Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide roll-out

Multimodal programs to change hand hygiene (HH) culture have achieved significant sustained improvements in HH compliance by health care workers and reductions in rates of infection with methicillin-resistant Staphylococcus aureus (MRSA) and other nosocomial pathogens in individual institutions in Australia and elsewhere.1-5 Although the World Health Organization and other bodies have advocated large-scale roll-outs of such programs, there are currently no data to support the efficacy of such system-wide initiatives or to describe an optimal approach.6,7 In fact, some researchers have expressed doubts about whether such programs can be effectively introduced across a range of institutions or as a statewide policy initiative, owing to their perceived dependence on enthusiastic individual champions and the complexity of developing a generic culture-change template that is suitable for multiple disparate institutions.8

After the success of a recent single-site HH culture-change program (HHCCP),1 we assessed the efficacy of a similar, but more focused, centrally coordinated 2-year pilot program in six Victorian health care institutions, and then of a 1-year program in all Victorian public hospitals (“statewide roll-out”).

The HHCCP was sponsored, funded and coordinated by the Victorian Quality Council (VQC). A project coordination and data analysis centre was established in the Infectious Diseases Department at Austin Health, Melbourne, to provide training for project officers at each site; standardisation of HH compliance assessment; data collection and analysis (rates of HH compliance and MRSA); education and promotional support; and liaison between participating institutions and the VQC.

This is the largest multisite HHCCP both in Australia and worldwide to describe the implementation and efficacy of a generic program with hard endpoints such as HH compliance and rates of MRSA infection. As in the previous single-site study,1 we found that the pilot program resulted in significant sustained increases in overall HH compliance and significant reductions in both the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates identified, standardised for hospital activity (ie, per 100 PD per month). These results are particularly notable, as the HHCCP was conducted in only two or three wards, yet significant reductions in rates of MRSA disease occurred throughout each institution. We were encouraged that these reductions in MRSA disease reached significance 23 months after the start of the HHCCP, as we had expected from our previous study1 that such improvements would not be evident until about 30 months after the start.

Similarly, the statewide roll-out, which involved all but two of the eligible public hospitals in the entire state, resulted in significant sustained increases in overall HH compliance and reductions in both the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates identified.

We believe our data demonstrate that generic multisite HHCCPs, including statewide initiatives, can be highly effective if they are carefully planned and implemented, and that previously expressed scepticism is unfounded.8 Nevertheless, the fact that some sites demonstrated a temporary reduction in their rates of HH compliance (albeit not to baseline levels) when there were delays in replacing nurse project officers highlights the fragility of such early initiatives and the difficulty in totally embedding HH culture change in organisations in short time periods. As in other culture-change initiatives, such as the wearing of seatbelts in vehicles or drink-driving campaigns, ongoing education, constant message re-enforcement and data feedback are necessary to bring about sustained change.5,6,8

Long-term sustainability of improved HH compliance is likely to require that such programs become a permanent feature of the way each hospital does business, probably by including responsibility (and funding) for the HHCCP in the routine work portfolio of the quality or infection control team at each institution.

Unlike the previous single-site study, we did not screen for nasal or cutaneous MRSA colonisation, as it had previously proved extremely costly, did not generally affect the management of patients (unless they were about to undergo complex surgery) and did not correlate with demonstrated reductions in MRSA infections.1 We believe our findings justify this approach, as we were able to focus the majority of funding on the intervention and collect outcome data solely on endpoints that had clear practical relevance. One exception was the recording of ABHRS supply data, which we had initially believed might be a simple surrogate for HH compliance. In fact, supply data correlated poorly with HH compliance in both the pilot program and the statewide roll-out, owing to irregular ordering patterns and stockpiling. Our experience suggests that it is unlikely to be a useful indicator. This is notable, given that some European countries plan to use rates of ABHRS usage at public hospitals as a quality and funding performance measure (Didier Pittet, Director, WHO Global Safety Challenge, Geneva, personal communication).

As we expected during the design of the HHCCP, considerable effort was expended on staff education. Although we did not formally assess this, it soon became evident that HH was not a routine component of the educational curricula for most medical or nursing staff, with even very recent graduates being unaware of the importance of HH or the use of ABHRS. We believe this issue should receive more attention among educators of health care workers. A national standard approach may be worthwhile.

