Hospital acquired infection is regarded as the leading cause of mortality, hospital stay and health care cost. Hand hygiene practices is one quality indicator that predicts the quality and safety in health care service. Compliance to hand hygiene practices is crucial to the prevention of hospital acquired infection as this practice breaks the chain of infection that is transmitted from staff to patient by direct contact. It is regarded as one major indicator of healthcare quality and patient safety as it is an integral component of infection control standard (Mumford et al. 2014). However, interventions implemented to improve hand hygiene and prevent infection differ based on contextual setting and different cause of non-compliance. This report aims to discuss about the quality indicator of hand hygiene and methods used for measurement of the indicator in a specific clinical setting. Literature review on chosen indicator and quality improvement plan related to the chosen indicator is also provided to improve quality and safety of care.

Hand hygiene practices relates to the use of soap and water, hand sanitizers or disinfectants to prevent transmission of infection in clinical setting. Compliance with Hand hygiene is regarded as one of the pillar of infection control and adequate hand hygiene practice is crucial to reduce risk of infection, mortality, morbidity and health care cost. Health care practitioners are looking back to the basics of hand hygiene to reduce transmission of infection in hospitals (Mathur 2011). Compliance to hand hygiene can be regarded as an appropriate indicator of quality and safety in a hospital’s quality improvement programme as improving hand hygiene compliance rate has been found to decrease the rate of health care associated infection (Sickbert-Bennett et al. 2016) According to World Health Organization (2017), empty alcohol dispense, failure to educate staffs regarding hand hygiene technique and failure to practice hand hygiene after glove removes results in serious failure at important phases in the patient care system. Failure to comply with hand hygiene practices at critical point results in patient safety issues and poor clinical performance. Apart from patient and staff, the environment of hospitals also plays a role in compliance to hand hygiene practice (Mathur 2011). Hence, assessment of links between hand hygiene and compliance rate is crucial to identify the factors affecting quality and patient safety and develop appropriate intervention to address individual, organization and environment level barrier to hand hygiene practice.  Hand Hygiene Practices And Compliance Safety In Healthcare Discussion Paper

Methods Used To Measure Hand Hygiene Compliance At St Vincent’s Private Hospital Melbourne

There are different methods to assess compliance with hand hygiene practices among health care staffs at St Vincent’s Private Hospital Melbourne. Monitoring and improving each hand hygiene action can prevent sepsis in health care stetting and lead to optimal patient outcome. This section provides an overview about methods used to measure the quality indicator within St Vincent’s Private Hospital Sydney. The hospital is renowned for delivery of quality patient care since the past 100 years. It has achieved optimal performance through the commitment of experience team of health care professionals consisting of clinicians, support staff and nurses. The hospital has an Infection Prevention and Control (IPC) team that works with different staffs within the hospital to promote health and safety of patient, staffs and visitors. The main aim of this collaboration is to eliminate risk of transmission of infection. The environmental context that has helped the hospital to sustain hand hygiene practices includes presence of appropriate hand hygiene culture and accessibility of hand foam dispensers at the clinical setting. All nurse and staffs are training in correct hand hygiene procedure and hand foam dispensers are available to each ward thus eliminating common barrier to hand hygiene compliance (St. Vincent’s Private Hospital 2018). Hence, it can be said that that the hospital has a multi-disciplinary approach to improve hand hygiene practices and promote quality and safety in care. Monsalve et al. (2014) states that individual and institutional factors are interdependent in terms of behavioral change and improve hand hygiene practices in clinical setting.

