***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: OBJECTIVE To assess the efficacy of a multimodal , central ly coordinated , multisite h and hygiene culture-change program ( HHCCP ) for reducing rates of  methicillin-resistant Staphylococcus aureus ( MRSA ) bacteraemia and disease in Victorian hospitals . DESIGN , PARTICIPANTS AND SETTING A pilot HHCCP was conducted over a 24-month period ( October 2004 to September 2006 ) in six Victorian health care institutions ( 4 urban , 2 rural ; total beds , 2379 ) . Subsequently , we assessed the efficacy of an identical program implemented throughout Victorian public hospitals over a 12-month period ( beginning between March 2006 and July 2006 ) . MAIN OUTCOME MEASURES Rates of h and hygiene ( HH ) compliance ; rates of MRSA disease ( patients with bacteraemia and number of clinical isolates per 100 patient discharges [ PD ] ) . RESULTS Mean HH compliance improved significantly at all pilot program sites , from 21 % ( 95 % CI , 20%-22 % ) at baseline to 48 % ( 95 % CI , 47%-49 % ) at 12 months and 47 % ( 95 % CI , 46%-48 % ; range , 31%-75 % ) at 24 months . Mean baseline rates for the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates were 0.05/100 PD per month ( range , 0.00 - 0.13 ) and 1.39/100 PD per month ( range , 0.16 - 2.39 ) , respectively . These were significantly reduced after 24 months to 0.02/100 PD per month for bacteraemia ( P = 0.035 for trend ; 65 fewer patients with bacteraemia ) and 0.73/100 PD per month for MRSA isolates ( P = 0.003 ; 716 fewer isolates ) . Similar findings were noted 12 months after the statewide roll-out , with an increase in mean HH compliance ( from 20 % to 53 % ; P < 0.001 ) and reductions in the rates of MRSA isolates ( P = 0.043 ) and bacteraemias ( P = 0.09 ) . CONCLUSIONS Pilot and subsequent statewide implementation of a multimodal HHCCP was effective in significantly improving HH compliance and reducing rates of MRSA infection CONTEXT Experts and policy makers have repeatedly called for universal screening at hospital admission to reduce nosocomial methicillin-resistant Staphylococcus aureus ( MRSA ) infection . OBJECTIVE To determine the effect of an early MRSA detection strategy on nosocomial MRSA infection rates in surgical patients . DESIGN , SETTING , AND PATIENTS Prospect i ve , interventional cohort study conducted between July 2004 and May 2006 among 21 754 surgical patients at a Swiss teaching hospital using a crossover design to compare 2 MRSA control strategies ( rapid screening on admission plus st and ard infection control measures vs st and ard infection control alone ) . Twelve surgical wards including different surgical specialties were enrolled according to a prespecified agenda , assigned to either the control or intervention group for a 9-month period , then switched over to the other group for a further 9 months . INTERVENTIONS During the rapid screening intervention periods , patients admitted to the intervention wards for more than 24 hours were screened before or on admission by rapid , multiplex polymerase chain reaction . For both intervention ( n=10 844 ) and control ( n=10 910 ) periods , st and ard infection control measures were used for patients with MRSA in all wards and consisted of contact isolation of MRSA carriers , use of dedicated material ( eg , gown , gloves , mask if indicated ) , adjustment of perioperative antibiotic prophylaxis of MRSA carriers , computerized MRSA alert system , and topical decolonization ( nasal mupirocin ointment and chlorhexidine body washing ) for 5 days . MAIN OUTCOME MEASURES Incidence of nosocomial MRSA infection , MRSA surgical site infection , and rates of nosocomial acquisition of MRSA . RESULTS Overall , 10 193 of 10 844 patients ( 94 % ) were screened during the intervention periods . Screening identified 515 MRSA-positive patients ( 5.1 % ) , including 337 previously unknown MRSA carriers . Median time from screening to notification of test results was 22.5 hours ( interquartile range , 12.2 - 28.2 hours ) . In the intervention periods , 93 patients ( 1.11 per 1000 patient-days ) developed nosocomial MRSA infection compared with 76 in the control periods ( 0.91 per 1000 patient-days ; adjusted incidence rate ratio , 1.20 ; 95 % confidence interval , 0.85 - 1.69 ; P = .29 ) . The rate of MRSA surgical site infection and nosocomial MRSA acquisition did not change significantly . Fifty-three of 93 infected patients ( 57 % ) in the intervention wards were MRSA-free on admission and developed MRSA infection during hospitalization . CONCLUSION A universal , rapid MRSA admission screening strategy did not reduce nosocomial MRSA infection in a surgical department with endemic MRSA prevalence but relatively low rates of MRSA infection . TRIAL REGISTRATION is rct n.org Identifier : IS RCT N06603006 A prospect i ve epidemiological survey was carried out over a period of seven weeks in a medical intensive care unit . Bacteria from patients , staff and air were monitored and the transmission of isolated microorganisms was followed . H and washing sample s revealed pathogenic bacteria in 30.8 % of physicians ( average number of colony forming units : 71,300 per h and ) and 16.6 % of nurses ( 39,800 cfu per h and ) . Air cultures yielded pathogens in 15 % of sampling periods and nine of 53 patients were found to be colonized with Gram-negative bacteria , Staphylococcus aureus or C and ida spp . The spectrum of bacteria recovered from patients and air was generally different , whereas strains recovered from patients and their attendants ' h and s were indistinguishable on multiple occasions . The results of this study confirm that direct contact is the principal pathway of microbial transmission , whereas little evidence for a significant role of airborne transmission is shown . The call for more extensive air-filtering and ventilation systems in medical intensive care units is not supported by the results shown in this communication 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 OBJECTIVE To evaluate the impact of an institutional h and hygiene accountability program on  healthcare personnel h and hygiene adherence .  