National Hand Hygiene Initiative Research Articles

Using video-based surveillance for monitoring hand hygiene compliance according to the World Health Organization (WHO) Five Moments framework: A pragmatic trial.

To examine the utility of video-based monitoring systems (VMSs) for auditing hand hygiene compliance according to the World Health Organization (WHO) Five Moments. Pragmatic quasi-experimental observation trial. The New South Wales Biocontainment Centre, Westmead, New South Wales, Australia. Volunteer healthcare workers (HCWs). Six high-fidelity simulations were recorded and subsequently assessed for their ability to audit hand hygiene compliance according to the WHO Five Moments for hand hygiene criteria using tools provided by the National Hand Hygiene Initiative (NHHI). In total, 206 minutes of recorded footage were reviewed in 120 minutes, yielding 111 moments. Overall HCW hand hygiene compliance was 88% according to the WHO Five Moments framework. The cost per moment was $0.91 AUD ($0.66 USD) and the time required per moment was 64 seconds. Auditing of hand hygiene compliance according to all 5 of the WHO Five Moments from recorded footage is not only possible but provides cost and time savings. In addition, the process may produce output that is less subject to the biases inherent in direct human observational auditing.

Safety briefing and visual design key to protecting health care personnel during the COVID-19 pandemic

The COVID-19 pandemic has led to widespread changes as countries echo the call for millions to stay at home in an attempt to limit transmission of SARS-CoV-2, the virus that is responsible for the COVID-19 infection. Health care personnel (HCP), on the other hand, continue to serve on the front line. With their being a limited, human resource, it is paramount that the safety of HCP is not compromised.1Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA. doi: 10.1001/jama.2020.3972. Accessed July 17. 2020Google Scholar At our health service in Victoria, Australia, we have implemented a human factor-centric education model with the aim to maximize safety through key messages and clear communication. Our health service, Monash Health is Victoria's largest public health service network and includes three major metropolitan hospitals. Our education model is based on providing consistent and clear safety messages to all HCP, regardless of role and hospital site. It is modelled on the principles of pre-flight safety announcements used in the aviation industry; another high-stakes sector. Infographics (Fig 1), video summaries and pre-shift briefings are part of the education model.2COVID19AsOne. Sourcing non-medical grade personal protection equipment (PPE) for use in healthcare worker (HCW) training. 2020. Available at: https://www.covid19asone.com/sourcing-ppe-1. Accessed May 20, 2020.Google ScholarFig. 1.Visual design for safety briefing at the start of the shift and at clinical areas.View Large Image Figure ViewerDownload Hi-res image Download (PPT) This model encompasses 6 key messages to:1.Reinforce the importance of identifying the virus as the predominant danger2.Include personal protective equipment (PPE) in response to danger3.Focus on hand hygiene4.Reinforce social distancing5.Encourage HCP wellness and teamwork6.Maximize communication, ensure understanding, and provide an opportunity for feedback and questions The importance of cognitive aids for education of HCP is important to maximize their safety. As countries transition to an endemic phase of COVID-19 and the rate of asymptomatic carriage increases, we aim to use these aids to reduce danger to HCP, patients and the community. We believe it is important to reinforce the need to consider all potential dangers when managing COVID-19 patients (“The D [danger] comes first”). The DRSABCD mnemonic actively used in critical care and resuscitation is displayed to relay the acuity of the situation.3Australian Resuscitation Council. ARC flowcharts. 2016. Available at: https://resus.org.au/guidelines/flowcharts-3/. Accessed April 7, 2020Google Scholar This will encourage the health care team to respond (“R” in DRSABCD) appropriately by applying PPE. Hand hygiene compliance has been effective in reducing hospital-acquired infections,4Grayson ML Stewardson AJ Russo PL et al.Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study.Lancet Infect Dis. 2018; 18: 1269-1277Abstract Full Text Full Text PDF PubMed Scopus (47) Google Scholar and remains vital during a pandemic to reduce viral spread in HCP and patients with known, suspected or unknown COVID-19. Through active and passive social distancing, we aim to reduce the risk of COVID-19 transmission between HCP, patients and community. The reinforcement of adherence to PPE and double-checking PPE fit with a co-worker minimizes risk a virus transmission to other HCP and patients. The briefing is designed to be multidisciplinary and inclusive of the whole HCP team. Part of the safety model is the wellness check for HCP. Finally, closed loop feedback and communication allows for active updates to our education model to ensure continued relevance for all HCP staff. With the use of human factors, our education model aims to become a cognitive aid for all HCP to maintain safety during the pandemic. A recent study identified suboptimal hand hygiene and long duty hours as risk factors for COVID-19 transmission to HCP.5Ran L, Chen X, Wang Y, Wu W, Zhang L, Tan X. Risk factors of healthcare workers with corona virus disease 2019: a retrospective cohort study in a designated hospital of Wuhan in China. Clin Infect Dis. doi: 10.1093/cid/ciaa287. Accessed July 17. 2020Google Scholar Therefore, one must consider other factors apart from PPE to prevent transmission of COVID-19. The use of easily identifiable infographics with simple and consistent shift briefings allows for the rapid communication of information to HCP across multiple hospitals, while maintaining message recognition. A culture of safety and confidence among HCP during this pandemic will not only ensure their safety, but also that of their patients and the community.

