Clean hands save lives

Improving hand hygiene practices in health care has been a major challenge for more than 160 years.1 Despite much evidence that hand hygiene practices are effective in preventing infection and reducing the spread of microbial resistance, the hand-cleaning behaviour of health care workers (HCWs) remains largely unchanged.2 Indeed, in almost all settings where it has been assessed, compliance with hand hygiene practices at appropriate times during the course of patient care has been less than 50%. But should HCWs carry all the blame? How do working conditions affect hand hygiene behaviour? Can behaviour change? If so, how much change in individual behaviour is necessary to reflect change at a group level? Is a major system change sufficient to transform practices? Is hand hygiene behaviour integrated into the theory of ecological perspective3 once change is targeted? What should the targets for improvement be? How far can HCWs be expected to modify their practices? How long will it take to succeed? How can behavioural change be sustained, if and when it is achieved? What does “success” mean in terms of hand hygiene promotion? What are the best indicators of success? How much local success is needed to predict more global achievements? These are some of the many questions to be kept in mind by all those embarking on hand hygiene promotion. Successful promotion is a crusade, and we should not forget the “first crusader”, Ignaz Semmelweis, who paved the way in 1847.1 Semmelweis’s crusade was long and difficult and, although extremely beneficial to patient safety, it was certainly not rewarding for him, and was even detrimental to his career.4 But attitudes and evidence have changed over the past 162 years. Thankfully, it is now well established that successful hand hygiene promotion does not result from forcing HCWs to plunge their hands into a caustic, chlorinated lime solution before patient contact and accusing them of being murderers if they refuse! Ample evidence suggests that successful hand hygiene promotion is the result of multimodal strategies involving multiple partners and key players.2 The proposed, tested and validated World Health Organization strategy now used in many hospitals worldwide (Box 1) includes at least five key elements: homogeneous HCW education; performance monitoring and feedback; reminders in the workplace; facilitated access to alcohol-based hand rub (AHR) at the point of patient care; and promotion of a safety culture at all levels.2,5 This strategy has been modelled on previous longstanding experience at the University of Geneva hospitals6,7 before being adopted at single8,9 and multiple institutions10,11 and, importantly, adapted to different cultures for worldwide use in both developed and developing countries.12,13 Clean hands save lives is a good example of a statewide multimodal promotion campaign. The strategy included monitoring of HCWs’ compliance, with performance feedback; using staff “champions” and local leaders; placing reminders in the workplace; engaging patients and their families; and ensuring the availability of AHR at the point of care. This supplement includes four reports that summarise important aspects of the project’s management and present early results relating to structures, processes and outcomes.14-17 System change has been one of the first measurable, successful achievements of the Clean hands save lives campaign. Over a period of less than 6 months, the availability of AHR at the point of care improved markedly, to the point where 70% of all available hospital beds in New South Wales had at least one AHR dispenser nearby. Importantly, such a system change must be sustainable, with a measurable increase in AHR use over time.6,7 System change implies culture change.18,19 Pre- and post-campaign surveys showed that the NSW campaign significantly raised HCWs’ awareness of hand hygiene and improved their perceptions of the need for the campaign and of its ability to help improve their own practices. Most HCWs believed that they could sustain system and behavioural change over time, and some even gained sufficient confidence to remind their peers. Furthermore, a quarter of surveyed patients and hospital visitors said they would be willing to actively participate in hand hygiene promotion by reminding staff about hand hygiene. Thus, the Clean hands save lives campaign clearly initiated a culture change at an organisational6,20 and possibly regional level. It helped to promote positive attitudes and dispel negative perceptions held by staff, patients, and visitors. Whether such a change has been sufficiently embedded in health care organisations at all levels to induce individual and institutional accountability remains to be evaluated in the near future. Among the campaign’s process and outcome measures were compliance with hand hygiene practices and monitoring of methicillin-resistant Staphylococcus aureus (MRSA) cross-transmission and infection rates. Overall hand hygiene compliance, monitored before and after patient contact, improved from 47% to an average of 61%, and all categories of HCW except medical staff improved their compliance. As universally reported,2,6,8-13,18-20 compliance after patient contact was markedly better than before patient contact, emphasising the need for further education to improve patient safety. Preventing pathogen transmission to patients relies above all on cleaning hands before touching each patient, before performing clean and aseptic tasks,21,22 after contact with a patient or the patient’s close environment, or after exposure to body fluids. Respecting these recommendations will mostly protect HCWs and patients and prevent environmental contamination (Box 2). Whether the observed improvement in hand hygiene compliance between the pre- and post-campaign periods may have been partly due to a Hawthorne effect is debatable. However, such an effect need not be considered an undesirable outcome if it contributes to positive culture change. Although improvement in hand hygiene practice was paralleled with some measurable reductions in indicators of MRSA infection, the effect of major confounders should be recognised, particularly in the context of statewide surveillance and interventions. In summary, the Clean hands save lives campaign has achieved remarkable success in NSW health care institutions — system change, culture change and practice improvement, with early signs of an impact on some patient safety indicators. Ensuring the sustainability of the campaign, together with organisational and regional changes to foster accountability at different levels, will be challenging. Further improvement will require HCWs to integrate the “My five moments for hand hygiene” concept (Box 2)22 into their thinking and routine behaviour and thus shift the focus towards greater patient safety. Further development of the concept of staff champions and local leaders to drive compliance improvement among all HCWs, particularly medical staff, is critical.23 Importantly, all health care institutions in NSW need to adopt the Clean hands save lives strategy. Successful diffusion of innovation and change requires adaptation.2,18,24 Campaign strategists and crusaders need to understand that having the support of management can be extremely helpful in making a campaign more cost-effective. Adaptation of tools and interventions to local needs is critical for universal endorsement, sustainability and long-term success. Combining the efforts and successes of the NSW campaign with the statewide campaign in Victoria10 would be a positive move towards the future roll-out of national action in Australia, and would follow the example of more than 40 campaigning countries worldwide.25,26 Long live the Clean hands save lives crusade and its army of crusaders and numerous descendants. We’ll remind you again in 162 years. 1 Health care institutions that have endorsed the World Health Organization’s multimodal hand hygiene promotion strategy* * As at May 2009. 2 “My 5 moments for hand hygiene”* * Adapted from Sax et al.22

