Advertisement

Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

Open AccessPublished:September 08, 2022DOI:https://doi.org/10.1016/j.jhin.2022.08.013

      Summary

      Background

      Direct observation of hand hygiene compliance is the gold standard despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance among physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

      Aim

      To explore differences in compliance between physicians and nurses further, and to determine whether compliance estimates differed when observations were covert rather than overt.

      Methods

      A systematic search of databases PubMed, Embase, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

      Findings

      The weighted pooled compliance rate for nurses was 52% (95% CI: 47–57) and for doctors was 45% (95% CI: 40–49%). Heterogeneity was considerable (I2 = 99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%; 95% CI for the difference: 0.8–13.5; P = 0.027) and covert (difference of 7%; 95% CI: 3–11; P = 0.0002) observation. Considerable heterogeneity was found in all analyses.

      Conclusion

      Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.

      Keywords

      Introduction

      Hand hygiene in the healthcare setting has been shown to reduce the incidence of healthcare-associated infections (HAIs) [
      World Health Organization
      Evidence of hand hygiene to reduce transmission and infections by multidrug resistant organisms in health-care settings 2014.
      ]. Despite guidelines for their prevention, HAIs remain a widespread challenge, and are associated with prolonged hospital admission, increased financial cost and excess mortality [
      World Health Organization
      Report on the burden of endemic health care-associated infection worldwide.
      ]. The SARS-CoV-2 pandemic has highlighted the need for renewed focus on the fundamentals of infection control including hand hygiene.
      In May 2009, the World Health Organization (WHO) published guidelines on hand hygiene in healthcare, outlining ‘five moments for hand hygiene’ [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ]. These five moments are: (1) before touching a patient, (2) before clean/aseptic procedure, (3) after body fluid exposure, (4) after touching a patient, and (5) after touching patient surroundings. Methods for observing hand hygiene include direct methods (e.g. direct observation or self-reported compliance) and indirect methods (e.g. automated monitoring or product consumption). As the only method that can assess hand hygiene at all moments, direct observation of hand hygiene compliance is currently recommended as the ‘gold standard’. However, direct observation is not without limitations. Potential areas of bias include observation bias, observer bias, and selection bias, with previous reviews highlighting bias in hand hygiene compliance monitoring [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ,
      • Haas J.P.
      • Larson E.L.
      Measurement of compliance with hand hygiene.
      ,
      • Jeanes A.
      • Coen P.G.
      • Gould D.J.
      • Drey N.S.
      Validity of hand hygiene compliance measurement by observation: a systematic review.
      ].
      Observation bias, induced by the presence of an observer influencing participant behaviour, is a widely cited source of bias in hand hygiene research and termed the Hawthorne effect [
      • Chen L.F.
      • Vander Weg M.W.
      • Hofmann D.A.
      • Reisinger H.S.
      The Hawthorne effect in infection prevention and epidemiology.
      ,
      • Roethlisberger F.J.
      • Dickson W.J.
      Management and the worker.
      ]. Recent work by Purssell et al. attempted to quantify the Hawthorne effect by analysing nine studies comparing covert with overt measurement and concluded that occasional covert monitoring may give a better estimate of hand hygiene compliance [
      • Purssell E.
      • Drey N.
      • Chudleigh J.
      • Creedon S.
      • Gould D.J.
      The Hawthorne effect on adherence to hand hygiene in patient care.
      ].
      Observer bias may result from systematic error introduced by inter-observer variation in recording observations. Appropriate validation of observers is recommended to minimize this bias [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ]. It has also been suggested that unit-based observers may introduce bias into compliance estimates, and that peers could be biased in their compliance estimates towards non-peers [
      • Haas J.P.
      • Larson E.L.
      Measurement of compliance with hand hygiene.
      ,
      • Dhar S.
      • Tansek R.
      • Toftey E.A.
      • Dziekan B.A.
      • Chevalier T.C.
      • Bohlinger C.G.
      • et al.
      Observer bias in hand hygiene compliance reporting.
      ]. Selection bias may arise because groups of participants differ in ways other than the intervention or exposure of interest or may differ systematically from the population of interest and are not representative. In studies of observation of hand hygiene, this bias may arise when the selection of participants is not random [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ].
      A previous systematic review in 2010 on studies using direct observation or self-reported compliance found that compliance is lower among physicians than among nurses, and lower before rather than after patient contact [
      • Erasmus V.
      • Daha T.J.
      • Brug J.
      • Richardus J.H.
      • Behrendt M.D.
      • Vos M.C.
      • et al.
      Systematic review of studies on compliance with hand hygiene guidelines in hospital care.
      ]. However, the impact of overt and covert observation on hand hygiene compliance estimates among physicians and nurses is unclear. In addition, the WHO ‘five moments for hand hygiene’ are now recommended for compliance estimates rather than before and after contact [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ]. An up-to-date review of the literature is needed to explore compliance among physicians and nurses using direct observation, and whether differences in compliance are also seen when observations are covert rather than overt. Finally, the review seeks to determine whether observation by peers impacts on compliance estimates, and if poorer compliance by physicians is seen at all opportunities for hand hygiene as per the WHO ‘five moments’ or at specific opportunities.

      Objectives

      The primary and secondary questions that the review seeks to address are: (1) How do levels of compliance by direct observation of hand hygiene compare between physicians and nurses? (2) Are there differences between physicians and nurses in compliance rates measured by overt and covert observation? (3) Are there differences between physicians and nurses in compliance rates measured by different types of observers (e.g. nurses, physicians, infection control personnel, etc.)?; (4) Are there differences between physicians and nurses in compliance as per the WHO ‘five moments for hand hygiene’?

      Methods

      This review is reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • Boutron I.
      • Hoffmann T.C.
      • Mulrow C.D.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      ].

      Registration and protocol

      The review protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO) database under the following registration number: CRD42021253106.
      Protocol amended on June 2nd, 2021 at title and abstract screening: Addition of reviewer (D.O.D.). Inclusion criteria updated to include high-income countries only (as defined by World Bank 2021). Protocol amended on June 16th, 2021 at full text screening: Addition to planned data extraction of observer category, and to strategy for data synthesis to analyse whether differences in compliance estimates by different observers. Protocol amended on July 24th, 2021: Change to risk-of-bias tools to RoB2 for cluster-randomized trials and JBI checklist for quasi-experimental studies for non-randomized studies of interventions.

      Eligibility criteria

      Studies were included if meeting the following eligibility criteria: healthcare worker population; an experimental or observational study design; compliance quantitatively measured by direct observation either overt or covert; specifies individual compliance estimates for both nurses and physicians; hospital setting; conducted in a high-income country as defined by the World Bank 2021 [

      World Bank. World Bank country and lending groups. Washington DC: World Bank; n.d. Available at: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups [last accessed June 2021].

      ]; published in English; published from 2010 onwards.
      Studies were excluded if: non-healthcare worker population; self-reported compliance; compliance measured by indirect methods (e.g. electronic monitoring or soap/alcohol-based hand rub (ABHR) usage); individual compliance estimates for both physicians and nurses not specified; surgical handwashing as relates to a different technique; non-hospital setting; conducted in a low- or middle-income country (LMIC) as defined by the World Bank 2021 [

      World Bank. World Bank country and lending groups. Washington DC: World Bank; n.d. Available at: https://datahelpdesk.worldbank.org/knowledgebase/articles/906519-world-bank-country-and-lending-groups [last accessed June 2021].

      ]; not published in English; published prior to 2010; articles without original data; conference abstracts or posters.
      Studies from LMICs were excluded due to significant challenges and barriers to hand hygiene compliance (e.g. water or ABHR availability) that may create large variation in compliance estimates [
      • World Health Organization and the United Nations Children’s Fund
      WaSH in health care facilities: global baseline report 2019.
      ]. Studies from 2010 onwards were included to reflect theoretical methodological changes in assessing hand hygiene compliance following the WHO guidelines on hand hygiene in healthcare [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ]. Study designs included were experimental or quasi-experimental (randomized controlled trials (RCTs), before–after studies and interrupted time series) and observational studies (cohort and cross-sectional) as potentially providing valid evidence for the review question.

      Information sources and search strategy

      A comprehensive search was conducted on PubMed, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), and CINAHL (EBSCOhost) databases for relevant literature on April 26th, 2021. A library information specialist and the Peer Review of Electronic Search Strategies (PRESS) checklist were consulted to refine the search strategy [
      • McGowan J.
      • Sampson M.
      • Salzwedel D.M.
      • Cogo E.
      • Foerster V.
      • Lefebvre C.
      PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement.
      ]. The search strategy was validated by checking whether it could retrieve a set of eligible key studies [
      • El-Saed A.
      • Noushad S.
      • Tannous E.
      • Abdirizak F.
      • Arabi Y.
      • Al Azzam S.
      • et al.
      Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia.
      ,
      • Hagel S.
      • Reischke J.
      • Kesselmeier M.
      • Winning J.
      • Gastmeier P.
      • Brunkhorst F.M.
      • et al.
      Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
      ,
      • Kovacs-Litman A.
      • Wong K.
      • Shojania K.G.
      • Callery S.
      • Vearncombe M.
      • Leis J.A.
      Do physicians clean their hands? Insights from a covert observational study.
      ]. The search strategy is presented in full in Supplementary Appendix A. The reference lists of relevant systematic reviews and study reports included in the systematic review were manually hand-searched for any additional relevant studies [
      • Jeanes A.
      • Coen P.G.
      • Gould D.J.
      • Drey N.S.
      Validity of hand hygiene compliance measurement by observation: a systematic review.
      ,
      • Purssell E.
      • Drey N.
      • Chudleigh J.
      • Creedon S.
      • Gould D.J.
      The Hawthorne effect on adherence to hand hygiene in patient care.
      ,
      • Clancy C.
      • Delungahawatta T.
      • Dunne C.P.
      Hand-hygiene-related clinical trials reported between 2014 and 2020: a comprehensive systematic review.
      ,
      • Kingston L.
      • O’Connell N.H.
      • Dunne C.P.
      Hand hygiene-related clinical trials reported since 2010: a systematic review.
      ,
      • Seo H.J.
      • Sohng K.Y.
      • Chang S.O.
      • Chaung S.K.
      • Won J.S.
      • Choi M.J.
      Interventions to improve hand hygiene compliance in emergency departments: a systematic review.
      ].

      Selection process

      Title and abstract screening were independently performed in duplicate by two reviewers (D.B. and D.O.D.) based on the previously described inclusion/exclusion criteria. Discrepancies were resolved by discussion and consensus. Full text screening of studies that appeared to meet the eligibility criteria were assessed for inclusion independently by two reviewers (D.B. and D.O.D.). Discrepancies were resolved by discussion and consensus.

      Data collection process

      Extraction of study outcomes data was performed in duplicate by two reviewers independently (D.B. and D.O.D.) with data on study characteristics extracted by one reviewer (D.B.). A piloted data extraction form was used, with any discrepancies resolved by discussion and consensus. In cases of linked studies with multiple reports corresponding to a study at different time-points, the final report was used as containing the most complete outcomes data.

      Data items

      Data were collected on the study identifying features (author, title, publication year, journal, country of origin), study design, study setting, sample size (where the unit of analysis is the number of hand hygiene opportunities), type of participants, method of observation, compliance measurement tool, observer category and validation, funding, intervention type if used, baseline compliance rates of physicians and nurses, and compliance rates as per the WHO ‘five moments for hand hygiene’ of physicians and nurses [
      World Health Organization
      WHO guidelines on hand hygiene in health care.
      ]. The primary outcome of interest was hand hygiene compliance measured by direct observation. Baseline data were taken as the reported overall baseline compliance estimate or the first compliance estimate if multiple estimates were reported. If discrepancies were found in study data between tables and text, numeric data were taken from tables.

      Study risk-of-bias assessment

      Two reviewers independently assessed the risk of bias and methodological quality of the included studies (D.B. and D.O.D.). Any discrepancies were resolved by discussion and consensus agreement. Risk of bias for cluster-randomized controlled trials was assessed using the revised Cochrane risk-of-bias tool (RoB2) for cluster-randomized trials [

      Eldridge S CM, Campbell MJ, Drahota AK, Giraudeau B, Reeves BC, Siegfried N, Higgins JPT. Revised Cochrane risk of bias tool for randomized trials (RoB 2): Additional considerations for cluster-randomized trials (RoB 2 CRT). [Updated 18 March 2021.] Available at: https://www.riskofbias.info/welcome/rob-2-0-tool/rob-2-for-cluster-randomized-trials [last accessed July 2021].

      ]. Bias was assessed relating to the randomization process, timing of identification or recruitment of participants, deviations from the intended interventions, missing outcome data, outcome measurement, selection of the reported results.
      The Joanna Briggs Institute (JBI) checklist for quasi-experimental studies was used for non-randomized studies of interventions [
      • Tufanaru C.M.Z.
      • Aromataris E.
      • Campbell J.
      • Hopp L.
      Chapter 3: Systematic reviews of effectiveness.
      ]. Bias was assessed relating to the temporal relationship of cause and effect, differences between partici-pants, differences in interventions between compared groups, use of a control group, multiple outcome measurements pre and post intervention, completeness of follow-up, outcomes measurement in comparison groups, outcomes measurement reliability, and statistical analysis.
      For cross-sectional studies, the JBI Critical Appraisal Checklist for analytical cross-sectional studies was used, assessing bias related to sample inclusion criteria, participant and setting description, exposure measurement, confounding identification, confounding strategies, outcome measurement, and statistical analysis [
      • Moola S.M.Z.
      • Tufanaru C.
      • Aromataris E.
      • Sears K.
      • Sfetcu R.
      • Currie M.
      • et al.
      Chapter 7: Systematic reviews of etiology and risk.
      ]. For cohort studies, the JBI Critical Appraisal Checklist for cohort studies was used and assessed bias relating to recruitment, exposure measurement, confounding identification, confounding strategies, outcome measurement, follow-up and statistical analysis [
      • Moola S.M.Z.
      • Tufanaru C.
      • Aromataris E.
      • Sears K.
      • Sfetcu R.
      • Currie M.
      • et al.
      Chapter 7: Systematic reviews of etiology and risk.
      ].

