***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: Abstract H and washing practice s are persistently suboptimal among healthcare professionals and are also stubbornly resistant to change . The purpose of this quasi-experimental intervention trial was to assess the impact of an intervention to change organizational culture on frequency of staff h and washing ( as measured by counting devices inserted into soap dispensers on four critical care units ) and nosocomial infections associated with methicillin-resistant Staphylococcus aureus ( MRSA ) and vancomycin-resistant enterococci ( VRE ) . All staff in one of two hospitals in the mid-Atlantic region received an intervention with multiple components design ed to change organizational culture ; the second hospital served as a comparison . Over a period of 8 months , 860 567 soap dispensings were recorded , with significant improvements in the study hospital after 6 months of follow-up . Rates of MRSA were not significantly different between the two hospitals , but rates of VRE were significantly reduced in the intervention hospital during implementation OBJECTIVES To assess h and washing frequency according to CDC recommendations ; and to test a simple intervention to increase h and  washing compliance , design ed for the unique setting of the ED . METHODS A prospect i ve , observational , before- and -after study design with a convenience sampling technique was used to assess h and washing  compliance in the ED of a 742-bed urban , university-affiliated medical center with 65,000 visits annually . Emergency physicians ( EPs ) , registered nurses ( RNs ) , and nurse practitioners ( NPs ) were informed that their patient encounters were being monitored , but the nature of the study was kept confidential . A single observer evaluated individual EPs , RNs , and NPs in one- , two- , or three-hour blocks , recording compliance with CDC h and washing recommendations . After two weeks , brightly colored signs with CDC recommendations for h and washing were posted at all sinks and a copy of a related publication on h and washing by medical personnel was distributed to all staff . H and washing behaviors were again observed . RESULTS A total of 252 situations requiring h and washing were observed , 132 pre-intervention and 120 post-intervention . Total h and washing , h and washing by each staff design ation , and h and washing in each CDC recommendation category -- except h and washing between contacts with different patients --all showed tendencies toward improvement , though none was significant ( p > 0.05 ) . Both the NPs and RNs demonstrated significantly higher adherence to recommended h and washing between patients after the intervention than did the EPs ( 85 % vs 71 % vs 31 % , p < 0.01 and p < 0.05 , respectively ) . CONCLUSION Despite a trend in improvement of compliance with CDC recommendations , h and washing among ED personnel remained unacceptably low BACKGROUND H and hygiene prevents cross infection in hospitals , but compliance with recommended instructions is commonly poor . We attempted to promote h and hygiene by implementing a hospital-wide programme , with special emphasis on bedside , alcohol-based h and disinfection . We measured nosocomial infections in parallel . METHODS We monitored the overall compliance with h and hygiene during routine patient care in a teaching hospital in Geneva , Switzerl and , before and during implementation of a h and -hygiene campaign .  Seven hospital-wide observational surveys were done twice yearly from December , 1994 , to December , 1997 . Secondary outcome measures were nosocomial infection rates , attack rates of methicillin-resistant Staphylococcus aureus ( MRSA ) , and consumption of h and rub disinfectant .  FINDINGS We observed more than 20,000 opportunities for h and hygiene .  Compliance improved progressively from 48 % in 1994 , to 66 % in 1997 ( p<0.001 ) . Although recourse to h and washing with soap and water remained stable , frequency of h and disinfection substantially increased during the study period ( p<0.001 ) . This result was unchanged after adjustment for known risk factors of poor adherence . H and hygiene  improved significantly among nurses and nursing assistants , but remained poor among doctors . During the same period , overall nosocomial infection decreased ( prevalence of 16.9 % in 1994 to 9.9 % in 1998 ; p=0.04 ) , MRSA transmission rates decreased ( 2.16 to 0.93 episodes per 10,000 patient-days ; p<0.001 ) , and the consumption of alcohol-based h and rub solution  increased from 3.5 to 15.4 L per 1000 patient-days between 1993 