November issue - Infection Control

Issue FOUR • NOVEMBER 2012
the clean hands
chronicle
CLEAN HANDS SAVE LIVES
Why opinion
leaders are key
to widespread hand
hygiene improvement
inside:
Glove use:
Hand hygiene
still vital
HHNZ video
competition
winners!
Education: ‘Why’
is a powerful
motivator
www.handhygiene.org.nz

Contents
03 EXPANDING THE HAND
HYGIENE MESSAGE
From when to why
Welcome from the
Clinical Lead
Welcome to our last issue of The
Clean Hands Chronicle for 2012.
04 glove up
But don’t forget hand
hygiene
05 hand care
Steps to reduce skin
irritation
06 opinion leaders
Key to widespread hand
hygiene improvement
08 VIDEO COMPETITION
RESULTS
How our top teams
produced their winning
videos
10 HHNZ QUARTERLY
AWARDS
Congratulations to our
winners
It’s hard to believe we are nearing the end of the year already. 2012
has been a busy year and I think we can say with confidence that the Hand
Hygiene New Zealand (HHNZ) programme has come a long way. Perhaps
most notably, for the first time ever, all 20 DHBs are contributing data to the
national hand hygiene compliance database. This is a huge achievement.
Getting to this point is the direct result of a lot of hard work by many people,
in particular, hand hygiene coordinators, platinum auditors, gold auditors
and many others. Data collection is absolutely critical for the success of the
programme, but we also know that auditing and submitting data can be a
very demanding process. So thanks to you all; it has been a truly team effort
at a national level.
This coming year one of the key focuses of HHNZ will be education,
which is also the focus of this edition of the Chronicle. An important part
of education is not only to explain when hand hygiene is necessary but
also why it is important. We also look at how different healthcare worker
groups respond to different messaging and provide some practical tips for
developing a strategy to engage with opinion leaders (those whose opinions
strongly influence the opinions and practice of other healthcare workers).
Glove use is also a key topic that relates directly to hand hygiene practice
and is the basis for an article in this issue. International research and
our own data indicate that compliance with best hand hygiene practice
decreases with glove use. More education around glove use is, therefore, of
key importance.
On a lighter note we profile our fabulous HHNZ video competition winner
and runner up – make sure you read all about how they created their
winning videos. We also profile the winners of our HHNZ Quarterly Awards –
congratulations to each of our winners; your awards are very well deserved.
I hope you enjoy this issue of the Chronicle and that you have a safe and
very happy summer.
12 news in brief
Interesting hand hygiene
news
13 editorial
Reflections of a hand
hygiene advocate
Best wishes,
Dr Joshua Freeman
Clinical Lead
Hand Hygiene New Zealand
As always, if you have any questions or feedback about any aspect of
the programme, please contact us. Email info@handhygiene.org.nz or
visit the contact us section of the HHNZ website –
www.handhygiene.org.nz – for other contact details.
2 THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES

EDUCATION
Expanding the
hand hygiene
message from
when
to why
Looking back over the last year, tangible progress has
been made with hand hygiene education. Nonetheless, much
educational work still remains. Healthcare workers that don’t
know when hand hygiene is necessary during patient care
are unlikely to improve their practice, so education remains a
key priority.
“Our aim is to get to the point where every healthcare worker
employed in a New Zealand hospital knows exactly when
hand hygiene is necessary during patient care to interrupt the
transmission of potentially harmful microorganisms,” says Dr
Joshua Freeman, Clinical Lead of Hand Hygiene New Zealand
(HHNZ)
Changing hand hygiene practice also requires changing
beliefs about why hand hygiene is necessary, which can be a
powerful motivator.
At its most basic level, hand hygiene prevents transmission
of harmful microorganisms between patients or between
anatomical sites on the individual patient that are prone to
becoming infected. 1 The driving reason to perform hand
hygiene is, therefore, not for self-protection but for the
protection of our patients.
Encouragingly, patient safety oriented messaging tends
to have greater resonance with healthcare workers than selfprotection
messages. 2
“International research shows there is a widespread belief
among healthcare workers that hand hygiene is primarily for
self-protection rather than for the protection of patients,” says
Dr Freeman.
“But the good news is that compliance is more likely to
improve when healthcare workers recognise and understand
that hand hygiene is important for patient safety.”
Explaining why hand hygiene is necessary, by highlighting
the negative impact that poor hand hygiene can potentially
have on patients – serious illness, emotional stress, financial
strain, disability, and in the worst case preventable death – is
a message that is likely to resonate with healthcare workers’
sense of altruism.
“As healthcare workers become more aware of when hand
hygiene is required, it is important to increase explanations about
why hand hygiene is necessary, moving away from the basic
message to provide more detail and evidence,” says Dr Freeman.
Taking a one-size-fits-all approach is unlikely to be effective.
Differing types of information are required to change the belief
systems of different healthcare worker groups. For some
healthcare worker groups, patient oriented messages and
supporting resources such as patient stories may compel
healthcare workers to improve their hand hygiene practice. For
others, greater levels of scientific evidence may be required.
