Hand hygiene compliance by direct observation in physicians and nurses: a systematic review and meta-analysis

Direct observation of hand hygiene compliance is the gold standard despite limitations and potential for bias. Previous literature highlights poorer hand hygiene compliance among physicians than nurses and suggests that covert monitoring may give better compliance estimates than overt monitoring.

To explore differences in compliance between physicians and nurses further, and to determine whether compliance estimates differed when observations were covert rather than overt.

A systematic search of databases PubMed, Embase, CENTRAL and CINAHL was performed. Experimental or observational studies in hospital settings in high-income countries published in English from 2010 onwards were included if estimates for both physicians and nurses using direct observation were reported. The search yielded 4814 studies, of which 105 were included.

The weighted pooled compliance rate for nurses was 52% (95% CI: 47-57) and for doctors was 45% (95% CI: 40-49%). Heterogeneity was considerable (I² = 99%). The majority of studies were at moderate or high risk of bias. Random-effects meta-analysis of low risk of bias studies suggests higher compliance for nurses than physicians for both overt (difference of 7%; 95% CI for the difference: 0.8-13.5; P = 0.027) and covert (difference of 7%; 95% CI: 3-11; P = 0.0002) observation. Considerable heterogeneity was found in all analyses.

Wide variability in compliance estimates and differences in the methodological quality of hand hygiene studies were identified. Further research with meta-regression should explore sources of heterogeneity and improve the conduct and reporting of hand hygiene studies.