      Synthesis methods

      Meta-analysis was planned as per protocol. Compliance was defined as the percentage of total hand hygiene opportunities for which participants performed hand hygiene actions. The risk difference and 95% confidence interval (CI) between nurses and physicians in dichotomous outcomes of hand hygiene compliance was calculated for each study with available outcomes data using the baseline compliance estimates. In cases where hand hygiene opportunities and compliance percentage were reported but not hand hygiene actions, these were calculated using the information provided in text or tables. A random-effects proportion meta-analysis was used to estimate a weighted pooled compliance rate with 95% confidence interval, separately for nurses and doctors across all studies. Meta-analysis was conducted using MedCalc software version 20.1. A random-effects meta-analysis using the DerSimonian–Laird method was used to estimate a pooled risk difference between compliance for nurses and physicians with a 95% confidence interval, with overt and covert studies analysed separately. Heterogeneity was assessed by visual inspection of the forest plots, the χ2-test and I2. The I2 threshold of >75%–100% was taken to approximate to considerable heterogeneity [
      • Higgins J.P.T.
      • Thomas J.
      ]. The meta-analysis was conducted using StatsDirect version3.

      Results

      Study selection

      The search yielded 7217 studies, with 4814 remaining after removal of duplicates. After title and abstract screening, the full texts of 441 studies were retrieved and screened. Following full text screening, 340 studies were excluded with reasons for exclusion listed in the PRISMA flow diagram Figure 1 and Supplementary Appendix B. The full text of an additional seven studies identified through citation searching were also retrieved and screened with three further studies excluded. A total of 105 studies were finally selected as matching the inclusion criteria in this review (Figure 1).
      Figure 1
      Figure 1PRISMA flow diagram for the selection of studies [
      • Page M.J.
      • McKenzie J.E.
      • Bossuyt P.M.
      • Boutron I.
      • Hoffmann T.C.
      • Mulrow C.D.
      • et al.
      The PRISMA 2020 statement: an updated guideline for reporting systematic reviews.
      ].

