Presentation on theme: "WRHA Hand Hygiene Auditing – 4 Moments"— Presentation transcript:
1WRHA Hand Hygiene Auditing – 4 Moments When you ask any healthcare worker if they perform correct hand hygiene- the answer is usually ‘absolutely’. If you ask them do they do it at the right time? ‘absolutely’ and they believe thisWhen we look at hand hygiene a little more closely- we realize there are inherent and non-inherent issues connected to hand hygiene. When we were children we learned from our parents when we should wash our hands and how to wash our hands, and so on. However- the day to day hand hygiene is very different from the hand hygiene expected within a healthcare setting. The inherent practices are those we learned from childhood- the non-inherent are those which are applied to the healthcare setting: it’s important to recognize they’re different with different rulesBehaviour based on inherent habits = difficult to change. It’s important to understand this is the framework people are thinking with.Therefore, we need to close the gap between perception and practiceTraining SessionMay 2013
2AcknowledgementsWe’d like to acknowledge Public Health Ontario for contributing to the development of the new WRHA Hand Hygiene Monitoring Program
3Agenda Welcome and Introduction to Hand Hygiene Campaign Introduction to Observation Tool and Audit ProcessObservation Tool and Audit Process
4About the InitiativeCollaborative effort between WRHA Infection Prevention and Control, LTC Infection Prevention and Control, Patient Voice Facilitation with Patient Safety and Quality, Communications
5Initiative GoalTo promote the importance of appropriate hand hygiene in reducing the occurrence of healthcare-associated infections and improving patient safety in the Winnipeg Regional Health Authority
6Hand Hygiene Implementation Strategy Evidence-based approach, made up of 5 core components, to improve hand hygieneSYSTEM CHANGE: ABHR at point-of-care+Training and Education of Staff+Hand Hygiene Observation and Feedback+System change: Hand hygiene at point of care refers to a hand hygiene product (e.g., ABHR) which is easily accessible to staff by being as close as possible (as resources permit) to where patient contact is taking place (WHO, 2006)Training and education: routine practices projectHand hygiene observation and feedback: your observationsReminders in the workplace: fact sheets, brochures, stickers, and so onEstablishment of a safety climate: senior leadership commitment and patient involvementReminders in the Workplace+Establishment of a Safety Climate –Individual active participation & site support
7Hand Hygiene LMSIt is recommended the Hand Hygiene LMS module also be completed by health care providersAvailable at
8OverviewDiscussion of environments for hand hygiene and impact on transmission of germsReview methods for cleaning hands and the importance of technique in reducing spread of infections and maintaining skin integrityPractical training re: WRHA important moments for hand hygieneHigh-level synopsis of observational audit process
9Definition Healthcare Associated Infection (HAI) Infection occurring during process of care in any type of healthcare facility, which wasn’t present or incubating at time of admission (incubating = 48 hours)Includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility
10DefinitionPatientRefers to patient (Acute Care), resident (LTC and PCH), and client (Community Settings)
11Germ TransmissionTransmission of germs by hands of healthcare workers from patient-to-patient can result in HAIsWhat’s been found through research is the biggest ‘problem’ is the transmission of organisms by HCWs, not visitors or patients themselves, that’s resulting in HAI’sThe nature of the HCW job is to go from patient-to-patientThis is why we believe we need to change HCW behaviour...the auditing will identify for us how good (or bad) the current behaviour is and where we should target efforts to improve performanceAll patients are treated as if they were infectious each and every time contact occurs. In this way, even if a patient who has an infectious disease has not been identified, the use of Routine Practices will prevent the spread of the infection.
13Contact Transmission CONTACT TRANSMISSION The most common means of transmissionOccurs when germs are spread by direct physical contact from an infected or colonized personMost frequent means of transmission = Contact Transmission (healthcare setting or not)
14Contact Transmission CONTACT TRANSMISSION Indirect contact Occurs when germs are spread by an object or intermediate person
15Did You Know?HAIs are the most common serious complication of hospitalization: 1 in 9 patients admitted to Canadian hospitals acquire an infection as a consequence of their hospital stayIn Canada, ~220,000 incidents of HAI occur each year, resulting in more than 8,000 deathsThis slide and the next slide are helpful when reminding individuals why hand hygiene mattersWhen we compare the rates of deaths due to HAI – we find they’re much higher than we may have realizedThere are more deaths due to HAI’s compared to the annual number of breast CA and MVA’s combined.- approximately 5000 due to Breast CA and 2085 MVA- yet we hear more about these than we ever do about HAI caused deathsAccreditation Canada has made hand hygiene auditing a required organizational practice
16Did You Know?HAIs were 11th leading cause of death two decades ago; now are 4th leading cause of death for Canadians (behind cancer, heart disease, stroke)2Hospital infections kill 8000 – Canadians every year1Increase in hand hygiene adherence of only 20% results in a 40% reduction in HAI rate2Zoutman, D., et al. Canadian Hospital Epidemiology Committee,Canadian Nosocomial Infection Surveillance ProgramMcGeer, A. (2008). Hand hygiene by habit. Ontario Medical Review, 75(3).
