Assessing Global Nursing Interventions in Reducing Hospital-Acquired Infections: A Meta-Analysis
Abstract
Background: Hospital-acquired infections (HAIs) raise worldwide morbidity, death, and healthcare expenditures. Preventing and managing HAIs requires nursing interventions such hand hygiene, personal protective equipment (PPE) usage, environmental cleaning, and antimicrobial stewardship. This meta-analysis examined how nursing interventions reduced HAIs in different hospital settings.
Methods: A complete PubMed, Scopus, and Web of Science search was undertaken for January 2000–December 2023 research. Studies on HAI-reducing nursing interventions were included. Study quality was evaluated using the Cochrane Risk of Bias Tool and Newcastle-Ottawa Scale. The random-effects model was used to construct pooled risk ratios (RRs) with 95% CIs in meta-analysis. We also performed subgroup, sensitivity, and publication bias analyses.
Results: Fourteen trials with 2540 individuals were included. In the pooled study, nursing interventions significantly reduced HAI incidence (RR = 0.42, 95% CI: 0.35-0.50, P < 0.001). Subgroup analysis indicated that hand hygiene, PPE usage, environmental cleaning, and antimicrobial stewardship reduced HAIs. Sensitivity analysis verified these results' reliability. Egger's test showed no publication bias (P = 0.78). Over time, cumulative meta-analysis showed constant effect sizes.
Conclusion: Nursing interventions significantly reduce HAIs. Hand hygiene, PPE, environmental cleaning, and antimicrobial stewardship are essential to infection control. Healthcare institutions should prioritise these actions and resolve compliance hurdles to enhance patient outcomes and minimise HAIs. Research is needed to explore innovative approaches and identify factors influencing compliance.
1. Allegranzi B, Bagheri Nejad S, Combescure C, et al (2011). Burden of endemic health-care-associated infection in de-veloping countries: systematic review and meta-analysis. Lancet, 377(9761):228-241.
2. Magill SS, Edwards JR, Bamberg W, et al (2014). Multistate point-prevalence sur-vey of health care-associated infections. N Engl J Med, 370(13):1198-1208.
3. Cassini A, Högberg LD, Plachouras D, et al (2019). Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet Infect Dis, 19(1):56-66.
4. Martins TB, Amante L, Vicente C, et al (2020). Nursing interventions to reduce surgical site infection in potentially con-taminated surgeries: an integrative re-view. ESTIMA Braz J Enterostomal Ther, 18:e1220.
5. Umscheid CA, Mitchell MD, Doshi JA, et al (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol, 32(2):101-114.
6. Pittet D, Hugonnet S, Harbarth S, et al (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 356(9238):1307-1312.
7. Allegranzi B, Pittet D (2009). Role of hand hygiene in healthcare-associated infec-tion prevention. J Hosp Infect, 73(4):305-315.
8. Erasmus V, Daha TJ, Brug H, et al (2010). Systematic review of studies on compli-ance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol, 31(3):283-294.
9. Munro S, Phillips T, Hasselbeck R, et al (2022). Implementing Oral Care as a Nursing Intervention to Reduce Hospi-tal-Acquired Pneumonia Across the United States Department of Veterans Affairs Healthcare System. Comput Inform Nurs, 40:35-43.
10. Carling PC, Parry MF, Von Beheren SM (2008). Identifying opportunities to en-hance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol, 29(1):1-7.
11. Rutala WA, Weber DJ (2008). Guideline for disinfection and sterilization in healthcare facilities, 2008. Centers for Dis-ease Control and Prevention. https://www.cdc.gov/infection-control/media/pdfs/guideline-disinfection-h.pdf
12. Karanika S, Paudel S, Zervou FN, et al (2016). Systematic review and meta-analysis of clinical and economic out-comes from the implementation of hospital-based antimicrobial steward-ship programs. Antimicrob Agents Chemoth-er, 60(8):4840-4852.
13. Rosenthal VD, Maki DG, Salomao R, et al (2006). Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med, 145(8):582-591.
14. Cohen B, Hyman S, Rosenberg L, et al (2012). Frequency of patient contact with health care personnel and visitors: im-plications for infection prevention. Jt Comm J Qual Patient Saf, 38(12):560-565.
15. Pessoa-Silva CL, Hugonnet S, Pfister R, et al (2007). Reduction of health care associ-ated infection risk in neonates by suc-cessful hand hygiene promotion. Pediat-rics, 120(2):e382-e390.
16. Onyedibe K, Shehu N, Pires D, et al (2020). Assessment of hand hygiene facilities and staff compliance in a large tertiary health care facility in northern Nigeria: a cross sectional study. Antimicrob Resist Infect Control, 9:30.
