National Multi-Center Study To Evaluate the Effect of Education and Performance Feedback on Handwashing in the Intensive Care Units of Three Mexican Hospitals: Differences between Gender, Healthcare Worker, and Type of Procedure

BACKGROUND: Our objective was to evaluate the effects of education plus performance feedback on handwashing in the intensive care unit (ICU) before contact with patients in three Mexican hospitals. METHODS: Three hospital ICUs were studied. One healthcare worker (HCW) per hospital was trained to detect the handwashing compliance of physicians, nursing staff, and technicians at random times. The contacts were monitored with direct observation and were recorded before contact with each patient. To provide feedback, bar charts of handwashing rates were posted monthly in ICUs. Following 3 months of initial observations, we evaluated the effect of education plus performance feedback. RESULTS: We observed 6861 patient contacts. The baseline rate of handwashing before contact with patients was 35.8% (260/727). With education plus performance feedback, this increased to 75.8% (4652/6134) (RR 2.12; 95% CI 1.87–2.40, p VALUE=0.0000). Using univariate analysis we found a statistically significant association of handwashing compliance and gender: women versus men, 73.8% and 65.8%, (RR 1.12; 95% CI 1.05–1.20, p VALUE=0.0004). There was an association between type of procedure: invasive versus superficial 78.9% versus 66.9% (RR 1.18; 95% CI 1.11–1.25, p VALUE=0.0000), and HCW: nurse versus physician 75.3% and 65.3% (RR 1.15; 95% CI 1.07-1.24, P value: 0.0002). There was also an association between nurse versus ancillary staff, nurse 75.3% and 56.3% (RR 1.34; 95% CI 1.20–1.49, p VALUE=0.0000), and physician versus ancillary staff (RR 1.16; 95% CI 1.03–1.31, p VALUE=0.017). CONCLUSIONS: Policies, education, and performance feedback can significantly improve HCW adherence to the handwashing protocol. Women, nurses, and invasive procedures are associated with greater handwashing compliance.