from patient‐to‐patient transmission (e.g. via HCW hands) as determined by Grundmann et al. in the ICUs of two German university hospitals [124], it is understandable that improved HH will not easily result in reduced HAI rates. Silvestri et al. also concluded that only 40% of all ICU‐acquired infections are influenced by HH, as 60% are caused by micro‐ organisms with which patients are already colonised at admission [125]. In the Dutch Accomplish study, HH compliance had no significant effect on overall HAI prevalence, despite the relatively high initial prevalence of 13.4‐14.2%, but perhaps the attained HH levels (35.9% in the intervention hospitals and 23.3% in the control hospitals) were still too modest [126]. What do we know about the level of HH adherence in other Dutch hospitals? As in many other countries HCWs and IP staff in the Netherlands have become weary of trying to increase HH [127] and improving HH, although regularly addressed in audits, is for many no longer a subject of scientific interest. There have, however, been a few recent studies. In the “Roll up your sleeves” study (“Handen uit de mouwen”), HCWs of 11 centres in greater Rotterdam measured HH and received feedback on compliance along with additional training elements [128]. HH compliance at the centres increased from 42.9% in 2014 to 51.4% in 2016 and 64.6% in 2019 [129]. In another intervention study in the same period, in a university hospital, the mean baseline compliance was 46% (33‐74% among various wards) and improved in some but not all wards [130]. Compliance was 33% in another university hospital, in 2012 [131]. In the earlier Helping Hands study, the attained HH levels were 46‐53% [132]. Based on these results one suspects that HH is far from perfect in many Dutch hospitals, although there could be a bias, as hospitals where HH is deemed satisfactory will be less inclined to start or continue a HH improvement programme. If the above‐mentioned compliance levels are indeed representative for other Dutch hospitals, there is certainly room for improvement. As observed in the evaluation of individual HH, both the nurse‐to‐patient ratio and work intensity are associated with individual performance (chapter 9). However, few published intervention programmes address work pressure. Hiring more HCWs is costly and difficult, given the present nurse shortages in the Netherlands and elsewhere, but it may be more effective than interventions that address HH knowledge or intentions. Additionally important and probably related is the patient safety culture in a particular hospital or unit. In 2005‐2007, HCWs from 45 hospitals who would later participate in the DHPSP completed a translated Hospital Survey on Patient Safety Culture from the Agency for Healthcare Research and Quality. In 2012, HCWs from 24 hospitals that had participated in the DHPSP also completed the Agency survey. The outcome measures included a self‐reported patient safety grade and the number of errors reported in the 250 Chapter 10
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