      Study characteristics

      Among the included studies were five cluster-RCTs, 52 non-randomized studies of interventions, and 48 observational studies [
      • El-Saed A.
      • Noushad S.
      • Tannous E.
      • Abdirizak F.
      • Arabi Y.
      • Al Azzam S.
      • et al.
      Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia.
      ,
      • Hagel S.
      • Reischke J.
      • Kesselmeier M.
      • Winning J.
      • Gastmeier P.
      • Brunkhorst F.M.
      • et al.
      Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
      ,
      • Kovacs-Litman A.
      • Wong K.
      • Shojania K.G.
      • Callery S.
      • Vearncombe M.
      • Leis J.A.
      Do physicians clean their hands? Insights from a covert observational study.
      ,
      • Aghdassi S.J.S.
      • Schröder C.
      • Lemke E.
      • Behnke M.
      • Fliss P.M.
      • Plotzki C.
      • et al.
      A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial.
      ,
      • Al-Dorzi H.M.
      • Matroud A.
      • Al Attas K.A.
      • Azzam A.I.
      • Musned A.
      • Naidu B.
      • et al.
      A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center.
      ,
      • Al-Tawfiq J.A.
      • Abed M.S.
      • Al-Yami N.
      • Birrer R.B.
      Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections.
      ,
      • Albert B.D.
      • Petti C.
      • Caraglia A.
      • Geller M.
      • Horak R.
      • Barrett M.
      • et al.
      Multidisciplinary quality improvement intervention to achieve sustained improvement in hand hygiene reliability in a pediatric intensive care unit.
      ,
      • AlNakhli D.J.
      • Baig K.
      • Goh A.
      • Okji H.
      • Din S.S.
      Determinants of hand hygiene non-compliance in a cardiac center in Saudi Arabia.
      ,
      • Alshammari M.
      • Reynolds K.A.
      • Verhougstraete M.
      • O’Rourke M.K.
      Comparison of perceived and observed hand hygiene compliance in healthcare workers in MERS-CoV endemic regions.
      ,
      • Alsubaie S.
      • Maither A.
      • Alalmaei W.
      • Al-Shammari A.D.
      • Tashkandi M.
      • Somily A.M.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      ,
      • Arntz P.R.
      • Hopman J.
      • Nillesen M.
      • Yalcin E.
      • Bleeker-Rovers C.P.
      • Voss A.
      • et al.
      Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department.
      ,
      • Azim S.
      • Juergens C.
      • McLaws M.L.
      An average hand hygiene day for nurses and physicians: the burden is not equal.
      ,
      • Baccolini V.
      • D’Egidio V.
      • de Soccio P.
      • Migliara G.
      • Massimi A.
      • Aless
      • et al.
      Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital.
      ,
      • Baek E.H.
      • Kim S.E.
      • Kim D.H.
      • Cho O.H.
      • Hong S.I.
      • Kim S.
      The difference in hand hygiene compliance rate between unit-based observers and trained observers for World Health Organization checklist and optimal hand hygiene.
      ,
      • Barker A.K.
      • Cowley E.S.
      • McKinley L.
      • Wright M.O.
      • Safdar N.
      An in-room observation study of hand hygiene and contact precaution compliance for Clostridioides difficile patients.
      ,
      • Birnbach D.J.
      • Rosen L.F.
      • Fitzpatrick M.
      • Everett-Thomas R.
      • Arheart K.L.
      A ubiquitous but ineffective intervention: signs do not increase hand hygiene compliance.
      ,
      • Bow E.J.
      • Bourrier V.
      • Phillips D.
      • Winski G.
      • Williams M.
      • Kostiuk N.
      • et al.
      Hand hygiene compliance at a Canadian provincial cancer centre – the complementary roles of nurse auditor-driven and patient auditor-driven audit processes and impact upon practice in ambulatory cancer care.
      ,
      • Bow E.J.
      • Bourrier V.
      • Trudel J.
      • Kostiuk N.
      • McLeod J.M.
      Patient-driven hand hygiene audit process at a regional cancer center.
      ,
      • Brühwasser C.
      • Hinterberger G.
      • Mutschlechner W.
      • Kaltseis J.
      • Lass-Flörl C.
      • Mayr A.
      A point prevalence survey on hand hygiene, with a special focus on Candida species.
      ,
      • Buffet-Bataillon S.
      • Leray E.
      • Poisson M.
      • Michelet C.
      • Bonnaure-Mallet M.
      • Cormier M.
      Influence of job seniority, hand hygiene education, and patient-to-nurse ratio on hand disinfection compliance.
      ,
      • Bukhari S.Z.
      • Hussain W.M.
      • Banjar A.
      • Almaimani W.H.
      • Karima T.M.
      • Fatani M.I.
      Hand hygiene compliance rate among healthcare professionals.
      ,
      • Chen J.K.
      • Wu K.S.
      • Lee S.S.
      • Lin H.S.
      • Tsai H.C.
      • Li C.H.
      • et al.
      Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan.
      ,
      • Chen L.F.
      • Carriker C.
      • Staheli R.
      • Isaacs P.
      • Elliott B.
      • Miller B.A.
      • et al.
      Observing and improving hand hygiene compliance: implementation and refinement of an electronic-assisted direct-observer hand hygiene audit program.
      ,
      • Costers M.
      • Viseur N.
      • Catry B.
      • Simon A.
      Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene.
      ,
      • Crews J.D.
      • Whaley E.
      • Syblik D.
      • Starke J.
      Sustained improvement in hand hygiene at a children’s hospital.
      ,
      • Cunningham D.
      • Brilli R.J.
      • McClead Jr., R.E.
      • Davis J.T.
      The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.
      ,
      • Deyneko A.
      • Cordeiro F.
      • Berlin L.
      • Ben-David D.
      • Perna S.
      • Longtin Y.
      Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study.
      ,
      • Dhar S.
      • Marchaim D.
      • Tansek R.
      • Chopra T.
      • Yousuf A.
      • Bhargava A.
      • et al.
      Contact precautions: more is not necessarily better.
      ,
      • di Martino P.
      • Ban K.M.
      • Bartoloni A.
      • Fowler K.E.
      • Saint S.
      • Mannelli F.
      Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation.
      ,
      • Dierssen-Sotos T.
      • Brugos-Llamazares V.
      • Robles-García M.
      • Rebollo-Rodrigo H.
      • Fariñas-Alvarez C.
      • Antolín-Juarez F.M.
      • et al.
      Evaluating the impact of a hand hygiene campaign on improving adherence.
      ,
      • Fonguh S.
      • Uwineza A.
      • Catry B.
      • Simon A.
      Belgian hand hygiene campaigns in ICU, 2005–2015.
      ,
      • Fouad M.
      • Eltaher S.
      Hand hygiene initiative: comparative study of pre- and postintervention outcomes.
      ,
      • Freeman J.
      • Dawson L.
      • Jowitt D.
      • White M.
      • Callard H.
      • Sieczkowski C.
      • et al.
      The impact of the Hand Hygiene New Zealand programme on hand hygiene practices in New Zealand’s public hospitals.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel before patient contact. Part I.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II.
      ,
      • Ghonim E.
      • Nolan R.
      • Benghuzzi H.
      Increasing hand hygiene compliance by use of a novel hand held device at a University Hospital.
      ,
      • Gilbert K.
      • Stafford C.
      • Crosby K.
      • Fleming E.
      • Gaynes R.
      Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs?.
      ,
      • Graf K.
      • Ott E.
      • Wolny M.
      • Tramp N.
      • Vonberg R.P.
      • Haverich A.
      • et al.
      Hand hygiene compliance in transplant and other special patient groups: an observational study.
      ,
      • Grant A.
      • Hofmann D.
      It’s not all about me: motivating hand hygiene among health care professionals by focusing on patients.
      ,
      • Gras-Valentí P.
      • Mora-Muriel J.G.
      • Fuster-Pérez M.
      • Benito-Miralles C.M.
      • Vela-Morales M.C.
      • González-Hernández M.
      • et al.
      Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital.
      ,
      • Grayson M.L.
      • Russo P.L.
      • Cruickshank M.
      • Bear J.L.
      • Gee C.A.
      • Hughes C.F.
      • et al.
      Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative.
      ,
      • Grayson M.L.
      • Stewardson A.J.
      • Russo P.L.
      • Ryan K.E.
      • Olsen K.L.
      • Havers S.M.
      • et al.
      Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.
      ,
      • Guanche Garcell H.
      • Villanueva Arias A.
      • Ramírez Miranda F.
      • Rubiera Jimenez R.
      • Alfonso Serrano R.N.
      Direct observation of hand hygiene can show differences in staff compliance: do we need to evaluate the accuracy for patient safety?.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Gombotz V.
      • Pregartner G.
      • Zierler R.
      • Schwarz C.
      • et al.
      Hand hygiene compliance in intensive care units: an observational study.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Pregartner G.
      • Gombotz V.
      • Tax C.
      • Zierler R.
      • et al.
      Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: an iterative process of information, training and feedback.
      ,
      • Jeanes A.
      • Coen P.G.
      • Drey N.S.
      • Gould D.J.
      The development of hand hygiene compliance imperatives in an emergency department.
      ,
      • Johnson L.
      • Grueber S.
      • Schlotzhauer C.
      • Phillips E.
      • Bullock P.
      • Basnett J.
      • et al.
      A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections.
      ,
      • Keller J.
      • Wolfensberger A.
      • Clack L.
      • Kuster S.P.
      • Dunic M.
      • Eis D.
      • et al.
      Do wearable alcohol-based handrub dispensers increase hand hygiene compliance? – a mixed-methods study.
      ,
      • Kramer T.S.
      • Bunte K.
      • Schröder C.
      • Behnke M.
      • Clausmeyer J.
      • Reichardt C.
      • et al.
      No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.
      ,
      • Kukanich K.S.
      • Kaur R.
      • Freeman L.C.
      • Powell D.A.
      Evaluation of a hand hygiene campaign in outpatient health care clinics.
      ,
      • Kwon J.H.
      • Reske K.
      • O’Neil C.A.
      • Cass C.
      • Seiler S.
      • Wallace M.A.
      • et al.
      Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures.
      ,
      • Langston M.
      Effects of peer monitoring and peer feedback on hand hygiene in surgical intensive care unit and step-down units.
      ,
      • Lebovic G.
      • Siddiqui N.
      • Muller M.P.
      Predictors of hand hygiene compliance in the era of alcohol-based hand rinse.
      ,
      • Lee A.
      • Chalfine A.
      • Daikos G.L.
      • Garilli S.
      • Jovanovic B.
      • Lemmen S.
      • et al.
      Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: a multicenter observational study.
      ,
      • Lee S.S.
      • Park S.J.
      • Chung M.J.
      • Lee J.H.
      • Kang H.J.
      • Lee J.A.
      • et al.
      Improved hand hygiene compliance is associated with the change of perception toward hand hygiene among medical personnel.
      ,
      • Lieber S.R.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Fumagalli C.
      • Bartolozzi D.
      • et al.
      The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany.
      ,
      • Linam W.M.
      • Margolis P.A.
      • Atherton H.
      • Connelly B.L.
      Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene.
      ,
      • Ling M.L.
      • How K.B.
      Impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections.
      ,
      • Mahfouz A.A.
      • Al-Zaydani I.A.
      • Abdelaziz A.O.
      • El-Gamal M.N.
      • Assiri A.M.
      Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia.
      ,
      • Mahfouz A.A.
      • El Gamal M.N.
      • Al-Azraqi T.A.
      Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia.
      ,
      • Mayer J.
      • Mooney B.
      • Gundlapalli A.
      • Harbarth S.
      • Stoddard G.J.
      • Rubin M.A.
      • et al.
      Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.
      ,
      • Mazi W.
      • Senok A.C.
      • Al-Kahldy S.
      • Abdullah D.
      Implementation of the World Health Organization hand hygiene improvement strategy in critical care units.
      ,
      • Mertz D.
      • Johnstone J.
      • Krueger P.
      • Brazil K.
      • Walter S.D.
      • Loeb M.
      Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.
      ,
      • Mestre G.
      • Berbel C.
      • Tortajada P.
      • Alarcia M.
      • Coca R.
      • Gallemi G.
      • et al.
      “The 3/3 strategy”: a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology.
      ,
      • Monistrol O.
      • Calbo E.
      • Riera M.
      • Nicolás C.
      • Font R.
      • Freixas N.
      • et al.
      Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards.
      ,
      • Moro M.L.
      • Morsillo F.
      • Nascetti S.
      • Parenti M.
      • Allegranzi B.
      • Pompa M.G.
      • et al.
      Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007–2008 and 2014.
      ,
      • Muller M.P.
      • Carter E.
      • Siddiqui N.
      • Larson E.
      Hand hygiene compliance in an emergency department: the effect of crowding.
      ,
      • Musu M.
      • Finco G.
      • Mura P.
      • oni G.
      • Piazza M.F.
      • Messina M.
      • et al.
      Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units.
      ,
      • Musu M.
      • Lai A.
      • Mereu N.M.
      • Galletta M.
      • Campagna M.
      • Tidore M.
      • et al.
      Assessing hand hygiene compliance among healthcare workers in six intensive care units.
      ,
      • Peponis T.
      • Cropano M.C.
      • Larentzakis A.
      • van der Wilden M.G.
      • Mejaddam Y.A.
      • Sideris C.A.
      • et al.
      Trauma team utilization of universal precautions: if you see something, say something.
      ,
      • Petrilli C.M.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Bartoloni A.
      The effect of merging two infectious disease units on hand hygiene adherence in Italy.
      ,
      • Pontivivo G.
      • Rivas K.
      • Gallard J.
      • Yu J.
      • Perry L.
      A new approach to improving hand hygiene practice in an inner city acute hospital in Australia.
      ,
      • Price L.
      • Roome K.
      • Lisa R.
      • Reilly J.
      • McIntyre J.
      • Godwin J.
      • et al.
      Toward improving the World Health Organization fifth moment for hand hygiene in the prevention of cross-infection.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      • Wharrad H.
      • Windle R.
      An observational study of hand hygiene adherence following the introduction of an education intervention.
      ,
      • Randle J.
      • Firth J.
      • Vaughan N.
      An observational study of hand hygiene compliance in paediatric wards.
      ,
      • Roberts S.A.
      • Sieczkowski C.
      • Campbell T.
      • Balla G.
      • Keenan A.
      Implementing and sustaining a hand hygiene culture change programme at Auckland District Health Board.
      ,
      • Saitoh A.
      • Sato K.
      • Magara Y.
      • Osaki K.
      • Narita K.
      • Shioiri K.
      • et al.
      Improving hand hygiene adherence in healthcare workers before patient contact: a multimodal intervention in four tertiary care hospitals in Japan.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Kamiya T.
      • Sato Y.
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Shimizu T.
      • Kamiya T.
      • et al.
      Hand hygiene adherence among health care workers at Japanese hospitals: a multicenter observational study in Japan.
      ,
      • Sakihama T.
      • Kayauchi N.
      • Kamiya T.
      • Saint S.
      • Fowler K.
      • Ratz D.
      • et al.
      Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals.
      ,
      • Salama M.F.
      • Jamal W.Y.
      • Mousa H.A.
      • Al-Abdulghani K.A.
      • Rotimi V.O.
      The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital.
      ,
      • Scheithauer S.
      • Kamerseder V.
      • Petersen P.
      • Brokmann J.C.
      • Lopez-Gonzalez L.A.
      • Mach C.
      • et al.
      Improving hand hygiene compliance in the emergency department: getting to the point.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Heimann K.
