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1 WRHA Hand Hygiene Auditing – 4 Moments Training Session May 2013.

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Presentation on theme: "1 WRHA Hand Hygiene Auditing – 4 Moments Training Session May 2013."— Presentation transcript:

1 1 WRHA Hand Hygiene Auditing – 4 Moments Training Session May 2013

2 2 Acknowledgements We’d like to acknowledge Public Health Ontario for contributing to the development of the new WRHA Hand Hygiene Monitoring Program

3 3 Agenda Welcome and Introduction to Hand Hygiene Campaign Introduction to Hand Hygiene Introduction to Observation Tool and Audit Process Observation Tool and Audit Process

4 4 About the Initiative Collaborative effort between WRHA Infection Prevention and Control, LTC Infection Prevention and Control, Patient Voice Facilitation with Patient Safety and Quality, Communications

5 5 Initiative Goal To 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

6 6 Hand Hygiene Implementation Strategy Evidence-based approach, made up of 5 core components, to improve hand hygiene SYSTEM CHANGE: ABHR at point-of-care + Training and Education of Staff + Hand Hygiene Observation and Feedback + Reminders in the Workplace + Establishment of a Safety Climate – Individual active participation & site support

7 7 Hand Hygiene LMS It is recommended the Hand Hygiene LMS module also be completed by health care providers Available at

8 8 Overview 1. Discussion of environments for hand hygiene and impact on transmission of germs 2. Review methods for cleaning hands and the importance of technique in reducing spread of infections and maintaining skin integrity 3. Practical training re: WRHA important moments for hand hygiene 4. High-level synopsis of observational audit process

9 9 Definition 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

10 10 Definition Patient – Refers to patient (Acute Care), resident (LTC and PCH), and client (Community Settings)

11 11 Germ Transmission Transmission of germs by hands of healthcare workers from patient-to-patient can result in HAIs

12 12 Chain of Infection

13 13 Contact Transmission CONTACT TRANSMISSION – The most common means of transmission – Occurs when germs are spread by direct physical contact from an infected or colonized person

14 14 Contact Transmission CONTACT TRANSMISSION – Indirect contact Occurs when germs are spread by an object or intermediate person

15 15 Did 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 stay In Canada, ~220,000 incidents of HAI occur each year, resulting in more than 8,000 deaths

16 16 Did You Know? HAIs were 11 th leading cause of death two decades ago; now are 4 th leading cause of death for Canadians (behind cancer, heart disease, stroke) 2 – Hospital infections kill 8000 – Canadians every year 1 Increase in hand hygiene adherence of only 20% results in a 40% reduction in HAI rate 2 1.Zoutman, D., et al. Canadian Hospital Epidemiology Committee, Canadian Nosocomial Infection Surveillance Program 2.McGeer, A. (2008). Hand hygiene by habit. Ontario Medical Review, 75(3).

17 17 Did You Know? At least 50% of HAI’s can be prevented 1,2 Most healthcare providers believe they’re already practicing good hand hygiene Research has shown hand hygiene compliance is <40% 1.Pittet, D., et al. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 14:356, pp Patient Safety and Hand Hygiene Matter! – CRS Week 2006 brochure

18 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 18 Why The Difference Between Perception and Reality?

19 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 19 Why The Difference Between Perception and Reality?

20 20 The Case for Hand Hygiene One of the most effective measures to reduce occurrence of HAI Correct hand hygiene saves lives and reduces strain on the healthcare system 1 Takes 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 effective 1 Roth, Virginia, MD, FRCPC “Hands that harm, hands that heal” November 2006 PowerPoint presentation, slide 31

21 21 Hand Hygiene in Healthcare Healthcare workers move from patient-to-patient and room-to-room while providing care and working in the patient environment This movement while carrying out tasks and procedures provides many opportunities for the transmission of germs on hands

22 22 Obstacles to Hand Hygiene Too busy Skin irritation Glove use Not top of mind

23 23 Why Perform Hand Hygiene? 1. To protect the patient against harmful germs carried on staff/visitors hands or present on his/her own skin 2. To protect yourself and the healthcare environment from harmful germs

24 24 Why Does Hand Hygiene Work? 1. Hand hygiene with ABHR – correctly applied – kills germs in seconds 2. Hand hygiene with soap and water – done correctly – physically removes germs

25 25 Key Rules Must perform hand hygiene at POINT OF CARE Defined times during care delivery when it’s essential hand hygiene is performed Hand rub is normally recommended over hand washing Must use appropriate techniques and time duration in order to be effective

26 26 How 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 soiled Hand washing with soap and running water must be done when hands are visibly soiled

27 27 Technique Matters… 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 providers Discourage wearing of rings and bracelets Remove chipped nail polish immediately Ensure sleeves are rolled up (don’t get wet) Clean hands for at least 10 seconds Rinse all product from hands Dry hands thoroughly

28 28 Technique Matters… Soap Wet hands under warm running water Apply soap and distribute over hands Rub hands together vigorously for 15 seconds to create lather Palm to palm Rub fingertips of each hand with opposite hand Between & around fingers Rub each thumb clasped in opposite hand Rub back of each hand with opposite palm Rinse hands thoroughly under warm running water Pat hands dry with a paper towel Turn off faucet using a paper towel

