Hand Hygiene Compliance Observation and Analysis

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Hand Hygiene Compliance -Observation and
Analysis
Version 1.1
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Acknowledgement

• The Ministry of Health and Long-Term Care would
  like thank the WHO World Alliance
• for Patient Safety for sharing its Clean Care is
  Safer Care materials. This presentation includes
  slides from annex 16 and concepts from the
  Observers Manual of Clean Care is Safer Care, the
  WHO multimodal hand hygiene improvement strategy
  developed by the World Alliance for Patient
  Safety.

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Instructions for Trainer

• This presentation should be used by trainers to
  teach observers how to conduct observations.
  After reviewing slides 1-24 observers should
  complete activities on slide 25
• Observers must complete training on Your 4
  Moments for Hand Hygiene before this presentation
• Following the teaching session, practical
  sessions either at the patient bedside or by
  simulation, could be organized.
• An Excel workbook is provided to enter and
  analyze data from the observation too. The
  individual responsible for this activity should
  review the Instructions for Observation Tool
  analysis available on justcleanyourhands.ca
  website

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Overview

• Practical training for observers on how to
  observe hand hygiene compliance and complete
  Observation Tool
• Overview of audit process
• Overview of analysis and reporting process

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How to observe hand hygiene?
Adapted from

• Direct observation using a consistent approach
  and validated tool, is the most accurate
  methodology
• The observer must familiarize him/herself with
  the methods and tools used in the Just Clean Your
  Hands program and must be trained (and
  validated) to identify and distinguish the
  indications for hand hygiene occurring during
  health care practices at the point of care
• The observer must conduct observations openly,
  without interfering with the ongoing work, and
  keep the identity of the health care providers
  confidential
• Compliance should be detected according to the
  four indications for hand hygiene recommended by
  Just Clean Your Hands program.

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Crucial concepts for observing hand hygiene
indication and opportunity

• Health care activity a succession of tasks
  during which health care providers' hands touch
  different types of surfaces the patient, his/her
  body fluids, objects or surfaces located in the
  patient environment.
• Each contact is a potential source of
  contamination for health care providers' hands
• Indication the reason why hand hygiene is
  necessary at a given moment. It is justified by a
  
• risk of organism transmission from one surface
  to another.

Opportunity the need to perform hand hygiene,
whether there are single or multiple indications.
Hand hygiene must correspond to each
opportunity. Multiple indications may come
together to create a single opportunity.
HAND HYGIENE
RISK OF TRANSMISSION
INDICATION
OPPORTUNITY
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Indication and opportunity
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Preparing to Audit

• General Recommendations for Observation
• Determine how to best identify the types of
  health care providers you may be observing.
• Accurate identification of health care provider
  is critical to ensure reliability of data.
• Introduce yourself to the observed health care
  provider(s) and patients as appropriate and
  explain your role.

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Preparing to Audit

• Positioning for observation
• Find a convenient place to observe without
  disturbing care activities you can move to
  follow the health care provider, but never
  interfere with their work. However you can
  provide feedback after the session using On-
  the-Spot form.
• It is important to take into account any concerns
  the health care providers may have with your
  presence. Your presence should be as discreet as
  possible and in no way infringe on the actions of
  the health care provider. If a health care
  provider feels uncomfortable with your presence
  he/she has the right to ask you to leave and you
  must do so if asked.

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Preparing to Audit (continued)

• You may observe up to three health care providers
  simultaneously provided you are an experienced
  observer and are very careful not to miss
  opportunities. Note Multiple health care
  providers performing sequential tasks quickly may
  preclude accuracy of missed hand hygiene
  opportunities.
• You may include more health care providers
  sequentially during one observation session.
• One observation session is for 20 minutes (/- 10
  minutes) prolong the session if you get the
  chance to observe a care sequence to its end.

