The data presented by Roberts et al in the 11 May 2012 issue of the N Z Medical Journal show that even modest improvements in hand hygiene compliance by hospital healthcare workers can lead to significant reductions in healthcare-associated Staphylococcus aureus bacteraemia rates.1 This conclusion is supported by recently published data from the first 2 years of the Hand Hygiene Australia programme. Their data showed that an increase in hand hygiene compliance from 46% to 63% nationally (excluding the State of Victoria) was associated with a significant reduction in the national incidence of MRSA bloodstream infections.2

These reports contribute to the growing body of evidence suggesting that successful hand hygiene programmes improve patient outcomes and reduce healthcare costs.3–6 In New Zealand in 2005 the financial cost of each healthcare-associated bloodstream infection was approximately $20,000 and in 2003, the overall cost of healthcare associated infections to the New Zealand healthcare system was estimated to be NZD $140 million.7,8

Given these figures, it is not surprising that in one study it was concluded that every time an individual healthcare worker fails to perform hand hygiene at an appropriate “moment” during patient care, the cost to the healthcare system is somewhere between US$2 and US$50.9

With these facts in mind, we report national hand hygiene compliance data for the first quarter of 2012 and compare the results to those obtained by Roberts et al.

For the first auditing period of 2012 (ending 31 March) 10 DHBs submitted data: The total number of moments audited was 11,298 and correct hand hygiene was performed on 7356/11298 occasions, giving an overall compliance rate of 65%. When examined by healthcare worker category, medical practitioners had the lowest rate (54.8%; 95%CI: 52.5–57.0) and phlebotomists had the highest rate (71%; 95%CI: 66.1–75.6). When examined by each of the WHO 5 moments; higher rates were observed for “after” moments than “before” moments (“before patient contact” 60% versus “after patient contact” 74%; and “before a procedure” 55% versus “after a procedure or body fluid exposure risk” 71%).

Whilst a compliance rate of 65% indicates that hand hygiene in New Zealand hospitals has considerable room to improve, it should be remembered that this is the first audit since the HHNZ programme was reinvigorated in late 2011 under the auspices of the Health, Quality & Safety Commission (the Commission). For this reason, the 10 DHBs that submitted data should be commended for their efforts to improve their hand hygiene practice and for their ongoing commitment to the national programme.

As pointed out by Roberts et al, changing institutional culture with respect to hand hygiene practice is a gradual process and one that requires commitment from the highest levels of hospital management. Moreover, such commitment must consist of more than endorsement of the programme; DHB CEOs and managers who are serious about improving hand hygiene compliance need to provide the modest investment of resources necessary to allow meaningful participation in the national programme.

For example, resources need to be provided at DHB level to ensure that sufficient numbers of auditors have been trained and secondly to ensure that once trained, auditors are provided with sufficient time outside of their normal workload to perform their auditing duties. Similarly, resource needs to be provided to ensure hand hygiene coordinators have sufficient time to feed back audit results, organise educational programmes, and to organise strategic promotional activities.

Nonetheless, although investment by senior management is necessary to improve hand hygiene compliance, it is not by itself sufficient to ensure success. It is also essential to gain the support and commitment of senior opinion leaders in the hospital (such as senior doctors). Senior opinion leaders play a huge role in determining institutional culture, largely by influencing their more junior medical colleagues who in turn behave as role models to other healthcare workers. However, the power of senior opinion leaders to influence others by their example is a double-edged sword.

Just as positive role modeling can have a very positive impact on the hand hygiene practice of others negative role modeling can undo a lot of hard work. Unfortunately, the fact that among all healthcare worker groups, the lowest compliance rates were observed among medical staff (52%) indicates that when it comes to hand hygiene practice, many doctors are not currently functioning as the role models they ought to be.

Finally, the national auditing data indicate higher compliance with the “after” moments than the “before” moments. This is consistent with data reported by Roberts et al and reflects the common misperception among healthcare workers that performing hand hygiene is primarily for self-protection rather than for the safety and protection of patients.

Hand hygiene education programmes, therefore, need to strongly emphasize that hand hygiene is about patient safety. In a recent study, framing hand hygiene education programmes in this way was reported to lead directly to substantial improvements in compliance.10

In summary, participation in the HHNZ programme offers an opportunity for CEOs and management to improve patient safety while reducing financial costs. Encouragingly, many DHBs have already made the necessary investment, although recent auditing data indicate there is still scope for improvement. Of all healthcare worker groups it is senior doctors and opinion leaders in particular who need to improve their role modeling, doing so will help provide much needed leadership in this area.

Finally the primary purpose for performing hand hygiene is to improve the safety of our patients. This is a simple but key message and one that deserves repeated emphasis.