This Program and manual have been developed by the HHA Co-ordinating Centre at Austin Health.

Transcription

1 Advanced Draft Version 4 December 2008

2 This Program and manual have been developed by the HHA Co-ordinating Centre at Austin Health. Acknowledgements Australian Commission on Safety and Quality in Healthcare Hand Hygiene Victoria - Department of Human Services Victoria Infectious Disease and Infection Control Departments of Austin Health Hand Hygiene Australia Coordinating Centre Professor Lindsay Grayson Dr Joe Torresi Mr Phil Russo Mrs Kaye Bellis Mrs Kate Ryan With assistance from : Mr Kel Heard and Ms Rhea Martin Contact Details: hha@austin.org.au Phone : Fax : Website: Hand Hygiene before and after every patient contact

3 Foreword Improving hand hygiene (HH) among healthcare workers (HCW) is currently the single most effective intervention to reduce the risk of hospital-acquired infections in Australian hospitals. Although improving HH compliance seems an obvious and intuitive idea, changing attitudes and behaviour among HCWs in a healthcare system that for decades has not emphasised the importance of HH requires a major change in HCW culture and education. Instituting and sustaining culture-change among humans is always a challenging task, but recent Australian and international studies have shown that, given the right approach, Australian HCWs have readily adopted HH culture-change and the increased use of alcohol-based hand rub in their healthcare practice. These changes in attitudes and behaviour have resulted in a greater than 50% reduction in the rates of nosocomial disease associated with methicillin-resistant Staphylococcus aureus (MRSA) and other multi-resistant pathogens in some States after just 1-2 years. Until recently, many Australian medical and nursing schools did not have education regarding alcohol-based hand rub and the importance of HH compliance as components of their curricula clearly there is a lot to do in achieving sustainable HH culture-change. Nevertheless, a systematic approach can be taken with HH culture-change in which not only HCWs, but the entire Australian community, places a greater importance on good HH as a crucial means of controlling disease transmission. Excellent HH compliance needs to become one of the key indicators of whether a hospital delivers good healthcare and becomes an integrated feature of the Australian healthcare system. The National Hand Hygiene Initiative is a first step in instituting nationwide HH culture-change. Hand Hygiene Australia (HHA) has the responsibility of coordinating this national program that we hope will soon result in major improvements in HH and disease reduction, and the eventual embedding of HH as a key component of how we judge healthcare quality. This manual outlines in a clear and systematic manner the HHA approach to HH culture-change in Australia. It builds on the highly successful programs recently conducted in Australia and by the World Health Organization. Integration of the WHO 5 Moments program into the HHA program allows Australian HCWs and hospitals to benchmark their rates of HH compliance both nationally and internationally and helps to ensure that Australian healthcare is of a truly international standard. This manual does not aim to provide an in-depth analysis of infection control or be a textbook on infectious diseases. Instead, it provides a practical step-by-step guide to implementing HH culture-change in your hospital and how to participate in the HHA national HH program. We hope that it helps your hospital to provide even better healthcare to your patients and the Australian community. Prof. M. Lindsay Grayson Director, Hand Hygiene Australia Infectious Diseases Department, Austin Health University of Melbourne, Victoria Hand Hygiene before and after every patient contact

4 Contents Glossary Chapter 1 Introduction 1.1 The Problem Page The Solution Page The Hand Hygiene Australia Culture-Change Program Page 1.2 Chapter 2 Project management and Outcomes 2.1 Aim Page Project implementation model Page Initial Tasks of the Hand Hygiene Project Team Page Hand Hygiene Program Targets and Outcome Measures Page Timetable for data submission Page 2.3 Chapter 3 Achieving Effective Cultural Change 3.1 Leadership and ownership Page Development of policies and protocols Page Promotion of Hand Hygiene Page Sustainability Page 3.3 Chapter 4 Hand Hygiene Product Selection and Placement 4.1 Aim Page Product selection Page Staff preference Page Product placement and supply Page Alcohol Based Hand Rub Use Page Alcohol Based Hand Rub Limitations Page Hand Hygiene Product Compatibility Page Hand care issues Page Cutaneous Absorption Page Fire Safety Page Cost Page Storage and Safety Page 4.6 Chapter 5 Health Care Worker Education 5.1 Aim Page Educational approach Page Strategies to educate staff on Hand Hygiene practices Page Teaching tools Page Educating medical staff Page 5.2 Chapter 6 The 5 Moments 6.1 Aim Page What are the 5 Moments for HH Page The 5 Moments in Detail Page Detailed Examples of the 5 Moments Page The Rules for Auditing the 5 Moments Page 6.7 Hand Hygiene before and after every patient contact

5 Chapter 7 Hand Hygiene Outcome Measures - Compliance 7.1 Aim Page Training, Analysis and targets Page Methodology Page Practical issues associated with Hand Hygiene Compliance Page Data entry and management Page Data Analysis Page Reporting Results Page 7.5 Chapter 8 Hand Hygiene Outcome Measures - Rates of SAB 8.1 Aim Page Rates of MRSA bacteraemia Page Specific Details and Definitions Page 8.1 Chapter 9 Other Useful Interventions 9.1 Aim Page Clean Between Program Page 9.1 Frequently Asked Questions Contact Details for Assistance References Appendices 1. WHO Glove Use Recommendations 2. Checklist for Introduction of a HH Culture Change Program 3. Recommendations for the placement of ABHR in public areas 4. Sample HH Credentialing Policy 5. Sample Cleaning Shared Equipment Policy 6. Guidelines for the Standardisation of HH Compliance Auditors 7. Sample Hand Hygiene compliance assessment tool 8. Hand Hygiene Compliance Tool Coding Sheet 9. Sample HH Compliance Assessment Form 10. Sample Hand Hygiene Policy 11. Indications for Hand washing & Hand antisepsis 12. Ranking System for Evidence 13. Sample Jewellery / Nails Policy 14. Flow Chart for Management of Staff with Hand Concerns 15. Sample Department Product Auditing Form 16. Sample Allocation Schedule 17. HHA Compliance Database 18. Sample HHA Compliance Report - Ward Format 19. Sample HHA Compliance Report Health Service Format 20. Prospective SAB Data Collection Form 21. Retrospective SAB Data Collection Form 22. SAB Case Review Form 23. SAB Database Snapshot 24. Aussie 5 Moments Poster 25. WHO Hand Wash Poster 26. WHO Hand Rub Poster 27. Website Links Hand Hygiene before and after every patient contact

6 Glossary

7 Glossary The following terms are referred to throughout this manual: Alcohol-based hand rub (ABHR) An alcohol-containing preparation designed for application to the hands in order to reduce the number of viable organisms with maximum efficacy and speed. Bacteraemia The presence of bacteria in the blood. Body Fluids Any substance secreted by the body with the exception of sweat. These include: Blood, Lochia, Saliva, Secretions from mucous membranes, Pus, Gastric and respiratory secretions, Semen, Tears, Wax, Breast milk, Colostrum, Urine, Faeces, Meconium, Vomitus, Pleural fluid, Cerebrospinal fluid, Ascites fluid, Biliary fluid, Bone Marrow, Organic body samples eg. Biopsy samples, organ and cell samples. Body Fluid Exposure Risk Any situation where contact with body fluids may occur. Such contact may pose a contamination risk to either HCW or the environment. Contact The touching of any patient, their immediate surroundings or performing any procedure. Decontaminate hands Application of either an antimicrobial soap/solution and water or an alcohol-based hand rub product, to the surface of the hands. This process reduces microbial counts on hands. Glove use Glove use by HCWs is recommended for two main reasons: to prevent microorganisms which may be infecting, commensally carried, or transiently present on HCW s hands from being transferred to patients and from one patient to another; and to reduce the risk of HCWs acquiring infections from patients (1) (see Appendix 1 for The WHO recommended guidelines). Hand Hygiene (HH) A process that reduces the number of micro-organisms on hands. Hand hygiene is a general term applying to the use of soap/solution (non-antimicrobial or antimicrobial) and water or a waterless antimicrobial agent to the surface of the hands (e.g. alcoholbased hand rub). Hand Hygiene Action A Hand Hygiene Action can be undertaken either by rubbing with an ABHR, or hand washing with soap and water. Hand Hygiene before and after every patient contact

8 Hand Hygiene Compliance Is a measurement of appropriate HH. It is defined when HH is considered necessary and is classified according to one of the 5 Moments (see below). If the action is performed when there is no indication and it has no impact in terms of preventing microbial transmission, then it is not considered to be an act of HH compliance. The number of Moments constitutes the denominator for assessing HH compliance. The actual HH actions undertaken are compared to the number of Moments observed to calculate the rate of HH compliance. HH non-compliance is defined when there is an indication for HH (i.e. a Moment ) and yet no HH was undertaken. Hand Hygiene inter-observer reliability A measure of the agreement or consistency of ratings between two or more HH observers after observing the HH compliance on a series of subjects (see section 7.3.5). Hand Hygiene Moments Moments are based on those defined by the WHO Guidelines on Hand Hygiene (1). Some minor modifications have been made for Australian healthcare conditions. A Moment is when there is a perceived or actual risk of pathogen transmission from one surface to another via the hands. HCWs hands will come in contact with many different types of surfaces while undertaking a succession of tasks. The 5 Moments for HH are: Moment 1: Moment 2: Moment 3: Moment 4: Moment 5: Before touching a patient Before a procedure After a procedure or body fluid exposure risk After touching a patient After touching a patient s surroundings Hand Hygiene Opportunity In Australia, this term is no longer commonly used; instead the term Moment is used. Hand Hygiene Product Any product used for the purpose of HH, including soap and water. Hand washing The application of non-antimicrobial soap and water to the surface of the hands. Healthcare-Associated Infections (HCAI) Infections that originate from, or are related to, a healthcare setting or the delivery of healthcare. Healthcare Surroundings Refers to all regions outside of the Patient zone. This includes the curtains, partitions and doors between separate patient areas. Health Care Worker (HCW) Any employee of a healthcare institution who has patient care responsibilities and / or contact with a patient (see Contact). Hand Hygiene before and after every patient contact

9 Hospital-associated infections (HAI) An infection that was not present or incubating prior to the patient being admitted to the hospital, but occurred > 48 hours after admittance to the hospital. HAI s are also termed nosocomial infections. Inter-rater (or Observer) Reliability A measure of agreement or consistency of ratings by two or more observers on a series of subjects. Intra-rater Reliability A measure of agreement or consistency of two or more ratings by a single observer on a series of subjects. Invasive Medical Device Any piece of equipment that enters a patient s skin or body cavity. This encompasses the entire device (eg. IV line, IV pump and IV pole). Methicillin-resistant Staphylococcus aureus (MRSA) Staphylococcus aureus that is resistant to methicillin/flucloxacillin. Commonly referred to as golden staph. Methicillin-susceptable Staphylococcus aureus Staphylococcus aureus that is susceptible to methicillin/flucloxacillin. Occupied Bed Days (OBDs) Is the sum of the number of occupied beds for each day of the specified period. Outcome Measure A feature used to describe the effects of care on the health status of patients and populations (e.g. infection rate). Patient Refers to any part of the patient, their clothes, or any medical device that is connected to the patient. Patient contact or direct patient contact This involves touching the patient, and their immediate surroundings or performing any procedure on the patient. Patient Immediate Surroundings The Patient Surroundings is the space temporarily dedicated to an individual patient for that patient s stay. This includes, furniture, medical equipment, medical chart and personal belongings that are touched by the patient and HCWs while caring for that patient. Patient Zone Includes the Patient and the Patient Immediate Surroundings. Procedure Is an act of care for a patient where there is a risk of direct introduction of a pathogen into the patient s body. Hand Hygiene before and after every patient contact

10 Process Measure Is a measurement of what is actually done in giving and receiving care, e.g. timing of surgical antibiotic prophylaxis, measuring how many times staff wash hands. Reliability The extent to which a measurement is consistent and free from error. Separations A separation from a healthcare facility occurs anytime a patient leaves due to discharge, death, or transfer. Sterile task A task performed in such a way as to avoid microbial contamination or inoculation. Structured observation A method to quantify HCW behaviour using a format that is structured in a manner that is likely to avoid bias and improve consistency. Structured observations provide information on what people actually do, rather than on what they say they do or did. They also provide information on the associated activities and behaviours that precede and follow HH compliance (2). Validity Refers to the accuracy of a measure. It is the extent to which a measuring instrument actually measures what it is supposed to measure. Hand Hygiene before and after every patient contact

11 Chapter 1 Introduction

12 Chapter 1 Introduction Hand Hygiene before and after every patient contact 1.1 The problem Poor HH practice (hand washing, hand disinfection) among Health Care Workers (HCWs) is strongly associated with nosocomial infection transmission and is a major factor in the spread of antibiotic-resistant pathogens within hospitals (3, 4). Despite this, efforts to improve the rate of HH compliance have generally been ineffective or their efficacy poorly sustained. Numerous barriers to appropriate HH have been reported (5, 6) including: HH agents causing skin irritation and dryness Patient needs perceived to take priority over HH Hand washing sinks/basins inconveniently located and/or not available The perception that glove use dispenses with the need for additional HH Insufficient time for HH, due to high workload and understaffing Inadequate knowledge of guidelines or protocols for HH Lack of role models Lack of recognition of the risk of cross-transmission of microbial pathogens Until recently, lack of scientific information showing a definitive impact of improved HH on nosocomial infection rates Simple forgetfulness 1.2 The solution The use of alcohol-based hand rub (ABHR), coupled with changes in the recommended indications for HH and a change in the HH culture of HCWs (attitudes and behaviour) provides the best approach to preventing nosocomial infection transmission. Recent research (1,3) has demonstrated that ABHRs are better than traditional soap and water because they: Require less time to use Result in a significantly greater reduction in bacterial numbers than soap and (7) water in many clinical situations Cause less irritation to the skin Can be made readily accessible to HCWs (8, 9) Are more cost effective HCWs must perform HH before and after every patient contact to prevent patients becoming colonized with nosocomial pathogens from other patients and the hospital environment. Emphasis must also be placed on preventing the transfer of organisms from a contaminated body site to a clean body site during patient care. The latest guidelines also recommend HH after contact with inanimate objects, including (3) m edical charts and equipment in the immediate vicinity of the patient. Minimisation of irritant contact dermatitis related to appropriate HH is essential for improved HH compliance. The provision of a moisturising skin-care product, staff Hand Hygiene before and after every patient contact 1.1