17<40% Did You Know? At least 50% of HAI’s can be prevented1,2 Most healthcare providers believe they’re already practicing good hand hygieneResearch has shown hand hygiene compliance is<40%We are all clients of the healthcare system, of which we have increased wait times due to increased lengths of stay due to infectionsIf we can stop transmission of harmful germs, we don’t have to deal with isolation cases and extend hospital staysThis is meant to empower the healthcare worker: the power is in my handsPittet, D., et al. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 14:356, ppPatient Safety and Hand Hygiene Matter! – CRS Week 2006 brochure
18Why The Difference Between Perception and Reality? Health care providers generally clean their hands when visibly soiled, sticky or gritty, or for personal hygiene purposes (e.g., after using the toilet). Usually these indications require handwashing with soap and water. This “habit” is frequently learned in early childhood
19Why The Difference Between Perception and Reality? Other hand hygiene indications unique to health care settings aren’t triggered by “habit”. Stressing these indications is needed to create new “habits”Examples of actions that do not naturally trigger need to clean hands include touching a patient, taking a pulse or BP, or touching the environment... This is frequently missed in health care settings
20The Case for Hand Hygiene One of the most effective measures to reduce occurrence of HAICorrect hand hygiene saves lives and reduces strain on the healthcare system1Takes less than 1 minute to properly wash hands (soap and water) and less than 30 seconds to properly clean hands with alcohol-based hand rub (ABHR). Both methods are effectiveAlcohol takes secondsSoap and water takes seconds1 Roth, Virginia, MD, FRCPC “Hands that harm, hands that heal” November 2006 PowerPoint presentation, slide 31
21Hand Hygiene in Healthcare Healthcare workers move from patient-to-patient and room-to-room while providing care and working in the patient environmentThis movement while carrying out tasks and procedures provides many opportunities for the transmission of germs on handsImportant to take into consideration the type of population being served and the workflow of the environment in which you’re monitoring…working in an acute care setting is different than working in a residence or nursing homeHowever, there still are inherent and non-inherent behaviours related to hand hygiene and the setting: the difference is the healthcare setting vs. personal livesFor instance, in a non-healthcare setting I might go and shake hands with someone…and I wouldn’t clean my hands. However if the ‘someone’ was a patient in a healthcare facility, I’d be expected (and required) to clean my hands before (and after) I touched herPrevious groups in other provinces who’ve tried auditing reported feeling staff perhaps felt somewhat threatened when approached re: how they should be cleaning their hands and when they should be cleaning their hands. Staff reported feeling they were being ‘blamed’; but when it’s discussed in terms of inherent vs. non-inherent reasons of cleaning hands, it dropped that barrier by creating a level of understanding that made it more comfortable to move forwardPlease note: you’re not expected to ‘correct’ hand hygiene processes or errors you might witness
22Obstacles to Hand Hygiene Too busySkin irritationGlove useNot top of mindTime: healthcare providers are busy, but they must make time to clean their hands.Information Overload: Healthcare workers need to pay attention to many details. Sometimes everything seems like priority. Clean hands are a priority.Hand Irritation: Use a good skin cream. Clean, healthy hands are less likely to transmit infection.Glove Use: Not a substitute for hand hygiene;Lack of Information: It is important to understand the very real human and financial costs of healthcare associated infections
23Why Perform Hand Hygiene? To protect the patient against harmful germs carried on staff/visitors hands or present on his/her own skinTo protect yourself and the healthcare environment from harmful germsCleaning your hands is integral to patient safety. Cleaning your hands protects the patient against harmful germs carried on your hands or is present on his/her own skin. Cleaning your hands is also an important measure to protect yourself and the health-care environment from harmful germs.
