table of contents executive summary final report · hygiene observations submitted for the june...

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TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT Table 1 Table 2 Table 3 Table 4 Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 BALCARRES INTEGRATED CARE CENTRE BROADVIEW CENTENNIAL LODGE CENTRAL NETWORK CUPAR & DISTRICT NURSING HOME EMERGENCY MEDICAL SERVICES REGINA FORT QU’APPELLE ALL NATIONS HEALING HOSPITAL FORT QU’APPELLE ECHO LODGE GRENFELL HEALTH CENTRE GRENFELL PIONEER HOME HOME CARE TREATMENT CENTRE ADULT

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Page 1: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

TABLE OF CONTENTS

EXECUTIVE SUMMARY

FINAL REPORT

Table 1

Table 2

Table 3

Table 4

Figure 1

Figure 2

Figure 3

Figure 4

Figure 5

Figure 6

Figure 7

Figure 8

BALCARRES INTEGRATED CARE CENTRE

BROADVIEW CENTENNIAL LODGE

CENTRAL NETWORK

CUPAR & DISTRICT NURSING HOME

EMERGENCY MEDICAL SERVICES REGINA

FORT QU’APPELLE ALL NATIONS HEALING HOSPITAL

FORT QU’APPELLE ECHO LODGE

GRENFELL HEALTH CENTRE

GRENFELL PIONEER HOME

HOME CARE TREATMENT CENTRE ADULT

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HOME CARE TREATMENT CENTRE PEDIATRIC

