Guest Post: The National Hand Hygiene Initiative in Australia

This is a guest post by Nicholas Graves, Professor of Health Economics at Institute of Biomedical and Health Innovation, School of Public Health, Queensland University of Technology Queensland Health, Australia. Nick is currently the Academic Director for The Australian Centre for Health Services Innovation (AusHSI) and the Academic Director for the Centre of Research Excellence in Reducing Healthcare Associated Infections (CRE-RHAI), Queensland University of Technology / Institute of Health and Biomedical Innovation.

Between 2009 and 2012 Hand Hygiene Australia implemented an initiative to improve hand hygiene compliance in all Australian hospitals. Federal and state governments provided the funding and there was political support for this high profile patient safety program. My research group at QUT obtained funding of almost $1M in 2012 to evaluate whether it was cost-effective and here are the results just published in PLoS ONE.

We found the annual maintenance costs to be $2.9M per year. This investment of scarce resources prevented 67 cases of S. aureus bloodstream infection and 96 years of life were gained. The cost per one life year gained was $29,700. Hand Hygiene Australia have indicated the program is today likely to be less costly, due to a 50% reduction in their own running costs and that compliance auditors now spend 50% less time on their tasks. Testing these scenarios in our cost-effectiveness model suggest the cost per one life year gained falls to $25,094 and then $18,960.

The only outcome measure for which reliable data were available was S. aureus bloodstream infection. Because SAB is very expensive to treat and has large mortality risk it is a good outcome measure to demonstrate cost-effectiveness. We did evaluate other infection outcomes in a separate paper and found a statistically significant reduction in 11/23 rates, no change for 9/23 and increases for 3/23. Whether we underestimated the health benefits of the initiative by only including SAB outcomes is uncertain.

This was a challenging and difficult study, but that made it interesting. Now that the project has finished, what do I think?

Estimating the value for money of infection prevention programmes is important. Particularly in today's climate where health funding is tight, and there are multiple competing demands on scarce resources. If this Hand Hygiene initiative displaced other infection prevention programmes that deliver larger health benefits for the same or less money, then has been an opportunity cost measurable in health benefits lost.

Rolling out a national program of this complexity requires massive energy. Hand Hygiene Australia did a remarkable job achieving improvements in hand hygiene compliance. They were successful by being single minded and building momentum for the initiative. They did not let obstacles get in the way. Hand Hygiene Australia achieved the task they set themselves.

The timing of our evaluation was wrong. If it were done during a pilot phase then the results might have been useful to change the national initiative. Presenting the study and results after the programme had gained momentum and had political support reduced the usefulness of the findings. 

Doing this project has been interesting and I learned a lot, and I hope the papers and talks I have given are valuable for others interested in estimating the cost-effectiveness of infection prevention programs.

This blog presents my views alone.


  1. Nicholas, I came across your paper when it was published. At my hospital system we are focusing on hand hygiene as our primary method to decrease MRSA bloodstream infections. I was wondering if the method used to increase hand hygiene adherence was different at each hospital and if there were any particular methods that you felt were more effective for increasing overall hand hygiene adherence.


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