24Why Does Hand Hygiene Work? Hand hygiene with ABHR – correctly applied – kills germs in secondsHand hygiene with soap and water – done correctly – physically removes germsAlcohol kills organisms on contact...must be rubbed into skin completely and allowed to AIR DRY. WRHA requires at least 60% in alcohol based hand rubsSoap and water- physically removes organismsEither can prevent transmission of organismsABHR is the preferred method and is actually kinder on the hands (emollients built-in to product)...one of the many myths is it’s harder on hands- not so!
25Key Rules Must perform hand hygiene at POINT OF CARE Defined times during care delivery when it’s essential hand hygiene is performedHand rub is normally recommended over hand washingMust use appropriate techniques and time duration in order to be effectiveYou should wash your hands with soap and water only when visibly soiled (or select organisms).Point of Care, as it relates to hand hygiene, is defined by the World Health Organization as the place where three elements come together: the patient, the healthcare worker, and care or treatment involving contact with the patient or his/her surroundings (within the patient zone).
26How To Perform Hand Hygiene: 2 Methods ABHR (60- 90%) is preferred method for cleaning hands. It’s better than washing hands (even with antibacterial soap) when hands aren’t visibly soiledHand washing with soap and running water must be done when hands are visibly soiledMoving more towards 70% as the lower concentrationKinder on the hands and more easily accessible compared to- soap and waterDo not use alcohol if visibly soiled- need soap and water.
27Technique Matters… Points to Remember: It’s important for skin on hands to remain intact to reduce spread of germs.Points to Remember:Keep nails short and clean; NO artificial nails for direct care providersDiscourage wearing of rings and braceletsRemove chipped nail polish immediatelyEnsure sleeves are rolled up (don’t get wet)Clean hands for at least 10 secondsRinse all product from handsDry hands thoroughlyBest practice documents don’t take a firm stance re: jewellery… Literature shows issues with rings- but real outbreak data is soft and waffles on the issueBUT: we know rings with stones can tear gloves (and skin); eczema tends to develop under ringsRegarding sleeves- in the UK- they moved to have no sleeves below the elbows- however there are trade offs –this has the potential to interfere with HCWs getting cold, etc.Important for staff to take care of the condition of their hands…otherwise they won’t practice as is required/expectedImportant not to loose focus (don’t want to win the fight, but not the battle): don’t focus on rings – this can/hopefully will be addressed later. Focus on when and how to perform hand hygiene appropriately
28Technique Matters… Soap Wet hands under warm running waterApply soap and distribute over handsRub hands together vigorously for 15 seconds to create latherPalm to palmRub fingertips of each hand with opposite handBetween & around fingersRub each thumb clasped in opposite handRub back of each hand with opposite palmRinse hands thoroughly under warm running waterPat hands dry with a paper towelTurn off faucet using a paper towelVIEW TRAINING DVD: ‘English’ – ‘HH Techniques’ – H Wash – H Rub – Back
29Technique Matters… ABHR Apply dime-sized amount of product into palms of dry handsRub product into hands for 15 secondsPalm to palmRub fingertips of each hand with opposite palmBetween & around fingersRub each thumb clasped in opposite handRub back of each hand with opposite palmAllow hands to dry by rubbing (do not wipe off)…15-20 secEnsure hands completely dry before performing another task
30Key Points About Hand Hygiene Wash with soap and water when hands are visibly soiledDon’t touch contaminated surfaces or objects after performing hand hygieneAvoid touching face, especially your eyes and noseHand and wrist jewelry not recommended
31When Should Hand Hygiene Be Performed? BEFOREDirect hands-on carePerforming invasive proceduresHandling dressings/touching open woundsPreparing/administering medicationsPreparing, handling, serving, or eating foodFeeding a patientIMMEDIATELY AFTERDirect hands-on careContact with blood, body fluids, non-intact skin, and/or mucous membranesContact with items known/considered contaminatedRemoval of glovesBETWEENProcedures on same patient where soiling of hands is likelyCaring for multiple patients
