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Effect of a Multifaceted Intervention on

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Workers: A Cluster-Randomized Trial

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 infection control and hospital epidemiology november 2010, vol. 31, no. 11

original article

Effect of a Multifaceted Intervention on Adherence to Hand

Hygiene among Healthcare Workers: A Cluster-Randomized Trial

Dominik Mertz, MD; Nancy Dafoe, RN; Stephen D. Walter, PhD; Kevin Brazil, PhD; Mark Loeb, MD, MSc

objectives. Adherence to hand hygiene among healthcare workers (HCWs) is widely believed to be a key factor in reducing the spread
of healthcare-associated infection. The objective of this study was to evaluate the impact of a multifaceted intervention to increase rates
of adherence to hand hygiene among HCWs and to assess the effect on the incidence of hospital-acquired methicillin-resistant Staphylococcus
aureus (MRSA) colonization.
design. Cluster-randomized controlled trial.
setting. Thirty hospital units in 3 tertiary care hospitals in Hamilton, Ontario, Canada.
intervention. After a 3-month baseline period of data collection, 15 units were randomly assigned to the intervention arm (with
performance feedback, small-group teaching seminars, and posters) and 15 units to usual practice. Hand hygiene was observed during
randomly selected 15-minute periods on each unit, and the incidence of MRSA colonization was measured using weekly surveillance
specimens from June 2007 through May 2008.
results. We found that 3,812 (48.2%) of 7,901 opportunities for hand hygiene in the intervention group resulted in adherence, compared
with 3,205 (42.6%) of 7,526 opportunities in the control group (P ! .001 ; independent t test). There was no reduction in the incidence of
hospital-acquired MRSA colonization in the intervention group.
conclusion. Among HCWs in Ontario tertiary care hospitals, the rate of adherence to hand hygiene had a statistically significant
increase of 6% with a multifaceted intervention, but the incidence of MRSA colonization was not reduced.
Infect Control Hosp Epidemiol 2010; 31(11):1170-1176

Despite evidence that adherence to hand hygiene among
healthcare workers (HCWs) plays an important role in re-
ducing the rate of nosocomial infection,1-4 adherence remains
low.2,5 Factors such as skin irritation, inaccessible supplies,
forgetfulness, insufficient time, lack of positive models, and
perceived lack of evidence appear to be important reasons
for lack of adherence, whereas self-protection has been iden-
tified as the main motivating factor associated with
adherence.2,6-8
Among psychological theories to establish the basis of in-
terventions to change behavior of HCWs, the theory of
planned behavior and operant conditioning may be the most
important.9 Planned behavior suggests that poor hand hy-
giene is in part attributable to poor knowledge. This lack of
knowledge may be remedied by feedback in combination with
education.10 Operant conditioning suggests that performance
is mainly influenced by external stimuli and can be changed
by feedback, incentives, modeling, and external reinforcement.
Consequently, performance feedback may be a key com-
ponent of multifaceted interventions aiming to optimize ad-
herence by addressing both theories. Observational studies
corroborate this hypothesis: in a recently published systemat-
ic review,5 7 of 9 studies evaluating performance feedback
showed a positive effect,11-17 with 2 also reporting a decrease
in the incidence of methicillin-resistant Staphylococcus aureus
(MRSA) colonization.14,17 However, methodological and oth-
er limitations of many of these studies exist, including in-
complete ascertainment of events, the fact that more than
two-thirds of the studies took place in the intensive care
unit (ICU) setting and therefore limit generalizability, lack
of use of validated instruments, and use of inadequate con-
trol groups.5,18-20 To our knowledge, not one randomized con-
trolled trial of multifaceted interventions has been conducted.
We conducted a cluster-randomized trial of a multifaceted
intervention based on a performance feedback approach. We
hypothesized that the intervention would increase the ad-
herence to hand hygiene and in so doing would reduce the
incidence of hospital-acquired MRSA colonization.

