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CHARTPACK

Reporting hand hygiene compliance

January 2018

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Key findings 3 Setting the scene 4 Hand hygiene data collection 5 Current reporting on hand hygiene compliance 6 Data and reporting 7 Comparisons over time: ‘before moments’ and ‘all moments’ 8 Comparisons: by healthcare worker 9 Comparisons: by ward type 10 Comparisons: by local health district and specialty network 11 Comparisons: by facility 12 Patient survey data on hand hygiene 14 Compliance and patient-observed hand washing 15 Appendix: Additional information 16

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• 1. Compliance reporting based on the two ‘before moments’ resulted in similar findings as current compliance reporting

using all five moments.

• 2. While there has been an increase in hand hygiene compliance rates over time, rates are starting to plateau.
• 3. Patient survey data also show an increase over time in the percentage of patients who said they ‘always’ saw nurses and

doctors wash or clean their hands before touching them. However, there was no strong correlation between compliance and survey results for public hospitals.

• 4. More work is needed to understand compliance and hand hygiene data in relation to patient safety outcomes and patient

experiences.

• 5. Future work on reporting may consider the impact of the case-mix by ward type, health care worker, and the mix of

moments in compliance reporting. Regular monitoring may also benefit from using a minimal reporting level of 100 or more observations, which would increase the power of statistical significance testing.

Key findings

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The Clinical Excellence Commission (CEC) manages the National Hand Hygiene Initiative in NSW. The program, run in conjunction with Hand Hygiene Australia, provides training, education, and promotional and reporting resources in order to raise awareness of the importance of hand hygiene. A key part of the program is audit. Throughout the year, trained hand hygiene auditors collect data using direct observation of their colleagues’ hand cleaning before and after clinical encounters. The audit focuses on the ‘five moments’ of hand hygiene as defined by the World Health

• Organisation. Hand hygiene compliance is

reported as the percentage of observed moments for which appropriate hand hygiene was performed. This chartpack explores options for hand hygiene compliance reporting – specifically considering whether a focus on reporting the first two moments – the ‘before moments’ that

• ccur before patients are touched – represents

a viable alternative to reporting ‘all moments’.

Setting the scene

The ‘five moments’ of hand hygiene

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Data collection More than 200 facilities in NSW submit data to the National Hand Hygiene Initiative. Participating facilities include acute inpatient hospitals, residential aged care centres, community health networks and dental facilities and are located across the state’s local health districts (LHDs) and specialty networks. Observations are collected in plain sight by trained staff on the ward or facility. Reporting to date The CEC provides progress reports in its e-Chartbook. Results are generally reported by type of moment, healthcare worker and ward. Limitations Hand hygiene compliance results may be influenced by the level and experience of the staff auditors and inter-rater reliability is not routinely assessed. Results are not adjusted for variation in staff mix, moment type and ward.

Hand hygiene data collection

BACK TO CONTENTS Hand hygiene compliance (all staff) – Trends in overall hand hygiene compliance (%) by all staff, NSW and Australia, November 2009 to June 2017

60.9 61.7 68.5 71.6 71.8 74.7 75.9 76.9 78.9 79.3 79.6 80.4 81.1 81.6 83.0 83.4 83.5 84.1 84.1 84.8 84.9 84.9 85.3 84.5

10 20 30 40 50 60 70 80 90 100 Nov 09 Apr 10 Aug 10 Nov 10 Mar 11 Jun 11 Oct 11 Mar 12 Jun 12 Oct 12 Mar 13 Jun 13 Oct 13 Mar 14 Jun 14 Oct 14 Mar 15 Jun 15 Oct 15 Mar 16 Jun 16 Oct 16 Mar 17 Jun 17 % of staff complying with hand hygeine guidelines NSW Australia

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Hand hygiene compliance has improved over time in NSW, but varies across healthcare worker and ward types. In 2016, dental staff, nurses and midwives had the highest compliance, and domestic workers the lowest compliance, when all five moments of care are considered. Compliance varied across ward types, ranging from 77.5% in emergency departments to 92.7% in dental wards. Compliance also varied across LHDs, ranging from 77.5% in Central Coast to 90.0% in Far West. Results for the Justice and Sydney Children’s specialty networks were relatively high, at 90.7% and 91.7%,

• respectively. Across the 238 individual

facilities included in the 2016 audit, compliance ranged from 63.4% to 100.0% [data not shown].