13 education and a tolerant, supportive attitude to any reported problems are a key part of successful introduction of a new ABHR. Australian, Asian, and European studies (1,5,10,11,12,13) have demonstrated the clinical efficacy of a HH Culture-Change Program that includes the introduction of ABHR, with a marked and sustainable increase in HH compliance and a significant reduction in nosocomial infections. 1.3 The Hand Hygiene Australia Culture-Change Program The Australian Commission on Safety and Quality in Health Care (ACSQHC) has instigated the National Hand Hygiene Initiative (NHHI) and assigned its delivery to Hand Hygiene Australia (HHA). The primary aim of the HHA Program is to improve HH compliance among HCWs, and subsequently the Australian public, to reduce the transmission of infection in health services throughout Australia. This involves a multi-interventional culture-change program to improve HH compliance via the increased use of ABHR. Key features of the HHA Culture-Change Program include the following: Use of alcohol-based hand rub (ABHR) ABHR should be placed at point-of-care (e.g. foot of the bed). Clear signage regarding appropriate use should be present. Ensuring ABHR is readily available at the point-of-care, including patient beds, on trolleys and in clinical areas, can reduce many of the potential barriers to good HH. Education should be provided clearly stating the advantages of ABHR namely that it takes approximately seconds to decontaminate hands, is less irritating and drying than soap and water and does not require the use of paper towels. (See Chapter 4 regarding specific ABHR product selection) National Hand Hygiene Initiative The National Hand Hygiene Initiative aims to improve knowledge about infection control among HCWs, especially regarding the importance of appropriate HH in reducing the risk of healthcare associated infections (10,11,14,15,16). The program, which will be introduced by HHA, is multi-faceted and includes education regarding HH and ABHR, monitoring HH compliance and measuring infection rates. Crucial to this education process is timely feedback of these results to HCWs. The recruitment of ward champions to facilitate the process and encourage local ownership of the program is an advantage Monitoring Outcome Measures Monitoring the effects of the interventions involve assessing: The rates of HH compliance as recorded by validated observers The rates of SAB Ensuring appropriate Infection Prevention education To assist with improving HCWs general knowledge about infection prevention and HH, a computer-based credentialing program will be available to Australian institutions via the HHA website ( Executive endorsement of credentialing as a compulsory requirement for all staff and students has proven successful in many institutions in improving HH compliance. The program assists with education even in situations where there are high rates of staff turnover. Hand Hygiene before and after every patient contact 1.2

14 Chapter 2 Program Management and Outcomes

15 Chapter 2 Program Management and Outcomes 2.1 Aim To form a multidisciplinary team to lead the implementation of the Hand Hygiene Program. 2.2 Program Implementation Model The program aims to decrease hospital-acquired infections in health services by introducing the National Hand Hygiene Initiative program and increasing the use of ABHR. The program involves: Choosing a Program Officer and Medical Champion who, along with the Infection Control team, will be the core team responsible for the project Introducing an ABHR and new improved HH practices to selected pilot wards. Evaluation of pilot ward data Hospital-wide introduction of an ABHR and new improved HH practices Achieving a hospital-wide improvement in HH Monitoring the two key outcome measures of HH compliance and rates of SAB. This should include a baseline assessment of HH compliance and collection of the previous 24 months data on SAB A step-by-step guide to introducing a HH culture-change program can be found in Appendix Initial tasks of the HH Project Team Forming a Steering Committee Identifying key members of a health service is a critical element for engaging clinical and non-clinical staff in the project, and for supporting the core HH Program Team. It is important that an Executive sponsor is identified and that they are a part of the Steering Committee. The following list identifies some potential members for this committee: Project officer Medical champion Infection control consultant(s) Pharmacist Infectious Diseases Physician(s) Microbiology laboratory representative Medical and/or surgical representative Quality Improvement representative Human resources/public relations/corporate development representative OH&S representative HH program representative from each pilot ward (ward champion) Clinical education representative Allied Health Environmental Services representative Patient representative/consumer Hand Hygiene before and after every patient contact 2.1

16 2.3.2 Allocate roles and responsibilities Areas for consideration: Line of reporting for committee members Education Marketing Data collection ABHR selection Product placement o A well organised and executed plan for installation of HH products is an essential step in any program to enhance HH adherence in health care settings (17) Implementation of policies and procedures (see Appendices 3 to 6) o HH Credentialing o Cleaning shared equipment o OH&S safety management of ABHR o Standardisation of HH Compliance Auditors Selection of Pilot wards HHA recommend the initial selection of three acute wards to pilot the project in larger health services, and at least one ward in smaller health services. Selection should be based on: Known high rates of HAI Wards where infections result in poor patient outcomes (eg. Cardiac surgery, orthopaedic, vascular, general surgery, renal, ICU) High proportions of shared rooms to facilitate the measurement of HH compliance For hospitals with an ICU it is encouraged that it be selected due to the high-risk nature of the patient care 2.4 Hand Hygiene Program Targets & Outcome Measures Outcome Measure 1: Hand Hygiene Compliance HH compliance should be measured at specified intervals during the program, with the number of acute in-patient beds at each facility dictating the number of areas required to be audited, and the number of observations to be undertaken once the pilot period has been completed (see Table below). The standardised HH compliance assessment tool should be used for all assessments (see Appendix 7-9). Number of acute inpatient beds at the hospital Required number of HH audits per year Required number of wards/areas per HH audit > < Required number of HH observations per ward area Training in the HH compliance assessment tool, data collection, data entry and data analysis will be provided for all participating hospitals by HHA. Hand Hygiene before and after every patient contact 2.2

17 Further assistance is available by contacting Hand Hygiene Australia Coordinating Centre by on or see contact details for assistance. Regional visits will be provided as required. Rates of HH compliance will be assessed and reported according to a number of specified criteria, including by professional category, HH product used, glove use, and type of activity performed. Timely feedback and education should be provided to all HCWs observed (e.g. nurses, medical staff, allied health and other, See Chapter 7 for details) Outcome measure 2: Rates of Staphylococcus aureus bacteraemia Monthly rates of clinical SAB for each healthcare institution should be submitted at the same time as HH compliance data are submitted. The monthly rates of SAB will be reported for each hospital and each State. Reports should be submitted three times a year with the results of each HH compliance audit. (See Chapter 8 for details). 2.5 Timetable for data submission HH compliance assessments and SAB rates should be undertaken according to the following recommended schedule: Commence HH compliance audit Complete HH compliance audit Submission deadline to State Co-ordinator Hand Hygiene Australia Reports Due: Audit 1 February Mid March 3 rd April May Audit 2 June End July 7 th August September Audit 3 September Mid November 27 th November January Any changes to the above timeframes will be published on the HHA website. Data is to be initially submitted to the State /Territory Coordinator, who will then forward to HHA. Hand Hygiene Australia State / Territory Coordinator Healthcare Network 1 Hospital 2 Hospital 3 Hospital 1a Hospital 1b Hospital 1c Hand Hygiene before and after every patient contact 2.3

18 Chapter 3 Achieving Effective Culture-Change

19 Chapter 3 Achieving Effective Culture- Change Sustaining improved HH involves a culture-change program. The following are the key components of this program. 3.1 Leadership and Ownership Executive commitment The Hospital Executive should demonstrate commitment and support of the HH Program (10) through interest, participation and regular reporting on the Program at Executive meetings, and to the Hospital Board. For the successful implementation and sustainability of the HH Program, resources will be required to initiate the program within each hospital. Some of the requirements may include: appointment of a project co-ordinator, initial purchasing of ABHR for the entire hospital, then ongoing ABHR costs, and educational materials Clinical leadership team Staff from the Departments of Infection Control, Infectious Diseases, Microbiology and Pharmacy (where available) should have an active role in the program implementation throughout the organisation Staff ownership Staff ownership of the program should be encouraged and supported through: Interested ward/department staff who should be appointed as HH liaison officers or ward champions to take responsibility for HH promotion in the ward/department, including HH credentialing. Ensuring each ward/department nominates a staff member to be accountable for a HH portfolio (see Section 3.1.4) The use of education tools and constant reminders Provision of audit tools to ward staff to assess product availability Staff completion of HH credentialing package Ward-based promotional activities (see Section 3.3) Promotional material such as ABHR T-shirts, hats etc. these can be worn by the HH program team during educational sessions, presentations and launches. Merchandise may also be supplied to staff as prizes Regular and timely feedback to ward staff Recognition of each ward/department s achievements Hand Hygiene Program Liaison Officers The appointment of ward/department-based HH liaison officers or champions are helpful in linking the ward and the HH program and assist with the National Hand Hygiene Initiative. Hand Hygiene before and after every patient contact 3.1

20 This role involves: Motivating staff Facilitating involvement and ownership of the project by HCWs in each ward Presenting outcome data to staff Monitoring product placement and availability by conducting audits Assisting with promotional activities in their ward Assisting HCWs in their ward to complete the credentialing package Acting as role models for other staff Educating new staff in HH and ABHR use 3.2 Development of policies and protocols To embed the changes in HH practices into the culture of each healthcare institution a number of policies need to be developed: Hand Hygiene Policy Hand Hygiene before and after every patient contact recommending the use of ABHR by all HCWs (see Appendix 10-12) Credentialing of HCWs in knowledge about HH. Support for credentialing by hospital Executive can greatly assist with its implementation. (see Appendix 4) Clear guidelines about wearing jewellery and acrylic/false nails in clinical areas (38) due to increased risk of colonization (see Appendix 13) Guidelines for appropriately managing HCWs who have contact dermatitis potentially associated with HH product use. (see Appendix 14) Cleaning shared equipment policy Clean Between (see Appendix 5) Clear guidelines on placement of ABHR in healthcare facilities (see Appendix 3) Occupational Health and Safety policy on storage of ABHR (as per ABHR MSDS from company supplying product) Credentialing of HH auditors on knowledge of HH compliance assessment (see Appendix 6) Identify key staff figures to ensure ABHR bottles are replaced when empty, and brackets are installed appropriately and replaced when broken. 3.3 Promotion of Hand Hygiene Promotion of HH in each hospital can be undertaken in many ways. The following include a few popular suggestions: Talking Walls campaign A popular method to assist with staff ownership is the Geneva Talking Walls model (10). The principle of Talking Walls is to use art and humour to reinforce the principles of infection prevention through improved HH among staff. Staff from each ward can be invited to help design a poster featuring their own HH message. The resulting posters can then be placed throughout the hospital acknowledging the ward s creativity (ensure own hospital policy on poster placement is known prior). Benefits of this approach include: Promotion of program ownership to reinforce the National Hand Hygiene Initiative by directly involving local HCWs Reinforcement of the rational left brain messages with pictorial right brain emotional messages (for further details see Hand Hygiene before and after every patient contact 3.2

21 The Talking Walls campaign involves ward staff meeting with the Program Officer, Infection Control staff and often the HH artist to discuss ideas for posters depicting a campaign message. The poster should depict activities or practices reflective of their ward environment and should include identification of the ward that helped in its design. HCW involvement in the process should include: Selecting Talking Wall sites to be background-painted for poster display Determining the winning poster out of the various drafts that are developed Assisting with rotation of all ward posters as new posters became available. Ensure posters are laminated to enable suitable cleaning If suitable, some posters can also be used to label promotional material such as on wine bottle labels, display boards and Christmas cards, brochures etc. Posters are also useful in HH Program presentations and launch activities Other promotional activities Give aways BBQ lunch/ward lunch/afternoon tea Spot prizes Stickers/badges/pens/sticky note pads (with HH slogan on them) Slogan competitions Quizzes, crosswords, word search Pay slip notices Internal magazines/newsletters Screen savers 3.4 Sustainability Key features of long-term sustainability include the following: Hospital-wide rollout For this program to be successful the enthusiastic and continued support of your hospital Executive is essential. HCW acceptance and ownership of the National Hand Hygiene Initiative program assists sustainability Hand Hygiene Credentialing HH credentialing can play a key role in sustaining good HH practice and maintaining the National Hand Hygiene Initiative. An online HH learning and credentialing package has been shown to be effective in supporting this process (18). The package includes a series of educational slides and questions, and provides immediate feedback after each answer is selected - users can only move to the next slide after they have selected the correct answer. A user is considered credentialed in HH if they achieve a score of 100%. The implementation of credentialing will vary from hospital to hospital and each will need to work with their respective IT departments, HR departments or others as needed. All data should be recorded (user name, type of HCW, department, employment status, answers selected and final score) which should allow access to reports by managers and clinical coordinators regarding the number of staff who are credentialed. To access a copy of a HH online learning package monitor the HHA website as the learning package should be available in the near future. Alternatively, healthcare institutions can develop their own package. Hand Hygiene before and after every patient contact 3.3

22 Some important components of the policy for consideration include: Credentialing in HH to be a condition of employment for all new HCWs. This condition can been written into employment contracts and also made a requirement for all student HCWs in a number of institutions. The HH credentialing package should be readily available to all staff by means of the hospital intranet or by paper-based copies where the results can be later entered onto the credentialing database. Alternatively, the credentialing can be undertaken during the hospital orientation program for new staff. Ideally new employees should complete the credentialing package before they can obtain their photo ID badge, at hospital induction programs, or as soon as possible after employment. Certificates can be generated on successful completion of the credentialing process. A database should be maintained enabling Infection Control staff and ward managers to identify non-credentialed staff or Departments that require further assistance. The credentialing package could become a mandatory component of the annual or biannual performance appraisal of all HCWs. Awareness of the credentialing package can be promoted via: Hospital Intranet Promotional cards Pay slip messages Recruitment of HH Program representatives Poster displays Electronic reminders, including lists of HCWs sent to key managers Barriers to achieving change Change is a fundamental component of continuous quality improvement. Any improvement methodology involves introducing change and measuring its impact. In health care there has been recognition of the need for system change to support the delivery of safe, quality care. Every system is perfectly designed to achieve exactly the results it gets. This focus on system change has been associated with the development of a number of tools and improvement strategies. Health services are also implementing system change in response to risk areas identified through review of adverse events. It may help those involved in managing the HH Program to be aware of the barriers that normally confront any change process. Knowledge or awareness of change processes may assist in ensuring the success of a project. The following figure provides an example of how the principles of culture change may be communicated to show the ways in which the various aspects of the projecteducation, promotion, advocacy, policies and standards, environmental support, credentialing interact to achieve cultural change (19). Hand Hygiene before and after every patient contact 3.4

23 Figure HH Culture-Change (19) Increase awareness of the importance of HH: Program Launch Promotional initiatives Monitoring and feedback of HH Compliance, and SAB rates to provide encouragement Hand Hygiene Provide education to enable staff to learn correct HH Provide a supportive environment to encourage and promote ABHR use and HH compliance Strong executive and clinical leadership Ready access to ABHR Access to moisturiser Development of policies and procedures Hand Hygiene before and after every patient contact 3.5

