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Evaluation of the national Cleanyourhands campaign to reduce Staphylococcus aureus bacteraemia and Clostridium difficile infection in hospitals in England and Wales by improved hand hygiene: four year, prospective, ecological, interrupted time series study

BMJ 2012; 344 doi: (Published 03 May 2012) Cite this as: BMJ 2012;344:e3005
  1. Sheldon Paul Stone, senior lecturer, stroke physician, and general physician for older people1,
  2. Christopher Fuller, project manager and nursing research fellow2,
  3. Joan Savage, research associate2,
  4. Barry Cookson, director3,
  5. Andrew Hayward, senior lecturer2,
  6. Ben Cooper, mathematical modeller510,
  7. Georgia Duckworth, director4,
  8. Susan Michie, professor of health psychology6,
  9. Miranda Murray, consultant scientist 4,
  10. Annette Jeanes, consultant nurse in infection control 7,
  11. J Roberts, emeritus professor of economics of infectious disease 8,
  12. Louise Teare, consultant microbiologist and infection control doctor 9,
  13. Andre Charlett, head of department10
  1. 1Royal Free Campus, University College London Medical School, London NW3 2PF, UK
  2. 2Research Department of Infection and Population Health, Royal Free Hospital, London
  3. 3Laboratory of HealthCare Associated Infection, Health Protection Agency, London
  4. 4Department of Healthcare Associated Infection and Antimicrobial Resistance, Health Protection Agency, London
  5. 5Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
  6. 6Department of Psychology, University College London
  7. 7Department of Microbiology, University College London Hospitals, London
  8. 8Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London
  9. 9Department of Microbiology, Mid-Essex NHS Trust, Chelmsford, Essex, UK
  10. 10Department of Statistics, Modelling, and Economics, Health Protection Agency
  1. Correspondence to: Sheldon Paul Stone s.stone{at}
  • Accepted 2 April 2012


Objective To evaluate the impact of the Cleanyourhands campaign on rates of hospital procurement of alcohol hand rub and soap, report trends in selected healthcare associated infections, and investigate the association between infections and procurement.

Design Prospective, ecological, interrupted time series study from 1 July 2004 to 30 June 2008.

Setting 187 acute trusts in England and Wales.

Intervention Installation of bedside alcohol hand rub, materials promoting hand hygiene and institutional engagement, regular hand hygiene audits, rolled out nationally from 1 December 2004.

Main outcome measures Quarterly (that is, every three months) rates for each trust of hospital procurement of alcohol hand rub and liquid soap; Staphylococcus aureus bacteraemia (meticillin resistant (MRSA) and meticillin sensitive (MSSA)) and Clostridium difficile infection for each trust. Associations between procurement and infection rates assessed by mixed effect Poisson regression model (which also accounted for effect of bed occupancy, hospital type, and timing of other national interventions targeting these infections).

Results Combined procurement of soap and alcohol hand rub tripled from 21.8 to 59.8 mL per patient bed day; procurement rose in association with each phase of the campaign. Rates fell for MRSA bacteraemia (1.88 to 0.91 cases per 10 000 bed days) and C difficile infection (16.75 to 9.49 cases). MSSA bacteraemia rates did not fall. Increased procurement of soap was independently associated with reduced C difficile infection throughout the study (adjusted incidence rate ratio for 1 mL increase per patient bed day 0.993, 95% confidence interval 0.990 to 0.996; P<0.0001). Increased procurement of alcohol hand rub was independently associated with reduced MRSA bacteraemia, but only in the last four quarters of the study (0.990, 0.985 to 0.995; P<0.0001). Publication of the Health Act 2006 was strongly associated with reduced MRSA bacteraemia (0.86, 0.75 to 0.98; P=0.02) and C difficile infection (0.75, 0.67 to 0.84; P<0.0001). Trust visits by Department of Health improvement teams were also associated with reduced MRSA bacteraemia (0.91, 0.83 to 0.99; P=0.03) and C difficile infection (0.80, 0.71 to 0.90; P=0.01), for at least two quarters after each visit.

Conclusions The Cleanyourhands campaign was associated with sustained increases in hospital procurement of alcohol rub and soap, which the results suggest has an important role in reducing rates of some healthcare associated infections. National interventions for infection control undertaken in the context of a high profile political drive can reduce selected healthcare associated infections.


  • We thank Richard Horsfall (NHS Supply Chain), Tracey Prothero (Welsh Health Supplies, NHS Wales), Peter Phillips (Intercontinental Marketing Services), Ginny Edwards (UK Department of Health), infection control teams in all English and Welsh acute trusts, Katherine Wilson (National Patient Safety Agency), and the two referees for their helpful comments on the paper.

  • Contributors: All authors read and had input in the final version of the paper; had access to the data and analyses; and were involved in the conception, design, and conduct of the study over four years, and interpretation of the data. CF wrote the first draft of the manuscript. CF and JS collected and organised data with help from AC, MM, and GD. AC did the data analysis with support from CF, JS, and SM. SPS wrote the original grant with input from AH, BCookson, BCooper, GD, AC, LT, AJ, SM, and JR.

  • Funding: The study received funding from the Patient Safety Research Programme (with donations from the trustees of the Royal Free London NHS Foundation Trust) and sponsorship from University College London. The funder had no role in the design, conduct, or analysis of the study.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: the study received funding from the Patient Safety Research Programme (with donations from the trustees of the Royal Free London NHS Foundation Trust) and sponsorship from University College London; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: The study protocol was approved by the multicentre research ethics committee (04MRE/10/66 Scotland).

  • Data sharing: Databases from the study are described on the website of the National Observation Study of the Effectiveness of the Cleanyourhands Campaign, with which data sharing arrangements can be entered into. The Infectious Diseases Research Network has agreed to facilitate this sharing of data, thus reaching a wider audience within the infection control research community.

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