Improving Hand Hygiene - Difficult, but not Impossible
The Children's Hospital at Westmead
Abstract
A number of studies demonstrate that hand hygiene is an effective means of preventing hospital acquired infections (HAI). Adherence to hand hygiene practice (HHP) is even more important in the paediatric setting, due to the frequent contact between patients, their environment, their parents, visitors, other admitted patients and healthcare workers.
In the last two years, The Children's Hospital at Westmead (CHW) improved compliance with hand hygiene from 23 % to 85 % (p < 0.001). The amount of alcohol-based hand rub (ABHR) used confirms the significant improvement in HHP and there has been a downward trend in HAIs.
This result was achieved through strong leadership, good stakeholder engagement, accessible ABHR at the point of patient care, a multifaceted education program, monitoring of adherence to HHP and contemporaneous feedback of performance data.
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Aim
To reduce the spread of serious germs, including healthcare associated infections, by increasing good hand hygiene in all clinical areas to 80 % by June 2007.
Nature of the Problem
Reducing the spread of germs in hospitals is vital for improving patient safety. A number of completed studies clearly demonstrate that hand hygiene is an effective means of preventing HAIs.
An Expert Group was established by the NSW Minister for Health in June 2005, to advise on aspects of preventing infections. This group identified the need to improve hand hygiene among all healthcare workers and a statewide campaign was launched in March 2006. CHW remained linked with the state-wide campaign, but added a number of initiatives to respond to local needs and our unique environment.
Extent of the Problem
The international literature suggests that even though HHPs exist, compliance with them is significantly low (Creedon , 2005). Pittet (2001) reviewed the then current evidence of hand hygiene compliance and noted that rates of compliance in non ICU settings ranged from 16 % to 60 % and in ICUs 28 % to 81 %.
Adherence to HHP is even more important in the paediatric setting, due to the frequent contact between patients, their environment, their parents, visitors, other admitted patients and healthcare workers, which all raise the risk of potential cross contamination.
An initial audit of the HHP at CHW was completed in August 2006 and a low compliance rate of only 23 % was noted. Whilst this was similar to figures across the state, it galvanised CHW into action to raise awareness and improve hand hygiene practice.
Strategic Importance
NSW Health is striving to prevent illness, while continuing to treat illness effectively. Our project directly relates to the NSW Health Strategic Direction ‘Make prevention everybody’s business’. The project is in line with the strategic plan to conduct programs and campaigns, using evidence-based strategies, to promote health and wellness and prevent injury and illness. The project also reinforces that the principle of prevention is embedded into delivery of health services at CHW.
The project positively impacts on key performance measures of NSW Health’s state-wide program of reducing healthcare associated infections in NSW.
Planning and Implementing Solutions
Multidisciplinary and multifaceted interventions were implemented to improve adherence to HHP at CHW:
- A multidisciplinary project team was established and hand hygiene became a regular agenda item at meetings of the Hospital’s Health Care Quality Committee.
- Accessibility to ABHR near patient locations is key to assisting staff decontaminate their hands (World Health Organisation, 2005). Different hand cleaning products were trialled and extensive staff feedback was sought. Avagard ABHR was made available throughout the Hospital, with dispenser brackets installed at a certain height to avoid children accessing them. This was a unique problem as adult hospitals generally do not face such challenges. The installation was completed in consultation with the staff of the area, the vendor and the Maintenance Department.
- Education sessions, using ultra-violet light, were conducted for staff to improve their understanding of what constituted good hand hygiene practice. A number of promotional items, including posters and brochures, are used to enhance awareness amongst staff, patients and families.
- Regular presentations on compliance rates and status of various interventions are made to the senior management, medical, allied health and nursing staff. This helps to keep staff engaged.
- A standardised overt observation tool is used and over 1000 observations per month are conducted in all clinical areas to monitor staff adherence to HHP. A number of auditors are also trained from different areas to help the auditing process.