Cleaning Staff's Attitudes about Hand Hygiene in a Metropolitan Hospital in Australia: A Qualitative Study.

Background: In 2009, the National Hand Hygiene Initiative (NHHI) was implemented in hospitals across Australia with the aim of improving hand hygiene practices and reducing healthcare-associated infections. Audits conducted post-implementation showed the lowest rates of compliance with hand hygiene practices are among operational staff including hospital cleaners. There is limited information about hand hygiene issues in hospital cleaners to inform development of evidence-based interventions to improve hand hygiene compliance in this group. Aim: This qualitative study was undertaken to explore the attitudes of hospital cleaning staff regarding hand hygiene and the National Hand Hygiene Initiative. Methodology: Focus groups were conducted with 12 cleaning staff at a large Australian hospital implementing the National Hand Hygiene Initiative. Findings: Hospital cleaners recognise the importance of hand hygiene in preventing healthcare-associated infections. Cleaners cite peer support, leadership, and the recognition and reward of those excelling in hand hygiene as strong motivators. Barriers to optimal hand hygiene practice include the presence of multiple conflicting guidelines, hand hygiene “overload” and a lack of contextualised education programs. This exploratory qualitative study reveals three themes about attitudes of hospital cleaning staff towards hand hygiene. These themes are: (1) “The culture of hand hygiene: It’s drummed into us”; (2) “Reminders and promotion for hand hygiene: We just need a big ‘Please wash your hands’ sign”; and (3) “The personal value of hand hygiene: Like he said, it’s second nature to us”. Conclusion: Hand-hygiene messages and training need to be more consistent and contextualised to achieve improvements in hand hygiene practices in hospital cleaning staff in Australia.

Effects of the Australian National Hand Hygiene Initiative after 8 years on infection control practices, health-care worker education, and clinical outcomes: a longitudinal study

The National Hand Hygiene Initiative (NHHI) is a standardised culture-change programme based on the WHO My 5 Moments for Hand Hygiene approach to improve hand hygiene compliance among Australian health-care workers and reduce the risk of health-care-associated infections. We analysed its effectiveness. In this longitudinal study, we assessed outcomes of the NHHI for the 8 years after implementation (between Jan 1, 2009, and June 30, 2017), including hospital participation, hand hygiene compliance (measured as the proportion of observed Moments) three times per year, educational engagement, cost, and association with the incidence of health-care-associated Staphylococcus aureus bacteraemia (HA-SAB). Between 2009 and 2017, increases were observed in national health-care facility participation (105 hospitals [103 public and two private] in 2009 vs 937 hospitals [598 public and 339 private] in 2017) and overall hand hygiene compliance (36 213 [63·6%] of 56 978 Moments [95% CI 63·2-63·9] in 2009 vs 494 673 [84·3%] of 586 559 Moments [84·2-84·4] in 2017; p<0·0001). Compliance also increased for each Moment type and for each health-care worker occupational group, including for medical staff (4377 [50·5%] of 8669 Moments [95% CI 49·4-51·5] in 2009 vs 53 620 [71·7%] of 74 788 Moments [71·4-72·0]; p<0·0001). 1 989 713 NHHI online learning credential programmes were completed. The 2016 NHHI budget was equivalent to AUD$0·06 per inpatient admission nationally. Among Australia's major public hospitals (n=132), improved hand hygiene compliance was associated with declines in the incidence of HA-SAB (incidence rate ratio 0·85; 95% CI 0·79-0·93; p≤0·0001): for every 10% increase in hand hygiene compliance, the incidence of HA-SAB decreased by 15%. The NHHI has been associated with significant sustained improvement in hand hygiene compliance and a decline in the incidence of HA-SAB. Key features include sustained central coordination of a standardised approach and incorporation into hospital accreditation standards. The NHHI could be emulated in other national culture-change programmes. Australian Commission on Safety and Quality in Health Care.

