CLOSING THE LOOP: IMPROVING HAND HYGIENE COMPLIANCE IN A COLORECTAL SURGICAL WARD AT MONASH HEALTH DANDENONG.

Abstract

Background: 1-3 cases of superficial surgical site infection (SSI) are reported each month in North 3, the colorectal surgical ward at Monash Health Dandenong. While the overall ward hand hygiene compliance has remained above the target (85%), audit results showed that the medical staff compliance was poor, ranging from 71-82% between December 2024 to February 2025. Action: To address this issue, a series of targeted interventions were implemented. These included focused hand hygiene education during unit meetings, providing immediate feedback, regular reporting of compliance data, promotion of 'bare below the elbows' policy, reinforcement of positive behaviour and proper orientation for newly rotated doctors in the ward. Result(s): Following these changes, the medical team's compliance improved to 90% in both March and April 2025. The team became more engaged, and conversations around infection prevention became more frequent and open. Whilst any impact this will have on SSI rate cannot yet be assessed, the shift in practice and mindset has been reported by ward staff. However, continuous monitoring remains essential to ensure hand hygiene becomes a sustained and ingrained practice in daily routines. Conclusion(s): Improving hand hygiene takes more than reminders-it requires consistent education, leadership support, and regular feedback. Creating a culture where good habits are reinforced daily is key to supporting both staff and patient safety. Acknowledgement: Dr. Christopher Robson and Dandenong Hospital North 3 ward.