Working out which healthcare worker groups require which
type of messages, is an important step. It is also important to
anticipate the type of response or questions that may be asked
by each group. Research suggests, for example, that medical
staff may initially question the evidence that hand hygiene is an
important patient safety initiative. 3
“If we are to persuade healthcare workers that their individual
hand hygiene behaviour can make a real difference we need to
be prepared to confidently explain why hand hygiene is beneficial
for our patients,” adds Dr Freeman.
“The reality is that healthcare workers in general want to
do the best for their patients. When healthcare workers come
to believe that hand hygiene is necessary for patient safety,
improvements in practice will follow,” says Dr Freeman.
References:
1) Pittet, D., Allegranzi, B., Sax, H., Dharan, S., Pessoa-Silva, CL.,
Donaldson, L., & Boyce, JM. (2006). Evidence-based model for hand
transmission during patient care and the role of improved practices.
The Lancet Infectious Diseases, 6(10), 641-652.
2) Grant, A,. & Hofmann, D. (2011). It’s not all about me: Motivating hand
hygiene among health care professionals by focusing on patients.
Psychological Science, 22(12), 1494-1499.
3) Erasmus, V., Brouwer, W., van Beeck, E., Oenema, A., Daha, T.,
Richardus, J ., Vos, M., & Brug, J. (2009). A qualitative exploration
of reasons for poor hand hygiene among hospital workers: Lack
of positive role models and of convincing evidence that hand
hygiene prevents cross-infection. Infection Control and Hospital
Epidemiology, 30(5), 415-419.
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES
3

GLOVE use
Glove up
But don’t forget
hand hygiene
There are many times when wearing
gloves during patient care is important for
self-protection. But wearing gloves does
not negate the need for hand hygiene.
According to Louise Dawson, National Coordinator for the
HHNZ programme, several international studies show that glove
use is associated with decreased hand hygiene at the appropriate
times during patient care.
“Some of this behaviour may stem from misunderstandings
about when gloves are necessary. I suspect that many healthcare
workers still believe gloves can be used as a substitute for hand
hygiene to protect themselves and patients from harmful bacteria,”
says Louise.
“Unfortunately, glove use can actually harm patients if
healthcare workers perform hand hygiene less often when they
wear them,” she adds.
Without performing hand hygiene before donning gloves
healthcare workers can contaminate the outside of gloves and
potentially transfer microorganisms to the patient. Removing
gloves can also contaminate healthcare workers hands, not only
from handling the gloves but from a splash back effect that can
occur when they are pulled off.
Data collected by DHBs as part of HHNZ’s compliance
auditing indicates that healthcare workers are missing vital hand
hygiene moments immediately before donning gloves and
straight after taking them off.
For DHBs that collected glove use data, the June
2012 audit period showed that the proportion of hand
hygiene moments missed when gloves were taken off
was 18.5 per cent. The proportion of hand hygiene
moments missed when gloves were put on was
38.6 per cent.
Likewise, the 31 October audit period
showed that when gloves were taken off
the proportion of moments missed was
16.6 per cent. When gloves were put
on the proportion of moments missed
was 44 per cent.
“Hand hygiene should
be performed whenever
an indication for hand hygiene applies according to the 5
moments approach, regardless of whether gloves are used or
not,’ says Louise”.
World Health Organization (WHO)
advice on hand hygiene and medical glove use
The use of gloves does not replace the need for cleaning
your hands.
Hand hygiene must be performed when appropriate
regardless of the indications for glove use.
Remove gloves to perform hand hygiene when an
indication occurs while wearing gloves.
Discard gloves after each task and clean your hands –
gloves may carry germs.
Wear gloves only when indicated according to Standard and
Contact Precautions (see examples in the pyramid below) –
otherwise they become a major risk for germ transmission.
The WHO Glove Pyramid
Gloves must be worn according to STANDARD and
CONTACT PRECAUTIONS. The pyramid details some
clinical examples in which gloves are not indicated, and
others in which clean or sterile gloves are indicated. Hand
hygiene should be performed when appropriate regardless of
indications for glove use.
STERILE
GLOVES
INDICATED
Any surgical procedure;
vaginal delivery; invasive
radiological procedures;
performing vascular access and
procedures (central lines); preparing total
parental nutrition and chemotherapeutic agents.
EXAMINATION GLOVES INDICATED IN
CLINICAL SITUATIONS
Potential for touching blood, body fluids, secretions,
excretions, and items visibly soiled by body fluids.
DIRECT PATIENT EXPOSURE: Contact with blood; contact with
mucous membrane and with non-intact skin; potential presence of highly
infectious and dangerous organism; epidemic or emergency situations; IV
insertion and removal; drawing blood; discontinuation of venous line; pelvic and
vaginal examination; suctioning non-closed systems of endotracheal tubes.
INDIRECT PATIENT EXPOSURE: Emptying emesis basins; handling/cleaning instruments;
handling waste; cleaning up spills of body fluids.
GLOVES NOT INDICATED (except for CONTACT precautions)
No potential for exposure to blood or body fluids, or contaminated environment
DIRECT PATIENT EXPOSURE: Taking blood pressure; temperature and pulse; performing SC and IM injections;
bathing and dressing the patients; transporting patient; caring for eyes and ears (without secretions);
any vascular line manipulation in absence of blood leakage.
INDIRECT PATIENT EXPOSURE: Using the telephone; writing in the patient chart; giving oral medications;
distributing or collecting patient dietary trays; removing and replacing linen for patient bed; placing non-invasive
ventilation equipment and oxygen cannula; moving patient furniture.