24 Chapter 4 Hand Hygiene Product Selection And Placement

25 Chapter 4 Product Selection and Placement 4.1 Aim To successfully implement and sustain a HH Culture-change program a major factor is to ensure the choice of HH solution is acceptable to the users, and that all logistical issues in product installation have been addressed. A well-planned and wellexecuted installation of HH products is an essential step in any program to enhance hand hygiene adherence (17). Before deciding on the selection and placement of ABHR for your facility, it may be useful to provide HCWs with the opportunity to evaluate these products. 4.2 Product selection Product features Alcohol-based hand rubs are more effective against most bacteria and many viruses than either medicated or non-medicated soaps (see figure 1 below). Ideally, ABHR products should to be listed on the Australian Register of Therapeutic Goods for use in hospitals. Figure 1: Effectiveness of different HH products in reducing bacterial counts after 30 sec. use. Efficacy of hand hygiene products Log reduction in bacterial counts after 30 sec Mean Change (Log CFU) Soap Iodophor 4% CHG 70% Alcohol Original data from: Ayliffe GAJ et al. J Hosp Infection 1988;11:226 The activity of ABHRs against bacteria, fungi and viruses is affected by a number of factors including: Type of alcohol: Isopropanol and ethanol both have in-vitro activity against bacteria, fungi and viruses. When tested at the same concentration, isopropanol is more efficacious than ethanol (1), however ethanol has greater activity against viruses than isopropanol (1, 47). Hand Hygiene before and after every patient contact 4.1

26 Alcohol-only ABHR versus. alcohol-chlorhexidine ABHR: Although alcohols are rapidly germicidal when applied to the skin, they have no appreciable persistent or residual activity. The addition of chlorhexidine results in persistent activity (20) and therefore potentially improved efficacy. Notably, all published clinical studies that have demonstrated reductions in healthcareassociated infections (HAIs) with the use of ABHR, have been associated with the use of ABHR that contains at least 70% alcohol (isopropanol), 0.5% chlorhexidine and skin emollient (10,11). Thus, although alcohol-only ABHR may be effective in reducing HAIs (indeed, it is one of the formulations recommended by WHO), there have been no clinical studies to confirm its efficacy. For this reason HHA suggests healthcare facilities select an ABHR solution that contains >70% alcohol + 0.5% chlorhexidine + emollient Alcohol concentration: There is a clear positive association between the extent of bacterial reduction and the concentration of alcohol contained in ABHR products. Furthermore the concentration for maximum efficacy is different for isopropanol than ethanol e.g. ABHR containing 60% isopropanol is associated with similar cutaneous bactericidal activity as ABHR that contains 77% ethanol (20). Overall, however, the ideal ABHR is one that has an alcohol content of > 70% (1) Alcohol absorption The selection of an ABHR may be influenced by religious factors. According to some religions alcohol consumption is prohibited. ABHR with isopropanol appears more predictable in its lack of cutaneous alcohol absorption when compared with an ethanol-based AHBR, and may therefore be more acceptable to some religious groups (21) Solutions versus gels: Laboratory studies have found that ABHR solutions are more effective than ABHR gels that contain an equivalent concentration of alcohol (22). Usually gels contain approximately 10% less effective alcohol than a similar solution. For example, an ABHR gel containing 60% alcohol has similar effective alcohol activity as a 50% ABHR solution (5). Technically it has proven difficult to develop ABHR gels that contain >70% alcohol without the gel becoming less viscous and more solution-like. Thus, ABHR solutions are generally preferred to gels ABHR purchase cost: While the purchase price of ABHR is an important factor in product selection, it is far less important than the acceptability of the ABHR to HCWs (see Section 4.11). Nevertheless, purchase price should be factored into product choice ABHR volume and drying time: The volume of hand rub dispensed is important. One ml of alcohol has been shown to be substantially less effective than 3 ml (7). The effective volume of ABHR (2-3 ml; 1-2 squirts from most ABHR dispensers) generally takes seconds to dry on hands hence ABHR drying time is a convenient indicator that sufficient ABHR has been applied If hands are wet when ABHR is applied: The antimicrobial efficacy of alcohols is very sensitive to dilution with water and is therefore vulnerable to inactivation, especially if only small volumes of ABHR are applied. For instance, if 60% isopropanol were rubbed onto wet hands in two Hand Hygiene before and after every patient contact 4.2

27 portions of 3 ml (each for 1 minute), the mean log bacterial reduction achieved is 3.7, as compared to 4.3 with dry hands (20). Thus, it is recommended that ABHR be applied to dry hands ABHR activity versus other HH antiseptic agents: From: Pittet D, Boyce J. Hand hygiene and patient care: pursuing the Semmelweis legacy. The Lancet Infectious Diseases 2001 April: Staff preference The level of HCW acceptance of ABHRs is a crucial factor in the success of any HH Culture-Change Program. The following ABHR features appear to be important in influencing ABHR acceptability (1) : Fragrance and colour - these may increase the initial appeal but may cause allergenic reactions, and are therefore discouraged. The emollient agent(s) in the ABHR should prevent skin drying and irritant skin reactions, but not leave a sticky residue on hands Drying characteristics. In general, ABHR solutions have lower viscosity than gels and therefore tend to dry quicker. This is usually more acceptable to HCWs Risk of skin irritation and dryness. Proactive and sympathetic management of this problem is vital (see section 4.8) Product availability. Product should be readily available at the bedside and in other patient-care areas Peer group pressure 4.4 Product placement and supply Critical to the success of the program is having ABHR readily available to HCWs in their work area and near the patient (1). Dispensers act as a visual cue for hand hygiene behaviour, and their strategic and ubiquitous placement makes the product highly accessible for frequent use (19). Placement of ABHR needs to be consistent and reliable. Clinical staff should assist with the decision-making process, as they generally best understand the workflow in their area. Although this may be timeconsuming the benefit of behavioural adherence will be marked. Hand Hygiene before and after every patient contact 4.3

28 There is no advantage in placing dispensers next to sinks as this can cause confusion for some HCWs who may think they need to rinse their hands with water after using ABHR. The following issues should be considered: Special consideration is necessary when locating ABHR in clinical areas where oral ABHR consumption or accidental splashing of ABHR is a particular risk. Such areas include: Paediatrics locate ABHR in supervised areas and out of reach of small children Aged Care locate ABHR in supervised areas, where cognitively-impaired patients cannot access it easily Mental Health ABHR should be located with care near psychotic, schizophrenic or suicidal patients, or patients undergoing alcohol- or drug-withdrawal Accidental ingestion of ABHR has been reported, but is uncommon (23). Public areas - ABHR needs placement in high traffic areas with clear signage regarding appropriate use and the need for parents to carefully supervise their children Bracket design is important since ABHR placement may be affected if ABHR brackets are ill-fitting (e.g. varying sizes of bed rails can affect the efficacy of some ABHR brackets). Consider bracket availability and installation costs, since these expenses can be substantial. The following ABHR placement locations are suggested: On the end of every patient bed (fixed or removable brackets) Affixed to mobile work trolleys (e.g. intravenous, drug and dressing trolleys) High staff traffic areas (e.g. nurse s station, pan room, medication room and patient room entrance) Other multi-use patient-care areas, such as examination rooms and outpatient consultation rooms. Entrance to each ward, outpatient clinic or Department Public areas e.g. waiting rooms, receptions areas, hospital foyers, near elevator doors in high traffic areas (see Appendix 3 for guidelines on product placement). Pocket bottles may be useful in some circumstances, but are relatively expensive when compared with larger bedside bottles. A clear decision needs to be made about whose responsibility it will be to replace empty ABHR bottles. Workplace agreements or job descriptions may need to be changed to accommodate prompt replacement of these bottles (11). 4.5 ABHR Use There is no maximum number of times that ABHR can be used before hands need to (24) be washed with soap and water. 4.6 ABHR Limitations ABHR is not the recommended HH product in the following situations; when washing (1) hands with soap and water is preferred : Hand Hygiene before and after every patient contact 4.4

29 4.6.1 Bacterial spores Alcohol has virtually no activity against bacterial spores or protozoan oocysts. Washing hands with soap and water is preferred in this situation because it is the best method of physically removing spores from the hands. For example, after known or suspected exposure to Clostridium difficile, soap and water hand washing is preferred Non-enveloped (non-lipophilic) viruses Alcohol has a poor activity against some non-enveloped viruses. (e.g. rotavirus, norovirus, polio, Hepatitis A). However, there is conflicting evidence suggesting that ABHR is more effective than soaps in reducing virus titres on finger pads (1,25,26). Thus, in norovirus outbreaks it is usually best to reinforce the use of ABHR, unless hands are visibly soiled when soap and water HH is preferred Parasites Alcohol has a poor activity against tropical parasites. Hand washing is preferred. 4.7 HH Product Compatibility It is important to ensure that the selected ABHR, soaps, and moisturising lotions are chemically compatible to minimise skin reactions among staff (17). 4.8 Hand Care Issues The management of hand care problems associated with the use of HH products requires early recognition and a systematic approach to ensure success. Strategies for minimising occupational hand dermatitis include: Use of a HH product that contains skin emollient to minimise the risk of skin irritation and drying Educating staff on caring for their hands, including the regular use of skin moisturizers both at work and at home - such moisturizing skin-care products need to be compatible with ABHR (see 4.7 above). Providing a supportive attitude towards staff with skin problems. The vast majority of skin problems among HCWs that are related to HH are due to irritant contact dermatitis (27). Irritant contact dermatitis is primarily due to frequent and repeated use of HH products - especially soaps and other detergents, which result in skin drying. The initial use of ABHR among such HCWs often results in a stinging sensation. However, recent studies have suggested that the ongoing use of emollient-containing ABHR leads to improvement in irritant contact dermatitis in approximately 70% of affected HCWs (28). The most common causes of contact allergies are fragrances and preservatives - so these should be kept to a minimum or eliminated when selecting an ABHR. ABHR produces the lowest incidence of irritant contact dermatitis of all the HH products currently available. Among the various alcohols included in ABHRs, isopropanol is generally considered less drying than ethanol. True allergy to ABHR is rare and allergy to alcohol alone has never been described. Although some reports have suggested that irritant contact dermatitis can occur in up to 30% HCWs (29) ; the incidence of this problem among a recent study of Victorian HCWs was extremely low (0.47%) (28). All staff should be educated about appropriate skin hand care and be encouraged to use moisturizer at home as well as at work. Hand Hygiene before and after every patient contact 4.5

30 HCWs should be encouraged to notify the HH Program Officer if skin irritation occurs following the use of ABHR. All complaints should be taken seriously and a review process instigated. All hospitals should have referral access to an Occupational Dermatologist for HCWs with persistent skin problems (see Appendix 14). 4.9 Cutaneous Absorption Recent studies have demonstrated minimal rates of cutaneous alcohol absorption such that there should be no concern for HCWs (21,30). A recent study suggested that isopropanol might be less likely to be absorbed than ethanol. Thus, HCWs concerned about absorption for religious reasons may elect to use an ABHR that contains isopropanol rather than ethanol (21) Fire Safety Although some OH&S Fire Safety Officers initially expressed concerns regarding the location of ABHR throughout hospitals, a number of studies have confirmed the safety of ABHR (31,32). Despite many years of use, there have been no documented fires directly related to the presence of ABHR in hospital wards in Australia, and only one documented in the USA. To further reduce the risk of fire following the application of ABHR, hands should be rubbed together until dry and all alcohol is evaporated (1). ABHR is not considered a useful terrorist weapon or threat. (See Appendix 3) 4.11 Cost While the purchase price of ABHR is an important factor in product selection, it is far less important than the acceptability of the ABHR to HCWs. There is little point having a cheap ABHR available that has poor HCW acceptance and is therefore rarely used resulting in poor rates of HH compliance. Thus, the key driver for ABHR selection should not be simple purchase cost (33). However, a recent study in the dental setting has reported that use of ABHR is more cost effective than antimicrobial soap (8), and the expenditure on ABHR products when compared with excess hospital costs associated with HAI can easily be justified (9). Cost is an important consideration on set-up, and the ongoing funding source within the health service needs to be clearly identified for the sustainable success of the program Storage and Safety Ensure a material safety data sheet (MSDS) for ABHR is available in areas where ABHR is stored (check with local OH&S regulations). All ABHR products are flammable with flash-points ranging from 21 o C to 24 o C, depending on the type and concentration of alcohol present. They should be stored away from high temperatures or flames (13). When considering the requirements for minor storage, the total quantities of all flammable liquids must be considered. Minor storage of all flammable liquids is not to exceed 10 litres per 50m 2 of floor space (AS , Section 2, Table 2.1) For further product safety information see Appendix 3 Hand Hygiene before and after every patient contact 4.6

31 Chapter 5 Healthcare Worker Education

32 Chapter 5 Health Care Worker Education 5.1 Aim To develop and maintain an ongoing education program to initiate and sustain HH behaviour change. All HCWs and support staff should be included in educational activities. 5.2 Educational approach HCW education is a key component of any multi-modal intervention strategy. This should include the following components: Use of the best available HH product Regular monitoring and feedback Promotion of personal ownership and involvement of HCWs Engineering factors that ensure HH product is easily and conveniently available to all HCWs Promotion and facilitation of good skin care for HCWs hands Provision of a tolerant and supportive attitude to reported skin care problems Improvement in general safety awareness in the hospital (33). Public awareness Information presented at education sessions could include: Evidence that increased HH compliance decreases the risk of healthcareassociated infections due to a reduction in colonization with nosocomial pathogens HH guidelines Practical guidelines on use of the various HH products, including when to use soap and water, ABHR, or gloves Feedback on HH compliance results and comparison with other units, including stratification by infection risk Discussion about reasons for poor HH compliance among HCWs (5) Information regarding environmental contamination and the importance of cleaning shared patient equipment. 5.3 Strategies to educate staff on hand hygiene practices Formal education Medical and Nursing Grand Rounds Ward / Department in-services - Ensure all staff in all areas of the hospital are educated Nurse Unit Manager/clinical unit meetings Hospital orientations and student intake sessions Promotional weeks (e.g. Infection Control Awareness week) Hand Hygiene before and after every patient contact 5.1

