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INTRODUCTION: Efforts to improve teamwork in health care have received considerable attention. The current systematic review was conducted to identify recent studies that implemented practices to improve teamwork and were associated with positive improvements on the job. METHODS: Electronic searches of 2 databases (i.e., CINAHL and MEDLINE) were conducted to identify relevant articles published between 2008 and 2018. RESULTS: Twenty articles were selected for inclusion in this review. The studies most often used quasiexperimental designs and interventions were applied in a variety of hospital settings including labor and delivery, operating rooms, and emergency departments. Across studies, measures assessing teamwork skills on the job were most often collected and showed sustained improvements up to 12 months. Moreover, evidence of improved clinical processes (e.g., compliance with guidelines and efficiency) and increased patient safety (e.g., reduction in adverse events) was found in both studies of team training interventions, as well as in those that introduced performance support tools (e.g., checklist). CONCLUSIONS: The results of the current review are consistent with previous research and add to the evidence base on the practices to improve teamwork within hospital settings. Although efforts to improve teamwork have spread to other health care settings such as office-based care, published studies are lagging behind.

Introduction The aim of this systematic review was to determine the impact of automated patient monitoring systems (PMSs) on sepsis recognition and outcomes. Methods Systematic searches were conducted using CINAHL, MEDLINE, and Cochrane, for articles published from 2008 through 2018. English-language, peer-reviewed articles that reported the impact of PMS on sepsis care were included. For selected articles, the authors abstracted information, with the study designed to be compliant with Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. Results Nineteen articles were identified for inclusion: 4 systematic reviews and 15 individual studies. Study design and quality varied, with some randomized controlled trials and quasiexperimental studies, as well as many observational studies. Study results for outcome measures (e.g., mortality, intensive care unit [ICU] length of stay, ICU transfer) were mixed, with more than half of the studies showing a significant improvement in at least one measure. Evidence for process measure (e.g., time to antibiotic administration, lactate measurement, etc.) improvement was of moderate strength across multiple types of hospital units, and evidence was most consistent outside the ICU. Conclusions Automated sepsis PMSs have the potential to improve sepsis recognition and outcomes, but current evidence is mixed on their effectiveness. More high-quality studies are needed to understand the effects of PMSs on important sepsis-related process and outcome measures in different hospital units.

OBJECTIVE: The aim of this systematic review was to examine the most effective and feasible methods for environmental cleaning and decontamination to prevent Clostridioides difficile infection (CDI) in health care settings. METHODS: A systematic search of the databases CINAHL and MEDLINE was conducted from 2008 to 2018 for English language articles with search terms including "Clostridium difficile," and related medical subject headings, in combination with terms like "disinfection," "decontamination," and "no-touch decontamination." RESULTS: Twelve studies and 2 systematic reviews were selected for inclusion in this review. The studies were primarily in hospitals (10/12) and used a before-after approach. The studied interventions included cleaning and decontamination with a chlorine-based agent (i.e., bleach; 2 studies), standard cleaning plus the use of hydrogen peroxide decontamination (3 studies), and standard bleach cleaning plus the use of ultraviolet light decontamination (6 studies), and there was 1 study about launderable bed covers. The interventions ranged in frequency, duration, and the area selected for cleaning and decontamination (e.g., all patient rooms versus only CDI patients' rooms). Studies showed significant reductions in CDI associated with use of bleach (versus quaternary ammonium compound) and hydrogen peroxide decontamination after standard bleach cleaning (versus bleach cleaning alone). Four of 6 studies found significant reductions in CDI after the implementation of ultraviolet light decontamination after standard bleach cleaning. CONCLUSIONS: The studied practices for environmental cleaning and decontamination were associated with significant decreases in facility-level CDI rates in most of the reviewed studies; however, study quality was low. Implementation challenges are worthy of further examination.

