Interventions to Improve Hand Hygiene Compliance

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Interventions to Improve Hand Hygiene Compliance

• Pat Kulich, RN, CIC
• The Ohio State University Medical Center
  Department Of Clinical Epidemiology

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Wash Your Hands

• Universally believed to reduce infection risk
• Numerous guidelines recommendations support the
  practice
• CDC Guideline for Hand Hygiene in Health Care
  Settings 02
• WHO Guidelines on Hand Hygiene in Health Care
  07
• Joint Commission standards focus on preventing
  the transmission of infections Patient Safety
  Goal 7A
• Institute for Healthcare Improvement Improving
  Hand Hygiene A Guide for Improving Practices
  among Health Care Workers (HCW) 05
• Individual HCW believe their compliance rate is
  high
• Failure to identify hand hygiene non-compliance
  with infection outcome

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Impact of Healthcare Associated Infections (HAI)

• HAIs cause significant morbidity, mortality
  cost
• Affects nearly 2 million individuals
• 100,000 deaths annually
• 4.5 to 5.7 billion patient care cost
• Transmission of pathogens occurs most often via
  the contaminated hands of HCW
• Estimated 1/3 of infections can be prevented
  through hand hygiene
• Hand hygiene compliance generally below 50

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Factors influencing poor compliance

• Lack of knowledge
• Importance of hand hygiene
• How hands become contaminated
• Lack of understanding
• Hand hygiene technique
• Glove wearing practices
• Insufficient time/too busy/overworked
• Poor access to hand washing facilities
• Contact dermatitis
• Frequent hand washing
• Poor quality hand washing agents
• Lack of institutional commitment to good hand
  hygiene

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Elements for Improving Hand Hygiene Institute
for Healthcare Improvement - IHI

• Implement a sustained, comprehensive,
  multi-modal, multi-disciplinary program
• Staff education and motivation
• Adoption of alcohol-based hand rub
• Use of performance indicators
• Commitment of all stakeholders including
• HC leaders
• Management
• Staff
• Patients and families

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Education

• Establish consistent recommendations
• Provide supporting guidelines references
• Develop policies procedures
• Make readily accessible (computer/hard copy)
• Orientation and annual education
• New employee education
• Lectures, interactive learning sessions, videos,
  CBL
• Develop learning packet with pre post test
• Identify educate physician champions

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Education

• Understand key elements
• Correct technique
• Correct time
• Correct product
• Demonstrate knowledge

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Education

• Identify activities that result in hand
  contamination
• Visual methods to illustrate contamination
  (culture plates with growth from HCW hands)
• If you touch this, clean your hands reminders
• Simple tasks contaminate hands
• Pulling patients up in bed
• Taking BP or pulse
• Rolling patient over in bed
• Touching patients gown or bed linens
• Touching bedside rails and tables, IV pumps

Wilson, B et al. IHIs National Forum, 2005.
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Education

• Make it real - personalize the issue
• Incorporate in annual competency credentialing
  process
• Publish hand hygiene procedure recommendations
  in hospital physician newsletters
• Include infection control articles in the
  hospital newsletter

Goldmann, D. NEJM, 2006355121-123
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Educational Resources Programs

• Posters, buttons, stickers, t-shirts, name tag
  pulls
• Numerous resources (CDC, professional
  organizations, manufacturers, state health dept,
  VA dept, International Center for Patient Safety)
• Some free products online (posters www.va.gov)
• Engage creative staff community
• Need financial resources for most
• Frequently replace posters to keep them fresh

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Educational Resources Programs

• Video training sessions (professional in-house
  developed)
• Short hand hygiene commercials on patient
  hospital TV channels
• Counters measure number of times dispenser used
• Sensor technology (ComSens) measures hand
  hygiene behavior
• Screen saver message (update periodically)
• Imprint hand hygiene message (name tags, patient
  gowns, water jugs)
• Last slide in all presentations
• Toilet paper with health messages

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Educational Resources Programs

• Screen saver message (update periodically)
• Cedars-Sinai MC cultured physician hands
• Culture result was photographed and made into
  screen saver

Illustration by Paul Sahre and Loren Flaherty
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Educational Resources Programs

• Logo printed on patient gowns, U of Pittsburgh
  MC, Shadyside, PA

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Last slide in all presentations
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Selecting Hand Hygiene Products

• Interdepartmental team to evaluate select
  product based on product efficacy skin
  compatibility
• Solicit input regarding feel, fragrance skin
  tolerance
• Provide hand lotions to minimize dermatitis

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Frequent hand washing with soap and water can dry
out your hands

• Frequent hand washing with soap and water often
  causes skin irritation and dryness.
• In the winter months, some workers may even
  develop cracks in their skin that cause bleeding,
  as seen in the photo.