29 29 Technique Matters… ABHR Apply dime-sized amount of product into palms of dry hands Rub product into hands for 15 seconds Palm to palm Rub fingertips of each hand with opposite palm Between & around fingers Rub each thumb clasped in opposite hand Rub back of each hand with opposite palm Allow hands to dry by rubbing (do not wipe off)…15-20 sec Ensure hands completely dry before performing another task

30 30 Key Points About Hand Hygiene Wash with soap and water when hands are visibly soiled Don’t touch contaminated surfaces or objects after performing hand hygiene Avoid touching face, especially your eyes and nose Hand and wrist jewelry not recommended

31 When Should Hand Hygiene Be Performed? BEFORE – Direct hands-on care – Performing invasive procedures – Handling dressings/touching open wounds – Preparing/administering medications – Preparing, handling, serving, or eating food – Feeding a patient IMMEDIATELY AFTER – Direct hands-on care – Contact with blood, body fluids, non-intact skin, and/or mucous membranes – Contact with items known/considered contaminated – Removal of gloves 31 BETWEEN ― Procedures on same patient where soiling of hands is likely ― Caring for multiple patients

32 When 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 32

33 33 Your 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. Clean hands immediately before any aseptic procedure. To protect patient against harmful organisms, including the patient’s own organisms, entering his or her body. Clean hands immediately after an exposure risk to body fluids (and after glove removal). To protect yourself and health care environment from harmful patient organisms. Clean 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. BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT BEFORE CLEAN/ASEPTIC PROCEDURE AFTER BODY FLUID EXPOSURE RISK AFTER PATIENT/PATIENT ENVIRONMENT CONTACT

34 Health Care Environment – Environment beyond the patient’s immediate area In a single room this is outside the room In a shared room this is everything outside patient’s bed space Patient Environment – This is the patient’s area In a single room this is everything in the patient’s room In a shared room this is everything in immediate proximity to the patient 34 Two Different Environments

35 35 Definition of Patient’s Environment Note: the patient environment may differ in some settings

36 36 Examples by Indication to Perform Hand Hygiene Some examples: Shaking hands, stroking an arm Helping patient to move around, get washed, giving a massage Taking pulse, BP, chest auscultation, abdominal palpation Before adjusting an IV rate 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. BEFORE INITIAL PATIENT/ PATIENT ENVIRONMENT CONTACT

37 37 Examples by Indication to Perform Hand Hygiene Some examples: Oral care, giving eye drops, secretion aspiration Skin lesion care, wound dressing, subcutaneous injection Catheter insertion, opening a vascular access system or draining system Preparation of medication, dressing sets Clean 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 PROCEDURE

38 38 Examples by Indication to Perform Hand Hygiene Some examples: Oral care, giving eye drops, secretion aspiration Skin lesion care, wound dressing, subcutaneous injection Drawing & manipulating any fluid sample, opening a draining system, endotracheal tube insertion & removal Clearing urine, feces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning contaminated or visibly soiled material/areas (bathroom, medical instruments) Clean 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 RISK

39 39 Examples by Indication to Perform Hand Hygiene Some examples: Shaking hands, stroking an arm Helping a patient move around, get washed, giving a massage Taking pulse, BP, chest auscultation, abdominal palpation Changing bed linen Perfusion speed adjustment Monitoring alarm Holding a bed rail Clearing bedside table Touching walls or curtains AFTER PATIENT/PATIENT ENVIRONMENT CONTACT Clean 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.

40 40 Hand Hygiene and Glove Use Glove use doesn’t replace need to clean hands Let hands dry completely before donning gloves Remove gloves to perform hand hygiene Discard gloves immediately after each procedure and clean hands – gloves may carry germs Wear gloves only when indicated, otherwise they become a major risk for germ transmission

41 41 Measuring Hand Hygiene Compliance Auditing compliance by healthcare providers provides benchmark for improvement Results of observational audits help identify most appropriate interventions for education, training and promotion

42 42 Method of Observation Direct observation of hand hygiene practices done by trained observers using standardized audit tool Observation based on WRHA Routine Practices Observer conducts observations openly – Identity of HCW kept confidential, no names attached to the information Each observation session is ~20 minutes

43 43 Who’s Observed? All healthcare providers working with patients or in the patient care area may be observed – NOT visitors and patients Observers ONLY record what they see

44 44 Method of Feedback Data collected, analyzed and reported back to each unit Data also publically reported on the WRHA Internet (by site and some HCW categories)

45 45 Direct observation using consistent approach and tool is most accurate methodology Observer must familiarize him/herself with methods and tools and be trained to identify and distinguish opportunities for hand hygiene occurring during healthcare practices How to Observe Hand Hygiene

46 46 Observer must conduct observations openly without interfering with ongoing work, and keep HCW identity confidential Compliance should be detected according to opportunities for hand hygiene as recommended How to Observe Hand Hygiene