17. Smith C (2020). Behavioural science and design thinking: re-framing the hospital medication chart to improve hand hy-giene compliance in nurses. British Jour-nal of Healthcare Management, 26(2):1-4.
18. Brown L (2019). Use of personal protective equipment in nursing practice. Nurs Standard, 34(5):59-66.
19. Nguyen T, Pham T, Tang HK, et al (2021). Unmet needs in occupational health: prevention and management of viral hepatitis in healthcare workers in Ho Chi Minh City, Vietnam: a mixed-methods study. BMJ Open, 11(10):e052668.
20. Osei-Bonsu K, Masroor N, Cooper K, et al (2019). Alternative doffing strategies of personal protective equipment to pre-vent self-contamination in the health care setting. Am J Infect Control, 47(5):534-9.
21. Martínez-González NA, Coenen S, Plate A, et al (2017). The impact of interventions to improve the quality of prescribing and use of antibiotics in primary care patients with respiratory tract infections: a systematic review protocol. BMJ Open, 7(6):e016253.
22. Patel K, Schmidtke KA, Taj U, et al (2021). Co-designing theoretically informed, conceptual prototypes for interventions to increase hand hygiene in hospital set-tings: a case study. Design for Health, 5(3):313-29.
23. Davis KG, Kotowski SE (2015). Prevalence of musculoskeletal disorders for nurses in hospitals, long-term care facilities, and home health care: a comprehensive review. Hum Factors, 57(5):754-92.
24. Lee SE, Scott LD (2018). Hospital nurses’ work environment characteristics and patient safety outcomes: A literature re-view. West J Nurs Res, 40(1):121-145.
25. Ahmed S, Tareq AH, Ilyas D (2024). The Impact of Antimicrobial Resistance and Stewardship Training Sessions on Knowledge of Healthcare Students of Wah Cantonment, Pakistan. Inquiry, 61:00469580241228443.
26. Rojas‐García A, Turner S, Pizzo E, et al (2018). Impact and experiences of de-layed discharge: A mixed‐studies sys-tematic review. Health Expect, 21(1):41-56.
27. Wang Z (2014). Hand hygiene promotion: An essential strategy for preventing foodborne disease in elementary schools: Clemson University, (12): 1-92.
28. Kim H, Hegde S, LaFiura C, et al (2021). Access to personal protective equipment in exposed healthcare workers and COVID-19 illness, severity, symptoms and duration: a population-based case-control study in six countries. BMJ Glob Health, 6(1): e004611.
29. Johnson J, Akinboyo IC, Schaffzin JK (2021). Infection prevention in the neo-natal intensive care unit. Clin Perinatol, 48(2):413-29.
30. Gibbons JA, Smith HL, Kumar SC, et al (2017). Antimicrobial stewardship in the treatment of skin and soft tissue infec-tions. Am J Infect Control, 45(11):1203-7.
31. Prüss-Ustün A, Wolf J, Bartram J, et al (2019). Burden of disease from inade-quate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries. Int J Hyg Environ Health, 222:765-777.
32. Girum T, Shumbej T, Shewangizaw M (2019). Burden of malaria in Ethiopia, 2000-2016: findings from the Global Health Estimates 2016. Trop Dis Travel Med Vaccines, 5:11.
33. Kurizky PS, Neto LLS, Aires RB, et al (2020). Opportunistic tropical infections in immunosuppressed patients. Best Pract Res Clin Rheumatol, 34(4):101509.
34. Adebisi YA, Agumage I, Sylvanus TD, et al (2019). Burden of Tuberculosis and Challenges Facing Its Eradication in West Africa. Int J Infect, 6(3): e92250.
35. Liberati A, Altman DG, Tetzlaff J, et al (2009). The PRISMA statement for re-porting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS Med, 6(7):e1000100.
36. Higgins JP, Altman DG, Gøtzsche PC, et al (2011). The Cochrane Collaboration’s tool for assessing risk of bias in ran-domised trials. BMJ, 343:d5928.
37. Wells GA, Shea B, O’Connell D, et al (2000). The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-analyses. Scholar Archive, (1): 1-12.
38. Higgins JP, Green S, editors. (2011). Cochrane handbook for systematic reviews of interventions. Vol. 4. John Wiley & Sons.
39. Cohen J (1988). Statistical power analysis for the behavioral sciences. Vol. 2. Lawrence Erlbaum Associates.
40. Egger M, Smith GD, Schneider M, et al (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109):629-634.
41. DerSimonian R, Laird N (1986). Meta-analysis in clinical trials. Control Clin Tri-als, 7(3):177-188.
42. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, et al (2006). Assessing heter-ogeneity in meta-analysis: Q statistic or I² index? Psychol Methods, 11(2):193-206.