- Comprehensive information on HHP is forwarded to all clinical areas on a monthly basis, allowing them to track their performance. The best performing areas are rewarded with chocolates, a certificate and a visit from the Chief Executive, Director Clinical Governance or Director Clinical Operations. This sharing of information and acknowledgement has been a major success factor in improving hand hygiene practice.
- Family Advisory Council (FAC) is a formal mechanism for partnership with consumers. The FAC provided advice on initiatives from the consumer perspective and reviewed the promotional and educational material. This partnership has been one of the keys to our success.
Outcomes and Evaluation
Three measures are regularly monitored.
Compliance to Hand Hygiene
The overall compliance to HHP for June 2008 was 85 %. This was the seventh consecutive month when we achieved or exceeded our initial target of 80 %.The overall compliance to HHP at CHW has increased from 23 % to 85 % (p < 0.001). In comparison, the overall compliance at the end of similar statewide campaigns in NSW was 63 % (Clinical Excellence Commission, 2007) and 53 % in Victoria (Grayson et al, 2008).
Hospital Acquired Infection Rate
A set of HAIs (Rotavirus, MROs and Bacteremia) is regularly monitored to assess the overall effectiveness of interventions. A downward trend in HAIs is noted, as hand hygiene rates have improved. This data is very important for clinical staff to see the direct effect of their efforts to keep children safe.
Use of alcohol-based hand rub (ABHR)
Use of ABHR provides a good indication of compliance with HHP. Currently, over 250 litres of ABHR rub are used each month. The Victorian study (Grayson et al, 2008) noted an increase in use of ABHR to a mean of 20.9 L/1000 patient days. At CHW, average monthly use in 2008 is over 35 L/1000 patient days.
Sustaining Change
Hand Hygiene is a regular agenda item on the Hospital’s peak committee, the Health Care Quality Committee, which is chaired by the Chief Executive.
All the interventions, including education, auditing, sharing of performance and monitoring of outcomes are embedded in our regular activities at CHW, providing everyone with confidence that the Hospital is maintaining a high level of hand hygiene.
We have made significant and sustained improvement to our hand hygiene rate: more than 80 % compliance rate for the last seven consecutive months. We have not found any other such example of compliance rates in the published literature.
Future Scope
As hospitals fight to reduce HAIs and face the challenge to improve hand hygiene practice, the example set by CHW provides direction for all healthcare facilities to establish a framework with multimodal and multidisciplinary strategies to achieve their desired outcomes.
We managed to eliminate the gap between what is best practice and what we were actually practicing. By using available knowledge and bringing the evidence into practice, we found that the interventions outlined above were successful in improving and maintaining hand hygiene practice. These interventions could be applied to any other health care setting.
References
- Clinical Excellence Commission 2007, Final report of the NSW Hand Hygiene campaign, Sydney, NSW.
- Creedon S 2005, ‘Healthcare workers’ hand decontamination practices: compliance with recommended guidelines’, Journal of Advanced Nursing 51(3), 208-216.
- Grayson, ML, Jarvie, LJ, Martin, R,Johnson PD, 2008, ‘Significant reductions in methicillin-resistant Staphylococcus aureus bacteremia and clinical isolates associated with a multisite, hand hygiene culture change program and subsequent successful state-wide roll-out, MJA, Volume 188 Number 11, 2 June 2008.
- Pittet, D 2001, “Improving Adherence to Hand Hygiene Practice: A Multidisciplinary Approach”, Emerging Infectious Diseases, Vol. 7, No. 2, March–April 2001.
- World Health Organization 2005, Guidelines for Hand Hygiene in Health Care, World Health Organization, Geneva, Switzerland.
Contact
Co-ordinator, Service Improvement Unit
The Children's Hospital at Westmead
Phone: 02 9845 2093
This project was entered in the 2008 NSW Health Awards, Making Prevention Everybody's Business category.