Objective The aim of the study was to summarize the latest evidence for patient bathing with a 2% to 4% chlorhexidine gluconate solution to reduce multidrug-resistant organism (MDRO) transmission and infection. Methods We searched 3 databases (CINAHL, MEDLINE, and Cochrane) for a combination of the key words "chlorhexidine bathing" and MeSH terms "cross-infection prevention," "drug resistance, multiple, bacterial," and "drug resistance, microbial." Articles from January 1, 2008, to December 31, 2018, were included, as well as any key articles published after December 31. Results Our findings focused on health care-associated infections (HAIs) and 3 categories of MDROs: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and carbapenem-resistant Enterobacteriaceae (CRE). Chlorhexidine bathing reduces MRSA acquisition and carriage, but not all studies found significant reductions in MRSA infections. Several studies found that chlorhexidine bathing reduced VRE acquisition and carriage, and one study showed lower VRE infections in the bathing group. Two studies found that bathing reduced CRE carriage (no studies examined CRE infections). Two very large studies (more than 140,000 total patients) found bathing significantly reduced HAIs, but these reductions may be smaller when HAIs are already well controlled by other means. Conclusions There is a high level of evidence supporting chlorhexidine bathing to reduce MDRO acquisition; less evidence is available on reducing infections. Chlorhexidine bathing is low cost to implement, and adverse events are rare and resolve when chlorhexidine use is stopped. There is evidence of chlorhexidine resistance, but not at concentrations in typical use. Further research is needed on chlorhexidine bathing's impact on outcomes, such as mortality and length of stay.

The Socio-Technical Probabilistic Risk Assessment, a proactive risk assessment tool imported from high-risk industries, was used to identify risks for surgical site infections (SSIs) associated with the ambulatory surgery center setting and to guide improvement efforts. This study had 2 primary objectives: (1) to identify the critical risk factors associated with SSIs resulting from procedures performed at ambulatory surgery centers and (2) to design an intervention to mitigate the probability of SSI for the highest risk factors identified. Inputs included quantitative and qualitative data sources from the evidence-based literature and from health care providers. The Socio-Technical Probabilistic Risk Assessment ranked the failure points (events) on the basis of their contribution to an SSI. The event, entitled “Failure to protect the patient effectively,” which included several failure points, was the most critical unique event with the highest contribution to SSI risk. A total of 51.87% of SSIs in this setting were caused by this failure. Consequently, we proposed an intervention aimed at all 5 major components of this failure. The intervention targets improvements in skin preparation; proper administration of antibiotics; staff training in infection control principles, including practices for the prevention of glove punctures; and procedures to ensure the removal of watches, jewelry, and artificial nails.

OBJECTIVETo observe patient care across hemodialysis facilities enrolled in the National Opportunity to Improve Infection Control in ESRD (end-stage renal disease) (NOTICE) project in order to evaluate adherence to evidence-based practices aimed at prevention of infection.SETTING AND PARTICIPANTSThirty-four hemodialysis facilities were randomly selected from among 772 facilities in 4 end-stage renal disease participating networks. Facility selection was stratified on dialysis organization affiliation, size, socioeconomic status, and urban/rural status.MEASUREMENTSTrained infection control evaluators used an infection control worksheet to observe 73 distinct infection control practices at the hemodialysis facilities, from October 1, 2011, through January 31, 2012.RESULTSThere was considerable variation in infection control practices across enrolled facilities. Overall adherence to recommended practices was 68% (range, 45%–92%) across all facilities. Overall adherence to expected hand hygiene practice was 72% (range, 10%–100%). Compliance to hand hygiene before and after procedures was high; however, during procedures hand hygiene compliance averaged 58%. Use of chlorhexidine as the specific agent for exit site care was 19% overall but varied from 0% to 35% by facility type. The 8 checklists varied in the frequency of perfect performance from 0% for meeting every item on the checklist for disinfection practices to 22% on the arteriovenous access practices at initiation.CONCLUSIONSOur findings suggest that there are many areas for improvement in hand hygiene and other infection prevention practices in end-stage renal disease. These NOTICE project findings will help inform the development of a larger quality improvement initiative at dialysis facilities.Infect Control Hosp Epidemiol 2015;36(7):802–806

