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WRHA Hand Hygiene Auditing –

4 Moments

Training SessionMay 2013

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Acknowledgements

We’d like to acknowledge Public Health Ontario for contributing to the development of the new WRHA

Hand Hygiene Monitoring Program

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Agenda

Welcome and Introduction to Hand Hygiene Campaign

Introduction to Hand Hygiene

Introduction to Observation Tool and Audit Process

Observation Tool and Audit Process

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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

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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

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Hand Hygiene Implementation Strategy

Evidence-based approach, made up of 5 core components, to improve hand hygiene

SYSTEM CHANGE: ABHR at point-of-care

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Training and Education of Staff

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Hand Hygiene Observation and Feedback

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Reminders in the Workplace

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Establishment of a Safety Climate – Individual active participation & site support

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Hand Hygiene LMS

• It is recommended the Hand Hygiene LMS module also be completed by health care providers

• Available at www.wrha.mb.ca/ipc

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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

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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

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Definition

Patient– Refers to patient (Acute Care), resident (LTC

and PCH), and client (Community Settings)

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Germ Transmission

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

INFECTIOUS AGENT

RESERVOIR

PORTAL OF EXIT

MEANS OF TRANSMISSION

PORTAL OF ENTRY

SUSCEPTIBLE HOST

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Chain of Infection

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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

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Contact Transmission• CONTACT TRANSMISSION

– Indirect contact• Occurs when germs are

spread by an object or intermediate person

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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

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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 – 12 000 Canadians every year1

• Increase in hand hygiene adherence of only 20% results in a 40% reduction in HAI rate2

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).

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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%

1. Pittet, D., et al. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 14:356, pp.1307-1312

2. Patient Safety and Hand Hygiene Matter! – CRS Week 2006 brochure

• 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

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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

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Why The Difference Between Perception and Reality?

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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

1 Roth, Virginia, MD, FRCPC “Hands that harm, hands that heal” November 2006 PowerPoint presentation, slide 31

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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

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Obstacles to Hand Hygiene

• Too busy

• Skin irritation

• Glove use

• Not top of mind

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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

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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

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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

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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

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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

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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

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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

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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

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

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BETWEEN― Procedures on same patient where soiling of hands is likely― Caring for multiple patients

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

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Your 4 Moments for Hand HygieneClean 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.

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BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT

BEFORE CLEAN/ASEPTIC PROCEDURE

AFTER BODY FLUID EXPOSURE RISK

AFTER PATIENT/PATIENT ENVIRONMENT CONTACT

• 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

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Two Different Environments

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Definition of Patient’s Environment

Note: the patient environment may differ in some settings

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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

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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

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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

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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

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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)

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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

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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

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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.

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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

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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

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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

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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

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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)

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• 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

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• 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

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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

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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

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• 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

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• 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

Positioning for Observation

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• 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

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Hand Hygiene Observation Tool

Observer-ID: End Time: Date (dd / mm / yyyy): Form #: Day of Week: Facility-ID: Start Time: Patient Care Unit: Healthcare Worker (HCW) Category code: Key:

1 = Physician 7 = Physiotherapy 13 = Dietary W = Wash 2 = Nurse 8 = Occupational Therapy 14 = Sp. Language/Audiology A = Alcohol-based handrub 3 = Healthcare Aide 9 = Housekeeping 15 = Rec. Therapy M = No hand hygiene; 4 = Social Work 10 = Patient Transport 16 = Pharmacy Missed opportunity 5 = Spiritual Care 11 = Radiology/DI 17 = Other 6 = IV Team/DSM/Lab 12 = Respiratory Therapy

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ate

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de

BEFORE AFTER OTHER

Before initial P/R/C or P/R/C

ENV contact

Before aseptic/clean

procedure

After blood or body fluids exposure

After P/R/C or P/R/C ENV

contact Artificial

Nails

Hand Jewelry (rings,

bracelets, not watches)

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

W A M W A M W A M W A M Y N Y N

Comments: ____________________________________________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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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:

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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)

Healthcare Worker (HCW) Category code:

 1 = Physician 7 = Physiotherapy 13 = Dietary2 = Nurse 8 = Occupational Therapy 14 = Sp. Language/Audiology3 = 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

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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

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Before Initial Patient or Patient Environment Contact

• Opportunity– Before entering patient room/space

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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

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After Blood or Body Fluids Exposure

• Opportunities: after contacting any body fluid (e.g., urine, feces, wound exudate), including blood

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After Patient or Patient Environment Contact

• Opportunity: on leaving the patient room/space

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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

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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

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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

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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

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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

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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)

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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

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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

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Sample Observation Schedule

• Fri., Sept. 18/13 - 0800 (nine 20-min obs)

• Sun., Sept. 20/13 - 1200 (nine 20-min obs)

• Tues., Sept. 22/13 – 1600 (nine 20-min obs)

• Thurs., Sept. 24/13 - 2000 (nine 20-min obs)

• Sat., Sept. 26/13 - 2400 (nine 20-min obs)

• Mon., Sept. 28/13 - 0400 (nine 20-min obs)

• Wed., Sept. 30/13 - 0800 (nine 20-min obs)

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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