Characteristics of the study hospitals
Among the 40 study hospitals, 75% were in the eastern region of the United States, and 60% were affiliated with an academic health center. The mean number of active beds of participating hospitals was 417, with 10% having 100 to 199 beds, 40% having 200 to 399 beds, and 50% having ≥400 beds. There were 71 ICUs in the study hospitals, including 30 medical-surgical (42%), 18 medical (25%), 13 surgical (18%), and 10 pediatrics (14%). Most infection control directors (85%) had ≥9 years of experience.
Hand Hygiene Guideline implementation and hand hygiene compliance
The Guideline Implementation scores ranged from 7 to 12 (median, 10.5). In hospitals in which the infection control director had <9 years of infection control experience, only 16.7% had implementation scores above the median (P = .18). Information about the Guideline was widely disseminated: in all hospitals surveyed, the Guideline had been discussed at staff meetings and infection control meetings (as confirmed by meeting minutes), included in staff educational programs (as confirmed by continuing education records), and 89.7% of 1158 staff members who were anonymously surveyed confirmed that they were familiar with the Guideline. Appropriate supplies and products were readily available on all patient care units observed, and every hospital had a written policy prohibiting artificial nails. However, in 44.2% of the hospitals (19/40), there was no evidence that the Guideline recommendation to “implement multidisciplinary program to improve compliance” was in place.
Generally, educational efforts were targeted to nursing and ancillary personnel, and physician staff members did not participate. Furthermore, the majority of hospitals had no effective way to monitor hand hygiene compliance. The observed hand hygiene compliance rates ranged from 24% to 89% (mean, 56.6%) per ICU. None of the hospital characteristics examined were associated with Guideline implementation scores or observed compliance rates ().
Association between hospital characteristics and Guideline implementation score and hand hygiene compliance rates
HAI rates pre- and post-Guideline and correlates of changes
CL-BSI and VAP rates were significantly lower after implementation of the Guideline; the VAP rate decreased from 6.2 per 1000 device-days prior to the release of the Guideline to 4.8 per 1000 device-days (P < .001), and the CL-BSI rate decreased from 5.5 to 4.8 per 1000 device-days (P < .001), . There were no significant differences in rates of CA-UTI or SSI following Guideline implementation. When stratified by implementation status (high vs low), however, the significant reductions in CL-BSI and VAP were observed among hospitals with both high and low implementation scores. SSI rates were significantly lower after Guideline implementation only in hospitals with low implementation scores (P = .04) but not in hospitals with high scores, .
Rates of health care-associated infections before and after Guideline implementation
Rates of HAI stratified by level of Guideline implementation
When stratified by hand hygiene compliance status, a significant reduction in VAP was observed among hospitals with both high and low compliance rates. However, rates of CL-BSI were decreased significantly among hospitals with high compliance rates (from 6.3 to 4.8 per 1000 device-days, P < .001) but not among hospitals with low compliance rates (from 4.9 to 4.7 per 1000 device-days, P = .74). Again, SSI rates were reduced significantly from 1.1 to 0.9 per 1000 patient-days in the low hand hygiene compliance hospitals (P = .02) but not in the high compliance hospitals, .
Rates of HAI stratified by hand hygiene compliance
There were no changes reported by the directors of infection control in patient acuity in any hospital, but 17 of 40 (42.5%) hospitals reported some type of policy change (eg, written antibiotic policy) during the course of the study. There were no significant correlations between hospitals reporting policy changes or not and any HAI rate (all P > .29). Therefore, this variable was not included in the regression models.
Overall, the majority of hospitals had lower rates of infection control following Guideline implementation: 55.6% for CL-BSI, 55.6% for CA-UTI, 63.1% for VAP, and 64.5% for SSI, but none of the pre- to post-rates of change were associated with hospital characteristics except for CA-UTI: 76.2% of hospitals affiliated with an academic health center had reduced rates as compared with 26.7% of hospitals not affiliated with an academic health center (P = .006), . That association remained significant after controlling in the logistic regression model for geographic location, bed size, and rates of hand hygiene.
Relationship between infection rates after Guideline implementation and demographic variables