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

Direct observation of health professionals is recognised as the 'gold standard' for monitoring hand hygiene compliance. Trained and validated auditors directly observe health professionals' hand hygiene behaviours, and assess their compliance with standard guidelines. In June 2010, a hand hygiene program that coincided with the adoption of the National Hand Hygiene Initiative (NHHI), including the Five Moments for Hand Hygiene, was introduced into a rural health service district in Australia. Infection prevention and control representatives from each inpatient facility within the district attended hand hygiene auditor training during a 2-day face-to-face workshop using standard models and training materials. The district infection control practitioner and a representative from the jurisdiction's infection prevention and control unit conducted the workshop. The success of the program has been variable, particularly at the institutional level. In part, this has been due to a lack of administrative leadership and refusal by Directors of Nursing in some facilities to site the alcohol-based hand hygiene product at the point of care. At the individual level, not all representatives have achieved the benchmark set by the NHHI for validation of auditors, with some reporting difficulty grasping the definitions and methodology of auditing. The subsequent process of re-training auditors has been resource-intensive due to the significant physical distance between facilities and limited on-site resources. These challenges and difficulties have brought into question the sustainability of the NHHI model for a geographically vast health service district. This paper examines the implementation of a nationally sanctioned hand hygiene program in a rural and remote health service district, and proposes a novel model for monitoring hand hygiene compliance in such settings.