33 5.3.2 Informal education Prompt feedback of HH practice results, including rewards/incentives for good results Ward "walkabouts" Increased presence on the ward by the HH Program Officer and Infection Control staff Program staff acting as a resource for all staff Working one-on-one with staff to improve HH practices Corridor/tearoom chats 5.4 Teaching tools Various tools are available, depending on the teaching opportunity. Examples include: HHA 5 Moments Program DVD PowerPoint presentations for Grand Rounds and other educational sessions Fact sheets Hospital Policy Peer-reviewed journal publications regarding HH HH brochures Role play sessions Regular newsletters Promotional products o Stickers for staff identification badges once HCWs are credentialed o Pens and sticky note pads Incentives may be offered as a form of positive re-enforcement once all staff have completed the education and credentialing package. o E.g. wine, chocolates, pens, stickers and movie passes 5.5 Educating medical staff Numerous published studies suggest that medical staff repeatedly under-perform in HH compliance and are difficult to reach with education to generate behaviour change (1). HH Medical Champions should become involved and encourage medical staff to act as role models for all others. Although a multi-modal approach is likely to be most effective, one-on-one discussions with key/high profile medical officers are especially valuable, particularly for senior medical staff. Successful programs should: Identify those willing to be role models Discuss any potential stumbling blocks to implementation with medical staff Identify medical opinion leaders, Clinical Champions and Heads of Unit Regular attendance by Infection Control staff at medical ward rounds, enables informal HH education to senior and junior medical staff during these rounds As with all HCWs, medical staff should be regularly assessed for their rates of HH compliance and be provided with rapid feedback of results Regular scientific presentations at Surgical and Medical meetings, including Grand Rounds are especially important Target interns and RMOs during formal education sessions and orientations that are a required component of all HMO training programs Timely feedback from observational studies Ensure all medical staff are credentialed in HH Hand Hygiene before and after every patient contact 5.2

34 Chapter 6 The 5 Moments of Hand Hygiene

35 Chapter 6 The 5 Moments of Hand Hygiene 6.1 Aim To ensure all staff involved in the HHA 5 Moments program clearly understand the 5 Moments 6.2 What are the 5 Moments for HH: Moment 1: Moment 2: Moment 3: Moment 4: Moment 5: Before touching a patient Before a procedure After a procedure or body fluid exposure risk After touching a patient After touching a patient s surroundings The Levels of Evidence to Support the 5 Moments Moment 1 Before and after touching patients (1B) Moment 2 Before handling an invasive medical device for patient care, regardless of whether or not gloves are used (1B) If moving from a contaminated body site to a clean body site during patient care (1B) Moment 3 After removing gloves (1B) After contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (1A) If moving from a contaminated body site to a clean body site during patient care (1B) Moment 4 Before and after touching patients (1B) Moment 5 After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (1B) (see Appendix 12 for a detailed description of the levels of evidence) Hand Hygiene before and after every patient contact 6.1

36 6.3 The 5 Moments in Detail Moment 1 Before Touching a Patient WHY: To protect the patient against acquiring harmful germs from the hands of the HCW WHEN: Touching a patient in any way Any personal care activities Any non-invasive observations Any non-invasive treatment Preparation and administration of oral medications Oral care and feeding Contacts with a patient s surroundings before, during & after any of the above Shaking hands, assisting a patient to move, Allied health interventions Bathing, Dressing, Brushing hair, Putting on personal aids such as glasses Taking a pulse, blood pressure, oxygen saturation, temperature, Chest auscultation, Abdominal palpation, Applying ECG electrodes, CTG Applying an oxygen mask or nasal cannula, Fitting slings/braces, application of incontinence aids (including condom drainage) Oral medications, nebulised medications Feeding a patient, Brushing teeth or dentures Bedside table, medical chart Moment 2 Before a Procedure WHY: To protect the patient from harmful germs (including their own) from entering their body during a procedure WHEN: Insertion of a needle into a patient s skin, or into an invasive medical device Preparation and administration of any medications given via an invasive medical device Administration of medications where there is direct contact with mucous membranes Insertion of, or disruption to, the circuit of an invasive medical device Any assessment, treatment and patient care where contact is made with non-intact skin or mucous membranes. Venipuncture, Blood glucose level, Arterial blood gas, Subcutaneous or Intramuscular injections, IV flush IV medication, NGT feeds, PEG feeds, baby formula Eye drop instillation, Suppository insertion, vaginal pessary Procedures involving the following: ETT, tracheostomy, nasopharyngeal airways, suctioning of airways, Urinary catheter, colostomy/ileostomy, Vascular access systems, Invasive monitoring devices, Wound drains, PEG tubes, NGT, Secretion aspiration Wound dressings, Burns dressings, Surgical procedures, Digital rectal examination, invasive obstetric and gynaecological examinations and procedures, digital assessment of newborn palate Hand Hygiene before and after every patient contact 6.2

37 Moment 3 After a Procedure or body fluid exposure risk WHY: To protect yourself and the healthcare surroundings from harmful patient germs WHEN: After any Moment 2 See Moment 2 After any potential body fluid exposure Contact with a used urinary bottle / bedpan, with sputum either directly or indirectly via a cup or tissue, contact with used specimen jars / pathology samples, cleaning dentures, cleaning spills of urine, faeces or vomit from patient surroundings Contact with any of the following: Blood, Saliva, Mucous, Semen, Tears, Wax, Breast milk, Colostrum Urine, Faeces, Vomitus, Pleural fluid, Cerebrospinal fluid, Ascites fluid, Organic body samples eg. Biopsy samples, Cell samples, Lochia, Meconium, Pus, Bone Marrow. Moment 4 After touching a Patient WHY: To protect yourself and the healthcare surroundings from harmful patient germs WHEN: After any Moment 1 except where there has been a potential body fluids exposure See Moment 1 and 2 Moment 5 After touching a Patient s Surroundings WHY: To protect yourself and the healthcare surroundings from harmful patient germs WHEN: After touching the patient s immediate surroundings when the patient has not been touched. Patient surroundings include: Bed, bedrails, linen, table, bedside chart, Bedside locker, Call bell/tv remote control, Light switches, personal belongings (including books, Mobility aids), chair, foot stool, monkey bar Hand Hygiene before and after every patient contact 6.3

38 6.4 Detailed Examples of the 5 Moments 1. HCW walks in, silences IV alarm, then leaves Moment by Moment: 1 prior to touching patient 4 after touching patient 2. HCW changes IV fluid bag, then leaves Moment by Moment: 2 prior to disconnecting IV 3 after reconnecting IV 3. HCW prepares oral medications with medications sitting on patient medical chart, then signs chart whilst giving medications to patient, then moves curtain aside Moment by Moment: 1 pre giving medications to patient 4 prior to moving curtain 4. HCW walks in, touches the patient, moves the over bed table, adjusts the sheets, moves the chair, gets the patient out of bed then leaves Moment by Moment: 1 prior to touching patient 4 after touching the patient 5. HCW walks in, picks up IDC to read it, puts it down, then leaves Moment by Moment: 1 pre IDC as IDC is considered to be a part of the patient 3 after IDC (potential body fluid risk) 6. HCW walks into the room, picks up IDC to read it, puts it down, writes on the medical chart then leaves Moment by Moment: 1 pre IDC as IDC is considered to be a part of the patient 3 after IDC (potential body fluid risk) 4 after chart after continuum of patient care 7. HCW walks in, cleans up urine from the floor, then leaves Moment by Moment: 3 after clean up as body fluid exposure risk 8. HCW walks in, cleans up vomit from the floor, moves patient furniture, then leaves Moment by Moment: 3 after clean up as body fluid exposure risk 5 after touching patient surroundings 9. HCW walks into patient room, touches patient, then picks up IDC to read it, then touches patient again then leaves the room Moment by Moment: 1 pre patient 3 after touching IDC (body fluid exposure risk) 1 pre patient 4 after patient 10. HCW walks into the room, picks up IDC and empties it, puts it down, writes on the medical chart at the foot of the bed, then leaves Moment by Moment: 2 pre IDC 3 after IDC (potential body fluid risk) 4 after chart after continuum of patient care Hand Hygiene before and after every patient contact 6.4

39 11. HCW picks up medication chart, gets medications out of patient draw, prepares medication, gives medication via NGT, signs chart then leaves Moment by Moment: 2 immediately prior to preparing medications 3 after giving medications 4 after chart after continuum of patient care 12. HCW walks into patient room, touches patient, then moves curtain, then touches patient. Moment by Moment: 1 pre patient 4 after patient pre curtain 1 after curtain pre patient No Moment 4 is recorded as HCW has not left the room 13. HCW walks into patient room, touches patient, then moves curtain, then moves the over bed table, then leaves. Moment by Moment: 1 pre patient 4 after patient pre curtain (by touching the curtain the HCW has left the patient zone) 5 after patient surroundings (new moment as re-entered room) 14. HCW walks into patient room moves curtain back then walks out again Moment by Moment: Nil as curtain is external to the patient zone. 15. HCW picks up medication chart, puts it down and walks out Moment by Moment: 5 after chart contact with patient environment 16. HCW picks up medication chart and walks out with it Moment by Moment: Nil as the moment has not finished 17. HCW walks in, touches patient, does hand hygiene, touches the chart, then leaves Moment by Moment: 1 prior to touching patient 4 on leaving (after chart after continuum of patient care) The hand hygiene that was done in the scenario was not required 18. HCW walks in, touches patient, empties IDC, then leaves Moment by Moment: 1 prior to touching patient 4 after touching the patient 2 prior to emptying the IDC 3 after empting the IDC 19. HCW walks up to a single room with a patient who has VRE, puts gloves on, walks in, touches patient, empties IDC, then leaves Moment by Moment: 1 prior to touching patient 4 after touching the patient 2 prior to emptying the IDC 3 after empting the IDC Hand Hygiene before and after every patient contact 6.5

40 20. HCW walks in, picks up IDC to read, puts it back, picks up NGT drainage bag to review, puts it back, picks up wound drain to review, puts it back, then leaves Moment by Moment: 1 prior to touching the patient (IDC) 3 after body fluid exposure risk (IDC) 1 prior to touching the patient (NGT drainage bag) 3 after body fluid exposure risk (NGT drainage bag) 1 prior to touching the patient (wound drain) 3 after body fluid exposure risk (wound drain) Hand Hygiene before and after every patient contact 6.6

41 6.5 Rules for Auditing the 5 Moments Rules Moment 1 Moment 2 Moment 3 Moment 4 Moment 5 Notes Note 1 HH Moment 1 should be performed prior to touching the patient Only record Moment 1 once the HCW touches the patient HH Moment 2 must be performed immediately prior to any procedure HH Moment 3 must be performed immediately after a procedure or body fluid exposure risk Touching the outside of a drain or drainage bag (e.g. urinary catheter, wound drain, chest tube drain, CSF drain), even when the circuit is not broken, is considered a Moment 3 since there is a risk of body fluid exposure (see example 5) Moment 3 will usually be paired with a Moment 2 except that: Moment 3 may be recorded as a stand alone HH Moment when there is a body fluid exposure risk, but the HCW has not touched the patient - e.g. cleaning a spill of vomit, urine or faeces HH Moment 4 should be performed after touching the patient Moment 4 will usually be paired with a Moment 1 Touching the patient surroundings after touching the patient is recorded as a single Moment 4. (see example 4 ) If after a Moment 3 there is touching of patient surroundings this is recorded as a Moment 4 (see examples 6 &10). HH Moment 5 is performed when there has been no touching of the patient but there has been touching of the patient s immediate surroundings. (see example 15) When multiple items in the patient surroundings are touched, only one Moment 5 is recorded Generally for every before Moment there should be an after Moment recorded, unless the auditor does not witness the action. Moment 1 is generally paired with Moment 4 Moment 2 is generally paired with Moment 3 Moment 5 is not paired with other Moments There are very few situations when two afters may be recorded sequentially (see examples 6,8,10,11 &13) Note 2 For every procedure (see Glossary) there should be a Moment 2 and Moment 3 recorded Note 3 Note 4 Note 5 The HCW must be observed to perform HH as they approach the patient. If HH is not observed it should be recorded as a missed action (i.e. HH not performed). In such circumstances the HCW can be asked (at the conclusion of the sequence of care) if they performed HH immediately prior to entering the room and if they did then the Moment should be scored as HH performed. No before Moment can be recorded if auditing commences after a HCW is already touching a patient, or in the process of performing a procedure. No after Moment can be recorded unless the Moment is observed. Patient bed curtains are outside the patient zone and are frequently contaminated. Touching the curtains is leaving the patient zone. HH should be performed between touching the curtains and touching the patient. ( see example 13 & 14) Hand Hygiene before and after every patient contact 6.7

42 Chapter 7 Hand Hygiene Outcome Measures Hand Hygiene Compliance

43 Chapter 7 Hand Hygiene Outcome Measures: Hand Hygiene Compliance 7.1 Aim To accurately assess HH compliance in accordance with published guidelines using a standardised HH observation assessment tool (1,35) 7.2 Training, analysis and targets The approach to accurately assessing HH compliance according to the 5 Moments is described below. In addition, training in the HH compliance assessment tool, data entry and data analysis will be provided at training workshops conducted by Hand Hygiene Australia. Further support is available to all hospitals by contacting the Hand Hygiene Australia representative for your State or Territory. HH compliance can be analysed and reported in a variety of ways depending on your target audience. For example, rates can be reported according to professional category, HH product used, and stratification by HH Moment. Feedback and education should be provided to all HCWs groups observed (i.e. nurses, medical staff, allied health etc.). 7.3 Methodology Direct observation is the gold standard to monitor compliance with optimal hand hygiene practice (1) Hand Hygiene Observation Team The HH observation team consists of a number of trained HCWs who will be responsible for undertaking HH observations. The following points should be considered in the functioning of this team: The Program Officer should maintain overall responsibility and coordination of the field team and data collection All members of the HH team should participate in all aspects of HH observations, including training, conducting observations, data entry, data analysis, data presentation and dissemination of results, so they fully understand the process Active participation of Infection Control staff make it more likely that the results will be effectively used A minimum of two staff, should be selected for the HH observation team Only staff who have been appropriately trained and validated to accurately record potential HH Moments should be members of the team (see Appendix 6 on HH compliance standardisation) Hand Hygiene before and after every patient contact 7.1