43. Higgins JP, Thompson SG (2002). Quantify-ing heterogeneity in a meta-analysis. Stat Med, 21(11):1539-1558.
44. Baujat B, Mahé C, Pignon JP, et al (2002). A graphical method for exploring hetero-geneity in meta-analyses: application to a meta-analysis of 65 trials. Stat Med, 21(18):2641-2652.
45. Sterne JA, Sutton AJ, Ioannidis JP, et al (2011). Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised con-trolled trials. BMJ, 343:d4002.
46. Duval S, Tweedie R (2000). Trim and fill: a simple funnel-plot–based method of testing and adjusting for publication bi-as in meta-analysis. Biometrics, 56(2):455-463.
47. Higgins JP, Thompson SG, Deeks JJ, et al (2003). Measuring inconsistency in meta-analyses. BMJ, 327(7414):557-560.
48. Egger M, Davey Smith G, Altman DG, edi-tors. (2008). Systematic reviews in health care: meta-analysis in context. John Wiley & Sons.
49. Borenstein M, Hedges LV, Higgins JP, et al (2011). Introduction to meta-analysis. John Wiley & Sons.
50. Dimitriadou I, Pittas S, Sidiropoulos A, et al (2022). Perception of Nursing Staff in ICU Regarding Measures to Prevent Hospital-Acquired Infections: A Qualita-tive Approach. Cureus, 14(12): e33029.
51. Fuster C, Vaqué J, Solé J (2010). Compliance of healthcare workers with guidelines on antibiotic therapy. Enferm Infecc Microbiol Clin, 28(8):491-496.
52. Apisarnthanarak A, Greene MT, Kennedy EH, et al (2012). National survey of prac-tices to prevent healthcare-associated infections in Thailand: the role of pre-vention bundles. Infect Control Hosp Epi-demiol, 33(7):711-717.
53. Murni IK, Duke T, Kinney S, et al (2015). Reducing hospital-acquired infections and improving the rational use of anti-biotics in a developing country: an ef-fectiveness study. Arch Dis Child, 100(5):454-9.
54. Kirkland KB, Weinstein JM (1999). Adverse effects of contact isolation. Lancet, 354(9185):1177-1178.
55. Bearman GM, Wenzel RP (2005). Bactere-mias: a leading cause of death. Arch Med Res, 36(6):646-659.
2. Magill SS, Edwards JR, Bamberg W, et al (2014). Multistate point-prevalence sur-vey of health care-associated infections. N Engl J Med, 370(13):1198-1208.
3. Cassini A, Högberg LD, Plachouras D, et al (2019). Attributable deaths and disability-adjusted life-years caused by infections with antibiotic-resistant bacteria in the EU and the European Economic Area in 2015: a population-level modelling analysis. Lancet Infect Dis, 19(1):56-66.
4. Martins TB, Amante L, Vicente C, et al (2020). Nursing interventions to reduce surgical site infection in potentially con-taminated surgeries: an integrative re-view. ESTIMA Braz J Enterostomal Ther, 18:e1220.
5. Umscheid CA, Mitchell MD, Doshi JA, et al (2011). Estimating the proportion of healthcare-associated infections that are reasonably preventable and the related mortality and costs. Infect Control Hosp Epidemiol, 32(2):101-114.
6. Pittet D, Hugonnet S, Harbarth S, et al (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 356(9238):1307-1312.
7. Allegranzi B, Pittet D (2009). Role of hand hygiene in healthcare-associated infec-tion prevention. J Hosp Infect, 73(4):305-315.
8. Erasmus V, Daha TJ, Brug H, et al (2010). Systematic review of studies on compli-ance with hand hygiene guidelines in hospital care. Infect Control Hosp Epidemiol, 31(3):283-294.
9. Munro S, Phillips T, Hasselbeck R, et al (2022). Implementing Oral Care as a Nursing Intervention to Reduce Hospi-tal-Acquired Pneumonia Across the United States Department of Veterans Affairs Healthcare System. Comput Inform Nurs, 40:35-43.
10. Carling PC, Parry MF, Von Beheren SM (2008). Identifying opportunities to en-hance environmental cleaning in 23 acute care hospitals. Infect Control Hosp Epidemiol, 29(1):1-7.