4
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES

HAND CARE
Skin irritation can be a troubling barrier to hand hygiene. A quick fire poll
conducted via the HHNZ website showed that 13.5 per cent of respondents
agreed that skin irritation affected their hand hygiene performance.
But how does it occur
According to the World
Health Organization (WHO)
(2009) some healthcare
workers can develop skin
irritation due to the frequency
of performing hand hygiene.
This is often identified as
irritant contact dermatitis,
where the skin has been
damaged and can include
dryness, irritation, itching,
and in some cases cracking.
The good news is,
however, that many studies
(Slotosch, Kampf, & Loffler,
2007; Pedersen et al, 2005;
Picheansathian, 2004) suggest
that healthcare workers who
regularly use alcohol based
hand rubs (ABHR), experience
less skin irritation and dryness
than those who use soap
and water.
HHNZ recommends
healthcare workers use
alcohol-based hand rubs
at all times other than when
hands are visibly soiled, after
visiting the bathroom, or
according to specific DHB
infection control guidelines.
What factors influence
contact dermatitis
ABHR products
containing fragrances
and preservatives; HHNZ
recommends these are
kept to a minimum or
eliminated.
Washing hands regularly
with soap and water
immediately before or
after using an ABHR.
Donning gloves while
hands are still wet from
either hand washing or
applying ABHR.
Using hot water for hand
washing.
How can I reduce
contact dermatitis
Use cold water for hand
washing.
Use a hand hygiene
product containing skin
emollient.
Provide alternative hand
hygiene products for
healthcare workers with
confirmed allergies or
adverse reactions to the
standard ABHR product.
These products could be
carried by the affected
healthcare worker.
Educate staff on practices
to reduce risk of irritant
contact dermatitis
including the regular use
of skin moisturisers both
at work and at home.
Moisturising skin-care
products need to be
compatible with an
alcohol product.
Provide healthcare
workers with hand lotions
or creams to minimise
the occurrence of irritant
contact dermatitis
associated hand washing.
Provide a supportive
attitude to staff with skin
problems.
Any concerns from
healthcare workers about
skin problems should
be taken seriously. All
hospitals should have a
referral protocol so that
healthcare workers with
persistent skin problems
can be referred to the
Occupational Health
Service within their DHB. •
References:
1) World Health Organization. (2009). WHO guidelines on hand hygiene
in health care: A summary. Geneva, Switzerland: World Health
Organization.
2) Slotosch, C,. Kampf, G., & Loffler, H. (2007). Effects of disinfectants and
detergents on skin irritation. Contact Dermatitis, 57(4), 235-241.
3) Pedersen, LK., Held, E., Johnsen, J., & Agner, T. (2005). Less skin
irritation from alcohol-based disinfectant than from detergent used for
hand disinfection. British Journal of Dermatology, 153(6), 1142-1146.
4) Picheansathian, W. (2004). A systematic review on the effectiveness
of alcohol-based solutions for hand hygiene. International Journal of
Nursing Practice, 10(1), 3-9.
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES 5

STAKEHOLDER ENGAGEMENT
Opinion
leaders
key to widespread
hand hygiene IMPROVEMENT
Medical staff and senior doctors are a vital ally in the fight to improve hand hygiene
behaviour and reduce healthcare associated infections. They are generally regarded as
opinion leaders, whose attitudes and beliefs help to shape the attitudes and beliefs of those
around them. It is vitally important, therefore, to gain their support whenever possible.
But it’s no secret that medical staff and senior doctors
throughout the world and in New Zealand, can be a difficult
group to engage.
“Often the most influential healthcare workers, typically
senior doctors, are the most difficult to persuade that
current hand hygiene practice recommendations are based
on a scientifically compelling rationale,” says Dr Freeman,
Clinical Lead of the Hand Hygiene New Zealand (HHNZ)
programme.
“As the level of education and training increases among
healthcare workers, so too does the level of detail and
evidence that tends to be required to convince them about
the need for improving hand hygiene practice.
“But once they are on board and are actively
demonstrating compliance with each of the 5 moments
themselves, medical staff and senior doctors can have a
significant and positive impact on the hand hygiene practice
of other healthcare workers,” says Dr Freeman.
“On the other hand, failing to engage opinion leaders,
can lead to negative role-modeling, which can be very
damaging” he adds.
For those tasked with implementing their DHB’s hand
hygiene programme, devising a strategy to engage opinion
leaders, particularly senior medical professionals, may help.
“There’s no simple formula for engaging with opinion
leaders. Careful thought, innovation and commitment are
needed,” says Dr Freeman.
“Despite the challenges, there are potentially major gains
to be made by taking this approach. If our most influential
healthcare workers genuinely believe hand hygiene is
necessary to protect their patients, then more widespread
improvements in practice will inevitably follow,” he says.
Throughout the next year, HHNZ will support DHB
hand hygiene coordinators by ‘recruiting’ a HHNZ medical
spokesperson within each DHB. It is hoped this approach
will provide a strong source of support for hand hygiene
coordinators and will assist them to identify and engage
with further medical opinion leaders throughout the DHB.
