The challenges of implementing a national hand hygiene initiative in rural and remote areas: Is it time for a new approach to auditing?
Jenny Stackelroth A C and Ramon Z. Shaban A B
+ Author Affiliations
- Author Affiliations
A School of Nursing and Midwifery, Research Centre for Clinical and Community Practice Innovation Griffith Health Institute, Griffith University, Meadowbrook, Qld 4131, Australia.
B Department of Emergency Medicine, Princess Alexandra Hospital, Brisbane, Qld 4102, Australia.
C Corresponding author. 3 Coolac Street, Belmont, Qld 4153, Australia. Email: jenny.stackelroth@griffithuni.edu.au
Healthcare Infection 16(2) 63-70 https://doi.org/10.1071/HI11001
Submitted: 15 January 2011 Accepted: 11 March 2011 Published: 23 June 2011
Abstract
Direct observation of health professionals is recognised as the ‘gold standard’ for monitoring hand hygiene compliance. Trained and validated auditors directly observe health professionals’ hand hygiene behaviours, and assess their compliance with standard guidelines. In June 2010, a hand hygiene program that coincided with the adoption of the National Hand Hygiene Initiative (NHHI), including the Five Moments for Hand Hygiene, was introduced into a rural health service district in Australia. Infection prevention and control representatives from each inpatient facility within the district attended hand hygiene auditor training during a 2-day face-to-face workshop using standard models and training materials. The district infection control practitioner and a representative from the jurisdiction’s infection prevention and control unit conducted the workshop. The success of the program has been variable, particularly at the institutional level. In part, this has been due to a lack of administrative leadership and refusal by Directors of Nursing in some facilities to site the alcohol-based hand hygiene product at the point of care. At the individual level, not all representatives have achieved the benchmark set by the NHHI for validation of auditors, with some reporting difficulty grasping the definitions and methodology of auditing. The subsequent process of re-training auditors has been resource-intensive due to the significant physical distance between facilities and limited on-site resources. These challenges and difficulties have brought into question the sustainability of the NHHI model for a geographically vast health service district. This paper examines the implementation of a nationally sanctioned hand hygiene program in a rural and remote health service district, and proposes a novel model for monitoring hand hygiene compliance in such settings.
Additional keywords: hand hygiene, auditing, compliance, electronic monitoring.
References
[1] Pittet D, Boyce JM. Hand hygiene and patient care: pursuing the Semmelweis legacy. Lancet Infect Dis 2001; 1 9–20.| Hand hygiene and patient care: pursuing the Semmelweis legacy.Crossref | GoogleScholarGoogle Scholar | 11871420PubMed |
[2] Martin-Madrazo C, Canada-Dorado A, Salinero-Fort M, Abanades-Herranz J, Arnal-Selfa R, Garcia-Ferradal I, et al Effectiveness of a training programme to improve hand hygiene compliance in primary healthcare. BMC Public Health 2009; 9 469
| 20015368PubMed |
[3] Moret L, Tequi B, Lombrail P. Should self-assessment methods be used to measure compliance with handwashing recommendations? A study carried out in a French university hospital. Am J Infect Control 2004; 32 384–90.
| Should self-assessment methods be used to measure compliance with handwashing recommendations? A study carried out in a French university hospital.Crossref | GoogleScholarGoogle Scholar | 15525912PubMed |
[4] Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009; 73 305–15.
| Role of hand hygiene in healthcare-associated infection prevention.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1MjmsFOktA%3D%3D&md5=5932ff45439c781fb534f16cd4d00d91CAS | 19720430PubMed |
[5] Pashman J, Bradley E, Wang H, Higa B, Fu M, Dembry L. Promotion of hand hygiene techniques through use of a surveillance tool. J Hosp Infect 2007; 66 249–54.
| Promotion of hand hygiene techniques through use of a surveillance tool.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2szoslOmsQ%3D%3D&md5=41ac07d8444d86943f245d3436ed7432CAS | 17544167PubMed |
[6] The Joint Commission. Measuring Hand Hygiene Adherence: Overcoming the challenges, 2009. Available at: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf (Accessed 01/08/2010)
[7] Grayson ML, Jarvie LJ, Martin RL, Johnson PDR, Jodin ME, McMullan C, et al on behalf of the Victorian Quality Council’s Hand Hygiene Study Group and Hand Hygiene Statewide Rollout Group. Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust 2008; 188 633–40.
| 18513171PubMed |
[8] McGuckin M, Waterman R, Govednik J. Hand Hygiene Compliance Rates in the United States – A One-year Multicenter Collaboration Using Product/Volume Usage Measurement and Feedback. Am J Med Qual 2009; 24 205–13.