44 All observers should be standardized against a gold standard observer to ensure inter-observer, and intra-observer reliability. To become a standardised HH compliance observer the HCW must have attended a HH compliance workshop, and have achieved the prescribed level of inter-rater and intra-rater reliability Observation sessions and scheduling A number of important issues should be considered when planning HH observation sessions: To achieve appropriately valid results, HH compliance should be assessed on a defined minimum number of HH observations (Moments). The time taken to complete the required number of observations will vary depending on the level of clinical activity in the observed area. Nevertheless, the key determinate of adequate HH compliance assessment is the use of HH Moments, not the time taken. HH compliance should be assessed on all types of HCWs who enter selected ward bays. The presence or absence of a convenient location from which to observe patient beds and HH facilities may impact on which patient bays are selected for observation. The data collection schedule will be influenced by the number of acute beds in each facility (see Table below) and the number of trained staff available to undertake HH observations. HH compliance rates should be reflective of a crosssection of the institutions HCWs, rather than just repeated or prolonged observations on a small number of HCWs. The time taken to complete the observation sessions will depend upon the number of HH Moments observed for each session, the number of observation sessions completed each day and the number of field observers available. Number of acute inpatient beds at the hospital Required number of HH audits per year Required number of wards/areas per HH audit > < Required number of HH observations per ward area When HCWs know HH compliance is being measured, they often initially attempt to behave correctly Hawthorn Effect (36) ; therefore HH compliance data is likely to be positively skewed towards higher rates of HH compliance. However, with repeated observations, HCWs generally grow accustomed to the observer and are less affected by their presence (2). HH observers should have a generic response to enquiries about the purpose of their observation. Sessions should be undertaken in an ad hoc manner during both morning and afternoon shifts. Busy periods are the best time for HH observations. Day-to-day variation in HH compliance may occur therefore, observation sessions are best run over several days/weeks. Information regarding when the observation sessions will be occurring should be provided to ward Unit Managers prior to commencing compliance auditing. Hand Hygiene before and after every patient contact 7.2

45 Observation sessions conducted over a number of days are more likely to be representative of HCWs true HH behaviour than when all observations are conducted on just one day. Inter-observer reliability sessions (see Section 7.3.5) should be conducted the week before commencing real observations to allow HCWs to feel at ease and to behave as if the observer is not present. Timely feedback of results to HCWs helps to bring about improvements in HH compliance. After such feedback, HCWs will be aware of the reason for future observation sessions. There can be circumstances where it is not appropriate to conduct a HH observation session; these include: o Emergency situations where HH is secondary to patient safety (e.g. When any hospital code is called) o In palliative care situations o If patient/family object Validation of HH compliance assessment Only HH compliance data recorded by a validated HH compliance observer should be submitted. To become a validated HH compliance observer, the HCW must have attended an appropriate training workshop, and achieved the prescribed level of competency (see Section 7.3.5) Inter-observer reliability and validation Practice sessions may be necessary for HH observers prior to each data collection period to ensure reliable results. Careful attention is required to ensure that observations are recorded correctly and there is consistent reporting, not only by the individual observers (intra-rater reliability) but also between the various observers (inter-rater reliability). The HH team should discuss issues as they arise and reach a consensus opinion/approach. Inter-observer reliability should be addressed by pairing HH observers for observations of the same session and then comparing observations recorded, using the most experienced observer as the gold standard. Each HH observer should be paired with each of the other validated observers (if more than 2 observers). Until there is >90% inter-rater agreement in all recordings (e.g. type of HCW, HCW activity, HH Moment, HH performance), the official data collection process should not begin. Intra-observer reliability should be addressed through use of the HHA 5 Moments Program DVD. This DVD should be observed on at least two occasions, a few days apart. Data should be recorded on the standard data collection form. The rate of agreement for all recordings is then calculated. If there is less than 90 % agreement, HH observers should seek further training (see Appendix 6). Hand Hygiene before and after every patient contact 7.3

46 7.4 Practical issues associated with Hand Hygiene compliance Observation issues The HH observer team should remain alert to reliability problems and devise strategies to reduce them. During the first few days of data collection, the HH Program Officer should review data collection forms for consistency and query inconsistencies or illegible recordings. HH observers should discuss and resolve observational process or recording difficulties. The Program Observer should tally the total number of HH Moments, and the number of correct HH actions recorded for each session on a regular basis to monitor progress (See Appendix 16). When commencing an observation session, HH observers need to check that: At least one patient is present in the bay A bottle of ABHR is available on the end of all patient beds and/or in other standard areas (bay entry/exit points). If none present, ensure correct placement before commencing audit. Observers need to position themselves to view the patient beds and sink area. When patients bed curtains are drawn, permission should be sought from the relevant HCW and patient to allow observers to continue to view activities in the area. Although there may be some occasions when this is not appropriate, these are rare. Observing HCW activities behind closed curtains in the ICU is a necessity. A HH Moment is only documented when the field observer can accurately observe the HCW and the Moment that has been completed. If an observer is unsure whether the observed HCW performed HH, then such Moments should not be recorded. The number of HCWs observed at one time depends on their level of activity. More than one HCW can be observed at the same time, provided their HH Moments can be accurately observed and recorded. If this is not possible, then the compliance of additional HCWs should not be recorded until the index HCW has left the bay. It is better to record fewer Moments accurately than many Moments inaccurately. If no activity occurs, HH observers should proceed to another room. Reasons for no activity may include: No HCW entering the room after 2 minutes of observation HCW activities were performed unobserved behind closed curtains for >2 minutes (N.B. this dose not apply to ICU) All patients leave the bay during the observation session Moments should not be recorded before they have been undertaken. If you are unsure if a HCW performed any HH then do not record it A Mome nt finishes when a HCW: o Moves from one patient to another o Leaves the room on completion of patient care o Touches the curtain partition in a multi-patient room A Moment can finish in another area outside a patient room if patient care is not yet completed eg. transporting a bedpan to the pan room Hand Hygiene before and after every patient contact 7.4

47 7.4.2 Documentation Points to consider: Data sheets should be stored in a safe and secure place Following each observation session, forms should be secured together and numbered (e.g. page 1 of 2 ) A cumulative tally of the number of HH Moments observed should be recorded on the audit schedule (see Appendix 16) to ensure that the target number of observations has been achieved - this can be analysed by the HH Program Officer at the end of each day Before commencing data entry, each data collection form should be accounted for by cross-checking with the audit schedule 7.5 Data entry and management Data collection form All HH compliance data should be recorded for each of the 5 Moments (see Chapter 6) on the standard paper data collection form (see Appendices 7-9) and later entered into the Hand Hygiene Australia MS Access database for analysis (see Appendix 17). Alternative data collection methods and forms may be used as long as the data fields are identical to those required by HHA, and these data are submitted to HHA in the prescribed format (see Appendices 18,19) To ensure accuracy of data entry, each session entered should be doublechecked to verify the total correct HH actions and total Moments correspond to the data collection form (see Appendices 18,19) 7.6 Data analysis To calculate the overall rate of HH compliance for each area, the following data are required: Y = total number of Moments observed X = Total number of appropriately performed HH Moments Rate of overall HH compliance = X/Y x 100 = % rate of overall HH compliance If a sub-analysis of only certain specific Moments is required, then a similar calculation is performed, but where Y = the number of specified Moments and X = number of appropriately performed HH actions for that particular Moment. 7.7 Reporting Results How to generate reports from the database HH compliance should be reported in a defined manner: 1. Overall HH compliance 2. HH compliance rate for Moments 2 and 3 combined (%) 3. Overal l HH compliance according to: a. Each of the 5 Moments b. HCW type c. HH product used d. Glove Use See Appendices 18,19 for a sample report Hand Hygiene before and after every patient contact 7.5

48 The HHA database allows easy calculation of all these rates (at both a ward and hospital level), and reporting of HH compliance according to the above criteria Report submissions to Hand Hygiene Australia HH compliance data should be submitted to HHA using the standard HHA database Using reports for further education about HH compliance HH compliance rates are both a useful outcome measure for the HH culture-change program, and a very useful educational tool for HCWs. Reporting results of hand hygiene observation to HCWs is an essential element of multi-modal strategies to improve hand hygiene practices (25). Early feedback of HH compliance rates to audited HCWs is a crucial and effective component to achieving improvements in HH compliance and to engaging HCWs in effective cultural-change. The HH Program team should oversee such education and feedback Hospital, State/Territory, National Reporting of HH Compliance Overall rates of HH compliance (including 95% confidence intervals) will be reported for each healthcare institution, each state/territory and nationally three times per year. Hand Hygiene before and after every patient contact 7.6

49 Chapter 8 Hand Hygiene Outcome Measures Rates of Staphylococcus aureus bacteraemia

50 Chapter 8 Hand Hygiene Outcome Measures: Rates of Staphylococcus aureus bacteraemia (SAB) 8.1 Aim To accurately assess the rates of SAB within the Australian healthcare system. 8.2 Rate of MRSA bacteraemia A standardised system of assessing the patient rates of SAB in each hospital and for each State/Territory has been developed (see Appendix 20). This will include information regarding antibiotic susceptibility and whether the infection was likely to have been hospital-acquired all standardised against hospital activity. The following information will be collected: Antibiotic susceptibility of each isolate to allow categorisation as: o Methicillin-susceptible S. aureus (MSSA) o Methicillin-resistant S. aureus (MRSA) Timing of SAB in relation to patient admission: <48 hours, >48 hours, within 48 hours of hospital discharge Total number of patient separations (including all day cases) per month for each healthcare facility Total number of occupied bed days per month for each healthcare facility SAB rates will per calculated for each healthcare facility and State/Territory per month as follows: o No. patient-episodes of SAB divided by no. separations at the healthcare facility x 100 o No. patient-episodes of SAB divided by no. occupied bed days at the healthcare facility x Specific Details & Definitions Patient-episode of S. aureus bacteraemia (SAB): A patient-episode of bacteraemia is defined as a positive blood culture for Staphylococcus aureus, but only the first isolate per patient is counted, unless at least 14 days has passed without a positive blood culture, after which an additional episode is recorded. Hand Hygiene before and after every patient contact 8.1

51 For example: A patient has SAB in which 4 sets of blood cultures are positive over the initial 3 days of the patient s admission = one episode SAB. If the same patient had a further set of positive blood cultures on day 6 of the same admission, these would not be counted again, but would be considered part of the initial patientepisode. If the same patient had a further positive blood culture 20 days after admission (i.e. >14 days after their last positive on day 5), then this would be considered a second patient-episode of SAB Timing of patient-episode of SAB The time when the first positive blood culture is collected compared to the time/date of patient admission will be used to define whether a SAB is likely to have been hospital-acquired. Community-onset patient-episode of SAB = first SAB collected <48 hours after hospital admission Hospital-acquired patient-episode of SAB = first SAB collected >48 hours after hospital admission or within 48hours of hospital discharge Information regarding the timing of SABs (<48 h, >48 h) can often be generated from the Microbiology laboratory where these data are routinely stored. Thus, a laboratory printout defining the timing of the first SAB for each patient-episode will assist Type of SAB Laboratory antibiotic susceptibility data should define whether an SAB is due to: Methicillin-susceptible S. aureus (MSSA) Methicillin-resistant S. aureus (MRSA) SAB Case Review Among SABs occurring <48hours after hospital admission, a number of SABs will be related in some manner to a recent episode of health care. To identify whether SABs are truly community-acquired or are in fact healthcare-associated, all SABs should undergo a minimum standard Case Review by a HCW trained in Infectious Diseases, or Infection Control. The data collected in this standard SAB Case Review should be recorded on the HHA SAB Case Review form (see Appendix 22), and entered in the HHA SAB database (see Appendix 23) for analysis. It is expected that each standard case review will take only minutes Defining patient activity for each hospital A Separation from a healthcare facility occurs anytime a patient leaves due to discharge, death or transfer. Patient activity at each hospital can be defined by the total number of patient separations per month (including all day cases). Occupied bed days (OBDs) per month should be reported for each institution. OBDs are the sum of the number of occupied beds for each day of the specified period Defining the rates of SAB Total SAB rates will per calculated for each hospital and State/Territory per month using both separations and OBDs (separately) as the denominator: Hand Hygiene before and after every patient contact 8.2

52 Total SAB rate per month Rate per 100 Separations Rate per 1000 Occupied Bed Days (OBD) No. SABs x 100 No. SABs x 1000 No. separations No. OBDs Rate of Hospitalacquired SAB No. SABs >48 h after admission x 100 No. SABs >48 h after admission x 1000 No. of separations No. of OBDs Rate of Communityonset SAB No. SABs </=48 h after admission x 100 No. SABs </=48 h after admission x 1000 No. of separations No. of OBDs Rate of MSSA SAB Rate of MRSA SAB No. MSSA SABs x 100 No. MSSA SABs x 1000 No. of separations No. of OBDs No. MRSA SABs x 100 No. MRSA SABs x 1000 No. of separations No. of OBDs Rate of Hospitalacquired MRSA SAB No. MRSA SABs >48 h after admission x 100 No. MRSA SABs >48 h after admission x 1000 No. of separations No. of OBDs Rate of Communityonset MRSA SAB No. MRSA SABs </=48 h after admission x 100 No. MRSA SABs </=48 h after admission x 1000 No. of separations No. of OBDs Rate of Hospitalacquired MSSA SAB No. MSSA SABs >48 h after admission x 100 No. MSSA SABs >48 h after admission x 1000 No. of separations No. of OBDs Rate of Communityonset MSSA SAB No. MSSA SABs </=48 h after admission x 100 No. MSSA SABs </=48 h after admission x 1000 No. of separations No. of OBDs Following 12 months of prospective SAB data collection, results will be reviewed and a decision made by HHA in consultation with all States/Territories regarding the reporting of SABs whether Separations or OBDs represent the best denominator for reporting SAB rates (See Appendix 20) Retrospective Assessment of SAB rates To provide relevant comparative data regarding SAB rates prior to the commencement of the HH Culture-Change program in January 2009, all hospitals and State/Territories are requested to provide monthly SAB rates (total SABs and MRSA SABs) for the 24 months prior to program commencement (Jan 2007-Dec 2008 inclusive). Where possible, both Separation and OBD denominator data should be supplied. A specific HHA Retrospective SAB data form will be provided to assist with this process, as will HHA staff if necessary (See Appendix 21) Multi-resistant MRSA vs. Non-multi-resistant MRSA Community-acquired cases of MRSA SAB appear to be increasing dramatically in Australia in some regions. Generally such SAB cases are due to Non-muliti-resistant MRSA (nmr-mrsa). Thus, among SABs due to MRSA it may be helpful to identify which are Multi-resistant MRSA (mr-mrsa) vs. nmr-mrsa. For healthcare institutions interested in collecting such information, see Appendices 22, and 23. However, this is optional. For sites contributing this optional data, the following should be reported: Hand Hygiene before and after every patient contact 8.3

53 Susceptibility testing for the following antibiotics should be undertaken on at least the first MRSA SAB isolate: 1. Oxacillin or cefoxitin resistance to these agents confirms the isolate is an MRSA 2. Tetracycline 3. Trimethoprim-sulfamethoxazole (Bactrim) or trimethoprim 4. Erythromycin 5. Ciprofloxacin 6. Gentamicin 7. Rifampicin 8. Fusidic acid These detailed susceptibility data can be provided by the Microbiology laboratory and should be reported for each patient-episode of SAB due to MRSA. It is not appropriate to simply label the SAB as due to mr-mrsa or nmr-mrsa without providing the above susceptibility data. mr-mrsa: nmr-mrsa: The standard Australian definition for mr-mrsa is resistance to (46) > 3 of the above agents (other than oxacillin/cefoxitin). Resistance to <3 of these agents defines the isolate as nmr- MRSA. Hand Hygiene before and after every patient contact 8.4