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(No Transcript)
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How to use the form

• Use a pencil to fill in the form and an eraser to
  correct. Use a clipboard to hold the form.
• First, fill in the head of the form by indicating
  your ID number (Observer-ID), the date, the
  current time including am/pm (Start time), the
  number of the form used for a single session
  using the format 1, 2, 3, etc. (Form-No.) (See
  also point 19 on reverse of Observation Tool),
  the identity of the facility (Facility-ID), the
  identity of the patient care unit (Patient Care
  Unit)

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How to use the form

• Indicate any rooms where Additional/Isolation
  Precautions are in place by entering in the
  Comments section. (Observe outside the room.)
• Indicate the type of health care provider being
  observed by entering the number that corresponds
  with the categories listed at the top of the
  form. The coding system is a number followed by a
  letter (e.g., first physician in the room is 1A,
  
• if second physician enters the room he/she is
  1B).

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How to use the form (continued)

• Each column is for recording hand hygiene
  opportunities of one health care provider only.
  Use additional columns for each additional health
  care provider being observed simultaneously or
  sequentially. The health care provider may
  interact with more than one patient during the
  time you are observing.
• As soon as you observe the first indication for
  hand hygiene, indicate the corresponding
  information in the first of the numbered
  opportunity sections in the column corresponding
  to the health care provider being observed.

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Before Initial Patient/Patient Environment Contact

• BEF-PAT/ ENV before initial patient/patient
  environment contact
• if the health care provider touches the patients
  environment and then touches the patient or
• goes directly to touch the patient after having
  touched the hospital environment ( any other
  surface not in the patients environment) or
  another patients environment
• if the health care provider enters the patients
  environment from the hospital environment and
  touches only the patients environment (does not
  touch patient) and then leaves the patients
  environment.

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Before Aseptic Procedure

• BEF-ASP before aseptic procedure if the
  health care provider is to perform any of the
  following after having touched any other surface
  including the concerned patient himself/herself
  and his/her environment
• touch/manipulate a body site that should be
  protected against any colonization (e.g., wound
  care including dressing change and wound
  assessment)
• manipulate an invasive device that could result
  in colonization of a body area that should be
  protected against colonization (e.g., priming
  intravenous infusion set, inserting spike into
  opening of IV bag, flushing line, adjusting
  intravenous site, administering medication
  through IV port, changing IV tubing).

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After Body Fluid Exposure Risk

• AFT-BFL after body fluid exposure risk if the
  health care provider has been engaged in a care
  activity involving a risk of body fluid exposure
• and before touching any other surface including
  the concerned patient himself/herself and his/her
  environment (e.g., contact with blood or blood
  products, emptying urinal/catheter bag and
  suctioning oral/nasal secretions).

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After Patient/Patient Environment Contact

• AFT-PAT/ ENV after patient/patient environment
  contact
• if the health care provider is leaving the
  patient and his/her environment to go on working
  in the hospital environment or with another
  patient
• if the health care provider is leaving the
  patient area after touching objects in the
  patient environment (without touching the
  patient) to go on working in the hospital
  environment or with another patient.

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If there is more than one indication on one
opportunity, mark them all

• Note If several indications fall together on the
  same hand hygiene opportunity, tick all.
• Example 1 health care provider enters room,
  cleans hands with alcohol and immediately
  performs aseptic procedure this would result in
  checking
• BEF-PAT/ENV and BEF-ASP.

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For each opportunity, indicate the hand hygiene
action of the health care provider

• Mark whether the health care provider used
  alcohol-based hand rub (RUB), soap and water
  (WASH) or did not do hand hygiene (MISSED)
• If a health care provider used soap and water and
  then alcohol-based hand rub
• (or vice-versa), mark both.

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Gloves

• For each opportunity, tick if the health care
  provider was wearing gloves when the opportunity
  occurred.
• In this audit, wearing gloves does not change the
  number of opportunities for health care providers
  to clean their hands.
• Hand hygiene done with gloves on is incorrect
  therefore, it is marked as a missed opportunity.
• Examples when gloves may be used when handling
  blood and body fluids, mucous membranes, wound
  care, contact with non-intact skin and where
  indicated for additional precautions/isolation.

