***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Context : The role of h and hygiene in preventing health care associated infections ( HCAIs ) has been clearly established . However , compliance rates remain poor among health care personnel . Aims : a ) To investigate the health care workers ’  h and hygiene compliance rates in the intensive care unit ( ICU ) , b ) to assess reasons for non-compliance and c ) to study the efficacy of a multimodal intervention strategy at improving compliance . Setting s : A mixed medical – surgical ICU of a tertiary level hospital . Design : A before – after prospect i ve , observational , intervention study . Material s and Methods : All health care personnel who came in contact with patients in the ICU were observed for their h and hygiene compliance before and after a multimodal intervention strategy ( education , posters , verbal reminders and easy availability of products ) . A self-report question naire was also circulated to assess perceptions regarding compliance . Statistical analysis was done using χ2 test or Fisher exact test ( Epi info software ) . Results : H and hygiene compliance among medical personnel working in the ICU was 26 % and the most common reason cited for non-compliance was lack of time ( 37 % ) . The overall compliance improved significantly following the intervention to 57.36 % ( P<0.000 ) . All health care worker groups showed significant improvements : staff nurses ( 21.48–61.59 % , P<0.0000 ) , nursing students ( 9.86–33.33 % , P<0.0000 ) , resident trainees ( 21.62–60.71 % , P<0.0000 ) , visiting consultants ( 22–57.14 % , P=0.0001 ) , physiotherapists ( 70–75.95 % , P=0.413 ) and paramedical staff ( 10.71–55.45 % , P < 0.0000 ) . Conclusions : H and hygiene compliance among health care workers in the ICU is poor ; however , intervention strategies , such as the one used , can be useful in improving the compliance rates significantly BACKGROUND H and hygiene is a fundamental measure for the control of nosocomial infection . However , sustained compliance with h and hygiene in health care workers is poor . We attempted to enhance compliance with h and hygiene by implementing education , training , and performance feedback . We measured nosocomial infections in parallel . METHODS We monitored the overall compliance with h and hygiene during routine patient care in intensive care units ( ICUs ) ; 1 medical surgical ICU and 1 coronary ICU , of 1 hospital in Buenos Aires , Argentina , before and during implementation of a  h and hygiene education , training , and performance feedback program . Observational surveys were done twice a week from September 2000 to May 2002 . Nosocomial infections in the ICUs were identified using the National Nosocomial Infections Surveillance ( NNIS ) criteria , with prospect i ve surveillance . RESULTS We observed 4347 opportunities for h and hygiene in both ICUs .  Compliance improved progressively ( h and washing adherence , 23.1 % ( 268/1160 ) to 64.5 % ( 2056/3187 ) ( RR , 2.79 ; 95 % CI : 2.46 - 3.17 ; P < .0001 ) . During the same period , overall nosocomial infection in both ICUs decreased from 47.55 per 1000 patient-days ( 104/2187 ) to 27.93 per 1000 patient days ( 207/7409 ) RR , 0.59 ; 95 % CI : 0.46 - 0.74 , P < .0001 ) . CONCLUSION A program consisting of focused education and frequent performance feedback produced a sustained improvement in compliance with h and hygiene , coinciding with a reduction in nosocomial infection rates in the ICUs OBJECTIVE To evaluate the effectiveness of a positive deviance strategy for the improvement of h and hygiene compliance in 2 adult step-down units . DESIGN A 9-month , controlled trial comparing the effect of positive deviance on compliance with h and hygiene . SETTING Two 20-bed step-down units at a tertiary care private hospital . METHODS The first phase of our study was a 3-month baseline period ( from April to June 2008 ) in which h and hygiene episodes were counted by use of electronic h and washing counters . From July to September 2008 ( ie , the second phase ) , a positive deviance strategy was implemented in the east unit ; the west unit was the control unit . During the period from October to December 2008 ( ie , the third