Sandra Neva 


Abstract Title: Improving Hand Hygiene in Emergency Department

Emergency Department (ED) was included in the 'National Gold Hand Hygiene' audit. In 2012 national target was set at 70%. We achieved a dismal compliance rating of 20%.  It was clear ED needed to make fundamental changes in our attitude towards hand hygiene. 

Senior staff were recruited to participate in the quality improvement programme, and hand hygiene champions were established. We identified problems by following the A3 improvement methodology. During the analysis phase, a survey was developed to understand the perceived barriers to compliance. In order to mitigate the issues, 'Plan, Do, Study, Act' (PDSA) cycles were implemented. This included availability of hand-gel at point of care, updates for staff, profiled patient stories, and teaching sessions both on and off the floor. We used agar plates to illustrate to ED staff what was growing on their hands and in their environment. Repeat agar plates were used during the following national audits. 

The result of the quarterly national gold audit, demonstrates our success. In the June 2016 audit, ED achieved 83% compliance pass rate. One of the unexpected benefits came as a result of the PDSA using the agar plates. This showed we were not just meeting a target, but we actually had cleaner hands in ED. 

The key success factors :

ED took ownership of the issues, and found our own unique way to improve.

Personal story 

Culture change towards hand hygiene.              

Agar plates - provided credibility to the campaign.

Furthermore, we have been approached by HQSC and HHNZ, to share our ED hand hygiene experience with other EDs.. We are extremely proud that we are the first ED to participate in the national audit.


Sandra Neva
Deborah Hailstone

Counties Manukau Health
New Zealand


Add these key dates to your calendar

30 Mar 2016


31 July 2016


5 August 2016


27 June 2016


30 Sept 2016


3 - 4 Nov 2016