From the Departments of Clinical Epidemiology and Biostatistics (D.M., S.D.W., K.B., M.L.), Pathology and Molecular Medicine (N.D., M.L.), and Medicine
(M.L.), and the Michael G. DeGroote Institute for Infectious Disease Research (D.M., M.L.), McMaster University, Hamilton, Ontario, Canada.
䉷 2010 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2010/3111-0011$15.00. DOI: 10.1086/656592
Received April 20, 2010; accepted May 19, 2010; electronically published October 4, 2010.

methods
Study Site
The study was conducted in 3 acute care sites of Hamilton
Health Sciences, a tertiary center with a catchment area pop-
ulation of 2.2 million residents in Ontario, Canada. All 30
hospital units (wards) serving adult patients were enrolled in
the study. The study units comprised 9 that provided intensive
care, 5 general medical, 3 oncologic and/or hematologic, 3
cardiac and/or vascular, 1 neurologic, 2 rehabilitation, 3 or-
thopedic, 2 general surgery, 1 surgery and/or trauma, and 1
spinal injury unit. With the exception of 2 ICUs, all ICUs
featured private rooms only (ICU rooms comprised 58 private
rooms, 14 two-bed rooms, and 1 four-bed room). On the
remaining units, 4 private rooms, 97 two-bed rooms, 12
three-bed rooms, 50 four-bed rooms, and 1 eight-bed room
were audited in the study. The study was approved by the
Research Ethics Board of Hamilton Health Sciences.
Outcomes
The primary outcome was adherence to hand hygiene, eval-
uated at the unit level. Two trained research assistants with
an excellent interrater reliability (k 1 0.9) audited adherence
to hand hygiene during 5 randomly selected 15-minute pe-
riods per week on each unit during an 8-hour time slot (7:
30 AM to 3:30 PM) in which the majority of clinical activity
occurred. The instrument to measure adherence was a mod-
ification of the Boyce hand hygiene monitoring tool,21 sup-
plemented by an extensive instruction manual. Similar to the
World Health Organization guidelines2 and the “My five mo-
ments for hand hygiene” concept,22 the following indications
were classified as opportunities to clean the hands: before and
after contact with a patient’s skin, wounds, or mucous
membrane or risk of contact with body fluids; before and
after care or insertion of an intravenous line or handling
similar devices; after contact with inanimate objects and pa-
tients’ gowns; and after removal of gloves. Hand hygiene
adherence before the first patient contact could not be ob-
served accurately and therefore was excluded from the list of
indications, because the observers were waiting outside the
patient rooms rather than following HCWs from patient to
patient. Therefore, it was unknown whether the HCWs
cleaned their hands after having left the previous room before
approaching the observed room. For reasons of privacy, the
auditors were not allowed to enter the patient rooms. There-
fore, the door was left ajar to permit observation of the HCW.
With time, the auditors became acquainted with the HCWs,
and it was inevitable that the HCWs became aware of being
observed.
An opportunity for hand hygiene referred to the period
during which a single hand hygiene action was deemed nec-
essary. If this opportunity consisted of more than 1 indication
for hand hygiene, the indication with the highest risk was
cluster-randomized trial on hand hygiene adherence 1171
recorded;23 for example, if an HCW had contact with the
patient’s skin and gown and administered medication
through an intravenous port afterwards, the indication at
highest risk (ie, the manipulation of the intravenous line) was
recorded. An opportunity was deemed successful if the HCW
rubbed his or her hands with an alcohol-based gel (70% ethyl
alcohol) or foam (62.5% ethyl alcohol) for at least 15 seconds
or washed hands with soap and water for at least 1 minute.
For each opportunity, the observer recorded if alcohol-based
gel use or hand washing was performed, if an opportunity
was missed, or if a potential opportunity could not be ob-
served (eg, because of an obstructed view).
The secondary outcome was the unit-specific incidence of
hospital-acquired MRSA colonization. Hospital acquisition
was defined as acquisition at least 72 hours after admission
in patients who had tested negative for MRSA on hospital
admission. Patients were screened within the first 72 hours
after admission and then biweekly until discharge. Swab sam-
ples were obtained by a registered nurse from the anterior
nares and rectally. If a patient was screened for MRSA as part
of a unit-wide point prevalence study initiated by infection
control staff within a week of the scheduled screening, no
additional screening for the purpose of the study was per-
formed. Furthermore, when results of routine screenings by
the infection control staff were available, they were used and
no additional screenings for the purpose of the study were
performed.
Not all rooms and beds on study units were included in
the study. Private rooms on regular units were excluded from
observations, because transmission of MRSA within single
rooms would be rare.
Study Design
In this cluster-randomized trial, the unit of allocation, in-
tervention, and analysis was at the level of hospital units.
After a 3-month assessment of the baseline hand hygiene
adherence, from October through December 2006, the trial
was conducted for 1 year, from June 2007 through May 2008.
Randomization of units was stratified by hospital site and
by type of hospital unit (ie, ICUs vs other units). The ran-
domization scheme was generated using a random numbers
table by a statistician who was not an investigator in this
study, and allocation was concealed from the study team upon
start of the study. The intervention and educational material
on the intervention units precluded blinding of the audited
HCWs and the data collectors.
Intervention
Clinical managers of the study units in both arms were in-
formed about the objectives and scope of the study. Alcohol-
based gel dispensers were installed outside all patient rooms
before the onset of the intervention throughout the hospital,
including in the control units. At least 1 hand-wash sink was
1172 infection control and hospital epidemiology november 2010, vol. 31, no. 11