DESIGN Time-series design with correlation analysis . SETTING Tertiary care academic medical center , including outpatient clinics and procedural areas . PARTICIPANTS Medical center healthcare personnel . METHODS A comprehensive h and hygiene initiative was implemented in 2 major phases starting in July 2009 . Key facets of the initiative included extensive project planning , leadership buy-in and goal setting , financial incentives linked to performance , and use of a system-wide shared accountability model . Adherence was measured by design ated h and hygiene observers . Adherence rates were compared between baseline and implementation phases , and monthly h and hygiene adherence rates were correlated with monthly rates of device-associated infection . RESULTS A total of 109,988 observations were completed during the study period , with a sustained increase in h and hygiene adherence throughout each implementation phase ( P < .001 ) as well as from one phase to the next ( P < .001 ) , such that adherence greater than 85 % has been achieved since January 2011 . Medical center departments were able to recl aim some rebate dollars allocated through a self-insurance trust , but during the study period , departments did not achieve full reimbursement . H and hygiene adherence rates were inversely correlated with device-associated st and ardized infection ratios ( R(@ ) = 0.70 ) . CONCLUSIONS Implementation of this multifaceted , observational h and hygiene program was associated with sustained improvement in h and hygiene adherence . The principles of this program could be applied to other medical centers pursuing improved h and hygiene adherence among healthcare personnel BACKGROUND Improving h and hygiene compliance is still a major challenge for most hospitals . Innovative approaches are needed . OBJECTIVE We tested whether an innovative , theory based , team and leaders-directed strategy would be more effective in increasing h and hygiene compliance rates in nurses than a literature based state-of-the-art strategy . DESIGN AND SETTING A cluster r and omised controlled trial called HELPING H AND S was conducted in 67 nursing wards of three hospitals in the Netherl and s. PARTICIPANTS All affiliated nurses of the nursing wards . Wards were r and omly assigned to either the team and leaders-directed strategy ( 30 wards ) or the state-of-the-art strategy ( 37 wards ) . METHODS The control arm received a state-of-the-art strategy including education , reminders , feedback and targeting adequate products and facilities . The experimental group received all elements of the state-of-the-art strategy supplemented with interventions based on social influence and leadership , comprising specific team and leaders-directed activities . Strategies were delivered during a period of six months . We monitored nurses ' HH compliance during routine patient care before and directly after strategy delivery , as well as six months later . Secondary outcomes were compliance with each type of h and hygiene opportunity , the presence of jewellery and whether the nurses wore long-sleeved clothes . The effects were evaluated on an intention-to-treat basis by comparing the post- strategy h and hygiene compliance rates with the baseline rates . Multilevel analysis was applied to compensate for the clustered nature of the data using mixed linear modelling techniques . RESULTS During the study , we observed 10,785 opportunities for appropriate h and hygiene in 2733 nurses . The compliance in the state-of-the-art group increased from 23 % to 42 % in the short term and to 46 % in the long run . The h and hygiene compliance in the team and leaders-directed group improved from 20 % to 53 % in the short term and remained 53 % in the long run . The difference between both strategies showed an Odds Ratio of 1.64 ( 95 % CI 1.33 - 2.02 ) in favour of the team and leaders-directed strategy . CONCLUSIONS Our results support the added value of social influence and enhanced leadership in h and hygiene improvement strategies . The methodology of the latter also seems promising for improving team performance with other patient safety issues . TRIAL REGISTRATION Clinical Trials.gov [ NCT00548015 ] Mixed treatment comparison ( MTC ) meta- analysis is a generalization of st and ard pairwise meta- analysis for A vs B trials , to data structures that include , for example , A vs B , B vs C , and A vs C trials . There are two roles for MTC : one is to strengthen inference concerning the relative efficacy of two treatments , by including both ' direct ' and ' indirect ' comparisons . The other is to facilitate simultaneous inference regarding all treatments , in order for example to select the best treatment . In this paper , we present a range of Bayesian hierarchical models using the Markov chain Monte Carlo software WinBUGS . These are multivariate r and om effects models that allow for variation in true treatment effects across trials . We consider models where the between-trials variance is homogeneous across 
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Network meta- analysis indicated considerable uncertainty in the relative effectiveness of interventions , but nonetheless provided evidence that WHO-5 is effective and that compliance can be further improved by adding interventions including goal setting , reward incentives , and accountability .
Promotion of h and hygiene with WHO-5 is effective at increasing compliance in healthcare workers .
Addition of goal setting , reward incentives , and accountability strategies can lead to further improvements .