phase ) , positive deviance was applied in both units . RESULTS During the first phase , there was no statistically significant difference between the 2 step-down units in the number of episodes of h and hygiene per 1,000 patient-days or in the incidence density of healthcare-associated infections ( HAIs ) per 1,000 patient-days . During the second phase , there were 62,000 h and hygiene episodes per 1,000 patient-days in the east unit and 33,570 h and hygiene episodes per 1,000 patient-days in the west unit ( P < .01 ) . The incidence density of HAIs per 1,000 patient-days was 6.5 in the east unit and 12.7 in the west unit ( p = .04 ) . During the third phase , there was no statistically significant difference in h and hygiene episodes per 1,000 patient-days ( P = .16 ) or in incidence density of HAIs per 1,000 patient-days . CONCLUSION A positive deviance strategy yielded a significant improvement in h and hygiene , which was associated with a decrease in the overall incidence of HAIs Introduction Achieving a sustained improvement in h and -hygiene compliance is the WHO ’s first global patient safety challenge . There is no RCT evidence showing how to do this . Systematic review s suggest feedback is most effective and call for long term well design ed RCTs , applying behavioural theory to intervention design to optimise effectiveness . Methods Three year stepped wedge cluster RCT of a feedback intervention testing hypothesis that the intervention was more effective than routine practice in 16 English/Welsh Hospitals ( 16 Intensive Therapy Units [ ITU ] ; 44 Acute Care of the Elderly [ ACE ] wards ) routinely implementing a national cleanyourh and s campaign ) . Intervention-based on Goal & Control theories . Repeating 4 week cycle ( 20 mins/week ) of observation , feedback and personalised action planning , recorded on forms . Computer-generated stepwise entry of all hospitals to intervention . Hospitals aware only of own allocation . Primary outcome : direct blinded h and hygiene compliance ( % ) . Results All 16 trusts ( 60 wards ) r and omised , 33 wards implemented intervention ( 11 ITU , 22 ACE ) . Mixed effects regression analysis ( all wards ) accounting for confounders , temporal trends , ward type and fidelity to intervention ( forms/month used ) . Intention to Treat Analysis Estimated odds ratio ( OR ) for h and hygiene compliance rose post r and omisation ( 1.44 ; 95 % CI 1.18 , 1.76;p<0.001 ) in ITUs but not ACE wards , equivalent to 7–9 % absolute increase in compliance . Per- Protocol Analysis for Implementing Wards OR for compliance rose for both ACE ( 1.67 [ 1.28–2.22 ] ; p<0.001 ) & ITUs ( 2.09 [1.55–2.81];p<0.001 ) equating to absolute increases of 10–13 % and 13–18 % respectively . Fidelity to intervention closely related to compliance on ITUs ( OR 1.12 [ 1.04 , 1.20];p = 0.003 per completed form ) but not ACE wards . Conclusion Despite difficulties in implementation , intention-to-treat , per- protocol and fidelity to intervention , analyses showed an intervention coupling feedback to personalised action planning produced moderate but significant sustained improvements in h and -hygiene compliance , in wards implementing a national h and -hygiene campaign . Further implementation studies are needed to maximise the intervention ’s effect in different setting s. Trial Registration Controlled-Trials.com IS RCT Introduction The clinical and economic burden of ventilator-associated pneumonia ( VAP ) is uncontested . We conducted the present study to determine whether low nurse-to-patient ratio increases the risk for VAP and whether this effect is similar for early-onset and late-onset VAP . Methods This prospect i ve , observational , single-centre cohort study was conducted in the medical intensive care unit ( ICU ) of the University of Geneva Hospitals . All patients who were at risk for ICU-acquired infection admitted from January 1999 to December 2002 were followed from admission to discharge . Collected variables included patient characteristics , admission diagnosis , Acute Physiology and Chronic Health Evaluation II score , co-morbidities , exposure to invasive devices , daily number of patients and nurses on duty , nurse training level and all-site ICU-acquired infections . VAP was diagnosed using st and ard definitions . Results Among 2,470 patients followed during their ICU stay , 262 VAP episodes were diagnosed in 209/936 patients ( 22.3 % ) who underwent mechanical ventilation .  