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Service Enhancement Presentations HOSPITAL AUTHORITY CONVENTION 2016

F8.3 Young HA Investigators Presentations 14:30 Room 421

An Innovative Strategy to Improve Hand Hygiene Compliance: Use of Evidenced-based Hand Hygiene Bundled

Interventions
Lam CW 1, Yuen SL1, Kwong MK1, Lee SY 2, Mak PC 3, Hung YKS 1 ,Ng YMW 4, Law WHJ 5, Cheng WY 5, Chan SY 3, Kong MY 3
1Central Nursing Division, 2Infection Control Team, 3Department of Intensive Care Unit, 4Surgery Department,
5Medicine Department, Queen Elizabeth Hospital, Hong Kong

Introduction

Healthcare associated infections pose a threat on global patient safety. Despite the fact that there is an increasing trend
of compliance rate in Queen Elizabeth Hospital (QEH) (from 62% in 2013 to 88% in 2014), compliance enhancement and
sustaining behavioural change remained a significant challenge. Based on the studies by Pittet et al(2000) and Whitby et
al(2008), hand hygiene compliance was improved by using a multimodal approach.

Objectives

To address this challenge, the hospital developed the one-year evidence-based hand hygiene bundle to remark its
significance in infection control.

Methodology

The evidence-based hand hygiene bundle recommended by World Health Organization(WHO) consists of five elements: (1)
Administrative leadership support demonstrated on visual reminders which conveyed powerful messages to improve hand
hygiene compliance. (2) The top-down marketing and promotion team from various departments engaged in the team. The
team formulated strategic plan and improved compliance outcomes. (3) Visual and audio reminders such as posters and
table stickers were posted in six strategic areas. Clinical leaders and hospital staff participated in music video shooting to
promulgate hand hygiene. (4) Behavioural reinforcement was demonstrated by “Two-week Hand Hygiene Reinforcement
Programme in Wards”, “Patient Hand Rub Round” and “Training Workshop on Hand Hygiene Compliance”. (5) Regular audits
were essential to evaluate hand hygiene compliance. The compliance measurement was adopted from WHO hand hygiene
observation tool performed by trained hand hygiene auditors in QEH. Compliance rate was also measured in “Two-week
Hand Hygiene Reinforcement Program in Wards”. The overall hand hygiene compliance rate is calculated by dividing the
number of hand hygiene actions by the total number of opportunities.

Results Wednesday, 4 May

During the second quarter of 2015, the hand hygiene compliance rate in inpatient units was 89%. It was steadily increasing
and the overall compliance rate in 2014 and 2015 was over 80%. In the “Two-week Hand Hygiene Reinforcement Programme
in Wards”, the overall compliance rate had reached 90%. In the training workshop, 16 nurses were awarded the “Qualified
Hand Hygiene Auditors” on best hand hygiene practices. The evidence-based hand hygiene bundle served as an innovative
strategy to improve hand hygiene compliance. It applied five elements in a synergistic manner to target such encouraging
outcomes.

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