Given the evidence supporting the dramatic efficacy of hand hygiene (HH) culture-change programs and use of alcohol-based hand rub (AHR) solution worldwide and locally,1-4 a national HH initiative has been launched by the Australian Commission on Safety and Quality in Health Care, with the support of all states and territories. Although some jurisdictions have already undertaken programs in this important area,2-5 including some impressive studies described in the supplement to this issue of the Journal,6-9 this national program, organised by Hand Hygiene Australia (HHA), aims to introduce a standard HH culture-change program throughout all Australian public and private hospitals. The aims of the program are to improve HH compliance, increase the use of AHR, and establish a common system of measuring the disease outcomes associated with improved HH that can be used by hospitals to compare their performance against national and international benchmarks. The HHA program has three crucial components.

1. Use of the World Health Organization’s “5 Moments for hand hygiene” program: Adoption and adaptation of the WHO’s 5 Moments HH culture-change program has been important, as it includes a standard HH compliance auditing tool that defines the five key moments at which hand-cleaning is required during patient care (Box).10 Although some Australian states previously had their own “home-grown” auditing tools, the HHA–WHO 5 Moments tool has the advantages of simplicity and validated clinical accuracy. Moreover, it allows HH rates in Australian hospitals to be compared internationally with rates in other hospitals that have similar health care systems. The HHA has developed detailed educational tools, including a popular website (http://www.hha.org.au). In close partnership with health departments in each state and territory, it has conducted multiple training workshops throughout Australia to implement the HH culture-change program, which is controlled and coordinated by the states.

2. Validation of HH compliance educators and assessors: Fundamental to obtaining accurate HH compliance data has been the development of a standard training and validation program for infection control practitioners and other health care workers responsible for HH culture change. The training program prepares them to accurately and reproducibly teach and measure HH compliance using the 5 Moments tool in their hospitals. This validation feature has been crucial to ensuring that all HH compliance data are accurate and comparable between hospitals and between health services in different states.

3. Measurement of hospital-acquired infections: A key reason for improving HH compliance among health care workers is to reduce the risk of nosocomial disease transmission, yet there has been no system in Australia for accurately measuring the incidence of these infections. An important outcome measure for the HHA program is the monthly reporting by all Australian hospitals of the rate of new hospital-acquired Staphylococcus aureus bacteraemia (SAB) infections. The number of SAB infections (methicillin-susceptible and methicillin-resistant) occurring more than 48 hours after hospital admission is standardised against hospital activity (occupied bed-days and patient separations [discharges]). Although the relationship between nosocomial SAB infections and HH practice is not exactly defined, it is estimated that in Australia about 60% of SAB infections are probably directly related to poor HH.2,3 Thus, SAB data are likely to be a valid outcome measure for HH compliance. The SAB reporting system established by HHA is internationally unique and will potentially provide a useful template upon which any future expanded national system of nosocomial disease measurement could be based.

The roll-out of the HHA program has progressed rapidly, with initial data submission by all regions commencing in early 2009 and subsequently ramping up quickly, to the extent that in the second audit period (July 2009), 168 hospitals submitted data.

The National Hand Hygiene Initiative is an internationally unique culture-change program that will hopefully not only improve HH compliance and reduce the risk of nosocomial disease transmission, but also establish a standard system for accurately recording rates of key hospital-acquired infections.

The HHA–WHO “5 Moments for hand hygiene”*

HHA = Hand Hygiene Australia. WHO = World Health Organization. * Adapted from Sax et al.10