47 47 Healthcare activity: succession of tasks during which HCWs' hands touch different surfaces: patient, his/her body fluids, objects or surfaces located in patient environment Each contact is a potential source of contamination for HCWs' hands Crucial Concepts and Definitions

48 48 Opportunity: need (when) to perform HH, whether single or multiple indications Indication = reason why HH necessary at a given moment Hand hygiene must relate to each opportunity Multiple indications may come together to create a single opportunity Crucial Concepts and Definitions RISK OF TRANSMISSION OPPORTUNITY HAND HYGIENEINDICATION

49 49 Determine how to best identify the types of HCWs you may be observing  Accurate HCW identification is critical to ensure reliability of data Recommendations for Observation

50 50 Find convenient place to observe w/o disturbing care activities…c an move to follow HCW, but never interfere with work Important to consider any concerns HCWs may have with your presence…must be as discreet as possible and don’t infringe on HCW’s actions – If HCW uncomfortable with your presence he/she has right to ask you to leave – you must do so if asked Positioning for Observation

51 51 May observe up to 3 HCWs at one time provided you’re experienced and VERY careful not to miss opportunities – Multiple HCWs performing sequential tasks quickly may prohibit accuracy of missed opportunities One observation session is ~ 20 minutes (+/- 10 min) – Prolong session if you get chance to observe a care sequence to its end Positioning for Observation

52 52

53 53 How to Use the Form Pencil & eraser to complete; clipboard to hold First complete data at top of form. Indicate – Observer ID number – Date and day of week – Current (start) time (state am or pm) – Number of form used for a single session (e.g., 1, 2, 3) – Identity of the facility – Identity of the patient care unit Observer-ID:End Time: Date (dd / mm / yyyy):Form #: Day of Week:Facility-ID: Start Time:Patient Care Unit:

54 54 How to Use the Form Indicate 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., 1 st physician in room is 1A, if 2 nd enters, he/she is 1B) Healthcare Worker (HCW) Category code: 1 = Physician7 = Physiotherapy13 = Dietary 2 = Nurse8 = Occupational Therapy14 = Sp. Language/Audiology 3 = Healthcare Aide9 = Housekeeping15 = Rec. Therapy 4 = Social Work10 = Patient Transport16 = Pharmacy 5 = Spiritual Care11 = Radiology/DI 17 = Other 6 = IV Team/DSM/Lab12 = Respiratory Therapy

55 55 How to Use the Form Each row for recording HH opportunities of one HCW, up to maximum of 3 opportunities – Use additional rows for same HCW if opportunities exceed three – Use additional rows for each additional HCW being observed simultaneously or sequentially – HCW may interact with more than 1 patient during time you’re observing As soon as you note first hand hygiene opportunity, indicate same information in first opportunity section of row corresponding to HCW being observed

56 56 Before Initial Patient or Patient Environment Contact Opportunity – Before entering patient room/space

57 57 Before Aseptic or Clean Procedure Opportunities: if HCW to perform any of following Manipulating 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 care

58 58 After Blood or Body Fluids Exposure Opportunities: after contacting any body fluid (e.g., urine, feces, wound exudate), including blood

59 59 After Patient or Patient Environment Contact Opportunity: on leaving the patient room/space

60 60 Number of Opportunities If more than one opportunity, mark them all – Example 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

61 61 Opportunity and Action For each opportunity, indicate hand hygiene action of HCW Mark whether HCW used ABHR or soap & water, or did no hand hygiene – missed opportunity If HCW used soap and water and then ABHR (or vice-versa), DO NOT mark both, just one or the other

62 62 Technique: Nails, Rings, and Bracelets Identify if HCW does not meet standards re: – Has nail extensions/artificial nails – Has jewellery: rings or bracelets Only do this ONCE for each HCW

63 63 Important Notes Each row for recording HH opportunities of 1 HCW, up to maximum of 3 opportunities. HCW may interact with > 1 patient during observation – Use additional rows for same HCW if opportunities to perform hand hygiene exceed three – Use additional rows for each additional HCW being observed – Note: Multiple HCWs sequentially performing tasks quickly may make it difficult to maintain accurate observation of missed hand hygiene opportunities

64 64 Important Notes If you observe more than 3 opportunities for one HCW, use another row and number it consistently in the HCW Category Column – Remember 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

65 65 Important Notes End the observation if the privacy curtain is drawn around the patient’s bed or if a HCW asks you to leave Record any additional relevant data in the Comments section (e.g., Additional Precautions)

66 66 Activities for Observers Buddy with current auditor to assist with consistency Debrief with others when first learning how to use the Observation Tool, to assist with consistency and understanding of audit process Discuss results as a group to compare your observations with answers discussed/provided

67 67 Planning Observation Schedule Suggest observing: Nine 20-minute observations/day At least seven different days of eight periods of observation At different times of day (different shifts; different times within shifts) Therefore, there will be ~ 63 observation sessions

68 68 Sample Observation Schedule Fri., Sept. 18/ (nine 20-min obs) Sun., Sept. 20/ (nine 20-min obs) Tues., Sept. 22/13 – 1600 (nine 20-min obs) 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)

69 69 Feedback Observation 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-executive


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