WRHA Hand Hygiene Auditing – 4 Moments

1. WRHA Hand Hygiene Auditing – 4 Moments Training Session May 2013

2. Acknowledgements We’d like to acknowledge Public Health Ontario for contributing to the development of the new WRHA Hand Hygiene Monitoring Program

3. Agenda

4. 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

5. Initiative Goal To promote the importance of appropriate hand hygiene in reducing the occurrence of healthcare-associated infections and improving patient safety in the Winnipeg Regional Health Authority

6. 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

7. 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

8. Overview • Discussion of environments for hand hygiene and impact on transmission of germs • Review methods for cleaning hands and the importance of technique in reducing spread of infections and maintaining skin integrity • Practical training re: WRHA important moments for hand hygiene • High-level synopsis of observational audit process

9. 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

10. Definition Patient • Refers to patient (Acute Care), resident (LTC and PCH), and client (Community Settings)

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

12. Chain of Infection

13. 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

14. Contact Transmission • CONTACT TRANSMISSION • Indirect contact • Occurs when germs are spread by an object or intermediate person

15. 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

16. 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 • Zoutman, D., et al. Canadian Hospital Epidemiology Committee, • Canadian Nosocomial Infection Surveillance Program • McGeer, A. (2008). Hand hygiene by habit. Ontario Medical Review, 75(3).

17. 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% • Pittet, D., et al. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet, 14:356, pp.1307-1312 • Patient Safety and Hand Hygiene Matter! – CRS Week 2006 brochure

18. 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

19. 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

20. The Case for Hand Hygiene • One of the most effective measures to reduce occurrence of HAI • Correct hand hygiene saves lives and reduces strain on the healthcare system1 • Takes less than 1 minute to properly wash hands (soap and water) and less than 30 seconds to properly clean hands with alcohol-based hand rub (ABHR). Both methods are effective 1 Roth, Virginia, MD, FRCPC “Hands that harm, hands that heal” November 2006 PowerPoint presentation, slide 31

21. 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

22. Obstacles to Hand Hygiene • Too busy • Skin irritation • Glove use • Not top of mind

23. Why Perform Hand Hygiene? • To protect the patient against harmful germs carried on staff/visitors hands or present on his/her own skin • To protect yourself and the healthcare environment from harmful germs

24. Why Does Hand Hygiene Work? • Hand hygiene with ABHR – correctly applied – kills germs in seconds • Hand hygiene with soap and water – done correctly – physically removes germs

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

31. When Should Hand Hygiene Be Performed? BEFORE • Direct hands-on care • Performing invasive procedures • Handling dressings/touching open wounds • Preparing/administering medications • Preparing, handling, serving, or eating food • Feeding a patient IMMEDIATELY AFTER • Direct hands-on care • Contact with blood, body fluids, non-intact skin, and/or mucous membranes • Contact with items known/considered contaminated • Removal of gloves BETWEEN • Procedures on same patient where soiling of hands is likely • Caring for multiple patients

32. 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

33. Your 4 Moments for Hand Hygiene 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. 1 BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT Clean hands immediately before any aseptic procedure. To protect patient against harmful organisms, including the patient’s own organisms, entering his or her body. 2 BEFORE CLEAN/ASEPTIC PROCEDURE 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. 3 AFTER BODY FLUID EXPOSURE RISK 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. 4 AFTER PATIENT/PATIENT ENVIRONMENT CONTACT

34. Two Different Environments • Patient Environment • This is the patient’s area • In a single room this is everything in the patient’s room • In a shared room this is everything in immediate proximity to the patient • Health Care Environment • Environment beyond the patient’s immediate area • In a single room this is outside the room • In a shared room this is everything outside patient’s bed space

35. Definition of Patient’s Environment Note: the patient environment may differ in some settings

36. Examples by Indication to Perform Hand Hygiene 1 • 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 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.

37. Examples by Indication to Perform Hand Hygiene • Some examples: • Oral care, giving eye drops, secretion aspiration • Skin lesion care, wound dressing, subcutaneous injection • Catheter insertion, opening a vascular access system or draining system • Preparation of medication, dressing sets 2 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.

38. Examples by Indication to Perform Hand Hygiene • Some examples: • Oral care, giving eye drops, secretion aspiration • Skin lesion care, wound dressing, subcutaneous injection • Drawing & manipulating any fluid sample, opening a draining system, endotracheal tube insertion & removal • Clearing urine, feces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning contaminated or visibly soiled material/areas (bathroom, medical instruments) 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.

39. Examples by Indication to Perform Hand Hygiene • Some examples: • Shaking hands, stroking an arm • Helping a patient move around, get washed, giving a massage • Taking pulse, BP, chest auscultation, abdominal palpation • Changing bed linen • Perfusion speed adjustment • Monitoring alarm • Holding a bed rail • Clearing bedside table • Touching walls or curtains 4 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.

40. 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

41. 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

42. 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

43. 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

44. 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)

45. 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

46. 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

47. 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

48. 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 HAND HYGIENE OPPORTUNITY

49. 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

50. 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