6 THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES

Developing an opinion leader engagement strategy
Here are some handy hints to help you on your way.
Identify key medical opinion leaders throughout your
organisation. Which medical staff and senior doctors are
renowned for being highly respected or influential Ask
around – see what names your colleagues come up with.
Can your chief medical officer recommend anyone
Develop three key messages to communicate to
opinion leaders.
Summarise key information, facts and figures that
support your argument/perspective. Highlight the
impact that their actions can have on influencing staff
around them.
Develop a short handout that you can leave with them
that covers your key messages, write an executive
summary about your DHB’s compliance results and
outcomes data, and include evidence-based journal
articles about hand hygiene compliance reducing
healthcare associated infections. For a New Zealand
perspective remember to include the New Zealand
Medical Journal article Implementing and sustaining a
hand hygiene culture change programme at Auckland
District Health Board, (11 May 2012, Vol 125 No 1354).
Present at medical grand rounds and other forums.
In all of the above, work closely with a medical
spokesperson if you have one. Keep at it and
eventually you will build an enviable list of medical
hand hygiene supporters! •
HHNZ seeks medical
spokespeople
If you are passionate about reducing healthcare
associated infections and improving hand hygiene
behaviour, let us know! We want to establish a
network of hand hygiene medical spokespeople
throughout all DHBs in New Zealand.
Key to this role is providing hand hygiene
educational messages to senior doctors, clinical
directors, and to junior medical staff, addressing
the when and the why of hand hygiene.
Interested Contact Dr Joshua Freeman
on 09 307 4949 ext 6411
or joshuaf@adhb.govt.nz
National Patient Safety
Campaign to Launch in 2013
At the recent APAC Forum in Auckland, Associate
Minister of Health Hon Jo Goodhew announced the
development of a national patient safety campaign. The
campaign is to be launched in early 2013 and led by the
Health Quality & Safety Commission.
“New Zealand has an excellent health and disability system
by international standards, and the vast majority of patients
are treated safety and effectively,” said Mrs Goodhew.
“However for a small number of people, events happen
that cause harm or have the potential to cause harm. This
harm causes great distress to patients, their families and
clinicians, as well as increasing health sector costs.”
The four priority areas for the campaign are reducing harm
from health care associated infections, surgery, medication,
and falls.
The campaign will align and work with existing patient
safety campaign initiatives, and national initiatives, for
example Hand Hygiene New Zealand, Target CLAB Zero and
First, Do No Harm.
The campaign is a nationally coordinated effort to reduce
patient harm in these areas by raising awareness and
increasing knowledge, skills and use of interventions known
to improve patient safety. It will be led and coordinated
nationally by the Commission, implemented and led regionally
and locally by the health sector.
The initial focus will be on harm caused in hospital
settings, and will focus on initiatives that have been shown
internationally to reduce harm and cost, and which fit within
providers’ existing quality and safety strategies.
The Commission is working with the sector to confirm
quality and safety markers for the campaign which will track
progress in reducing harm caused to patients in the four
priority areas.
These markers give the Commission a practical and
relevant way to track the progress of the campaign, in
reducing harm in the four priority areas. Regular reporting of
progress against the markers will begin from June 2013.
In November 2012 the Commission is focussing on
gathering feedback and input from the sector and ensuring
alignment with current activities.
To read more about the Commission’s role in
improving safety and quality in health care go to:
www.hqsc.govt.nz
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES
7

competition results
MidCentral DHB receive their $1,000 charitible donation for winning the HHNZ video competition
Competition attracts fantastic
hand hygiene video entries
From bugs and busters, to singing, dancing, and cleverly designed Lego videos;
competition was stiff between teams vying to win Hand Hygiene New Zealand’s
(HHNZ) national hand hygiene video competition.
But only one team could take out the top spot and with
their toe-tappingly catchy Hand Hygiene I Care video,
MidCentral DHB scooped first prize and a donation of $1000
to their charity of choice. Congratulations!
Following closely behind, taking out runner-up status
and $200 of cinema tickets, was South Canterbury District
Health Board’s Bug Busters team, with its bug-tastically
enthusiastic Timaru Hand Wash video.
The HHNZ video competition sought to encourage
teamwork and collaboration, through which hospital-based
healthcare workers would learn about the importance
of hand hygiene to patient safety, as well as when hand
hygiene should be performed.
Videos will now be used in a variety of ways by District
Health Boards and HHNZ as a promotional and educational
resource. To view all videos entered as part of the HHNZ
video competition go to www.handhygiene.org.nz click on
resources and then videos.
WINNERS: MidCentral DHB Infection
Prevention Control & Associates team
Doing magic for patients by caring about
hand hygiene
A moment of inspiration while cleaning at home led
to the theme tune and concept for MidCentral DHB’s
winning video.
“We had a strong desire to enter but we didn’t know
how to go about it,” said Anne Jaques, Video Team
Leader and Clinical Nurse Specialist in the IPC team at
MidCentral DHB.
“I was actually at home cleaning and thinking about
a tune that we could tie the video into. The ABBA CD
happened to be lying there, so I put it on and their ‘Rock
Me’ song immediately grabbed me,” she said.
From there, the IPC team spent their lunchtimes writing
8 THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES

the lyrics to go with the song, making sure they tied it
into the 5 moments approach and messaging about hand
rubbing and washing. They also started recruiting clinical
staff to star in the video.