| Hand Hygiene Compliance Rates in the United States – A One-year Multicenter Collaboration Using Product/Volume Usage Measurement and Feedback.Crossref | GoogleScholarGoogle Scholar | 19332864PubMed |
[9] Grayson ML, Russo P, Ryan K, Bellis K. K. H. 5 Moments for Hand Hygiene, 2009. Available at: http://www.hha.org.au/home/5-moments-for-hand-hygiene.aspx (Accessed 01/08/2010)
[10] Helms B, Dorval P, St. Laurent P, Winter M. Improving hand hygiene compliance: a multidisciplinary approach. Am J Infect Control 2010; 38 572–4.
| Improving hand hygiene compliance: a multidisciplinary approach.Crossref | GoogleScholarGoogle Scholar | 20176413PubMed |
[11] Chou T, Kerridge J, Kulkarni M, Wickman K, Malow J. Changing the culture of hand hygiene compliance using a bundle that includes a violation letter. Am J Infect Control 2010; 38 575–8.
| Changing the culture of hand hygiene compliance using a bundle that includes a violation letter.Crossref | GoogleScholarGoogle Scholar | 20416974PubMed |
[12] Gould D, Chudleigh J, Moralejo D, Drey N. Interventions to improve hand hygiene compliance rates in patient care. Cochrane Database of Systematic Reviews. 2007(2).
[13] Whitby M, Pessoa-Silva C, McLaws M, Allegranzi B, Sax H, Larson E, et al Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2007; 65 1–8.
| Behavioural considerations for hand hygiene practices: the basic building blocks.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD28jltVagtA%3D%3D&md5=773910bbca2ff751dd75885ebe098679CAS | 17145101PubMed |
[14] Grayson ML, Russo P, Ryan K, Bellis K, Heard K. 5 Moments for Hand Hygiene, 2009 Available at: http://www.hha.org.au/home/5-moments-for-hand-hygiene.aspx (Accessed 01/08/2010)
[15] Australian Institute of Health and Welfare. Appendix 5: Hospital contributing to this report and public hospital peer groups, 2009 Available at: http://www.aihw.gov.au/publications/hse/ahs00-01/ahs00-01-x05.pdf (Accessed 02/10/2010)
[16] Silvermann D. Doing qualitative research. 3rd ed. Thousand Oaks, California USA: Sage Publications; 2010.
[17] van de Mortel T, Murgo M. An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions. Am J Infect Control 2006; 34 95–9.
| An examination of covert observation and solution audit as tools to measure the success of hand hygiene interventions.Crossref | GoogleScholarGoogle Scholar | 16630970PubMed |
[18] McAteer J, Stone S, Fuller C, Charlett A, Cookson B, Slade R, et al group NF. Development of an observational method of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT). J Hosp Infect 2008; 68 222–9.
| group NF. Development of an observational method of healthcare worker hand-hygiene behaviour: the hand-hygiene observation tool (HHOT).Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1czhsFKntg%3D%3D&md5=735e970046a17deacbf34e81148ac189CAS | 18478625PubMed |
[19] Sax H, Allegranzi B, Uçkay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007; 67 9–21.
| ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2srktVOnuw%3D%3D&md5=81867a536f7cde00a27a1fded0a363f6CAS | 17719685PubMed |
[20] World Health Organization. WHO Guidelines on Hand Hygiene in Health Care, 2009. Available at: http://www.who.int/gpsc/en/ (Accessed 01/08/2010)
[21] Scheithauer S, Haefner H, Schwanz T, Schulze-Steinen H, Schiefer J, Kock A, et al Compliance with hand hygiene on surgical, medical, and neurologic intensive care units: direct observation versus calculated disinfectant usage. Am J Infect Control 2009; 37 835–41.
| Compliance with hand hygiene on surgical, medical, and neurologic intensive care units: direct observation versus calculated disinfectant usage.Crossref | GoogleScholarGoogle Scholar | 19775774PubMed |
[22] Magiorakos AP, Suetens C, Boyd L, Costa C, Cunney R, Drouvot V, et al National Hand Hygiene Campaigns in Europe, 2000–2009. Eurosurveillance 2009; 14 9–15.