11. Rutala WA, Weber DJ (2008). Guideline for disinfection and sterilization in healthcare facilities, 2008. Centers for Dis-ease Control and Prevention. https://www.cdc.gov/infection-control/media/pdfs/guideline-disinfection-h.pdf
12. Karanika S, Paudel S, Zervou FN, et al (2016). Systematic review and meta-analysis of clinical and economic out-comes from the implementation of hospital-based antimicrobial steward-ship programs. Antimicrob Agents Chemoth-er, 60(8):4840-4852.
13. Rosenthal VD, Maki DG, Salomao R, et al (2006). Device-associated nosocomial infections in 55 intensive care units of 8 developing countries. Ann Intern Med, 145(8):582-591.
14. Cohen B, Hyman S, Rosenberg L, et al (2012). Frequency of patient contact with health care personnel and visitors: im-plications for infection prevention. Jt Comm J Qual Patient Saf, 38(12):560-565.
15. Pessoa-Silva CL, Hugonnet S, Pfister R, et al (2007). Reduction of health care associ-ated infection risk in neonates by suc-cessful hand hygiene promotion. Pediat-rics, 120(2):e382-e390.
16. Onyedibe K, Shehu N, Pires D, et al (2020). Assessment of hand hygiene facilities and staff compliance in a large tertiary health care facility in northern Nigeria: a cross sectional study. Antimicrob Resist Infect Control, 9:30.
17. Smith C (2020). Behavioural science and design thinking: re-framing the hospital medication chart to improve hand hy-giene compliance in nurses. British Jour-nal of Healthcare Management, 26(2):1-4.
18. Brown L (2019). Use of personal protective equipment in nursing practice. Nurs Standard, 34(5):59-66.
19. Nguyen T, Pham T, Tang HK, et al (2021). Unmet needs in occupational health: prevention and management of viral hepatitis in healthcare workers in Ho Chi Minh City, Vietnam: a mixed-methods study. BMJ Open, 11(10):e052668.
20. Osei-Bonsu K, Masroor N, Cooper K, et al (2019). Alternative doffing strategies of personal protective equipment to pre-vent self-contamination in the health care setting. Am J Infect Control, 47(5):534-9.
21. Martínez-González NA, Coenen S, Plate A, et al (2017). The impact of interventions to improve the quality of prescribing and use of antibiotics in primary care patients with respiratory tract infections: a systematic review protocol. BMJ Open, 7(6):e016253.
22. Patel K, Schmidtke KA, Taj U, et al (2021). Co-designing theoretically informed, conceptual prototypes for interventions to increase hand hygiene in hospital set-tings: a case study. Design for Health, 5(3):313-29.
23. Davis KG, Kotowski SE (2015). Prevalence of musculoskeletal disorders for nurses in hospitals, long-term care facilities, and home health care: a comprehensive review. Hum Factors, 57(5):754-92.
24. Lee SE, Scott LD (2018). Hospital nurses’ work environment characteristics and patient safety outcomes: A literature re-view. West J Nurs Res, 40(1):121-145.
25. Ahmed S, Tareq AH, Ilyas D (2024). The Impact of Antimicrobial Resistance and Stewardship Training Sessions on Knowledge of Healthcare Students of Wah Cantonment, Pakistan. Inquiry, 61:00469580241228443.
26. Rojas‐García A, Turner S, Pizzo E, et al (2018). Impact and experiences of de-layed discharge: A mixed‐studies sys-tematic review. Health Expect, 21(1):41-56.
27. Wang Z (2014). Hand hygiene promotion: An essential strategy for preventing foodborne disease in elementary schools: Clemson University, (12): 1-92.
28. Kim H, Hegde S, LaFiura C, et al (2021). Access to personal protective equipment in exposed healthcare workers and COVID-19 illness, severity, symptoms and duration: a population-based case-control study in six countries. BMJ Glob Health, 6(1): e004611.
29. Johnson J, Akinboyo IC, Schaffzin JK (2021). Infection prevention in the neo-natal intensive care unit. Clin Perinatol, 48(2):413-29.
30. Gibbons JA, Smith HL, Kumar SC, et al (2017). Antimicrobial stewardship in the treatment of skin and soft tissue infec-tions. Am J Infect Control, 45(11):1203-7.
31. Prüss-Ustün A, Wolf J, Bartram J, et al (2019). Burden of disease from inade-quate water, sanitation and hygiene for selected adverse health outcomes: An updated analysis with a focus on low- and middle-income countries. Int J Hyg Environ Health, 222:765-777.
32. Girum T, Shumbej T, Shewangizaw M (2019). Burden of malaria in Ethiopia, 2000-2016: findings from the Global Health Estimates 2016. Trop Dis Travel Med Vaccines, 5:11.
33. Kurizky PS, Neto LLS, Aires RB, et al (2020). Opportunistic tropical infections in immunosuppressed patients. Best Pract Res Clin Rheumatol, 34(4):101509.