32When Should Hand Hygiene Be Performed? While all indications for hand hygiene are important, there are some essential moments where the risk of transmission is greatest and hand hygiene must be performed.This concept is what Your 4 Moments for Hand Hygiene is all about
33Your 4 Moments for Hand Hygiene Clean hands when entering before touching the patient or any object or furniture in the patient’s environment.To protect patient/ patient environment from harmful organisms carried on your hands.1BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT2Clean hands immediately before any aseptic procedure.To protect patient against harmful organisms, including the patient’s own organisms, entering his or her body.BEFORE CLEAN/ASEPTIC PROCEDURE3Clean hands immediately after an exposure risk to body fluids (and after glove removal).To protect yourself and health care environment from harmful patient organisms.AFTER BODY FLUID EXPOSURE RISKNote the words:Before initial patient/patient environment contact—the word “initial” and “contact” are important in making decisions of when to clean handsAfter body fluid exposure risk– the word “risk” are important in making decisions of when to clean handsClean hands when leaving after touching patient or any object or furniture in the patient’s environment.To protect yourself and health care environment from harmful patient organisms.4AFTER PATIENT/PATIENT ENVIRONMENT CONTACT
34Two Different Environments Health Care EnvironmentEnvironment beyond the patient’s immediate areaIn a single room this is outside the roomIn a shared room this is everything outside patient’s bed spacePatient EnvironmentThis is the patient’s areaIn a single room this is everything in the patient’s roomIn a shared room this is everything in immediate proximity to the patient
35Definition of Patient’s Environment This is showing it is the area behind the patient curtain in a multi bed roomIf the patient is in a single room, it would be the entire roomThere are many different “patient environments” depending on the settingOne needs to assess what the patient environment in their settings.E.G In an oncology clinic, it may be the chair the patient receives chemotherapy inIn a NICU it may be defined as inside the incubatorNote: the patient environment may differ in some settings
36Examples by Indication to Perform Hand Hygiene 1Some examples:Shaking hands, stroking an armHelping patient to move around, get washed, giving a massageTaking pulse, BP, chest auscultation, abdominal palpationBefore adjusting an IV rateBEFORE INITIAL PATIENT/ PATIENT ENVIRONMENT CONTACTClean hands when entering before touching the patient or any object or furniture in the patient’s environment.To protect patient/ patient environment from harmful organisms carried on your hands.
37Examples by Indication to Perform Hand Hygiene Some examples:Oral care, giving eye drops, secretion aspirationSkin lesion care, wound dressing, subcutaneous injectionCatheter insertion, opening a vascular access system or draining systemPreparation of medication, dressing sets2BEFORE CLEAN/ASEPTIC PROCEDUREClean hands immediately before any aseptic procedure.To protect patient against harmful organisms, including the patient’s own organisms, entering his or her body.
38Examples by Indication to Perform Hand Hygiene Some examples:Oral care, giving eye drops, secretion aspirationSkin lesion care, wound dressing, subcutaneous injectionDrawing & manipulating any fluid sample, opening a draining system, endotracheal tube insertion & removalClearing urine, feces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning contaminated or visibly soiled material/areas (bathroom, medical instruments)3AFTER BODY FLUIDEXPOSURE RISKClean hands immediately after an exposure risk to body fluids (and after glove removal).To protect yourself and health care environment from harmful patient organisms.
39Examples by Indication to Perform Hand Hygiene 4Some examples:Shaking hands, stroking an armHelping a patient move around, get washed, giving a massageTaking pulse, BP, chest auscultation, abdominal palpationChanging bed linenPerfusion speed adjustmentMonitoring alarmHolding a bed railClearing bedside tableTouching walls or curtainsAFTER PATIENT/PATIENT ENVIRONMENT CONTACTClean hands when leaving after touching patient or any object or furniture in the patient’s environment.To protect yourself and health care environment from harmful patient organisms.