[23] Cromer AL, Latham SC, Bryant KG, Hutsell S, Gansauer L, Bendyk HA, et al Monitoring and feedback of hand hygiene compliance and the impact on facility-acquired methicillin-resistant Staphylococcus aureus. Am J Infect Control 2008; 36 672–7.
| Monitoring and feedback of hand hygiene compliance and the impact on facility-acquired methicillin-resistant Staphylococcus aureus.Crossref | GoogleScholarGoogle Scholar | 18834733PubMed |
[24] Bernstein P, Mendez-Augsburg G, Cannon J-M, O’Sullivan S, McGloin D, Fracaro M. Improving Surveillance of Hand Hygiene Compliance with Hired Observers. Am J Infect Control 2008; 36 E182–3.
| Improving Surveillance of Hand Hygiene Compliance with Hired Observers.Crossref | GoogleScholarGoogle Scholar |
[25] Donaldson AD, Fisher DA, Scharmer C, Ng TM, Tambyah PA. Hand hygiene audits utilising medical student observers and measuring product consumption. Healthc Infect 2008; 13 10–4.
| Hand hygiene audits utilising medical student observers and measuring product consumption.Crossref | GoogleScholarGoogle Scholar |
[26] Saint S, Conti A, Bartoloni A, Virgili G, Mannelli F, Fumagalli S, et al Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany. Qual Saf Health Care 2009; 18 429–33.
| Improving healthcare worker hand hygiene adherence before patient contact: a before-and-after five-unit multimodal intervention in Tuscany.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1MjpvVWksQ%3D%3D&md5=e24d0a0376727c6cf377f7c880c5a374CAS | 19955452PubMed |
[27] Boscart V, Levchenko A, Fernie G. Defining the configuration of a hand hygiene monitoring system. Am J Infect Control 2010; 38 518–22.
| Defining the configuration of a hand hygiene monitoring system.Crossref | GoogleScholarGoogle Scholar | 20570394PubMed |
[28] Mooney C, Roberts P, Cheney P. Automated collection of hand hygiene data shows a statistical relationship which can alert health care facility when rates fall below acceptable level. Am J Infect Control 2010; 38 e56–7.
| Automated collection of hand hygiene data shows a statistical relationship which can alert health care facility when rates fall below acceptable level.Crossref | GoogleScholarGoogle Scholar |
[29] Braun B, Kusek L, Larson E. Measuring adherence to hand hygiene guidelines: a field survey for examples of effective practices. Am J Infect Control 2009; 37 282–8.
| Measuring adherence to hand hygiene guidelines: a field survey for examples of effective practices.Crossref | GoogleScholarGoogle Scholar | 19118921PubMed |
[30] Harrington L, Lesh K, Doell L, Ward SK. Reliability and validity of hand hygiene measures. J Healthc Qual 2007; 29 20–9.
| 17849676PubMed |
[31] Fuller C, Besser S, Cookson BD, Fragaszy E, Gardiner J, McAteer J, et al Technical note: assessment of blinding of hand hygiene observers in randomized controlled trials of hand hygiene interventions. Am J Infect Control 2010; 38 332–4.
| Technical note: assessment of blinding of hand hygiene observers in randomized controlled trials of hand hygiene interventions.Crossref | GoogleScholarGoogle Scholar | 20189686PubMed |
[32] Tibbles L, Smith A, Manzi S. Train-the-Trainer for Hospital-wide Safety Training. J Nurs Staff Dev 1993; 9 266–9.
| 1:STN:280:DyaK2c%2Fosleitg%3D%3D&md5=d3677ec9bd2b0bd8cf77cd5edf8d367cCAS | 8263588PubMed |
[33] Corelli R, Fenlon C, Kroon L, Prokhorov A, Hudmon K. Evaluation of a Train-the-Trainer Program for Tobacco Cessation. Am J Pharm Educ 2007; 71 Available at: http://www.ajpe.org/aj7106/aj7106109/aj7106109.pdf.
| 19503693PubMed |
[34] Trovillion E, Murphy D, Mayfield J, Dorris J, Traynor P, Fraser V. Cost of implementing a tuberculosis control plan: a complete education module that uses a train-the-trainer concept. Am J Infect Control 1998; 26 258–62.
| Cost of implementing a tuberculosis control plan: a complete education module that uses a train-the-trainer concept.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK1czgt1WgtA%3D%3D&md5=3ec5011b60842377879ac8b06f94c550CAS | 9638289PubMed |
[35] Gonzalez V, Perego C, Hackett B, Graviss L, Raad L. Unit-based Staff Hand Hygiene (HH) Monitors to Improve Compliance in a Comprehensive Cancer Center. Am J Infect Control 2006; 34 E58–9.
| Unit-based Staff Hand Hygiene (HH) Monitors to Improve Compliance in a Comprehensive Cancer Center.Crossref | GoogleScholarGoogle Scholar |
[36] Stead K, Kumar S, Schultz T, Tiver S, Pirone C, Adams R, et al Teams communicating through STEPPS. Med J Aust 2009; 190 S128–32.
| 19485861PubMed |
[37] Wijesinha S, Kirby C, Tasker C, Piterman L. GPs as medical educators. An Australian train-the-trainer program. Aust Fam Physician 2008; 37 684–8.
| 18704224PubMed |
[38] Australian Commission on Safety and Quality in Healthcare. Reducing harm to patients from healthcare associated infections: An Australian infection prevention and control model for acute hospitals. Canberra: Commonwealth of Australia; 2009.