Didier Pittet MD, MS

Objective: To describe the planning and execution of a statewide campaign aimed at improving compliance with hand hygiene practices in New South Wales public hospitals.Design and setting: The campaign was conducted in all area health services (AHSs) in NSW (covering 208 public hospitals) between February 2006 and February 2007. Clinical practice improvement methods and campaign strategies were used to improve the availability and use of alcohol-based hand rub (AHR) at the point of patient care, using staff champions and local leaders, engaging patients and families, and measuring compliance. Staff were given regular feedback on their performance. Project officers funded by the Clinical Excellence Commission (CEC) provided local project management support and implemented the campaign in a standardised format orchestrated by the CEC.Main outcome measures: Proportion of available beds with secured and unsecured AHR containers nearby; amount of AHR used (based on purchasing patterns).Results: Hospital visits before the campaign identified a lack of appropriately placed AHR at the point of care. The number of AHR containers per available bed in near-patient locations increased to 13 280/18 951 (70%) after the campaign. The quantity of AHR purchased per month across NSW public hospitals increased from 1477 L to 5568 L (a 377% increase).Conclusion: The CEC was successful in systematising the placement of AHR in all NSW public hospitals at the point of patient care. Although the use of AHR increased substantially, some staff were resistant to changing their hand hygiene practices.

Annette C Pantle MB BS, MPH, FRACMA · Kimberley R Fitzpatrick BHSM · Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Clifford F Hughes MB BS, FRACS, FACS

Objective: To present the results of surveys of staff, patients and visitors about their perceptions of hand hygiene behaviour before and after implementation of the Clean hands save lives campaign in New South Wales public hospitals.Design and setting: Pre- and post-campaign questionnaires, disseminated through project officers in each health authority, were completed by selected staff and patients/visitors in all 208 public hospitals in NSW. Combined, de-identified results for each health authority were forwarded to the NSW Clinical Excellence Commission for analysis.Main outcome measures: Awareness of campaign material; staff perceptions about their ability to maintain a high level of hand hygiene compliance before and after contact with patients; compliance self-reported by staff compared with compliance perceived by patients/visitors and compliance assessed by overt observation.Results: Most staff and patients/visitors were aware of campaign materials. Eighty-six per cent of staff respondents (495/578) believed that placement of alcohol-based hand rub (AHR) close to the point of patient care had improved hand hygiene compliance, and 76% (510/671) believed they could sustain their level of compliance. Only 1 in 4 patients or visitors (106/397) were willing to question health care workers who appeared not to be complying with hand hygiene practices.Conclusion: As the first coordinated statewide campaign to modify hand hygiene culture, the Clean hands save lives campaign successfully engendered positive attitudes and dispelled negative perceptions about the onerous nature of before- and after-patient-contact hand hygiene compliance.