      • Haefner H.
      • Schwanz T.
      • Waitschies B.
      • et al.
      Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Stollbrink-Peschgens C.
      • Haefner H.
      • Waitschies B.
      • Wagner N.
      • et al.
      Suspicion of viral gastroenteritis does improve compliance with hand hygiene.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Seto W.H.
      • Cowling B.J.
      • Cheung C.W.Y.
      • Wong C.Y.Y.
      • Pty Ching
      • Pittet D.
      • et al.
      Impact of the first hand sanitizing relay world record on compliance with hand hygiene in a hospital.
      ,
      • Seto W.H.
      • Yuen S.W.
      • Cheung C.W.
      • Ching P.T.
      • Cowling B.J.
      • Pittet D.
      Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.
      ,
      • Smith S.J.
      • Young V.
      • Robertson C.
      • Dancer S.J.
      Where do hands go? An audit of sequential hand-touch events on a hospital ward.
      ,
      • Song X.
      • Stockwell D.C.
      • Floyd T.
      • Short B.L.
      • Singh N.
      Improving hand hygiene compliance in health care workers: strategies and impact on patient outcomes.
      ,
      • Squeri R.
      • Genovese C.
      • Palamara M.A.
      • Trimarchi G.
      • La Fauci V.
      “Clean care is safer care”: correct handwashing in the prevention of healthcare associated infections.
      ,
      • Stahmeyer J.T.
      • Lutze B.
      • von Lengerke T.
      • Chaberny I.F.
      • Krauth C.
      Hand hygiene in intensive care units: a matter of time?.
      ,
      • Staines A.
      • Amherdt I.
      • Lécureux E.
      • Petignat C.
      • Eggimann P.
      • Schwab M.
      • et al.
      Hand hygiene improvement and sustainability: assessing a breakthrough collaborative in western Switzerland.
      ,
      • Stewardson A.J.
      • Sax H.
      • Gayet-Ageron A.
      • Touveneau S.
      • Longtin Y.
      • Zingg W.
      • et al.
      Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial.
      ,
      • Tromp M.
      • Brink-Huis A.
      • De Guchteneire I.
      • Van Der Meer J.
      • Van Achterberg T.
      • Hulscher M.
      • et al.
      The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement programme.
      ,
      • van der Kooi Tii
      • Sax H.
      • Pittet D.
      • Dissel J.
      • Benthem B.
      • Walder B.
      • et al.
      Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.
      ,
      • van Dijk M.D.
      • Mulder S.A.
      • Erasmus V.
      • van Beeck A.H.E.
      • Vermeeren J.
      • Liu X.
      • et al.
      A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance.
      ,
      • Venkatesh A.K.
      • Pallin D.J.
      • Kayden S.
      • Schuur J.D.
      Predictors of hand hygiene in the emergency department.
      ,
      • Visan F.A.
      • Zakaria A.
      • Castro J.
      • Alhasanat O.
      • Ismail K.A.
      • Ansari N.A.
      • et al.
      SWITCH: Al Wakra Hospital journey to 90% hand hygiene practice compliance, 2011–2015.
      ,
      • von Lengerke T.
      • Lutze B.
      • Krauth C.
      • Lange K.
      • Stahmeyer J.T.
      • Chaberny I.F.
      Promoting hand hygiene compliance: PSYGIENE – a cluster-randomized controlled trial of tailored interventions.
      ,
      • Watson J.A.
      The role of a multimodal educational strategy on healthcare workers’ hand washing.
      ,
      • Wetzker W.
      • Bunte-Schönberger K.
      • Walter J.
      • Pilarski G.
      • Gastmeier P.
      • Reichardt C.
      Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany.
      ,
      • Wu K.S.
      • Chen Y.S.
      • Lin H.S.
      • Hsieh E.L.
      • Chen J.K.
      • Tsai H.C.
      • et al.
      A nationwide covert observation study using a novel method for hand hygiene compliance in health care.
      ,
      • Wu K.S.
      • Lee S.S.J.
      • Chen J.K.
      • Chen Y.S.
      • Tsai H.C.
      • Lin H.S.
      Identifying the heterogenicity of the Hawthorne effect in hand hygiene: a case–control study of overt and covert observation results.
      ,
      • Yoo E.
      • Ursua L.
      • Clark R.
      • Seok J.
      • Jeon J.
      • Kim H.B.
      The effect of incorporating covert observation into established overt observation-based hand hygiene promotion programs.
      ]. Key characteristics of included studies are summarized in Table I. A full table of findings including outcomes data for each included study, presented according to risk of bias and sample size, is contained in Supplementary Appendix C.
      Table ICharacteristics of included studies
      CharacteristicNo. of studiesReferences
      Region
       Europe45[
      • Hagel S.
      • Reischke J.
      • Kesselmeier M.
      • Winning J.
      • Gastmeier P.
      • Brunkhorst F.M.
      • et al.
      Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
      ,
      • Aghdassi S.J.S.
      • Schröder C.
      • Lemke E.
      • Behnke M.
      • Fliss P.M.
      • Plotzki C.
      • et al.
      A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial.
      ,
      • Arntz P.R.
      • Hopman J.
      • Nillesen M.
      • Yalcin E.
      • Bleeker-Rovers C.P.
      • Voss A.
      • et al.
      Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department.
      ,
      • Baccolini V.
      • D’Egidio V.
      • de Soccio P.
      • Migliara G.
      • Massimi A.
      • Aless
      • et al.
      Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital.
      ,
      • Brühwasser C.
      • Hinterberger G.
      • Mutschlechner W.
      • Kaltseis J.
      • Lass-Flörl C.
      • Mayr A.
      A point prevalence survey on hand hygiene, with a special focus on Candida species.
      ,
      • Buffet-Bataillon S.
      • Leray E.
      • Poisson M.
      • Michelet C.
      • Bonnaure-Mallet M.
      • Cormier M.
      Influence of job seniority, hand hygiene education, and patient-to-nurse ratio on hand disinfection compliance.
      ,
      • Costers M.
      • Viseur N.
      • Catry B.
      • Simon A.
      Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene.
      ,
      • di Martino P.
      • Ban K.M.
      • Bartoloni A.
      • Fowler K.E.
      • Saint S.
      • Mannelli F.
      Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation.
      ,
      • Dierssen-Sotos T.
      • Brugos-Llamazares V.
      • Robles-García M.
      • Rebollo-Rodrigo H.
      • Fariñas-Alvarez C.
      • Antolín-Juarez F.M.
      • et al.
      Evaluating the impact of a hand hygiene campaign on improving adherence.
      ,
      • Fonguh S.
      • Uwineza A.
      • Catry B.
      • Simon A.
      Belgian hand hygiene campaigns in ICU, 2005–2015.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel before patient contact. Part I.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II.
      ,
      • Graf K.
      • Ott E.
      • Wolny M.
      • Tramp N.
      • Vonberg R.P.
      • Haverich A.
      • et al.
      Hand hygiene compliance in transplant and other special patient groups: an observational study.
      ,
      • Gras-Valentí P.
      • Mora-Muriel J.G.
      • Fuster-Pérez M.
      • Benito-Miralles C.M.
      • Vela-Morales M.C.
      • González-Hernández M.
      • et al.
      Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Gombotz V.
      • Pregartner G.
      • Zierler R.
      • Schwarz C.
      • et al.
      Hand hygiene compliance in intensive care units: an observational study.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Pregartner G.
      • Gombotz V.
      • Tax C.
      • Zierler R.
      • et al.
      Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: an iterative process of information, training and feedback.
      ,
      • Jeanes A.
      • Coen P.G.
      • Drey N.S.
      • Gould D.J.
      The development of hand hygiene compliance imperatives in an emergency department.
      ,
      • Keller J.
      • Wolfensberger A.
      • Clack L.
      • Kuster S.P.
      • Dunic M.
      • Eis D.
      • et al.
      Do wearable alcohol-based handrub dispensers increase hand hygiene compliance? – a mixed-methods study.
      ,
      • Kramer T.S.
      • Bunte K.
      • Schröder C.
      • Behnke M.
      • Clausmeyer J.
      • Reichardt C.
      • et al.
      No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.
      ,
      • Lee A.
      • Chalfine A.
      • Daikos G.L.
      • Garilli S.
      • Jovanovic B.
      • Lemmen S.
      • et al.
      Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: a multicenter observational study.
      ,
      • Lieber S.R.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Fumagalli C.
      • Bartolozzi D.
      • et al.
      The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany.
      ,
      • Mestre G.
      • Berbel C.
      • Tortajada P.
      • Alarcia M.
      • Coca R.
      • Gallemi G.
      • et al.
      “The 3/3 strategy”: a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology.
      ,
      • Monistrol O.
      • Calbo E.
      • Riera M.
      • Nicolás C.
      • Font R.
      • Freixas N.
      • et al.
      Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards.
      ,
      • Moro M.L.
      • Morsillo F.
      • Nascetti S.
      • Parenti M.
      • Allegranzi B.
      • Pompa M.G.
      • et al.
      Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007–2008 and 2014.
      ,
      • Musu M.
      • Finco G.
      • Mura P.
      • oni G.
      • Piazza M.F.
      • Messina M.
      • et al.
      Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units.
      ,
      • Musu M.
      • Lai A.
      • Mereu N.M.
      • Galletta M.
      • Campagna M.
      • Tidore M.
      • et al.
      Assessing hand hygiene compliance among healthcare workers in six intensive care units.
      ,
      • Petrilli C.M.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Bartoloni A.
      The effect of merging two infectious disease units on hand hygiene adherence in Italy.
      ,
      • Price L.
      • Roome K.
      • Lisa R.
      • Reilly J.
      • McIntyre J.
      • Godwin J.
      • et al.
      Toward improving the World Health Organization fifth moment for hand hygiene in the prevention of cross-infection.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      • Wharrad H.
      • Windle R.
      An observational study of hand hygiene adherence following the introduction of an education intervention.
      ,
      • Randle J.
      • Firth J.
      • Vaughan N.
      An observational study of hand hygiene compliance in paediatric wards.
      ,
      • Scheithauer S.
      • Kamerseder V.
      • Petersen P.
      • Brokmann J.C.
      • Lopez-Gonzalez L.A.
      • Mach C.
      • et al.
      Improving hand hygiene compliance in the emergency department: getting to the point.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Heimann K.
      • Haefner H.
      • Schwanz T.
      • Waitschies B.
      • et al.
      Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Stollbrink-Peschgens C.
      • Haefner H.
      • Waitschies B.
      • Wagner N.
      • et al.
      Suspicion of viral gastroenteritis does improve compliance with hand hygiene.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Smith S.J.
      • Young V.
      • Robertson C.
      • Dancer S.J.
      Where do hands go? An audit of sequential hand-touch events on a hospital ward.
      ,
      • Squeri R.
      • Genovese C.
      • Palamara M.A.
      • Trimarchi G.
      • La Fauci V.
      “Clean care is safer care”: correct handwashing in the prevention of healthcare associated infections.
      ,
      • van Dijk M.D.
      • Mulder S.A.
      • Erasmus V.
      • van Beeck A.H.E.
      • Vermeeren J.
      • Liu X.
      • et al.
      A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance.
      ,
      • von Lengerke T.
      • Lutze B.
      • Krauth C.
      • Lange K.
      • Stahmeyer J.T.
      • Chaberny I.F.
      Promoting hand hygiene compliance: PSYGIENE – a cluster-randomized controlled trial of tailored interventions.
      ,
      • Wetzker W.
      • Bunte-Schönberger K.
      • Walter J.
      • Pilarski G.
      • Gastmeier P.
      • Reichardt C.
      Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany.
      ]
       North America27[
      • Kovacs-Litman A.
      • Wong K.
      • Shojania K.G.
      • Callery S.
      • Vearncombe M.
      • Leis J.A.
      Do physicians clean their hands? Insights from a covert observational study.
      ,
      • Albert B.D.
      • Petti C.
      • Caraglia A.
      • Geller M.
      • Horak R.
      • Barrett M.
      • et al.
      Multidisciplinary quality improvement intervention to achieve sustained improvement in hand hygiene reliability in a pediatric intensive care unit.
      ,
      • Barker A.K.
      • Cowley E.S.
      • McKinley L.
      • Wright M.O.
      • Safdar N.
      An in-room observation study of hand hygiene and contact precaution compliance for Clostridioides difficile patients.
      ,
      • Birnbach D.J.
      • Rosen L.F.
      • Fitzpatrick M.
      • Everett-Thomas R.
      • Arheart K.L.
      A ubiquitous but ineffective intervention: signs do not increase hand hygiene compliance.
      ,
      • Bow E.J.
      • Bourrier V.
      • Phillips D.
      • Winski G.
      • Williams M.
      • Kostiuk N.
      • et al.
      Hand hygiene compliance at a Canadian provincial cancer centre – the complementary roles of nurse auditor-driven and patient auditor-driven audit processes and impact upon practice in ambulatory cancer care.
      ,
      • Bow E.J.
      • Bourrier V.
      • Trudel J.
      • Kostiuk N.
      • McLeod J.M.
      Patient-driven hand hygiene audit process at a regional cancer center.
      ,
      • Chen L.F.
      • Carriker C.
      • Staheli R.
      • Isaacs P.
      • Elliott B.
      • Miller B.A.
      • et al.
      Observing and improving hand hygiene compliance: implementation and refinement of an electronic-assisted direct-observer hand hygiene audit program.
      ,
      • Crews J.D.
      • Whaley E.
      • Syblik D.
      • Starke J.
      Sustained improvement in hand hygiene at a children’s hospital.
      ,
      • Cunningham D.
      • Brilli R.J.
      • McClead Jr., R.E.
      • Davis J.T.
      The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.
      ,
      • Deyneko A.
      • Cordeiro F.
      • Berlin L.
      • Ben-David D.
      • Perna S.
      • Longtin Y.
      Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study.
      ,
      • Dhar S.
      • Marchaim D.
      • Tansek R.
      • Chopra T.
      • Yousuf A.
      • Bhargava A.
      • et al.
      Contact precautions: more is not necessarily better.
      ,
      • Ghonim E.
      • Nolan R.
      • Benghuzzi H.
      Increasing hand hygiene compliance by use of a novel hand held device at a University Hospital.
      ,
      • Gilbert K.
      • Stafford C.
      • Crosby K.
      • Fleming E.
      • Gaynes R.
      Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs?.
      ,
      • Grant A.
      • Hofmann D.
      It’s not all about me: motivating hand hygiene among health care professionals by focusing on patients.
      ,
      • Johnson L.
      • Grueber S.
      • Schlotzhauer C.
      • Phillips E.
      • Bullock P.
      • Basnett J.
      • et al.
      A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections.
      ,
      • Kukanich K.S.
      • Kaur R.
      • Freeman L.C.
      • Powell D.A.
      Evaluation of a hand hygiene campaign in outpatient health care clinics.
      ,
      • Kwon J.H.
      • Reske K.
      • O’Neil C.A.
      • Cass C.
      • Seiler S.
      • Wallace M.A.
      • et al.
      Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures.
      ,
      • Langston M.
      Effects of peer monitoring and peer feedback on hand hygiene in surgical intensive care unit and step-down units.
      ,
      • Lebovic G.
      • Siddiqui N.
      • Muller M.P.
      Predictors of hand hygiene compliance in the era of alcohol-based hand rinse.
      ,
      • Linam W.M.
      • Margolis P.A.
      • Atherton H.
      • Connelly B.L.
      Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene.
      ,
      • Mayer J.
      • Mooney B.
      • Gundlapalli A.
      • Harbarth S.
      • Stoddard G.J.
