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| Journal of the New Zealand Medical Association,
11-May-2012, Vol 125 No 1354
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Implementing and sustaining
a hand hygiene culture change programme at Auckland District Health
Board
Sally A Roberts, Christine
Sieczkowski, Taima Campbell, Greg Balla, Andrew Keenan; on behalf of the
Auckland District Health Board Hand Hygiene Steering and Working Groups
Hand hygiene is one of the most effective means of reducing
healthcare-associated infections, yet it is
done poorly by healthcare workers for many
reasons.1 In a recent systematic review of
studies looking at hand hygiene compliance in hospitals, the overall median
compliance with hand hygiene was only 40%.2
Multimodal programmes to achieve improvement in hand hygiene compliance
by healthcare workers can achieve significant sustained improvements in hand
hygiene compliance and reductions in infections due to methicillin-resistant
Staphylococcus aureus (MRSA) and other nosocomial
pathogens.3-5
S. aureus causes a significant number of
healthcare-associated infections; at Auckland District Health Board (ADHB) it is
the leading cause of surgical site infections, and is the second leading cause
of healthcare-associated bloodstream infections (unpublished data).Whilst MRSA
bacteraemia remains an uncommon event in New Zealand hospitals the rates of
patients colonized or infected with MRSA and extended-spectrum beta
lactamase-producing Enterobacteriaceae continue to increase in New
Zealand6,7 and concerted efforts to prevent
healthcare-associated infections with these organisms is even more pressing.
In 2007 the Quality Improvement Committee of the Ministry of
Health initiated a number of quality improvement projects. ADHB was the lead DHB
for the Infection Prevention and Control projects. In conjunction with Waikato
and Tairawhiti DHBs, ADHB participated in stage 1 of the national rollout of the
Hand Hygiene New Zealand (HHNZ) programme8, a
culture change programme aimed at improving hand hygiene compliance in all
clinical areas. The programme was based on the World Health Organisation (WHO)
‘5 moments for hand hygiene’ initiative, Figure 1, and was aligned
with Hand Hygiene Australia (HHA).
The key components to the programme were as follows:
Figure 1. WHO 5 moments for hand
hygiene
  In January 2009 ADHB commenced implementation of the HHNZ
programme. We describe the implementation process and assess the effectiveness
of this programme 36 months after implementation.
MethodAuckland District Health Board (ADHB) provides care for
an estimated 460,000 people. The clinical services consist of Auckland City
Hospital, Starship Children’s Hospital and Green Lane Clinical Centre
comprising of 1100 in-patient beds. In keeping with the HHNZ
guideline8 the implementation was divided into
five steps: roll-out and facility preparation, baseline evaluation,
implementation, follow-up evaluation and sustainability.
Roll-out and facility
preparation—A fulltime project manager was employed to implement
the HHNZ project. A steering group was formed to oversee the implementation; the
membership of the group included members of the senior management team
(Director’s of Performance and Innovation, Nursing, Allied Health,
Clinical Training, General Manager of Operations, Quality Manager, Nurse Leader
of Women’s and Child Health, Materials Manager), a Clinical Microbiologist
and the project manager. The responsibilities of this group were to be the
sponsors of the project, ensure that the project was delivered and that it
aligned with the strategic goals of the ADHB.
A working group was tasked with the implementation of
the project and this group worked with the project manager to provide among
other things operational advice and assistance. The membership of this group
included senior nurses with expertise in infection control, education and
occupational health, the Daily Operations Manager, Procurement Specialists and a
Clinical Microbiologist.
The specifications for the ABHR required a product that
contained a minimum of 70% alcohol and 0.5% chlorhexidine. The choice of
alcohol-based hand rub was made after a period of evaluation in selected
clinical areas. Sterigel + (Solumed, Les Entreprises Solumed Inc, Laval
(Québec) Canada) met the requirements of the programme and 500ml
dispensing bottles were placed at the end of the beds in brackets and 780 ml
wall dispensers were also placed outside patient rooms and in other relevant
clinical areas.
The Occupational Health and Safety Department undertook
to monitor adverse events associated with the product.
Baseline evaluation—For
reporting purposes, and in keeping with HHA recommendations, HHNZ required a
hospital with > 400 beds to report the results of hand hygiene audits in 7
wards/clinical areas and undertake 350 observations in each of these areas
during each audit period. These wards/clinical areas were termed the national
reporting wards. The 7 national reporting wards were chosen for a number of
reasons; the wards/clinical areas had high risk patients for whom
healthcare-associated infections had serious consequences, outbreaks or higher
rates of multiple antibiotic resistant organisms had been reported in these
areas and the senior staff showed a willingness to be involved in the programme.