INDIAN HEAD GOLDEN PRAIRIE HOME

INDIAN HEAD UNION HOSPITAL

LESTOCK ST. JOSEPH’S INTEGRATED CARE CENTRE

LONG LAKE VALLEY INTEGRATED FACILITY

MENTAL HEALTH CLINIC

MENTAL HEALTH SERVICES ADDICTIONS TREATMENT CENTRE

MENTAL HEALTH & ADDICTION SERVICES CHILD & YOUTH

MONTMARTRE INTEGRATED HEALTH CENTRE

PASQUA HOSPITAL 1G

PASQUA HOSPITAL 2C

PASQUA HOSPITAL 3A

PASQUA HOSPITAL 3B

PASQUA HOSPITAL 3D

PASQUA HOSPITAL 4A

PASQUA HOSPITAL 4B

PASQUA HOSPITAL 4C

PASQUA HOSPITAL CT

PASQUA HOSPITAL DS/PAC

PASQUA HOSPITAL EMERGENCY

PASQUA HOSPITAL ENVIRONMENTAL SERVICES

PASQUA HOSPITAL EYE CENTRE

PASQUA HOSPITAL ICU

PASQUA HOSPITAL LABORATORY

PASQUA HOSPITAL MAMMOGRAPHY

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PASQUA HOSPITAL MSU

PASQUA HOSPITAL NUCLEAR MEDICINE

PASQUA HOSPITAL OR

PASQUA HOSPITAL PHLEBOTOMY

PASQUA HOSPITAL RESPIRATORY THERAPY

PASQUA HOSPITAL ULTRASOUND

PASQUA HOSPITAL X-RAY

POPULATION & PUBLIC HEALTH SERVICES REGULAR AUDIT

POPULATION AND PUBLIC HEALTH SERVICES SELF AUDIT

QU’APPELLE HOUSE

REGINA CROSSING CENTRE FMU

REGINA LUTHERAN HOME

REGINA PIONEER VILLAGE 2 EAST

REGINA PIONEER VILLAGE 2 WEST

REGINA PIONEER VILLAGE 3 EAST

REGINA PIONEER VILLAGE 3 WEST

REGINA PIONEER VILLAGE 4 EAST

REGINA PIONEER VILLAGE 4 WEST

REGINA PIONEER VILLAGE MAIN WEST

REGINA GENERAL HOSPITAL 0D/1D/1DW

REGINA GENERAL HOSPITAL 3B

REGINA GENERAL HOSPITAL 3C

REGINA GENERAL HOSPITAL 3E

REGINA GENERAL HOSPITAL 3F

REGINA GENERAL HOSPITAL 4B

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REGINA GENERAL HOSPITAL 4F

REGINA GENERAL HOSPITAL 5A

REGINA GENERAL HOSPITAL 5E

REGINA GENERAL HOSPITAL 6A

REGINA GENERAL HOSPITAL 6F

REGINA GENERAL HOSPITAL AMBULATORY CARE

REGINA GENERAL HOSPITAL ANGIO

REGINA GENERAL HOSPITAL CARDIAC CATH/EP

REGINA GENERAL HOSPITAL CCU

REGINA GENERAL HOSPITAL CSU

REGINA GENERAL HOSPITAL CT

REGINA GENERAL HOSPITAL DAY SURGERY

REGINA GENERAL HOSPITAL ENDOSCOPY

REGINA GENERAL HOSPITAL ENVIRONMENTAL SERVICES

REGINA GENERAL HOSPITAL EMERGENCY

REGINA GENERAL HOSPITAL LABORATORY

REGINA GENERAL HOSPITAL LABOUR & BIRTH

REGINA GENERAL HOSPITAL MBU

REGINA GENERAL HOSPITAL MDRU

REGINA GENERAL HOSPITAL MEDEC & PODIATRY

REGINA GENERAL HOSPITAL MI

REGINA GENERAL HOSPITAL MICU

REGINA GENERAL HOSPITAL MRI

REGINA GENERAL HOSPITAL NICU

REGINA GENERAL HOSPITAL NUCLEAR MEDICINE

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REGINA GENERAL HOSPITAL OR

REGINA GENERAL HOSPITAL PACU

REGINA GENERAL HOSPITAL PEDIATRIC OUTPATIENT

REGINA GENERAL HOSPITAL PHLEBOTOMY

REGINA GENERAL HOSPITAL PULMONARY FUNCTION

REGINA GENERAL HOSPITAL RENAL UNIT

REGINA GENERAL HOSPITAL RESPIRATORY THERAPY

REGINA GENERAL HOSPITAL SICU

REGINA GENERAL HOSPITAL SLEEP DISORDER CLINIC

REGINA GENERAL HOSPITAL THERAPIES

REGINA GENERAL HOSPITAL ULTRASOUND

REGINA GENERAL HOSPITAL X-RAY

SANTA MARIA

SILVER HEIGHTS SPECIAL CARE HOME

SOUTHEAST INTEGRATED CARE CENTRE/MOOSOMIN ACUTE CARE

SOUTHEAST INTEGRATED CARE CENTRE/MOOSOMIN LABORATORY

SOUTHEAST INTEGRATED CARE CENTRE/MOOSOMIN LTC

WHITEWOOD COMMUNITY HEALTH CENTRE

WILLIAM BOOTH SPECIAL CARE HOME

WASCANA REHABILITATION CENTRE 2-5

WASCANA REHABILITATION CENTRE 2-6

WASCANA REHABILITATION CENTRE 3-2

WASCANA REHABILITATION CENTRE 3-3

WASCANA REHABILITATION CENTRE 3-5

WASCANA REHABILITATION CENTRE 3-6

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WASCANA REHABILITATION CENTRE ADULT THERAPY

WASCANA REHABILITATION CENTRE CHILDREN’S PROGRAM

WASCANA REHABILITATION CENTRE ENVIRONMENTAL SERVICES

WASCANA REHABILITATION CENTRE FRP

WASCANA REHABILITATION CENTRE MAIN 5

WASCANA REHABILITATION CENTRE MAIN 6

WASCANA REHABILITATION CENTRE ORTHOTICS & PROSTHETICS

WOLSELEY MEMORIAL INTEGRATED CARE CENTRE LTC

Page 7: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

EXECUTIVE SUMMARY

This report provides an analysis of the June 2015 hand hygiene audits for the Regina

Qu'Appelle Health Region (RQHR). Methods of analyses included hand hygiene compliance,

the frequency of missed hand hygiene opportunities and the presence of jewellery and artificial

nails/nail polish at the regional, hospital, unit, and healthcare worker levels.

The number of facilities/units participating in the June 2015 audit was approximately the same

as the number of facilities/units from February 2015. Although the overall number of hand

hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional

audit, the number of RQHR hand hygiene observations submitted still remains high since May

2013. Overall, hand hygiene compliance at the regional level increased 4.6% from the last

audit. The number of RQHR healthcare workers observed with jewellery, artificial nails/nail

polish, or failing to conduct hand hygiene has decreased since May 2013. For the Regina

General Hospital and Pasqua Hospital, a larger number of units posted hand hygiene

compliance rates greater than 80% compared to February 2015. Hand hygiene compliance will

be re-assessed in October 2015.

In May 2015, monthly blind hand hygiene audits of randomly chosen departments in the RQHR

were initiated. Results of these blind audits are posted on the Infection Prevention and Control

intranet site. Each month, approximately 10 units will be randomly chosen for a blind hand

hygiene audit conducted by an unidentified auditor. Presently, units that are blind audited are

de-identified in the monthly reports. However, starting in October 2015, the identity of units will

be provided in the blind hand hygiene audit reports.

