Hand Hygiene Compliance: Observation & Analysis The Canadian Patient Safety Institute would like to thank the Ontario Ministry of Health and Long Term Care for their efforts toward development of training materials Stop! Clean Your Hands | Hand Hygene Toolkit

Instructions for Trainer This presentation should be used to teach health care workers how to conduct observations. Observers must complete training on Your 4 Moments for Hand Hygiene before this presentation Following the teaching session, practical sessions either at the patient bedside or by simulation, can be organized. An Excel workbook is provided to enter and analyze data from the observation tool. The individual responsible for this activity should review the Instructions for Observation Tool analysis.

Overview Practical training for observers on how to observe hand hygiene compliance and complete Observation Tool Overview of audit process Overview of analysis and reporting process

How to observe hand hygiene Direct observation using a consistent approach and validated tool, is the most accurate methodology The observer must familiarize him/herself with the methods and tools and must be trained to identify and distinguish the indications for hand hygiene occurring at the point of care The observer must conduct observations openly, without interfering with the ongoing work, and keep the identity of the health care providers confidential Compliance should be determined according to the four indications for hand hygiene

Key concepts: Indication & Opportunity Health care activity = a succession of tasks during which health care providers' hands touch different types of surfaces: the patient, his/her body fluids, objects or surfaces located in the patient environment. Each contact is a potential source of contamination for health care providers' hands Indication: the reason why hand hygiene is necessary at a given moment. It is justified by a risk of organism transmission from one surface to another. … contact 1  indication(s)  contact 2   indication(s)]  contact 3   indication(s) … Opportunity: the need to perform hand hygiene, whether there are single or multiple indications. Hand hygiene must correspond to each opportunity. Multiple indications may come together to create a single opportunity. RISK OF TRANSMISSION INDICATION OPPORTUNITY HAND HYGIENE

Indication and Opportunity

Preparing to Audit General Recommendations for Observation: Determine how to best identify the types of health care providers you may be observing. Accurate identification of health care provider is critical to ensure reliability of data. Introduce yourself to the observed health care provider(s) and patients as appropriate and explain your role.

Preparing to Audit Positioning for observation: Find a convenient place to observe without disturbing care activities Move to follow the health care provider, but never interfere with their work. You can also provide feedback after the session using “On- the-Spot” form. Take into account any concerns the health care providers may have with your presence. You should be as discreet as possible and in no way infringe on the actions of the health care provider. If a health care provider feels uncomfortable with your presence he/she has the right to ask you to leave and you must do so if asked.

Preparing to Audit (continued) You may observe up to three health care providers simultaneously (with experience) Note: Multiple health care providers performing sequential tasks quickly may interfere with audit accuracy. You may include more health care providers sequentially during one observation session. One observation session is for 20 minutes (+/- 10 minutes); prolong the session if you get the chance to observe a care sequence to its end.

Observation Tool

How to use the form Use a pencil to fill in the form and an eraser to correct. Use a clipboard to hold the form. Fill in the head of the form by indicating your ID number (Observer-ID), the date, the current time including am/pm (Start time), the number of the form used for a single session using the format 1, 2, 3, etc. (Form-No.) See also point 19 on reverse of Observation Tool), the identity of the facility (Facility-ID), the identity of the patient care unit (Patient Care Unit)

How to use the form Indicate any rooms where Additional/Isolation Precautions are in place by entering in the Comments section. (Observe outside the room.) Indicate the type of health care provider being observed by entering the number that corresponds with the categories listed at the top of the form. The coding system is a number followed by a letter (e.g., first physician in the room is 1A, if second physician enters the room he/she is 1B).

How to use the form (continued) Each column is for recording hand hygiene opportunities of one health care provider only. Use additional columns for each additional health care provider being observed simultaneously or sequentially. The health care provider may interact with more than one patient during the time you are observing. As soon as you observe the first indication for hand hygiene, indicate the corresponding information in the first of the numbered opportunity sections in the column corresponding to the health care provider being observed.