Current reporting on hand hygiene compliance

Percentage compliance by healthcare worker, five moments, 2016

92.7 91.0 90.1 89.7 89.5 89.2 88.5 88.1 87.9 87.6 87.1 86.6 86.2 83.5 83.5 82.7 82.3 79.5 77.5 20 40 60 80 100

Percentage compliance by ward type, five moments, 2016

91.7 88.8 87.5 83.9 83.3 79.8 76.6 73.2 68.7 20 40 60 80 100

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This chartpack explores the effect of a change in reporting practices – specifically whether a focus on compliance for the two before moments provides substantially different picture of performance when compared with compliance for all moments. Comparisons between the before moments and all moments are shown over time, by healthcare worker, by ward type and by LHD. Compliance data: In 2016, a total of 647,447 moments were observed and of these, 40% were ‘before moments’ and 60% were ‘after moments’. Among the ‘before moments’ there were more than twice as many observations recorded before touching a patient than before a procedure (72% and 28%, respectively) [see Appendix]. Patient Survey data: Data drawn from patient surveys, detailing hand hygiene practices that were observed by patients, provides additional

• context. The 2016 NSW Adult Admitted Patient

Survey (AAPS) included responses from 28,693 patients across 80 public hospitals (response rate 42%). Reporting at a facility, hospital or group level is limited to units with more than 30 observations.

Data and reporting

All moments Before moments After moments BACK TO CONTENTS

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In many ways the first two moments of hand hygiene – the ‘before moments’ – are more important in preventing healthcare associated infections. The hand hygiene audit program has recorded an improvement in compliance

• ver time. In recent collection periods, rates

have plateaued, but remained above the 2017 national hand hygiene benchmark of 80% as set by the Australian Health Ministers' Advisory Council. Over time ‘before moment’ results have been consistently lower than ‘all moment’ results, although the pattern of improvement is similar.

Comparisons over time: ‘before moments’ and ‘all moments’

72.6 83.5 82.9

10 20 30 40 50 60 70 80 90 100 2011 2012 2013 2014 2015 2016 2017 (up to June)

Compliance (%) Before moments All moments Compliance for ‘before moments’ and ‘all moments’, NSW, 2011 to 2017 BACK TO CONTENTS

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Click to edit Master subtitle style Comparisons: by healthcare worker

Hand hygiene compliance varies by healthcare worker types. These differences may be important to consider when comparing facilities or regions with different mixes of workers. For ‘before moments’ and ‘all moments’, dental staff and nurses/midwives had the highest compliance. Comparing ‘before moments’ and ‘all moments’, the largest difference in the two measures was for personal carers, where the gap in compliance between ‘before moments’ and ‘all moments’ was more than five percentage points. For dental staff, other workers and domestic workers (such as food preparation staff), compliance was higher for ‘before moments’. All other groups had higher compliance for ‘all moments’. Compliance for ‘before moments’ and ‘all moments’ by healthcare worker, NSW, 2016 BACK TO CONTENTS

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Click to edit Master subtitle style Comparisons: by ward type

Looking across different ward types revealed different patterns of ‘before moment’ compliance, ranging from 75.7% in emergency departments to 92.0% in dental wards. The largest gap between ‘before moment’ and ‘all moment’ compliance was observed for radiology – a five percentage point difference. Neonatal, paediatric and peri-operative wards had higher compliance for ‘before moments’ than ‘all moments’. Compliance for ‘before moments’ and ‘all moments’ by ward type, NSW, 2016 BACK TO CONTENTS

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Click to edit Master subtitle style Comparisons: by local health district and specialty network

Across LHDs and specialty networks, the gaps between results for ‘before moments’ and ‘all moments’ were modest. Western Sydney, Central Coast and Northern Sydney LHDs had the largest gaps – ‘before moment’ compliance was more than two percentage points lower than ‘all moment’ compliance. For five LHDs and networks however – St Vincent’s, Sydney Children's Hospital Network, Hunter New England, Mid North Coast and Murrumbidgee – compliance was higher for ‘before moments’. For the remaining 13 LHDs and networks, ‘before moment’ compliance was lower than ‘all moments’ compliance. Compliance for ‘before moments’ and ‘all moments’ by LHD and specialty network, NSW, 2016 BACK TO CONTENTS