Median duration of mechanical ventilation was 3 days ( interquartile range 2 to 6 days ) among patients without VAP and 11 days ( 6 to 19 days ) among patients with VAP . Late-onset VAP accounted for 61 % of all episodes . The VAP rate was 37.6 episodes per 1,000 days at risk ( 95 % confidence interval 33.2 to 42.4 ) . The median daily nurse-to-patient ratio over the study period was 1.9 ( interquartile range 1.8 to 2.2 ) . By multivariate Cox regression analysis , we found that a high nurse-to-patient ratio was associated with a decreased risk for late-onset VAP ( hazard ratio 0.42 , 95 % confidence interval 0.18 to 0.99 ) , but there was no association with early-onset VAP . Conclusion Lower nurse-to-patient ratio is associated with increased risk for late-onset VAP OBJECTIVE Our aim was to ascertain the effect of an infection control program , using education and performance feedback on intensive care units , for intravascular device (IVD)-associated bloodstream infection ( BSI ) . METHODS Within 4 level III , adult , intensive care units in Argentina , all admitted , adult patients with a central vascular catheter in place for at least 24 hours were included . This was a prospect i ve before- and -after trial in which rates of IVD-associated BSI determined during a period of active surveillance without education or performance feedback ( phase 1 ) were compared after sequential implementation of an infection control program using education ( phase 2 ) and performance feedback ( phase 3 ) . RESULTS A total of 1219 IVD days were accumulated in phase 1 ; 586 during phase 2 ; and 4140 during phase 3 . Compliance with central vascular catheter -- site care improved significantly from baseline during the study period . Overall rates of IVD-associated BSI were lowered significantly from baseline after sequential implementation of education and performance feedback ( 11.10 vs 46.63 BSI/1000 IVD days ; relative risk=0.25 ; 95 % confidence interval=0.17 - 0.36 ; P<.0001 ) . Rates of IVD-associated BSI decreased significantly after implementation of an educational program ( phase 1 to phase 2 ) ( relative risk 0.37 ; confidence interval 0.19 - 0.73 ; P=.0026 ) and further reductions were seen after implementation of a performance feedback program ( phase 2 to phase 3 ) , although the reduction did not reach statistical significance ( 9.9 vs 17.06 BSI/1000 IVD days ; relative risk 0.58 ; confidence interval 0.29 - 1.18 ; P=.11 ) . Additional analysis of the data using chi2 for trends demonstrated that sequential implementation of an education and performance feedback program result ed in a significant trend toward reduced rates of IVD-associated BSI ( P<.001 ) . CONCLUSION Implementation of an infection control program , using education and performance feedback , result ed in significant reductions in rates of IVD-associated BSI OBJECTIVE To evaluate the effect of education and performance feedback regarding compliance with catheter care and h and washing on rates of catheter-associated urinary tract infection ( UTI ) in intensive care units ( ICUs ) . SETTING Two level III adult ICUs in a private healthcare facility in Argentina . PATIENTS All adult patients admitted to the study units who had a urinary catheter in place for at least 24 hours . METHODS A prospect i ve , open trial in which rates of catheter-associated UTI determined during a baseline period of active surveillance without education and performance feedback were compared with rates of catheter-associated UTI after implementing education and performance feedback . RESULTS There were 1,779 catheter-days during the baseline period and 5,568 catheter-days during the intervention period . Compliance regarding prevention of compression of the tubing by a leg improved ( from 83 % to 96 % ; relative risk [ RR ] , 1.15 ; 95 % confidence interval [ CI 
    Output:
    
These components comprise manageable and widely applicable ways to reduce health-care-associated infections and improve patients ' safety