available in each room. Therefore, hand-wash sinks and al-

cohol-based gel dispensers were equally available in the 2
groups. No further interventions took place in the control
group. On the intervention units, performance feedback,
small group teaching seminars, and distribution of posters
and pamphlets were initiated. At the first meetings with the
clinical managers and staff on the intervention units, the
objectives of the study, the study design, unit-specific baseline
rates of adherence, and general education about proper hand
hygiene were provided. Clinical managers were asked to de-
velop, along with the HCWs on their unit, a target adherence
level and were encouraged to create their own approaches to
bring awareness to hand hygiene. Later, meetings were held
biweekly to provide unit-specific feedback. The adherence
rates were shown on a large whiteboard both graphically and
numerically. After 6 months, a comparison with the rates of
other intervention units was provided. The intervention was
aimed at HCWs who were affiliated with a single unit and
who provided direct care; for example, registered nurses, figure 1. Flow chart showing the random assignment of 30 hos-
nursing assistants, environmental aides, and allied health pro- pital units in a study of the impact of a multifaceted intervention
fessionals (occupational and physical therapists). HCWs who to increase rates of adherence to hand hygiene among healthcare
workers and to assess the effect on the incidence of hospital-acquired
were affiliated with multiple units (eg, physicians) were ex-
methicillin-resistant Staphylococcus aureus colonization.
cluded to prevent contamination between the groups.

Statistical Analysis results

The unit of analysis for this study was at the level of the
clusters (ie, HCWs and patients at the hospital unit). The use
of clusters as the unit of analysis accounts for the fact that
the same individuals within the cluster may have contributed
repeatedly to the results over time. Unpaired t tests on the
annual unit-specific rates of hand hygiene adherence and
Mann-Whitney U tests for comparison of rates of MRSA
colonization were performed. A 2-sided P value of less than
.05 was considered to be statistically significant. Effect sizes
are presented with their 95% confidence intervals (CIs).
To estimate the required sample size for the study, an av-
erage of 35 observations for hand hygiene per week was as-
sumed for each of the 30 units, resulting in approximately
3,000 opportunities per cluster over 84 weeks. Assuming an
intracluster correlation coefficient of 0.05 (on the basis of
pilot data), this sample size would give 90% power to detect
a 20% increase in adherence to hand hygiene (from a baseline
value of 30% to a new value of 50%) at an a level of .05 (2-
sided). Assuming an average unit incidence rate of MRSA
colonization of 0.6 cases per 1,000 patient-days (on the basis
of 12 months of 2004 data, unpublished), a coefficient of
variation of 0.53, a 1-sided t test, and 60 person-years of
follow-up per cluster, this sample size would give 80% power
to detect a reduction in the incidence rate of MRSA colo-
nization from 0.6 to 0.35 cases per 1,000 patient-days. All
statistical analyses were performed using SPSS, version 17.0
(SPSS Inc).
The study was conducted over 12 months in all 30 random-
ized hospital units (Figure 1). No units were excluded.
During the baseline period, hand hygiene was observed for
3,400 opportunities. Rates of adherence were similar within
the 2 groups (15.8% and 15.9%, respectively) (Table 1). In
the study, hand hygiene was performed for 7,017 of 15,427
opportunities, yielding an adherence rate of 45.5% (Table 2).
A significantly higher adherence rate was observed in the
intervention group (mean difference, 6.3% [95% CI, 4.3%–
8.4%]; P ! .001) (Figure 2).
The results of tests on 8,034 swab samples collected spe-
cifically for the purpose of the study plus the results of 130
unit-wide point prevalence surveys and of routine MRSA
screenings by infection control staff were available. Hospital-
acquired MRSA colonization was identified in 110 patients
(53 in the control group and 57 in the intervention group).
There was no significant difference in the incidence of MRSA
colonization between the study groups (mean in the inter-
vention group, 0.73 cases per 1,000 patient-days, vs mean in
the control group, 0.66 cases per 1,000 patient-days; median
in both groups, 0 cases per 1,000 patient-days; P p .919)
(Figure 3). Exclusion of outbreak periods from the analysis
(eg, January–February and July in the intervention group and
May in the control group) made only a small difference in
these results. As an additional sensitivity analysis, the unit-
specific standard deviations (SDs) of the 12 monthly MRSA
incidences were calculated, and monthly incidence rates
higher than 2 of these SDs were excluded as potential out-
 cluster-randomized trial on hand hygiene adherence 1173