The Australian National Hand Hygiene Initiative: framework for future research

The Australian National Hand Hygiene Initiative: framework for future research

Clean hands = best care; Evaluation, redesign and relaunching of a regional healthcare facility hand hygiene program

Background: Barwon Health (BH) has participated in the National Hand Hygiene Initiative since 2007. This hand hygiene project is based on The World Health Organisation 5 Moments for Hand Hygiene and included standardised education materials and a regular audit system of hand hygiene compliance (HHC). BH wanted to demonstrate multimodal interventions optimally delivered with support of executive and key stakeholders have the best chance of successfully improving adherence to hand hygiene practices. This project launched in 2012 evaluated the effect of the BH hand hygiene program, initiated in 2007. Aiming to improve HHC of existing staff and capture the attention of new staff towards the importance of hand hygiene.

Improving hand hygiene performance in Victoria – Beyond the national hand hygiene initiative

Introduction: This project was initiated to optimise efficiency of hand hygiene (HH) audits, improve access to education resources, and review implementation of the National Hand Hygiene Initiative (NHHI) in Victorian public health services (VPHS). Methods: Workshops were held to distribute mobile devices loaded with resources for HH auditing and education to VPHS. A review visit was conducted at each VPHS, comprising a standardised interview and side-by-side HH auditing. Questions addressed system change, healthcare worker education, auditing, performance feedback and safety climate. VPHS received recommendations and were requested to complete a final evaluation. Results: Seven workshops were held to distribute 117 mobile devices to 84 VPHS. Overall 62/85(73%) VPHS completed a project evaluation. Sixty percent (37/62) health services did not use a mobile device for HH auditing before the project. Of these, 84%(31/37) used mobile devices for auditing after the project. Mobile devices reduced auditing time by up to 50% compared with paper-based audits. All VPHS programs were consistent with the NHHI. Areas for improvement included opportunities for more interactive education, frontline ownership and targeting of specific clinical groups and departments. Most respondents (81% [48/59]) indicated that changes had been either planned or implemented on the basis of recommendations from their review visit. We identified local innovations that could be disseminated to other VPHS. Conclusion: Use of mobile devices improves efficiency of HH auditing. Innovations and key components of successful programs will be shared to facilitate improvement in HH practices and outcomes may be used to guide HH promotion in the future.

Challenges of implementing a haemodialysis specific hand hygiene program across multiple countries

Introduction: Haemodialysis patients are vulnerable to acquiring healthcare associated infections. This is due to their chronic disease, frequent exposure to healthcare facilities and receiving invasive dialysis treatments three times per week. Compliance with hand hygiene is very important in minimising healthcare associated infections. In 2012 a hand hygiene program was implemented in the Australian dialysis clinics. In 2015 we began implementing haemodialysis specific hand hygiene programs into our dialysis clinics in other Asia Pacific countries. The challenges we faced were creating a hand hygiene auditor training program specifically for haemodialysis which also addressed cultural and linguistic differences. Methods: Australia dialysis clinics had an effective Infection Prevention and Control (IPC) Link Nurse program which included hand hygiene auditing. This program was replicated in the Asia Pacific dialysis clinics. We developed haemodialysis specific hand hygiene auditor training resources which accommodated linguistic differences. Results: In 2012 two Australian dialysis clinics had trained hand hygiene auditors, but audits were not submitted to the National Hand Hygiene Initiative (NHHI). By December 2015 all 18 Australian dialysis clinics had qualified hand hygiene auditors and all clinics submitted audits to the NHHI. In Asia Pacific, in 2015 there were no trained IPC Link Nurses. By June 2016 there were 32 trained IPC Link Nurses in 29 clinics across four countries. The hand hygiene program improved awareness and compliance with hand hygiene actions. Additional benefits were improvements in general infection prevention and control processes in our haemodialysis clinics, which had IPC Link Nurses, across Asia Pacific.

