Australia: a leader in hand hygiene

Healthcare-associated infection is a global problem. It occurs in every healthcare facility in every country and affects hundreds of millions of patients annually worldwide. Hand hygiene has been recognised as the single, most important preventive measure. Since the launch of the World Health Organisation (WHO) First Global Patient Safety Challenge ‘Clean Care is Safer Care’ in 2005, much has been achieved in healthcare settings around the world to improve infection prevention and control, including hand hygiene practices, with the aim to reduce healthcare-associated infections. As part of the Challenge, over 140 countries have pledged their support to implement actions to reduce healthcare-associated infection, corresponding to a 90% coverage of the world population. Importantly 43 countries have reported the existence of formal hand hygiene campaigns and WHO has formed ‘WHO CleanHandsNet’ to facilitate progress in such countries, as well as to share successes and strategies.

Australia is a leader in national hand hygiene programs and has acted as an inspiration for many other countries in the Asia-Pacific region. In recognition of the achievements of its National Hand Hygiene Initiative, the WHO Collaborating Centre at the University of Geneva Hospitals recently awarded Hand Hygiene Australia (HHA) the ‘Hand Hygiene Excellence’ award – one of only four centres worldwide to be honoured so far. With this award, the leadership of the Australian Commission on Safety and Quality in Healthcare, who funded the National Hand Hygiene Initiative, is recognised along with the work of infection prevention and control teams across Australia.

As the Australian initiative reaches its 4th year since commencement and begins to move towards the maintenance phase, it is timely to reflect on what has been achieved by this major national effort and lessons learned along the way. From a landscape that comprised of several different local hand hygiene programs with varying educational messages, measurement tools, and reporting and governance processes, there are now over 450 public and 135 private sector facilities regularly contributing hand hygiene compliance data.

Infection control and prevention staff throughout Australia have worked tirelessly to implement the HHA-WHO ‘My 5 Moments for Hand Hygiene’ message, which has now become common language across healthcare facilities. Introduction of ‘My 5 Moments for Hand Hygiene’ has enabled consistent messages on when hand hygiene should be performed across all types of healthcare facilities and emphasises the importance of the availability of alcohol-based hand rubs located at every point of care.

The number of healthcare workers who have completed the basic hand hygiene online educational package is approaching 200 000, and work is underway with the Royal Australasian College of Surgeons for a similar package to be completed routinely by all surgical trainee applicants. Importantly, since its inception, hand hygiene compliance rates have steadily improved across all sectors and categories of healthcare workers and a general decline in the rates of methicillin-resistant Staphylococcus aureus bacteraemia has been observed throughout the country.¹

However, significant improvements are still to be made. Doctors continue to lag behind other healthcare worker categories in their compliance rates. This pattern can be observed across all sectors and jurisdictions and is a worldwide phenomenon that needs to be better understood so as to address more appropriate educational messages targeting behavioural change in this population. Surprisingly, compliance rates before touching a patient and before a procedure continue to be lower than after a procedure and touching a patient. This suggests a significant deficit in healthcare worker knowledge and workflow and needs a concentrated effort to provide educational material to convince them to comply with hand hygiene in these ‘before’ moments.

What next in a global context? In May 2009, WHO Patient Safety launched the ‘SAVE LIVES: Clean Your Hands’ initiative to encourage healthcare workers to be part of a global movement to improve and sustain hand hygiene. By January 2012, almost 15 000 healthcare facilities had registered their commitment to the initiative. The major challenge for the next decade will be to maintain the snowball effect and to show a significant impact on infection prevention across the world. To truly protect our patients, it will take leadership, commitment, a range of actions, and time. The efforts of WHO, together with countries and facilities, should help bring true ownership to healthcare workers in relation to disease transmission and its prevention and, subsequently, long-term patient safety improvement.

In Australia, the focus of future activities needs to be the embedding of good hand hygiene practices into routine healthcare. To achieve this we need to now fine-tune our educational strategies to the various healthcare worker categories and move towards a system of regular credentialing as a component of the new centralised annual registration for all Australian healthcare workers. Establishment of a standardised definition of S. aureus bacteraemia should also assist in regularly monitoring a disease outcome that is known to be tightly linked to hand hygiene compliance. National open public disclosure of each hospital’s rates of hand hygiene compliance and hospital-acquired disease is an important step to ensuring community awareness and discussion – after all, good hand hygiene and infection control is everybody’s business.