1. Hand Hygiene

2. WHO Patient Safety WHO launched a patient safety programme in 2004
Aims:
To coordinate, disseminate and accelerate improvements in patient safety worldwide.
Health care-associated infection was chosen as the first Global Patient Safety Challenge, focusing on the Clean Care is Safer Care theme. As part of this Challenge, WHO have developed WHO Guidelines on Hand Hygiene in Health Care and a set of complementary implementation tools.

3. Hand Transmission
Hands are the most common vehicle to transmit health care-associated pathogens
Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps

4. The contaminated hand or hands of the caregiver must come into direct contact with another patient or with an inanimate objects that will come into direct contact with the patient.
Step 1
Organism are present on patient’s skin, or have shed onto inanimate objects immediate surrounding the patients
Step 5
Step 2
Organisms must be transferred to the hands of the HCWs
Step 3
Step 4
Organisms must be capable of surviving or at least several minutes on HCWs hands.
Hand Hygiene performed by HCWs must be inadequate or entirely ommitted used for Hand
Hygiene or the agents must be inadequate.

5. Hand hygiene is the single most effective measure to reduce HCAIs
Simple evidence…
Hand hygiene is the single most effective measure to reduce HCAIs

6. Self-Reported Factors for Poor Adherence with Hand Hygiene
Handwashing agents cause irritation and dryness
Sinks are inconveniently located / lack of sinks
Lack of soap and paper towels
Too busy / insufficient time
Understaffing / overcrowding
Patient needs take priority
Low risk of acquiring infection from patients
Pittet D. Infect Control Hosp Epidemiol 2000;21:
Healthcare workers have reported several factors that may negatively impact their adherence with recommended practices including; handwashing agents cause irritation and dryness, sinks are inconveniently located, lack of soap and paper towels, not enough time, understaffing or overcrowding, and patient needs taking priority.
Lack of knowledge of guidelines/protocols, forgetfulness, and disagreement with the recommendations were also self reported factors for poor adherence with hand hygiene.
Perceived barriers to hand hygiene are linked to the institution and HCWs colleagues. Therefore, both institutional and small-group dynamics need to be considered when implementing a system change to secure and improve HCWs hand hygiene practice.

7. Shorter Time Improve Compliance to Hand Hygiene
This takes only 20–30 seconds!
This takes at least 40–60 secs

8. Key points on hand hygiene and glove use (1)
Indications for glove use do not modify any indication for hand hygiene
Glove use does not replace any hand hygiene action ≠
First the following principles are to be remained: in no way does glove use modify hand hygiene indications or replace HH by rubbing or washing. There is no relation between indications for HH and indications for gloves, only some gestural implication to be managed 8

9. How to handrub

10. How to observe hand hygiene practices among health-care workers

11. Why Observe Hand Hygiene Practices?
To determine the degree of compliance with hand hygiene practices by HCWs
To identify the most appropriate interventions for hand hygiene promotion, education and training.
The result can be use as a baseline to compare and follow-up to show any possible improvements resulting from the promotion efforts.

12. Hand Hygiene Performance Monitoring
Hand Hygiene performance can be monitored by either:-
Direct
- direct observations, patient assessment, HCW self -reporting
2) Indirect - Monitoring of consumption of products(Soaps or Handrub), automated monitoring of the use of sinks and handrub dispensers.
** Direct Observation is currently considered the gold standard in hand hygiene compliance monitoring

13. Potential Bias in hand hygiene Observations
Observation (Hawthorne effect)
- Presence of an observer induces better than usual hand hygiene behaviour.
Observer
- Observers systematically interpret the observation method and definition for hand hygiene opportunities and actions in their own ways, consequently their results are different from those of other observers.
3) Selection Bias - Observers systematically select certain times, care situations, healthcare sectors. HCWS or opportunities for their observations. Consequently, their results do not reflect the overall hand hygiene compliance.

