Hand Hygiene Observation and Analysis Version 1 4

Hand Hygiene Observation and Analysis Version 1. 4

Instructions • This presentation should be used to teach observers how to conduct observations. After reviewing slides 1 -25 observers should complete activities on slide 26 • Observers must complete training on Your 4 Moments for Hand Hygiene before this presentation • Following reviewing this presentation, the observer should practice in the clinical setting or by simulation. • An Excel workbook is provided to enter and analyze data from the observation tool. The individual responsible for this activity should review the Instructions for Observation Tool analysis available on justcleanyourhands. ca website 2

Overview 1. Practical training for observers on how to observe hand hygiene compliance and complete Observation Tool 2. Overview of audit process 3. Overview of analysis and reporting process 3

How to observe hand hygiene? Adapted from WHO • Direct observation using a consistent approach and validated tool, is the most accurate methodology • The observer must familiarize him/herself with the methods and tools used in the Just Clean Your Hands program and must be trained (and validated) to identify and distinguish the indications for hand hygiene occurring during health care practices at the point of care • The observer must conduct observations openly, without interfering with the ongoing work, and keep the identity of the health care providers confidential • Compliance should be detected according to the four indications for hand hygiene recommended by Just Clean Your Hands program. 4

Crucial concepts for observing hand hygiene Adapted from WHO Health care activity = a succession of tasks during which health care providers' hands touch different types of surfaces: the patient, his/her body fluids, objects or surfaces located in the patient environment. Each contact is a potential source of contamination for health care providers' hands … contact 1 indication(s) contact 2 indication(s)] contact 3 indication(s) … Indications Indication: the reason why hand hygiene is necessary at a given moment. It is justified by a risk of organism transmission from one surface to another. 5

Adapted from WHO Opportunity RISK OF TRANSMISSION INDICATION OPPORTUNITY HAND HYGIENE Opportunity: the need to perform hand hygiene, whethere are single or multiple indications. Hand hygiene must correspond to each opportunity. Multiple indications may come together to create a single opportunity. 6

Terminology: Moment, Indication and Opportunity • Moment/Indication: The terminology of indications and moments are used interchangeably to refer to the four times it is essential that hand hygiene be performed by health care providers (ie. before initial patient/patient environment contact, after aseptic procedure, after body fluid exposure risk, after patient/patient environment contact). • Moments: is usually referred to when teaching or for use on public materials such as posters and brochures. • Indications: is always used when discussing audits. An Indication is the reason why hand hygiene is necessary at a given moment. It is justified by a risk of organism transmission from one surface to another • Opportunity: is the need to perform hand hygiene, whethere are single or multiple indications. Hand hygiene action must correspond to each opportunity. Multiple indications may come together to create a single opportunity. The opportunity block on the observation tool is used to record single or multiple indications that provide a single opportunity for hand hygiene. 7

Preparing to Audit General Recommendations for Observation: • Determine how to best identify the types of health care providers you may be observing. § Accurate identification of health care provider is critical to ensure reliability of data. • Introduce yourself to the observed health care provider(s) and patients as appropriate and explain your role. 8

Preparing to Audit Positioning for observation: • Find a convenient place to observe without disturbing care activities; you can move to follow the health care provider, but never interfere with their work. However you can provide feedback after the session using “On- the-Spot” form. • It is important to take into account any concerns the health care providers may have with your presence. Your presence should be as discreet as possible and in no way infringe on the actions of the health care provider. If a health care provider feels uncomfortable with your presence he/she has the right to ask you to leave and you must do so if asked. 9

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

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How to use the form • Use a pencil to fill in the form and an eraser to correct. Use a clipboard to hold the form. • First, fill in the head of the form by indicating your ID number (Observer-ID), the date, the current time including am/pm (Start time), the number of the form used for a single session using the format 1, 2, 3, etc. (Form-No. ) (See also point 19 on reverse of Observation Tool), the identity of the facility (Facility-ID), the identity of the patient care unit (Patient Care Unit) 12

How to use the form (acute care categories) • Indicate any rooms where Additional/Isolation Precautions are in place by entering in the Comments section. (Observe outside the room. ) • Indicate the type of health care provider being observed by entering the number that corresponds with the categories listed at the top of the form. The coding system is a number followed by a letter (e. g. , first physician in the room is 1 A, if second physician enters the room he/she is 1 B). 13

