a patient [26], reduce risk factors for other HAI as well or increase HCWs’ awareness of the importance of infection prevention [108, 109]. Changing behaviour is most feasible when it occurs at a certain single timepoint, e.g. the insertion of a catheter or the hospital‐ or department‐wide choice for peptic ulcer prophylaxis. It is more challenging to change behaviour that needs to be repeated daily or more frequently, e.g. elevation of the head of the bed or, most notoriously, hand hygiene. 10.6 Effectiveness of hand hygiene compliance and hand hygiene in Dutch hospitals Poor HH in hospital wards enables transmission to all kinds of body parts and invasive devices, and good HH is therefore important. Hand hygiene needs to be performed at various indications and, when attending to hospitalised patients, repeatedly so. The link between suboptimal hand hygiene of one HCW (in a team) and the occurrence of HAI is more difficult to ascertain than the link between, for example, suboptimal CVC insertion and subsequent CRBSI. Additionally, personal perceptions involving cleanliness are varied and complex and frequent hand hygiene c competes for time with other HCW duties. Increasing knowledge on hand hygiene alone is therefore often not enough to change behaviour. Relatively few well‐powered studies have evaluated both HH compliance and HAI rates. Gould et al. concluded in a Cochrane review of HH interventions that the relationship between improved HH compliance and HAI reduction is not very certain [110]. Most recent studies, often evaluating a subset of HAI, have demonstrated positive results [111] [112], as did the PROHIBIT study. Other studies likewise found a reduction alongside a successful HH programme, but the initial HAI rates were relatively high [113], often limited to MRSA [114, 115] and ambiguous [115]. Eckmanns et al. evaluated transmission of pathogens by genotyping and found no correlation of the transmission rates with HH compliance (rather low in this setting) [116]. We conclude that there is evidence that increased HH compliance is associated with reduced HAI rates, but the evidence is not multifold for settings with relatively low HAI rates. Several model‐based investigations have sought a bottom level for HH, as mentioned in chapter 8. Recent studies conclude that no level apart from 100% is “good enough”, but these studies involved or assumed a setting with relatively high rate of baseline infection or introduction of MRSA or Acinetobacter baumanni, compared to Dutch settings [117‐121]. Mouajou et al concluded, based on a review of 35 papers, that HH and HAI had a negative relationship up to a compliance of approximately 60%[122]. Whether improving HH in a setting with relatively low HAI levels, such as Dutch hospitals, would further reduce the infection rates remains unclear, as already pointed out by Bonten et al. in 2014[123]. When only 14.5‐21.6% of nosocomial infections result 10 249 General Discussion
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