Hand hygiene initiative
The
MPSC goal for this project was to achieve at least a 50% increase in
hand hygiene compliance as compared to baseline in both Madison
hospitals and clinics through
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development and implementation of a system for measuring adherence of
healthcare workers to recommended hand hygiene practices and
improvements in compliance post-intervention and
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development, implementation and evaluation of interventions designed
to improve compliance.
Studies have found mean baseline compliance rates ranging anywhere from
5% to 81%, with an overall average of just 40%. Healthcare workers cite
a number of barriers that hinder compliance with recommended hand
hygiene practices.
Components of this initiative include:
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Implementation of a system to measure hand hygiene compliance
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Heightened education
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Interventions designed to reduce barriers
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Expansion of alcohol-based waterless products.
The
group worked together to devise processes and strategies to gauge and
facilitate hand hygiene:
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Shared previous efforts at each of the member organizations to promote
hand hygiene.
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Developed and implemented methodology to measure hand hygiene
compliance
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Completed baseline and subsequent quarterly data collection.
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Trialed & selected waterless alcohol-based products, where necessary.
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Implemented/expanded and promoted use of alcohol-based waterless
products across hospitals and clinics.
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Compiled compliance data and provided to staff, physicians and
organization leadership
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Provided heightened education on importance and proper hand hygiene
techniques and waterless products, including a community-wide Hand
Hygiene Awareness Week.
Lessons Learned
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Waterless product expanded/fully implemented at all 6 organizations.
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Achieved more than a 150% increase
in observed adherence thus far. However, there is still room for
improvement.
-
It has been beneficial to record compliance by categories of personnel
so that efforts can be focused on areas requiring greatest
improvement.
-
Project has proven instrumental in helping gain organizational support
for the implementation and expansion of the waterless alcohol-based
products.
Hand Hygiene Initiative Summary—Individual Organizations
Clinic A
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Shared packet of educational materials. Packets were provided to the
units for supervisors to use in educating all of their staff. The
comprehensive binders included presentations, handouts and scripts for
supervisors. As well, a segment is being prepared for the patient
newsletter specifically about the new guideline and product being
used.
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Adherence: 8-19%
Clinic B
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Med and clinic staff are using the waterless more now and now use
correctly more often.
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The storeroom has been keeping track of product volume. From Jan. to July, 19 cases were ordered by
clinics. From July to Nov., 32 cases were ordered by the clinics.
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Adherence: 3-43%
Hospital A
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Has product implemented
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Some
units hit 100% compliance
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For Infection Control Week, Hospital A developed a traveling trophy— awarded to the unit that has the best hand hygiene
adherence for the month/quarter.
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Made respiratory etiquette kits for distribution
to patients/family members in need. They include tissue, a mask, a
bottle of waterless alcohol handrub and a bag for disposal of tissues,
etc.
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Implemented
a patient education hand hygiene model that advocates the active
involvement of patients, particularly patients asking providers to
wash their hands before providing care. The program included a manual,
brochures and database support for measuring handwashing compliance
via amount of soap used and patient days.
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Data was collected for 6 weeks on product volume used.
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Buy-in and championing by the Chief of Staff.
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Patients were asked about staff hand hygiene on patient
satisfaction forms.
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Adherence: 14-86%
Hospital B
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Expanded waterless product to all units.
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Waterless foam up in all patient rooms (with the
exception of Psych) and areas, including ICU, ER and the waiting areas
for the ICUs. Individual gel bottles also available.
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Education programs for hospital and medical staff and observation
results communicated to medical staff via newsletter and Medical Staff
Office.
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The hand hygiene work is being extended to the rest of Hospital B’s
system and the MPSC measurement methodology and template have been
shared.
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Hand Hygiene is one of Hospital B’s 2004 safety themes, so there will
be education and posters around the hospital, etc. Focus will be on
when and how to use the waterless product. It will also be one of the
housewide competencies—including demonstration, that staff know it is
critical and a JCAHO goal and all departments will have to submit a
Hand Hygiene improvement plan in 2004.
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Adherence: 26-49%
Hospital C
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Hospital C has waterless dispensers up in all inpatient and clinic
rooms. People generally like the product a lot and have commented on
improved hand condition.
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Infection control physician has been speaking to Department Directors
re: hand hygiene.
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ICPs are speaking at meetings on each inpatient unit as a means of
heightening awareness and also fielding any questions/concerns.
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Hand Hygiene sheets were distributed with Payroll.
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Approach is to "pace" interventions over time in order to keep
awareness up. For example, Hospital C will wait a few months and then
will survey employees regarding use of the product, a little later
will distribute the hand hygiene buttons, etc. They hope to keep the
issue before employees long-term.
-
Currently
implementing Cereplex—an automated system to track infections and
antibiotic usage patterns.
Hospital D
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Has been trialing and evaluating a new formula of their waterless with
slightly less alcohol, more emollients, etc. Hospital D may also
change dispensers or add a splash/drip guard.
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Has recently changed how measure due to investigation of use of
suboptimal waterless category; this learning was shared with other
members.
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Adherence: 59-71%
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