54 Chapter 9 Other Useful Interventions

55 Chapter 9 Other useful interventions 9.1 Aim To complement the successful implementation, and sustainability of a HH culture change program by introducing other infection prevention interventions. 9.2 Clean Between Program To minimise the risk of cross-infection a program should be developed targeting the cleaning of shared patient equipment. Conduct baseline evaluation to detect the presence of Staphylococcus aureus on shared patient equipment eg. Blood pressure cuffs, patient slides, stethoscopes etc. Select type of alcohol-impregnated wipes Decide on placement of wipes Should be readily available throughout the wards, in high use areas, and attached to shared patient equipment such as intravenous trolleys and mobile blood pressure machines. Educate ward staff to use alcohol-impregnated wipes to clean clean equipment between each patient use. Educate ward staff to use soap and water to clean visibly soiled equipment between each patient use. Educate patient service assistants to clean fixed patient room equipment as part of the terminal cleaning of a bed area upon patient discharge. Alcohol-impregnated wipes should not be used on items that are visibly soiled these must be cleaned with soap and water prior to any additional cleaning, Electrical equipment should be wiped with a damp cloth only Alcohol wipes should not be used on hands for skin cleansing, Alcohol wipes should not be used with other chemicals Alcohol wipes should not be used on equipment which must be sterile Standardised auditing of Clean Between can be difficult. Nevertheless, promoting the cleaning of shared patient equipment, and the use of alcohol-impregnated wipes can dramatically reduce the risk of cross-transmission of pathogens (11). See Appendix 5 for an example of a Clean Between policy. Hand Hygiene before and after every patient contact 9.1

56 Frequently Asked Questions

57 Frequently Asked Questions Q: How do I use ABHR? A: Push the pump to get the metered amount, rub over all surfaces of your hands until evaporated. No need to wash your hands after use, this is a waterless system. If your hands are visibly soiled we recommend you wash them with soap and water. Q: What if my hands are clean? A: Even when our hands look clean many germs may be still present which could transmit disease or other infections. ABHR is effective against many types of viruses and bacteria, which are invisible to our eyes. To offer the best protection to everyone we recommend that you use the ABHR regularly. Q: When should I wash my hands? A: If hands are visibly soiled, or contaminated with blood or body fluids, then hand washing with plain or anti-microbial soap is recommended. The same is advised following known or suspected exposure to bacterial spores (e.g. Clostridium difficile), non-enveloped viruses (e.g. norovirus), or parasites. Washing hands with soap and water is preferred because it guarantees a mechanical removal effect. (see Appendix 11) Q: What are the advantages of alcohol-chlorhexidine hand rub over alcoholonly rub? A: The addition of chlorhexidine to ABHR is associated with a persistent effect for at least three hours after application. Alcohol-only ABHR results in an immediate effect on pathogens, but has no persistent activity (20). Q: Why have ABHR solutions and not gels been recommended? A: Laboratory studies have found that ABHR solutions reduce bacterial counts on the hands of volunteers to a greater degree than similar hand gels tested (22). Gels generally do not dry in 15 seconds, so HH takes longer with a gel, than with a solution. Q: Why do my hands sting when I apply an ABHR product? A: Stinging demonstrates pre-damaged epidermal tissue, most commonly caused by irritant-contact dermatitis related to excessive use of soap or detergents. The use of an ABHR may lead to an improvement in the condition of the hands because it contains an emollient, does not remove skin lipids and does not require paper towel for drying. However, if symptoms persist, medical opinion should be sought (see Appendix 14). Q: Will it matter if my hands are wet when I apply the ABHR? A: Yes, having wet hands dilutes the solution thus decreasing its effectiveness. The product must be applied to dry hands. Q: Can I bring in my own moisturising cream from home? A: No, many hand creams inactivate the components in ABHRs. The products used in each hospital should be chosen for their compatibility with the ABHR in use. Hand Hygiene before and after every patient contact

58 Q: Why do I have to decontaminate my hands after removing gloves? I thought the gloves stopped bugs getting onto my hands. A: The use of gloves does not replace the need for hand decontamination. ABHR should be used before and after glove use (see Appendix 1). Q: Can I wear artificial fingernails when having direct contact with patients? A: HCWs with artificial nails are more likely than those with natural nails to harbour gram-negative pathogens on their fingertips (see Appendix 13). Q: What happens if someone accidentally drinks ABHR? A: Most ABHRs on the market contain very unpleasant tasting products, which make consumption unlikely. The risk of poisoning from ingestion of ABHR is uncommon but there has been some diarrhoea and vomiting reported where accidental ingestion has occurred. There is potential for serious clinical effects if large amounts are ingested. It is recommended that care be taken with the placement of ABHR in highrisk areas, (paediatrics, psychiatric units, drug and alcohol units, psycho-geratic units etc) (see section 4.4). Q: Where is it best to position the ABHR in a hospital? A: Ideally ABHR should be located in high traffic flow areas (according to the guidelines) or common areas such as near reception, outside lift wells, entrance to wards/clinics. To help increase the public usage of the ABHR it is best if it s highly visible. As mentioned previously it is recommended that care be taken with the placement of ABHR in high-risk areas, (paediatrics, psychiatric units, drug and alcohol units, psycho-geratic units etc). Q: Does it matter if the ABHR is on a wall or a trolley? A: No it doesn t matter but the product should be secured to the area by means of an appropriate bracket according to the guidelines. This is aimed to help reduce the risk of splashes, spills or the product misplacement. Q: Who is responsible for maintaining the product, brackets and signage? A: This will be unique to each site/facility. The HH program should take responsibility for ensuring an appropriate system is in place. Q: What happens in the case of an adverse event? A: Each facility is responsible for the products used in their facility and must have resources in place to manage any adverse events. Material Safety Data Sheets (MSDS) should be available for each product, as well as clearly documented internal procedures/policies to be followed. It is up to each individual facility to make sure all involved are educated on the procedure to follow in case of an adverse event. Q: Can we recycle or top up the bottles? A: No, because the outside of the ABHR bottles often become contaminated, they should generally be discarded and not re-used. Attempts to recycle/re-use ABHR bottles have unfortunately proven to be cost ineffective in Australia to date. Q: Will over-use of ABHRs result in resistance? A: Unlike other antiseptics and antibiotics, there is no reported or likely resistance to ABHRs. Indeed, the more it is appropriately used, the less antibiotic-resistant bacteria are able to spread. Hand Hygiene before and after every patient contact

59 Q: How many times can staff use the ABHR? A: As often as is required. There is no need to wash hands with soap and water unless they are visibly soiled. Q: Should hand hygiene be performed prior to donning non-sterile gloves? A: Hand hygiene should be performed regardless of the use of gloves when an indication for hand hygiene applies. Usually there will be patient contact or the start of a procedure after the donning of gloves. The fact of donning gloves by itself does not constitute an indication for hand hygiene. Q: Why do the 5 Moments not include hand hygiene before touching furniture in the patient s immediate vicinity? A: The 5 Moments has been developed around the basis of pathogen transmission. There is not an indication to perform hand hygiene before touching the patients surroundings. Q: Should targets be set for hand hygiene compliance? If so, what level of increase would be good? A: Any such targets should first be realistic and attainable, in view of the long-term efforts required to bring about improvements in hand hygiene behaviour. Aiming for complete compliance in the short term would obviously be difficult to achieve in facilities where initial compliance rate may be less than 40% What should be aimed for is the establishment of a baseline, and a steady, sustainable, month by month, year on year improvement. Q: How important are clean hands in the overall patient safety agenda? A: Hand hygiene contributes significantly to keeping patients safe. It is a simple, lowcost action to prevent the spread of many of the microbes that cause HCAIs. While hand hygiene is no the only measure to counter HCAI, compliance with it alone can dramatically enhance patient safety. Improving the hand hygiene of healthcare staff is one of the most effective ways of preventing and reducing the spread of healthcare associated infection. The selection of hand hygiene as the first pillar to promote the Global Patient Safety Challenge of the WHO World Alliance for Patient Safety signifies its importance in the patient safety agenda. Q: What about patients and visitors hand hygiene? A: Promoting hand hygiene amongst patient and visitors might raise the profile of hand hygiene, but it is unlikely to reduce the transmission of microorganisms that cause HCAI. Q: What about relatives and carers that are helping to provide care to a patient? A: If relatives and carers are helping to nurse a patient they should be shown how and when to clean their hands at the point of care. However, they are unlikely to touch other patients in a similar way so are unlikely to transfer infection to other patients. Hand Hygiene before and after every patient contact

60 Q: Why is ABHR at the point of care so important? A: The point of care is the patient s immediate surroundings in which healthcare staff to patient contact or treatment is taking place. It represents the time and place where there is the highest likelihood of transmission of infection via thehands of the healthcare staff. Ensuring that staff have the means to clean their hands at this point is the first step in stopping the spread of infection. Q: What sort of microbes can spread during lapses in hand hygiene? A: The following are examples of the types of microbes that can be spread on the hands of HCWs: Staphylococcus aureus (including Pseudomonas MRSA) Clostridium difficile Streptococcus pyogenes (Group A Candida Strep) Rotavirus Vancomycin-resistant Adenovirus Enterococcus (VRE) Hepatitis A virus Klebsiella Norovirus Enterobacter Wounds, perineum, armpits, hands and trunk can be frequently covered in huge numbers of microbes. It is easy to understand that the hands of staff can become contaminated even after seemily clean procedures. Q: Is HHA saying that conventional handwashing at the sink is no longer important? A: Not at all. There will always be a place for conventional hand washing. Hands should always be cleaned with soap and water when they are visibly soiled, there has been direct contact with body fluids, there is an outbreak of diarrhoeal disease, or staff are caring for a patient with vomiting and/or diarrhoea. Evidence suggests that full compliance with hand hygiene through only soap and water is unachieveable because of time, location, accessibility to sinks, skin irritation and dryness. ABHR provides a quick and effective way for staff to clean their hands when they are with their patient. It also means that the patients can see the HCW clean their hands, which is important for patient confidence. Q: What role do patients and visitors play in the spread of infection? A: Patients can transfer pathogens from one site on their body to another. If patients are having contact with their wound or the insertion site of a device, hand hygiene should be encouraged. In the same way visitors having contact with the patient should perform hand hygiene. In instances where visitors are likely to have physical contact with more than one patient, then hand hygiene should be performed according to the 5 Moments. Hand Hygiene before and after every patient contact

61 Contact Details For Assistance

62 Contact Details for Assistance HHA Website HHA Ph: Fax: HHA Program Director Prof. Lindsay Grayson Ph: HHA Program Manager Mr Phil Russo Ph: Mob: HHA Medical Director Mr Joe Torresi Ph: HHA Program Co-ordinators Mrs Kaye Bellis Mob: Mrs Kate Ryan Ph: Hand Hygiene before and after every patient contact

63 References

64 References 1. World Alliance for Patient Safety. Who Guidelines on Hand Hygiene in Healthcare (Advanced Draft): Global patient safety challenge : Clean care is safer care. World Health Organisation; Bentley M, Boot M, Gittelsohn J, Stallings R. The use of structured observations in the study of health behaviour. IRC International Water and Sanitation Centre. The Hague, Netherlands & London School of Hygiene and Tropical Medicine, London, United Kingdom. Occasional Paper 27, Centres for Disease Control and Prevention. Guideline for Hand Hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report. 2002; 51 (No. RR-16). 4. Pittet D, Allegranzi B, Sax H, Dharan S, Pessca-Silva, Donaldson L, Boyce J. Evidence-based model for hand transmission during patient care and the role of improved practices. The Lancet Infectious Diseases 2006 Oct 6: Pittet D, Boyce J. Hand hygiene and patient care: pursuing the Semmelweis legacy. The Lancet Infectious Diseases 2001 April: Whitby M, McLaws ML, Ross MW. Why healthcare workers don t wash their hands: a behavioural explanation. Inf Control Hosp Epidemiol 2006; 27(5): Larson EL, Eke PI, Wilder MP, Laughan BE. Quantity of soap as a variable in hand washing. Infection Control 1987; 8: Huber MA, Holton RH, Terezhalmy GT. Cost analysis of hand hygiene using antimicrobial soap and water versus an alcohol-based hand rub. The Journal of Contemporary Dental Practice 2006 May 1:7(2): Boyce JM. Antiseptic technology: access, affordability, and acceptance. Emerging Infectious Diseases 2001; 7(2): Pittet D, Hugonnet S, Harbarth s, Mourouga P, Sauvan V, Touveneau S, Perneger TV. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: Johnson P, Martin R, Burrell LJ, Grabsch EA, Kirsa SW, O Keeffe J et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillinresistant Staphylococcus aureus (MRSA) infection. MJA 2005; 183: Grayson ML, Jarvie LJ, Martin R, Jodoin ME, McMullan C, Gregory RHC, Bellis K, Cunnington K, Wilson FL, Quin D, Kelly AM, on behalf of the Victorian Quality Council Hand Hygiene Study Group and Victorian Quality Council Hand Hygiene State-wide Roll-out Group. Significant reductions in methicillin-resistant Staphylococcus aureus bacteremia and clinical isolates associated with a multisite, hand hygiene culture-change program and subsequent successful statewide rollout. MJA 2008 June 2; 188(11): Won SP, Chou HC, Hsieh WS, Chen CY, Huang SM, Tsou KI, Tsao PN. Handwashing Program for the prevention of nosocomial infections in a neonatal intensive care unit. Infection control and hospital epidemiology (9): Grayson ML. The treatment triangle for staphylococcal infections. N Engl J Med 2006; 355: Wertheim HF, Vos MC, Boelens HA, Voss A, Vandenbrouche-Grauls CMJE, Meester MHM, Kluymans JAJW, van Kuelen PHJ, Verbrugh HA. Low prevalence of methicillin-resistant Staphylococcus aureus (MRSA) at hospital admission in the Netherlands: the value of search and destroy and restrictive antibiotic use. J Hosp Infect 2004; 56: Pittet D, Boyce JM. Revolutionising hand hygiene in health-care settings: guidelines revisited. Lancet Infect Dis 2003; 3:

