Australian hospitals show worth of handwashing campaigns

Since its implementation in 2009, the National Australian Hand Hygiene Initiative (NHHI) has seen significant and ongoing improvements in hand hygiene among healthcare workers, according to a study published in The Lancet Infectious Diseases.

“Hospital-acquired infections are a major concern for hospitals around the world”

Lindsay Grayson

The findings, which were presented this year’s European Congress of Clinical Microbiology and Infectious Diseases in Amsterdam, show the campaign was also linked to a reduction in Staphylococcus aureus bacteria, a leading cause of acute pneumonia and sepsis.

For every 10% increase in hand hygiene compliance, researchers found an associated 15% drop in the incidence of S. aureus bloodstream infection in Australia’s 132 largest public hospitals.

The results were achieved by promoting the World Health Organization’s “5 Moments for Hand Hygiene” resource, which highlights the key times when healthcare staff should clean their hands, such as before and after touching a patient or after being exposed to bodily fluids.

The programme could be a blueprint for similar initiatives in other countries, which have struggled to improve hand-washing practice, said the research team.

“Hospital-acquired infections are a major concern for hospitals around the world and S. aureus is among the most dangerous. The risks to patients are enormous, as are the associated hospital costs,” said lead researcher Professor Lindsay Grayson, from Hand Hygiene Australia.

But she said, despite the evidence that good hand hygiene was important, getting people to stick to hand washing regimes was “notoriously difficult” and “few national programmes have been sustained in the long-term”.

The campaign included training healthcare workers with educational resources developed for specific groups including nurses, doctor and non-clinical staff.

Compliance with the “5 moments” regime was regularly checked by trained “auditors” and results were publicly reported.

The campaign also included a drive to raise awareness of hand hygiene among patients, with the message that it was “okay to ask” if they noticed staff had not washed their hands.

In 2013, participation in the initiative became one of 10 core safety and quality standards for the accreditation of healthcare services with those unable to show failing to meet set criteria losing out financially.

The clinical impact of the NHHI was analysed by comparing individual hospitals’ S. aureus rates with hand hygiene compliance, which was observed three times a year.

Compliance was measured as a percentage of key instances witnessed by auditors when staff did follow the “5 moments” guidance and wash their hands.

The analysis found a significant improvement in hand hygiene compliance in hospitals nationally, from 64% of potential hand hygiene opportunities in 2009 to 84% in 2017.

However, the researchers noted that compliance levels varied between different types of staff despite an improvement across the board.

For example, adherence to hand hygiene routines was consistently 10-15% lower among doctors compared with nursing staff across the eight-year study.

Improvement in hand washing practice were linked to a decline in S. aureus.

Overall, average rates of S. aureus infection fell from 1.27 new cases per 10,000 bed-days in 2010-11 to 0.87 per 10,000 bed-days in 2016-17.

“The NHHI might be a template for other national culture-change initiatives in healthcare”

Study authors

The study’s limitations included the fact healthcare workers were far more like to follow hand hygiene guidelines when they knew they were being watched.

Meanwhile, auditors trying to record compliance in a busy setting may have missed things.

While the researchers found a strong link between improved hand hygiene compliance and declining rates of S. aureus infection, they said other factors such as viral respiratory outbreaks in hospitals or infection control programmes may also have had some impact.

Nevertheless, Professor Grayson said it was clear the initiative had achieved “impressive results” and was unusual in that it had been successfully integrated into national healthcare structures.

The study paper concluded that the “NHHI appears to have been highly successful in sustainably improving hand hygiene compliance among Australian healthcare workers nationally and to have effectively raised awareness about the importance of infection control among the Australian population”.

“The NHHI might be a template for other national culture-change initiatives in healthcare,” concluded the paper.