table 1. Baseline Rates of Hand Hygiene Adherence among Healthcare Workers in a Study of the Impact of a
Multifaceted Intervention to Increase Rates of Hand Hygiene Adherence
Intervention group Control group
No. of opportunities No. of opportunities
Variable Rate, % observed Rate, % observed
Overall 15.8 1,749 15.9 1,651
By individual unit, identifier
ICUs
1 11.5 130 13.8 145
2 15.2 125 18.5 124
3 20.3 143 23.8 164
4 24.5 184 26.1 69
5 29.8 47 29.0 131
Other units
6 7.4 148 3.6 84
7 9.8 92 9.7 113
8 11.0 127 10.1 109
9 11.3 80 10.6 104
10 11.5 104 12.7 118
11 13.7 161 13.0 54
12 14.4 90 13.3 83
13 15.5 116 14.7 116
14 20.0 100 16.4 110
15 26.5 102 16.5 127
note. The intervention group had 15 units, of which 5 were intensive care units (ICUs) (including 1 burn unit), and 315 fixed
beds. The control group had 15 units, of which 5 were ICUs, and 317 fixed beds.

breaks24 (exclusion of 20 data points in the control group
and 21 data points in the intervention group). After exclusion
of suspected outbreaks, the MRSA colonization incidence
rates of 0.30 and 0.31 cases per 1,000 patient-days for the
intervention group and the control group, respectively, were
again very similar (median in both groups, 0; P p .967).
Notably, the best adherence rates were found after wound
and skin contact (Table 2). The main differences in adherence
rates between groups were found after contact with patients’
gown and contact with inanimate objects. In general, the
adherence rates were much lower before than after patient
contact.

table 2. Rates of Hand Hygiene Adherence among Healthcare Workers in a Study of the Impact of a Multifaceted Intervention
to Increase Rates of Hand Hygiene Adherence
Intervention group Control group
No. of opportunities No. of opportunities
Variable Rate, % observed Rate, % observed
At baseline 15.8 1,749 15.9 1,651
Triala
Overall 48.2 7,901 42.6 7,526
After skin contact 71.8 1,217 70.1 1,172
After contact with patient’s gown 71.3 773 62.3 664
After contact with inanimate objects 36.7 4,132 30.5 3,904
After care of intravenous line 50.8 661 48.2 635
After contact with body fluids 56.0 134 53.4 116
After contact with mucous membranes 47.3 419 46.0 441
After insertion of intravenous line 50.8 661 48.2 635
After wound contact 77.2 57 76.6 64
Before care of intravenous line 8.0 50 4.6 65
Before contact with body fluids 0.0 32 0.0 37
Before contact with mucous membranes 4.9 61 1.1 87
Before insertion of intravenous line 0.0 10 9.1 11
Before wound contact 5.3 19 0.0 26
note. The incidence of hospital-acquired methicillin-resistant Staphylococcus aureus colonization was 0.73 cases per 1,000 patient-days for the
intervention group and 0.66 cases per 1,000 patient-days for the control group.
a
The unweighted mean adherence rate for the t test was 41.8% in the control group and 48.1% in the intervention group.
1174 infection control and hospital epidemiology november 2010, vol. 31, no. 11

