Ms Christine Sharp1, Ms Suzan Ezer1, Mrs Kaye Bellis1, Ms Pauline Bass1, Associate Professor Andrew Stewardson1, Dr Philippa Hawkings1, Dr Rekha Pai Mangalore1, Dr Joseph Grant1, Dr Nina Murphy1, Dr Joel Le Couteur1
1Alfred Care Group Bayside Health, Melbourne, Australia
Biography:
With 26 years in Infection Prevention (IP), Kaye's passion has always been for hand hygiene and getting it right. Chrissy Sharp: An apprentice of Kaye's, and a background in IP in ICU, she has also found the ability to make hand hygiene achievable and fun.
Abstract:
Problem
Despite a robust multimodal improvement program, hand hygiene performance among medical staff at our health service was consistently suboptimal.
What was done: A quality improvement project with a dedicated project nurse and advisory committee supported by executive sponsorship. Activities were conceptualised within a multimodal promotion framework and included; (1) System change: alcohol-based hand rub (ABHR) availability at medical point-of-care and modification of ward-round workflow; (2) Education: interactive sessions in small medical teams; (3) Audit and feedback: both immediate and written feedback including action plans, target-setting and competition of medical ward round audits; (4) Workplace reminders: stickers worn by staff; and (5) Safety climate: medical leadership support and recognition of champions.
Results
From October 2024 until May 2026, we audited 132 ward rounds, with 56 unique medical teams, including 1047 staff. Feedback was provided during 89% (117/132) of rounds. ABHR was not universally available at the point-of-care on 61% (80/132) of rounds. We performed 54 education sessions involving 42 medical teams. Interventions included new ABHR brackets, the ‘Captain Clean Hands’ initiative, and a results ‘leaderboard’ in the medical newsletter. Medical hand hygiene compliance increased from 63.5% (653/1028) in audit period 3, 2024 to 76.5% (1165/1526) in audit period 1, 2026.
Conclusions
Implementation of a focused quality improvement project was associated with improved medical hand hygiene behaviour.
Lessons learnt
Medical staff welcome inclusion in hand hygiene promotional activities
The multimodal approach can be used as a framework for improving medical hand hygiene
Implementation required a dedicated project nurse and sustainability is challenging.