1. Improving Patient Safety Through Increased Hand Hygiene Compliance TEAM MEMBERS Janis Bartel, M.S.N., Infection Control Practitioner Gigi Marinakos-Trulis, Data Analyst Inpatient National Patient Safety Goal Liaisons Department of Marketing

2. Compliance with hand hygiene before and after patient care is mandated by the Centers for Disease Control as part of the October 2002 Hand Hygiene Guidelines. Hand hygiene compliance also is the seventh goal in the National Patient Safety Goals published by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). nIncrease overall hand hygiene compliance nReduce overall hospital- acquired infection rates n Promote a culture of safety OPPORTUNITY STATEMENT OUR GOALS: An infection control practitioner and the National Patient Safety Goal Liaisons began an aggressive campaign in April 2004 to improve our overall rate of hand hygiene compliance from 20.6 percent (June 2003) to 100 percent.

3. A perceived lack of time for hand washing also was a contributing factor for low compliance. Physician and nursing staff identified a lack of available sinks in the hospital prior to the implementation of alcohol-based hand gel. BARRIERS TO HAND HYGIENE COMPLIANCE THESE CAUSES WERE IDENTIFIED THROUGH INTERVIEWS AND OBSERVATIONS ON THE INPATIENT CLINICAL UNITS AND VALIDATED BY A LITERATURE REVIEW.

4. n Assembled project team with representation from nursing, infection control, marketing and housekeeping n Created National Patient Safety Goal Liaison structure with nursing representation from inpatient and ancillary units n Began monthly hand hygiene audits in April 2004 n Provided education on hand hygiene to inpatient and outpatient managers and clinical staff n Developed a cartoon featuring Super Soap, Hero Hand Gel and Germy that was published in the May 2004 through December 2004 issues of Inside the System, the monthly employee newsletter SOLUTIONS IMPLEMENTED: n Gave service associates access to hand gel dispensers to insure functionality n Developed a hand hygiene net learning tool with Nursing Education staff nDistributed pocket-sized hand gels and t-shirts to physicians in December 2003 and 2004 n Distributed hand hygiene-themed buttons and placed posters that encouraged hand hygiene in display cases and campus shuttle buses around the medical center campus

5. After the introduction of the inpatient National Patient Safety Goal Liaison structure, overall compliance increased from 20.6 percent to 75 percent during the first month of auditing. Compliance has consistently remained higher than the national average, which literature suggests is anywhere from 25 percent to 50 percent. RESULTS AND ANALYSIS In addition, the rate of Methicillin Resistant Staph Aureus (MRSA) and Vancomycin Resistant Enterococci (VRE) nosocomial infection rates have dropped below our inpatient mean for 10 straight months during 2004. There appears to be a correlation between the improved hand hygiene compliance and a decreased infection rate of multi-drug resistant organisms.

6. NOSOCOMIAL METHICILLIN RESISTANT STAPH AUREUS RATE (PER 100 PT DAYS)

7. NOSOCOMIAL VANCOMYCIN RESISTANT ENTEROCOCCI RATE (PER 100 PT DAYS)

8. OVERALL HAND HYGIENE COMPLIANCE

9. NEXT STEPS… n Expand representation to include outpatient care on the hand hygiene task force to insure consistency of data collection and analysis n Continue monthly auditing and share compliance results with National Patient Safety Goal liaisons, managers, the Infection Control Committee and the Quality and Safety Coordinating Council n Continue to identify and eliminate barriers to the consistent practice of hand hygiene n Continue awareness campaign of the value of hand hygiene