“We thought it was important to include clinical staff
in the video as the video is aimed at healthcare workers.
It was also a great way to encourage them to spread
messages about the importance of hand hygiene among
their colleagues,” she said. “We had a lot of people that
were great from a role modelling perspective”.
With a ten strong team recruited, they set about
refining the lyrics, organising costumes and rehearsing.
“It took less than one month from start to finish,” said Anne.
“The brainstorming and writing of lyrics, rehearsal and
filming was all carried out in staff own time.
“We had three lunchtime brainstorming sessions with
whoever could come and two evenings to plan the outline
of the video. One evening we rehearsed the singing part
of the video, figuring out how it was going to happen, and
the next evening we filmed it,” she added.
“The team were more than happy to dress up, and they
just stood up and danced and were fantastic,” says Anne.
Filming of the 5 moments scenes were carried out over
the course of the month as staff were available.
“The 5 moments were typically filmed during
lunchtimes. We would find an empty bed space and we
would gather everyone needed together. Some of it
was filmed in maternity, some in ICU, and some in
transitory care,” said Anne. “And the ‘patients’ were us –
the IPC team.”
Anne made sure that the team covered as much detail
as possible, including making sure that staff weren’t
wearing jewellery and ensuring that the moment they
were capturing really reflected the moment in practice.
“Then our video director Gael Haining Ede, a
Registered Nurse with MidCentral’s Sexual Health
Service, and the DHB’s webmaster, Scott Crowley
from the communications team sat down and edited
it together, interspersing the 5 moments examples in
amongst the singing.”
On hearing they had won Anne says members of the
team came rushing across to the IPC office. “Everyone
was super excited and absolutely delighted.”
Since then they’ve had a fantastic response to the
video in their own DHB, with emails from staff members
saying how great the video is.
“One of our team was out on a ward and the doctors
were watching it, so that is great to know. And of course
the clinical staff in the video have been showing it to
everyone as well.
“It was also played before a presentation to senior
doctors recently too and our senior executive team are
very pleased with it too,” she added.
MidCentral DHB’s IPC and Associates team have
donated HHNZ’s charitable donation of $1000 to the
Palmerston North Hospital Medical Trust, which provides
support for patient welfare, hospital equipment, and
professional development for staff within MidCentral Health.
“When I spoke to the charity’s secretary he was
delighted and wanted to know all about the video, what
the 5 moments were, and about Hand Hygiene New
Zealand, so it wasn’t a quick call!” Said Anne.
“The whole process was a lot of fun. We had a great
collaborative approach, and it was really well worth it.
“There were certainly lots of times when we couldn’t
get that tune out of our head though!” She added.
RUNNER-UP: South Canterbury DHB’s
Timaru Hospital Bug Busters team.
Who you gonna call Bug busters!
Brainstorming in the hospital cafeteria with a group of
house surgeons led to the concept for the catchy Timaru
hand wash video.
Celebrating runner-up status and $200 of cinema
tickets, South Canterbury DHB’s Bug Buster team came
together to create a video that would spread the hand
hygiene message far and wide.
Their bug-tastically enthusiastic video featured an
array of infectious germs, being chased away from
patients and out of the hospital by hand hygiene busters
to the theme tune of Ghostbusters.
But while the video showed plenty of humorous,
top tapping moments, a more serious side was also
displayed. The team worked hard to highlight the
importance of hand hygiene to patient safety and
demonstrated the 5 moments for hand hygiene,
highlighting a variety of common scenarios for when hand
hygiene should be performed.
According to video director, Dr Camille Hemlock, a Senior
Consultant at Timaru Hospital, the hardest part was initially
encouraging healthcare workers to star in the video.
“But once we convinced them to put on the pig suits to
represent swine flu and dress up as a variety of other bugs
such as norovirus and Asian flu, everyone enjoyed hamming
it up!” She said.
The video team was a multidisciplinary effort, consisting
of physiotherapists, medicine physicians, geriatricians,
emergency department staff, members of the outpatient
department, the radiology reception team, house surgeons,
nurses, and administrators.
After filming 45 minutes of video over four days, it was
edited down to three minutes. And there were no rehearsals
– they just jumped straight into it.
“It was actually a vital team building exercise. Hand
hygiene is an issue relevant to everyone at the hospital,
so we will continue to highlight the community spirit within
Timaru Hospital and will show the video at staff orientation. We
are also considering showing the video in the ED waiting room to
promote further awareness,” said Dr Hemlock.
“It was a lot of fun, but for an important purpose. We’ve
received an excellent response with many messages of support.
We were very proud to be selected as runner up – although we’re
keen to go one better next time!” She said. •
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9

ecognition
Hand Hygiene New Zealand
Quarterly Awards
The HHNZ Quarterly Awards recognise and
acknowledge the hard work of hand hygiene
coordinators, gold auditors and wards at DHBs
throughout New Zealand. The awards highlight,
among other things, examples of excellence and
success associated with the implementation of
hand hygiene programmes and the promotion and
education of good hand hygiene practices.
If you know a hand hygiene coordinator, gold auditor
or ward, that deserves to be recognised for their
hard work, please visit the news section of the
HHNZ website for more information and to download
a nomination form. The deadline for Q1 2013
nominations is Friday 21 December 2012. Remember
all winners receive a prize!
