Identifying issues with poor hand hygiene compliance in the Emergency Department using a self-assessment framework

Mrs Elizabeth Orr1, Ms Sally Havers2, Ms Mia Brill1, Ms Joanna Price1, Professor Linsday Grayson1,2

1Austin Health, Heidelberg, VIC, Australia
2Hand Hygiene Australia


Introduction: Hand hygiene compliance (HHC) in the Emergency Department (ED) was significantly lower than the rest of Austin Health at 58.9% (95%CI 54.0-63.7%) compared to 79.3% (95%CI 78.1-80.5%). Reasons were unknown, but potentially related to workflow and limited alcohol-based handrub (ABHR) access. There was a lack of engagement from ED staff who suggested the 5 moments didn’t apply to them and were also ‘too difficult’.

Methods: An initial gap analysis using an ED self-assessment framework was performed in October 2017. The issues identified included; erratic workflow with staff predominately in staff areas and corridors; inadequate ABHR placement; lack of understanding on when to perform HH and frequent closing of curtains. Key improvements included; purposeful ABHR placement with >50 additional brackets; focused education and simulation sessions targeting inappropriate glove and curtain use; increased number of HH auditors and moments collected; and improved governance to executive.

Results: HHC improved from Audit 3 2017 to Audit 1 2018 from 58.9% (234/397; 95%CI 54.0-63.7%) to 69.8% (245/351; 95%CI 64.8-74.4%) and was sustained in Audit 2, 2018 at 66.1% (95%CI 61.1-70.8%). Compliance has not yet reached the target of 80%. Lack of engagement and auditor burnout remains ongoing issues.

Conclusion: ED is a challenging area for HHC improvement due to workflow, different ABHR placement requirements and need for leadership. The self-assessment framework provided Infection Control with a way to identify actual problems. A short-term focus on multimodal program components was sufficient to demonstrate improved HHC but further work is required to show additional improvements.


Elizabeth Orr is an Infection Control Consultant who is passionate about hand hygiene and improving patient care through quality activities that strive for best practice. Elizabeth has previously held positions as an Infection Control Consultant within Monash Health, VICNISS, Hand Hygiene Australia and Austin Health.

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