How to use the form (LTC categories) • Indicate any rooms where Additional/Isolation Precautions are in place by entering in the Comments section. (Observe outside the room. ) • Indicate the type of health care provider being observed by entering the number that corresponds with the categories listed at the top of the form. The coding system is a number followed by a letter (e. g. , first physican in the room is 1 A, if second physician enters the room he/she is 1 B). 14

How to use the form (continued) • Each column is for recording hand hygiene opportunities of one health care provider only. Use additional columns for each additional health care provider being observed simultaneously or sequentially. The health care provider may interact with more than one patient during the time you are observing. Note: The Long-Term Care Observation Tool uses “Category” instead of HCP. • As soon as you observe the first indication for hand hygiene, indicate the corresponding information in the first of the numbered opportunity sections in the column corresponding to the health care provider being observed. 15

Before Initial Patient/Patient Environment Contact BEF-PAT/ ENV = “before initial patient/patient environment contact” a) if the health care provider touches the patient’s environment and then touches the patient or b) goes directly to touch the patient after having touched the hospital environment (= any other surface not in the patient’s environment) or another patient’s environment c) if the health care provider enters the patient’s environment from the hospital environment and touches only the patient’s environment (does not touch patient) and then leaves the patient’s environment. 16

Before Aseptic Procedure BEF-ASP = “before aseptic procedure” if the health care provider is to perform any of the following after having touched any other surface including the concerned patient himself/herself and his/her environment: a) touch/manipulate a body site that should be protected against any colonization (e. g. , wound care including dressing change and wound assessment) b) manipulate an invasive device that could result in colonization of a body area that should be protected against colonization (e. g. , priming intravenous infusion set, inserting spike into opening of IV bag, flushing line, adjusting intravenous site, administering medication through IV port, changing IV tubing). 17

After Body Fluid Exposure Risk AFT-BFL = “after body fluid exposure risk” if the health care provider has been engaged in a care activity involving a risk of body fluid exposure and before touching any other surface including the concerned patient himself/herself and his/her environment (e. g. , contact with blood or blood products, emptying urinal/catheter bag and suctioning oral/nasal secretions). 18

After Patient/Patient Environment Contact AFT-PAT/ ENV = “after patient/patient environment contact” a) if the health care provider is leaving the patient and his/her environment to go on working in the hospital environment or with another patient b) if the health care provider is leaving the patient area after touching objects in the patient environment (without touching the patient) to go on working in the hospital environment or with another patient. 19

If there is more than one indication on one opportunity, mark them all Note: If several indications fall together on the same hand hygiene opportunity, tick all. • Example 1: health care provider enters room, cleans hands with alcohol and immediately performs aseptic procedure; this would result in checking • BEF-PAT/ENV and BEF-ASP. 20

For each opportunity, indicate the hand hygiene action of the health care provider • Mark whether the health care provider used alcohol-based hand rub (RUB), soap and water (WASH) or did not do hand hygiene (MISSED) • If a health care provider used soap and water and then alcoholbased hand rub (or vice-versa), mark both. 21

Gloves • For each opportunity, tick if the health care provider was wearing gloves when the opportunity occurred. • In this audit, wearing gloves does not change the number of opportunities for health care providers to clean their hands. • Hand hygiene done with gloves on is incorrect; therefore, it is marked as a missed opportunity. • Examples when gloves may be used: when handling blood and body fluids, mucous membranes, wound care, contact with non-intact skin and where indicated for additional precautions/isolation. 22

Technique: Nails, Rings and Bracelets • Tick the corresponding boxes if the health care provider does not meet the guidelines regarding: § correct nail length (3 -4 mm, ¼ inch) § no nail extensions/artificial nails § no rings or bracelets. • It is necessary to do this only once for each health care provider. 23

Technique: Timing of hand hygiene • Timing of the duration of hand hygiene • T = “timing” This is the duration of hand hygiene performed by the health care provider when hand hygiene occurs for: § BEF-PAT/ ENV and AFT-PAT/ ENV indications. • Use a wristwatch or stopwatch to record duration (seconds) of hand hygiene before patient/patient environment contact and after patient/patient environment contact. Begin timing when the health care providers start rubbing his/her hands with the product, and stop timing when he/she completes the motion of rubbing their hands with the product. • Note: Rinsing of hands with water does not constitute a hand wash – this would be coded as a missed opportunity. 24