Background.Antibiograms have effectively improved antibiotic prescribing in acute-care settings; however, their effectiveness in skilled nursing facilities (SNFs) is currently unknown.Objective.To develop SNF-specific antibiograms and identify opportunities to improve antibiotic prescribing.Design and Setting.Cross-sectional and pretest-posttest study among residents of 3 Maryland SNFs.Methods.Antibiograms were created using clinical culture data from a 6-month period in each SNF. We also used admission clinical culture data from the acute care facility primarily associated with each SNF for transferred residents. We manually collected all data from medical charts, and antibiograms were created using WHONET software. We then used a pretest-posttest study to evaluate the effectiveness of an antibiogram on changing antibiotic prescribing practices in a single SNF. Appropriate empirical antibiotic therapy was defined as an empirical antibiotic choice that sufficiently covered the infecting organism, considering antibiotic susceptibilities.Results.We reviewed 839 patient charts from SNF and acute care facilities. During the initial assessment period, 85% of initial antibiotic use in the SNFs was empirical, and thus only 15% of initial antibiotics were based on culture results. Fluoroquinolones were the most frequently used empirical antibiotics, accounting for 54.5% of initial prescribing instances. Among patients with available culture data, only 35% of empirical antibiotic prescribing was determined to be appropriate. In the single SNF in which we evaluated antibiogram effectiveness, prevalence of appropriate antibiotic prescribing increased from 32% to 45% after antibiogram implementation; however, this was not statistically significant (P = .32).Conclusions.Implementation of antibiograms may be effective in improving empirical antibiotic prescribing in SNFs.

OBJECTIVE: This article describes the role of the hospital environment in the spread of pathogens by direct and indirect contact. In addition, the prevention of transmission through interventions involving the built environment is discussed. BACKGROUND: The hospital environment can become contaminated with pathogenic microorganisms, some of which can persist for long periods of time. Although contamination is common, the contribution of the hospital environment to the development of healthcare-associated infections remains unclear. In part spurred by the development of newer technologies to enhance environmental cleaning or to prevent contamination, research into the role of the environment in causing healthcare-associated infections has accelerated. TOPICAL HEADINGS: A review of the recent literature finds an increasing body of evidence implicating contaminated surfaces in patient care areas in the transmission of pathogens and the development of infections. Single-patient rooms and optimally placed alcohol hand rub dispensers and other design features can mitigate infection risk. Enhanced environmental cleaning including touchless technologies and self-cleaning surfaces can reduce environmental contamination and may prevent infections. CONCLUSIONS: The hospital environment contributes to transmission of pathogens in hospitals and to the development of healthcare-associated infections. Newer technologies to prevent environmental contamination or to enhance cleaning are promising although additional studies with the endpoints of reduction of infections are needed before the role of these technologies is known.

OBJECTIVE: To assess expert knowledge, perceptions, and experience on the role of the built environment in the acquisition and transmission of healthcare-associated infections (HAIs), facility design decision-making considerations, and strategies for intervention through facility design and technologies. BACKGROUND: Healthcare-associated infections pose a serious and costly threat to public health in the United States. A growing evidence base suggests that the built environment can play a role in interrupting the chain of infection. METHODS: Semi-structured individual interviews and triads were conducted with 26 experts in hospital administration, architecture, interior design, infection control, and air and water quality. A grounded theory approach was used for interview coding and interpretation. RESULTS: Participants characterized the shift in thinking about the relationship between the built environment and HAI transmission as a “progression,” as accountability for infection prevention has expanded beyond clinicians. Organizational leaders aim to make informed design decisions, but this can be challenging due to the paucity of efficacy and return on investment data. Emerging interventions include copper impregnated materials, seamless flooring, and chilled beams. CONCLUSIONS: No single intervention is entirely effective in mitigating HAI risk; multiple interventions are needed. In addition to the built environment, human behavior must be considered, as noncompliance can render even the best designs ineffective. Increased multidisciplinary collaboration is needed to improve the application of evidence and experience in healthcare facility design. In the absence of conclusive evidence regarding interventions aimed at reducing HAI transmission, a combination of research data and practical experience should be used to inform design decisions.

