(1.3 [1.2–1.5]; p<0.0001), and from 78% to 96% (6.0 [5.5–6.6]; p<0.0001), respectively. The CVC insertion score per quarter improved already during baseline (OR 1.05 [1.02– 1.09]). When adjusting for the possible underlying hospital‐specific trends and taking into account an intervention‐specific trend, the odds ratios for the CVCi‐, HHi‐, and COMBi arms were 2.6 (2.2–3.0), 1.1 (0.6–1.3), and 3.4 (2.9–4.0), respectively. The improvement per quarter increased after the introduction of the intervention in the CVCi and COMBi arms (average additional OR 1.2 (1.1–1.5) and 1.5 (1.3–1.8), respectively), but did not change significantly in the HHi arm (OR 0.95 [0.9–1.1]). Increasing CVC insertion scores were significantly associated with decreasing CRBSI incidence density: the incidence rate ratio (95% CI) per percentage point (PP) increase of the CVC score over the entire study was 0.97 (0.96–0.98). After adjustment for the proportions of patients with bloodstream infection at the time of insertion and of patients with prolonged ICU stay before insertion, this association remained significant with an incidence rate ratio of 0.97 (0.96–0.98) for the entire population, and for both the CVCi and COMBi arm; however, the adjusted association was not significant in the HHi arm) (Supp. Table 6). Hand hygiene compliance A total of 59,122 hand hygiene opportunities were observed during 6,749 observation sessions. Nurses were the main contributors (74.4%), followed by medical doctors (14.5%), auxiliaries (8.8%), and other healthcare professionals (2.3%). Overall hand hygiene compliance at baseline averaged 49%. Between baseline and intervention period, hand hygiene compliance in the CVCi‐, HHi‐ and COMBi arms improved from 51% (50–52%) to 62% (61–63%; p < 0.0001), from 36% (34–37%) to 58% (57–59%; p < 0.0001), and from 54% (52–55%) to 63% (62–64%; p<0.0001), respectively (Fig. 2, individual hospital data in Supp. Fig. 4). During baseline, hand hygiene compliance decreased by ‐1 [‐2– ‐0.05] percentage points (PPs) per quarter. When adjusted for healthcare professional category, ICU type and activity index, improvement of hand hygiene compliance in the CVCi‐, HHi‐, and COMBi arms was 6 PP (4–8 PP), 20 PP (18–22 PP), and 8 PP (7–10 PP), respectively. When adjusted for underlying hospital‐specific trends and taking into account an intervention‐specific trend, improvement of hand hygiene compliance in the CVCi‐, HHi‐, and COMBi arms was 10 PP (6–14 PP), 18 PP (15–22 PP) and 6 PP (3–9 PP), respectively. Hand hygiene compliance improved in all four healthcare professional categories in the HHi‐ and COMBi arms, while hand hygiene compliance in the CVCi arm improved only in nurses (Supp. Table 7). HH compliance by indication is displayed in Supp.Table 8.
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