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The procedure that the IPC team has implemented to prevent infection includes education of staff, infection prevention advice, audits, surveillance and development of IPC policies and guidelines. The advantage of these activities for infection prevention is that it has the potential to address individual as well as organizational barrier to infection control. Performance of staffs in hand hygiene practices is measured by recruitment of trained observers and their role in looking for moment or opportunities at which hand hygiene should occur. The number of audited moments at the hospital was taken as a method to estimate compliance rate (myhospitals.gov.au 2017). The hand hygiene and infection prevention program indicates use of soap to keep hands clean. The hospital also provides directive to patients to prevent infection. They encourage visitors to clean hands before visiting hospital to prevent transmission of infection from outside source. The screening program for carriage of MRSA has been the most beneficial initiative at the hospital that has increased identification of infection risk and early treatment for patient (St. Vincent’s Private Hospital 2018). The most effective measurement method at the hospital is use of direct observation to measure quality indicator of hand hygiene. However, as the process is time consuming, improvement in direct observation method is needed to gain accurate results.

Quality Improvement Plan

There are much research evidence that has used different hand hygiene protocol to improve quality of care and reduce hospital-acquired infection. Chassin, Mayer and Nether, (2015) used hand hygiene as an indicator to prevent infection and identify causes of non-compliance to hand hygiene protocol. The research gave data regarding eight hospital’s identification of specific causes of hand hygiene non-compliance at their setting and targeting interventions to solve the problem. By means of implementation of a 22 month Hand Hygiene Project, compliance to hand hygiene was collected from eight hospitals. The compliance to hand hygiene was measured by two ways. Firstly, the cause of non-compliance was identified by secret observers. The second method was to observe for instance of non-compliance and inquire the reasons for not cleaning the hands. The analysis of compliance data by means of above two methods revealed inconvenient location of hand rubs, poor hand hygiene culture and poor supply of dispensers as some of the cause of non-compliance. Incomplete education and poor safety culture was also the reason for non-compliance. This outcome helped in planning appropriate intervention to improve hand hygiene practices and quality of care. For example, some hospitals implemented training program to educate on relation between hand hygiene and gloves when it was reported by staffs that hand hygiene is not necessary while wearing gloves. For difference cause identified in seven hospitals, different solutions were proposed. The strength of the literature was that it emphasized on identify most important cause on non-compliance and implement targeted approach to improve quality of care. Mumford et al. (2014) suggested development of framework as important to identify what quality indicator can encourage quality improvement in hospital setting.

The study by Gould et al. (2017) clarified regarding the effectiveness of different intervention to evaluate hand hygiene practices and its impact on patient outcome. The study reported that hand hygiene audit can be done by direct observation or by utilization of direct alcohol based hand rub.      Direct observation is regarded as gold standard methodology to evaluate hand hygiene. The benefit of direct observation method is that it can detect all opportunities of hand hygiene, identify barriers to compliance and improve performance in real time. However, the disadvantage of the method is that it is time consuming and cannot capture large data. Other approach to hand hygiene monitoring is product uptake rate which regarded as more sensitive indicator to evaluate impact of alcohol based antiseptic on hospital associated infection rate. The advantage of the product uptake method is that the process is cheaper and large amount data related to factors disrupting patient’s care can be identified. Electronic monitoring by the use of computerized devices has also been proposed and the advantage of this method is that it increases compliance rates. The research indicates that one challenge in the process is conducting auditing by different staffs.

Literature Review On Hand Hygiene Practices As A Quality Indicator

Marra and Edmond (2014) gave the evidence that compliance with hand hygiene is a good quality indicator for hospital patient safety programmes. Hand hygiene is necessary to control infection however the compliance rate of in many hospital is less than 50%. As direct observation to measure compliance to hand hygiene is regarded as inefficient and time consuming method, the researcher suggested several new technologies to monitor hand hygiene compliance. The study showed that by the use of electronic hand hygiene sensors. The research gave example of one study where nurse wore a credit card size badge that detects alcohol vapors and if the nurse used alcohol hand rub within 8 seconds of entering the patient room, the badge light turns green. This data was transmitted to a centralized database to monitor individual compliance data. However, the intervention cannot work if other agents are used by nurses. Hence, it is necessary that other important factors such as five moments for hygiene be incorporated in the electronic process to support health care workers to improve hand hygiene compliance and enhance patient safety in hospital setting.

