LDPM 85 - Implementing Supplemental Interventions to Improve Hand Hygiene Compliance in an Acute Care Hospital

Background: Appropriate hand hygiene (HH), including the use of alcohol-based hand rub or soap and water, has shown to be effective in reducing both hospital acquired infections and the spread of antibiotic-resistant germs. Thus, it plays a critical role in infection prevention. We implemented a wide-ranging series of initiatives with the goal of achieving 90% compliance with HH hospital-wide.

Methods: After the installation of an electronic HH monitoring system in 2016, a HH dashboard with unit-based data was deployed hospital-wide. These data were shared with local leaders for targeted monitoring and intervention as appropriate. Staff received education and training via real-time observation-based feedback and online teaching modules with pre/post-test review and/or coaching. Top performers were incentivized with awards such as an employee of the month parking spot and a traveling trophy. A HH poster campaign was run concurrent with these activities. Additionally, a HH Steering Committee was constituted to further address issues related to technology, education, accountability and recognition, and to stress the strategic importance of these initiatives for our institution.

Results: Facility-wide HH compliance improved from 48% in 2017, to 72% in 2018, 75% in 2019, 77% in 2020, and 82% in 2021. Two units who piloted the HH coaching model improved their HH performance from 66% to 79% and 74% to 83%, respectively, between January to March 2021. A total of 25 departments showed HH compliance scores at or above 80% between 2021-2022.

Conclusions: The interventions were successful in improving facility-wide HH compliance. Frontline staff and department leaders understood the importance of appropriate HH and how it impacts patient outcomes. The efforts to improve HH compliance demonstrate the need for supplemental interventions and involvement from all hospital staff and leaders to have a significant impact. The initiatives to improve HH also fostered strong relationships between departments.