The regional hand hygiene report is available on-line for healthcare workers and the public at

the following sites:

http://rhdintranet/InfectionControl/public/Stats/stats.htm

http://www.rqhrlean.com/hand-hygiene.html

http://www.rqhealth.ca/programs/infection_control/hand_hygiene.shtml

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FINAL REPORT

A total of 3131 hand hygiene observations were submitted for analysis. Of these, only 3036

(97%) observations could be analyzed. Information regarding compliance at the facility and

healthcare worker levels is provided in this report.

For the analysis, the following definition of hand hygiene was used:

Compliant:

1) Hand gel or wash, AND

2) A required time component of ≥ 15 seconds

Noncompliant:

1) Gloves only,

2) Missed hand hygiene opportunity,

3) Hand gel or wash with a time component of < 15 seconds,

4) Jewellery, and/or

5) Artificial nails/nail polish

Page 9: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

Table 1: Regional hand hygiene audit results, May 2013 – June 2015.

Measurement

May

2013

(%)

October

2013

(%)

February

2014

(%)

June

2014

(%)

October

2014

(%)

February

2015

(%)

June

2015

(%)

Number of observations submitted 2847 2651 2626 2078 2528 3415 3131

Number of observations excluded

from analysis

1177

(41.3)

36

(1.4)

67

(2.6)

24

(1.2)

29

(1.1)

39

(1.1)

95

(3.0)

Compliance at the region level 572/1670

(34.3)

1513/2615

(57.9)

1516/2559

(59.2)

Not

reported

1461/2499

(58.5)

2346/3376

(69.5)

2251/3036

(74.1)

Noncompliance at the region level 1098/1670

(65.7)

1102/2615

(42.1)

1043/2559

(40.8)

Not

reported

1038/2499

(41.5)

1030/3376

(30.5)

785/3036

(25.9)

Number of observations in which

the healthcare worker wore

jewellery

331/1670

(19.8)

246/2615

(9.4)

259/2559

(10.1)

129/2054

(6.3)

156/2499

(6.2)

183/3376

(5.4)

78/3036

(2.6)

Number of observations in which

the healthcare worker had artificial

nails/nail polish

46/1670

(2.8)

71/2615

(2.7)

46/2559

(1.8)

68/2054

(3.3)

51/2499

(2.0)

81/3376

(2.4)

33/3036

(1.1)

Number of observations in which

the healthcare worker did not

conduct hand hygiene at all

Not

reported

Not

reported Not reported

438/2054

(21.3)

602/2499

(24.1)

615/3376

(18.2)

487/3036

(16)

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Table 2: Facilities and units that participated in the June 2015 regional hand hygiene audit.

Facility Unit

REGINA GENERAL

HOSPITAL

0D/1D/1DW

3B

3E

3F

4B

4F

5A

5E

6A

6F

Ambulatory Care

Cardiac Cath/EP

CCU

CSU

Day Surgery

Endoscopy

Emergency

Environmental Services1

Laboratory

Labour & Birth

MBU1

MEDEC and Podiatry1

Medical Imaging – Angio, C.T., MDRU, MI, MRI, Nuclear Medicine,

Ultrasound, X-Ray

MICU

NICU

OR

PACU

1 A hand hygiene audit was conducted by the unit using a self-audit process. As the self-audit process is

different compared to the audit process for other patient care areas, the results are not included in the overall

analyses for this report.

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Pediatric OP

Phlebotomy

Pulmonary Function

Renal

Respiratory Therapy

SICU

Sleep Disorder Centre

Therapies

Women's Health Centre – 3C

PASQUA

HOSPITAL

1G – Ambulatory Care

2C - Cardio Neuro

3A

3B

3D

4A

4B

4C

DS/PAC

Emergency

Environmental Services1

Eye Centre

ICU

Imaging – C.T., Mammography, Nuclear Medicine, Ultrasound, X-

Ray,

Laboratory

MSU

OR

Phlebotomy

Respiratory Therapy

WASCANA

REHABILITATION

CENTRE

2-5

2-6

3-2

3-3

3-5

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3-6

Main 5

Main 6

Adult OT

Children's Program

Environmental Services1

FRP

Orthotics & Prosthetics

RURAL ACUTE

Balcarres Integrated Care Centre

Fort Qu'Appelle All Nations Healing Hospital

Indian Head Union Hospital

Southeast Integrated Care Centre – Moosomin (Acute, Laboratory)

