Effectiveness of bundled behavioural interventions to control healthcare-associated infections: a systematic review of the literature

Summary

Attempts to address the growing problem of healthcare-associated infections (HAIs) and their impact on healthcare systems have historically relied on infection control policies that recommend good hygiene through standard and enhanced precautions (e.g. barrier precautions and patient isolation). In order for infection control strategies to be effective, however, healthcare workers' behaviour must be congruent with these policies. The purposes of this systematic review were to evaluate studies testing the effectiveness of interventions aimed at changing healthcare workers' behaviour (in reducing HAIs) and to summarize the findings of the studies with the highest quality scores. A total of 33 published studies met the inclusion criteria and were evaluated. Four of these earned a study quality score of ≥80%. In all four significant reductions in HAI or colonization rates were reported. Behavioural interventions used in these high quality studies included an educational programme (in four), the formation of a multi-disciplinary quality improvement team (three), compliance monitoring and feedback (two), and a mandate to sign a hand hygiene requirement statement (one). In all 33 studies, bundles of two to five interventions were employed, making it difficult to determine the effectiveness of individual interventions. The usefulness of ‘care bundling’ has recently been recognized and recommended by the Institute for Healthcare Improvement. Considering the multi-factorial nature of the HAI problem and the logistical and ethical difficulties of applying the randomized clinical trial approach to infection control research, it may be necessary to study interventions as sets of practices.

Introduction

Healthcare-associated infections (HAIs) are a serious and growing problem at every level of the healthcare system. HAIs are associated with an increased attributable mortality, length of stay, and healthcare costs incurred by patients, insurers and healthcare facilities.¹ A growing proportion of HAIs are attributed to multiple-drug-resistant organisms (MDROs); for example, 60–70% of Staphylococcus aureus strains isolated among inpatients in many countries are resistant to meticillin and often several other first-line antibiotics.²

Strategies for tackling the growing problem of HAIs have historically relied on infection control policies that recommend good hygiene through standard precautions and enhanced precautions such as isolation for patients infected with an MDRO. For these interventions to be effective, provider behaviour must be uniformly congruent with the institutional policies. Additionally, there is lack of consensus among different guidelines for the recommended use of barrier precautions and isolation leading to a lack of clear standards for care, which may further increase the variability of provider behaviour in a single institution.

Our group recently conducted a systematic review of the literature evaluating the effectiveness of barrier precautions, patient isolation, and use of surveillance cultures. We noted an intriguing difference in the findings of three studies evaluating the effectiveness of glove use alone compared with glove and gown use.³ In the two studies that found no difference in infection rates between the two groups, the glove and gown use was monitored and a compliance rate of 50–80% was reported.4, 5 In contrast, no monitoring or compliance rates were reported in another study in which a decrease in infection rates was found.⁶ With high compliance, gloves alone appeared as effective as gloves and gowns. This observation raised the question as to whether the findings from studies assessing the impact of barrier precautions could be attributed to lack of efficacy (i.e. they don't work) or lack of effectiveness (i.e. they might work, but are not actually performed properly). Moreover, what is the impact of behavioural interventions to improve awareness and compliance with barrier precautions on rates of MDROs and other HAIs? Despite the publication of several recent reviews of infection control practices aimed at reducing HAIs, the impact of behavioural interventions has not been specifically summarized.7, 8 The purposes of this systematic literature review were to identify studies in which behavioural interventions to reduce HAI were evaluated, to assess the quality of these studies, to summarize the findings of the studies with the highest quality scores, and to make recommendations for future investigation.