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Technique Nails, Rings and Bracelets

• Tick the corresponding boxes if the health care
  provider does not meet the guidelines regarding
  
• correct nail length (3-4 mm, ¼ inch)
• no nail extensions/artificial nails
• no rings or bracelets.
• It is necessary to do this only once for each
  health care provider.

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Technique Timing of hand hygiene

• Timing of the duration of hand hygiene
• T timing This is the duration of hand hygiene
  performed by the health care provider when hand
  hygiene occurs for
• BEF-PAT/ ENV and AFT-PAT/ ENV opportunities.
• Use a wristwatch or stopwatch to record duration
  (seconds) of hand hygiene before patient/patient
  environment contact and after patient/patient
  environment contact. Begin timing when the health
  care providers start rubbing his/her hands with
  the product, and stops timing when he/she
  completes the motion of rubbing their hands with
  the product.
• Note Rinsing of hands with water does not
  constitute a hand wash this would be coded as a
  missed opportunity.

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Important Notes

• Each column is for recording hand hygiene
  opportunities of one health care provider only.
  Use additional columns for each additional health
  care provider being observed simultaneously or
  sequentially. The health care provider may
  interact with more than one patient during the
  time you are observing.
• Note Multiple health care providers sequentially
  performing tasks quickly may make it difficult to
  maintain accurate observation of missed hand
  hygiene opportunities.
• If you observe more than four opportunities for
  one health care provider, use another form,
  numbering them sequentially in the variable
  Form-No. Remember to code the health care worker
  in the same way (e.g., if they were 2A on the
  first form, they are 2A on the second form).
• At the end of the session, do not forget to fill
  in the End time and check the form(s) for missing
  values before handing it in.
• End the observation if the privacy curtain is
  drawn around the patients bed or if a health
  care worker asks you to leave.
• Record any additional qualitative data in the
  Comments section E.g., Additional
  Precautions/Isolation.

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Activities for Observers

• .

• Review Training Scenarios 1-4 on Training DVD and
  record the appropriate observation results for
  each scenario.
• Debrief with others when first learning how to
  use the Observation Tool, to assist with
  consistency and understanding of the audit
  process.
• Review Observer Scenarios 5-8 on Training DVD and
  record the appropriate observation results for
  each scenario.
• Discuss your results as a group or compare your
  recorded observations with the answers for each
  scenario in the Hand Hygiene DVD Answer Key

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Selecting a Sample Size

• It is important to have a large enough sample
  size to be meaningful.
• Not collecting enough data means the rates are
  not reliable as any changes could be due to
  chance alone rather than the effect of the
  intervention.
• It is recommended that 56 observation sessions of
  20 minutes is needed to collect enough data for a
  reliable compliance rate for the specific area.
  (This provides for approximately 200 observations
  for the area)
• The time frame for the audit period should be no
  less than a 2 week period.
• Note The baseline observations should be
  completed before the Implementation Phase of
  the program starts.

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Planning Observation Schedule

• Observe
• Eight 20-minute observations/day
• At least seven different days of eight periods of
  observation
• At different times of the day (different shifts
  and different times within the shift)
• Therefore, there will be approximately 56
  observation sessions for calculating the
  aggregate data.

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Sample Hand Hygiene Observation Schedule used to
audit 80 beds in a pilot site

• Friday, January 19, 2008 - 800 a.m. (eight
  20-minute observations)
• Sunday, January 21, 2008 - 1200 p.m. (eight
  20-minute observations)
• Tuesday, January 23, 2008 - 400 p.m. (eight
  20-minute observations)
• Thursday, January 25, 2008 - 800 p.m. (eight
  20-minute observations)
• Saturday, January 27, 2008 - 1200 a.m. (eight
  20-minute observations)
• Monday, January 29, 2008 - 400 a.m. (eight
  20-minute observations)
• Wednesday, January 31, 2008 - 800 a.m. (eight
  20-minute observations)

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Feedback Aggregate Data

• An Excel workbook tool has been provided to enter
  and analyze observation results
• The data entry can be done by the observer or
  another resource may be assigned
• Predefined reports have been included to analyze
  data
• using four different methods
• Report table and charts can be pasted into
  presentations to support feedback of progress to
  health care providers, management and hospital
  board

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Feedback Aggregate Data

• Compliance rates reported are only analyzing the
  compliance of when hand hygiene was performed
  as compared to the number of opportunities that
  were indicated to perform hand hygiene.
• The compliance rate is not altered by technique
  or the how hand hygiene was performed.