Baseline evaluation of hand hygiene compliance was
undertaken in a staged manner starting with the 7 wards/clinical areas
designated as the national reporting wards. All other clinical areas were
audited over the next 12 months. Clinical areas were grouped together in medical
or surgical services to reduce the volume of auditing required and were audited
in a stage manner, groups 2-8. For example, group 2 included the general
medical, medical specialty and older person health wards and group 3 included
the general and specialty surgical wards. 200 observations were made in each
ward/clinical area within each group and then the mean hand hygiene compliance
was calculated for each group.
The auditing was undertaken by auditors. The auditors
were members of the Infection Prevention and Control Service (IP&CS) at ADHB
and had successfully undertaken training in hand hygiene compliance assessment,
the use of the data collection tool and data analysis provided at training
workshops conducted by HHNZ. Prior to each audit period the auditors were
required to demonstrate acceptable inter-observer variability. No less than 85%
inter-observer variability agreement in all observations is required before
formal data collection can commence.
HHNZ developed an electronic data collection tool using
a PDA. Hand hygiene compliance for each of the 5 moments is recorded. At each
session, information about the session, type of healthcare worker, hand hygiene
product used, glove use and inter-patient healthcare worker activities were
recorded.
Compliance was measured against each of the five
moments; moment 1, before patient contact, moment 2, before a procedure, moment
3, after a procedure or body fluid exposure, moment 4, after patient contact and
moment 5, after contact with the patient environment.
Implementation—Baseline
evaluation of hand hygiene compliance was carried out and the results were
feedback to the ward/clinical area. Healthcare workers in each ward/clinical
area were then educated about hand hygiene and the WHO ‘5 moments for hand
hygiene’.
Oral presentations at ward-based education sessions, at
medical grand rounds and other clinical forums were undertaken and an online
learning package was developed. Promotional activities have included the
development of themed posters, participation in World Hand Hygiene Day
(5th May), ward compliance competitions and
display boards, give-aways, IPC newsletters. The implementation of the programme
across all clinical areas took 18 months.
Follow-up evaluation and
sustainability—Following baseline auditing and education in the
ward/clinical area a programme of regular auditing of hand hygiene compliance
across all clinical areas was undertaken. The number of observations recorded
per audit period for national reporting wards was 350 and for all other clinical
areas it was 200.
During auditing the auditors record compliance data
directly into the PDA and upon return to their work space the data is
automatically downloaded to the national HHNZ database. The data can then be
analysed and reported in a variety of ways. The overall compliance rate for each
clinical area was determined along with compliance rate per moment and per
healthcare worker group.
Since S. aureus is the most common healthcare
acquired pathogen in New Zealand hospitals, the number of patients with clinical
infections and with healthcare-associated S. aureus bloodstream
infections were calculated as a rate per inpatient days and compared over
time.
Baseline rates for the preceding 36 months were
available for healthcare-associated episodes of blood stream infection and for
the preceding 12 months for clinical infections. The quarterly rate was reported
as this information was already been collected for reporting purposes. The rates
were compared pre and post implementation using segmented piecewise regression
analysis.
The project manager was fulltime during the first 18
months of the project and subsequently the role has reduced to 0.5FTE and
integrated into the IP&CS. The role of the hand hygiene coordinator was to
promote and sustain improvement in hand hygiene compliance across ADHB.
ResultsThe project was started in January 2009 and auditing of
baseline hand hygiene compliance rates for the national reporting wards was
completed in March 2009. This was followed by a staged rollout across all other
clinical areas which was completed by August 2010. Four monthly post
implementation audits were undertaken in the national reporting wards and a one
yearly post-implementation audit was done in all other clinical areas. By
November 2011 the national reporting wards had completed seven
post-implementation audits and all other areas had had at least one
post-implementation audit.
National Reporting Wards—The mean
(95% CI; range) baseline compliance rates for the national reporting wards was
35% (95% CI 24-46%, 25-61%). Compliance amongst healthcare workers was nurses
38%; doctors 33%, healthcare assistants 46%, and allied health staff 38%.
Compliance with individual moments was as follows: moment 1, 28%; moment 2, 31%;
moment 3, 42%; moment 4, 49% and moment 5, 24%.
The compliance rates increased over the first two audit
periods for all areas. However, by the third and fourth audit period, compliance
rates had fallen in three of the seven areas but still remained above baseline,
Figure 2. At subsequent audits the compliance rate increased in these
areas.
Figure 2. Hand hygiene compliance rates (%) at
baseline and after implementation for the national reporting
wards
 Amongst the healthcare worker sustained improvement was seen
in all groups; overall compliance in these four groups by the 7th audit period
was 60% (95% CI 46 –74; range 47-91). Nursing staff showed the greatest
sustained improvement from 39% to 63%, Figure 3. Doctors also increased from 33%
at baseline to 60% by the 7th audit but
improvement varied between audit periods..