HHNZ 2012 Q4 award winners
– Congratulations!
Hand Hygiene
Coordinator of the
Quarter:
Ray Pickles,
Clinical Nurse
Specialist, Infection
Prevention Control
Team, Tairawhiti
District Health Board
Ray Pickles
regularly goes the extra
mile to improve hand
hygiene behaviour
within his DHB.
Ray Pickles, Tairawhiti District Health Board
His commitment
and determination to
increase compliance has seen Tairawhiti go from a
baseline compliance rate of 25 per cent in 2009, to 71 per
cent in June 2012.
According to Jim Green, Chief Executive of Tairawhiti
DHB, it hasn’t always been easy convincing staff to
improve their hand hygiene. But with the belief it is the right
thing to do and support from senior DHB clinical leadership
and management, Ray has determinedly pushed on.
“After three years of persistently promoting and
educating staff about the 5 moments for hand hygiene,
Ray’s efforts have shown a direct correlation between
improved hand hygiene and a reduction in the rate of
infection, which demonstrates the importance of hand
hygiene to patient safety,” says Jim, who nominated Ray for
the award.
“Hand hygiene is only one aspect of Ray’s role but his
dedicated approach really benefits patient care,” adds Jim.
Over the past three years Ray has worked his way
around the DHB, making sure all healthcare worker and
hospital disciplines, including cleaning staff, received
training in the 5 moments for hand hygiene.
Not one to let an opportunity pass, he has also spent
time dressed as a bug on World Hand Hygiene Day
encouraging staff to use hand rub.
Likewise, Ray has activated a number of other
awareness raising initiatives throughout the DHB, such
as placing pink hand stickers on the floor at the entrance
of every ward and unit to remind people to perform hand
hygiene.
He has enthusiastically waved foam hands in the air to
promote each of the 5 moments for hand hygiene, and
is proactive at keeping the hand hygiene message alive
through the DHB’s communications team.
Ray also ensures that a lack of access to hand rub
cannot be an excuse. He regularly distributes hand rub
to every bedside, ward, and hospital entrance and even
ensures that Tairawhiti’s district nursing and inpatient
mental health unit receive pocket sized bottles of hand rub.
“On top of his role as an infection control clinical nurse
specialist and hand hygiene coordinator, Ray is also a gold
auditor and collects a substantial proportion of the data
submitted quarterly to HHNZ”, says Jim.
“He gives each ward or unit an individual compliance
report, highlighting their quarterly result and supports them
to maintain or improve hand hygiene compliance.
“Ray asked if he should nominate an area within the
hospital for the HHNZ Quarterly Awards. I thought it would
be good to nominate him!” adds Jim.
10
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES

Hand Hygiene Ward of the Quarter:
Rangatira Ward, Waitakere Hospital, Waitemata District
Health Board
Hand Hygiene Gold
Auditor of the
Quarter:
Julie Ritchie,
Infection Control
Clinical Nurse
Specialist, West Coast
District Health Board
Members of the Rangatira ward team at Waitakere Hospital
Despite being a very busy department, good hand hygiene
practice is a key priority for the healthcare team on Rangatira
Ward at Waitakere Hospital.
So much so, that their great attitude and can-do approach to
hand hygiene makes them stand out as a positive role model for
the rest of their DHB, says Heather Salisbury, Infection Prevention
Control Nurse Specialist and HHNZ gold auditor for Waitemata
DHB.
“Rangatira Ward is an acute, medical, paediatric ward. The
team, as proven by their June 2012 audit result of 82.2 per cent,
take hand hygiene extremely seriously,” says Heather.
Rangatira comprises a large multidisciplinary team, and the
high standard of hand hygiene is consistent across all groups of
healthcare workers.
“This is vital because the vast majority of their patients are
infectious and usually require contact and other transmissionbased
precautions,” says Heather.
“Good hand hygiene at each of the 5 moments has become a
routine part of their care, no matter how busy they are. It’s just too
important not to take it seriously.
“The ward has two infection prevention control link
representatives who promote hand hygiene and are very good
at reminding staff if they spot someone missing a hand hygiene
moment,” adds Heather.
For World Hand Hygiene Day, Rangatira’s play therapist
involved children on the ward by printing some hands for the
children to colour in. These were displayed in the main foyer,
reminding staff, patients, and visitors to clean their hands.
On top of their busy workload, recent refurbishments at the
hospital meant that half of the Rangatira Ward was closed. Staff
had to work in much smaller quarters and also had half of their
beds in the outpatient’s medical day stay area, effectively splitting
their ward into two.
“Despite this they managed to maintain great hand hygiene
standards, which is a testament to their hard work and
commitment to protecting their patients,” says Heather.
Until recently, Julie
Ritchie was the sole gold
auditor for West Coast
DHB’s (WCDHB) hand
hygiene project – a role
she has managed singlehandedly
since 2008, on
Julie Ritchie, West Coast District Health Board
top of her usual workload.
During this time Julie has become a hand hygiene and
infection control champion, and is well respected throughout the
DHB for her tireless efforts to improve hand hygiene behaviour.
