Statewide hand hygiene improvement: embarking on a crusade

The Medical Journal of Australia ISSN: 0025729X 19 October 2009 191 8 SS5-SS7 ©The Medical Journal of Australia 2009 www.mja.com.au Supplement conditions affect hand hygiene behaviour? Ca change? If so, how much change in individual necessary to reflect change at a group level? Is a change sufficient to transform practices? Is hand hy iour integrated into the theory of ecological pers change is targeted? What should the targets for imp How far can HCWs be expected to modify their pr mp ma ev I roving hand hygiene practices in health care has been a jor challenge for more than 160 years. Despite much idence that hand hygiene practices are effective in preventing infection and reducing the spread of microbial resistance, the hand-cleaning behaviour of health care workers (HCWs) remains largely unchanged. Indeed, in almost all settings where it has been assessed, compliance with hand hygiene practices at appropriate times during the course of patient care has been less than 50%. But should HCWs carry all the blame? How do working n behaviour behaviour is major system giene behavpective once rovement be? actices? How long will it take to succeed? How can behavioural change be sustained, if and when it is achieved? What does “success” mean in terms of hand hygiene promotion? What are the best indicators of success? How much local success is needed to predict more global achievements? These are some of the many questions to be kept in mind by all those embarking on hand hygiene promotion. Successful promotion is a crusade, and we should not forget the “first crusader”, Ignaz Semmelweis, who paved the way in 1847. Semmelweis’s crusade was long and difficult and, although extremely beneficial to patient safety, it was certainly not rewarding for him, and was even detrimental to his career. But attitudes and evidence have changed over the past 162 years. Thankfully, it is now well established that successful hand hygiene promotion does not result from forcing HCWs to plunge their hands into a caustic, chlorinated lime solution before patient contact and accusing them of being murderers if they refuse! Ample evidence suggests that successful hand hygiene promotion is the result of multimodal strategies involving multiple partners and key players.2 The proposed, tested and validated World Health Organization strategy now used in many hospitals worldwide (Box 1) includes at least five key elements: homo-