34. Adebisi YA, Agumage I, Sylvanus TD, et al (2019). Burden of Tuberculosis and Challenges Facing Its Eradication in West Africa. Int J Infect, 6(3): e92250.
35. Liberati A, Altman DG, Tetzlaff J, et al (2009). The PRISMA statement for re-porting systematic reviews and meta-analyses of studies that evaluate healthcare interventions: explanation and elaboration. PLoS Med, 6(7):e1000100.
36. Higgins JP, Altman DG, Gøtzsche PC, et al (2011). The Cochrane Collaboration’s tool for assessing risk of bias in ran-domised trials. BMJ, 343:d5928.
37. Wells GA, Shea B, O’Connell D, et al (2000). The Newcastle-Ottawa Scale (NOS) for assessing the quality of non-randomised studies in meta-analyses. Scholar Archive, (1): 1-12.
38. Higgins JP, Green S, editors. (2011). Cochrane handbook for systematic reviews of interventions. Vol. 4. John Wiley & Sons.
39. Cohen J (1988). Statistical power analysis for the behavioral sciences. Vol. 2. Lawrence Erlbaum Associates.
40. Egger M, Smith GD, Schneider M, et al (1997). Bias in meta-analysis detected by a simple, graphical test. BMJ, 315(7109):629-634.
41. DerSimonian R, Laird N (1986). Meta-analysis in clinical trials. Control Clin Tri-als, 7(3):177-188.
42. Huedo-Medina TB, Sánchez-Meca J, Marín-Martínez F, et al (2006). Assessing heter-ogeneity in meta-analysis: Q statistic or I² index? Psychol Methods, 11(2):193-206.
43. Higgins JP, Thompson SG (2002). Quantify-ing heterogeneity in a meta-analysis. Stat Med, 21(11):1539-1558.
44. Baujat B, Mahé C, Pignon JP, et al (2002). A graphical method for exploring hetero-geneity in meta-analyses: application to a meta-analysis of 65 trials. Stat Med, 21(18):2641-2652.
45. Sterne JA, Sutton AJ, Ioannidis JP, et al (2011). Recommendations for examining and interpreting funnel plot asymmetry in meta-analyses of randomised con-trolled trials. BMJ, 343:d4002.
46. Duval S, Tweedie R (2000). Trim and fill: a simple funnel-plot–based method of testing and adjusting for publication bi-as in meta-analysis. Biometrics, 56(2):455-463.
47. Higgins JP, Thompson SG, Deeks JJ, et al (2003). Measuring inconsistency in meta-analyses. BMJ, 327(7414):557-560.
48. Egger M, Davey Smith G, Altman DG, edi-tors. (2008). Systematic reviews in health care: meta-analysis in context. John Wiley & Sons.
49. Borenstein M, Hedges LV, Higgins JP, et al (2011). Introduction to meta-analysis. John Wiley & Sons.
50. Dimitriadou I, Pittas S, Sidiropoulos A, et al (2022). Perception of Nursing Staff in ICU Regarding Measures to Prevent Hospital-Acquired Infections: A Qualita-tive Approach. Cureus, 14(12): e33029.
51. Fuster C, Vaqué J, Solé J (2010). Compliance of healthcare workers with guidelines on antibiotic therapy. Enferm Infecc Microbiol Clin, 28(8):491-496.
52. Apisarnthanarak A, Greene MT, Kennedy EH, et al (2012). National survey of prac-tices to prevent healthcare-associated infections in Thailand: the role of pre-vention bundles. Infect Control Hosp Epi-demiol, 33(7):711-717.
53. Murni IK, Duke T, Kinney S, et al (2015). Reducing hospital-acquired infections and improving the rational use of anti-biotics in a developing country: an ef-fectiveness study. Arch Dis Child, 100(5):454-9.
54. Kirkland KB, Weinstein JM (1999). Adverse effects of contact isolation. Lancet, 354(9185):1177-1178.
55. Bearman GM, Wenzel RP (2005). Bactere-mias: a leading cause of death. Arch Med Res, 36(6):646-659.
| Files | ||
| Issue | Vol 54 No 5 (2025) | |
| Section | Review Article(s) | |
| DOI | https://doi.org/10.18502/ijph.v54i5.18627 | |
| Keywords | ||
| Hospital-acquired infections Nursing interventions Personal protective equipment Meta-analysis | ||
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How to Cite
1.
Ye F, Ma L. Assessing Global Nursing Interventions in Reducing Hospital-Acquired Infections: A Meta-Analysis. Iran J Public Health. 2025;54(5):915-927.