RURAL LTC

Broadview Centennial Lodge

Cupar and District Nursing Home

Fort Qu'Appelle Echo Lodge

Grenfell Pioneer Home

Indian Head Golden Prairie Home

Lestock St. Joseph's Integrated Care Centre

Long Lake Valley Integrated Facility

Montmartre Integrated Health Centre

Qu’Appelle House

Santa Maria (2, 4, Recreation Therapy, Support Services)

Silver Heights Special Care Home

Southeast Integrated Care Centre - Moosomin

Whitewood Community Health Centre

William Booth Specialty Care Home

Wolseley Memorial Integrated Care Centre

Regina Lutheran Home

Regina Pioneer Village – 2 East and West, 3 East and West, 4 East

and West, Main West

COMMUNITY

Central Network (Meadow)

Grenfell Health Centre

EMS

Home Care Treatment Centre (Adult and Pediatric)1

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Mental Health and Addiction Services (Child & Youth)1

Mental Health Clinic (2110 Hamilton)

Mental Health Services (Victoria Ave)

Population & Public Health Services Regular Audit (East Office, North

Office, Travel Health/Central Immunization)

Population & Public Health Services Self Audit (Outreach, Clinic,

Office, Home Visit, Needle Exchange Program)1

Regina Crossing Centre – FMU

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Table 3: Facilities and units that did not participate in the June 2015 regional hand hygiene audit.

Facility Facility/Unit

REGINA GENERAL HOSPITAL

5F

FAU

Food and Nutrition Services

Infectious Disease Clinic

PASQUA HOSPITAL

3C

4D

Food and Nutrition Services

WASCANA REHABILITATION

CENTRE Food and Nutrition Services

RURAL ACUTE Broadview Union Hospital

Wolseley Memorial Integrated Care Centre

RURAL LTC

Golden Prairie Nursing Home

Regina Pioneer Village - Hostel

COMMUNITY

Kidney Health Centre

Regina Crossing Centre - PAC, Surgical Assessment

Centre

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Table 4: Participating facilities and units that did not submit the required number of hand hygiene

observations for the June 2015 regional hand hygiene audit.

Facility Unit

REGINA GENERAL HOSPITAL 4B

Medical Imaging – MI, X-Ray

WASCANA REHABILITATION CENTRE 2-6

RURAL LTC Long Lake Valley Integrated Facility

Regina Pioneer Village – 3 West

COMMUNITY Central Network (Meadow)

Mental Health Clinic (2110 Hamilton)

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Figure 1: Regional hand hygiene audit results for Regina Qu'Appelle Health Region, May 2013 – June 2015*.

Page 17: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

Figure 2: Hand hygiene compliance, by facility, Regina Qu'Appelle Health Region, June 2015.

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Figure 3: Hand hygiene compliance, by healthcare worker category, Regina Qu'Appelle Health Region, June 2015.

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Figure 4: Hand hygiene compliance, before and after patient contact, by healthcare worker category, Regina Qu'Appelle Health

Region, June 2015.

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Figure 5: Distribution of jewellery, artificial nails/nail polish, and missed hand hygiene opportunities by healthcare worker

category, Regina Qu'Appelle Health Region, June 2015.

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Figure 6: Hand hygiene compliance, by unit, Regina General Hospital, June 2015.

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Figure 7: Hand hygiene compliance, by unit, Pasqua Hospital, June 2015.

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Figure 8: Hand hygiene compliance, by unit, Wascana Rehabilitation Centre, June 2015.

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BALCARRES INTEGRATED CARE CENTRE HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene before patient

contact

6% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

85%

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BROADVIEW CENTENNIAL LODGE HAND HYGIENE RESULTS

43% of staff were not compliant with hand hygiene before patient

contact

8% of staff were not compliant with hand hygiene after patient

contact

4 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

68%

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CENTRAL NETWORK HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the facility

90%

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CUPAR & DISTRICT NURSING HOME HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the facility

100%

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EMERGENCY MEDICAL SERVICES REGINA HAND HYGIENE RESULTS

83% of staff were not compliant with hand hygiene before patient

contact

59% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

31%

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FORT QU’APPELLE ALL NATIONS HEALING HOSPITAL

HAND HYGIENE RESULTS

32% of staff were not compliant with hand hygiene before patient

contact

33% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

64%

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FORT QU’APPELLE ECHO LODGE HAND HYGIENE RESULTS

13% of staff were not compliant with hand hygiene before patient

contact

32% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

74%

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GRENFELL HEALTH CENTRE HAND HYGIENE RESULTS

13% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

93%

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GRENFELL PIONEER HOME HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

19% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

76%

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HOME CARE TREATMENT CENTRE ADULT HAND HYGIENE RESULTS

June 2015

Overall compliance for the unit

78%

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HOME CARE TREATMENT CENTRE PEDIATRIC

HAND HYGIENE RESULTS

1 staff member wore jewellery

1 staff member wore artificial nails/nail polish

June 2015

Overall compliance for the unit

97%

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INDIAN HEAD GOLDEN PRAIRIE HOME HAND HYGIENE RESULTS

50% of staff were not compliant with hand hygiene before patient

contact

47% of staff were not compliant with hand hygiene after patient

contact

3 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

52%

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INDIAN HEAD UNION HOSPITAL HAND HYGIENE RESULTS

79% of staff were not compliant with hand hygiene before patient

contact

25% of staff were not compliant with hand hygiene after patient

contact

3 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

44%

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LESTOCK ST. JOSEPH’S INTEGRATED CARE CENTRE

HAND HYGIENE RESULTS

7% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the facility

97%

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LONG LAKE VALLEY INTEGRATED FACILITY

HAND HYGIENE RESULTS

67% of staff were not compliant with hand hygiene before patient

contact

43% of staff were not compliant with hand hygiene after patient

contact

3 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

50%

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MENTAL HEALTH CLINIC HAND HYGIENE RESULTS

20% of staff were not compliant with hand hygiene before patient

contact

63% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

1 staff member wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

60%

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MENTAL HEALTH SERVICES ADDICTIONS TREATMENT CENTRE

HAND HYGIENE RESULTS

0 staff members wore jewellery

1 staff member wore artificial nails/nail polish

11 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

54%

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MENTAL HEALTH & ADDICTION SERVICES CHILD & YOUTH

HAND HYGIENE RESULTS

11 staff members wore jewellery

13 staff members wore artificial nails/nail polish

16 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

31%

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MONTMARTRE INTEGRATED HEALTH CENTRE

HAND HYGIENE RESULTS

54% of staff were not compliant with hand hygiene before patient

contact

20% of staff were not compliant with hand hygiene after patient

contact

4 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

67%

Page 43: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 1G HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene before patient

contact

17% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

88%

Page 44: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 2C HAND HYGIENE RESULTS

5% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

90%

Page 45: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 3A HAND HYGIENE RESULTS

7% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

96%

Page 46: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 3B HAND HYGIENE RESULTS

29% of staff were not compliant with hand hygiene before patient

contact

5% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

Page 47: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 3D HAND HYGIENE RESULTS

29% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

74%

Page 48: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 4A HAND HYGIENE RESULTS

28% of staff were not compliant with hand hygiene before patient

contact

30% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

71%

Page 49: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 4B HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene before patient

contact

17% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

11 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

84%

Page 50: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL 4C HAND HYGIENE RESULTS

25% of staff were not compliant with hand hygiene before patient

contact

18% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

74%

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PASQUA HOSPITAL CT HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

17% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

6 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

78%

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PASQUA HOSPITAL DS/PAC HAND HYGIENE RESULTS

7% of staff were not compliant with hand hygiene before patient

contact

17% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

88%

Page 53: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL EMERGENCY HAND HYGIENE RESULTS

60% of staff were not compliant with hand hygiene before patient

contact

6% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

74%

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PASQUA HOSPITAL ENVIRONMENTAL SERVICES

HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

89%

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PASQUA HOSPITAL EYE CENTRE HAND HYGIENE RESULTS

42% of staff were not compliant with hand hygiene before patient

contact

30% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

63%

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PASQUA HOSPITAL ICU HAND HYGIENE RESULTS

36% of staff were not compliant with hand hygiene before patient

contact

31% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

67%

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PASQUA HOSPITAL LABORATORY HAND HYGIENE RESULTS

19% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

1 staff member wore artificial nails/nail polish

June 2015

Overall compliance for the unit

81%

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PASQUA HOSPITAL MAMMOGRAPHY HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

100%

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PASQUA HOSPITAL MSU HAND HYGIENE RESULTS

21% of staff were not compliant with hand hygiene before patient

contact

8% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

85%

Page 60: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

PASQUA HOSPITAL NUCLEAR MEDICINE HAND HYGIENE RESULTS

31% of staff were not compliant with hand hygiene before patient

contact

38% of staff were not compliant with hand hygiene after patient

contact

4 staff members wore jewellery

0 staff members wore artificial nails/nail polish

7 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

63%

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PASQUA HOSPITAL OR HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