14. The WHO-recommended method for direct observation
1) Profile and task observers - Observers have to understand the logic of care.
2) Training of Observers - Observers become excellent monitors for hand hygiene during health-care delivery based on principles of 5 moments of Hand Hygiene.
3) Validation of Observers - Once knowledge in the use of observation form and process, observers must be validated either by parallel observation jointly with a confirmed observer or tested through the use of the WHO Training Film.

15. The WHO-recommended method for direct observation
Understanding the 5 moments for hand hygiene
Hand Hygiene is defined as either rubbing hands with an alcohol-based handrub/handwashing. (duration, quantity of product used, gloves, length of fingernails, jewellery is assessed).
5) Understanding the Observation Form
Determining the scope of an Observation Period
- Selection of location and time, selection of HCWs, Observation session(after 20 mins +/- 10 mins)
Analysis
- Overall Compliance

16. The WHO-recommended method for direct observation
Reporting of Results
- Report directly to HCWs after each session - Continual feedback of unchanging bad result without any intervention should be avoided, as it may lead to ‘desensibilization’ and ‘demotivation’.

17. Recommendations
The WHO Manual for Observers recommend that there will be opportunities per observation period.
Hand Hygiene Compliance = Total No of Actions(Hw & HR) X 100
Total No of Opportunities

18. The 5 Moments of Hand Hygiene

19. The geographical conceptualization of the transmission risk
The patient zone is defined as
patient’s intact skin and his/her
surroundings colonized by the
patient flora and health care area.

20. ~ Contaminated surfaces increase cross-transmission ~
In one study, hands of 131 healthcare workers (HCWs) were cultured before, and hands and gloves after, routine care.
A mean of 56% of body sites and 17% of environmental sites were VRE positive.
After touching the patient and environment, 75% of ungloved HCWs hands and 9% of gloved HCWs hands were contaminated with VRE.
After touching only the environment, 21% of ungloved and 0 gloved HCWs hands were contaminated.
The inanimate environment plays a role in facilitating transmission of organisms.
~ Contaminated surfaces increase cross-transmission ~
Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

21. The geographical conceptualization of the transmission risk
The Healthcare zone contains all surfaces in the healthcare settings outside the patient zone .
Health Care Zone

22. Your 5 Moments for Hand Hygiene

23. Moment 1 – Before Touching a Patient
When
Examples
Touching a Patient in any way
- Shaking hands
- Assisting patient to move
- Touching any medical device connected to patient
Any Personal Care Activities
Bathing
Dressing
Brushing hair
Putting on personal aids such as glasses
Any non-invasive observations
Taking Pulse, blood pressure
Any non-invasive treatments
-Applying an exygen mask or nasal cannula
-Fitting slings/braces
Preparation and administration of oral medications
- Oral Medications, Nebulised medications

24. Moment 2 –Before Clean/Antiseptic Procedures
When
Examples
Insertion of a needle into a patient’s skin or into an invasive medical device.
Venipuncture
Blood glucose level
Subcutaneous or Intramuscular Injections.
Preparation and administration of any medications given via an invasive medical device. Preparation of a sterile field
IV medication
NGT Tube, PEG Feeds
Administration of medications where there is direct contact with Mucous membranes
Eye drop instillation
Suppository insertion
- Vagina Pessaryl
Insertion of or disuption to, the circuit of an invasive medical device
Procedures involving the following:-
ETT, Tracheostomy, Nasopharyngeal airways
Suctioning of airways
Any assessment, treatment and patient care where contact is made with non-intact or mucous membrane
Wound Dressings
Digital Rectal Examinations
Invasive Obstetric and Gynaecological Examination

25. Moment 3 – After body Fluid Exposure Risk
When body,
Examples
After any potential body fluid exposure
Contact with a used Urinary bottle/bedpan
Contact with sputum either directly or indiectly via a cup or tissue
Cleaning dentures
Contac with any of the following:
Blood, Saliva, Mucus, Tears, Semen, Breast Milk, Colostrum Urine, Faeces, Vomitus, Pleural Fluid, Cerebrospinal Fluid, Ascites Fluid, Organic Samples.