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Click to edit Master subtitle style Comparisons: by facility

At a facility level, results for ‘before moments’ and ‘all moments’ were similar. Of 238 facilities included in the 2016 audit, most (213) had compliance results above 75% for both ‘before moments’ and ‘all moments’. Four facilities were below 75% for both sets of results, but three of these were small facilities (<100 ‘before moments’). There were 20 facilities below 75% based

• n ‘before moments’, but above 75% for

‘all moments’. Only one facility had ‘before moment’ compliance of over 75%, but less than 75% for ‘all moments’. Compliance for ‘before moments’ and ‘all moments’ by facility, 2016

20 40 60 80 100 20 40 60 80 100

% 'before moments‘ compliance % 'all moments‘ compliance Facilities above 75% for ‘before moments’ and ‘all moments’ compliance Facilities below 75% compliance for both ‘before moments’ and ‘all moments’ Facility above 75% for ‘before moments’ and below 75% for ‘all moments’ compliance Facilities below 75% for ‘before moments’ and above 75% for ‘all moments’ compliance BACK TO CONTENTS

Facility 75% compliance 75% compliance

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NSW patient surveys provide further context

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Click to edit Master subtitle style Patient survey data on hand hygiene

The results from the Adult Admitted Patient Survey provide context to the hand hygiene audit results. In 2016, 60% of adult patients said they ‘always’ saw nurses clean their hands, while 51% said they ‘always’ saw doctors clean their hands before touching them. Quarterly results between January 2015 and December 2016 show an increase in the percentage of patients who said they ‘always’ saw nurses (58% to 61%) and doctors (48% to 52%) wash their hands or use hand gel before touching them. In comparison, audit data show for ‘before moments’ compliance for nurses was 87% and for doctors 71% (see page 8). While levels of patient-observed handwashing were lower than the audit compliance data, both results improved over time. The results are notably higher for nurses compared with doctors in both sources.

51 60 13 16 18 11 18 13 Hospital doctors Hospital nurses Yes, always Yes, sometimes No, I did not see this Can't remember 58 59 60 59 59 58 60 61 48 49 49 50 50 50 52 52 10 20 30 40 50 60 70 80 90 100 Jan-Mar 2015 Apr-Jun 2015 Jul-Sep 2015 Oct-Dec 2015 Jan-Mar 2016 Apr-Jun 2016 Jul-Sep 2016 Oct-Dec 2016

% of patients

Nurses Doctors

Percentage of adult admitted patients who said they ‘always’ saw professionals wash their hands before touching them, NSW public hospitals, Jan-Mar 2015 to Oct-Dec 2016 “Did you see nurses/doctors wash their hands or use hand gel to clean their hands before touching you?”, adult admitted patient responses, NSW public hospitals, 2016 BACK TO CONTENTS

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Across 79 public hospitals results for ‘before moments’ compliance were compared with and patient-observed handwashing. There was no observed association between hand hygiene compliance results and the patient survey data at a facility level. Public hospitals with the highest percentages

• f patients who said they ‘always’ saw nurses

wash their hands before touching them were not necessarily the same hospitals with the highest compliance based on ‘before moments’. Similarly there was no association observed between the percentage of patients who said they ‘always’ saw doctors wash their hands before touching them, and ‘before moment’ compliance.

Compliance and patient-observed handwashing

Patient-observed handwashing by nurses and ‘before moments’ compliance, public hospitals, NSW, 2016

R² = 0.0095 10 20 30 40 50 60 70 80 90 100 20 40 60 80 100 compliance 'before moments'(%) % of patients who said they 'always' saw nurses wash their hands

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Public hospital

Note: R = the coefficient of correlation, a measure of the strength and direction of the relationship between two variables

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Appendix: Additional information

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Results in this chart pack combined the two ‘before moments’. ‘Before moments’ include moment one (before touching a patient) and moment two (before a procedure). Compliance before a procedure is higher than compliance before touching a patient.