100%

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PASQUA HOSPITAL PHLEBOTOMY HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene before patient

contact

21% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

85%

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PASQUA HOSPITAL RESPIRATORY THERAPY

HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

100%

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PASQUA HOSPITAL ULTRASOUND HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene before patient

contact

38% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

81%

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PASQUA HOSPITAL X-RAY HAND HYGIENE RESULTS

45% of staff were not compliant with hand hygiene before patient

contact

13% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

73%

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POPULATION & PUBLIC HEALTH SERVICES REGULAR AUDIT

HAND HYGIENE RESULTS

9% of staff were not compliant with hand hygiene before patient

contact

14% of staff were not compliant with hand hygiene after patient

contact

4 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

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POPULATION AND PUBLIC HEALTH SERVICES SELF AUDIT

HAND HYGIENE RESULTS

1 staff member wore jewellery

1 staff member wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

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QU’APPELLE HOUSE HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the facility

100%

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REGINA CROSSING CENTRE FMU HAND HYGIENE RESULTS

26% of staff were not compliant with hand hygiene before patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

76%

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REGINA LUTHERAN HOME HAND HYGIENE RESULTS

17% of staff were not compliant with hand hygiene before patient

contact

56% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

6 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

53%

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REGINA PIONEER VILLAGE 2 EAST HAND HYGIENE RESULTS

38% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

64%

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REGINA PIONEER VILLAGE 2 WEST HAND HYGIENE RESULTS

10% of staff were not compliant with hand hygiene before patient

contact

14% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

6 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

76%

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REGINA PIONEER VILLAGE 3 EAST HAND HYGIENE RESULTS

47% of staff were not compliant with hand hygiene before patient

contact

20% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

2 staff members wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

59%

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REGINA PIONEER VILLAGE 3 WEST HAND HYGIENE RESULTS

40% of staff were not compliant with hand hygiene before patient

contact

50% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

56%

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REGINA PIONEER VILLAGE 4 EAST HAND HYGIENE RESULTS

92% of staff were not compliant with hand hygiene before patient

contact

21% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

11 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

44%

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REGINA PIONEER VILLAGE 4 WEST HAND HYGIENE RESULTS

73% of staff were not compliant with hand hygiene before patient

contact

40% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

48%

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REGINA PIONEER VILLAGE MAIN WEST HAND HYGIENE RESULTS

73% of staff were not compliant with hand hygiene before patient

contact

14% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

58%

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REGINA GENERAL HOSPITAL 0D/1D/1DW HAND HYGIENE RESULTS

41% of staff were not compliant with hand hygiene before patient

contact

43% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

10 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

58%

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REGINA GENERAL HOSPITAL 3B HAND HYGIENE RESULTS

15% of staff were not compliant with hand hygiene before patient

contact

5% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

91%

Page 80: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

REGINA GENERAL HOSPITAL 3C HAND HYGIENE RESULTS

25% of staff were not compliant with hand hygiene before patient

contact

7% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

85%

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REGINA GENERAL HOSPITAL 3E HAND HYGIENE RESULTS

47% of staff were not compliant with hand hygiene before patient

contact

20% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

1 staff member wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

63%

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REGINA GENERAL HOSPITAL 3F HAND HYGIENE RESULTS

25% of staff were not compliant with hand hygiene before patient

contact

13% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

80%

Page 83: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

REGINA GENERAL HOSPITAL 4B HAND HYGIENE RESULTS

20% of staff were not compliant with hand hygiene before patient

contact

29% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

1 staff member wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

76%

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REGINA GENERAL HOSPITAL 4F HAND HYGIENE RESULTS

55% of staff were not compliant with hand hygiene before patient

contact

27% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

61%

Page 85: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

REGINA GENERAL HOSPITAL 5A HAND HYGIENE RESULTS

29% of staff were not compliant with hand hygiene before patient

contact

25% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

74%

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REGINA GENERAL HOSPITAL 5E HAND HYGIENE RESULTS

55% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

56%

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REGINA GENERAL HOSPITAL 6A HAND HYGIENE RESULTS

43% of staff were not compliant with hand hygiene before patient

contact

50% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

56%

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REGINA GENERAL HOSPITAL 6F HAND HYGIENE RESULTS

21% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

87%

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REGINA GENERAL HOSPITAL AMBULATORY CARE

HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

17% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

74%

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REGINA GENERAL HOSPITAL ANGIO HAND HYGIENE RESULTS

36% of staff were not compliant with hand hygiene before patient

contact

36% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

6 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

67%

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REGINA GENERAL HOSPITAL CARDIAC CATH/EP

