Adoption of an embedded model to improve accountability and compliance in an ICU hand hygiene program

Christine Sharp 1, Kaye Belliss 1, Gillian Land 1, Pauline Bass 1

Alfred Health, Melbourne, VIC, Australia


Hand hygiene (HH) programs must encompass and engage all clinical departments and disciplines. Our intensive care unit (ICU) employs over 600 staff providing care for patients including heart/lung /bone marrow transplants, burns, trauma. Average HH compliance rates from Audit 1 2013 to Audit 1 2014/14 were 74%. The objective was to meet a target of 90% using an ‘embedded model’ for HH education in the ICU context.

ICU executive seconded a part time nurse who undertook HH auditor training and had demonstrated educational skills and ability to engage with peers. ICU specific educational material, packages, promotions and orientation of new staff and close liaison with Infection Prevention staff promoted local accountability.

An average compliance rate of 78.5% was sustained from Audit 2 2014 to Audit 1 2016 following adoption of the new model. Specific initiatives included multidisciplinary engagement of staff, improved placement of alcohol based hand rub and gloves, timely feedback of audit findings, increased numbers of ICU staff undertaking HH auditor training and ICU specific workflow practices to remove perceived barriers.

Establishing an embedded model of a local champion for HH in our ICU has facilitated accountability and enhanced HH rates of compliance. To ensure sustainability and meet the objective of a target of 90%, an ongoing part time role is considered necessary. This model holds potential gains for other specialised units where local buy in is central to the success of the HH program.

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