      • Rubin M.A.
      • et al.
      Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.
      ,
      • Mertz D.
      • Johnstone J.
      • Krueger P.
      • Brazil K.
      • Walter S.D.
      • Loeb M.
      Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.
      ,
      • Muller M.P.
      • Carter E.
      • Siddiqui N.
      • Larson E.
      Hand hygiene compliance in an emergency department: the effect of crowding.
      ,
      • Peponis T.
      • Cropano M.C.
      • Larentzakis A.
      • van der Wilden M.G.
      • Mejaddam Y.A.
      • Sideris C.A.
      • et al.
      Trauma team utilization of universal precautions: if you see something, say something.
      ,
      • Song X.
      • Stockwell D.C.
      • Floyd T.
      • Short B.L.
      • Singh N.
      Improving hand hygiene compliance in health care workers: strategies and impact on patient outcomes.
      ,
      • Venkatesh A.K.
      • Pallin D.J.
      • Kayden S.
      • Schuur J.D.
      Predictors of hand hygiene in the emergency department.
      ,
      • Watson J.A.
      The role of a multimodal educational strategy on healthcare workers’ hand washing.
      ]
       Middle East15[
      • El-Saed A.
      • Noushad S.
      • Tannous E.
      • Abdirizak F.
      • Arabi Y.
      • Al Azzam S.
      • et al.
      Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia.
      ,
      • Al-Dorzi H.M.
      • Matroud A.
      • Al Attas K.A.
      • Azzam A.I.
      • Musned A.
      • Naidu B.
      • et al.
      A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center.
      ,
      • Al-Tawfiq J.A.
      • Abed M.S.
      • Al-Yami N.
      • Birrer R.B.
      Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections.
      ,
      • AlNakhli D.J.
      • Baig K.
      • Goh A.
      • Okji H.
      • Din S.S.
      Determinants of hand hygiene non-compliance in a cardiac center in Saudi Arabia.
      ,
      • Alshammari M.
      • Reynolds K.A.
      • Verhougstraete M.
      • O’Rourke M.K.
      Comparison of perceived and observed hand hygiene compliance in healthcare workers in MERS-CoV endemic regions.
      ,
      • Alsubaie S.
      • Maither A.
      • Alalmaei W.
      • Al-Shammari A.D.
      • Tashkandi M.
      • Somily A.M.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      ,
      • Bukhari S.Z.
      • Hussain W.M.
      • Banjar A.
      • Almaimani W.H.
      • Karima T.M.
      • Fatani M.I.
      Hand hygiene compliance rate among healthcare professionals.
      ,
      • Fouad M.
      • Eltaher S.
      Hand hygiene initiative: comparative study of pre- and postintervention outcomes.
      ,
      • Guanche Garcell H.
      • Villanueva Arias A.
      • Ramírez Miranda F.
      • Rubiera Jimenez R.
      • Alfonso Serrano R.N.
      Direct observation of hand hygiene can show differences in staff compliance: do we need to evaluate the accuracy for patient safety?.
      ,
      • Mahfouz A.A.
      • Al-Zaydani I.A.
      • Abdelaziz A.O.
      • El-Gamal M.N.
      • Assiri A.M.
      Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia.
      ,
      • Mahfouz A.A.
      • El Gamal M.N.
      • Al-Azraqi T.A.
      Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia.
      ,
      • Mazi W.
      • Senok A.C.
      • Al-Kahldy S.
      • Abdullah D.
      Implementation of the World Health Organization hand hygiene improvement strategy in critical care units.
      ,
      • Salama M.F.
      • Jamal W.Y.
      • Mousa H.A.
      • Al-Abdulghani K.A.
      • Rotimi V.O.
      The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital.
      ,
      • Visan F.A.
      • Zakaria A.
      • Castro J.
      • Alhasanat O.
      • Ismail K.A.
      • Ansari N.A.
      • et al.
      SWITCH: Al Wakra Hospital journey to 90% hand hygiene practice compliance, 2011–2015.
      ,
      • Yoo E.
      • Ursua L.
      • Clark R.
      • Seok J.
      • Jeon J.
      • Kim H.B.
      The effect of incorporating covert observation into established overt observation-based hand hygiene promotion programs.
      ]
       Asia12[
      • Baek E.H.
      • Kim S.E.
      • Kim D.H.
      • Cho O.H.
      • Hong S.I.
      • Kim S.
      The difference in hand hygiene compliance rate between unit-based observers and trained observers for World Health Organization checklist and optimal hand hygiene.
      ,
      • Chen J.K.
      • Wu K.S.
      • Lee S.S.
      • Lin H.S.
      • Tsai H.C.
      • Li C.H.
      • et al.
      Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan.
      ,
      • Lee S.S.
      • Park S.J.
      • Chung M.J.
      • Lee J.H.
      • Kang H.J.
      • Lee J.A.
      • et al.
      Improved hand hygiene compliance is associated with the change of perception toward hand hygiene among medical personnel.
      ,
      • Ling M.L.
      • How K.B.
      Impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections.
      ,
      • Saitoh A.
      • Sato K.
      • Magara Y.
      • Osaki K.
      • Narita K.
      • Shioiri K.
      • et al.
      Improving hand hygiene adherence in healthcare workers before patient contact: a multimodal intervention in four tertiary care hospitals in Japan.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Kamiya T.
      • Sato Y.
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Shimizu T.
      • Kamiya T.
      • et al.
      Hand hygiene adherence among health care workers at Japanese hospitals: a multicenter observational study in Japan.
      ,
      • Sakihama T.
      • Kayauchi N.
      • Kamiya T.
      • Saint S.
      • Fowler K.
      • Ratz D.
      • et al.
      Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals.
      ,
      • Seto W.H.
      • Cowling B.J.
      • Cheung C.W.Y.
      • Wong C.Y.Y.
      • Pty Ching
      • Pittet D.
      • et al.
      Impact of the first hand sanitizing relay world record on compliance with hand hygiene in a hospital.
      ,
      • Seto W.H.
      • Yuen S.W.
      • Cheung C.W.
      • Ching P.T.
      • Cowling B.J.
      • Pittet D.
      Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.
      ,
      • Wu K.S.
      • Chen Y.S.
      • Lin H.S.
      • Hsieh E.L.
      • Chen J.K.
      • Tsai H.C.
      • et al.
      A nationwide covert observation study using a novel method for hand hygiene compliance in health care.
      ,
      • Wu K.S.
      • Lee S.S.J.
      • Chen J.K.
      • Chen Y.S.
      • Tsai H.C.
      • Lin H.S.
      Identifying the heterogenicity of the Hawthorne effect in hand hygiene: a case–control study of overt and covert observation results.
      ]
       Oceania6[
      • Azim S.
      • Juergens C.
      • McLaws M.L.
      An average hand hygiene day for nurses and physicians: the burden is not equal.
      ,
      • Freeman J.
      • Dawson L.
      • Jowitt D.
      • White M.
      • Callard H.
      • Sieczkowski C.
      • et al.
      The impact of the Hand Hygiene New Zealand programme on hand hygiene practices in New Zealand’s public hospitals.
      ,
      • Grayson M.L.
      • Russo P.L.
      • Cruickshank M.
      • Bear J.L.
      • Gee C.A.
      • Hughes C.F.
      • et al.
      Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative.
      ,
      • Grayson M.L.
      • Stewardson A.J.
      • Russo P.L.
      • Ryan K.E.
      • Olsen K.L.
      • Havers S.M.
      • et al.
      Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.
      ,
      • Pontivivo G.
      • Rivas K.
      • Gallard J.
      • Yu J.
      • Perry L.
      A new approach to improving hand hygiene practice in an inner city acute hospital in Australia.
      ,
      • Roberts S.A.
      • Sieczkowski C.
      • Campbell T.
      • Balla G.
      • Keenan A.
      Implementing and sustaining a hand hygiene culture change programme at Auckland District Health Board.
      ]
      Study design
       Cluster-RCT5[
      • Aghdassi S.J.S.
      • Schröder C.
      • Lemke E.
      • Behnke M.
      • Fliss P.M.
      • Plotzki C.
      • et al.
      A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial.
      ,
      • Grant A.
      • Hofmann D.
      It’s not all about me: motivating hand hygiene among health care professionals by focusing on patients.
      ,
      • Stewardson A.J.
      • Sax H.
      • Gayet-Ageron A.
      • Touveneau S.
      • Longtin Y.
      • Zingg W.
      • et al.
      Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial.
      ,
      • van der Kooi Tii
      • Sax H.
      • Pittet D.
      • Dissel J.
      • Benthem B.
      • Walder B.
      • et al.
      Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.
      ,
      • von Lengerke T.
      • Lutze B.
      • Krauth C.
      • Lange K.
      • Stahmeyer J.T.
      • Chaberny I.F.
      Promoting hand hygiene compliance: PSYGIENE – a cluster-randomized controlled trial of tailored interventions.
      ]
       Non-randomized study of intervention52[
      • Al-Dorzi H.M.
      • Matroud A.
      • Al Attas K.A.
      • Azzam A.I.
      • Musned A.
      • Naidu B.
      • et al.
      A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center.
      ,
      • Al-Tawfiq J.A.
      • Abed M.S.
      • Al-Yami N.
      • Birrer R.B.
      Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections.
      ,
      • Albert B.D.
      • Petti C.
      • Caraglia A.
      • Geller M.
      • Horak R.
      • Barrett M.
      • et al.
      Multidisciplinary quality improvement intervention to achieve sustained improvement in hand hygiene reliability in a pediatric intensive care unit.
      ,
      • Arntz P.R.
      • Hopman J.
      • Nillesen M.
      • Yalcin E.
      • Bleeker-Rovers C.P.
      • Voss A.
      • et al.
      Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department.
      ,
      • Baccolini V.
      • D’Egidio V.
      • de Soccio P.
      • Migliara G.
      • Massimi A.
      • Aless
      • et al.
      Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital.
      ,
      • Birnbach D.J.
      • Rosen L.F.
      • Fitzpatrick M.
      • Everett-Thomas R.
      • Arheart K.L.
      A ubiquitous but ineffective intervention: signs do not increase hand hygiene compliance.
      ,
      • Buffet-Bataillon S.
      • Leray E.
      • Poisson M.
      • Michelet C.
      • Bonnaure-Mallet M.
      • Cormier M.
      Influence of job seniority, hand hygiene education, and patient-to-nurse ratio on hand disinfection compliance.
      ,
      • Chen J.K.
      • Wu K.S.
      • Lee S.S.
      • Lin H.S.
      • Tsai H.C.
      • Li C.H.
      • et al.
      Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan.
      ,
      • Costers M.
      • Viseur N.
      • Catry B.
      • Simon A.
      Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene.
      ,
      • Crews J.D.
      • Whaley E.
      • Syblik D.
      • Starke J.
      Sustained improvement in hand hygiene at a children’s hospital.
      ,
      • Cunningham D.
      • Brilli R.J.
      • McClead Jr., R.E.
      • Davis J.T.
      The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.
      ,
      • di Martino P.
      • Ban K.M.
      • Bartoloni A.
      • Fowler K.E.
      • Saint S.
      • Mannelli F.
      Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation.
      ,
      • Dierssen-Sotos T.
      • Brugos-Llamazares V.
      • Robles-García M.
      • Rebollo-Rodrigo H.
      • Fariñas-Alvarez C.
      • Antolín-Juarez F.M.
      • et al.
      Evaluating the impact of a hand hygiene campaign on improving adherence.
      ,
      • Fonguh S.
      • Uwineza A.
      • Catry B.
      • Simon A.
      Belgian hand hygiene campaigns in ICU, 2005–2015.
      ,
      • Fouad M.
      • Eltaher S.
      Hand hygiene initiative: comparative study of pre- and postintervention outcomes.
      ,
      • Freeman J.
      • Dawson L.
      • Jowitt D.
      • White M.
      • Callard H.
      • Sieczkowski C.
      • et al.
      The impact of the Hand Hygiene New Zealand programme on hand hygiene practices in New Zealand’s public hospitals.
      ,
      • Ghonim E.
      • Nolan R.
      • Benghuzzi H.
      Increasing hand hygiene compliance by use of a novel hand held device at a University Hospital.
      ,
      • Graf K.
      • Ott E.
      • Wolny M.
      • Tramp N.
      • Vonberg R.P.
      • Haverich A.
      • et al.
      Hand hygiene compliance in transplant and other special patient groups: an observational study.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Gombotz V.
      • Pregartner G.
      • Zierler R.
      • Schwarz C.
      • et al.
      Hand hygiene compliance in intensive care units: an observational study.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Pregartner G.
      • Gombotz V.
      • Tax C.
      • Zierler R.
      • et al.
      Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: an iterative process of information, training and feedback.
      ,
      • Johnson L.
      • Grueber S.
      • Schlotzhauer C.
      • Phillips E.
      • Bullock P.
      • Basnett J.
      • et al.
      A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections.
      ,
      • Keller J.
      • Wolfensberger A.
      • Clack L.
      • Kuster S.P.
      • Dunic M.
      • Eis D.
      • et al.
      Do wearable alcohol-based handrub dispensers increase hand hygiene compliance? – a mixed-methods study.
      ,
      • Kukanich K.S.
      • Kaur R.
      • Freeman L.C.
      • Powell D.A.
      Evaluation of a hand hygiene campaign in outpatient health care clinics.
      ,
      • Langston M.
      Effects of peer monitoring and peer feedback on hand hygiene in surgical intensive care unit and step-down units.
      ,
      • Lee S.S.
      • Park S.J.
      • Chung M.J.
      • Lee J.H.
      • Kang H.J.
      • Lee J.A.
      • et al.
      Improved hand hygiene compliance is associated with the change of perception toward hand hygiene among medical personnel.
      ,
      • Linam W.M.
      • Margolis P.A.
      • Atherton H.
      • Connelly B.L.
      Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene.
      ,
      • Mahfouz A.A.
      • Al-Zaydani I.A.
      • Abdelaziz A.O.
      • El-Gamal M.N.
      • Assiri A.M.
      Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia.
      ,
      • Mayer J.
      • Mooney B.
      • Gundlapalli A.
      • Harbarth S.
      • Stoddard G.J.
      • Rubin M.A.
      • et al.
      Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.
      ,
      • Mazi W.
      • Senok A.C.
      • Al-Kahldy S.
      • Abdullah D.
      Implementation of the World Health Organization hand hygiene improvement strategy in critical care units.
      ,
      • Mestre G.
      • Berbel C.
      • Tortajada P.
      • Alarcia M.
      • Coca R.
      • Gallemi G.
      • et al.
      “The 3/3 strategy”: a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology.
      ,
      • Monistrol O.
      • Calbo E.
      • Riera M.
      • Nicolás C.
      • Font R.
      • Freixas N.
      • et al.
      Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards.
      ,
      • Moro M.L.
      • Morsillo F.
      • Nascetti S.
      • Parenti M.
      • Allegranzi B.
      • Pompa M.G.
      • et al.
      Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007–2008 and 2014.
      ,
      • Musu M.
      • Finco G.
      • Mura P.
      • oni G.
      • Piazza M.F.
      • Messina M.
      • et al.
      Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units.
      ,
      • Peponis T.
      • Cropano M.C.
      • Larentzakis A.
      • van der Wilden M.G.
      • Mejaddam Y.A.
      • Sideris C.A.
      • et al.
      Trauma team utilization of universal precautions: if you see something, say something.
      ,
      • Pontivivo G.
      • Rivas K.
      • Gallard J.
      • Yu J.
      • Perry L.
      A new approach to improving hand hygiene practice in an inner city acute hospital in Australia.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      • Wharrad H.
      • Windle R.
      An observational study of hand hygiene adherence following the introduction of an education intervention.
      ,
      • Roberts S.A.
      • Sieczkowski C.
      • Campbell T.
      • Balla G.
      • Keenan A.
      Implementing and sustaining a hand hygiene culture change programme at Auckland District Health Board.