HAND HYGIENE RESULTS

79% of staff were not compliant with hand hygiene before patient

contact

38% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

16 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

41%

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REGINA GENERAL HOSPITAL CCU HAND HYGIENE RESULTS

20% of staff were not compliant with hand hygiene before patient

contact

12% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

85%

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REGINA GENERAL HOSPITAL CSU HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene before patient

contact

11% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

87%

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REGINA GENERAL HOSPITAL CT HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

88%

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REGINA GENERAL HOSPITAL DAY SURGERY

HAND HYGIENE RESULTS

31% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

1 staff member wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

85%

Page 96: TABLE OF CONTENTS EXECUTIVE SUMMARY FINAL REPORT · hygiene observations submitted for the June 2015 audit was 8.3% less than the last regional audit, the number of RQHR hand hygiene

REGINA GENERAL HOSPITAL EMERGENCY

HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

38% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

63%

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REGINA GENERAL HOSPITAL ENDOSCOPY

HAND HYGIENE RESULTS

13% of staff were not compliant with hand hygiene before patient

contact

21% of staff were not compliant with hand hygiene after patient

contact

3 staff members wore jewellery

3 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

81%

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REGINA GENERAL HOSPITAL ENVIRONMENTAL SERVICES

HAND HYGIENE RESULTS

7 staff members wore jewellery

2 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

53%

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REGINA GENERAL HOSPITAL LABORATORY

HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

100%

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REGINA GENERAL HOSPITAL LABOUR & BIRTH

HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

23% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

8 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

71%

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REGINA GENERAL HOSPITAL MBU HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

10 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

69%

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REGINA GENERAL HOSPITAL MDRU HAND HYGIENE RESULTS

25% of staff were not compliant with hand hygiene before patient

contact

12% of staff were not compliant with hand hygiene after patient

contact

3 staff members wore jewellery

2 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

85%

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REGINA GENERAL HOSPITAL MEDEC & PODIATRY

HAND HYGIENE RESULTS

2 staff members wore jewellery

5 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

88%

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REGINA GENERAL HOSPITAL MI HAND HYGIENE RESULTS

22% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

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REGINA GENERAL HOSPITAL MICU HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

93%

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REGINA GENERAL HOSPITAL MRI HAND HYGIENE RESULTS

67% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

10 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

62%

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REGINA GENERAL HOSPITAL NICU HAND HYGIENE RESULTS

6% of staff were not compliant with hand hygiene before patient

contact

9% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

93%

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REGINA GENERAL HOSPITAL NUCLEAR MEDICINE

HAND HYGIENE RESULTS

18% of staff were not compliant with hand hygiene before patient

contact

7% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

88%

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REGINA GENERAL HOSPITAL OR HAND HYGIENE RESULTS

7% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

96%

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REGINA GENERAL HOSPITAL PACU HAND HYGIENE RESULTS

14% of staff were not compliant with hand hygiene before patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

92%

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REGINA GENERAL HOSPITAL PEDIATRIC OUTPATIENT

HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

1 staff member wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

95%

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REGINA GENERAL HOSPITAL PHLEBOTOMY

HAND HYGIENE RESULTS

69% of staff were not compliant with hand hygiene before patient

contact

62% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

35%

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REGINA GENERAL HOSPITAL PULMONARY FUNCTION

HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene before patient

contact

16% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

87%

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REGINA GENERAL HOSPITAL RENAL UNIT HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene before patient

contact

8% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

92%

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REGINA GENERAL HOSPITAL RESPIRATORY THERAPY

HAND HYGIENE RESULTS

44% of staff were not compliant with hand hygiene before patient

contact

68% of staff were not compliant with hand hygiene after patient

contact

4 staff members wore jewellery

3 staff members wore artificial nails/nail polish

18 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

43%

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REGINA GENERAL HOSPITAL SICU HAND HYGIENE RESULTS

23% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

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REGINA GENERAL HOSPITAL SLEEP DISORDER CLINIC

HAND HYGIENE RESULTS

38% of staff were not compliant with hand hygiene before patient

contact

15% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

7 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

73%

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REGINA GENERAL HOSPITAL THERAPIES HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

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REGINA GENERAL HOSPITAL ULTRASOUND

HAND HYGIENE RESULTS

15% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

85%

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REGINA GENERAL HOSPITAL X-RAY HAND HYGIENE RESULTS

33% of staff were not compliant with hand hygiene before patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