40Hand Hygiene and Glove Use Glove use doesn’t replace need to clean handsLet hands dry completely before donning glovesRemove gloves to perform hand hygieneDiscard gloves immediately after each procedure and clean hands – gloves may carry germsWear gloves only when indicated, otherwise they become a major risk for germ transmissionSome cases of people cleaning their hands with gloves on- thinking they are doing a favour and saving $- need to be discarded and only used when really neededDon’t replace- need to clean handsThere are 30% failure rates with glovesRings can tear holes in them- gloves are not impervious to organismsMicroscopic holes in gloves (HBV, HCV, HIV all smaller than holes)Hand lotions and creams should be used to reduce irritant contact dermatitis - take care of your hands frequently using a protective hand cream or lotion, at least daily.Staff prone to allergies or adverse reactions should use alternative products
41Measuring Hand Hygiene Compliance Auditing compliance by healthcare providers provides benchmark for improvementResults of observational audits help identify most appropriate interventions for education, training and promotionIf there’s an expectation staff will perform in a certain manner, it makes much sense to audit the practice to ensure complianceAdditionally, Accreditation Canada now has a requirement to audit hand hygiene complianceThe auditing process is not about punishment and personal performance- it is used to identify issues in the system needing changeInitially, the purpose will be to get a baseline for a facility. This can ultimately be compared to audits following additional teaching, etc. to see if compliance improves and the initiatives have accomplished those points it’s intended to. It’s also useful for determining whether the systems are in place so workers can do their jobSome other points:It is not about changing the world overnightWe’re changing behaviour, which is an incremental process - its about changing behaviour and shifting old thinking patterns in peopleNeed to enforce language- Hand hygiene not hand washing compliance
42Method of ObservationDirect observation of hand hygiene practices done by trained observers using standardized audit toolObservation based on WRHA Routine PracticesObserver conducts observations openlyIdentity of HCW kept confidential, no names attached to the informationEach observation session is ~20 minutesHand hygiene is a habitThe question always arises: will compliance artificially improve because workers are being observed- Hawthorne effect?The Hawthorne effect is not an ongoing effect. If they improve for a short while then possibly Hawthorne; but over the long run you’ll get accurate compliance rates. Remember: the hand hygiene program is working towards changing behaviour over the long runConduct the observations openly and transparentlyEnsure the participants that data is collated and shared only in an aggregate way- so no one’s performance in particular is focused onDirect observation is the only reliable way to do thisUse of product- ABHR does not equate with compliance- the point of the compliance is the WHEN it is used (according to the opportunities outlined previously)The audit will assist in closing perceptual gaps between what should be done and what really is doneThe data collected is closer to the user and should drive an improvement in practice (rather than some theoretic study)
43Who’s Observed?All healthcare providers working with patients or in the patient care area may be observedNOT visitors and patientsObservers ONLY record what they seeThis includes anyone – HSKG, RT, PT, nursing, physicians, social workers…any healthcare worker who has contact with the patientVery important you only record what you see: can’t assume something has, or hasn’t occurred
44Method of FeedbackData collected, analyzed and reported back to each unitData also publically reported on the WRHA Internet (by site and some HCW categories)Interestingly, in Ontario they found the patients who observed the compliance audits were occurring felt happy about it (studies showed 91% of patients felt more confident knowing HCWs are performing correct hand hygiene)
45How to Observe Hand Hygiene Direct observation using consistent approach and tool is most accurate methodologyObserver must familiarize him/herself with methods and tools and be trained to identify and distinguish opportunities for hand hygiene occurring during healthcare practices
46How to Observe Hand Hygiene Observer must conduct observations openly without interfering with ongoing work, and keep HCW identity confidentialCompliance should be detected according to opportunities for hand hygiene as recommendedIn one org- When they did peer to peer they had 80% compliance rates. When they had a 3rd party- their rates dropped to 21%. Consistency in training very important!If not auditing the same way, can see rates of compliance drop instead of improveNeed to do the same way and report the same way otherwise can undermine the programThe observations are done in transparent manner- you can advertise they‘re going to occur- be clear the observation is not about personal performance, but gathering total dataAs an observer it is also important to know when to step out of a situation- if there‘s a medical emergency and you‘re in the way- or if there is something happening of a sensitive or very confidential nature that you should leave- step out.Helpful to have observers who have the ability to recognize when it is inappropriate to remain