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Sink Accessibility

• Personnel are unlikely to use sinks if not
  readily accessible
• Empty soap paper towel dispensers discourage
  use
• Involvement in new construction design (sink
  placement)

Sink located behind bed and IV pumps
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Adoption of alcohol-based hand rub

• Point-of-need alcohol hand rubs
• Preferred time saving method of hand antisepsis
• Make readily accessible (patient rooms, exam
  rooms, corridors, family waiting areas, elevator
  lobbies, med isolation carts, cafeteria)
• Endorse pocket carriage of alcohol hand rub
• Bischoff et al. found compliance greater when
  dispenser adjacent to patients bed then if only
  one dispenser for every 4 beds

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Use of performance indicators

• Accurate measurement key to improving hand
  hygiene
• Compliance measurement difficult
• Requires additional resources
• Lack of a standardized measurement approach
• Difficult to determine trends or benchmark
• Meaningful results require numerous observations
• Many different care providers
• Numerous locations

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Joint Commission Partners with Infection Control
Leaders

• 9/7/06 Joint Commission partners with IC leaders
  (CDC, WHO, APIC, SHEA, IHI, NFID)
• Lack consensus on how to measure hand hygiene
  compliance
• 18 month project-E. Larson, Chair
• Identify best approaches to measure compliance
• Develop educational monograph

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Hand Hygiene Monitoring Tool

• Observation monitoring
• Develop standardized monitoring tool (examples
  available at www.Handhygiene.org)
• Keep tool simple
• Random audits deck of cards each with hand
  hygiene question, Cook Childrens MC Fort Worth,
  TX
• Hand held devices expedite turnaround time
• Educate observers to ensure reliability
  consistency
• Select non-peer reviewers
• Random, in a way staff unaware of the observation
• Hawthorne effect statistically significant
  increase

Eckmanns, T et al. Infect Control Hosp
Epidemiol2006931-934
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Hand Hygiene Monitoring Tool

• Measure and compare volume of soap and alcohol
  product used per patient care unit/area
• vol/bed days/vol per use hand hygiene events
  per bed day
• Provide staff regular feedback on compliance

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Motivational Techniques for Creating Behavioral
Social Change

• Positive deviance (Billings Clinic, MT)
• Identify certain problem solvers
  (individuals/groups)
• Community identifies builds on internally
  generated successes
• Offer awards for best compliance
• 10 Starbuck cards (Cedars-Sinai MC)

• Six Sigma approach (HealthEast St. Josephs
  Hospital, MN)
• Tie together improvement methods with identified
  process failures
• Develop control plan to sustain gains
• Sanctions for failure to comply with standards
  (The Medical Center in Bowling Green, KY)

Goldmann, D. NEJM, 2006355121-123.
Christenson, M et al. Material Management
Magazine, 2007
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Commitment of administrative leaders and
stakeholders

• Develop an organizational culture of
  expectation
• Culture creates an environment that empowers
  staff to make hand hygiene the expectation
• Written statement regarding value support for
  rigid adherence to hand hygiene standard
• Top-down administrative support
• Clinical leaders as mentors and role models
• Identify unit champions
• Allocate dedicated resources, financial staff

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Examples of leadership and stakeholders showing
commitment

• Participation in educational programs
• Being the face on the hand hygiene poster
• Sign hand hygiene pledge banner post
• Letter of commitment to hand hygiene compliance
  sent to all HCW physicians
• IHI states commitment of leadership is the key
  determinant of success

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Hand Hygiene Task Force

• Appoint ongoing multidisciplinary committee
• Routine ongoing scheduled meetings
• Members unified in mindset
• Membership should include
• Administration help remove implementation
  barriers
• Product manager supplies product to units
• Implement a sustained hand hygiene program
• Establish hand hygiene compliance goals
• Involved in the designing of educational tools
• Develop observational tool/monitor communicate
  performance data
• Ensure that high level of performance is
  maintained

Pyrek, K. ICT-Main Articles
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Patient Family

• Encourage patients, families visitors to remind
  HCW to clean their hands
• Place signs in patient rooms
• We promise to clean our hands before touching
  you. Please let us know if we have forgotten.
  Billings Clinic
• Before you touch me, can you please wash your
  hands? U. of Pittsburgh MC, Shadyside, PA.
• Develop patient/visitor hand hygiene brochures,
  include in admission packet

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Partners in Your Care SM

• Patient, family HCW education program
• Monitor, measure and benchmark compliance
• Developed by M. McGuckin, U. of PA, marketed by
  STERIS
• Empowers patients/families to ask HCW about hand
  hygiene practice
• Educational tools posters, flyers, newsletters,
  lectures, letters from administration, bedside
  reminders
• Monitor hand hygiene product use

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Patients and Visitors

• Its okay to ask health care providers if they
  have cleaned their hands.

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PIYC Lessons Learned at OSUMC

• Sustaining program without a designated ongoing
  committee is difficult
• Without repeated staff encouragement patients are
  reluctant to ask
• Incorporate family visitors into PIYC education
  much more willing to ask
• Patient questionnaires difficult to obtain
• Product usage data difficult to collect
• Plan to reinstate committee with broader hand
  hygiene agenda and goals

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Summary

• Achieving and sustaining high rates of compliance
  requires
• Commitment of all stakeholders
• Multidisciplinary team dedicated to improving
  compliance
• Financial and manpower support
• Ongoing creative educational programs
• Compliance monitoring and dissemination of data
• Strategies to motivate and create personal
  accountability

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Resources

• Dept. of VA Affairs http//www.patientsafety.gov/s
  afetytopics/handhygiene
• CDC http//www.cdc.gov/handhygiene/materials.htm
• University of Geneva Hospitals http//www.hopisaff
  e.ch
• Association for Professionals in Infection
  Control and Epidemiology http//www.apic.org
• Partners in Your Care http//www.med.upenn.edu/mcg
  uckin/handwashing
• IHI http//www.ihi.org/IHI/Topics/CriticalCare/Int
  ensiveCare/Tools/HowtoGuideImprovingHandHygiene.ht
  m
• Hand Hygiene Resource Center http//www.handhygien
  e.org/educational_tools.asp

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