and 1998 ( p<0.001 ) . INTERPRETATION The campaign produced a sustained improvement in compliance with h and  hygiene  , coinciding with a reduction of nosocomial infections and MRSA transmission . The promotion of bedside , antiseptic h and rubs largely contributed to the increase in compliance We tested the effectiveness of specific vs. general infection control interventions in a teaching hospital in Guatemala City . After 3 months of prospect i ve surveillance , we implemented targeted interventions ( i.e. , modification of respiratory tract care and use of a closed urinary catheter drainage system ) , an educational program focused on respiratory intervention , and general interventions ( i.e. , aseptic technique ) . The rate of nosocomial pneumonia , the most common nosocomial infection , decreased from 33 % ( 41 of 123 patients ) before intervention to 16 % ( 21 of 130 patients ) after intervention ( P = .001 ) . Although the frequency of h and washing increased from 5 % to 63 % ( P < .001 ) , the rates of other types of nosocomial infections did not change significantly . The combination of targeted respiratory intervention and an intense , focused educational campaign reduced the rate of nosocomial pneumonia . General improvements in hygiene and h and washing rates , or even implementation of a closed urinary drainage system without focused education , may not be sufficient to reduce infection rates in intensive care units in developing countries OBJECTIVE To determine whether a multimodal intervention could improve adherence to h and hygiene and glove use recommendations and decrease the incidence of  antimicrobial resistance  in different types of healthcare facilities . DESIGN Prospect i ve , observational study performed from October 1 , 1999 , through December 31 , 2002 . We monitored adherence to h and hygiene and glove use recommendations and the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures . We evaluated trends in and predictors for adherence and preferential use of alcohol-based h and rubs , using multivariable analyses . SETTING Three intervention hospitals ( a 660-bed acute and long-term care hospital , a 120-bed community hospital , and a 600-bed public teaching hospital ) and a control hospital ( a 700-bed university teaching hospital).Intervention . At the intervention hospitals , we introduced or increased the availability of alcohol-based h and rub , initiated an interactive education program , and developed a poster campaign ; at the control hospital , we only increased the availability of alcohol-based h and rub . RESULTS We observed 6,948 h and hygiene opportunities . The frequency of h and hygiene performance or glove use significantly increased during the study period at the intervention hospitals but not at the control hospital ; the maximum quarterly frequency of h and hygiene performance or glove use at intervention hospitals ( 74 % , 80 % , and 77 % ) was higher than that at the control hospital ( 59 % ) . By multivariable analysis , preferential use of alcohol-based h and rubs rather than soap and water for h and hygiene was more likely among workers at intervention hospitals compared with nonintervention hospitals ( adjusted odds ratio , 4.6 [ 95 % confidence interval , 3.3 - 6.4 ] ) and more likely among physicians ( adjusted odds ratio , 1.4 [ 95 % confidence interval , 1.2 - 1.8 ] ) than among nurses at intervention hospitals . A significantly reduced incidence of antimicrobial-resistant bacteria among isolates from clinical culture was found at a single intervention hospital , which had the greatest increase in the frequency of h and hygiene performance . CONCLUSIONS During a 3-year period , a multimodal intervention program increased adherence to h and hygiene recommendations , especially to the use of alcohol-based h and rubs . In one hospital , a concomitant reduction was found in the incidence of antimicrobial-resistant bacteria among isolates from clinical cultures Objective Nosocomial infection is an important contributor to morbidity and mortality in pediatric solid organ transplantation . The relative effect of protective gown and glove isolation was compared with strict h and washing in pediatric intensive care unit ( PICU ) patients with solid organ transplantation . Design / Setting A prospect i ve , r and omized design was used ; children in a 23-bed PICU with solid organ transplantation were enrolled into a gown and glove protective isolation protocol or a strict h and washing protocol . Patients All children admitted to the PICU immediately after solid organ transplantation , excluding renal