89%

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SANTA MARIA HAND HYGIENE RESULTS

5% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

0 staff members wore artificial nails/nail polish

1 staff member did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

89%

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SILVER HEIGHTS SPECIAL CARE HOME HAND HYGIENE RESULTS

100% of staff were not compliant with hand hygiene before patient

contact

87% of staff were not compliant with hand hygiene after patient

contact

2 staff members wore jewellery

12 staff members wore artificial nails/nail polish

15 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

7%

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SOUTHEAST INTEGRATED CARE CENTRE/MOOSOMIN ACUTE CARE

HAND HYGIENE RESULTS

23% of staff were not compliant with hand hygiene before patient

contact

38% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

69%

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SOUTHEAST INTEGRATED CARE CENTRE/MOOSOMIN LABORATORY

HAND HYGIENE RESULTS

18% of staff were not compliant with hand hygiene before patient

contact

8% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

3 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

88%

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SOUTHEAST INTEGRATED CARE CENTRE/MOOSOMIN LONG TERM

CARE HAND HYGIENE RESULTS

29% of staff were not compliant with hand hygiene before patient

contact

31% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

7 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

70%

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WHITEWOOD COMMUNITY HEALTH CENTRE

HAND HYGIENE RESULTS

11% of staff were not compliant with hand hygiene before patient

contact

10% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

4 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the facility

83%

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WILLIAM BOOTH SPECIAL CARE HOME HAND HYGIENE RESULTS

8% of staff were not compliant with hand hygiene before patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the facility

96%

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WASCANA REHABILITATION CENTRE 2-5 HAND HYGIENE RESULTS

25% of staff were not compliant with hand hygiene before patient

contact

18% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

80%

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WASCANA REHABILITATION CENTRE 2-6 HAND HYGIENE RESULTS

100% of staff were not compliant with hand hygiene before patient

contact

67% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

6 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

26%

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WASCANA REHABILITATION CENTRE 3-2 HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

100%

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WASCANA REHABILITATION CENTRE 3-3 HAND HYGIENE RESULTS

50% of staff were not compliant with hand hygiene before patient

contact

25% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

7 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

62%

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WASCANA REHABILITATION CENTRE 3-5 HAND HYGIENE RESULTS

13% of staff were not compliant with hand hygiene before patient

contact

25% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

2 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

81%

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WASCANA REHABILITATION CENTRE 3-6 HAND HYGIENE RESULTS

50% of staff were not compliant with hand hygiene before patient

contact

33% of staff were not compliant with hand hygiene after patient

contact

3 staff members wore jewellery

0 staff members wore artificial nails/nail polish

6 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

58%

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WASCANA REHABILITATION CENTRE ADULT THERAPY

HAND HYGIENE RESULTS

63% of staff were not compliant with hand hygiene before patient

contact

47% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

5 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

48%

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WASCANA REHABILITATION CENTRE CHILDREN’S PROGRAM

HAND HYGIENE RESULTS

39% of staff were not compliant with hand hygiene before patient

contact

55% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

4 staff members wore artificial nails/nail polish

10 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

55%

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WASCANA REHABILITATION CENTRE ENVIRONMENTAL SERVICES

HAND HYGIENE RESULTS

2 staff members wore jewellery

2 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

93%

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WASCANA REHABILITATION CENTRE FRP HAND HYGIENE RESULTS

13% of staff were not compliant with hand hygiene before patient

contact

6% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the unit

92%

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WASCANA REHABILITATION CENTRE MAIN 5

HAND HYGIENE RESULTS

100% of staff were not compliant with hand hygiene before patient

contact

50% of staff were not compliant with hand hygiene after patient

contact

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

11 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

30%

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WASCANA REHABILITATION CENTRE MAIN 6

HAND HYGIENE RESULTS

64% of staff were not compliant with hand hygiene before patient

contact

46% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

0 staff members wore artificial nails/nail polish

9 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

42%

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WASCANA REHABILITATION CENTRE ORTHOTICS & PROSTHETICS

HAND HYGIENE RESULTS

87% of staff were not compliant with hand hygiene before patient

contact

75% of staff were not compliant with hand hygiene after patient

contact

1 staff member wore jewellery

1 staff member wore artificial nails/nail polish

13 staff members did not conduct hand hygiene at all

June 2015

Overall compliance for the unit

19%

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WOLSELEY MEMORIAL INTEGRATED CARE CENTRE LTC

HAND HYGIENE RESULTS

0 staff members wore jewellery

0 staff members wore artificial nails/nail polish

June 2015

Overall compliance for the facility

100%