Carter et al. (2016) measured hand hygiene compliance by looking for relationship between environmental conditions and proper hand hygiene in clinical setting. By means of a single-site observational study, trained observers recorded hand compliance among staffs. The observed also recorded other variable associated with hand hygiene compliance such as glove used, shift of observation, location, crowding and type of health worker type. The study proved links between environment and hand hygiene practices by showing that highest hand hygiene compliance rate was seen during non-crowding periods and among patients in private areas. Hence, the strength of the methodology was that it proved crowding as a barrier to hand hygiene compliance in the ED. It reflects the need to change health care environment and analyze role if crowding on infection transmission in hospital setting. Environmental modifications may help to support proper infection prevention practice and sustain high level of hand hygiene compliance

Plan: The process of direct observation method has been used as an audit method to evaluate compliance to hand hygiene practices among staffs at the St Vincent Hospital. The staffs were trained regarding hand hygiene practices too. However, one barrier that leads to non-adherence despite training staffs and implementation of hand hygiene protocol is the issue that staffs fail to conduct hand hygiene because of distraction or failure to implement hand hygiene protocol at critical moments during emergency situations or because of busy shift. Rees (2016) explains that multiple demands during shift and interruptions during the process affects compliance to hand hygiene (Quality indicator) Hence, the main purpose of quality improvement initiative is to address distractions during the process of hand hygiene and plan activities to reduce distraction and reduce moments of failure to hand hygiene practices. It is planned to reduce distractions during the process by training health care workers regarding the use of code work to signal missed opportunities of hand washing. It is planned to make changes in environment too so that staffs get the right support to comply with hand hygiene during critical moments.

Different Intervention Techniques For Improving Hand Hygiene Practices

To implement the plan, the desired action is to arrange safety training program where each staffs is educated regarding the need to complete all five moments of hand hygiene and remind other peer regarding performing hand hygiene at all times. The staffs will be trained regarding the use of code words while any peers missed an opportunity to hand wash. To make the process easier, it is also planned to use new technologies like automatic reminders and RFID to ensure that health care workers clean their hands during all critical moments. Evidence shows that electronic hand hygiene reminder system has the potential to increase hand hygiene activity and provide real time feedback regarding the procedure too (Ellison et al. 2015).  To track distractions and effectiveness of new technologies in preventing distraction during hand hygiene, coaches will be also appointed so that feedback could be provided to staffs regarding the way to manage distraction and maintain hand hygiene practices at the hospital.

With regard to the plan of making environmental changes in hand hygiene, the suggested action is to reinforce visual cues throughout the hospital setting so that nurses and other staffs do miss hand hygiene protocol during normal time as well as during a busy shift. Stickers and posters related to hand washing can be posted in important areas where hand hygiene is necessary. Hand Hygiene Practices And Compliance Safety In Healthcare Discussion Paper Nurses can use this to get reminders too. Evidence has shown the effectiveness of simple visual cue in improving hand washing compliance. It states that an environment that provides visual cues are effective strategies to minimize barrier to hand washing compliance (Ford et al., 2014).

The effectiveness of above mentioned plan of activities can be done by collecting data on number of missed opportunities to hand hygiene and reduction in infection rate at the hospital. The strategy of peer reminders and use of new technology to remind peers about hand hygiene can track the reduction in hand hygiene non-compliance rate. The electronic reminded system can be adjusted to collect data related to real time hand hygiene activity. In addition, the effectiveness of peer reminder can be judged by recruitment of a trained observer who can assess the manner in which staffs provided reminders to their peers and the rate of reduction in missed cases due to the activity. Furthermore, the effectiveness of visual cue can be done by evaluating the volume of hand hygiene products that has been used by the worker after implementation of the quality improvement initiative.

Measuring Hand Hygiene Compliance Rates Based On Environmental Conditions

After the evaluation of the effect of changes proposed to reduce distraction and improve hand hygiene, the above mentioned activities will be repeated every year at the clinical setting to sustain hand hygiene practices.

