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Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study

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Summary

Background

The National Hand Hygiene Initiative (NHHI) is a standardised culture-change programme based on the WHO My 5 Moments for Hand Hygiene approach to improve hand hygiene compliance among Australian health-care workers and reduce the risk of health-care-associated infections. We analysed its effectiveness.

Methods

In this longitudinal study, we assessed outcomes of the NHHI for the 8 years after implementation (between Jan 1, 2009, and June 30, 2017), including hospital participation, hand hygiene compliance (measured as the proportion of observed Moments) three times per year, educational engagement, cost, and association with the incidence of health-care-associated Staphylococcus aureus bacteraemia (HA-SAB).

Findings

Between 2009 and 2017, increases were observed in national health-care facility participation (105 hospitals [103 public and two private] in 2009 vs 937 hospitals [598 public and 339 private] in 2017) and overall hand hygiene compliance (36 213 [63·6%] of 56 978 Moments [95% CI 63·2–63·9] in 2009 vs 494 673 [84·3%] of 586 559 Moments [84·2–84·4] in 2017; p<0·0001). Compliance also increased for each Moment type and for each health-care worker occupational group, including for medical staff (4377 [50·5%] of 8669 Moments [95% CI 49·4–51·5] in 2009 vs 53 620 [71·7%] of 74 788 Moments [71·4–72·0]; p<0·0001). 1 989 713 NHHI online learning credential programmes were completed. The 2016 NHHI budget was equivalent to AUD$0·06 per inpatient admission nationally. Among Australia's major public hospitals (n=132), improved hand hygiene compliance was associated with declines in the incidence of HA-SAB (incidence rate ratio 0·85; 95% CI 0·79–0·93; p≤0·0001): for every 10% increase in hand hygiene compliance, the incidence of HA-SAB decreased by 15%.

Interpretation

The NHHI has been associated with significant sustained improvement in hand hygiene compliance and a decline in the incidence of HA-SAB. Key features include sustained central coordination of a standardised approach and incorporation into hospital accreditation standards. The NHHI could be emulated in other national culture-change programmes.

Funding

Australian Commission on Safety and Quality in Health Care.

Introduction

Improvement of hand hygiene compliance among health-care workers is an important national patient safety strategy,1, 2, 3, 4, 5, 6, 7 but few national programmes have been sustained over many years and become successfully integrated into a national health-care structure. In 2011, we reported4 the early outcomes of the Australian National Hand Hygiene Initiative (NHHI), citing an association between significant improvements in hand hygiene compliance among health-care workers and a reduction in the incidence of meticillin-resistant Staphylococcus aureus bacteraemia. Since this preliminary report, the NHHI has progressed from the implementation phase to maintenance and establishment within the Australian health-care system, such that all public and private hospitals are mandated to participate to maintain accreditation.8 Thus, 8 years after implementation, we did a detailed analysis of NHHI outcomes, including hand hygiene compliance and potential impact on incidence of health-care-associated S aureus bacteraemia (HA-SAB), given that S aureus infections are linked to poor hand hygiene compliance,1, 2, 7 and summarised the various structural features of the NHHI that could be used as a template for other national intervention programmes.

Section snippets

Organisational structure and governance

Details regarding the NHHI have been described previously4 and are available on the Hand Hygiene Australia website.9 In brief, the NHHI is based on the WHO Multimodal Hand Hygiene Improvement Strategy,1 with a focus on system change, health-care worker education, and audit and feedback. The My 5 Moments for Hand Hygiene methodology was incorporated as a standardised, evidence-based educational and auditing approach.4 The primary focus of the NHHI is to improve hand hygiene compliance among

Results

The number of health-care institutions submitting hand hygiene audit data increased from 105 (103 public and two private hospitals) in March 31, 2009, to 937 (598 public and 339 private hospitals) in June 30, 2017 (figure 1). Between Jan 1, 2016, and June 30, 2017, the number of non-hospital health facilities grew to 6% of all participating sites (n=56), although hospital-derived hand hygiene compliance data still constituted 575 360 (98·1%) of 586 559 of all hand hygiene Moments in the most

Discussion

We believe the Australian NHHI is the largest, most comprehensive and effective national hand hygiene programme in existence and that we have, for the first time, shown on a national scale the significant association between improvements in hand hygiene compliance and reductions in HA-SAB. On the basis of our analysis of the largest public hospitals, which provide about 77% of all Australian public inpatient care days (ie, 15·3 million nationally in 2016–17),15 for every 10% increase in hand

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