***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: In a pediatric intensive care unit we conducted a 1-year prospect i ve study of 454 patients to determine whether wearing a gown decreased the overall nosocomial infection rate , incidence of intravascular catheter colonization , breaks in h and washing technique , and traffic . The overall infection rate was 26 ( 13 % ) of 198 admissions during the gown-wearing periods v 23 ( 9 % ) of 256 admissions for the periods when gowns were not worn ( P less than .25 ) . Of 348 intravascular catheter tips cultured 16 ( 4.6 % ) were colonized during gown-wearing periods compared with 21 ( 6.3 % ) of 330 when no gowns were worn ( P less than .25 ) . Of 78 patient contacts 54 ( 69 % ) were followed by no h and washing during gown-wearing periods and 59 ( 70 % ) of 84 contacts were followed by no h and washing during periods when no gowns were worn . The mean occurrence of visits per patient per hour and total visits per hour differed between gown-wearing and no-gown-wearing periods by analysis of variance , P less than .01 and P less than .005 , respectively . Although traffic was decreased during periods of gown use , overgowns are an expensive , ineffective method of decreasing nosocomial infection rates , vascular catheter colonization rates , and breaks in h and washing technique 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 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 Background Limited data describe the sustained impact of  h and hygiene programs ( HHPs )  implemented in teaching hospitals , where the burden of healthcare-associated infections ( HAIs ) is high . We use a quasi-experimental , before and after , study design with prospect i ve hospital-wide surveillance of HAIs to assess the cost effectiveness of HHPs . Methods and Findings A 4-year hospital-wide HHP , with particular emphasis on using an alcohol-based h and rub , was implemented in April 2004 at a 2,200-bed teaching hospital in Taiwan .  Compliance was measured by direct observation and the use of h and rub products . Poisson regression analyses were employed to evaluate the densities and trends of HAIs during the preintervention ( January 1999 to March 2004 ) and intervention ( April 2004 to December 2007 ) periods . The economic impact was estimated based on a case-control study in Taiwan . We observed 8,420 opportunities for h and hygiene during the study period . Compliance improved from 43.3 % in April 2004 to 95.6 % in 2007 ( p<.001 ) , and was closely correlated with increased consumption of the alcohol-based h and rub ( r = 0.9399 ) . The disease severity score ( Charlson comorbidity index ) increased ( p = .002 ) during the intervention period . Nevertheless , we observed an 8.9 % decrease in HAIs and a decline in the occurrence of bloodstream , methicillin-resistant Staphylococcus aureus , extensively drug-resistant Acinetobacter baumannii , and intensive care unit infections . The intervention had no discernable impact on HAI rates in the hematology/oncology wards . The net benefit of the HHP was US$ 5,289,364 , and the benefit-cost ratio was 23.7 with a 3 % discount rate . Conclusions Implementation of a HHP reduces preventable HAIs and is cost effective 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 It is now well known that st and ard statistical procedures become invali date d when applied to cluster r and omized trials in which the unit of inference is the individual . A result ing consequence is that research ers conducting such trials are faced with a multitude of design choices , including selection of the primary unit of inference , the degree to which clusters should be matched or stratified by prognostic factors at baseline , and decisions related to cluster subsampling . Moreover , application of ethical principles developed for individually r and omized trials may also require modification . We discuss several topics related to these issues , with emphasis on the choices that must be made in the planning stages of a trial and on some potential pitfalls to be avoided OBJECTIVES . H and hygiene promotion interventions rarely result in sustained improvement , and an assessment of their impact on individual infection risk has been lacking . We sought to measure the impact of h and hygiene promotion on health care worker compliance and health care – associated infection risk among neonates . METHODS . We conducted an intervention study with a 9-month follow-up among all of the health care workers at the neonatal unit of the Children 's Hospital , University of Geneva Hospitals , between March 2001 and February 2004 . A multifaceted h and hygiene education program was introduced with compliance assessed during successive observational surveys . Health care – associated infections were prospect ively monitored , and genotypic relatedness of bloodstream pathogens was assessed by pulsed-field gel electrophoresis . A comparison of observed h and hygiene compliance and infection rates before , during , and after the intervention was conducted . RESULTS . A total of 5325 opportunities for h and hygiene were observed . Overall compliance improved gradually from 42 % to 55 % across study phases . This trend remained significant after adjustment for possible confounders and paralleled the measured increase in h and -rub consumption ( from 66.6 to 89.2 L per 1000 patient-days ) . A 9-month follow-up survey showed sustained improvement in compliance ( 54 % ) , notably with direct patient contact ( 49 % at baseline vs 64 % at follow-up ) . Improved compliance was independently associated with infection risk reduction among very low birth weight neonates . Bacteremia caused by clonally related pathogens markedly decreased after the intervention . CONCLUSIONS . H and hygiene promotion , guided by health care workers ' perceptions , identification of the dynamics of bacterial contamination of health care workers ' h and s , and performance feedback , is effective in sustaining compliance improvement and is independently associated with infection risk reduction among high-risk neonates 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 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 [ IT 
    Output:
    
The quality of intervention studies intended to increase h and hygiene compliance remains disappointing .
Although multifaceted campaigns with social marketing or staff involvement appear to have an effect , there is insufficient evidence to draw a firm conclusion .