      ,
      • Saitoh A.
      • Sato K.
      • Magara Y.
      • Osaki K.
      • Narita K.
      • Shioiri K.
      • et al.
      Improving hand hygiene adherence in healthcare workers before patient contact: a multimodal intervention in four tertiary care hospitals in Japan.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Kamiya T.
      • Sato Y.
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      ,
      • Sakihama T.
      • Kayauchi N.
      • Kamiya T.
      • Saint S.
      • Fowler K.
      • Ratz D.
      • et al.
      Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals.
      ,
      • Salama M.F.
      • Jamal W.Y.
      • Mousa H.A.
      • Al-Abdulghani K.A.
      • Rotimi V.O.
      The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital.
      ,
      • Scheithauer S.
      • Kamerseder V.
      • Petersen P.
      • Brokmann J.C.
      • Lopez-Gonzalez L.A.
      • Mach C.
      • et al.
      Improving hand hygiene compliance in the emergency department: getting to the point.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Seto W.H.
      • Yuen S.W.
      • Cheung C.W.
      • Ching P.T.
      • Cowling B.J.
      • Pittet D.
      Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.
      ,
      • Song X.
      • Stockwell D.C.
      • Floyd T.
      • Short B.L.
      • Singh N.
      Improving hand hygiene compliance in health care workers: strategies and impact on patient outcomes.
      ,
      • Staines A.
      • Amherdt I.
      • Lécureux E.
      • Petignat C.
      • Eggimann P.
      • Schwab M.
      • et al.
      Hand hygiene improvement and sustainability: assessing a breakthrough collaborative in western Switzerland.
      ,
      • Tromp M.
      • Brink-Huis A.
      • De Guchteneire I.
      • Van Der Meer J.
      • Van Achterberg T.
      • Hulscher M.
      • et al.
      The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement programme.
      ,
      • van Dijk M.D.
      • Mulder S.A.
      • Erasmus V.
      • van Beeck A.H.E.
      • Vermeeren J.
      • Liu X.
      • et al.
      A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance.
      ,
      • Visan F.A.
      • Zakaria A.
      • Castro J.
      • Alhasanat O.
      • Ismail K.A.
      • Ansari N.A.
      • et al.
      SWITCH: Al Wakra Hospital journey to 90% hand hygiene practice compliance, 2011–2015.
      ,
      • Watson J.A.
      The role of a multimodal educational strategy on healthcare workers’ hand washing.
      ,
      • Yoo E.
      • Ursua L.
      • Clark R.
      • Seok J.
      • Jeon J.
      • Kim H.B.
      The effect of incorporating covert observation into established overt observation-based hand hygiene promotion programs.
      ]
       Observational48[
      • El-Saed A.
      • Noushad S.
      • Tannous E.
      • Abdirizak F.
      • Arabi Y.
      • Al Azzam S.
      • et al.
      Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia.
      ,
      • Hagel S.
      • Reischke J.
      • Kesselmeier M.
      • Winning J.
      • Gastmeier P.
      • Brunkhorst F.M.
      • et al.
      Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
      ,
      • Kovacs-Litman A.
      • Wong K.
      • Shojania K.G.
      • Callery S.
      • Vearncombe M.
      • Leis J.A.
      Do physicians clean their hands? Insights from a covert observational study.
      ,
      • AlNakhli D.J.
      • Baig K.
      • Goh A.
      • Okji H.
      • Din S.S.
      Determinants of hand hygiene non-compliance in a cardiac center in Saudi Arabia.
      ,
      • Alshammari M.
      • Reynolds K.A.
      • Verhougstraete M.
      • O’Rourke M.K.
      Comparison of perceived and observed hand hygiene compliance in healthcare workers in MERS-CoV endemic regions.
      ,
      • Alsubaie S.
      • Maither A.
      • Alalmaei W.
      • Al-Shammari A.D.
      • Tashkandi M.
      • Somily A.M.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      ,
      • Azim S.
      • Juergens C.
      • McLaws M.L.
      An average hand hygiene day for nurses and physicians: the burden is not equal.
      ,
      • Baek E.H.
      • Kim S.E.
      • Kim D.H.
      • Cho O.H.
      • Hong S.I.
      • Kim S.
      The difference in hand hygiene compliance rate between unit-based observers and trained observers for World Health Organization checklist and optimal hand hygiene.
      ,
      • Barker A.K.
      • Cowley E.S.
      • McKinley L.
      • Wright M.O.
      • Safdar N.
      An in-room observation study of hand hygiene and contact precaution compliance for Clostridioides difficile patients.
      ,
      • Bow E.J.
      • Bourrier V.
      • Phillips D.
      • Winski G.
      • Williams M.
      • Kostiuk N.
      • et al.
      Hand hygiene compliance at a Canadian provincial cancer centre – the complementary roles of nurse auditor-driven and patient auditor-driven audit processes and impact upon practice in ambulatory cancer care.
      ,
      • Bow E.J.
      • Bourrier V.
      • Trudel J.
      • Kostiuk N.
      • McLeod J.M.
      Patient-driven hand hygiene audit process at a regional cancer center.
      ,
      • Brühwasser C.
      • Hinterberger G.
      • Mutschlechner W.
      • Kaltseis J.
      • Lass-Flörl C.
      • Mayr A.
      A point prevalence survey on hand hygiene, with a special focus on Candida species.
      ,
      • Bukhari S.Z.
      • Hussain W.M.
      • Banjar A.
      • Almaimani W.H.
      • Karima T.M.
      • Fatani M.I.
      Hand hygiene compliance rate among healthcare professionals.
      ,
      • Chen L.F.
      • Carriker C.
      • Staheli R.
      • Isaacs P.
      • Elliott B.
      • Miller B.A.
      • et al.
      Observing and improving hand hygiene compliance: implementation and refinement of an electronic-assisted direct-observer hand hygiene audit program.
      ,
      • Deyneko A.
      • Cordeiro F.
      • Berlin L.
      • Ben-David D.
      • Perna S.
      • Longtin Y.
      Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study.
      ,
      • Dhar S.
      • Marchaim D.
      • Tansek R.
      • Chopra T.
      • Yousuf A.
      • Bhargava A.
      • et al.
      Contact precautions: more is not necessarily better.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel before patient contact. Part I.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II.
      ,
      • Gilbert K.
      • Stafford C.
      • Crosby K.
      • Fleming E.
      • Gaynes R.
      Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs?.
      ,
      • Gras-Valentí P.
      • Mora-Muriel J.G.
      • Fuster-Pérez M.
      • Benito-Miralles C.M.
      • Vela-Morales M.C.
      • González-Hernández M.
      • et al.
      Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital.
      ,
      • Grayson M.L.
      • Russo P.L.
      • Cruickshank M.
      • Bear J.L.
      • Gee C.A.
      • Hughes C.F.
      • et al.
      Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative.
      ,
      • Grayson M.L.
      • Stewardson A.J.
      • Russo P.L.
      • Ryan K.E.
      • Olsen K.L.
      • Havers S.M.
      • et al.
      Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.
      ,
      • Guanche Garcell H.
      • Villanueva Arias A.
      • Ramírez Miranda F.
      • Rubiera Jimenez R.
      • Alfonso Serrano R.N.
      Direct observation of hand hygiene can show differences in staff compliance: do we need to evaluate the accuracy for patient safety?.
      ,
      • Jeanes A.
      • Coen P.G.
      • Drey N.S.
      • Gould D.J.
      The development of hand hygiene compliance imperatives in an emergency department.
      ,
      • Kramer T.S.
      • Bunte K.
      • Schröder C.
      • Behnke M.
      • Clausmeyer J.
      • Reichardt C.
      • et al.
      No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.
      ,
      • Kwon J.H.
      • Reske K.
      • O’Neil C.A.
      • Cass C.
      • Seiler S.
      • Wallace M.A.
      • et al.
      Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures.
      ,
      • Lebovic G.
      • Siddiqui N.
      • Muller M.P.
      Predictors of hand hygiene compliance in the era of alcohol-based hand rinse.
      ,
      • Lee A.
      • Chalfine A.
      • Daikos G.L.
      • Garilli S.
      • Jovanovic B.
      • Lemmen S.
      • et al.
      Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: a multicenter observational study.
      ,
      • Lieber S.R.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Fumagalli C.
      • Bartolozzi D.
      • et al.
      The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany.
      ,
      • Ling M.L.
      • How K.B.
      Impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections.
      ,
      • Mahfouz A.A.
      • El Gamal M.N.
      • Al-Azraqi T.A.
      Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia.
      ,
      • Mertz D.
      • Johnstone J.
      • Krueger P.
      • Brazil K.
      • Walter S.D.
      • Loeb M.
      Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.
      ,
      • Muller M.P.
      • Carter E.
      • Siddiqui N.
      • Larson E.
      Hand hygiene compliance in an emergency department: the effect of crowding.
      ,
      • Musu M.
      • Lai A.
      • Mereu N.M.
      • Galletta M.
      • Campagna M.
      • Tidore M.
      • et al.
      Assessing hand hygiene compliance among healthcare workers in six intensive care units.
      ,
      • Petrilli C.M.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Bartoloni A.
      The effect of merging two infectious disease units on hand hygiene adherence in Italy.
      ,
      • Price L.
      • Roome K.
      • Lisa R.
      • Reilly J.
      • McIntyre J.
      • Godwin J.
      • et al.
      Toward improving the World Health Organization fifth moment for hand hygiene in the prevention of cross-infection.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      ,
      • Randle J.
      • Firth J.
      • Vaughan N.
      An observational study of hand hygiene compliance in paediatric wards.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Shimizu T.
      • Kamiya T.
      • et al.
      Hand hygiene adherence among health care workers at Japanese hospitals: a multicenter observational study in Japan.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Heimann K.
      • Haefner H.
      • Schwanz T.
      • Waitschies B.
      • et al.
      Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Stollbrink-Peschgens C.
      • Haefner H.
      • Waitschies B.
      • Wagner N.
      • et al.
      Suspicion of viral gastroenteritis does improve compliance with hand hygiene.
      ,
      • Smith S.J.
      • Young V.
      • Robertson C.
      • Dancer S.J.
      Where do hands go? An audit of sequential hand-touch events on a hospital ward.
      ,
      • Squeri R.
      • Genovese C.
      • Palamara M.A.
      • Trimarchi G.
      • La Fauci V.
      “Clean care is safer care”: correct handwashing in the prevention of healthcare associated infections.
      ,
      • Stahmeyer J.T.
      • Lutze B.
      • von Lengerke T.
      • Chaberny I.F.
      • Krauth C.
      Hand hygiene in intensive care units: a matter of time?.
      ,
      • Venkatesh A.K.
      • Pallin D.J.
      • Kayden S.
      • Schuur J.D.
      Predictors of hand hygiene in the emergency department.
      ,
      • Wetzker W.
      • Bunte-Schönberger K.
      • Walter J.
      • Pilarski G.
      • Gastmeier P.
      • Reichardt C.
      Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany.
      ,
      • Wu K.S.
      • Lee S.S.J.
      • Chen J.K.
      • Chen Y.S.
      • Tsai H.C.
      • Lin H.S.
      Identifying the heterogenicity of the Hawthorne effect in hand hygiene: a case–control study of overt and covert observation results.
      ]
      Setting
       ICU15[
      • Hagel S.
      • Reischke J.
      • Kesselmeier M.
      • Winning J.
      • Gastmeier P.
      • Brunkhorst F.M.
      • et al.
      Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
      ,
      • Al-Dorzi H.M.
      • Matroud A.
      • Al Attas K.A.
      • Azzam A.I.
      • Musned A.
      • Naidu B.
      • et al.
      A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center.
      ,
      • Albert B.D.
      • Petti C.
      • Caraglia A.
      • Geller M.
      • Horak R.
      • Barrett M.
      • et al.
      Multidisciplinary quality improvement intervention to achieve sustained improvement in hand hygiene reliability in a pediatric intensive care unit.
      ,
      • Alsubaie S.
      • Maither A.
      • Alalmaei W.
      • Al-Shammari A.D.
      • Tashkandi M.
      • Somily A.M.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      ,
      • Baccolini V.
      • D’Egidio V.
      • de Soccio P.
      • Migliara G.
      • Massimi A.
      • Aless
      • et al.
      Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital.
      ,
      • Birnbach D.J.
      • Rosen L.F.
      • Fitzpatrick M.
      • Everett-Thomas R.
      • Arheart K.L.
      A ubiquitous but ineffective intervention: signs do not increase hand hygiene compliance.
      ,
      • Fonguh S.
      • Uwineza A.
      • Catry B.
      • Simon A.
      Belgian hand hygiene campaigns in ICU, 2005–2015.
      ,
      • Gilbert K.
      • Stafford C.
      • Crosby K.
      • Fleming E.
      • Gaynes R.
      Does hand hygiene compliance among health care workers change when patients are in contact precaution rooms in ICUs?.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Gombotz V.
      • Pregartner G.
      • Zierler R.
      • Schwarz C.
      • et al.
      Hand hygiene compliance in intensive care units: an observational study.
      ,
      • Musu M.
      • Finco G.
      • Mura P.
      • oni G.
      • Piazza M.F.
      • Messina M.
      • et al.
      Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units.
      ,
      • Musu M.
      • Lai A.
      • Mereu N.M.
      • Galletta M.
      • Campagna M.
      • Tidore M.
      • et al.
      Assessing hand hygiene compliance among healthcare workers in six intensive care units.
      ,
      • Salama M.F.
      • Jamal W.Y.
      • Mousa H.A.
      • Al-Abdulghani K.A.
      • Rotimi V.O.
      The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Heimann K.
      • Haefner H.
      • Schwanz T.
      • Waitschies B.
      • et al.
      Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance.
      ,
      • Stahmeyer J.T.
      • Lutze B.
      • von Lengerke T.
      • Chaberny I.F.
      • Krauth C.
      Hand hygiene in intensive care units: a matter of time?.
      ,
      • van der Kooi Tii
      • Sax H.
      • Pittet D.
      • Dissel J.
      • Benthem B.
      • Walder B.
      • et al.
      Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.
      ]
       Hospital-wide13[
      • Al-Tawfiq J.A.
      • Abed M.S.
      • Al-Yami N.
      • Birrer R.B.
      Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections.
      ,
      • Barker A.K.
      • Cowley E.S.
      • McKinley L.
      • Wright M.O.
      • Safdar N.
      An in-room observation study of hand hygiene and contact precaution compliance for Clostridioides difficile patients.
      ,
      • Bukhari S.Z.
      • Hussain W.M.
      • Banjar A.
      • Almaimani W.H.
      • Karima T.M.
      • Fatani M.I.
      Hand hygiene compliance rate among healthcare professionals.
      ,
      • Chen J.K.
      • Wu K.S.
      • Lee S.S.
      • Lin H.S.
      • Tsai H.C.
      • Li C.H.
      • et al.
      Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan.
      ,
      • Crews J.D.
      • Whaley E.
      • Syblik D.
      • Starke J.
      Sustained improvement in hand hygiene at a children’s hospital.
      ,
      • Cunningham D.
      • Brilli R.J.
      • McClead Jr., R.E.
      • Davis J.T.
      The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.
      ,
      • Ghonim E.
      • Nolan R.
      • Benghuzzi H.
      Increasing hand hygiene compliance by use of a novel hand held device at a University Hospital.
      ,
      • Johnson L.
      • Grueber S.
      • Schlotzhauer C.
      • Phillips E.
      • Bullock P.
      • Basnett J.
      • et al.
      A multifactorial action plan improves hand hygiene adherence and significantly reduces central line-associated bloodstream infections.
      ,
      • Lebovic G.
      • Siddiqui N.