figure 2. Monthly mean rates of adherence to hand hygiene in the control group and the intervention group.

In most cases, alcohol-based hand rub was preferred by
the HCWs over hand washing (the percentage of cleansing
events that used alcohol-based hand rub was 77% in the
intervention group and 78% in the control group). In con-
trast, hand disinfection was used during the baseline period
in only 39% of cleansing events in the intervention group
and 44% of cleansing events in the control group.
discussion
We found that a multifaceted intervention based on perfor-
mance feedback significantly increased the rate of hand hy-
giene among HCWs. Despite this increase, no difference in
MRSA colonization incidence was found.
thorne effect).25-27 This effect is expected to diminish over
time.28 Furthermore, hand rub dispensers were installed after
the baseline assessment and before the onset of the inter-
vention, potentially resulting in an increase in rates of ad-
herence in both groups.29-32 We have defined hand washing
to be appropriate if performed for at least 60 seconds. This
strict definition may be a reason for the comparably low ad-
herence rate at baseline, because of the higher likelihood
of hand washing rather than hand disinfection at baseline,

Hand Hygiene Adherence

The rate of adherence to hand hygiene was significantly bet-
ter in the intervention than in the control group (48.2%
vs 42.6%). However, the difference was modest, and impor-
tantly, there was an increase in the rate of adherence from
baseline in the control group, which may be due to several
factors, including contamination between groups, the Haw-
thorne effect, or hospital-wide installation of alcohol-based
hand rub dispensers.
To minimize the effects of contamination between the
study groups, we adopted a cluster-randomized trial, rather
than randomly assigning HCWs individually. However, it is
likely that knowledge about the trial was spread to the control
units, resulting in contamination between the groups. HCWs figure 3. Monthly incidence of hospital-acquired methicillin-
in the control group may have increased adherence because resistant Staphylococcus aureus (MRSA) colonization per 1,000 pa-
they were aware that they were being observed (ie, the Haw- tient-days.

