WRHA Hand Hygiene Auditing –
4 Moments
Training Session
May 2013
1
Acknowledgements
We’d like to acknowledge Public Health Ontario for
contributing to the development of the new WRHA
Hand Hygiene Monitoring Program
2
Agenda
Welcome and Introduction to Hand Hygiene Campaign
Introduction to Hand Hygiene
Introduction to Observation Tool and Audit Process
Observation Tool and Audit Process
3
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
4
Initiative Goal
To promote the importance of appropriate hand
hygiene in reducing the occurrence of healthcareassociated infections and improving patient safety
in the Winnipeg Regional Health Authority
5
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
+
Reminders in the Workplace
+
Establishment of a Safety Climate –
Individual active participation & site support
6
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
7
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
8
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
9
Definition
Patient
–
Refers to patient (Acute Care), resident (LTC
and PCH), and client (Community Settings)
10
Germ Transmission
•
Transmission of germs by hands of healthcare
workers from patient-to-patient can result in HAIs
11
Chain of Infection
INFECTIOUS
AGENT
SUSCEPTIBLE
HOST
RESERVOIR
PORTAL
OF EXIT
PORTAL OF
ENTRY
MEANS OF
TRANSMISSION
12
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
13
Contact Transmission
•
CONTACT TRANSMISSION
–
Indirect contact
•
Occurs when germs are
spread by an object or
intermediate person
14
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
15
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
16
2. McGeer, A. (2008). Hand hygiene by habit. Ontario Medical Review, 75(3).
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
17
2. Patient Safety and Hand Hygiene Matter! – CRS Week 2006 brochure
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
18
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
19
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
20
PowerPoint presentation, slide 31
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
21
Obstacles to Hand Hygiene
•
Too busy
•
Skin irritation
•
Glove use
•
Not top of mind
22
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
23
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
24
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
25
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
26
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
27
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
28
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
29
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
30
When Should Hand Hygiene Be
Performed?
IMMEDIATELY AFTER
BEFORE
–
Direct hands-on care
–
Direct hands-on care
–
Performing invasive procedures
–
–
Handling dressings/touching
open wounds
Contact with blood, body fluids,
non-intact skin, and/or mucous
membranes
–
Preparing/administering
medications
–
Contact with items
known/considered
contaminated
–
Preparing, handling, serving, or
eating food
–
Removal of gloves
–
Feeding a patient
BETWEEN
―
―
Procedures on same patient where soiling of hands is likely
Caring for multiple patients
31
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
32
Your 4 Moments for Hand Hygiene
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.
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.
Clean hands immediately after an exposure risk to
body fluids (and after glove removal).
AFTER BODY FLUID EXPOSURE RISK
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.
AFTER PATIENT/PATIENT ENVIRONMENT CONTACT
To protect yourself and health care environment
from harmful patient organisms.
33
Two Different Environments
• Health Care Environment
• Patient Environment
– Environment beyond
the patient’s immediate
area
– This is the patient’s
area
• In a single room this is
outside the room
• In a shared room this
is everything outside
patient’s bed space
• 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
34
Definition of Patient’s Environment
Note: the patient environment may differ in some settings
35
Examples by Indication to Perform Hand
Hygiene
Some examples:
•
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.
•
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
36
Examples by Indication to Perform Hand
Hygiene
Some examples:
•
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.
•
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
37
Examples by Indication to Perform Hand
Hygiene
Some examples:
•
•
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.
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)
38
Examples by Indication to Perform Hand
Hygiene
Some examples:
•
•
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.
•
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
39
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
40
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
41
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
42
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
43
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)
44
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
45
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
46
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
47
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
RISK OF
TRANSMISSION
INDICATION
OPPORTUNITY
HAND HYGIENE
48
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
49
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
50
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
51
Hand Hygiene Observation Tool
Observer-ID:
Date (dd / mm / yyyy):
Day of Week:
Start Time:
End Time:
Form #:
Facility-ID:
Patient Care Unit:
Healthcare Worker (HCW) Category code:
=
=
=
=
=
=
Physician
Nurse
Healthcare Aide
Social Work
Spiritual Care
IV Team/DSM/Lab
HCW Category
code
1
2
3
4
5
6
Key:
7 = Physiotherapy
8 = Occupational Therapy
9 = Housekeeping
10 = Patient Transport
11 = Radiology/DI
12 = Respiratory Therapy
13
14
15
16
17
BEFORE
Before initial
P/R/C or P/R/C
ENV contact
=
=
=
=
=
Dietary
Sp. Language/Audiology
Rec. Therapy
Pharmacy
Other
W = Wash
A = Alcohol-based handrub
M = No hand hygiene;
Missed opportunity
AFTER
Before
aseptic/clean
procedure
OTHER
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: ____________________________________________________________________________________________
________________________________________________________________________________________________________
52
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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:
53
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
2 = Nurse
3 = Healthcare Aide
4 = Social Work
5 = Spiritual Care
6 = IV Team/DSM/Lab
7 = Physiotherapy
8 = Occupational Therapy
9 = Housekeeping
10 = Patient Transport
11 = Radiology/DI
12 = Respiratory Therapy
13 = Dietary
14 = Sp. Language/Audiology
15 = Rec. Therapy
16 = Pharmacy
17 = Other
54
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
55
Before Initial Patient or Patient
Environment Contact
•
Opportunity
–
Before entering patient room/space
56
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
57
After Blood or Body Fluids Exposure
•
Opportunities: after contacting any body fluid (e.g.,
urine, feces, wound exudate), including blood
58
After Patient or Patient
Environment Contact
•
Opportunity: on leaving the patient room/space
59
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
60
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
61
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
62
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
63
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
64
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)
65
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
66
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
67
Sample Observation Schedule
•
Fri., Sept. 18/13 - 0800
(nine 20-min obs)
•
Thurs., Sept. 24/13 - 2000
(nine 20-min obs)
•
Sun., Sept. 20/13 - 1200
(nine 20-min obs)
•
Sat., Sept. 26/13 - 2400 (nine
20-min obs)
•
Tues., Sept. 22/13 –
1600 (nine 20-min obs)
•
Mon., Sept. 28/13 - 0400
(nine 20-min obs)
•
Wed., Sept. 30/13 - 0800
(nine 20-min obs)
68
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
69