OBJECTIVE: To summarize the findings and provide recommendations based on the multidisciplinary literature review and industry scan, focusing on the links between the built environment and healthcare-associated infections. To propose a research agenda in order to increase informed design decisions and advance the evidence base. BACKGROUND: The HAI-Design project explores the research linking a range of design interventions to healthcare-associated infection. The multidisciplinary team evaluated over 3,800 articles and conducted interviews with a range of stakeholders including CEOs, architects, designers, physicians and other healthcare experts, the results of which are featured in this special Supplement as topical papers. TOPICAL HEADINGS: The four topical papers describing the role of the built environment in the acquisition of healthcare-associated infections are summarized. The evidence evaluating the strategies for intervention through the built environment is analyzed, and a research agenda is proposed. CONCLUSIONS: While the evidence base supporting the efficacy of strategies and technologies continues to grow, there are currently few data that demonstrate a reduction in infection rates. The need for multidisciplinary collaboration and increased efforts to standardize the evaluation of environmental studies are essential to overcome the many challenges and improve the reliability of data

OBJECTIVE: To describe the conceptual framework and methodology used to conduct a comprehensive literature review of current evidence evaluating the role of the built environment in the transmission of healthcare-associated infections. BACKGROUND: A multidisciplinary approach to evaluating a vast and diverse dataset requires a conceptual framework to create a common understanding for interpretation. This common understanding is accomplished through the application of a “chain of transmission” model depicting temporal and physical paths of pathogens that cause healthcare-associated infections. The chain of transmission interventions model argues that infection can potentially be reduced by interrupting any of several links in the chain. TOPICAL HEADINGS: The key pathogens impacted by the built environment are identified. The chain of transmission and the conceptual framework are described. Opportunities for intervention through the built environment are presented, which in turn guide the subsequent methodology used to conduct the systematic literature review. CONCLUSIONS: The chain of transmission interventions model is a multidisciplinary conceptualization of the interaction between pathogens and the built environment, and this model facilitated a systematic literature review of a very large amount of data.

This article describes the results of the Interventions to Safeguard Safety breakout session of the 2011 Academic Emergency Medicine (AEM) consensus conference entitled “Interventions to Assure Quality in the Crowded Emergency Department.” Using a multistep nominal group technique, experts in emergency department (ED) crowding, patient safety, and systems engineering defined knowledge gaps and priority research questions related to the maintenance of safety in the crowded ED. Consensus was reached for seven research priorities related to interventions to maintain safety in the setting of a crowded ED. Included among these are: 1) How do routine corrective processes and compensating mechanism change during crowding? 2) What metrics should be used to determine ED safety? 3) How can checklists ensure safer care and what factors contribute to their success or failure? 4) What constitutes safe staffing levels / ratios? 5) How can we align emergency medicine (EM)-specific patient safety issues with national patient safety issues? 6) How can we develop metrics and skills to recognize when an ED is getting close to catastrophic overload conditions? and 7) What can EM learn from experts and modeling from fields outside of medicine to develop innovative solutions? These priorities have the potential to inform future clinical and human factors research and extramural funding decisions related to this important topic.

Aim To identify and characterise hazardous conditions in an Emergency Department (ED) using active surveillance. Methods This study was conducted in an urban, academic, tertiary care medical centre ED with over 45 000 annual adult visits. Trained research assistants interviewed care givers at the discharge of a systematically sampled group of patient visits across all shifts and days of the week. Care givers were asked to describe any part of the patient's care that they considered to be ‘not ideal.’ Reports were categorised by the segment of emergency care in which the event occurred and by a broad event category and specific event type. The occurrence of harm was also determined. Results Surveillance was conducted for 656 h with 487 visits sampled, representing 15% of total visits. A total of 1180 care giver interviews were completed (29 declines), generating 210 non-duplicative event reports for 153 visits. Thirty-two per cent of the visits had at least one non-ideal care event. Segments of care with the highest percentage of events were: Diagnostic Testing (29%), Disposition (21%), Evaluation (18%) and Treatment (14%). Process-related delays were the most frequently reported events within the categories of medication delivery (53%), laboratory testing (88%) and radiology testing (79%). Fourteen (7%) of the reported events were associated with patient harm. Conclusions A significant number of non-ideal care events occurred during ED visits and involved failures in medication delivery, radiology testing and laboratory testing processes, and resulted in delays and patient harm.

Communication in acute hospital care occurs frequently in group settings, with “rounds” as the prototypical forum for care providers to review and plan for patient care. Many care providers spend hours each day in rounds. While studies have demonstrated the importance of rounds as a mechanism to improve care coordination, care providers frequently express frustration about rounds. Previous observational studies of rounds have identified factors influencing information transfer: physical, social, cognitive, and supporting artifacts. In this paper, we adopt three perspectives in advancing our understanding of communication during rounds and in devising interventions: distributed cognition, computer-supported cooperative work, and common ground. We use video recordings of rounds discussion of one patient in a pediatric intensive care unit to illustrate the choreography of information flow aided by artifacts, the use of visual “text” in discourse, and the scaffolding process of incrementally building a shared understanding about the care and the status of the patient. We highlight the importance of detailed studies of communication in embedded work practices and the need for a multi-theoretical approach for future studies of communication.