      • Muller M.P.
      Predictors of hand hygiene compliance in the era of alcohol-based hand rinse.
      ,
      • Lee S.S.
      • Park S.J.
      • Chung M.J.
      • Lee J.H.
      • Kang H.J.
      • Lee J.A.
      • et al.
      Improved hand hygiene compliance is associated with the change of perception toward hand hygiene among medical personnel.
      ,
      • Ling M.L.
      • How K.B.
      Impact of a hospital-wide hand hygiene promotion strategy on healthcare-associated infections.
      ,
      • Visan F.A.
      • Zakaria A.
      • Castro J.
      • Alhasanat O.
      • Ismail K.A.
      • Ansari N.A.
      • et al.
      SWITCH: Al Wakra Hospital journey to 90% hand hygiene practice compliance, 2011–2015.
      ,
      • Yoo E.
      • Ursua L.
      • Clark R.
      • Seok J.
      • Jeon J.
      • Kim H.B.
      The effect of incorporating covert observation into established overt observation-based hand hygiene promotion programs.
      ]
       Emergency Department (ED)10[
      • Alshammari M.
      • Reynolds K.A.
      • Verhougstraete M.
      • O’Rourke M.K.
      Comparison of perceived and observed hand hygiene compliance in healthcare workers in MERS-CoV endemic regions.
      ,
      • Arntz P.R.
      • Hopman J.
      • Nillesen M.
      • Yalcin E.
      • Bleeker-Rovers C.P.
      • Voss A.
      • et al.
      Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department.
      ,
      • di Martino P.
      • Ban K.M.
      • Bartoloni A.
      • Fowler K.E.
      • Saint S.
      • Mannelli F.
      Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation.
      ,
      • Fouad M.
      • Eltaher S.
      Hand hygiene initiative: comparative study of pre- and postintervention outcomes.
      ,
      • Jeanes A.
      • Coen P.G.
      • Drey N.S.
      • Gould D.J.
      The development of hand hygiene compliance imperatives in an emergency department.
      ,
      • Keller J.
      • Wolfensberger A.
      • Clack L.
      • Kuster S.P.
      • Dunic M.
      • Eis D.
      • et al.
      Do wearable alcohol-based handrub dispensers increase hand hygiene compliance? – a mixed-methods study.
      ,
      • Muller M.P.
      • Carter E.
      • Siddiqui N.
      • Larson E.
      Hand hygiene compliance in an emergency department: the effect of crowding.
      ,
      • Peponis T.
      • Cropano M.C.
      • Larentzakis A.
      • van der Wilden M.G.
      • Mejaddam Y.A.
      • Sideris C.A.
      • et al.
      Trauma team utilization of universal precautions: if you see something, say something.
      ,
      • Scheithauer S.
      • Kamerseder V.
      • Petersen P.
      • Brokmann J.C.
      • Lopez-Gonzalez L.A.
      • Mach C.
      • et al.
      Improving hand hygiene compliance in the emergency department: getting to the point.
      ,
      • Venkatesh A.K.
      • Pallin D.J.
      • Kayden S.
      • Schuur J.D.
      Predictors of hand hygiene in the emergency department.
      ]
       Medical/surgical wards9[
      • Azim S.
      • Juergens C.
      • McLaws M.L.
      An average hand hygiene day for nurses and physicians: the burden is not equal.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel before patient contact. Part I.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Pregartner G.
      • Gombotz V.
      • Tax C.
      • Zierler R.
      • et al.
      Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: an iterative process of information, training and feedback.
      ,
      • Lee A.
      • Chalfine A.
      • Daikos G.L.
      • Garilli S.
      • Jovanovic B.
      • Lemmen S.
      • et al.
      Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: a multicenter observational study.
      ,
      • Monistrol O.
      • Calbo E.
      • Riera M.
      • Nicolás C.
      • Font R.
      • Freixas N.
      • et al.
      Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      Twenty-four-hour observational study of hospital hand hygiene compliance.
      ,
      • Randle J.
      • Arthur A.
      • Vaughan N.
      • Wharrad H.
      • Windle R.
      An observational study of hand hygiene adherence following the introduction of an education intervention.
      ,
      • Tromp M.
      • Brink-Huis A.
      • De Guchteneire I.
      • Van Der Meer J.
      • Van Achterberg T.
      • Hulscher M.
      • et al.
      The short-term and long-term effectiveness of a multidisciplinary hand hygiene improvement programme.
      ]
       Paediatric wards4[
      • Gras-Valentí P.
      • Mora-Muriel J.G.
      • Fuster-Pérez M.
      • Benito-Miralles C.M.
      • Vela-Morales M.C.
      • González-Hernández M.
      • et al.
      Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital.
      ,
      • Linam W.M.
      • Margolis P.A.
      • Atherton H.
      • Connelly B.L.
      Quality-improvement initiative sustains improvement in pediatric health care worker hand hygiene.
      ,
      • Randle J.
      • Firth J.
      • Vaughan N.
      An observational study of hand hygiene compliance in paediatric wards.
      ,
      • Scheithauer S.
      • Oude-Aost J.
      • Stollbrink-Peschgens C.
      • Haefner H.
      • Waitschies B.
      • Wagner N.
      • et al.
      Suspicion of viral gastroenteritis does improve compliance with hand hygiene.
      ]
       ICU and various units34[
      • El-Saed A.
      • Noushad S.
      • Tannous E.
      • Abdirizak F.
      • Arabi Y.
      • Al Azzam S.
      • et al.
      Quantifying the Hawthorne effect using overt and covert observation of hand hygiene at a tertiary care hospital in Saudi Arabia.
      ,
      • AlNakhli D.J.
      • Baig K.
      • Goh A.
      • Okji H.
      • Din S.S.
      Determinants of hand hygiene non-compliance in a cardiac center in Saudi Arabia.
      ,
      • Baek E.H.
      • Kim S.E.
      • Kim D.H.
      • Cho O.H.
      • Hong S.I.
      • Kim S.
      The difference in hand hygiene compliance rate between unit-based observers and trained observers for World Health Organization checklist and optimal hand hygiene.
      ,
      • Brühwasser C.
      • Hinterberger G.
      • Mutschlechner W.
      • Kaltseis J.
      • Lass-Flörl C.
      • Mayr A.
      A point prevalence survey on hand hygiene, with a special focus on Candida species.
      ,
      • Buffet-Bataillon S.
      • Leray E.
      • Poisson M.
      • Michelet C.
      • Bonnaure-Mallet M.
      • Cormier M.
      Influence of job seniority, hand hygiene education, and patient-to-nurse ratio on hand disinfection compliance.
      ,
      • Costers M.
      • Viseur N.
      • Catry B.
      • Simon A.
      Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene.
      ,
      • Dhar S.
      • Marchaim D.
      • Tansek R.
      • Chopra T.
      • Yousuf A.
      • Bhargava A.
      • et al.
      Contact precautions: more is not necessarily better.
      ,
      • Dierssen-Sotos T.
      • Brugos-Llamazares V.
      • Robles-García M.
      • Rebollo-Rodrigo H.
      • Fariñas-Alvarez C.
      • Antolín-Juarez F.M.
      • et al.
      Evaluating the impact of a hand hygiene campaign on improving adherence.
      ,
      • Freeman J.
      • Dawson L.
      • Jowitt D.
      • White M.
      • Callard H.
      • Sieczkowski C.
      • et al.
      The impact of the Hand Hygiene New Zealand programme on hand hygiene practices in New Zealand’s public hospitals.
      ,
      • Graf K.
      • Ott E.
      • Wolny M.
      • Tramp N.
      • Vonberg R.P.
      • Haverich A.
      • et al.
      Hand hygiene compliance in transplant and other special patient groups: an observational study.
      ,
      • Grant A.
      • Hofmann D.
      It’s not all about me: motivating hand hygiene among health care professionals by focusing on patients.
      ,
      • Grayson M.L.
      • Stewardson A.J.
      • Russo P.L.
      • Ryan K.E.
      • Olsen K.L.
      • Havers S.M.
      • et al.
      Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.
      ,
      • Guanche Garcell H.
      • Villanueva Arias A.
      • Ramírez Miranda F.
      • Rubiera Jimenez R.
      • Alfonso Serrano R.N.
      Direct observation of hand hygiene can show differences in staff compliance: do we need to evaluate the accuracy for patient safety?.
      ,
      • Kramer T.S.
      • Bunte K.
      • Schröder C.
      • Behnke M.
      • Clausmeyer J.
      • Reichardt C.
      • et al.
      No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.
      ,
      • Kwon J.H.
      • Reske K.
      • O’Neil C.A.
      • Cass C.
      • Seiler S.
      • Wallace M.A.
      • et al.
      Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures.
      ,
      • Langston M.
      Effects of peer monitoring and peer feedback on hand hygiene in surgical intensive care unit and step-down units.
      ,
      • Mahfouz A.A.
      • Al-Zaydani I.A.
      • Abdelaziz A.O.
      • El-Gamal M.N.
      • Assiri A.M.
      Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia.
      ,
      • Mahfouz A.A.
      • El Gamal M.N.
      • Al-Azraqi T.A.
      Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia.
      ,
      • Mayer J.
      • Mooney B.
      • Gundlapalli A.
      • Harbarth S.
      • Stoddard G.J.
      • Rubin M.A.
      • et al.
      Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.
      ,
      • Mazi W.
      • Senok A.C.
      • Al-Kahldy S.
      • Abdullah D.
      Implementation of the World Health Organization hand hygiene improvement strategy in critical care units.
      ,
      • Mertz D.
      • Johnstone J.
      • Krueger P.
      • Brazil K.
      • Walter S.D.
      • Loeb M.
      Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.
      ,
      • Mestre G.
      • Berbel C.
      • Tortajada P.
      • Alarcia M.
      • Coca R.
      • Gallemi G.
      • et al.
      “The 3/3 strategy”: a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology.
      ,
      • Moro M.L.
      • Morsillo F.
      • Nascetti S.
      • Parenti M.
      • Allegranzi B.
      • Pompa M.G.
      • et al.
      Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007–2008 and 2014.
      ,
      • Pontivivo G.
      • Rivas K.
      • Gallard J.
      • Yu J.
      • Perry L.
      A new approach to improving hand hygiene practice in an inner city acute hospital in Australia.
      ,
      • Saitoh A.
      • Sato K.
      • Magara Y.
      • Osaki K.
      • Narita K.
      • Shioiri K.
      • et al.
      Improving hand hygiene adherence in healthcare workers before patient contact: a multimodal intervention in four tertiary care hospitals in Japan.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Kamiya T.
      • Sato Y.
      • et al.
      Improving healthcare worker hand hygiene adherence before patient contact: a multimodal intervention of hand hygiene practice in three Japanese tertiary care centers.
      ,
      • Sakihama T.
      • Honda H.
      • Saint S.
      • Fowler K.E.
      • Shimizu T.
      • Kamiya T.
      • et al.
      Hand hygiene adherence among health care workers at Japanese hospitals: a multicenter observational study in Japan.
      ,
      • Sakihama T.
      • Kayauchi N.
      • Kamiya T.
      • Saint S.
      • Fowler K.
      • Ratz D.
      • et al.
      Assessing sustainability of hand hygiene adherence 5 years after a contest-based intervention in 3 Japanese hospitals.
      ,
      • Squeri R.
      • Genovese C.
      • Palamara M.A.
      • Trimarchi G.
      • La Fauci V.
      “Clean care is safer care”: correct handwashing in the prevention of healthcare associated infections.
      ,
      • van Dijk M.D.
      • Mulder S.A.
      • Erasmus V.
      • van Beeck A.H.E.
      • Vermeeren J.
      • Liu X.
      • et al.
      A multimodal regional intervention strategy framed as friendly competition to improve hand hygiene compliance.
      ,
      • von Lengerke T.
      • Lutze B.
      • Krauth C.
      • Lange K.
      • Stahmeyer J.T.
      • Chaberny I.F.
      Promoting hand hygiene compliance: PSYGIENE – a cluster-randomized controlled trial of tailored interventions.
      ,
      • Watson J.A.
      The role of a multimodal educational strategy on healthcare workers’ hand washing.
      ,
      • Wetzker W.
      • Bunte-Schönberger K.
      • Walter J.
      • Pilarski G.
      • Gastmeier P.
      • Reichardt C.
      Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany.
      ,
      • Wu K.S.
      • Lee S.S.J.
      • Chen J.K.
      • Chen Y.S.
      • Tsai H.C.
      • Lin H.S.
      Identifying the heterogenicity of the Hawthorne effect in hand hygiene: a case–control study of overt and covert observation results.
      ]
       ED and various units3[
      • Kovacs-Litman A.
      • Wong K.
      • Shojania K.G.
      • Callery S.
      • Vearncombe M.
      • Leis J.A.
      Do physicians clean their hands? Insights from a covert observational study.
      ,
      • Song X.
      • Stockwell D.C.
      • Floyd T.
      • Short B.L.
      • Singh N.
      Improving hand hygiene compliance in health care workers: strategies and impact on patient outcomes.
      ,
      • Wu K.S.
      • Chen Y.S.
      • Lin H.S.
      • Hsieh E.L.
      • Chen J.K.
      • Tsai H.C.
      • et al.
      A nationwide covert observation study using a novel method for hand hygiene compliance in health care.
      ]
       Various/other wards11[
      • Aghdassi S.J.S.
      • Schröder C.
      • Lemke E.
      • Behnke M.
      • Fliss P.M.
      • Plotzki C.
      • et al.
      A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial.
      ,
      • Chen L.F.
      • Carriker C.
      • Staheli R.
      • Isaacs P.
      • Elliott B.
      • Miller B.A.
      • et al.
      Observing and improving hand hygiene compliance: implementation and refinement of an electronic-assisted direct-observer hand hygiene audit program.
      ,
      • Deyneko A.
      • Cordeiro F.
      • Berlin L.
      • Ben-David D.
      • Perna S.
      • Longtin Y.
      Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study.
      ,
      • Grayson M.L.
      • Russo P.L.
      • Cruickshank M.
      • Bear J.L.
      • Gee C.A.
      • Hughes C.F.
      • et al.
      Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative.
      ,
      • Lieber S.R.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Fumagalli C.
      • Bartolozzi D.
      • et al.
      The effect of leadership on hand hygiene: assessing hand hygiene adherence prior to patient contact in 2 infectious disease units in Tuscany.
      ,
      • Petrilli C.M.
      • Mantengoli E.
      • Saint S.
      • Fowler K.E.
      • Bartoloni A.
      The effect of merging two infectious disease units on hand hygiene adherence in Italy.
      ,
      • Roberts S.A.
      • Sieczkowski C.
      • Campbell T.
      • Balla G.
      • Keenan A.
      Implementing and sustaining a hand hygiene culture change programme at Auckland District Health Board.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Smith S.J.
      • Young V.
      • Robertson C.
      • Dancer S.J.
      Where do hands go? An audit of sequential hand-touch events on a hospital ward.
      ,
      • Staines A.
      • Amherdt I.
      • Lécureux E.
      • Petignat C.
      • Eggimann P.
      • Schwab M.
      • et al.
      Hand hygiene improvement and sustainability: assessing a breakthrough collaborative in western Switzerland.
      ,
      • Stewardson A.J.
      • Sax H.
      • Gayet-Ageron A.
      • Touveneau S.
      • Longtin Y.
      • Zingg W.
      • et al.
      Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial.
      ]
       Outpatients3[
      • Bow E.J.
      • Bourrier V.
      • Phillips D.
      • Winski G.
      • Williams M.
      • Kostiuk N.
      • et al.
      Hand hygiene compliance at a Canadian provincial cancer centre – the complementary roles of nurse auditor-driven and patient auditor-driven audit processes and impact upon practice in ambulatory cancer care.
      ,
      • Bow E.J.
      • Bourrier V.
      • Trudel J.
      • Kostiuk N.
      • McLeod J.M.
      Patient-driven hand hygiene audit process at a regional cancer center.
      ,
      • Kukanich K.S.
      • Kaur R.
      • Freeman L.C.
      • Powell D.A.
      Evaluation of a hand hygiene campaign in outpatient health care clinics.
      ]
       Not recorded3[
      • Price L.