Cost-Effectiveness of a National Initiative to Improve Hand Hygiene Compliance Using the Outcome of Healthcare Associated Staphylococcus aureus Bacteraemia

BackgroundThe objective is to estimate the incremental cost-effectiveness of the Australian National Hand Hygiene Inititiave implemented between 2009 and 2012 using healthcare associated Staphylococcus aureus bacteraemia as the outcome. Baseline comparators are the eight existing state and territory hand hygiene programmes. The setting is the Australian public healthcare system and 1,294,656 admissions from the 50 largest Australian hospitals are included.MethodsThe design is a cost-effectiveness modelling study using a before and after quasi-experimental design. The primary outcome is cost per life year saved from reduced cases of healthcare associated Staphylococcus aureus bacteraemia, with cost estimated by the annual on-going maintenance costs less the costs saved from fewer infections. Data were harvested from existing sources or were collected prospectively and the time horizon for the model was 12 months, 2011–2012.FindingsNo useable pre-implementation Staphylococcus aureus bacteraemia data were made available from the 11 study hospitals in Victoria or the single hospital in Northern Territory leaving 38 hospitals among six states and territories available for cost-effectiveness analyses. Total annual costs increased by $2,851,475 for a return of 96 years of life giving an incremental cost-effectiveness ratio (ICER) of $29,700 per life year gained. Probabilistic sensitivity analysis revealed a 100% chance the initiative was cost effective in the Australian Capital Territory and Queensland, with ICERs of $1,030 and $8,988 respectively. There was an 81% chance it was cost effective in New South Wales with an ICER of $33,353, a 26% chance for South Australia with an ICER of $64,729 and a 1% chance for Tasmania and Western Australia. The 12 hospitals in Victoria and the Northern Territory incur annual on-going maintenance costs of $1.51M; no information was available to describe cost savings or health benefits.ConclusionsThe Australian National Hand Hygiene Initiative was cost-effective against an Australian threshold of $42,000 per life year gained. The return on investment varied among the states and territories of Australia.

Understanding the determinants of Australian hospital nurses' hand hygiene decisions following the implementation of a national hand hygiene initiative.

Hand hygiene is the primary measure in hospitals to reduce the spread of infections, with nurses experiencing the greatest frequency of patient contact. The '5 critical moments' of hand hygiene initiative has been implemented in hospitals across Australia, accompanied by awareness-raising, staff training and auditing. The aim of this study was to understand the determinants of nurses' hand hygiene decisions, using an extension of a common health decision-making model, the theory of planned behaviour (TPB), to inform future health education strategies to increase compliance. Nurses from 50 Australian hospitals (n = 2378) completed standard TPB measures (attitude, subjective norm, perceived behavioural control [PBC], intention) and the extended variables of group norm, risk perceptions (susceptibility, severity) and knowledge (subjective, objective) at Time 1, while a sub-sample (n = 797) reported their hand hygiene behaviour 2 weeks later. Regression analyses identified subjective norm, PBC, group norm, subjective knowledge and risk susceptibility as the significant predictors of nurses' hand hygiene intentions, with intention and PBC predicting their compliance behaviour. Rather than targeting attitudes which are already very favourable among nurses, health education strategies should focus on normative influences and perceptions of control and risk in efforts to encourage hand hygiene adherence.

The keys to success: initial findings from the Hand Hygiene Australia (HHA) program review

The Australian Commission on Safety and Quality in Health Care engaged HHA to implement the National Hand Hygiene Initiative (NHHI) in 2008. The NHHI is based on the World Health Organisation clean care is safer care program. In 2014 HHA was asked to review hospital hand hygiene (HH) programs to evaluate their alignment with the NHHI.

Implementation of the Australian national hand hygiene initiative

In 2008, the Australian Commission on Quality and Safety in Health Care (ACSQHC) engaged Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI), a national approach to hand hygiene (HH) culture change adapted from the WHO Multimodal HH Improvement Strategy.

Changes in healthcare-associated infections after the introduction of a national hand hygiene initiative

Abstract Introduction Interventions that prevent healthcare-associated infections should lead to fewer deaths and shorter hospital stays. Cleaning hands with soap and water or alcohol rub is an effectiveway to prevent the transmission of organisms, but compliance is sometimes low. The National Hand Hygiene Initiative in Australia aimed to improve hand hygiene compliance among healthcare workers, with the goal of reducing rates of healthcare-associated infections. Methods We examined if the introduction of the National Hand Hygiene Initiative was associated with a change in infection rates. Monthly infection rates for six types of healthcare-associated infections were examined in 38 Australian hospitals across six states. Infection categories were: bloodstream infections, centralline associated bloodstream infections, methicillin-resistant and methicillin-sensitive Staphylococcus aureus , Staphylococcus aureus bacteraemia and surgical site infections. Results The National Hand Hygiene Initiative was associated with a statistically significant reduction in infection rates in 11 out of 23 state and infection combinations studied. There was no change in infection rates for nine combinations, and there was an increase in three infection rates in South Australia. Conclusions The intervention was associated with reduced infection rates in many cases. The lack of improvement in nine cases may have been because they already had effective initiatives before the national initiative's introduction.

