Limitations
Protocol results were compared with preintervention
results instead of a randomized control group,
limiting confidence in the effect of the protocol. The
demographics of the 2 groups were not evaluated
with respect to number of isolation patients or type
of isolation. Because many factors affect infection
rates, the study results cannot be solely attributed
to the intervention. In addition, physician training
and site of catheter insertion were not evaluated.
Although nurses were aware that their hand-washing
rates were being observed, they did not know who
was doing the observations. Knowing their practice
was being observed may have resulted in a
Hawthorne effect, resulting in higher than normal
hand-washing rates for the nurses. Because of the
nature of the intervention, participants were not
blinded to the hand hygiene procedure. The study
was completed in only 1 ICU at a single institution
during a 1-year period; therefore, the results have
limited generalizability to other institutions or units.