Before Initial Patient/Patient Environment Contact BEF-PAT/ ENV = “before initial patient/patient environment contact” if the health care provider touches the patient’s environment and then touches the patient or goes directly to touch the patient after having touched the hospital environment (= any other surface not in the patient’s environment) or another patient’s environment if the health care provider enters the patient’s environment from the hospital environment and touches only the patient’s environment (does not touch patient) and then leaves the patient’s environment.

Before Aseptic Procedure BEF-ASP = “before aseptic procedure” if the health care provider is to perform any of the following after having touched any other surface including the concerned patient himself/herself and his/her environment: touch/manipulate a body site that should be protected against any colonization (e.g., wound care including dressing change and wound assessment) manipulate an invasive device that could result in colonization of a body area that should be protected against colonization (e.g., priming intravenous infusion set, inserting spike into opening of IV bag, flushing line, adjusting intravenous site, administering medication through IV port, changing IV tubing).

After Body Fluid Exposure Risk AFT-BFL = “after body fluid exposure risk” if the health care provider has been engaged in a care activity involving a risk of body fluid exposure and before touching any other surface including the concerned patient himself/herself and his/her environment (e.g., contact with blood or blood products, emptying urinal/catheter bag and suctioning oral/nasal secretions).

After Patient/Patient Environment Contact AFT-PAT/ ENV = “after patient/patient environment contact” if the health care provider is leaving the patient and his/her environment to go on working in the hospital environment or with another patient if the health care provider is leaving the patient area after touching objects in the patient environment (without touching the patient) to go on working in the hospital environment or with another patient.

If there is more than one indication on one opportunity, mark them all Note: If several indications fall together on the same hand hygiene opportunity, tick all. Example 1: health care provider enters room, cleans hands with alcohol and immediately performs aseptic procedure; this would result in checking BEF-PAT/ENV and BEF-ASP.

For each opportunity, indicate the action of the provider Mark whether the health care provider used alcohol-based hand rub (RUB), soap and water (WASH) or did not do hand hygiene (MISSED) If a health care provider used soap and water and then alcohol-based hand rub (or vice-versa), mark both.

Gloves For each opportunity, tick if the health care provider was wearing gloves when the opportunity occurred. In this audit, wearing gloves does not change the number of opportunities for health care providers to clean their hands. Hand hygiene done with gloves on is incorrect; therefore, it is marked as a missed opportunity. Examples when gloves may be used: when handling blood and body fluids, mucous membranes, wound care, contact with non-intact skin and where indicated for additional precautions/isolation.

Technique: Nails, Rings and Bracelets Tick the corresponding boxes if the health care provider does not meet the guidelines regarding: correct nail length (3-4 mm, ¼ inch) no nail extensions/artificial nails no rings or bracelets. It is necessary to do this only once for each health care provider.

Technique: Timing of hand hygiene Timing of the duration of hand hygiene T = “timing” This is the duration of hand hygiene performed by the health care provider when hand hygiene occurs for: BEF-PAT/ ENV and AFT-PAT/ ENV opportunities. Use a wristwatch or stopwatch to record duration (seconds) of hand hygiene before patient/patient environment contact and after patient/patient environment contact. Begin timing when the health care provider starts rubbing his/her hands with the product, and stops timing when he/she completes the motion of rubbing their hands with the product. Note: Rinsing of hands with water does not constitute a hand wash – this would be coded as a missed opportunity.

Important Notes Each column is for recording hand hygiene opportunities of one health care provider only. Use additional columns for each additional health care provider being observed simultaneously or sequentially. The health care provider may interact with more than one patient during the time you are observing. Note: Multiple health care providers sequentially performing tasks quickly may make it difficult to maintain accurate observation of missed hand hygiene opportunities. If you observe more than four opportunities for one health care provider, use another form, numbering them sequentially in the variable Form-No. Remember to code the health care worker in the same way (e.g., if they were 2A on the first form, they are 2A on the second form). At the end of the session, do not forget to fill in the End time and check the form(s) for missing values before handing it in. End the observation if the privacy curtain is drawn around the patient’s bed or if a health care worker asks you to leave. Record any additional qualitative data in the Comments section E.g., Additional Precautions/Isolation.