A retrospective cohort study was conducted to evaluate the effect of the built environment of an emergency department (ED) on the timeliness of physician assessment of chest pain patients. The main outcome variable was time to initial physician assessment. Potential predictor variables included presence of a solid door, distance of treatment room from work area, staffing team, day of week, and the patient's age, sex, and triage level. After multi-variate adjustment, the only predictors of time to initial assessment greater than 10 minutes were being placed in a room with a door (adjusted odds ratio [OR] 1.58; 95% confidence interval [CI] 1.01-2.48) and being placed in a room 25 feet or more from the main physician work area (adjusted OR 1.38; 95% CI 1.13-1.67). These findings suggest that the ED built environment can be a barrier for providing timely care for this group of patients and may have implications for future ED architectural designs.

Affiliations: 1. SimTigrate Design Lab, School of Architecture, Georgia Institute of Technology, Atlanta, Georgia; 2. Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia; 3. Health Systems Institute, Georgia Institute of Technology, Atlanta, Georgia; 4. School of Industrial Design, Georgia Institute of Technology, Atlanta, Georgia; 5. Agency for Healthcare Research and Quality, Rockville, Maryland; 6. RTI International, Washington, DC. Received October 2, 2012; accepted November 21, 2012; electronically published April 9, 2013. 2013 by The Society for Healthcare Epidemiology of America. All rights reserved. 0899-823X/2013/3405-0011$15.00. DOI: 10.1086/670220 Evidence-based design (EBD) of healthcare facilities is an emerging field that has the potential to significantly reduce the burden of healthcare-associated infections (HAIs). There is a growing body of evidence demonstrating that the built environment of healthcare settings—their layout, materials, equipment, and furnishings—plays a key role in facilitating or preventing transmission of pathogens. The infection prevention community can be an important partner in further developing this evidence base by advocating for and including healthcare facility design in its research agenda. At the same time, the EBD of the built environment has the promise of providing an additional set of tools for infection prevention. A relatively new discipline, EBD has deep roots in environmental psychology, architecture, medicine, and other sciences. It postulates that the design of the built environment fundamentally impacts patient, provider, and organizational outcomes (ie, decreased infection rates, length of stay, falls, use of analgesics, and operating costs) while improving patient and caregiver experience and satisfaction. Similar to evidence-based medicine, EBD uses the best available evidence to inform decision making and includes measurement of outcomes. EBD of healthcare facilities gained prominence in the early 2000s with the publication of the Institute of Medicine’s report Crossing the Quality Chasm, a growing research evidence base, and the initiation of the largest hospital construction program in US history. After a decade of closing hospitals, the US began spending more than $40 billion annually on new healthcare facilities to accommodate shifting demographics, advancing technologies, and competitive pressures. EBD is a multistep process that includes (1) framing of goals and models, (2) incorporation of healthcare facility guidelines, (3) planning and design, and (4) operations (Figure 1). These are in turn affected by the economic and professional culture in which decisions are made: the evidence base, the greater visibility and pay for performance that comes from the “quality revolution,” best practices or examples, and shrinking reimbursement margins in a competitive environment. Infection prevention plays a key role at each step, as follows. Framing. Specific decisions about guidelines, planning and design, and operations are framed by stakeholders’ understanding of the goals of healthcare design and the models that drive it. Owners, clinicians, patients, regulators, and designers develop a view of “good” healthcare settings: what they should achieve and how to do so. Early models included envisioning hospitals as churches or, more recently, as pristine, white, modern laboratories. In the 2000s, a series of literature reviews highlighted that design and the built environment could improve patient safety, decrease pain, and increase satisfaction. These reviews and the growing focus on patientand family-centered care helped create demand for larger, light-filled, quieter healthcare facilities that provided comfort and positive distractions for patients and families, such as designated family areas in patient rooms, gardens, and water features. Families were provided increased access to patient rooms, including within intensive care units, where there had previously been strict visiting hours. Healthcare workers were provided spaces that better suited their tasks and afforded respite when on break. Several prominent articles emerged suggesting that the return on investment for these design features was achieved in as little as 1–3 years, based on designs that increased market share and decreased length of stay, due in part to decreased infections, reduced falls, and reduced analgesic use. Guidelines. Evidence and expectations are translated to design in part through the process of writing guidelines and standards. These guidelines, such as those promulgated by the Facilities Guidelines Institute (FGI), are often written by volunteer committees of professionals and offer guidance or are adopted as codes in the majority of the states. The Hospital Infection Control Practices Advisory Committee’s