Our study has some limitations. Firstly, only sites that were clearly interested in participating in the HHCCP were enrolled in the pilot program, and the hospital administrations at each site gave unqualified commitment — a crucial feature of successful HHCCPs.1,2,6 Thus, we cannot be certain that similar results would be achieved in institutions in which the commitment was less enthusiastic, although the results of the statewide roll-out are encouraging. Secondly, the financial model used in our project provided clearly identified salary and incidental funds so that participating institutions could be certain about which costs were covered and which required additional institutional support. Whether other, less transparent funding models would be equally effective is uncertain. Thirdly, all but one of our pilot sites were relatively large (> 250 beds), and all had established infection control departments with full-time staff. Thus, the efficacy of HHCCPs in smaller institutions without such infection control support remains less certain — although, once again, the success of the statewide roll-out is encouraging. Fourthly, although HH compliance auditing was required only on pilot wards in both the pilot program and the statewide roll-out, it is likely that the initiatives undertaken in these areas had a beneficial effect in other wards. Finally, we cannot be certain that the improvements we observed in the statewide roll-out are related entirely to our HHCCP. For instance, on 6 September 2006 (3–6 months after the start of the statewide roll-out), the Victorian minister for health announced that all visitors to hospitals would be encouraged to use ABHRS on entry and departure. This announcement appeared to increase the public profile of the HHCCP and may have influenced the behaviour of some health care workers and visitors.

As in previous studies,1,2 our results suggest that an active HHCCP, in combination with widespread availability of ABHRS in clinical areas and targeted education of health care workers, can produce dramatic and sustained improvement in HH compliance and statistically significant reductions in MRSA disease after only 1–2 years. Our data suggest that such HHCCPs represent the single most effective means of reducing the burden of MRSA disease in Australian hospitals. Consideration of a national roll-out of such HHCCPs is likely to be worthwhile.

1 Pilot program: hand hygiene (HH) compliance at each of the six pilot program hospitals before and after introduction of the HHCCP*

HHCCP = hand hygiene culture-change program. * Mean HH compliance increased significantly over the 24 months of the pilot study (P < 0.001).

2 Pilot program: supply of alcohol-based hand-rub solution (ABHRS) on pilot wards before and after introduction of the HHCCP*

HHCCP = hand hygiene culture-change program. * Overall, poor correlation was noted between supply data and hand hygiene compliance rates, owing to seasonal and episodic ordering of ABHRS supplies.

3 Pilot program: number of patients with MRSA bacteraemia per 100 patient discharges (PD) per month before and after introduction of the HHCCP*

HHCCP = hand hygiene culture-change program. MRSA = methicillin-resistant Staphylococcus aureus. * A statistically significant reduction in bacteraemias was noted at 24 months after the start of the intervention (P = 0.035 for trend).

4 Pilot program: number of clinical MRSA isolates per 100 patient discharges (PD) per month before and after introduction of the HHCCP*

HHCCP = hand hygiene culture-change program. MRSA = methicillin-resistant Staphylococcus aureus. * A statistically significant reduction in clinical MRSA isolates was noted at 24 months after the start of the intervention (P = 0.003 for trend).

6 Statewide roll-out: hand hygiene (HH) compliance before and after introduction of the HHCCP, by health service type*

HHCCP = hand hygiene culture-change program. * Overall HH compliance (for all hospitals [Stages I and II]) increased from 20% at baseline to 53% at 11–12 months. Increases in overall HH compliance were significant for both baseline to 4 months (P < 0.001) and 4 to 12 months (P < 0.001).

7 Statewide roll-out: hand hygiene (HH) compliance before and after introduction of the HHCCP, by stage of roll-out and individual health service*

HHCCP = hand hygiene culture-change program. * In Stage I hospitals, HH compliance increased from 18% (95% CI, 17%–19%; range, 13%–31%) at baseline to 51% (95% CI, 51%–52%; range, 26%–74%) after 11–12 months. In Stage II hospitals, HH compliance increased from 21% (95% CI, 21%–22%; range, 10%–44%) at baseline to 54% (95% CI, 53%–55%; range, 34%–83%) after 11–12 months. For Both Stage I and Stage II hospitals, increases in overall HH compliance were significant for both baseline to 4 months (P < 0.001) and 4 to 12 months (P < 0.001).

8 Statewide roll-out: patients with MRSA bacteraemia per 100 patient discharges (PD) per month before and after introduction of the HHCCP*

HHCCP = hand hygiene culture-change program. MRSA = methicillin-resistant Staphylococcus aureus. * The number of patients with MRSA bacteraemia per 100 PD fell from 0.029 at 24 months before the intervention to 0.012 at 12 months after the start of the intervention (P = 0.09 for trend).

9 Statewide roll-out: total clinical MRSA isolates per 100 patient discharges (PD) per month before and after introduction of the HHCCP*

HHCCP = hand hygiene culture-change program. MRSA = methicillin-resistant Staphylococcus aureus. * During the 24 months before the introduction of the HHCCP there was a significant reduction in rate of MRSA isolates per 100 PD per month (P = 0.0003 for trend). After the start of the intervention, the rate continued to decline, falling to a rate of 0.30/100 PD per month after 12 months (P = 0.043 for trend).