Activities for Observers . Review Training Scenarios 1-4 on Training DVD and record the appropriate observation results for each scenario. Debrief with others when first learning how to use the Observation Tool, to assist with consistency and understanding of the audit process. Review Observer Scenarios 5-8 on Training DVD and record the appropriate observation results for each scenario. Discuss your results as a group or compare your recorded observations with the answers for each scenario in the Hand Hygiene DVD Answer Key

Planning Observation Schedule Observation Suggestions: Eight 20-minute observations/day At least seven different days of eight periods of observation At different times of the day (different shifts and different times within the shift) Therefore, there will be approximately 56 observation sessions for calculating the aggregate data.

Feedback: “Aggregate Data” An Excel workbook tool has been provided to enter and analyze observation results The data entry can be done by the observer or another resource may be assigned Predefined reports have been included to analyze data using four different methods Report table and charts can be pasted into presentations to support feedback of progress to health care providers, management and hospital board

Observation Analysis Tool Data Entry Page

Methods of analysis Data can be analyzed as follows: Analyzing one type of “indication” for each health care provider category at a time to provide for accurate information to compare over time (most accurate method) combine health care providers, categories for a specific “indication” to obtain a generalized compliance rate for that “indication” combine the opportunities for each category of health care provider (HCP) to obtain a generalized compliance rate for each HCP category Compare alcohol-based hand rub with soap and water to assess behaviour change *Note: for 2 and 3 the information may not be comparative over time as the mix of “type of indication” gathered in opportunities in “2” or the category of health care provider” in “3“may vary and therefore not provide for accurate comparative rates.

Calculating Reliable Compliance Rates An overall hand hygiene compliance rate does not provide for reliable and comparative rates over time as compliance rates for the different types of health care provider and for the each of the four indications are frequently different. If a generalized rate is to be provided, reliability will increase if the same number is used for the overall analysis: for each category of health care provider and for the number of observations of each indication

Reports 1a–d: Preferred Method: Calculating reliable hand hygiene compliance rates Compliance rates are to be calculated separately for each type of indication and each health care provider category (e.g., Nurses BEF-PAT/ENV 70 per cent; Physicians AFT-PAT/ENV 70 per cent; Respiratory Therapist AFT-BFL-85 per cent) Compliance rates must be reported by: Each hand hygiene indication Each health care provider (HCP) category # times hand hygiene was performed for a specific indication /specific HCP category x 100% # observed hand hygiene indications for specific indication/specific HCP category (The number of observations to make the information meaningful will depend on unit size, patient population and hospital size) Breakdown of the compliance rates by indication and health care provider category provides data for developing targeted and appropriate interventions to improve compliance. Overall generalized compliance rate combining health care providers and/or combining types of indications will not provide for reliability.

Report 1 a - sample Calculation: # times hand hygiene was performed for BEF-PAT/ENV by specific HCP category X 100 = % compliance # observed hand hygiene indications for BEF-PAT/ENV by specific HCP category

Report 1 b – sample Calculation: # times hand hygiene was performed for BEF-ASP by specific HCP category X 100 = % compliance # observed hand hygiene indications for BEF-ASP by specific HCP category

Report 1 c - sample Calculation: # times hand hygiene was performed for AFT-BFL by specific HCP category X 100 = % compliance # observed hand hygiene indications for AFT-BFL by specific HCP category

Report 1 d - sample Calculation: # times hand hygiene was performed for AFT-PAT/ENV by specific HCP category X 100 = % compliance # observed hand hygiene indications for AFT-PAT/ENV by specific HCP category

Report 2 - sample Calculation: # times hand hygiene was performed for a specific indication by all categories of HCP x 100 = % compliance # observed hand hygiene indications for a specific indication by all categories of HCP

Report 3 - sample Calculation: # opportunities hand hygiene performed by specific HCP category x 100 = % compliance Total # observed hand hygiene opportunities for a specific HCP category

Report 4 - sample Calculation: Hand Hygiene Technique 75% 20% 5% rub wash both Calculation: # of opportunities hand rub was used to clean hands x 100 = % rub Total number of opportunities hand hygiene was observed # of opportunities soap and water was used to clean hands X 100 = % wash # of opportunities hand rub and soap and water were both used to clean hands X 100 = % both

Instructions for Trainer This presentation should be used to teach health care workers how to conduct observations. Observers must complete training on Your 4 Moments for Hand Hygiene before this presentation Following the teaching session, practical sessions either at the patient bedside or by simulation, can be organized. An Excel workbook is provided to enter and analyze data from the observation tool. The individual responsible for this activity should review the Instructions for Observation Tool analysis.