“Julie’s dedication, drive and initiative to improve hand
hygiene compliance within the West Coast DHB has been
consistent over many years,” says Jenny Woods, WCDHB’s
Community Quality Coordinator.
“She is a mentor for hand hygiene and infection control
and has a positive influence on staff. She has kept hand
hygiene awareness high up on the organisation’s radar,
always challenging staff to improve outcomes by incorporating
evidence of best practice standards,” adds Jenny.
To ensure auditing runs smoothly, Julie begins about four
to six weeks prior to the hand hygiene compliance submission
date. She also advises the clinical nurse managers in advance
that auditing is due to commence and audits wards for no
more than one hour each time, at the busiest time of the day,
usually between 8:30 and 10am.
When it comes to advising staff that they have missed
a hand hygiene moment, Julie takes it on a situation-bysituation
basis, but always makes sure she discusses it with
the healthcare worker, often handing them a 5 moments
educational wallet card and, where appropriate, raises it with
the clinical nurse manager.
Having such an in-depth focus on hand hygiene auditing
at WCDHB means Julie is completely in tune with where the
greatest need for hand hygiene education lies.
“Julie willingly goes the extra mile, guiding and helping
people to understand why and how hand hygiene should be
performed,” says Jenny.
To do this Julie uses compliance results to target healthcare
worker groups and wards that need most support, providing
educational resources and making herself available for
presentations and team talks.
“Hand hygiene as an essential part of infection control and
Julie always holds the patient and their safety at the centre of
all she does,” she adds. •
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES
11

news in brief
All DHBs submitting
hand hygiene data
For the first time ever, all District Health Boards
have submitted data to the HHNZ hand hygiene
compliance database. This is a fantastic achievement
and highlights the priority that DHBs place on the
importance of hand hygiene in protecting patients.
HHNZ congratulates all DHBs, hand hygiene
coordinators and gold auditors for their vigilance and
commitment in gathering and submitting data. •
Patient engagement
survey underway
An online survey that seeks to find out whether
people would ask healthcare workers to clean their hands
has been issued to 300 people via Auckland DHB’s Reo
Ora Health Voice Panel.
Results from the survey, which is being conducted
as part of Auckland DHB’s hand hygiene programme,
indicate that all those who have taken part so far clearly
believe it is very important for healthcare workers to
perform hand hygiene before touching or treating them.
But the majority also believe that patients and families
would be reluctant to ask healthcare workers to perform
hand hygiene for fear of offending the healthcare worker or
receiving poor care, with comments such as:
“I think there are a lot of people who do not like to
question medical staff and would be embarrassed or think
it rude to suggest this to staff.”
Full results will be available on the HHNZ website –
www.handhygiene.org.nz – once the survey is complete.
Meanwhile, please be visible with your own hand
hygiene in front of patients. They regard it as important, so
we need to show them we value it too. •
Personalised feedback
doubles hand hygiene
compliance
A major trial conducted by researchers at the
University College London (UCL) and the Health
Protection Agency in the United Kingdom has found
that personalised feedback can double hand hygiene
compliance among healthcare workers.
The three year Feedback Intervention Trial (FIT), which
is the largest of its type in the world, was carried out in
16 hospitals across 60 wards that were participating in
England and Wales’ Clean Your Hands campaign. It is
also the first such trial to use behavioural science as a
way to change hand hygiene behaviour among healthcare
workers, say the researchers.
The study demonstrated that a combined approach of
individual feedback and a personalised action plan improved
hand hygiene compliance by up to 18 per cent in Intensive
Therapy Units (ITUs) and 13 per cent In Acute Care of the
Elderly (ACE) wards. Soap use also increased by 30 per cent.
The intervention process involved a four-week audit
cycle, with healthcare workers observed for 20 minutes.
Immediate feedback was given after the period of
observation, and the individual was then helped to form a
personal action plan for better hand hygiene. The effect
was stronger on ITUs than ACEs, where it was easier to
implement. The more frequently wards carried out the
intervention, the stronger its effect.
Use of soap and alcohol hand-rub data was collected on
a monthly basis to build a more solid picture of compliance
as such data was not subject to observational bias.
“Although audit and feedback is often suggested as a
way of improving hand hygiene, this study puts its use on
a firmer footing than previous non-randomised studies,
providing the strongest evidence yet that this is an
effective way to improve hand hygiene when coupled with
a repeating cycle of personalised goal-setting and action
planning,” said principal investigator Dr Sheldon Stone, of
the UK’s UCL Medical School at the Royal Free Hospital.
According to Louise Dawson, National Coordinator for
the HHNZ programme and Auckland DHB’s hand hygiene
coordinator, the benefits of providing individual feedback
have been noticed at ADHB.
“We have noticed that staff perform much better on
audit once they have had a period of personal feedback
from a hand hygiene educator, particularly dealing with
common procedures like giving IV medication and before
and after patient contact,” says Louise.
Researchers are now calling for the NHS to explore
possible integration of the FIT approach in infection
control teams’ audit and appraisal systems as a way to
reduce the burden of healthcare associated infections in
UK hospitals. •
12 THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES

HAND HYGIENE EDITORIAL
Reflections of a
hand hygiene advocate
Dr David Hammer
Clinical Microbiologist and hand hygiene champion
Northland District Health Board
In 1847 Hungarian Obstetrician, Ignaz Semmelweis, was
tired of helplessly standing by while a third of his patients died
from puerperal sepsis. In a flash of inspiration, he realised for
the first time that a contagion of some kind was being passed
from patient to patient on healthcare workers’ hands. To test
this theory, he made all staff clean their hands between patients.