Changes in healthcare-associated Staphylococcus aureus bloodstream infections after the introduction of a national hand hygiene initiative.

Interventions that prevent healthcare-associated infection should lead to fewer deaths and shorter hospital stays. Cleaning hands (with soap or alcohol) is an effective way to prevent the transmission of organisms, but rates of compliance with hand hygiene are sometimes disappointingly low. The National Hand Hygiene Initiative in Australia aimed to improve hand hygiene compliance among healthcare workers, with the goal of reducing rates of healthcare-associated infection. We examined whether the introduction of the National Hand Hygiene Initiative was associated with a change in infection rates. Monthly infection rates for healthcare-associated Staphylococcus aureus bloodstream infections were examined in 38 Australian hospitals across 6 states. We used Poisson regression and examined 12 possible patterns of change, with the best fitting pattern chosen using the Akaike information criterion. Monthly bed-days were included to control for increased hospital use over time. The National Hand Hygiene Initiative was associated with a reduction in infection rates in 4 of the 6 states studied. Two states showed an immediate reduction in rates of 17% and 28%, 2 states showed a linear decrease in rates of 8% and 11% per year, and 2 showed no change in infection rates. The intervention was associated with reduced infection rates in most states. The failure in 2 states may have been because those states already had effective initiatives before the national initiative's introduction or because infection rates were already low and could not be further reduced.

Costing the Australian National Hand Hygiene Initiative

The Australian National Hand Hygiene Initiative (NHHI) is a major patient safety programme co-ordinated by Hand Hygiene Australia (HHA) and funded by the Australian Commission for Safety and Quality in Health Care. The annual costs of running this programme need to be understood to know the cost-effectiveness of a decision to sustain it as part of health services. To estimate the annual health services cost of running the NHHI; the set-up costs are excluded. A health services perspective was adopted for the costing and collected data from the 50 largest public hospitals in Australia that implemented the initiative, covering all states and territories. The costs of HHA, the costs to the state-level infection-prevention groups, the costs incurred by each acute hospital, and the costs for additional alcohol-based hand rub are all included. The programme cost AU$5.56 million each year (US$5.76, £3.63 million). Most of the cost is incurred at the hospital level (65%) and arose from the extra time taken for auditing hand hygiene compliance and doing education and training. On average, each infection control practitioner spent 5h per week on the NHHI, and the running cost per annum to their hospital was approximately AU$120,000 in 2012 (US$124,000, £78,000). Good estimates of the total costs of this programme are fundamental to understanding the cost-effectiveness of implementing the NHHI. This paper reports transparent costing methods, and the results include their uncertainty.

Doctor, do you have a moment? National Hand Hygiene Initiative compliance in Australian hospitals.

To examine hand hygiene compliance rates for medical and nursing staff, compliance with hand hygiene before touching a patient (Moment 1 of the Five moments for hand hygiene), and the effect of differential sampling of staff on the average national rate. Also, to establish whether hand hygiene rates impact Staphylococcus aureus bloodstream infections (SABSI). Analysis of data from three different cross-sectional datasets--Hand Hygiene Australia data for 246,665 hand hygiene opportunities during the first quarter (1 January to 31 March) of 2013 from 82 public hospitals representing eight Australian states and territories, and hand hygiene rates and SABSI rates from the MyHospitals website reported for 1 July 2011 to 30 June 2012. Compliance by medical and nursing staff for each hospital size (> 400 beds, 301-400 beds, 201-300 beds, and 101-200 beds); the proportion of hospitals with hand hygiene compliance rates for before touching a patient at or above, or below the national threshold of 70%; the impact of hand hygiene on SABSI. Medical staff consistently performed below the national threshold for hand hygiene compliance regardless of hospital size. Nurses' compliance was consistently above the threshold, and this inflated the total average national rate. A third of the patient interaction hand hygiene opportunities recorded involved before touching a patient, for which compliance was below the national threshold in 68% of hospitals. Hand hygiene has little impact on the rate of SABSI (incidence rate ratio, 0.97; P < 0.01). Posting a national unadjusted average hand hygiene compliance rate on a public website conceals the fact that most hospitals and medical staff are performing below the national hand hygiene compliance threshold. Given the poor compliance after 4 years of auditing to capture non-compliance, we must shift our focus to providing medical staff with immediate feedback and move to improving a single hand hygiene indication at a time, starting with before touching a patient.

