General Notes
Links
Main HPSC page on hand washing and hygiene
Hand hygiene information on the Health Service Executive (HSE) website
Background
Measuring hand hygiene compliance by direct observation is described as the gold standard by the World Health Organisation (WHO). The national hand hygiene standard operating procedure (SOP) was published in 2011 by the national hand hygiene steering group. The SOP outlines the methodology for undertaking hand hygiene observational audits, which was adopted from the WHO. Acute hospitals are required to measure healthcare worker compliance against 30 hand hygiene opportunities for each of the seven randomly selected wards in their facility, resulting in a total of 210 opportunities per hospital. For facilities that submitted more than the required 210 opportunities, the first 30 opportunities per ward were used for the analysis. Facilities that submitted fewer than 180 opportunities were not included in the analysis. Binomial exact 95% confidence intervals are presented. National workshops for training lead auditors are held biannually and the inter-rater reliability of each auditor is assessed using the Kappa statistic.
Please note that the overall analyses and the national average are based on HSE (public) hospitals only. In the SUMMARY BY HOSPITAL GROUPS page, the results are presented by HSE Hospital Groups. Note that results for private hospitals are both combined and listed together there in a single table so that compliance can be easily compared between private hospitals, and between private hospitals collectively and HSE Hospital Groups, however, this does not imply that private hospitals are governed as a group.
Limitations
The results as presented may not be reflective of healthcare worker compliance at all times. Compliance with hand hygiene is measured by trained, validated auditors observing healthcare workers undertaking patient care. It is well recognised that workers will change their behaviour if aware that they are being observed (Hawthorne effect). However, it is also known that this effect diminishes over time and that healthcare workers under observation may not be aware (due to the many competing demands on their attention) of the presence of the auditor. In addition, the purpose of auditing is to improve practice, therefore any action that improves compliance increases patient safety. Auditors are requested to give immediate feedback to ward staff following an audit, thereby increasing awareness and knowledge of hand hygiene.
While standardised hand hygiene auditor training and validation (with inter-rater reliability testing) should ensure that measurement of hand hygiene should be comparable, the results presented in this report have not been validated by external auditors. It is therefore possible that hand hygiene auditing may not have been performed in a comparable fashion in all hospitals.
All auditors measured compliance in the facility in which they work; therefore there may be an element of bias in the results. This risk of bias should be balanced by the benefits of increasing local staff knowledge and awareness of hand hygiene.
The sample size per hospital (210 opportunities) has a margin of error of nearly 7%. A larger sample size would provide proportions with a narrower margin of error especially at ward level. However, hand hygiene auditing is very labour intensive and without dedicated auditors, the time allocated must be balanced against other service needs.
The duration of, and the technique for hand hygiene, which are important elements of good practice were not measured as a mandatory component of this audit in line with the WHO protocol.
Measure Presented
Number of opportunities taken over total number of directly observed opportunities, in accordance with the five WHO moments, expressed as a percentage.