Emergency Department Hand Hygiene Project

Mrs Ning An1, Brendon Heley1, Ann Whitfield1

1Fiona Stanly Hospital, Perth, Australia

Healthcare Associated Infections (HAIs) are a major risk to patient safety and contribute to prolonged length of hospital stay as well as increasing cost, morbidity, and mortality.  Improving Hand Hygiene (HH) practice is a simple and cost-effective measure in preventing HAIs.  In the Emergency Department (ED) in Fiona Stanley Hospital  this is especially important given that patients are usually considered high-risk and are subject to multiple invasive procedures. Auditing undertaken in early 2018 indicated a compliance rate within the ED of only 54.2%, below the National HH Australia benchmark of 80%.

Multimodal and multidisciplinary strategies provide the greatest chance of success in HH improvement and risk associated with HAI.  In April 2018, a collaborative partnership was formed between ED and Infection Prevention and Management (IP&M), which led to use of the Emergency Department Hand Hygiene Program Self-Assessment Tool, and the development of an action plan to enhance HH practice.The Multimodal HH improvement strategy on the ED in FSH has substantial positive’s effects on HH compliance; HH compliance rates for ED exceeded the 80% benchmark by the National Hand Hygiene Initiative. This quality improvement project has not only increased the compliance rate across the “5 Moments for Hand Hygiene” for hand hygiene, but also improved communication, workflows and created a positive culture for patient and staff safety.


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