Ing phase 2, up to 42 corrective actions were performed. Overall, 57 (n = 24) were

Ing phase 2, up to 42 corrective actions were performed. Overall, 57 (n = 24) were aimed to discuss incorrect HH habits (repetitive incorrect actions related to HH), 33 (n = 14) were related to clarify doubts concerning HH practices and 16 (n = 4) were done to discuss missed specific HH Pepstatin site opportunities (i.e.: no HH performance before Pamapimod manufacturer aseptic technique). Main incorrect HH habits could be grouped in the following categories: a) wearing watches or jewels; b) fail to consider measuring blood pressure as a prepatient opportunity for HH; c) missing HH opportunities when performing capillary blood glucose determinations; d) not performing HH “after touching patient surroundings” ; e) incorrect HH technique (according to WHO standardized HH technique); f) use of gloves instead of hand hygiene; and g) wearing gloves outside the room without justification. Potential confounders of the putative effect of our intervention such as change in the case-mix (considering age, gender, length of hospital stay and weighted diagnoses-related group), did not changed over time (data not shown). As regards to overall antibiotic, and specifically fluoroquinolone consumption (DDD per 100 patient-days), there was a significant increase during the intervention period (overall consumption: 75.5 [95 CI: 75.3?75.6] vs 68.9 [95 CI: 68.7?9.1]; p,0.05; fluorquinolones consumption;17.0 [95 CI: 16.9?7.1] vs 16.4 [95 CI:16.3?16.5); p,0.05; intervention period vs preintervention period, respectively).intervention period [2010?011] with respect to the preintervention period [2007?008]); b) a sustained high level (82 ) of HH compliance during the intervention period; c) a significant increase in AHR consumption over time, with consistently significant rises in Phase 2; d) a significant decrease in healthcare-acquired MRSA infection/colonization coinciding with implementation of interventions; e) a small but significant improvement in HH compliance when comparing Phase 2 to Phase1 (particularly in the emergency department); and f) successful use of control charts to identify significant negative and positive deviations (special causes) in HH compliance over time.Main limitations and strengthsAs potential limitations, this study describes a quality improvement project and we cannot ruled out that other unmeasured factors or potential confounders may have influenced the results. However, there were no changes in terms of patient characteristics (age, gender, length of hospital stay and DRGs) or infection control practices during the evaluation period and no outbreaks were detected. Second, this study is limited by its quasiexperimental design. Randomisation of the intervention was not feasible since it was performed in a single center and because its design was originally programmed for hospital-wide implementation. Third, a Hawthorne effect [41,42,43] may have occurred due to the fact that HCWs were aware of being observed. Fourth, we consider unlikely that a systematic change in the way clinicians ordered culture tests may have influenced the results of MRSA rates. Finally, our study was performed only in one centre with specific features. The potential strengths of our study were the unusual large size of HH opportunities observed [12], and the novel use of CQI philosophy in our multimodal HH intervention (phase 2), highlighting the utility of Statistical Process Control (capable to detect either positive or negative “special causes”), immediate feedback to our HCWs a.Ing phase 2, up to 42 corrective actions were performed. Overall, 57 (n = 24) were aimed to discuss incorrect HH habits (repetitive incorrect actions related to HH), 33 (n = 14) were related to clarify doubts concerning HH practices and 16 (n = 4) were done to discuss missed specific HH opportunities (i.e.: no HH performance before aseptic technique). Main incorrect HH habits could be grouped in the following categories: a) wearing watches or jewels; b) fail to consider measuring blood pressure as a prepatient opportunity for HH; c) missing HH opportunities when performing capillary blood glucose determinations; d) not performing HH “after touching patient surroundings” ; e) incorrect HH technique (according to WHO standardized HH technique); f) use of gloves instead of hand hygiene; and g) wearing gloves outside the room without justification. Potential confounders of the putative effect of our intervention such as change in the case-mix (considering age, gender, length of hospital stay and weighted diagnoses-related group), did not changed over time (data not shown). As regards to overall antibiotic, and specifically fluoroquinolone consumption (DDD per 100 patient-days), there was a significant increase during the intervention period (overall consumption: 75.5 [95 CI: 75.3?75.6] vs 68.9 [95 CI: 68.7?9.1]; p,0.05; fluorquinolones consumption;17.0 [95 CI: 16.9?7.1] vs 16.4 [95 CI:16.3?16.5); p,0.05; intervention period vs preintervention period, respectively).intervention period [2010?011] with respect to the preintervention period [2007?008]); b) a sustained high level (82 ) of HH compliance during the intervention period; c) a significant increase in AHR consumption over time, with consistently significant rises in Phase 2; d) a significant decrease in healthcare-acquired MRSA infection/colonization coinciding with implementation of interventions; e) a small but significant improvement in HH compliance when comparing Phase 2 to Phase1 (particularly in the emergency department); and f) successful use of control charts to identify significant negative and positive deviations (special causes) in HH compliance over time.Main limitations and strengthsAs potential limitations, this study describes a quality improvement project and we cannot ruled out that other unmeasured factors or potential confounders may have influenced the results. However, there were no changes in terms of patient characteristics (age, gender, length of hospital stay and DRGs) or infection control practices during the evaluation period and no outbreaks were detected. Second, this study is limited by its quasiexperimental design. Randomisation of the intervention was not feasible since it was performed in a single center and because its design was originally programmed for hospital-wide implementation. Third, a Hawthorne effect [41,42,43] may have occurred due to the fact that HCWs were aware of being observed. Fourth, we consider unlikely that a systematic change in the way clinicians ordered culture tests may have influenced the results of MRSA rates. Finally, our study was performed only in one centre with specific features. The potential strengths of our study were the unusual large size of HH opportunities observed [12], and the novel use of CQI philosophy in our multimodal HH intervention (phase 2), highlighting the utility of Statistical Process Control (capable to detect either positive or negative “special causes”), immediate feedback to our HCWs a.