There was also an improvement in compliance with individual
‘moments’; particularly moment 3 and moment 4, Figure 3.
Other clinical areas—The mean (95%
CI;) baseline compliance rate for the other clinical areas per group was: 2, 30%
(95% CI 21-39); 3, 36% (95% CI 27-45); 4, 43% (95% CI 33-53); 5, 30% (95% CI
24-36); 6, 38% (95% CI 30-46); 7, 35% (95% CI 25-45) and 8, 45% (95% CI 33-71).
The overall compliance rate for all these areas was 37% (95% CI 32-42, 29-45).
The mean (95% CI; range) compliance rate one year after implementation for all
these areas was 50% (95% CI 45-55, 41-58).
Outcome measures—The overall ADHB
rate of healthcare-associated S. aureus bloodstream infection per 1000
inpatient days before implementation and for 36 months after implementation
(March 2009 – December 2011) is shown in Figure 4. There was a
statistically significant decrease in the rate over time
(R2 =0.44, p=0.027).
Figure 3. Hand hygiene compliance rate (%) at
baseline and post-implementation for healthcare worker groups and per
‘moment’ for the National Reporting Wards
 RN, registered nurse; DR, doctor; HCA, healthcare assistant
and AH, allied health
 Figure 4. Quarterly episodes of S. aureus
healthcare-associated bloodstream infection per 1000 inpatient day’s
pre and post implementation of the HHNZ programme
 The overall ADHB rate of clinical infection caused by S.
aureus per 100 inpatient days before implementation and for 24 months after
implementation (March 2009 – March 2011) showed no reduction in the rate,
Figure 5.
Figure 5. Quarterly rate of clinical infections
due to S. aureus per 100 inpatient day’s before and after
implementation of the HHNZ programme
 Discussion:This is the first report detailing the implementation of a
hospital-wide ‘culture change’ hand hygiene programme in a New
Zealand DHB. Baseline compliance rates with hand hygiene at ADHB were low but
were consistent with reported rates.2 Rates
tend to be lower in intensive care settings, lower among doctors than among
nurses and lower before, rather than after, patient
contact.2 Within the national reporting wards
the compliance with hand hygiene for nurses was 38% and for doctors 33%. All
healthcare worker groups improved compliance with hand hygiene following the
implementation of the project. Whilst the nursing staff showed the greatest
sustained improvement, the rate of compliance for doctors also increased but was
less consistent.
Overall hand hygiene compliance in the national reporting
wards increased from a mean rate 35% at baseline to 62% at 4 months and
sustained at 60% 36 months after implementation. The improvement in compliance
can be considered to be moderate at best in all areas except for one ward which
achieved and sustained compliance over 80%.
The baseline rates for ‘moment’ 1 and 2, the
before contact ‘moments’, were 37% and 31%, respectively compared to
the rates for ‘moment’ 3 and 4, the after moments, which were 42%
and 49%, respectively. The greatest improvement was seen with moments 3 and 4.
Compliance with hand hygiene following patient contact is universally better
than before patient contact.9 HCW perform hand
hygiene due to the perceived risk to themselves of pathogen transfer following
contact with the patient or following blood and body fluid exposure. Preventing
pathogen transfer to patients relies on the HCW performing hand hygiene before
contact with patients and before performing clean or aseptic tasks.
The initial improvement was not sustained beyond 12 months
in all areas. In early 2010 the project manager left and was not replaced until
the middle of that year. The loss of a project manager has been shown to impact
on the sustainability of hand hygiene compliance rates in a pilot programme in
Victoria, Australia.5 The project manager role
was replaced with a 0.5 FTE Infection Prevention and Control Nurse Specialist
and hand hygiene became core business for the IP&CS.
There was a statistically significant reduction in the rate
of healthcare-associated S. aureus bacteraemia over the 36 month period
following the implementation at ADHB. . S. aureus bacteraemia causes
significant morbidity and mortality in New Zealand and Australia; the all-cause
mortality at 30 days is 20.6%.10 About 40% of
episodes of S. aureus bacteraemia arise in the hospital and the
all-cause mortality at 30 days is significantly higher for hospital onset than
community onset (p=0.004).10 A number of
infection control interventions have been shown to reduce healthcare-associated
infections including those caused by S.
aureus.11-13
Improvement in hand hygiene compliance was associated with a
significant reduction in methicillin-resistant S. aureus (MRSA)
bacteraemia in Victoria with 65 fewer patients with MRSA bacteraemia 24 months
after implementation of a statewide hand hygiene culture-change
programme.5 With a more sustained improvement
in hand hygiene compliance we would hope to see a further reduction in the rate
of healthcare-associated S. aureus bacteraemia.