The results were dramatic. Deaths dropped by 90%. Sadly,
the medical community still managed to reject his findings and
he was subsequently dismissed. Maternal mortality rates rose
again and, with bitter irony, Semmelweis himself died several
years later from a healthcare associated infection.
We learn two things from Semmelweis. Firstly, clean hands
do indeed save lives. Secondly, encouraging healthcare workers
to clean their hands is by no means a simple task. Personally,
I am stunned that, 165 years after the findings of Semmelweis,
some colleagues still believe there is no evidence for hand
hygiene. Miasma theory is alive and well!
At the European Congress of Clinical Microbiology and
Infectious Diseases this year, the point was made that 27 out
of 30 hand hygiene studies showed an inverse correlation
between hand hygiene and nosocomial infection (the three
studies which did not, did not measure compliance). Another
interesting statistic is that in Australia in 2011, there were 1291
road fatalities, compared to official estimates of more than
3500 direct deaths from nosocomial infection 1,2 . In other words,
healthcare associated infections resulted in over three times
more deaths in Australia during 2011 than those caused by car
accidents. At least two aspects of healthcare remain unchanged
since the time of Semmelweis: healthcare associated infections
can still kill people, and clean hands can still save lives.
Let’s see; nosocomial infections affect 5 to 10% of patients,
increase the average length of stay by between two and ten
days, and consume up to 10% of your DHB’s inpatient budget. 3
Alcohol based hand rub costs about 10 cents a squirt 4 and
takes between 20 to 30 seconds 5 . You do the maths.
I would counter that we can’t afford not to practice hand
hygiene – every patient, every time. Let’s be seen to be
clean. Demonstrate to your patients how much you care
by demonstrating your hand cleaning in front of them. This
inspires trust.
Research shows that senior staff behaviour significantly
affects what their teams do. If they regularly clean their hands,
then so do their juniors 6 . The converse is also true. Even if you
are not senior, your practice does influence the practice of
others. The more you practice hand hygiene, the more it will
become the norm for your clinical area.
We are all consumers of healthcare, as well as providers. The
culture we establish in our hospitals also impacts on the care
our families receive when they become ill. How angry would you
feel if your family member contracted a healthcare associated
infection in your hospital
The cost of failing to perform hand hygiene is difficult to
estimate but is likely to be substantial. Cummings et al (2010)
estimated that the cost of each failure to perform hand hygiene
at the appropriate time is between 2 and 50 dollars 7 . Current
data suggests that thousands of failed moments are occurring
in our hospitals every day.
Imagine coming to work to find a huge pile of your DHB’s
money on fire in the car park. Do you 1) stand back and say
it’s not your problem, 2) claim you would help if only you
could, or 3) grab anything that passes for a bucket and try
to extinguish even a small portion so that it can be spent on
what really matters
This choice is yours and you make it every day. Most
importantly, your visible decision deeply affects the decisions of
those around you. Be seen to be clean! •
References:
1) Cruickshank, M., & Ferguson, J. (2008). Reducing harm to patients
from health care associated infection: the role of surveillance. Australian
Commission on Safety and Quality in Health Care.
2) Ferguson, J. (2009). Preventing healthcare-associated infection: risks,
healthcare systems and behaviour. Internal Medicine Journal, 39(9),
574-581.
3) Bourne, J. (2000). The Management and Control of Hospital Acquired
Infections in Acute NHS Trusts in England. Report by the Comptroller and
Auditor General, UK National Audit Office.
4) Personal correspondence.
5) WHO guidelines on hand hygiene in healthcare: A summary. (2009). World
Health Organization. Geneva: Switzerland.
6) Erasmus, V., Brouwer, W., van Beeck, E., Oenema, A., Daha, T., Richardus,
J., Vos, M., & Brug, J. (2009). A qualitative exploration of reasons for poor
hand hygiene among hospital workers: Lack of positive role models and of
convincing evidence that hand hygiene prevents cross-infection. Infection
Control and Hospital Epidemiology, 30(5), 415-419.
7) Cummings, K; Anderson, D; & Kaye, K. (2010) Hand hygiene
noncompliance and the cost of hospital-acquired methicillin-resistant
Staphylococcus aureus infection, Infection Control and Hospital
Epidemiology, 31(4), pp.357-364.
THE CLEAN HANDs CHRONICLE • CLEAN HANDS SAVE LIVES
13

The Clean Hands Chronicle is
Hand Hygiene New Zealand’s quarterly newsletter.
If you have a story idea or newsletter feedback to share
please contact the editor, Hayley Callard on
hayley.callard@handhygiene.org.nz
Hand Hygiene New Zealand is one component of the Health Quality & Safety
Commission’s (the Commission) Infection Prevention and Control (IPC) programme,
which aims to reduce healthcare associated infections. The HHNZ programme is
delivered by Auckland District Health Board on behalf of the Commission.
www.handhygiene.org.nz
THE CLEAN HAND CHRONICLE • CLEAN HANDS SAVE LIVES