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Hi John,
Many thanks for responding.
To continue putting $$ (mostly infection control personnel resources) into direct HH observations in the setting of gross overestimations of compliance rates should be evidence enough to review current practices.
There is a significant amount of information out there that challenges the accuracy of direct observational auditing of HH compliance, some of which has been undertaken in your own state of NSW see below.
While strides have been made by HHA since its establishment it is time to review the following given the information that is currently before use:
a) why do we continue to collect and report flawed data
b) why are we not reducing some of the current direct observation (infection control personnel /liaison nurses) auditing requirements until more accurate methods are investigated and,
c) why we are not looking at alternatives methods ( is see suggestions below – electronic devices/methods in combination with smaller observational audits).
In light of the available evidence (below) we should also be openly transparent and at this point in time when reporting direct observation compliance rates in Australia include a statement that cautions the reader that current research indicates the rates are likely to be significantly artificially inflated rather than implying to managers, CEOs and the general public that they are accurate.
Recent literature of interest
Australia – Yen Lee Angela Kwok et al. Automated hand hygiene auditing with and without an intervention. American Journal of Infection Control 44 (2016) 1475-80
*HHA rates (Hand Hygiene Australia human audits) for June 2014 were 85% and 87% on the medical and surgical wards, respectively. These rates were 55 percentage points (PPs) and 38 PPs higher than covert automation rates for June 2014 on the medical and surgical ward at 30% and 49%, respectively. During the intervention phase, average compliance did not change on the medical ward from their covert rate, whereas the surgical ward improved compared with the covert phase by 11 PPs to 60%. On average, compliance during the intervention without being refreshed did not change on the medical ward, whereas the average rate on the surgical ward declined by 9 PPs.
Australia – Mary-Louise et al. Hand hygiene compliance rates: Fact or fiction? AJIC online 17th May 2018
Direct human audit rates for the medical ward were inflated by an average of 55 PPs in 2014 and 64 PPs in 2015, 2.8-3.1 times higher than automated surveillance rates. The rates for the surgical ward were inflated by an average of 32 PPs in 2014 and 31 PPs in 2015, 1.6 times higher than automated surveillance rates. Over the 6 mandatory reporting quarters, human audits collected an average of 255 opportunities, whereas automation collected 578 times more data, averaging 147,308 opportunities per quarter.
The magnitude of the Hawthorne effect on direct human auditing was not trivial and produced highly inflated compliance rates.
Mandatory compliance necessitates accuracy that only automated surveillance can achieve, whereas daily hand hygiene ambassadors or reminder technology could harness clinicians ability to hyperrespond to produce habitual compliance.
Systematic review – Kingston L et al. Hand hygiene-related clinical trials reported since 2010: a systematic review. Journal of Hospital Infection 92 (2016) 309-320
We concluded that adopting a multimodal approach to hand hygiene improvement intervention strategies, whether guided by the WHO framework or by another tested multimodal framework, results in moderate improvements in hand hygiene compliance.
Editorial – Hand hygiene compliance: are we kidding ourselves? Editorial, Journal of Hospital Infection 92 (2016) 307-308
It is clear that monitoring hand hygiene compliance using direct observation is flawed and that electronic devices/methods in combination with smaller observational audits using appropriately trained staff would enable a better assessment Hence, in an era of multi-resistant Gram-negative bacteria, it is now time to take stock and consider that we have spent a number of years performing research on hand hygiene with little evidence that any particular strategy works. Perhaps future research should be focused not on campaigns to improve hand hygiene at all costs, but on understanding when hand hygiene is most beneficial, setting reasonable, achievable targets, and then monitoring using validated, reproducible methods.
Observational study – Scheithauer S et al. Workload even affects hand hygiene in a highly trained and well-staffed setting: a prospective 365/7/24 observational study. Journal of Hospital Infection 97 (2017) 11-16
Calculated compliance was inversely associated with nurses workload. Hand-rub activities (HRA)/patient-day (PD), observer-determined compliance and amount of disinfectant dispensed were used as surrogates for compliance, but did not correlate with actual compliance and thus should be used with caution.
The use of liaison nurses to undertake direct observation of HH compliance audits is not a common practice across Australia and Im not aware of any information that using a liaison nurse is any more accurate that an infection control professional? Happy to be corrected.
Ill cross posting my response with the Australasian College of infection Prevention and Control (ACIPC) list server in order to keep infection control personnel in on the discussions.
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
Hi Glenys
Im not sure Id agree that the current Australian HH audit system is broke and parliamentary records are not necessarily representative of what is really going on ! We should remember what little we had before HHA came into existence. In fact the load on infection control services has been minimised by training auditors who are link nurses etc. We now have such a brace of auditors that the main problem is keeping them credentialed. Our audits go across a large number of facilities each time and work pretty well like clockwork. Across Oz we have invested a lot of work in getting things to where they are and arguably there have been measurable gains in terms of SAB reduction etc. I think we should focus not on revolution but rather tinkering with the existing system.
A huge issue to me is that we medicos are still largely allowed to operate in a parallel universe, with no real accountability system ensuring that we (in NSW at least) have even completed 5 moments training or shock/horror been competency assessed for HH, PPE or aseptic technique. Aside from the College of Surgeons, it seems that the other colleges are dodging and weaving still and that is where ACIPC and ASID should be pushing +++. For instance our medical advanced trainees still have no explicit expectation put on them by the RACP concerning expectations of inf control practice during exams etc. We allow doctors to get about in all sorts of gear (suits, coats etc) or theatre scrubs and no-one wants to say boo. Why cant we adopt a bare below elbow standard nationally? Can we hear more about the Cognitive Institutes recent aust. pilot into Vanderbilt style accountability systems please? Royal Melb Hosp has been part of that pilot.
Other possible improvements:
a) At one of our sites, weve had the experience of a well credentialed external auditor conducting most of the HH audits for the past two audits. We have seen compliance there fall considerably indicating to me that all locations should adopt an approach to auditing whereby auditors are always drawn from a different ward or hospital (proper independent auditing).
b) We know also that the initial audit figures from a session are more indicative of actual practice and so, we should not allow for auditing at any site to go on for more than say 30 mins max.
c) We should ensure that audits occur more frequently than thrice yearly and across all shifts with at least monthly feedback of data to cadres and managers
d) Integrating HH auditing with AT audits
e) More careful operational research what is working , what is not, how valid are results, what effects are improvements in HH having, why are medicos not getting engaged with the system? etc
Best wishes
John
Dr John Ferguson MBBS DTM&H FRACP FRCPA
Director, Infection Prevention Service | HNE Local Health District
John Hunter Hospital, Locked Bag 1, Newcastle Mail Centre, NSW 2310, Australia
T: 61 2 49214444 | F: 61 2 49214440 | M: +61(0)428 885573 (Speed Dial 67607) | Tw @mdjkf
http://www.health.nsw.gov.au/images/communications/e-signatures/images/NSW-Health-Master.jpg
Dear All,
There was a debate in the UK parliament, Westminster Hall on 15/5/2018 in relation to hand hygiene compliance.
The parliament was told that actual hand hygiene compliance is only 18% – 44% in the UK and that direct observation is grossly overestimating HH compliance rates (Hawthorn effect).
The discussion has implications for direct observation of hand hygiene compliance programs in Australian healthcare settings.
It is time to review our direct observation HH compliance strategies and the significant infection control resources committed to such programs across Australia.
Regards
Glenys
Glenys Harrington
Infection Control Consultancy (ICC)
P.O. Box 6385
Melbourne
Australia, 3004
M: +61 404816434
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