Overview Practical training for observers on how to observe hand hygiene compliance and complete Observation Tool Overview of audit process Overview of analysis and reporting process

How to observe hand hygiene Direct observation using a consistent approach and validated tool, is the most accurate methodology The observer must familiarize him/herself with the methods and tools and must be trained to identify and distinguish the indications for hand hygiene occurring at the point of care The observer must conduct observations openly, without interfering with the ongoing work, and keep the identity of the health care providers confidential Compliance should be determined according to the four indications for hand hygiene

Key concepts: Indication & Opportunity Health care activity = a succession of tasks during which health care providers' hands touch different types of surfaces: the patient, his/her body fluids, objects or surfaces located in the patient environment. Each contact is a potential source of contamination for health care providers' hands Indication: the reason why hand hygiene is necessary at a given moment. It is justified by a risk of organism transmission from one surface to another. … contact 1  indication(s)  contact 2   indication(s)]  contact 3   indication(s) … Opportunity: the need to perform hand hygiene, whether there are single or multiple indications. Hand hygiene must correspond to each opportunity. Multiple indications may come together to create a single opportunity. RISK OF TRANSMISSION INDICATION OPPORTUNITY HAND HYGIENE

Indication and Opportunity

Preparing to Audit General Recommendations for Observation: Determine how to best identify the types of health care providers you may be observing. Accurate identification of health care provider is critical to ensure reliability of data. Introduce yourself to the observed health care provider(s) and patients as appropriate and explain your role.

Preparing to Audit Positioning for observation: Find a convenient place to observe without disturbing care activities Move to follow the health care provider, but never interfere with their work. You can also provide feedback after the session using “On- the-Spot” form. Take into account any concerns the health care providers may have with your presence. You should be as discreet as possible and in no way infringe on the actions of the health care provider. If a health care provider feels uncomfortable with your presence he/she has the right to ask you to leave and you must do so if asked.

Preparing to Audit (continued) You may observe up to three health care providers simultaneously (with experience) Note: Multiple health care providers performing sequential tasks quickly may interfere with audit accuracy. You may include more health care providers sequentially during one observation session. One observation session is for 20 minutes (+/- 10 minutes); prolong the session if you get the chance to observe a care sequence to its end.

Observation Tool

How to use the form Use a pencil to fill in the form and an eraser to correct. Use a clipboard to hold the form. Fill in the head of the form by indicating your ID number (Observer-ID), the date, the current time including am/pm (Start time), the number of the form used for a single session using the format 1, 2, 3, etc. (Form-No.) See also point 19 on reverse of Observation Tool), the identity of the facility (Facility-ID), the identity of the patient care unit (Patient Care Unit)

How to use the form Indicate any rooms where Additional/Isolation Precautions are in place by entering in the Comments section. (Observe outside the room.) Indicate the type of health care provider being observed by entering the number that corresponds with the categories listed at the top of the form. The coding system is a number followed by a letter (e.g., first physician in the room is 1A, if second physician enters the room he/she is 1B).

How to use the form (continued) Each column is for recording hand hygiene opportunities of one health care provider only. Use additional columns for each additional health care provider being observed simultaneously or sequentially. The health care provider may interact with more than one patient during the time you are observing. As soon as you observe the first indication for hand hygiene, indicate the corresponding information in the first of the numbered opportunity sections in the column corresponding to the health care provider being observed.

Before Initial Patient/Patient Environment Contact BEF-PAT/ ENV = “before initial patient/patient environment contact” if the health care provider touches the patient’s environment and then touches the patient or goes directly to touch the patient after having touched the hospital environment (= any other surface not in the patient’s environment) or another patient’s environment if the health care provider enters the patient’s environment from the hospital environment and touches only the patient’s environment (does not touch patient) and then leaves the patient’s environment.

