WRHA Hand Hygiene Auditing 4 Moments Training Session

WRHA Hand Hygiene Auditing 4 Moments Training Session

WRHA Hand Hygiene Auditing 4 Moments Training Session May 2013 1 Acknowledgements Wed 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 wasnt 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 HAIs can be prevented1,2

Most healthcare providers believe theyre 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 arent 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 20 2006 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 its 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. Its better than washing hands (even with antibacterial soap) when hands arent visibly soiled Hand washing with soap and running water must be done when hands are visibly soiled 26 Technique Matters Its 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 (dont 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 Dont 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 Contact with items known/considered contaminated Removal of gloves Preparing/administering medications Preparing, handling, serving, or eating food 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 1 2 3 4 BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT BEFORE CLEAN/ASEPTIC PROCEDURE Clean hands when entering before touching the

patient or any object or furniture in the patients 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 patients 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 patients 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 patients immediate area This is the patients area In a single room this is outside the room In a shared room this is everything outside patients bed space In a single room this is everything in the patients room In a shared room this is everything in immediate proximity to the patient 34 Definition of Patients Environment Note: the patient environment may differ in some settings

35 Examples by Indication to Perform Hand Hygiene 1 BEFORE INITIAL PATIENT/ PATIENT ENVIRONMENT CONTACT 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 Clean hands when entering before touching the patient or any object or furniture in the patients environment. To protect patient/ patient environment from harmful organisms carried on your hands. 36 Examples by Indication to Perform Hand Hygiene 2 BEFORE CLEAN/ ASEPTIC PROCEDURE 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 Clean hands immediately before any aseptic procedure. To protect patient against harmful organisms, including the patients own organisms, entering his or her body. 37 Examples by Indication to Perform Hand Hygiene Some examples: 3 AFTER BODY FLUID EXPOSURE RISK Clean hands immediately after an exposure risk to body fluids (and after glove removal).

To protect yourself and health care environment from harmful patient organisms. 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 4 AFTER PATIENT/PATIENT ENVIRONMENT CONTACT Clean hands when leaving after touching patient or any object or furniture in the patients environment. To protect yourself and health care environment from harmful patient organisms. 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 39 Hand Hygiene and Glove Use Glove use doesnt 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

Whos 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 activitiescan move to follow HCW, but never interfere with work Important to consider any concerns HCWs may have with your presencemust be as discreet as possible and dont infringe on HCWs 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 youre 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 H C Wa tCe g o r y code 1 2

3 4 5 6 Key: 7 = Physiotherapy 8 = Occupational Therap y 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 Aft er blood or body flui ds exposure Aft

er 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

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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

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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., 1 st 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 youre 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, theyre 2A on second form/row) At end of session, dont 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 patients 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

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