Guideline is published, the control groups will be informed as well. And this might withhold best practices from patients, raising ethical concerns.

The most rigorous study among those three articles was Allegranzi et al’s research. To examine the effectiveness of WHO’s hand hygiene improvement strategy, they prepared well with training the observers for a long time according to the WHO observation method. And for the baseline evaluation and follow-up evaluation WHO knowledge questionnaire was administered. Also, more scientific and specific categories such as hand hygiene infrastructure and healthcare workers’ level of knowledge were shown in this research than others.

Stout et al and Melissa et al reviewed articles by using a systematic review. In regards to the search strategy, Stout et al searched only PubMed for relevant articles. While Melissa et al searched MEDLINE, EMBASE, CINAHL, HMIC, the Web of Science and the Cochrane Library databases. There is evidence that single electronic database searches lack sensitivity and relevant articles may be missed if only one database is searched(Akobeng 2005). Meanwhile, Stout et al evaluated and reviewed 3,463 articles published between January 1, 2000 and March 31 2013. Forty two articles were selected and grouped into 1 of 4 categories after quality assessment of articles. Also, the earliest year of 2000 was selected because alcohol-based hand rub was not widely in use in prior years. This is a quite scientific strategy. While, there was no specific reason for Melissa et al to pick the articles between May and November 2004, as well as there was no mention about quality assessment of studies.

A systematic review was selected for these articles to examine primary studies on focused clinical questions so that specific answers from narrowly defined review questions were given.

Findings & Conclusion

The result of Larson et al indicates that hand hygiene guideline was disseminated and hospitals responded by modifying procedures and policies, compliance with hand hygiene recommendations remained low. Similarly, Monistrol et al suggested that no changes in incidences of HAI were shown after the multimodal campaign. However, Allegranzi et al found that hand hygiene improvement is affordable and effective in a healthcare setting with limited resources. The difference between



Author/s, year country




Main Findings

Strength/limitations of the study
1 Stout, Ritchie & Macpherson



To improve compliance with hand hygiene guidelines, resulting in low incidence of HAI. Search strategy with combined terms of ‘handwashing’, ‘alcohol cleanser’, ‘infection’, or ‘compliance’

Date or language limitation were applied.

A systematic review: MEDLINE, EMBASE, CINAHL, HMIC, the Web of Science and the Cochrane Library databases between May and November 2004
2 Melissa et al



To assess the existing evidence surrounding the adoption and accuracy of automated systems or electronically enhanced direct observations and also reviews the effectiveness of such systems in health care settings.
3 Allegranzi et al



To assess the feasibility and effectiveness of the World Health Organization hand hygiene improvement strategy in a low-income African country. University Hospital, Bamako, Mali Introducing a locally produced, alcohol-based handrub; monitoring hand hygiene compliance; providing performance feedback; educating staff; posting reminders in the workplace; and promoting an institutional safety climate according to the World Health Organization multimodal hand hygiene improvement strategy. Compliance increased from 8.0% at baseline to 21.8% at follow-up
4 Larson, Quiros& Lin



To evaluate implementation and compliance with clinical practices recommended in the new Centers for Disease Control and Prevention(CDC) Hand Hygiene Guideline

To compare rates of HAI before and after implementation of the guideline recommendations

To examine the patterns and correlates of changes in rates of HAI

Survey for 89.8% of 1359 staff members

Hospitals that were members of The National Nosocomial Infections Surveillance System

Quantitative study during 2001 – 2004, Hand Hygiene Guideline implementation and compliance measures: the introduction of the guideline within the hospital; the presence of the recommended products on clinical units; institutional policies and procedures regarding hand hygiene, includeing the presence of a formalized plan to monitor compliance.

Measure of HAI pre- and post-Guideline: collecting data regarding HAI rates in the ICUs of study hospitals for 12 months before and 12 months following publication of the Hand Hygiene Guideline.

Hand hygiene compliance: ranged from 24% to 89% per ICU

None of the pre to post-rates of change were associated with hospital characteristics.

Assessment of hand hygiene compliance was based on just 2 days of observation
5 Monistrol et al



To evaluate the effectiveness of a multimodal intervention in medical wards in relation to hand hygiene compliance, alcohol-based hand rub consumption and incidence of HAI and MRSA. 825 patients and 868 patients totally in the pre and post period respectively. Conducted at three internal medical wards(113 beds) in Hospital Universitari Mutua Terrassa, Spain Quantitative: Prospective study during 2007 – 2009. Carried out in four phases: a baseline phase(10 weeks from February 2007), an intervention period(5 months from June 2007), a post intervention(10 weeks from November 2007) and follow-up evaluation(November 2009) Hand hygiene compliance improved from 54.3% in the pre period to 75.8% in the post period.

Alcohol-based hand rub consumption increased from 10.5 to 27.2L per 1000 patient-days.

The incidence density of HAI ranged from 6.93 to 6.96 per 1000 hospital days and new Healthcare Associated MRSA went down from 0.92 to 0.25 per 1000 hospital-days.

Strengths: conducted in general medical wards with the long-term follow-up

Limitations: no control group was used; no group session, compliance observation or surveillance of HAIs was carried out outside the studied area

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