Before Aseptic Procedure BEF-ASP = “before aseptic procedure” if the health care provider is to perform any of the following after having touched any other surface including the concerned patient himself/herself and his/her environment: touch/manipulate a body site that should be protected against any colonization (e.g., wound care including dressing change and wound assessment) manipulate an invasive device that could result in colonization of a body area that should be protected against colonization (e.g., priming intravenous infusion set, inserting spike into opening of IV bag, flushing line, adjusting intravenous site, administering medication through IV port, changing IV tubing).

After Body Fluid Exposure Risk AFT-BFL = “after body fluid exposure risk” if the health care provider has been engaged in a care activity involving a risk of body fluid exposure and before touching any other surface including the concerned patient himself/herself and his/her environment (e.g., contact with blood or blood products, emptying urinal/catheter bag and suctioning oral/nasal secretions).

After Patient/Patient Environment Contact AFT-PAT/ ENV = “after patient/patient environment contact” if the health care provider is leaving the patient and his/her environment to go on working in the hospital environment or with another patient if the health care provider is leaving the patient area after touching objects in the patient environment (without touching the patient) to go on working in the hospital environment or with another patient.

If there is more than one indication on one opportunity, mark them all Note: If several indications fall together on the same hand hygiene opportunity, tick all. Example 1: health care provider enters room, cleans hands with alcohol and immediately performs aseptic procedure; this would result in checking BEF-PAT/ENV and BEF-ASP.

For each opportunity, indicate the action of the provider Mark whether the health care provider used alcohol-based hand rub (RUB), soap and water (WASH) or did not do hand hygiene (MISSED) If a health care provider used soap and water and then alcohol-based hand rub (or vice-versa), mark both.

Gloves For each opportunity, tick if the health care provider was wearing gloves when the opportunity occurred. In this audit, wearing gloves does not change the number of opportunities for health care providers to clean their hands. Hand hygiene done with gloves on is incorrect; therefore, it is marked as a missed opportunity. Examples when gloves may be used: when handling blood and body fluids, mucous membranes, wound care, contact with non-intact skin and where indicated for additional precautions/isolation.

Technique: Nails, Rings and Bracelets Tick the corresponding boxes if the health care provider does not meet the guidelines regarding: correct nail length (3-4 mm, ¼ inch) no nail extensions/artificial nails no rings or bracelets. It is necessary to do this only once for each health care provider.

Technique: Timing of hand hygiene Timing of the duration of hand hygiene T = “timing” This is the duration of hand hygiene performed by the health care provider when hand hygiene occurs for: BEF-PAT/ ENV and AFT-PAT/ ENV opportunities. Use a wristwatch or stopwatch to record duration (seconds) of hand hygiene before patient/patient environment contact and after patient/patient environment contact. Begin timing when the health care provider starts rubbing his/her hands with the product, and stops timing when he/she completes the motion of rubbing their hands with the product. Note: Rinsing of hands with water does not constitute a hand wash – this would be coded as a missed opportunity.

Important Notes Each column is for recording hand hygiene opportunities of one health care provider only. Use additional columns for each additional health care provider being observed simultaneously or sequentially. The health care provider may interact with more than one patient during the time you are observing. Note: Multiple health care providers sequentially performing tasks quickly may make it difficult to maintain accurate observation of missed hand hygiene opportunities. If you observe more than four opportunities for one health care provider, use another form, numbering them sequentially in the variable Form-No. Remember to code the health care worker in the same way (e.g., if they were 2A on the first form, they are 2A on the second form). At the end of the session, do not forget to fill in the End time and check the form(s) for missing values before handing it in. End the observation if the privacy curtain is drawn around the patient’s bed or if a health care worker asks you to leave. Record any additional qualitative data in the Comments section E.g., Additional Precautions/Isolation.