      • Roome K.
      • Lisa R.
      • Reilly J.
      • McIntyre J.
      • Godwin J.
      • et al.
      Toward improving the World Health Organization fifth moment for hand hygiene in the prevention of cross-infection.
      ,
      • Seto W.H.
      • Cowling B.J.
      • Cheung C.W.Y.
      • Wong C.Y.Y.
      • Pty Ching
      • Pittet D.
      • et al.
      Impact of the first hand sanitizing relay world record on compliance with hand hygiene in a hospital.
      ,
      • Seto W.H.
      • Yuen S.W.
      • Cheung C.W.
      • Ching P.T.
      • Cowling B.J.
      • Pittet D.
      Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.
      ]
      Observation method
       Overt68[
      • Hagel S.
      • Reischke J.
      • Kesselmeier M.
      • Winning J.
      • Gastmeier P.
      • Brunkhorst F.M.
      • et al.
      Quantifying the Hawthorne effect in hand hygiene compliance through comparing direct observation with automated hand hygiene monitoring.
      ,
      • Aghdassi S.J.S.
      • Schröder C.
      • Lemke E.
      • Behnke M.
      • Fliss P.M.
      • Plotzki C.
      • et al.
      A multimodal intervention to improve hand hygiene compliance in peripheral wards of a tertiary care university centre: a cluster randomised controlled trial.
      ,
      • Al-Dorzi H.M.
      • Matroud A.
      • Al Attas K.A.
      • Azzam A.I.
      • Musned A.
      • Naidu B.
      • et al.
      A multifaceted approach to improve hand hygiene practices in the adult intensive care unit of a tertiary-care center.
      ,
      • Al-Tawfiq J.A.
      • Abed M.S.
      • Al-Yami N.
      • Birrer R.B.
      Promoting and sustaining a hospital-wide, multifaceted hand hygiene program resulted in significant reduction in health care-associated infections.
      ,
      • Alshammari M.
      • Reynolds K.A.
      • Verhougstraete M.
      • O’Rourke M.K.
      Comparison of perceived and observed hand hygiene compliance in healthcare workers in MERS-CoV endemic regions.
      ,
      • Azim S.
      • Juergens C.
      • McLaws M.L.
      An average hand hygiene day for nurses and physicians: the burden is not equal.
      ,
      • Bow E.J.
      • Bourrier V.
      • Trudel J.
      • Kostiuk N.
      • McLeod J.M.
      Patient-driven hand hygiene audit process at a regional cancer center.
      ,
      • Brühwasser C.
      • Hinterberger G.
      • Mutschlechner W.
      • Kaltseis J.
      • Lass-Flörl C.
      • Mayr A.
      A point prevalence survey on hand hygiene, with a special focus on Candida species.
      ,
      • Buffet-Bataillon S.
      • Leray E.
      • Poisson M.
      • Michelet C.
      • Bonnaure-Mallet M.
      • Cormier M.
      Influence of job seniority, hand hygiene education, and patient-to-nurse ratio on hand disinfection compliance.
      ,
      • Chen J.K.
      • Wu K.S.
      • Lee S.S.
      • Lin H.S.
      • Tsai H.C.
      • Li C.H.
      • et al.
      Impact of implementation of the World Health Organization multimodal hand hygiene improvement strategy in a teaching hospital in Taiwan.
      ,
      • Costers M.
      • Viseur N.
      • Catry B.
      • Simon A.
      Four multifaceted countrywide campaigns to promote hand hygiene in Belgian hospitals between 2005 and 2011: impact on compliance to hand hygiene.
      ,
      • Deyneko A.
      • Cordeiro F.
      • Berlin L.
      • Ben-David D.
      • Perna S.
      • Longtin Y.
      Impact of sink location on hand hygiene compliance after care of patients with Clostridium difficile infection: a cross-sectional study.
      ,
      • di Martino P.
      • Ban K.M.
      • Bartoloni A.
      • Fowler K.E.
      • Saint S.
      • Mannelli F.
      Assessing the sustainability of hand hygiene adherence prior to patient contact in the emergency department: a 1-year postintervention evaluation.
      ,
      • Dierssen-Sotos T.
      • Brugos-Llamazares V.
      • Robles-García M.
      • Rebollo-Rodrigo H.
      • Fariñas-Alvarez C.
      • Antolín-Juarez F.M.
      • et al.
      Evaluating the impact of a hand hygiene campaign on improving adherence.
      ,
      • Fonguh S.
      • Uwineza A.
      • Catry B.
      • Simon A.
      Belgian hand hygiene campaigns in ICU, 2005–2015.
      ,
      • Fouad M.
      • Eltaher S.
      Hand hygiene initiative: comparative study of pre- and postintervention outcomes.
      ,
      • Freeman J.
      • Dawson L.
      • Jowitt D.
      • White M.
      • Callard H.
      • Sieczkowski C.
      • et al.
      The impact of the Hand Hygiene New Zealand programme on hand hygiene practices in New Zealand’s public hospitals.
      ,
      • Graf K.
      • Ott E.
      • Wolny M.
      • Tramp N.
      • Vonberg R.P.
      • Haverich A.
      • et al.
      Hand hygiene compliance in transplant and other special patient groups: an observational study.
      ,
      • Gras-Valentí P.
      • Mora-Muriel J.G.
      • Fuster-Pérez M.
      • Benito-Miralles C.M.
      • Vela-Morales M.C.
      • González-Hernández M.
      • et al.
      Evolution and associated factors of hand hygiene compliance in a pediatric tertiary hospital.
      ,
      • Grayson M.L.
      • Russo P.L.
      • Cruickshank M.
      • Bear J.L.
      • Gee C.A.
      • Hughes C.F.
      • et al.
      Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative.
      ,
      • Grayson M.L.
      • Stewardson A.J.
      • Russo P.L.
      • Ryan K.E.
      • Olsen K.L.
      • Havers S.M.
      • et al.
      Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.
      ,
      • Guanche Garcell H.
      • Villanueva Arias A.
      • Ramírez Miranda F.
      • Rubiera Jimenez R.
      • Alfonso Serrano R.N.
      Direct observation of hand hygiene can show differences in staff compliance: do we need to evaluate the accuracy for patient safety?.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Gombotz V.
      • Pregartner G.
      • Zierler R.
      • Schwarz C.
      • et al.
      Hand hygiene compliance in intensive care units: an observational study.
      ,
      • Hoffmann M.
      • Sendlhofer G.
      • Pregartner G.
      • Gombotz V.
      • Tax C.
      • Zierler R.
      • et al.
      Interventions to increase hand hygiene compliance in a tertiary university hospital over a period of 5 years: an iterative process of information, training and feedback.
      ,
      • Jeanes A.
      • Coen P.G.
      • Drey N.S.
      • Gould D.J.
      The development of hand hygiene compliance imperatives in an emergency department.
      ,
      • Keller J.
      • Wolfensberger A.
      • Clack L.
      • Kuster S.P.
      • Dunic M.
      • Eis D.
      • et al.
      Do wearable alcohol-based handrub dispensers increase hand hygiene compliance? – a mixed-methods study.
      ,
      • Kramer T.S.
      • Bunte K.
      • Schröder C.
      • Behnke M.
      • Clausmeyer J.
      • Reichardt C.
      • et al.
      No increase in compliance before aseptic procedures in German hospitals. A longitudinal study with data from the national surveillance system over four years.
      ,
      • Kukanich K.S.
      • Kaur R.
      • Freeman L.C.
      • Powell D.A.
      Evaluation of a hand hygiene campaign in outpatient health care clinics.
      ,
      • Kwon J.H.
      • Reske K.
      • O’Neil C.A.
      • Cass C.
      • Seiler S.
      • Wallace M.A.
      • et al.
      Assessment of antibiotic-resistant organism transmission among rooms of hospitalized patients, healthcare personnel, and the hospital environment utilizing surrogate markers and selective bacterial cultures.
      ,
      • Langston M.
      Effects of peer monitoring and peer feedback on hand hygiene in surgical intensive care unit and step-down units.
      ,
      • Lebovic G.
      • Siddiqui N.
      • Muller M.P.
      Predictors of hand hygiene compliance in the era of alcohol-based hand rinse.
      ,
      • Lee A.
      • Chalfine A.
      • Daikos G.L.
      • Garilli S.
      • Jovanovic B.
      • Lemmen S.
      • et al.
      Hand hygiene practices and adherence determinants in surgical wards across Europe and Israel: a multicenter observational study.
      ,
      • Lee S.S.
      • Park S.J.
      • Chung M.J.
      • Lee J.H.
      • Kang H.J.
      • Lee J.A.
      • et al.
      Improved hand hygiene compliance is associated with the change of perception toward hand hygiene among medical personnel.
      ,
      • Mahfouz A.A.
      • Al-Zaydani I.A.
      • Abdelaziz A.O.
      • El-Gamal M.N.
      • Assiri A.M.
      Changes in hand hygiene compliance after a multimodal intervention among health-care workers from intensive care units in Southwestern Saudi Arabia.
      ,
      • Mahfouz A.A.
      • El Gamal M.N.
      • Al-Azraqi T.A.
      Hand hygiene non-compliance among intensive care unit health care workers in Aseer Central Hospital, south-western Saudi Arabia.
      ,
      • Mayer J.
      • Mooney B.
      • Gundlapalli A.
      • Harbarth S.
      • Stoddard G.J.
      • Rubin M.A.
      • et al.
      Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement.
      ,
      • Mazi W.
      • Senok A.C.
      • Al-Kahldy S.
      • Abdullah D.
      Implementation of the World Health Organization hand hygiene improvement strategy in critical care units.
      ,
      • Mertz D.
      • Johnstone J.
      • Krueger P.
      • Brazil K.
      • Walter S.D.
      • Loeb M.
      Adherence to hand hygiene and risk factors for poor adherence in 13 Ontario acute care hospitals.
      ,
      • Mestre G.
      • Berbel C.
      • Tortajada P.
      • Alarcia M.
      • Coca R.
      • Gallemi G.
      • et al.
      “The 3/3 strategy”: a successful multifaceted hospital wide hand hygiene intervention based on WHO and continuous quality improvement methodology.
      ,
      • Monistrol O.
      • Calbo E.
      • Riera M.
      • Nicolás C.
      • Font R.
      • Freixas N.
      • et al.
      Impact of a hand hygiene educational programme on hospital-acquired infections in medical wards.
      ,
      • Moro M.L.
      • Morsillo F.
      • Nascetti S.
      • Parenti M.
      • Allegranzi B.
      • Pompa M.G.
      • et al.
      Determinants of success and sustainability of the WHO multimodal hand hygiene promotion campaign, Italy, 2007–2008 and 2014.
      ,
      • Muller M.P.
      • Carter E.
      • Siddiqui N.
      • Larson E.
      Hand hygiene compliance in an emergency department: the effect of crowding.
      ,
      • Musu M.
      • Finco G.
      • Mura P.
      • oni G.
      • Piazza M.F.
      • Messina M.
      • et al.
      Controlling catheter-related bloodstream infections through a multi-centre educational programme for intensive care units.
      ,
      • Musu M.
      • Lai A.
      • Mereu N.M.
      • Galletta M.
      • Campagna M.
      • Tidore M.
      • et al.
      Assessing hand hygiene compliance among healthcare workers in six intensive care units.
      ,
      • Peponis T.
      • Cropano M.C.
      • Larentzakis A.
      • van der Wilden M.G.
      • Mejaddam Y.A.
      • Sideris C.A.
      • et al.
      Trauma team utilization of universal precautions: if you see something, say something.
      ,
      • Pontivivo G.
      • Rivas K.
      • Gallard J.
      • Yu J.
      • Perry L.
      A new approach to improving hand hygiene practice in an inner city acute hospital in Australia.
      ,
      • Roberts S.A.
      • Sieczkowski C.
      • Campbell T.
      • Balla G.
      • Keenan A.
      Implementing and sustaining a hand hygiene culture change programme at Auckland District Health Board.
      ,
      • Salama M.F.
      • Jamal W.Y.
      • Mousa H.A.
      • Al-Abdulghani K.A.
      • Rotimi V.O.
      The effect of hand hygiene compliance on hospital-acquired infections in an ICU setting in a Kuwaiti teaching hospital.
      ,
      • Scheithauer S.
      • Rosarius A.
      • Rex S.
      • Post P.
      • Heisel H.
      • Krizanovic V.
      • et al.
      Improving hand hygiene compliance in the anesthesia working room work area: more than just more hand rubs.
      ,
      • Seto W.H.
      • Yuen S.W.
      • Cheung C.W.
      • Ching P.T.
      • Cowling B.J.
      • Pittet D.
      Hand hygiene promotion and the participation of infection control link nurses: an effective innovation to overcome campaign fatigue.
      ,
      • Squeri R.
      • Genovese C.
      • Palamara M.A.
      • Trimarchi G.
      • La Fauci V.
      “Clean care is safer care”: correct handwashing in the prevention of healthcare associated infections.
      ,
      • Stewardson A.J.
      • Sax H.
      • Gayet-Ageron A.
      • Touveneau S.
      • Longtin Y.
      • Zingg W.
      • et al.
      Enhanced performance feedback and patient participation to improve hand hygiene compliance of health-care workers in the setting of established multimodal promotion: a single-centre, cluster randomised controlled trial.
      ,
      • van der Kooi Tii
      • Sax H.
      • Pittet D.
      • Dissel J.
      • Benthem B.
      • Walder B.
      • et al.
      Prevention of hospital infections by intervention and training (PROHIBIT): results of a pan-European cluster-randomized multicentre study to reduce central venous catheter-related bloodstream infections.
      ,
      • Venkatesh A.K.
      • Pallin D.J.
      • Kayden S.
      • Schuur J.D.
      Predictors of hand hygiene in the emergency department.
      ,
      • von Lengerke T.
      • Lutze B.
      • Krauth C.
      • Lange K.
      • Stahmeyer J.T.
      • Chaberny I.F.
      Promoting hand hygiene compliance: PSYGIENE – a cluster-randomized controlled trial of tailored interventions.
      ,
      • Wetzker W.
      • Bunte-Schönberger K.
      • Walter J.
      • Pilarski G.
      • Gastmeier P.
      • Reichardt C.
      Compliance with hand hygiene: reference data from the national hand hygiene campaign in Germany.
      ]
       Covert28[
      • Albert B.D.
      • Petti C.
      • Caraglia A.
      • Geller M.
      • Horak R.
      • Barrett M.
      • et al.
      Multidisciplinary quality improvement intervention to achieve sustained improvement in hand hygiene reliability in a pediatric intensive care unit.
      ,
      • AlNakhli D.J.
      • Baig K.
      • Goh A.
      • Okji H.
      • Din S.S.
      Determinants of hand hygiene non-compliance in a cardiac center in Saudi Arabia.
      ,
      • Alsubaie S.
      • Maither A.
      • Alalmaei W.
      • Al-Shammari A.D.
      • Tashkandi M.
      • Somily A.M.
      • et al.
      Determinants of hand hygiene noncompliance in intensive care units.
      ,
      • Arntz P.R.
      • Hopman J.
      • Nillesen M.
      • Yalcin E.
      • Bleeker-Rovers C.P.
      • Voss A.
      • et al.
      Effectiveness of a multimodal hand hygiene improvement strategy in the emergency department.
      ,
      • Baccolini V.
      • D’Egidio V.
      • de Soccio P.
      • Migliara G.
      • Massimi A.
      • Aless
      • et al.
      Effectiveness over time of a multimodal intervention to improve compliance with standard hygiene precautions in an intensive care unit of a large teaching hospital.
      ,
      • Birnbach D.J.
      • Rosen L.F.
      • Fitzpatrick M.
      • Everett-Thomas R.
      • Arheart K.L.
      A ubiquitous but ineffective intervention: signs do not increase hand hygiene compliance.
      ,
      • Bukhari S.Z.
      • Hussain W.M.
      • Banjar A.
      • Almaimani W.H.
      • Karima T.M.
      • Fatani M.I.
      Hand hygiene compliance rate among healthcare professionals.
      ,
      • Crews J.D.
      • Whaley E.
      • Syblik D.
      • Starke J.
      Sustained improvement in hand hygiene at a children’s hospital.
      ,
      • Cunningham D.
      • Brilli R.J.
      • McClead Jr., R.E.
      • Davis J.T.
      The safety stand-down: a technique for improving and sustaining hand hygiene compliance among health care personnel.
      ,
      • Dhar S.
      • Marchaim D.
      • Tansek R.
      • Chopra T.
      • Yousuf A.
      • Bhargava A.
      • et al.
      Contact precautions: more is not necessarily better.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel before patient contact. Part I.
      ,
      • Garus-Pakowska A.
      • Sobala W.
      • Szatko F.
      Observance of hand washing procedures performed by the medical personnel after the patient contact. Part II.