The rate of S. aureus clinical infections following
implementation was unchanged. This is not surprising as skin and soft tissue
infections caused by S. aureus are a common cause for admission to New
Zealand hospitals.14-15 Improvement in hand
hygiene compliance by HCW is unlikely to impact on the rate of admissions for
S. aureus skin and soft tissue infections because 60-75% of these
infections are community acquired.10,15 We
conclude that this should no longer be used by HHNZ as an outcome measure.
The auditing is undertaken by trained auditors, members of
the IP&CS, and this has ensured consistency of reporting hand hygiene
compliance. It also avoids the risk of observer bias that may occur if the
observer worked in the area being audited. The timetable for auditing is set by
the IP&CS and this prevents avoidance of auditing in poorly performing
areas. The results of each audit are promptly reported to the Charge Nurse
Manager and Clinical Director in each area. Organisation wide disclosure of
individual ward/clinical area results has not occurred; this is under review as
it has been proposed as a means of improving quality of care while ensuring
transparency and accountability.16 The benefit
of public reporting of hospital hand hygiene compliance is
debated.17
Promotion of the programme is an important aspect of a
culture change programme. Involvement of the Communications Department helped
with the initial promotion of the programme and a detailed promotional package
was developed. The “Talking Walls”2
concept was modified to cover posters that were designed to promote hand
hygiene. The initial set of posters used to promote hand hygiene at ADHB was
from the HHNZ campaign and a further set were developed within house based on
pop art. The posters were placed at the entrance to clinical areas and beside
the ABHR dispensing units and basins in clinical areas. Individual ward/clinical
areas were encouraged to develop their own promotional activities. The IP&CS
promotes compliance with hand hygiene regularly and on occasions such as
‘World Hand hygiene Day’, the 5th
May.
One ward had achieved over 80% compliance by the second
audit period and has maintained hand hygiene compliance over 85% out to 36
months post-implementation. The healthcare-associated bloodstream infection rate
for that ward for the 12 months prior (2008) to implementation was 3.3/1000
inpatient days (95% CI 2.3-4.2) and in 2010 the rate was 1.8/1000 inpatient days
(95% CI 1.1-2.5).
Changing culture among healthcare workers with respect to
hand hygiene practices is an ongoing challenge. However, multi-modal culture
change programmes such as the one undertaken by ADHB can result in improvement
in compliance rates and create safer environments for patients by reducing the
risk of acquiring a serious healthcare-associated
infection.5,18 A collective responsibility is
necessary to improve patient outcomes; it cannot be left to individuals alone to
bring about change in practice.
The Health Quality & Safety Commission is now leading
the Infection Prevention and Control projects which are aimed at improving hand
hygiene, reducing central line-associated bacteraemia and developing a national
surgical site surveillance programme. Change management requires leadership to
champion the process and to make sure that progress stays on track. It is
important to ensure that the necessary resources, support and training are
available to bring about the change in practice. The Commission’s role is
to oversee the delivery of the projects and to work along side the teams
delivering the individual projects.
The ADHB programme is ongoing; as with any change process we
have been monitoring the progress along the way. This review has allowed us to
take stock of how far we have come, to assess what worked and what did not work,
and going forward, what is needed to sustain the programme long term. Achieving
a sustained improvement in hand hygiene compliance by healthcare workers will
require a long term commitment at a national level and the highest levels of
clinical and managerial leadership.
Competing interests: None
declared.
Author information: Sally Roberts,
Clinical Head of Microbiology, Department of
Microbiology, LabPlus, Auckland District Health Board,
Auckland; Christine Sieczkowski,
Coordinator Infection Prevention and Control Service,
Auckland District Health Board, Auckland; Taima
Campbell, Executive Director of Nursing,
Auckland District Health Board, Auckland;
Greg Balla, Director of Performance and
Innovation, Auckland District Health Board,
Auckland; Andrew Keenan, Quality
Manager, Auckland District Health Board,
Auckland
ADHB Steering Group: Taima Campbell, Greg Balla, Andrew
Keenan, Janice Mueller, Ngaire Buchanan, Chris Morgan, Stephen Child, Sally
Roberts.
ADHB Working Group: Sophie Worboys, Christine Sieczkowski,
Aarti Pratap, Laura Hughes, Jo MaCartney, Camilla McGuiness.
Acknowledgements: We acknowledge the
members of the Infection Prevention & Control Service and the other ADHB
staff involved in the implementation of the hand hygiene project. We also thank
Josh Freeman for his review of the manuscript and Rong Hu for her help with the
analysis of the data.
Correspondence: Sally Roberts, Department
of Microbiology, LabPlus, Auckland City Hospital, Park Road, Grafton, Auckland,
New Zealand. Fax : +64 (0)9 3074939; email : sallyrob@adhb.govt.nz
References:
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