1. WRHA 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 this
When 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 rules
Behaviour 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 practice
Training Session
May 2013

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

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

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. 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. 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 +
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 project
Hand hygiene observation and feedback: your observations
Reminders in the workplace: fact sheets, brochures, stickers, and so on
Establishment of a safety climate: senior leadership commitment and patient involvement
Reminders in the Workplace +
Establishment of a Safety Climate –
Individual active participation & site support

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

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

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

11. Germ Transmission
Transmission of germs by hands of healthcare workers from patient-to-patient can result in HAIs
What’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’s
The nature of the HCW job is to go from patient-to-patient
This 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 performance
All 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.

12. Chain of Infection

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
Most frequent means of transmission = Contact Transmission (healthcare setting or not)

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

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
This slide and the next slide are helpful when reminding individuals why hand hygiene matters
When we compare the rates of deaths due to HAI – we find they’re much higher than we may have realized
There 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 deaths
Accreditation Canada has made hand hygiene auditing a required organizational practice

16. Did 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)2
Hospital infections kill 8000 – Canadians every year1
Increase in hand hygiene adherence of only 20% results in a 40% reduction in HAI rate2
Zoutman, D., et al. Canadian Hospital Epidemiology Committee,
Canadian Nosocomial Infection Surveillance Program
McGeer, 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 hygiene
Research 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 infections
If we can stop transmission of harmful germs, we don’t have to deal with isolation cases and extend hospital stays
This is meant to empower the healthcare worker: the power is in my hands
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. Why 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

19. Why 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

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 system1
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
Alcohol takes seconds
Soap and water takes seconds
1 Roth, Virginia, MD, FRCPC “Hands that harm, hands that heal” November 2006 PowerPoint presentation, slide 31

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
Important 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 home
However, there still are inherent and non-inherent behaviours related to hand hygiene and the setting: the difference is the healthcare setting vs. personal lives
For 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 her
Previous 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 forward
Please note: you’re not expected to ‘correct’ hand hygiene processes or errors you might witness

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

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

24. Why Does Hand Hygiene Work?
Hand hygiene with ABHR – correctly applied – kills germs in seconds
Hand hygiene with soap and water – done correctly – physically removes germs
Alcohol kills organisms on contact...must be rubbed into skin completely and allowed to AIR DRY. WRHA requires at least 60% in alcohol based hand rubs
Soap and water- physically removes organisms
Either can prevent transmission of organisms
ABHR 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!

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
You 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).

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
Moving more towards 70% as the lower concentration
Kinder on the hands and more easily accessible compared to- soap and water
Do not use alcohol if visibly soiled- need soap and water.

27. Technique 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 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
Best 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 issue
BUT: we know rings with stones can tear gloves (and skin); eczema tends to develop under rings
Regarding 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/expected
Important 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

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
VIEW TRAINING DVD: ‘English’ – ‘HH Techniques’ – H Wash – H Rub – Back

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. 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
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

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. 1
BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT 2
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 3
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
Note the words:
Before initial patient/patient environment contact—the word “initial” and “contact” are important in making decisions of when to clean hands
After body fluid exposure risk– the word “risk” are important in making decisions of when to clean hands
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. 4
AFTER PATIENT/PATIENT ENVIRONMENT CONTACT

34. Two Different Environments
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

35. Definition of Patient’s Environment
This is showing it is the area behind the patient curtain in a multi bed room
If the patient is in a single room, it would be the entire room
There are many different “patient environments” depending on the setting
One 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 in
In a NICU it may be defined as inside the incubator
Note: the patient environment may differ in some settings

36. Examples by Indication to Perform Hand Hygiene1
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
BEFORE INITIAL PATIENT/ PATIENT ENVIRONMENT CONTACT
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.

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 2
BEFORE CLEAN/
ASEPTIC PROCEDURE
Clean hands immediately before any aseptic procedure.
To protect patient against harmful organisms, including the patient’s own organisms, entering his or her body.

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) 3
AFTER BODY FLUID
EXPOSURE RISK
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.

39. Examples by Indication to Perform Hand Hygiene4
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. 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
Some 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 needed
Don’t replace- need to clean hands
There are 30% failure rates with gloves
Rings can tear holes in them- gloves are not impervious to organisms
Microscopic 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

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
If there’s an expectation staff will perform in a certain manner, it makes much sense to audit the practice to ensure compliance
Additionally, Accreditation Canada now has a requirement to audit hand hygiene compliance
The auditing process is not about punishment and personal performance- it is used to identify issues in the system needing change
Initially, 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 job
Some other points:
It is not about changing the world overnight
We’re changing behaviour, which is an incremental process - its about changing behaviour and shifting old thinking patterns in people
Need to enforce language- Hand hygiene not hand washing compliance