[39] National Health and Medical Research Council. Australian guidelines for the prevention and control of infection in healthcare. Canberra: Commonwealth of Australia; 2010.
[40] Larson E, Bryan J, Adler L, Blane C. A multifaceted approach to changing handwashing behaviour. Am J Infect Control 1997; 25 3–10.
| A multifaceted approach to changing handwashing behaviour.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DyaK2s3htV2jug%3D%3D&md5=57affe87b6b70e1ea5967096ea44da44CAS | 9057937PubMed |
[41] Damschroder L, Banaszak-Holl J, Kowalski C, Forman K, Saint S, Krein S. The role of the “champion” in infection prevention: results from a multisite qualitative study. Qual Saf Health Care 2009; 18 434–40.
| The role of the “champion” in infection prevention: results from a multisite qualitative study.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD1MjpvVWktg%3D%3D&md5=c449c0d49df74fcb44c5f00d3409fe57CAS | 19955453PubMed |
[42] Haas J, Larson E. Measurement of compliance with hand hygiene. J Hosp Infect 2007; 66 6–14.
| Measurement of compliance with hand hygiene.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BD2s3ntV2muw%3D%3D&md5=95c1da775ae2d5d60e3e834fbbe7f348CAS | 17276546PubMed |
[43] Swoboda SM, Earsing K, Strauss K, Lane S, Lipsett PA. Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit. Crit Care Med 2004; 32 358–63.
| Electronic monitoring and voice prompts improve hand hygiene and decrease nosocomial infections in an intermediate care unit.Crossref | GoogleScholarGoogle Scholar | 14758148PubMed |
[44] Sahud S, Bhanot N. Measuring hand hygiene compliance: a new frontier for improving hand hygiene. Infect Control Hosp Epidemiol 2009; 30 1132
| Measuring hand hygiene compliance: a new frontier for improving hand hygiene.Crossref | GoogleScholarGoogle Scholar |
[45] Boyce J, Cooper T, Dolan M. Evaluation of an Electronic Device for Real-Time Measurement of Alcohol-Based Hand Rub Use. Infect Control Hosp Epidemiol 2009; 30 1090–5.
| Evaluation of an Electronic Device for Real-Time Measurement of Alcohol-Based Hand Rub Use.Crossref | GoogleScholarGoogle Scholar | 19775238PubMed |
[46] Polgreen PM, Hlady CS, Severson MA, Herman T. Method of automated monitoring of hand hygiene adherence without radio-frequency identification. Infect Control Hosp Epidemiol 2010; 31 1294–7.
| Method of automated monitoring of hand hygiene adherence without radio-frequency identification.Crossref | GoogleScholarGoogle Scholar | 20973724PubMed |
[47] Edmond MB, Goodell A, Zuelzer W, Sango K, Elam K, Bearman G. Successful use of alcohol sensor technology to monitor and report hand hygiene compliance. J Hosp Infect 2010; 76 364–5.
| Successful use of alcohol sensor technology to monitor and report hand hygiene compliance.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC3cbntVyitA%3D%3D&md5=f6d535749222a04c2906cbfa1404bac8CAS | 20869135PubMed |
[48] Sinnott M, Shaban RZ, Stackelroth J. Hand hygiene behaviours and placement of hand hygiene equipment in the emergency department: Electronic auditing of compliance. Griffith University, Brisbane, Australia: Queensland Emergency Medicine Research Foundation; 2010.
[49] The Courier Mail. Bonus for washed hands sees disease drop. The Courier Mail. Vol 31 December, 2010 ed. Brisbane: Queensland Newspapers Pty Ltd; 2010.
[50] Hintikka A, Kainulainen K, Anttilla V-J. The reality of hand hygiene compliance in two Finnish hospitals based on watching and analysing two hospital reality television series. J Hosp Infect 2011; 77 86–7.
| The reality of hand hygiene compliance in two Finnish hospitals based on watching and analysing two hospital reality television series.Crossref | GoogleScholarGoogle Scholar | 1:STN:280:DC%2BC3M%2FmvVCktg%3D%3D&md5=17fff4ba9b6d03f8def474ccd07f91a1CAS | 21122945PubMed |