Development of a standardised approach to observing hand hygiene compliance in Australia

Abstract Background Evidence indicates that improved hand hygiene compliance can lead to reductions in healthcare associated infection. However, there are few papers that clearly document the observation method used to collect the hand hygiene compliance data. This article describes the Hand Hygiene Australia 5 Moments for Hand Hygiene observation method in detail. Methods The Australian Commission for Safety and Quality in Health Care funded Hand Hygiene Australia (HHA) to implement the National Hand Hygiene Initiative (NHHI) to improve hand hygiene compliance (HHC) and establish a national validated system of HHC auditing. Based on the World Health Organisation (WHO) World Alliance for Patient Safety campaign ‘Clean Care is Safer Care', HHA adapted the WHO hand hygiene compliance data collection form to suit Australian healthcare facilities. Results Hand Hygiene Australia developed a standardised approach to direct observation of HHC of healthcare workers by developing a uniform suite of tools and a data management system for accurate data collection and report generation. Conclusion Implementation of the HHA 5 Moments HHC audit method has facilitated standardised, reliable and meaningful collection of hand hygiene compliance data that is driving HHC improvement across many different healthcare settings around Australia.

Evaluating the economics of the Australian National Hand Hygiene Initiative

The National Hand Hygiene Initiative, implemented in Australia in 2009, is currently being evaluated for effectiveness and cost-effectiveness by a multidisciplinary team of researchers. Data from a wide range of sources are being harvested to address the research questions. The data are observational and appropriate statistical and economic modelling methods are being used. Decision makers will be provided with new knowledge about how hand hygiene interventions should be organised and what investment decisions are justified. This is novel research and the authors are unaware of any other evaluation of hand hygiene improvement initiatives. This paper describes the evaluation currently underway.

Outcomes from the first 2 years of the Australian National Hand Hygiene Initiative

To report outcomes from the first 2 years of the National Hand Hygiene Initiative (NHHI), a hand hygiene (HH) culture-change program implemented in all Australian hospitals to improve health care workers' HH compliance, increase use of alcohol-based hand rub and reduce the risk of health care-associated infections. The HH program was based on the World Health Organization 5 Moments for Hand Hygiene program, and included standardised educational materials and a regular audit system of HH compliance. The NHHI was implemented in January 2009. HH compliance and Staphylococcus aureus bacteraemia (SAB) incidence rates 2 years after NHHI implementation. In late 2010, the overall national HH compliance rate in 521 hospitals was 68.3% (168,641/246,931 moments), but HH compliance before patient contact was 10%-15% lower than after patient contact. Among sites new to the 5 Moments audit tool, HH compliance improved from 43.6% (6431/14,740) at baseline to 67.8% (106,851/157,708) (P < 0.001). HH compliance was highest among nursing staff (73.6%; 116,851/158,732) and worst among medical staff (52.3%; 17,897/34,224) after 2 years. National incidence rates of methicillin-resistant SAB were stable for the 18 months before the NHHI (July 2007-2008; P = 0.366), but declined after implementation (2009-2010; P = 0.008). Annual national rates of hospital-onset SAB per 10,000 patient-days were 1.004 and 0.995 in 2009 and 2010, respectively, of which about 75% were due to methicillin-susceptible S. aureus. The NHHI was associated with widespread sustained improvements in HH compliance among Australian health care workers. Although specific linking of SAB rate changes to the NHHI was not possible, further declines in national SAB rates are expected.

Corrigendum: The challenges of implementing a national hand hygiene initiative in rural and remote areas: Is it time for a new approach to auditing?

The publisher wishes to apologize for errors that appeared in the above article. Page 64: participants were required to read Chapter 6 of the Hand Hygiene Australia Manual, not Chapter 5 as stated in the article. Page 68: Under “Conflict of Interest” Jenny Stackelroth wishes to declare that she is a member of the National Hand Hygiene Initiative Advisory Committee (as a representative of the Australian Commission on Safety and Quality in Healthcare's Healthcare Associated Infection Implementation Advisory Committee).