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Observation Analysis Tool Data and Reports
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Observation Analysis Tool Data Entry Page
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Methods of analysis

• Data can be analyzed as follows
• Analyzing one type of indication for each
  health care provider category at a time to
  provide for accurate information to compare over
  time (most accurate method)
• combine health care providers, categories for a
  specific indication to obtain a generalized
  compliance rate for that indication
• combine the opportunities for each category of
  health care provider (HCP) to obtain a
  generalized compliance rate for each HCP category
  
• Compare alcohol-based hand rub with soap and
  water to assess behaviour change
• Note for 2 and 3 the information may not be
  comparative over time as the mix of type of
  indication gathered in opportunities in 2 or
  the category of health care provider in 3may
  vary and therefore not provide for accurate
  comparative rates.

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Calculating reliable hand hygiene compliance rates

• An overall hand hygiene compliance rate does not
  provide for reliable and comparative rates over
  time as compliance rates for the different types
  of health care provider and for the each of the
  four indications are frequently different.
• If a generalized rate is to be provided,
  reliability will increase if the same number is
  used for the overall analysis
• for each category of health care provider and
• for the number of observations of each indication
  

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Reports 1a d Preferred Method Calculating
reliable hand hygiene compliance rates

• Compliance rates are to be calculated separately
  for each type of indication and each health care
  provider category (e.g., Nurses BEF-PAT/ENV 70
  per cent Physicians AFT-PAT/ENV 70 per cent
  Respiratory Therapist AFT-BFL-85 per cent)
• Compliance rates must be reported by
• Each hand hygiene indication
• Each health care provider (HCP) category
• times hand hygiene was performed for a
  specific indication /specific HCP category x
  100
• observed hand hygiene indications for
  specific indication/specific HCP category
• (The number of observations to make the
  information meaningful will depend on unit size,
  patient population and hospital size)
• Breakdown of the compliance rates by indication
  and health care provider category provides data
  for developing targeted and appropriate
  interventions to improve compliance.
• Overall generalized compliance rate combining
  health care providers and/or combining types of
  indications will not provide for reliability.
  

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Report 1 a - sample
Calculation times hand hygiene was performed
for BEF-PAT/ENV by specific HCP category X 100
compliance observed hand hygiene indications
for BEF-PAT/ENV by specific HCP category
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Report 1 b sample
Calculation times hand hygiene was performed
for BEF-ASP by specific HCP category X 100
compliance observed hand hygiene indications
for BEF-ASP by specific HCP category

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Report 1 c - sample
Calculation times hand hygiene was performed
for AFT-BFL by specific HCP category X 100
compliance observed hand hygiene indications
for AFT-BFL by specific HCP category
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Report 1 d - sample
Calculation times hand hygiene was performed
for AFT-PAT/ENV by specific HCP category X 100
compliance observed hand hygiene indications
for AFT-PAT/ENV by specific HCP category
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Report 2 - sample
Calculation times hand hygiene was performed
for a specific indication by all categories of
HCP x 100 compliance observed hand hygiene
indications for a specific indication by all
categories of HCP
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Report 3 - sample
Calculation opportunities hand hygiene
performed by specific HCP category
x 100 compliance Total observed hand
hygiene opportunities for a specific HCP category
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Report 4 - sample
Calculation of opportunities hand rub was used
to clean hands x 100 rub Total number of
opportunities hand hygiene was observed
of opportunities soap and water was used to
clean hands X 100 wash Total number of
opportunities hand hygiene was observed
of opportunities hand rub and soap and
water were both used to clean hands X 100
both Total number of opportunities hand hygiene
was observed