The two ‘before moments’

78.2 89.1 71.0 80.6 10 20 30 40 50 60 70 80 90 100 2011 2012 2013 2014 2015 2016 2017 (to June) Compliance (%) Before a procedure Before touching a patient

Compliance by moment type, for ‘before moments’, NSW, 2011 to 2017 (partial data to June) BACK TO CONTENTS

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The percentage of ‘before moments’ (orange)

• r ‘after moments’ (grey/black) of ‘all

moments’ data has been fairly consistent

• ver time.

Since 2011, here has been a slight increase in the percentage of moments collected before a procedure and a decrease in the percentage of moments collected after touching patient surroundings.

30 30 29 29 29 29 29 9 9 10 10 11 11 11 11 11 12 12 12 12 12 28 28 29 28 28 28 28 23 21 21 21 20 20 20 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2011 2012 2013 2014 2015 2016 2017 partial After touching patient surroundings After touching a patient After a procedure or body fluid exposure risk Before a procedure Before touching a patient

Distribution of moments collected over time

Percentage of moments collected by moment type, NSW, 2011 to 2017 (partial data to June) BACK TO CONTENTS

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Click to edit Master subtitle style Distribution of moments by LHD, health service and specialty network

The number of moments by LHD, health service and specialty network, and the percentage of ‘before moments’ add context to understanding compliance reporting based

• n ‘before moments’ only.

Across LHDs, health services and specialty networks, the number of moments collected and the proportion of ‘before moments’ varied considerably. Before moments All moments % before Justice Health 201 424 47% Far West 1476 3496 42% Southern NSW 2604 6342 41% Rural and Regional Health Services 2662 6454 41% Mid North Coast 3878 9545 41% Central Coast 4188 11417 37% Greater Metropolitan Health Services 6234 16284 38% Sydney Children's Hospital Network 6410 16995 38% St Vincent's Health Network 7359 18433 40% Murrumbidgee 10179 23914 43% Western NSW 10109 24462 41% Nepean Blue Mountains 10630 28241 38% Northern NSW 13349 35518 38% Northern Sydney 14472 37439 39% South Eastern Sydney 15411 37733 41% Hunter New England 19541 50888 38% Illawarra Shoalhaven 20599 52588 39% Sydney 28867 71652 40% Western Sydney 38251 93174 41% South Western Sydney 40884 102448 40% Total 257,304 647,447 40% Number of moments collected, ‘before moments’ and ‘all moments’, by LHD and specialty network, 2016 BACK TO CONTENTS

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Ward Before moments All moments % before Palliative 555 1413 39% Long term care 575 1559 37% Transplant unit 1106 2592 43% Dental 4153 8864 47% Acute aged care 3450 9144 38% Radiology 4843 10442 46% Neonatal intensive care 3615 11469 32% Paediatrics 6647 15114 44% Peri-operative 6149 15463 40% Mental health 7934 18440 43% Sub-acute 7172 18714 38% Ambulatory care 8315 20121 41% Oncology/haematology 9412 22033 43% Maternity 10409 23209 45% Renal 10081 23230 43% Emergency department 11253 29064 39% Mixed (usually means mixed speciality) 11427 29627 39% Critical care unit 16423 41146 40% Medical 26724 68167 39% Surgical 29584 80678 37% Other (ward not defined) 77477 196958 39% Number of moments collected, ‘before moments’ and ‘all moments’, by ward, 2016 The number of moments collected for different ward types ranges from 1,413 in palliative care wards to 80,678 in surgical wards. The percentage of ‘before moments’ varied from 32% in neonatal intensive care to 47% in dental wards. BACK TO CONTENTS

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Healthcare worker group Before moments All moments % before Dental staff 1741 3373 52% Invasive technician 3758 7970 47% Other (e.g. administrative and clerical staff) 3368 10540 32% Domestic 2225 13787 16% Personal carer 8520 24860 34% Student 10510 27073 39% Allied health 15281 36545 42% Medical practitioner 35654 92138 39% Nurse/midwife 176247 431161 41% Number of moments collected, ‘before moments’ and ‘all moments’, by healthcare worker, 2016 The number of moments collected for different ward types ranges from 1,741 for dental staff wards to 431,161 among nurses. The percentage of ‘before moments’ varied from 16% among domestic workers to 47% among invasive technicians. BACK TO CONTENTS