Study objective Duration of a stay in an emergency department (ED) is considered a measure of quality, but current measures average lengths of stay across all conditions. Previous research on ED length of stay has been limited to a single condition or a few hospitals. We use a census of one state's data to measure length of ED stays by patients' conditions and dispositions and explore differences between means and medians as quality metrics. Methods The data source was the Healthcare Cost and Utilization Project 2011 State Emergency Department Databases and State Inpatient Databases for Florida. Florida is unique in collecting ED length of stay for both released and admitted patients. Clinical Classifications Software was used to group visits based on first-listed International Classification of Disease, Ninth Edition, Clinical Modification , diagnoses. Results For the 10 most common diagnoses, patients with relatively minor injuries typically required the shortest mean stay (3 hours or less); conditions resulting in admission or transfer tended to be more serious, resulting in longer stays. Patients requiring the longest stays, by disposition, had discharge diagnoses of nonspecific chest pain (mean 7.4 hours among discharged patients), urinary tract infections (4.8 hours among admissions), and schizophrenia (9.6 hours among transfers) among the top 10 diagnoses. Conclusion Emergency department length of stay as a measure of ED quality should take into account the considerable variation by condition and disposition of the patient. Emergency department length of stay measurement could be improved in the United States by standardizing its definition; distinguishing visits involving treatment, observation, and boarding; and incorporating more distributional information.

Antibiotic-resistant bacteria are associated with increased patient morbidity and mortality. It is unknown whether wearing gloves and gowns for all patient contact in the intensive care unit (ICU) decreases acquisition of antibiotic-resistant bacteria.To assess whether wearing gloves and gowns for all patient contact in the ICU decreases acquisition of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) compared with usual care.Cluster-randomized trial in 20 medical and surgical ICUs in 20 US hospitals from January 4, 2012, to October 4, 2012.In the intervention ICUs, all health care workers were required to wear gloves and gowns for all patient contact and when entering any patient room.The primary outcome was acquisition of MRSA or VRE based on surveillance cultures collected on admission and discharge from the ICU. Secondary outcomes included individual VRE acquisition, MRSA acquisition, frequency of health care worker visits, hand hygiene compliance, health care–associated infections, and adverse events.From the 26,180 patients included, 92,241 swabs were collected for the primary outcome. Intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI, 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period, whereas control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI, 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI, 13.48 to 19.68) in the study period, a difference in changes that was not statistically significant (difference, −1.71 acquisitions per 1000 person-days, 95% CI, −6.15 to 2.73; P = .57). For key secondary outcomes, there was no difference in VRE acquisition with the intervention (difference, 0.89 acquisitions per 1000 person-days; 95% CI, −4.27 to 6.04, P = .70), whereas for MRSA, there were fewer acquisitions with the intervention (difference, −2.98 acquisitions per 1000 person-days; 95% CI, −5.58 to −0.38; P = .046). Universal glove and gown use also decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference, −0.96; 95% CI, −1.71 to −0.21, P = .02), increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference, 15.4%; 95% CI, 8.99% to 21.8%; P = .02) and had no statistically significant effect on rates of adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference, −15.7; 95% CI, −40.7 to 9.2, P = .24).The use of gloves and gowns for all patient contact compared with usual care among patients in medical and surgical ICUs did not result in a difference in the primary outcome of acquisition of MRSA or VRE. Although there was a lower risk of MRSA acquisition alone and no difference in adverse events, these secondary outcomes require replication before reaching definitive conclusions.clinicaltrials.gov Identifier: NCT0131821.