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
Hand hygiene is a habit
The 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 run
Conduct the observations openly and transparently
Ensure the participants that data is collated and shared only in an aggregate way- so no one’s performance in particular is focused on
Direct observation is the only reliable way to do this
Use 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 done
The data collected is closer to the user and should drive an improvement in practice (rather than some theoretic study)

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
This includes anyone – HSKG, RT, PT, nursing, physicians, social workers…any healthcare worker who has contact with the patient
Very important you only record what you see: can’t assume something has, or hasn’t occurred

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)
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)

45. How to Observe Hand Hygiene
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

46. How to Observe Hand Hygiene
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
In 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 improve
Need to do the same way and report the same way otherwise can undermine the program
The 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 data
As 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

47. Crucial 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 environment
Each contact is a potential source of contamination for HCWs' hands

48. Crucial Concepts and Definitions
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
Focus 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 TRANSMISSION
INDICATION
OPPORTUNITY
HAND HYGIENE

49. Recommendations for Observation
Determine how to best identify the types of HCWs you may be observing
Accurate HCW identification is critical to ensure reliability of data
A 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 HCW
Report by HCW category helps to target and teach differently depending on the profession- physicians learn differently from nurses from housekeepers- tailor education to the profession
Be transparent
If patients ask what’s happening- tell them you’re checking to make sure staff perform good hand hygiene

50. Positioning for Observation
Find convenient place to observe w/o disturbing care activities…can 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
May need to be closer depending on activity being performed
As get more experienced with observations may do up to 3 different HCW’s at a time
If asked to leave- must do so- never interfere in the care of pt
Auditors must be confidential and sensitive

51. Positioning for Observation
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
Most opportunities observed accurately in 20 min
If in 1 room and not much happening go to another
Up to 3 at a time- or 3 in 20 min
In a home setting- may simply be hand cleaning on entry and exit of house and during aseptic / blood and body fluid exp

52. This 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.

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
Get a pencil and clipboard- and have an eraser
Fill in data at the top
Date and time important because when looking back at the data- it may show something significant when you are analyzing your data
In the pilots- they found weakness was happening on the weekends or nights, or with the agencies
It is worth recording if they are on extra precautions- you may decide later on not to include these samples
Recommend 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 observations
Observer-ID:
End Time:
Date (dd / mm / yyyy):
Form #:
Day of Week:
Facility-ID:
Start Time:
Patient Care Unit:

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., 1st physician in room is 1A, if 2nd enters, he/she is 1B)
First physician observed = 1A
Second physician observed = 1B
First nurse observed = 2A
Second nurse observed = 2B
Healthcare Worker (HCW) Category code:
1 = Physician 7 = Physiotherapy 13 = Dietary
2 = Nurse 8 = Occupational Therapy 14 = Sp. Language/Audiology
3 = Healthcare Aide 9 = Housekeeping 15 = Rec. Therapy
4 = Social Work 10 = Patient Transport 16 = Pharmacy
5 = Spiritual Care 11 = Radiology/DI 17 = Other
6 = IV Team/DSM/Lab 12 = Respiratory Therapy

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
1 row per person being observed up to 3 opportunities, then use next/another row
As soon as you see an indicator to clean hands- start marking with W, A, or M
Observing HCW, not the different patients

56. Before Initial Patient or Patient Environment Contact
Opportunity
Before entering patient room/space
Before and Direct are the key words
Watch the ‘fiddler’: 95% of people who enter a room will touch things- bedrails, patting an arm, etc
What about a chart? It’s part of the hospital environment and therefore hands should be cleaned
Important to look at the environment and understand what’s considered a part of it

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
Touch or manipulate a body site> don’t want to contaminate it
Protect against contamination
IV device/ mouth- mucous membranes

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

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

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. 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. 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
Explain 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 later
Check off when doesn’t meet your guidelines
Rinse hands with water only = miss…other technique issues (e.g., not washing for long enough) = miss

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
The number and timing of missed opportunities is just as important as documenting those opportunities that were successfully done

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. 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)
Up to 3 at a time is optimum per moment
Put comments on if asked to leave room- anything important that might effect results for follow up later
Hawthorne effect- not about catching people doing the right or wrong things- its how are we improving our system
Even when standing there with a clipboard observing they still only got 40% compliance!

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
In a few minutes we’ll actually do this- review the 4 training scenarios and give you an opportunity to work with the observation tool
Then we’ll review the observer scenarios to get some more practice; the second group may be a little more complicated

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
Need approximately 21 hours of observation to get a baseline measure
In 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 addressed
You need a big enough sample to reflect what is going on
How long it takes depends on the size of the unit
Important to look at different shifts/WE’s as well

68. Sample 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

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
Drivers for the observers- accreditation/public aspects to it/most effective way to improve hand hygiene