The effectiveness of the quality improvement initiative can be done by extracting real time data related to hand hygiene activity after providing electronic reminders to staff. The comparison of number of hand hygiene activity before and after the use of electronic reminder can help to detect improvement in hand hygiene events. The benefits of the change process can be confirmed when increase in hand hygiene activity is seen in clinical setting due to electronic reminder. The effectiveness of visual cues as the stimulus to increase hand washing can be judged by the analysis of volume of hand wash and alcohol rubs used during the change process. The increase in use of dispenser will give idea about the effectiveness of the strategy in improving one element of hand hygiene practices.

Conclusion:

Hand hygiene is one of the important health care activities to control infection and prevent quality and patient safety issues in practice. The report discussed about the quality indicator of compliance to hand hygiene to determine the impact of indicator in improve quality of care. With support from evidence, the report gave insight into different methods to measure hand hygiene compliance and gave about strength and weakness of each method. The report regarded disruption as one care element that influence hand hygiene practices and proposed a quality improvement plan to improve issues related to disruptions during the process of hand hygiene.

References:

Chassin, M.R., Mayer, C. and Nether, K., 2015. Improving hand hygiene at eight hospitals in the United States by targeting specific causes of noncompliance. Joint Commission journal on quality and patient safety, 41(1), pp.4-12.

Gould, D.J., Creedon, S., Jeanes, A., Drey, N.S., Chudleigh, J. and Moralejo, D., 2017. Impact of observing hand hygiene in practice and research: a methodological reconsideration. Journal of Hospital Infection, 95(2), pp.169-174.

Ellison III, R.T., Barysauskas, C.M., Rundensteiner, E.A., Wang, D. and Barton, B., 2015, August. A prospective controlled trial of an electronic hand hygiene reminder system. In Open forum infectious diseases (Vol. 2, No. 4, p. ofv121). Oxford University Press.

Ford, E. W., Boyer, B. T., Menachemi, N., & Huerta, T. R. (2014). Increasing Hand Washing Compliance With a Simple Visual Cue. American Journal of Public Health, 104(10), 1851–1856. https://doi.org/10.2105/AJPH.2013.301477

Rees, L., 2016. Exploring the Barriers and Levers to Hand Hygiene of Nursing and Medical Staff in Emergency Departments: A Mixed Methods Study.

World Health Organization, 2017. WHO guidelines on hand hygiene in health care. First global patient safety challenge clean care is safer care. 2009. Retrieved from whqlibdoc. who. int/publications/2009/9789241597906_eng. pdf.

Sickbert-Bennett, E.E., DiBiase, L.M., Willis, T.M.S., Wolak, E.S., Weber, D.J. and Rutala, W.A., 2016. Reduction of healthcare-associated infections by exceeding high compliance with hand hygiene practices. Emerging infectious diseases, 22(9), p.1628.

St. Vincent’s Private Hospital (2018). Infection Prevention and Control. Retrieved from: https://svph.ie/visitors/announcements/

myhospitals.gov.au 2017. Safety and Quality. Retrieved from:  https://www.myhospitals.gov.au/hospital/016150J/st-vincents-private-sydney/hand-hygiene

Monsalve, M.N., Pemmaraju, S.V., Thomas, G.W., Herman, T., Segre, A.M. and Polgreen, P.M., 2014. Do peer effects improve hand hygiene adherence among healthcare workers?. Infection Control & Hospital Epidemiology and Nursing, 35(10), pp.1277-1285.

Mathur, P., 2011. Hand hygiene: back to the basics of infection control. The Indian journal of medical research, 134(5), p.611.

Carter, E.J., Wyer, P., Giglio, J., Jia, H., Nelson, G., Kauari, V.E. and Larson, E.L., 2016. Environmental factors and their association with emergency department hand hygiene compliance: an observational study. BMJ Qual Saf, 25(5), pp.372-378.  Hand Hygiene Practices And Compliance Safety In Healthcare Discussion Paper