compared with the likelihood in the intervention period.
However, contamination remains a likely reason for the in-
crease in the control group, and we suggest that future studies
randomly assign entire hospitals as clusters, rather than hos-
pital units, because contamination across units within hos-
pitals probably cannot be avoided.
The adherence rates in both groups were much lower if
an opportunity for hand hygiene was deemed necessary be-
fore tasks on the patient rather than afterward, as reported
previously.5 This may be explained by the notion that the
HCWs’ main motivation for hand hygiene is to protect them-
selves rather than the patients.6
Incidence of Hospital-Acquired MRSA Colonization
Despite screening patients every 2 weeks,31 we did not observe
a difference in the incidence of hospital-acquired MRSA col-
onization. This was not unexpected, given the modest dif-
ference in the rates of hand hygiene adherence between
groups. Our findings are in keeping with data suggesting that
the higher the baseline hand hygiene adherence rate, the
greater the relative increase in adherence needed to have an
effect on MRSA colonization incidence.33 Sensitivity analyses
redefining hospital-acquired MRSA colonization as coloni-
zation newly detected 5 or 10 days after admission instead
of 3 days after admission did not change the result (data not
shown); neither did the exclusion of suspected MRSA infec-
tion outbreaks. With the exception of 1 documented MRSA
infection outbreak taking place in January and February, the
monthly fluctuations of the MRSA colonization rates may
have been due to the low number of cases rather than due
to small MRSA infection outbreaks.
Our finding of no reduction in rates of hospital-acquired
MRSA colonization is in contrast to a recently published
review34 in which the majority of observational studies
showed an effect of increased rates of hand hygiene on the
rate of healthcare-associated infections. However, the re-
ported increase in rates of adherence among these studies
was larger than the increase we observed. Moreover, most
studies were restricted to the ICU environment or to other
selected hospital units. In 1 study that had an outcome similar
to ours, rates of hand hygiene adherence increased and MRSA
cross-transmission decreased.31 In a study by MacDonald et
al,17 a reduction in the number of MRSA colonization cases
occurred despite the absence of an increase in rates of hand
hygiene adherence. The study by MacDonald et al17 and our
study suggest that the relationship between rates of adherence
to hand hygiene and MRSA colonization rates is not a simple
one and that many other factors are involved.
Despite the attempt to encourage the staff, there was little
active participation. The HCWs seemed to be overwhelmed
because of staff shortages and their work loads. Therefore,
the actual impact of the intervention was based on the per-
formance feedback itself, the educational meetings, and the
posters and pamphlets provided by the study team as well as
cluster-randomized trial on hand hygiene adherence 1175
on external enforcement. One may hypothesize that the in-
tervention would have been more successful if the HCWs had
had more time and capacities to implement their own strat-
egies to increase rates of adherence to hand hygiene. If one
assumes that the modest increase in adherence rates and the
lack of improvement in MRSA colonization rates were real
and not the consequence of contamination of information,
the resources needed for such an intervention cannot be jus-
tified by the achieved results beyond the study.
Strengths of this study included use of a randomized de-
sign, high reliability for hand hygiene observations, and com-
prehensive and standardized screening for hospital-acquired
MRSA colonization. One limitation was that the study was
limited to HCWs who usually work on only a single hospital
unit. However, it is likely that the major limitation is that
the possibility of contamination of control units was under-
estimated, and probably hospitals rather than hospital units
should be randomly assigned to avoid contamination. Pre-
sumably, the HCWs discussed our intervention across units
more extensively than we expected. A further limitation is
the fact that only pooled unit-specific feedback was provided
to the HCWs, which may have resulted in the opportunity
to attribute nonadherent episodes to other HCWs on their
unit, overestimating their own hand hygiene performance. It
is possible that individual feedback would have increased the
improvement in rates of adherence. Because it was not feasible
to observe all HCWs and all patient contacts over 1 year,
theoretically a single HCW per unit that did not adhere to
hand hygiene could be responsible for the spread of MRSA
and for nullifying the effect of better hand hygiene adherence
performed by the other HCWs. Because of lack of feasibility,
the majority of private rooms were excluded from the au-
diting, which may have influenced the results. However, the
same HCWs were caring for patients in private rooms, and
we are not aware of any evidence that performance of hand
hygiene by the same HCWs is worse in private rooms than
in other rooms. A further limitation is the fact that swab
samples for MRSA testing were obtained only every second
week and not systematically before discharge of each patient,
which may have resulted in a misclassification bias.
In conclusion, we observed a significant increase in the
hand hygiene adherence rate in this hospital-wide, cluster-
randomized trial to evaluate the impact of a multifaceted in-
tervention based on a performance feedback approach. De-
spite a statistically significant increase in hand hygiene rates,
there was no decrease in rates of nosocomial acquisition of
MRSA colonization.
acknowledgments
We thank the 2 auditors, Vanessa Manning and Christina Pattison, for the
more than 15,000 observations they performed during the trial.
Financial support. Physicians’ Services Incorporated Foundation of On-
tario, Canada; Swiss National Science Foundation (grant PBBSP3–124436 to
D.M.).
1176 infection control and hospital epidemiology november 2010, vol. 31, no. 11
Potential conflicts of interest. All authors report no conflicts of interest
relevant to this article.
Address reprint requests to Mark Loeb, MD, MSc, Departments of Pa-
thology and Molecular Medicine and Clinical Epidemiology and Biostatistics,
McMaster University, MDCL 3203, 1200 Main Street W, Hamilton, ON, L8N
3Z5, Canada (loebm@mcmaster.ca).
Presented in part: 20th European Congress of Clinical Microbiology and
Infectious Diseases; Vienna, Austria; April 2010 (Abstract O-466).
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