Ward-Based Hand Hygiene Program Sees Improved Compliance Rates

Most efforts to improve hand hygiene in hospitals focus on individuals, but investigators at an acute care hospital (ACH) and a community care hospital (CCH) in Singapore saw good results when entire hospital wards were held accountable.

The ACH (Ng Teng Fong General Hospital) launched a hand hygiene program using the World Health Organization’s hand hygiene tool in April 2016. The CCH (Jurong Community Hospital) launched the same program.

The ACH saw admissions of 34,920 and 41,612 in 2016 and 2017, respectively. The CCH saw admissions of 2194 and 2863 in 2016 and 2017 respectively, according to the study published recently in Antimicrobial Resistance & Infection Control. 

One of the things investigators wanted to test was how to best address the “campaign fatigue” that takes the wind out of many hand hygiene initiatives. For instance, the hand hygiene compliance rates had plateaued at 67% in the ACH. 

“Hand Hygiene audits were performed by staff trained using the [World Health Organization] audit tools including ‘Secret Shoppers’ (who were administrative staff not known to ward staff) in addition to those done by our infection control liaison nurses (ICLNs)” and infection control nurses (ICNs), the study states. 

The wards that achieved the best compliance over the observation period were rewarded (the study did not specify the reward). If targets were not met in the first month, the ICNs would speak to ward leaders and increase education efforts. If they weren’t met in the second month, the infection control committee chairperson would step in and increase education efforts.

In instances of 3 consecutive months of underperformance, a ward-level task force would be formed to initiate a strategy for improvement. “Hand hygiene champions”-a doctor and a nurse-led the task forces.

“In reality, we found that this was not necessary,” the study states. “Most wards were already concerned with not being able to achieve their targets by the second month and had already instituted projects for improvement on their own and in every case, this resulted in an improvement in hand hygiene compliance so no ward was below target four months in a row.”

The ACH saw hand hygiene rates rise from 65% to 78%. Instances of methicillin-resistant Staphylococcus aureus (MRSA) fell from 5 episodes at the start of the study to 0 in 2017. 

The CCH saw an increase of 64% to 75%. There, the MRSA transmission rate decreased from 5.72 per 1000 patient days to 2.79 per 1000 patient days “with an admission prevalence of 13.1% for 2016 and 20.6% in 2017,” according to the study. 

The investigators note that prior studies have looked at hand hygiene programs that focus on individual providers. “There are several problems with this approach including losing the ability to do ‘secret shopper’ audits and questions of fairness in targeting,” the study states.

The challenge was in setting the right targets and methods to reach those targets and that involved asking providers on the ward what methods they wanted to employ. 

“Often when targets are set at a hospital wide level, some areas that are too far below these targets may view the exercise as futile and give up even before the initiative commences,” the study states. “The ‘sweet spot’ for a target which is neither too high to be unattainable or too low to be mediocre is challenging and we adopted a 10% increase above the baseline which seems to have worked, but perhaps we could be more ambitious the next time around.”