26. Moment 4 – After a Patient

27. Moment 5 – After Touching Patient’s Surroundings
When
Examples
After Touching patient’s immediate when the patients has not been touched
Patients Surroundings include,
Table
Bed, Bedrails, Linen, Table,
Bedside Chart, Bedside Locker,
Call Bell/TV Remote Control,
Light Switches,
Personal Belongings(including books, Mobility aids)
Chair,
Foot Stool
Monkey Bar

28. Definition
Opportunity - it determines the need to perform the hand hygiene action, whether the reason (the indication that leads to the action) be single or multiple.
Indication
- the reason why hand hygiene is necessary at a given moment to effectively interrupt microbial transmission during care.
HH action
response to the hand hygiene indication, it can be either a positive action by performing handrub or handwash or negative action by missing handrub or handwash.
Healthcare activity - a succession of tasks during which the HCWs hands touch different types of surfaces prior to and after patient contact.

29. Definition Point of Care:
The place where 3 element come together –patient, HCW & care/treatment (within the patient zone). This requires that a hand hygiene product be easily accessible and as close as possible – within arm’s reach of where patient care/treatment is taking place

30. Observation Form

32. WHO Observation Form - Header
The header allows observations to be classified and recorded accordingly
to: setting, date, session duration, observer

33. WHO Observation Form - Header
The Setting
Facility: Depends on different Settings Service: General Surgery, Oncology etc
Ward: Ward 1, Ward A etc Department Surgery, Medical
Country: Vietnam

34. WHO Observation Form - Header
Period Number: Pre/Post Intervention
Session Number: Session 1, Session 2……

35. WHO Observation Form – Prof.Cat, Code, N
Prof.cat: classified according to Professional Categories e.g 1 Nurse/midwife , 2 Auxillary)
Code: classified according to Sub-Professional
categories(e.g 1.1 Nurse, 1.2 Midwife..)
N: number of observed HCWs under the same category -

36. WHO Observation Form –Opportunity
Opportunity - it determines the need to perform the hand hygiene action, whether the reason (the indication that leads to the action) be single or multiple.

37. WHO Observation Form – Indication
- the reason why hand hygiene is necessary at a given moment to effectively interrupt microbial transmission during care.

38. WHO Observation Form – Indication
HH action
response to the hand hygiene indication, it can be either a positive action by performing handrub or handwash or negative action by missing handrub or handwash.

39. Scenario 1 Taking Pulse Nurse Recording
Indications: Before Patient Contact(Moment 1)
Action: Handrub

40. × Scenario 2 Suctioning Left Patient Nurse × ×
All double, triple, quadruple may be observed, EXCEPT after Patient Contact and after Patient Environment × ×

41. Scenario 3
Doctor
Patient A
Patient B
Recording Indications: Before Patient Contact(Moment 1) and After Patient Contact (Moment 2)
Action: Hand Rub
****2 indications but only 1 opportunity

42. 2 Indication, 1 Opportunity
1 hand Hygiene action
= 50% ×
2 Opportunity × × × ×
Incorrect
Entry!!!!!

43. 2 Indication, 1 Opportunity
1 hand Hygiene action
= 50% ×
2 Opportunity × ×
Incorrect Entry!!!!! × ？

44. Compilation Form

45. 1 Cat for each column
e.g Cat 1, only Nurse/midwives

46. Total Number of Handrub for that session
Total Number of Handwash for that session
Total Number of Opportunity for that session

47. Total Number of Handwash & HandRub for that Column/Categories
Total Number of Opportunities for that Column/Categories

48. Observation Form – Basic Compilation Form
Hand Hygiene Compliance:
Hand Hygiene actions X 100
Opportunities

49. Let’s Practice!!!