Kimberley R Fitzpatrick BHSM · Annette C Pantle MB BS, MPH, FRACMA · Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Clifford F Hughes MB BS, FRACS, FACS

Objective: To describe improvements in hand hygiene compliance after a statewide hand hygiene campaign conducted in New South Wales public hospitals.Design and setting: The campaign was conducted in all area health services in NSW (covering all 208 public hospitals). Alcohol-based hand rub (AHR) was introduced into all hospitals between March and June 2006. In each hospital, five overt observation surveys of hand hygiene compliance by health care workers (HCWs) were conducted: one pre-implementation survey and four post-implementation surveys (in August 2006, November 2006, February 2007 and July 2008).Main outcome measures: Overtly observed hand hygiene compliance rates by HCWs, stratified by before- and after-patient contact, Fulkerson’s contact risk categories, and four health care professional groupings.Results: The overall hand hygiene compliance rate improved from 47% before the intervention to an average of 61% over the last three observation periods (P < 0.001). All professional groups sustained improved compliance rates except medical staff, whose practices reverted to pre-intervention rates. Nursing staff maintained significantly improved compliance, with an average rate of 67% after the intervention. Overall hand hygiene compliance before patient contact improved from 39% (pre-campaign) to 52% (July 2008) (P < 0.001). Overall compliance after patient contact improved from 57% to 64% (P < 0.001) over the same period. Compliance associated with medium-risk contacts increased from an average of 51% in the first two observation periods to an average of 62% over the last three observation periods (P < 0.001). The corresponding compliance rates associated with low-risk contacts were 35% and 56%, respectively (P < 0.001).Conclusion: An overall improvement in hand hygiene rates was achieved with the introduction of AHR. Increased adherence to before-patient contact compliance, especially by nursing staff, contributed to the progress made, but an acceptable overall level of hand hygiene practice is yet to be achieved. It is now time to focus on a long-term behavioural change program directed specifically at medical staff.

Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Annette C Pantle MB BS, MPH, FRACMA · Kimberley R Fitzpatrick BHSM · Clifford F Hughes MB BS, FRACS, FACS

Objective: To examine whether improved hand hygiene compliance in health care workers after a statewide hand hygiene campaign in New South Wales hospitals was associated with a fall in rates of infection with multiresistant organisms.Design and setting: Data on rates of new methicillin-resistant Staphylococcus aureus (MRSA) infections (expressed as four clinical indicators) are reported by some Australian hospitals to the Australian Council on Healthcare Standards (ACHS) for accreditation purposes and are mandatorily reported by all NSW hospitals to the NSW Department of Health. Infections are classified according to whether they are acquired in the intensive care unit (ICU) or other wards and whether they are from sterile sites (blood cultures) or non-sterile sites. The clinical indicators reflect four different site categories (ICU sterile site, ICU non-sterile site, non-ICU sterile site and non-ICU non-sterile site) and are expressed as the number of new health care-associated infections per 10 000 acute care bed-days. Clinical indicator rates were examined for any decline between the pre-campaign period (July–December 2005) and post-campaign period (January–July 2007), and were compared with trends over a similar period in states without a hand hygiene campaign.Main outcome measures: Pre-campaign and post-campaign rates for four MRSA clinical indicators.Results: Between the pre- and post-campaign periods, there was a 25% fall in MRSA non-ICU sterile site infections, from 0.60/10 000 bed-days to 0.45/10 000 bed-days (P = 0.027), and a 16% fall in ICU non-sterile site infections, from 36.36/10 000 bed-days to 30.43/10 000 bed-days (P = 0.037). The pre- and post-campaign rates of MRSA infection from ICU sterile sites (5.28/10 000 bed-days v 4.80/10 000 bed-days; P = 0.664) and non-ICU non-sterile sites (5.92/10 000 bed-days v 5.66/10 000 bed-days; P = 0.207) remained stable. Australia-wide MRSA data reported to the ACHS showed a 45% decline in infections from ICU non-sterile sites, from 25.89/10 000 bed-days to 14.30/10 000 bed-days (P < 0.001), and a 46% decline in infections from non-ICU non-sterile sites, from 3.70/10 000 bed-days to 1.99/10 000 bed-days (P < 0.001) over the period 2005–2006.Conclusion: Two out of four clinical indicators of MRSA infection remained unchanged despite significant improvements in hand hygiene compliance in NSW hospitals. The reduction in MRSA infections from ICU non-sterile sites in NSW hospitals was mirrored in ACHS data for other Australian states and cannot be assumed to be the result of improved hand hygiene compliance. Concurrent clinical and infection control practices possibly influence MRSA infection rates and may modify the effects of hand hygiene compliance. More sensitive measurements of hand hygiene compliance are needed.

Mary-Louise McLaws DipTropPublHlth, MPH, PhD · Annette C Pantle MB BS, MPH, FRACMA · Kimberley R Fitzpatrick BHSM · Clifford F Hughes MB BS, FRACS, FACS