Activities for Observers . Review Training Scenarios 1-4 on Training DVD and record the appropriate observation results for each scenario. Debrief with others when first learning how to use the Observation Tool, to assist with consistency and understanding of the audit process. Review Observer Scenarios 5-8 on Training DVD and record the appropriate observation results for each scenario. Discuss your results as a group or compare your recorded observations with the answers for each scenario in the Hand Hygiene DVD Answer Key

Planning Observation Schedule Observation Suggestions: Eight 20-minute observations/day At least seven different days of eight periods of observation At different times of the day (different shifts and different times within the shift) Therefore, there will be approximately 56 observation sessions for calculating the aggregate data.

Feedback: “Aggregate Data” An Excel workbook tool has been provided to enter and analyze observation results The data entry can be done by the observer or another resource may be assigned Predefined reports have been included to analyze data using four different methods Report table and charts can be pasted into presentations to support feedback of progress to health care providers, management and hospital board

Observation Analysis Tool Data Entry Page

Methods of analysis Data can be analyzed as follows: Analyzing one type of “indication” for each health care provider category at a time to provide for accurate information to compare over time (most accurate method) combine health care providers, categories for a specific “indication” to obtain a generalized compliance rate for that “indication” combine the opportunities for each category of health care provider (HCP) to obtain a generalized compliance rate for each HCP category Compare alcohol-based hand rub with soap and water to assess behaviour change *Note: for 2 and 3 the information may not be comparative over time as the mix of “type of indication” gathered in opportunities in “2” or the category of health care provider” in “3“may vary and therefore not provide for accurate comparative rates.

Calculating Reliable Compliance Rates An overall hand hygiene compliance rate does not provide for reliable and comparative rates over time as compliance rates for the different types of health care provider and for the each of the four indications are frequently different. If a generalized rate is to be provided, reliability will increase if the same number is used for the overall analysis: for each category of health care provider and for the number of observations of each indication

Reports 1a–d: Preferred Method: Calculating reliable hand hygiene compliance rates Compliance rates are to be calculated separately for each type of indication and each health care provider category (e.g., Nurses BEF-PAT/ENV 70 per cent; Physicians AFT-PAT/ENV 70 per cent; Respiratory Therapist AFT-BFL-85 per cent) Compliance rates must be reported by: Each hand hygiene indication Each health care provider (HCP) category # times hand hygiene was performed for a specific indication /specific HCP category x 100% # observed hand hygiene indications for specific indication/specific HCP category (The number of observations to make the information meaningful will depend on unit size, patient population and hospital size) Breakdown of the compliance rates by indication and health care provider category provides data for developing targeted and appropriate interventions to improve compliance. Overall generalized compliance rate combining health care providers and/or combining types of indications will not provide for reliability.

Report 1 a - sample Calculation: # times hand hygiene was performed for BEF-PAT/ENV by specific HCP category X 100 = % compliance # observed hand hygiene indications for BEF-PAT/ENV by specific HCP category

Report 1 b – sample Calculation: # times hand hygiene was performed for BEF-ASP by specific HCP category X 100 = % compliance # observed hand hygiene indications for BEF-ASP by specific HCP category

Report 1 c - sample Calculation: # times hand hygiene was performed for AFT-BFL by specific HCP category X 100 = % compliance # observed hand hygiene indications for AFT-BFL by specific HCP category

Report 1 d - sample Calculation: # times hand hygiene was performed for AFT-PAT/ENV by specific HCP category X 100 = % compliance # observed hand hygiene indications for AFT-PAT/ENV by specific HCP category

Report 2 - sample Calculation: # times hand hygiene was performed for a specific indication by all categories of HCP x 100 = % compliance # observed hand hygiene indications for a specific indication by all categories of HCP

Report 3 - sample Calculation: # opportunities hand hygiene performed by specific HCP category x 100 = % compliance Total # observed hand hygiene opportunities for a specific HCP category

Report 4 - sample Calculation: Hand Hygiene Technique 75% 20% 5% rub wash both Calculation: # of opportunities hand rub was used to clean hands x 100 = % rub Total number of opportunities hand hygiene was observed # of opportunities soap and water was used to clean hands X 100 = % wash # of opportunities hand rub and soap and water were both used to clean hands X 100 = % both