65 17. Bush K, Mah MW, Meyers G, Armstrong P, Stoesz J, Strople S. Going dotty: A practical guide for installing new hand hygiene products. American Journal of Infection Control 2007; 35: Martin R, Burrell LJ, Johnson P, Barr W, Mayall B, Grabsch E et al. The answer s on-line, not on paper. Poster Presentation Austin Health Research Week; 2002; Melbourne. 19. World Alliance for Patient Safety. Manual for observers: Annex 17 WHO Multimodal hand hygiene improvement strategy. World Health Organisation; Rotter ML. Hand Washing & Hand Disinfection. In: Mayall CG, editor. Hospital Epidemiology and Infection Control. 2nd ed. Philadelphia, PA: Lippincott, Williams & Wilkins; p Brown TL, Gamon S, Tester P, Martin R, Hosking K, Bowkett GC, Gerostamoulos D, O Brien M, Grayson ML. Can alcohol-based hand-rub solutions cause you to lose your driver s licence? Comparative cutaneous absorption of various alcohols. Antimicrobial Agents Chemotherapy 2007; 51: Kramer A, Rudolph P, Kampf G, Pittet D. Limited efficacy of alcohol-based hand gels. Lancet 2002; 359: Roberts HS, Self RJ, Coxon M. An unusual complication of hand hygiene. Anaesthesia 2005; 60(1): (accessed on 4/8/08) 25. Ansari SA, Sattar SA, Springthorpe VS, Wells GA, Tostowaryk W. In vivo protocol for testing efficacy of hand-washing agents against viruses and bacteria: Experiments with Rotavirus and Escherichia coli. Applied Environmental Microbiology 1989; 55(12): Sattar SA, Abebe M, Bueti AJ, Jampani H, Newman J, Hua S. Activity of an alcohol based hand gel against human adeno-, rhino-, and rotaviruses using the fingerpad method. Infection control and epidemiology ; Tupker RA. Detergents and cleansers. In: Vander Valk PGM, Maibach HI Eds. The Irritant Contact Dermatitis Syndrome. New York: CRC Press; Graham M, Nixon R, Burrell LJ, Bolger C, Johnson PDR, Grayson ML. Low rates of Cutaneous Adverse Reactions to Alcohol-Based Hand Hygiene Solution during prolonged use in a Large Teaching Hospital. Antimicrobial Agents and Chemotherapy 2005 Oct: Kampf G, Loffler H. Dermatological aspects of a successful introduction and continuation of alcoholbased hand rubs for hygienic hand disinfection. J. Hosp Infect 2003; 55: Kramer A, Below H, Bieber N, Kampf G, Toma CD, Huebner NO, Assadian O. Quantity of ethanol absorption after excessive hand disinfection using three commercially available hand rubs is minimal and below toxic levels for humans. BMC Infectious Diseases 2007; 7: Boyce JM, Pearson ML. Low frequency of fires from alcohol hand rub dispensers in health care facilities. Infection control and hospital epidemiology 2003;24: Kramer A, Kampf G. Hand rub-associated fire incidents during 25,038 hospital years in Germany. Infection control and epidemiology 2007;28(6): Boyce JM. Antiseptic technology: access, affordability and acceptance. Emerg Infect Diseases 2001; 7: Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. My 5 moments for hand hygiene: a usercentres design and approach to understand, train, monitor and report hand hygiene. Journal of Hospital Infection 2007;67: Brown T, Burrell L, Edmonds D, Martin R, O Keeffe J, Johnson P, Grayson ML. Hand hygiene: a standardized tool for assessing compliance. Aust Infect Control 2005 June 10; 2:51-8.

66 36. Roethlisberger FJ, Dickson WJ. Management and the Worker; an account of a research program conducted by the Western Electric Company, Hawthorne Works. Cambridge: Harvard University Press; Start Clean Victorian Infection Control Strategy (September 2007). Department of Human Services, Victoria, Hedderwick SA, McNeil SA, Lyons MJ, Kauffman CA. Pathogenic organisms associated with artificial fingernails worn by healthcare workers. Inf Control Hosp Epidemiol 2000 Aug 21: Collignon P, Nimmo GR, Gottlieb T, Gosbell IB. Staphylococcus aureus Bacteremia, Australia. Emerging Infectious diseases 2005;11(4): Australian Institute of Health and Welfare [cited 2008, Aug 12] Available from: URL: Woodin D, Leaver C. Business Briefing: Hospital Engineering and Facilities Management. London: Touch Briefings; Alcohol based hand rubs. [Online]. [2008?] [cited 2008 Aug 19]. Available from: URL: Department of health and human services. Medicare & Medicaid Programs; Fire safety requirements for certain health care facilities; amendment. Federal Register 2005 Mar 25;70(57): Queensland Health Policy for Hand Hygiene: Clean Hands are Life savers [Online] [cited 2008 Jan]. Available from: URL: Hand Hygiene Resource Centre [Online] May 2 [cited 2008 Aug 19]; Available from: URL: Coombs GW, Nimmo GR, Bell JM, Huygens F, O Brien FG, Malkowski MJ, Pearson JC, Stephens AJ, Giffard PM; for the Australian Group for Antimicrobial Resistance. Genetic diversity among community Methicillin resistant Staphylococcus aureus strains causing outpatient infections in Australia. Journal of Clinical Microbiology 2004; 42(10): Kampf G, Kramer A. Epidemiologic background of hand hygiene and evaluation of the most important agents for scrubs and rubs. Clinical Microbiology Reviews 2004 Oct:

67 Appendices

68 Appendix 1 WHO Glove Use Recommendations

69 Appendix 1 (cont.) WHO Glove Use Recommendations

70 Appendix 2 Checklist for Introduction of a Hand Hygiene Culture Change Program Facility Preparedness Identify Co-ordinator who will: o Lead the Culture Change program within their health service, and be the primary point of contact for HHA o Undergo specific HHA training with either state representative of Infection Control, or with a HHA trainer o Develop a HH Steering committee o Create a team/working group (usually based in Infection Control) to assist with program implementation HH Steering Committee / Working Group will: o Develop an internal HH policy o Select ABHR Product and Decide on sites for product placement Ensure all local OH&S requirements are meet o Budget for implementation costs o Select Pilot wards Consideration should be given to ward activity, infection rates, and likely immediate impact of HH improvement Select a ward/department champion(s) o Provide training to infection control team for outcome assessment As per HHA auditing credentialing program o Undertake and provide data entry and data analysis training o Discuss with hospital laboratory data collection requirements o Develop a communication plan o Develop an education plan o Select program promotion tools Hospital executive to show visible commitment throughout hospital to support HH Baseline Evaluations Conduct HH baseline observations on pilot wards prior to implementation of ABHR Implement HH Compliance data analysis strategy o HHA will provide a HH compliance analysis database o Provide reports on HH compliance for pilot wards Initiate Prospective SAB data collection Initiate Retrospective SAB data for 24 months prior to program implementation Implementation Launch the HH program on pilot wards o HH training, credentialing and educational materials o ABHR and Promotional materials Provide ongoing education and assistance to pilot wards and especially ward champion Feedback baseline data Follow up evaluation Evaluate the pilot program o Conduct HH observation on all pilot wards after 3 month? trial period o Evaluate numbers of pilot ward staff who have completed the credentialing package Conduct analysis of pilot program Develop ongoing action plan and review cycle Review program results Review analysis and address outcomes Report program results to: o Executive champions o Infection control team o Hospital wide o State co-ordinator (who will report to HHA) Scale up HH Program to entire hospital/network Follow HHA recommendations for reporting national data

71 Appendix 3 Recommendations for the placement of Alcohol-Based Hand Rub in public areas of health care facilities Aim to help protect our patients, other visitors and staff from transmission of infectious agents such as colds, flu, gastroenteritis and other micro-organisms. Alcohol-based hand-rubs (ABHRs) are a quick and effective method of HH and should be freely available for use by all. The use of an alcohol-based hand-rub by visitors when they enter and leave the health care facility is recommended. Infection Control is Everybody s Business. There are many issues to be considered before a facility places ABHR in public areas, including: adherence to the Material Safety Data Sheet (MSDS), local fire regulations, facility engineering and occupational health and safety (OH&S) requirements. After consultation with a number of authorities including the Melbourne Metropolitan Fire Brigade the following guidelines have been developed: Unique to each site will be how the products are supplied, the type of brackets, the cost centers involved and storage of the products. The overall risk of fires associated with ABHR is extremely low a recent U.S. study of 766 healthcare facilities demonstrated that after a combined experience of 1,430 years of ABHR use, there had not been a single fire attributed to ABHR (31, 43). (44, 45) The maximum size of an individual ABHR dispenser should not exceed 500mls No more than 80 individual ABHR dispensers (each with a maximum capacity of 500ml) should be installed within a single smoke compartment Corridors should have at least 1.8m wide with at least 150cm between each ABHR (43, 44, 45) dispenser (41, 44, 45) Dispensers should not project more than 15cm into corridor egress Wall mounted brackets should be located at a height of between 92cms and 122 cm above (41, 42 the floor (avoid placing at eye level) Dispensers should not be located over carpeted areas, unless the area is protected by active sprinklers (43) Dispensers should not be located over, or directly adjacent to ignition sources (e.g. (41, 43, 44) electrical switches, power points, call buttons, or monitoring equipment) (41, 44) ABHR dispensers should be separated from heat sources and electric motors Dispensers should be installed according to manufacturer s recommendations and to minimise leaks or spills (43) Regular maintenance of dispensers and brackets should occur in accordance with manufacturer s guidelines (43) Product usage signs should be clearly visible and laminated Regular monitoring of each area is recommended for misuse, or removal of product Each facility should take adequate care regarding the placement of each dispenser so as to protect vulnerable populations, for example in psychiatric units, drug and alcohol units, paediatric units and units caring for cognitively impaired patients (44) ABHR bottles should not be decanted ABHR bottles should be designed so as to minimise evaporation due to the volatile nature of alcohols Site-specific instructions should be developed to manage adverse events, such as ABHR ingestion, eye splashes or allergic reactions

72 Appendix 4 Sample HH Credentialing Policy Hand Hygiene Credentialing Policy Staff this document applies to: All healthcare workers at this hospital State any related policies, procedures or guidelines: Hand Hygiene Standard Summary Our hospital strives to maintain improvements in hand hygiene compliance and reduce rates of MRSA bacteraemias. The Infection Control Team actively encourages all healthcare workers to have been credentialed in hand hygiene by completing the Hand hygiene Learning package biannually. Objective To improve the knowledge of all Healthcare Workers (HCWs) at our hospital in relation to the importance of hand hygiene in preventing Hospital Acquired Infections (HAI s). This is achieved by ensuring all staff complete the hand hygiene learning package which can be assessed either via the Infection Control intranet site or via the credentialing website (for the general public and medical/nursing students). Implementation: The hand hygiene learning package consists of 30 slides. After a set number of slides there is a multi-choice question about the preceding material (18 information and 12 questionnaire slides). Immediate feedback is provided after each answer is selected in the slide show and the next page is not shown until the correct answer is selected. On completion of the slide show, HCWs complete a registration form by entering either their Employee or NT login (computer) number and then proceed to the test questionnaire (the same 12 questions as seen in slide show, reinforcing each message). HCWs are considered credentialed in hand hygiene if they get at least 80% (10/12) correct. Once the hand hygiene learning package is complete (slide-show, registration page and test questionnaire), HCWs are informed of their score and if they scored at least 80%, an option of printing a certificate is provided. NB All data is recorded and available to managers and HCWs through accessing the reports on the Intranet. Policy Application 1. From January 2004, all new HCWs are required to be credentialed in hand hygiene as a condition of their employment. This condition is also written into all future employment contracts for our hospital HCWs, and is also a requirement for all student HCWs. 2. From January 2005, credentialing in hand hygiene is a mandatory component of the annual performance appraisal of all current and newly appointed HCWs. 3. From January 2005, re-credentialing of all HCWs in hand hygiene by completing the hand hygiene learning package, is required every two years.

73 Appendix 4 (cont) Sample HH Credentialing Policy Practical Issues Where practicable, all new staff will complete the hand hygiene learning package in Human Resources while waiting to have their photo-id badge prepared. By accessing the package on the Intranet, their details are recorded, together with the data on current HCWs. The hand hygiene learning package is also available to the general public on the Internet (no registration required). HCWs from our hospital must complete the package on the Intranet (with a hospital computer) for their details to be recorded. Other groups with access to register on the Internet include nursing students who will credential themselves before their placement at our hospital. CNED and University co-coordinators have access to reports on the Internet (accessed by password only) detailing the nursing students credentialed in hand hygiene. New Medical Interns, Residents, Registrars will be collectively credentialed during their orientation week. All other new Medical staff will be credentialed at the time of obtaining their photo-id badge. It is the responsibility of all managers to ensure that all students (of any type) who may have patient contact are credentialed in hand hygiene on commencement of their placement at our hospital. Author/s: Clinical Nurse Consultant Infection Control In Consultation with (If required): Clinical Nurse Consultant Infection Control Coordinator Endorsed by: Professor of Infectious Diseases Clinical Nurse Consultant Infection Control Coordinator References/Supporting Documents: Centres for Disease Control and Prevention. Guideline for Hand Hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly Report. 2002; 51 (No. RR-16) Johnson P, Martin R, Burrell LJ, Grabsch EA, Kirsa SW, O Keeffe J et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of nosocomial methicillinresistant Staphylococcus aureus (MRSA) infection. MJA 2005; 183: World Alliance for Patient Safety. Who Guidelines on Hand Hygiene in Healthcare (Advanced Draft): Global patient safety challenge : Clean care is safer care. World Health Organisation; Graham M, Nixon R, Burrell LJ, Bolger C, Johnson PDR, Grayson ML. Low rates of Cutaneous Adverse Reactions to Alcohol-Based Hand Hygiene Solution during prolonged use in a Large Teaching Hospital. Antimicrobial Agents and Chemotherapy 2005 Oct: List key words (to assist users in searching for this document): Hand Hygiene, Infection Control Primary department Responsible for Review Infection Control

74 Appendix 5 Sample Cleaning Shared Equipment Policy Equipment Cleaning Staff this document applies to (state Campus, Unit/s, Disciplines, Positions; also state any specific exclusions): All clinical staff at our hospital Clinical Alert 1. Alcohol wipes should not be used: For hand hygiene or skin cleansing With other chemicals If towelette is dry On equipment which must be sterile 2. Electrical equipment should be wiped with a damp cloth only (do not immerse) 3. Items which are visibly soiled MUST be cleaned with HC90 prior to any additional cleaning Rationale Equipment has the potential to harbour bacteria and other micro-organisms. Research has shown that shared patient equipment can be contaminated with organisms such as MRSA and VRE. Decontaminating shared patient equipment may lead to a decrease in the reservoir of organisms within the hospital environment, which in conjunction with good HH will lead to a reduction in HAI s. Definitions Cleaning: The mechanical removal of dirt and debris which results in a reduction in the number of micro-organisms from a surface, by a process such as washing in detergent (without prior processing). Shared patient equipment: Equipment used on more than one patient Expected Outcome All visibly clean shared equipment will be cleaned with an alcohol impregnated wipe between patients. Equipment Cleaning detergents such as HC90 for items visibly dirty, or contaminated with dirt or organic matter Disposable cloths Isopropyl alcohol impregnated wipes. Eg. Prowipes, with brackets and clamps. Procedure 1. Clean shared patient equipment between use with either HC90 or Prowipes 2. Washable surfaces should be wiped over with HC90 and dried thoroughly 3. Clean items such as computer keyboards, telephones, drug, IV and equipment trolleys DAILY and as required. 4. Ensure Prowipes are stored in a cool place, and the cap is sealed to prevent wipes from drying. 5. Any new items purchased by clinical departments should be able to be cleaned. Equipment for repair Prior to sending equipment for repair, the ward must clean all external surfaces and ensure they are free from dirt, blood, & body fluids References/Supporting Documents: Draft Guideline for Environmental Infection Control in Healthcare Facilities, Centres for Disease Control and Prevention (CDC) Healthcare Infection Control Practices Advisory Committee (HICPAC).