47Crucial Concepts and Definitions Healthcare activity: succession of tasks during which HCWs' hands touch different surfaces: patient, his/her body fluids, objects or surfaces located in patient environmentEach contact is a potential source of contamination for HCWs' hands
48Crucial Concepts and Definitions Opportunity: need (when) to perform HH, whether single or multiple indicationsIndication = reason why HH necessary at a given momentHand hygiene must relate to each opportunityMultiple indications may come together to create a single opportunityFocus on following the activities and marking if HH occurs rather than stationing oneself near a HH product and watching if it is used.RISK OF TRANSMISSIONINDICATIONOPPORTUNITYHAND HYGIENE
49Recommendations for Observation Determine how to best identify the types of HCWs you may be observingAccurate HCW identification is critical to ensure reliability of dataA general compliance rate doesn’t tell you very much- and doesn’t provide direction in what you need to do as follow up: need to know category of HCWReport by HCW category helps to target and teach differently depending on the profession- physicians learn differently from nurses from housekeepers- tailor education to the professionBe transparentIf patients ask what’s happening- tell them you’re checking to make sure staff perform good hand hygiene
50Positioning for Observation Find convenient place to observe w/o disturbing care activities…can move to follow HCW, but never interfere with workImportant to consider any concerns HCWs may have with your presence…must be as discreet as possible and don’t infringe on HCW’s actionsIf HCW uncomfortable with your presence he/she has right to ask you to leave – you must do so if askedMay need to be closer depending on activity being performedAs get more experienced with observations may do up to 3 different HCW’s at a timeIf asked to leave- must do so- never interfere in the care of ptAuditors must be confidential and sensitive
51Positioning for Observation May observe up to 3 HCWs at one time provided you’re experienced and VERY careful not to miss opportunitiesMultiple HCWs performing sequential tasks quickly may prohibit accuracy of missed opportunitiesOne observation session is ~ 20 minutes (+/- 10 min)Prolong session if you get chance to observe a care sequence to its endMost opportunities observed accurately in 20 minIf in 1 room and not much happening go to anotherUp to 3 at a time- or 3 in 20 minIn a home setting- may simply be hand cleaning on entry and exit of house and during aseptic / blood and body fluid exp
52This is the audit form- please refer to form Very important to understand the opportunities are what they’re keeping track of. Watch for the opportunities, not the ABHR dispensers or the sinks.
53How to Use the Form Pencil & eraser to complete; clipboard to hold First complete data at top of form. IndicateObserver ID numberDate and day of weekCurrent (start) time (state am or pm)Number of form used for a single session (e.g., 1, 2, 3)Identity of the facilityIdentity of the patient care unitGet a pencil and clipboard- and have an eraserFill in data at the topDate and time important because when looking back at the data- it may show something significant when you are analyzing your dataIn the pilots- they found weakness was happening on the weekends or nights, or with the agenciesIt is worth recording if they are on extra precautions- you may decide later on not to include these samplesRecommend just observing in / out of isolation rooms- too time consuming otherwise and won’t get lots of data in the time you have to record observationsObserver-ID:End Time:Date (dd / mm / yyyy):Form #:Day of Week:Facility-ID:Start Time:Patient Care Unit:
54How to Use the FormIndicate any room Additional Precautions are in place by entering in ‘Comments’ (observe outside room)Indicate HCW category being observed by entering corresponding category number (listed at top of form)Coding system = number followed by letter (e.g., 1st physician in room is 1A, if 2nd enters, he/she is 1B)First physician observed = 1ASecond physician observed = 1BFirst nurse observed = 2ASecond nurse observed = 2BHealthcare Worker (HCW) Category code:1 = Physician 7 = Physiotherapy 13 = Dietary2 = Nurse 8 = Occupational Therapy 14 = Sp. Language/Audiology3 = Healthcare Aide 9 = Housekeeping 15 = Rec. Therapy4 = Social Work 10 = Patient Transport 16 = Pharmacy5 = Spiritual Care 11 = Radiology/DI 17 = Other6 = IV Team/DSM/Lab 12 = Respiratory Therapy
55How to Use the FormEach row for recording HH opportunities of one HCW, up to maximum of 3 opportunitiesUse additional rows for same HCW if opportunities exceed threeUse additional rows for each additional HCW being observed simultaneously or sequentiallyHCW may interact with more than 1 patient during time you’re observingAs soon as you note first hand hygiene opportunity, indicate same information in first opportunity section of row corresponding to HCW being observed1 row per person being observed up to 3 opportunities, then use next/another rowAs soon as you see an indicator to clean hands- start marking with W, A, or MObserving HCW, not the different patients
56Before Initial Patient or Patient Environment Contact OpportunityBefore entering patient room/spaceBefore and Direct are the key wordsWatch the ‘fiddler’: 95% of people who enter a room will touch things- bedrails, patting an arm, etcWhat about a chart? It’s part of the hospital environment and therefore hands should be cleanedImportant to look at the environment and understand what’s considered a part of it
