Hand hygiene in hospitals generally refers to the use of soap and water or other products (such as alcohol-based hand rub) by healthcare workers to clean their hands. The aim is for healthcare workers to perform hand hygiene correctly at every opportunity, for example, before and after touching a patient. Good hand hygiene is one of the most effective ways to minimise the risk of healthcare-associated infections, such as Staphylococcus aureus bloodstream infections.
The National Hand Hygiene InitiativeExternal link, opens in a new window.[http://www.hha.org.au] is being progressively implemented in Australian hospitals to improve hand hygiene. Hand hygiene in hospitals is measured through an audit process, in which trained observers watch for opportunities (called ‘moments’) when hand washing or cleaning ought to occur in order to ensure good infection control.
The national benchmark is for healthcare workers to clean their hands correctly in at least 70.0% of these ‘moments’ observed during an audit period at a hospital. A higher number of audited 'moments' will generate a more reliable compliance rate estimate. Methods will be developed to enable fair comparison of the estimated compliance rate with the national benchmark and with results achieved by other hospitals.
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Hand hygiene data are provided by state and territory health authorities for public hospitals and by individual private hospitals. The data are derived from audits of hand hygiene ‘moments’ that are conducted up to three times per year under the National Hand Hygiene Initiative.
Hospitals that provide information on hand hygiene report:
The estimated hand hygiene rate based on the sample of ‘moments’ observed in an audit.
The number of observed hand hygiene ‘moments’.
The estimated rate is compared to the national benchmark and is reported as:
Higher than the benchmark
Similar to the benchmark, or
Lower than the benchmark.
Interim national benchmark
An interim benchmark of 70% for hand hygiene reporting on MyHospitals has been advised by the Australian Commission on Safety and Quality in Health Care.
Calculation of measures
The estimated hand hygiene rate for a hospital is a measure of how often (as a percentage) hand hygiene is correctly performed. It is calculated by dividing the number of observed hand hygiene ‘moments’ where proper hand hygiene was practised in a specified audit period, by the total number of observed hand hygiene ‘moments’ in the same audit period, and multiplying by 100. The rate is rounded to one decimal place.
Hand hygiene audits
Hand Hygiene Australia (HHA) defines the national hand hygiene auditing guidelines, sets standards of data quality used by hospitals and coordinates the National Hand Hygiene Initiative.
Audits are performed by individuals who have undergone HHA auditor training.
Hand hygiene is measured by observing a specified number of ‘moments’ (based on the number of occupied acute beds in a hospital, or the number of procedures performed annually in a private day hospital) to determine whether healthcare workers carry out hand hygiene as required.
As hospital wards provide different types of healthcare, such as surgical care or medical care, the audit process involves selecting wards for auditing.
Some of these are categorised as high risk (e.g. intensive care units, dialysis, and high dependency units) for hand hygiene auditing purposes. HHA uses three ward selection methods:
Option A: high risk wards with rotation of other wards
Option B: high risk wards with auditing of all other wards
Option C: intensive care unit with auditing of all other wards
Reasons for unavailable data
There are a number of reasons why hand hygiene data may not appear on MyHospitals. These reasons include:
The hospital has fewer than 25 occupied acute care beds. Participation is voluntary for small hospitals
The hospital primarily provides mental health or rehabilitation care. Participation is voluntary for such hospitals
The hospital is a private hospital. Participation is voluntary for all private hospitals, including day hospitals
The hospital had fewer than 100 observed ‘moments’ for the period. Data are not reported for all of these hospitals
Data were not collected for this hospital for the audit period
The data have otherwise not been provided to MyHospitals.
Hospitals not required to provide hand hygiene data can voluntarily provide it for inclusion on the MyHospitals website. A comparison with the national benchmark is not shown for hospitals with fewer than 25 occupied acute care beds or for day hospitals with fewer than 2,000 procedures per year, or for other private hospitals with fewer than 25 occupied acute care beds.
For most hospitals where the number of observed hand hygiene ‘moments’ was fewer than 100, data are not reported. Where data are reported for these hospitals, a comparison with the national benchmark is not shown.
Hand hygiene ‘moments’
HHA’s hand hygiene ‘moments’ are based on those defined in the World Health Organization Guidelines on Hand Hygiene. Some minor modifications have been made for Australian health care conditions. A ‘moment’ is when there is a perceived or actual risk of pathogen transmission from one surface to another via a person’s hands. HHA specifies five critical ‘moments’ when hand hygiene should be performed by healthcare workers. The ideal is to perform hand hygiene correctly in each of these five critical ‘moments’. The five ‘moments’ are:
Hand hygiene rate estimates and confidence intervals
Because the hand hygiene rates are based on audits from a sample of hand hygiene ‘moments’, in a sample of hospital wards the calculation is only an estimate of the true rate for that hospital, and is associated with a 95% confidence interval.
A ‘confidence interval’ is a statistical term describing the range (‘interval’) within which we can be sure (‘confident’) the true rate falls. Confidence intervals indicate the reliability of the estimated rate and are calculated using data provided by hospitals.
When only a small number of ‘moments’ are audited, the confidence interval is larger, meaning we are less sure of the true rate. When a large number of ‘moments’ are audited, the confidence interval is smaller, meaning we are more sure of the true rate.
Interpretability and comparability
States and territories commenced the National Hand Hygiene Initiative over a staggered period. Therefore, hospitals that started later may have lower rates than hospitals that started earlier.
Differences in ward selection methods may also affect comparability of the data. Some states and territories use the HHA ward selection methodologies, and some use locally modified HHA ward selection methods. The ward selection method used can sometimes change from one audit period to the next. In general, for public hospitals:
New South Wales predominantly uses HHA ward selection method Option A and B, with a range of other ward selection methods applying in about 20% of hospitals.
Victoria uses HHA ward selection method Option A.
Queensland uses a localised approach that varies between facilities. However, most public hospitals use a ward sampling method in line with Option B.
Western Australia predominantly uses HHA ward selection method Option B.
South Australia uses a modified version of HHA ward selection method Option C, which contains aspects of Options A and C, whereby all intensive care units and high risk wards are sampled plus a selection of general wards depending on the size of the hospital.
Northern Territory uses HHA ward selection method Option A.
The Australian Capital Territory uses HHA ward selection method Option A and C.