75 Appendix 6 Guidelines for Standardisation of HH Compliance Auditors Requirements for Auditing For consistency of data collection all auditors need to record Hand Hygiene (HH) observations using the same criteria. To become an approved Hand Hygiene auditor a HCW must attend a training workshop with HHA and complete the 5 Moments education program and the practical 5 Moments validation components. Once certified they can train others at their facility. These sessions will consist of a theoretical discussion, training DVD and a practical component: Attend a HHA 5 Moments Workshop where the following is covered: HHA 5 Moments Education Program a. Background of HH in Australia b. Introduction to the 5 Moments c. How to observe and record Moments using the tools provided d. 5 Moments Written Test e. View the HHA training DVD Participants are required to record their HH observations on the audit form. These responses are then scored, and the DVD can be replayed to address any issues that have arisen. HHA Practical 5 Moments Validation o Practical session on the ward with HHA Gold Standard Trainer o The site visit is undertaken to practice observations in real time. Both the trainer and the trainee(s) will observe the same HCWs for the duration of the session(s). o Assessment of practical ward session/s o A comparison of the ward observations will ensure inter-auditor reliability. A discussion will occur to help the trainee understand where, if any, issues may have arisen and a consensus opinion agreed upon. o Further practical sessions with trainer(s) to reinforce the previous session. o These sessions should continue until the trainee achieves the gold standard >95% agreement. A total of at least 100 HH Moments should be observed. o Data entry o A practical session using the HHA HH Compliance Database. Any of the above sessions can occur numerous times to ensure a full understanding and accuracy of both data collection and data entry. Once the training has been completed and a full comprehension of auditing and data entry has been shown then that person can be considered the gold standard (or approved) auditor for their facility.

76 Appendix 6 (cont.) Guidelines Hand Hygiene Auditing Intra-auditor reliability 1. Attend a HHA workshop to gain an understanding of the 5 Moments Program 2. Complete the HHA Auditors written test a. Achieve >90% correct (18/20) b. If <90% correct repeat test until >90% is achieved (do this over a number of days rather than on the same day) 3. Complete the Self Assessment section of HHA DVD a. Achieve >90% correct (76/85) b. If <90% correct repeat test until >90% is achieved (do this over a number of days rather than on the same day) 4. Repeat the Self Assessment section of HHA DVD a week after the last test where >90% accuracy was achieved a. If >90% correct repeat the above procedure on an annual basis b. If <90% correct repeat test until >90% is achieved, then repeat step 3. Attend a HHA Education Workshop Complete HHA Auditors Written Test Complete Self Assessment DVD If <90% Correct Achieve >90% Correct Repeat Self Assessment DVD >1 week after your last successful test If <90% correct Achieve >90% correct Repeat annually

77 Appendix 6 (cont.) Guidelines Hand Hygiene Auditing Inter-auditor Reliability 1. Attend a HHA workshop to gain an understanding of the 5 Moments Program 2. Complete Self Assessment DVD (as part of HHA workshop, or preferably as Intra-auditor reliability) 3. Practical session with HHA gold standard trainer a. Introduction to ward auditing b. Start auditing the same Moments together i. Compare and discuss answers as often as required ii. Once trainee is confident commence formal assessment c. Observe 25 Moments together i. Compare and discuss answers ii. If >90% agreement move on to part d iii. If <90% agreement start again from b d. Observe another 25 Moments together i. Compare and discuss answers ii. If >90% agreement move on to part e iii. If <90% agreement start again from d e. Observe 50 Moments together i. Hand audit sheet to assessor ii. If >95% agreement Gold Standard has been achieved iii. If <95% agreement start again from part e on a separate day 4. It is recommended that the Gold Standard trainer observe 100 Moments with the trainee in the assessment phase. Only in exceptional circumstances should this number of observations be reduced (at the discretion of the trainer). 5. If multiple attempts are required to achieve the appropriate level of accuracy it is recommended that these occur over a number of days. Attend HHA Practical Validation Session Complete Self Assessment DVD Practical audit session with gold standard auditor Audit 25 Moments >90% agreement <90% agreement Audit 25 Moments >90% agreement <90% agreement Audit 50 Moments >95% agreement <95% agreement Gold Standard Achieved

78 Appendix 7 Sample Hand Hygiene Compliance Assessment Tool Opportunities for HH are recorded using a standardised tool developed by the HHA Coordinating Centre (based on the previous tool developed by Austin Health) Coordinating Centre 12 and the WHO manual for observers (38) ).

79 Appendix 8 Sample HH Compliance Tool Coding Sheet

80 Appendix 9 Sample HH Compliance Assessment Form

81 Appendix 10 Sample Hand Hygiene Policy Effectively performing Hand Hygiene Staff this document applies to: All healthcare workers at our hospital State any related policies, procedures or guidelines: Hand Hygiene credentialing, Cleaning shared equipment DEFINITION Hand hygiene is a term that applies to the process of hand washing, or hand decontamination. Hand washing involves mechanically removing bacteria from your hands with plain, i.e. non-antimicrobial soap and water. Hand decontamination involves removal of bacteria by washing your hands with antimicrobial soap and water or alcohol/chlorhexidine hand rub. RATIONALE The most common way that bacteria are spread between patients in PRACTICE AUTHORISATION EXPECTED OUTCOME CLINICAL ALERT hospital is on the hands of health care workers. (CDC 2002) Additionally, systematic reviews indicate that effective hand decontamination can significantly reduce the rate of healthcare associated infections. Staff are required to complete the Hand Hygiene Learning package within one month of commencing employment at Austin Health. All current staff are required to complete the Hand Hygiene Learning package every second year. Appropriate hand hygiene practice before and after every patient applies to all health care workers. The rate of MRSA bacteremia s to remain below 3 per month Hand Hygiene compliance rates to remain above 60% 80 % of all staff working at Austin Health to have successfully completed the Hand Hygiene Learning package. Use of alcohol and chlorhexidine may potentially cause irritation of previously damaged skin (eg eczema). Our hospital experience has demonstrated that the skin integrity of health care workers improves with the use of ABHR, due to the emollient it contains. Applying a compatible moisturiser regularly can protect skin from the drying effects of hand decontamination. (Product used at our hospital is XX) Very rarely (<1:3000) staff may develop an allergy to the chlorhexidine component of the ABHR.

82 Appendix 10 (cont.) Sample Hand Hygiene Policy EQUIPMENT Non-antimicrobial liquid soap. PROCEDURE Antimicrobial liquid soap (4% Chlorhexidine). Alcohol and Chlorhexidine based hand rub Wall mounted brackets for alcohol/chlorhexidine hand rub Designated basin for hand washing. Moisturiser Hand Hygiene Learning package. Alcohol Based Hand Rub: Squirt, Rub, Roll Apply 1 squirt (1-3mls) to the palm of your hand and roll all over your hands for 15 seconds. Indications for use: Before and after every patient contact. Between each patient care activity (eg. emptying urine bottle to checking IV site) Before and after touching equipment in the patient bed zone. Before and after contact with inanimate objects that are potentially contaminated (eg: charts, curtains) Non-antimicrobial soap: Wet hands and apply product for seconds, cover all surfaces of hands, rinse with running water and pat dry with paper towel. Indications for use: If hands are visibly soiled, or after removal of powdered gloves. POST PROCEDURE Antimicrobial soap: Wet hands and apply product for seconds, (variable length based on type of procedure) cover all surfaces of hands, rinse with running water and pat dry with paper towel. Indications for use: When hands are visibly soiled Prior to any invasive procedure. On leaving an Isolation room Following any form of Hand Hygiene, health care workers are encouraged to care for their hands by applying a moisturiser, which is available throughout each clinical area. Testing has proven that the moisturiser is compatible with the ABHR, and will not deactivate the Chlorhexidine component.

83 Appendix 11 Indications for hand washing and hand antisepsis (1)

84 Appendix 12 Ranking System For Evidence CATEGORY IA Strongly recommended for implementation and strongly supported by well designed experimental, clinical, or epidemiological studies CATEGORY IB Strongly recommended for implementation and supported by some experimental, clinical, or epidemiological studies and a strong theoretical rationale CATEGORY IC Required for implementation, as mandated by federal and/or state regulation or standard CATEGORY II Suggested for implementation and supported by suggestive clinical or epidemiological studies or a rationale or a consensus by a panel of experts FROM: CDC/HICPAC. System for categorising recommendations. In: World Alliance for Patient Safety. Who Guidelines on Hand Hygiene in Healthcare (Advanced Draft): Global patient safety challenge : Clean care is safer care. World Health Organisation; 2005.

85 Appendix 13 Sample Jewellery - Nails Policy Guidelines JEWELLERY & NAIL CARE Purpose To provide information and guidelines for effective and timely hand hygiene practices in regard to the use of jewellery, artificial nails and nail polish. Rationale It is likely that rings and other jewellery harbor microorganisms that could increase the risk of contaminating a body site with potential pathogens (7). HCWs who wear artificial nails are more likely to harbour Gram-negative pathogens and fungal disease on their fingertips than those who have natural nails, regardless of whether appropiraite HH is perfomed. Policy Jewellery Jewellery must not interfere with effective Hand Hygiene. A plain band can be permitted in clinical areas but must be moved about on the finger during the act of performing hand hygiene. Total bacterial counts can be higher when rings are worn as they can interfere with the actual technique required to perform correct hand hygiene (4,7). In high-risk settings such as operating theatres the wearing of any jewellery even a plain band is not recommended (7) Bracelets, wrist watches and rings with stones or ridges should not be worn when providing clinical care. Rings and other jewellery can also hinder the donning of gloves and increase the risk of tearing of the gloves. Bracelets, wrist watches and rings with stones or ridges are not recommended when providing clinical care (7). Nails: Nails should be kept short, clean and healthy. The use of nail polish should be avoided in all clinical areas. Chipped nail polish may support the growth of larger numbers of organisms on the fingernails (4,7). There have been studies that have shown that the subungal areas of the hand harbor high concentrations of bacteria. Artificial nails have been implicated in a number of outbreaks of health care associated infections therefore it is not recommended that any HCWs with direct patient contact wear them (4,7). References: 1. Hand Hygiene Victoria, April Moments for Hand Hygiene Manual 2. Austin Health: Clinical Nursing Standard: Effectively performing Hand hygiene, 2003: revised Peninsula Health: Policies and Procedures Infection Prevention and Control, Hand Hygiene, 5:4:2, Centres for Disease Control and Prevention. Guideline for Hand Hygiene in health-care settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, Morbidity and Mortality Weekly Report, 2002; 51 (No. RR- 16): 5. Start Clean Victorian Infection Control Strategy (September 2007). Department of Human Services, Victoria, Grayson ML, Jarvie LJ, Martin R, Jodoin ME, McMullan C, Gregory RHC, Bellis K, Cunnington K, Wilson FL, Quin D, and Kelly A-M, on behalf of the Victorian Quality Council Hand Hygiene Study Group and Victorian Quality Council Hand Hygiene State-wide Roll-out Group. Significant reductions in methicillin-resistant Staphylococcus aureus bacteremia and clinical isolates associated with a multi-site, hand hygiene culture-change program and subsequent successful statewide rollout. Med J Aust 2008; 7. WHO Guidelines for Hand Hygiene in health care (Advanced Draft). Global Patient Safety Challenge : Clean Care is Safer Care, 2006

86 Appendix 14 Flow chart for management of staff with hand concerns Example only: This flow chart was developed to standardise the response to staff reporting hand irritation/dryness problems.

87 Appendix 15 Sample Ward / Department Product Auditing Form Ward: Date: Time: Bed Present, end of bed (Y/N) Product availability audit ABHR Alcohol Wipe Other Miscellaneous Areas Empty (Y or blank) Present outside bay (Y/N) Empty (Y or blank) Present (Y/N) Empty No. of brackets No. of ABHR Empty (Y or blank)

88 Appendix 16 Sample Allocation schedule Example only: The allocation schedule is likely to be more useful to larger facilities that have to undertake several sessions to obtain their quota of observations.

89 Appendix 17 HHA Compliance Database

90 Appendix 18 Sample HHA Compliance Report Ward Format

91 Appendix 19 Sample HHA Compliance Report Health Service Format

92 Appendix 20 Prospective SAB Data Collection Form HOSPITAL a b c d e f g h i j k Monthly SAB Data Summary TOTAL number of Staph. aureus bacteraemias Number of Staph. aureus bacteraemi as identified > 48 hours from admission Number of Staph. aureus bacteraemi as identified < 48 hours TOTAL from Number of admission MRSA Number of MRSA identified > 48 hours Number of MRSA TOTAL Number of MSSA identified < Number of identified > 48 hours MSSA 48 hours Number of MSSA identified < 48 hours Total number of separations Total number of occupied bed days Jan-09 Feb-09 Mar-09 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10

93 Appendix 21 Retrospective SAB Data Collection Form HOSPITAL Monthly SAB Data Summary TOTAL number of Staph. aureus bacteraemias TOTAL Number of MRSA TOTAL Number of MSSA Total number of separations Total number of occupied bed days Jan-07 Feb-07 Mar-07 Apr-07 May-07 Jun-07 Jul-07 Aug-07 Sep-07 Oct-07 Nov-07 Dec-07 Jan-08 Feb-08 Mar-08 Apr-08 May-08 Jun-08 Jul-08 Aug-08 Sep-08 Oct-08 Nov-08 Dec-08

94 Appendix 22 SAB Case Review Form This document is under construction and will be available at a later date

95 Appendix 23 SAB Database Snapshot This database is under construction and will be available at a later date

96 Appendix 24 5 Moments Poster for Australia