57Before Aseptic or Clean Procedure Opportunities: if HCW to perform any of followingManipulating invasive device (e.g., inserting IV/Foley, preparing IV set, inserting spike into IV bag, flushing line, adjusting IV site, giving IV medications, changing IV tubing)Wound careTouch or manipulate a body site> don’t want to contaminate itProtect against contaminationIV device/ mouth- mucous membranes
58After Blood or Body Fluids Exposure Opportunities: after contacting any body fluid (e.g., urine, feces, wound exudate), including blood
59After Patient or Patient Environment Contact Opportunity: on leaving the patient room/space
60Number of Opportunities If more than one opportunity, mark them allExample 1: HCW enters room, cleans hands with alcohol and immediately inserts an IV line; this would result in identifying…Before direct hands-on care AND before performing invasive procedures
61Opportunity and Action For each opportunity, indicate hand hygiene action of HCWMark whether HCW used ABHR or soap & water, or did no hand hygiene – missed opportunityIf HCW used soap and water and then ABHR (or vice-versa), DO NOT mark both, just one or the other
62Technique: Nails, Rings, and Bracelets Identify if HCW does not meet standards re:Has nail extensions/artificial nailsHas jewellery: rings or braceletsOnly do this ONCE for each HCWExplain P&P doesn’t state no jewelry…but recommend shouldn’t wear jewelry (or one piece per hand)Does not effect measurements of compliance rates- but it is a way of capturing technique and may be helpful laterCheck off when doesn’t meet your guidelinesRinse hands with water only = miss…other technique issues (e.g., not washing for long enough) = miss
63Important NotesEach row for recording HH opportunities of 1 HCW, up to maximum of 3 opportunities. HCW may interact with > 1 patient during observationUse additional rows for same HCW if opportunities to perform hand hygiene exceed threeUse additional rows for each additional HCW being observedNote: Multiple HCWs sequentially performing tasks quickly may make it difficult to maintain accurate observation of missed hand hygiene opportunitiesThe number and timing of missed opportunities is just as important as documenting those opportunities that were successfully done
64Important NotesIf you observe more than 3 opportunities for one HCW, use another row and number it consistently in the HCW Category ColumnRemember to code HCW in same way (e.g., if they were 2A on first form/row, they’re 2A on second form/row)At end of session, don’t forget to enter End Time and check form(s) for missing values before submitting
65Important NotesEnd the observation if the privacy curtain is drawn around the patient’s bed or if a HCW asks you to leaveRecord any additional relevant data in the Comments section (e.g., Additional Precautions)Up to 3 at a time is optimum per momentPut comments on if asked to leave room- anything important that might effect results for follow up laterHawthorne effect- not about catching people doing the right or wrong things- its how are we improving our systemEven when standing there with a clipboard observing they still only got 40% compliance!
66Activities for Observers Buddy with current auditor to assist with consistencyDebrief with others when first learning how to use the Observation Tool, to assist with consistency and understanding of audit processDiscuss results as a group to compare your observations with answers discussed/providedIn a few minutes we’ll actually do this- review the 4 training scenarios and give you an opportunity to work with the observation toolThen we’ll review the observer scenarios to get some more practice; the second group may be a little more complicated
67Planning Observation Schedule Suggest observing:Nine 20-minute observations/dayAt least seven different days of eight periods of observationAt different times of day (different shifts; different times within shifts)Therefore, there will be ~ 63 observation sessionsNeed approximately 21 hours of observation to get a baseline measureIn WHO they recommended a minimum of 200 opportunities (not observations, but opportunities for hand hygiene) for baseline to get data. If you end up with less than 200 observations, misinformation may result and you risk implementing wrong interventions to improve hand hygiene compliance. It skews the data and you will not focus your efforts on the issues that need to be addressedYou need a big enough sample to reflect what is going onHow long it takes depends on the size of the unitImportant to look at different shifts/WE’s as well
68Sample Observation Schedule Thurs., Sept. 24/ (nine 20-min obs)Sat., Sept. 26/ (nine 20-min obs)Mon., Sept. 28/ (nine 20-min obs)Wed., Sept. 30/ (nine 20-min obs)Fri., Sept. 18/ (nine 20-min obs)Sun., Sept. 20/ (nine 20-min obs)Tues., Sept. 22/13 – 1600 (nine 20-min obs)Drivers for the observers- accreditation/public aspects to it/most effective way to improve hand hygiene
69FeedbackObservation results will be entered into tool for analysis (once submitted to site-ICP by observer)Report table and charts can be utilized within presentations to support feedback of progress to HCW, management and facility-executiveDrivers for the observers- accreditation/public aspects to it/most effective way to improve hand hygiene