transplantation , and at subsequent readmissions to the PICU were eligible for the study . Children with current infection or known exposure to varicella were excluded from the study initially or at readmission . Interventions By using a block r and omization design based on organ transplanted , age , and initial admission vs. readmission , each patient was r and omized to either strict h and washing or protective gown and glove isolation intervention groups . Measurements We analyzed demographics , infection outcomes ( defined according to Centers for Disease Control criteria ) , and monitoring of patient contacts in compliance with protocol s. Results The infection rate in the overall PICU population did not change significantly from the year before the study compared with during the study ( 2.1 per 100 vs. 1.95 per 100 patient days;p = .4 ) The infection rate in the gown and glove group ( 2.3 per 100 patient days ) was reduced significantly compared with the pre study infection rate in the transplant population ( 4.9 per 100 patient days;p = .0008 ) . Strict h and washing also significantly reduced the infection rate in the transplant population ( 3.0 per 100 patient days;p = .008 ) . Compliance with gowning and gloving was 82 % and compliance with h and washing was 76 % ( compared with 22 % before study [ p < .0001 ] and 52 % after the study [ p < .0001 ] ) . Despite an increased mean length of stay in the PICU in the gown and glove group ( p = .014 ) , there was a trend toward reduction in the incidence of infection ( Fisher ’s exact test , p = .07 ; odds ratio , .76 ) in the gown and glove group . Conclusions Increased compliance with h and washing was associated with a reduction in nosocomial infections , and gown and glove isolation appeared to have an additional protective effect . Some nosocomial infections may be preventable in the pediatric solid organ transplantation population OBJECTIVE To evaluate the effects of a h and hygiene program on compliance with h and hygiene and the rate of nosocomial infections in a neonatal intensive care unit ( NICU ) . DESIGN Open trial . SETTING A level-III NICU in a teaching hospital . PARTICIPANTS Nurses , physicians , and other healthcare workers in the NICU . INTERVENTIONS A multimodal campaign for h and hygiene promotion was conducted beginning in September 1998 . This program consisted of formal lectures , written instructions and posted reminders regarding h and hygiene and proper h and washing techniques , covert observation , financial incentives , and regular group feedback on compliance . Surveillance of h and washing compliance and nosocomial infections before and during the program was analyzed . RESULTS Overall compliance with h and hygiene improved from 43 % at baseline to 80 % during the promotion program . The rate of nosocomial infections decreased from 15.13 to 10.69 per 1,000 patient-days ( P = .003 ) with improved h and washing compliance . In particular , respiratory tract infections decreased from 3.35 to 1.06 per 1,000 patient-days during the h and washing campaign ( P = .002 ) . Furthermore , the correlation between nosocomial infection of the respiratory tract and h and washing compliance also reached statistical significance ( r = -0.385 ; P = .014 ) . CONCLUSIONS Improved compliance with h and washing was associated with a significant decrease in overall rates of nosocomial infection and respiratory infections in particular . Washing h and s is a simple , economical , and effective method for preventing nosocomial infections in the NICU OBJECTIVE To evaluate h and hygiene compliance in 2 adult step-down units ( SDUs ) . DESIGN A 6-month ( from March to September 2007 ) , controlled trial comparing 2 SDUs , one with a feedback intervention program ( ie , the intervention unit ) and one without ( ie , the control unit ) . SETTING Two 20-bed SDUs at a tertiary care private hospital . METHODS H and hygiene episodes were measured by electronic recording devices and periodic observational surveys . In the intervention unit , feedback was provided by the SDU nurse manager , who explained twice a week to the healthcare workers the goals and targets for the process measures . RESULTS A total of 117,579 h and h 
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Conclusions By focussing on determinants of behaviour change , we found hidden and valuable components in HH improvement strategies .
Addressing only determinants such as knowledge , awareness , action control , and facilitation is not enough to change HH behaviour .
Addressing combinations of different determinants showed better results .