Important Notes • Each column is for recording hand hygiene opportunities of one health care provider only. Use additional columns for each additional health care provider being observed simultaneously or sequentially. The health care provider may interact with more than one patient during the time you are observing. • Note: Multiple health care providers sequentially performing tasks quickly make it difficult to maintain accurate observation of missed hand hygiene opportunities. • If you observe more than four opportunities for one health care provider, use another form, numbering them sequentially in the variable Form-No. Remember to code the health care provider in the same way (e. g. , if they were 2 A on the first form, they are 2 A on the second form). • At the end of the session, do not forget to fill in the End time and check the form(s) for missing values before handing it in. • End the observation if the privacy curtain is drawn around the patient’s bed or if a health care provider asks you to leave. • Record any additional qualitative data in the Comments section E. g. , Additional Precautions/Isolation. 25

Activities for Observers. • Review Training Scenarios 1 -4 on Training DVD and record the appropriate observation results for each scenario. • Debrief with others when first learning how to use the Observation Tool, to assist with consistency and understanding of the audit process. • Review Observer Scenarios 5 -8 on Training DVD and record the appropriate observation results for each scenario. • Discuss your results as a group or compare your recorded observations with the answers for each scenario in the Hand Hygiene DVD Answer Key 26

Selecting a Sample Size • It is important to have a large enough sample size to be meaningful. • Not collecting enough data means the rates are not reliable as any changes could be due to chance alone rather than the effect of the intervention. • For 100 beds it is estimated that 56 observation sessions of 20 minutes each is needed to collect enough data for reliable compliance rates. (This provides for approximately 200 observed opportunities) • The time frame for the audit period should be no less than a 2 week period. Note: Ideally, the baseline observations should be completed before the “Implementation Phase” of the program starts. 27

Sample Hand Hygiene Observation Schedule used to audit 80 beds in a pilot site • Friday, January 19, 2008 - 8: 00 a. m. (eight 20 -minute observation) • Sunday, January 21, 2008 - 12: 00 p. m. (eight 20 -minute observations) • Tuesday, January 23, 2008 - 4: 00 p. m. (eight 20 -minute observations) • Thursday, January 25, 2008 - 8: 00 p. m. (eight 20 -minute observations) • Saturday, January 27, 2008 - 12: 00 a. m. (eight 20 -minute observations) • Monday, January 29, 2008 - 4: 00 a. m. (eight 20 -minute observations) 28

Sample size for smaller facilities • To ensure data is valid a hospital with 50 beds should complete at least 100 observed opportunities • The minimum number of observed opportunities is 50 (ie. For 10 beds you would still require 50 observed opportunities to ensure statistical validity) • Data may need to be collected over a longer period of time 29

Feedback: “Aggregate Data” • An Excel workbook tool has been provided to assist with analyzing observation results • Using individual workbooks for each unit, floor or program area allows you to provide feedback specific to those areas. • The data entry can be done by the observer or another resource may be assigned • Predefined reports have been included to analyze data using four different methods • Report table and charts can be pasted into presentations to support feedback of progress to health care providers, management and hospital board 30

Analyzing compliance rates • Compliance rates analyze “when” hand hygiene was performed as compared to the number of times that were indicated to perform hand hygiene. Action Performed HCP : _____ 1 BEFP - AT/ £ AFTP - AT/ £ ENV T: T: BEF-ASP £ AFT-BFL £ £Rub Missed ™ Wash £ Gloves Nails £ £ Bracelets £ Rings £ HCP : _____ 1 BEFP - AT/ £ AFTP - AT/ £ ENV T: T: BEF-ASP £ AFT-BFL £ Rub £ Missed ™ Wash £ Gloves Nails £ £ Bracelets £ Rings £ 4 specific indications HCP : _____ 1 BEFP - AT/ £ AFTP - AT/ £ ENV T: T: BEF-ASP £ AFT-BFL £ Rub £ Missed ™ Wash £ Gloves Nails £ £ Bracelets £ Rings £ Opportunity Block HCP : _____ 1 £ BEFP - AT/ £ AFTP - AT/ ENV T: T: BEF-ASP £ AFT-BFL £ £Rub Missed ™ Wash £ Gloves Nails £ £ Bracelets £ Rings £ Calculation: # times hand hygiene was performed for a specific indication by all categories of HCP x 100 = % compliance # observed hand hygiene indications for a specific indication by all categories of HCP 31

Analyzing technique • The compliance rate is not impacted by technique or the “how” hand hygiene was performed. (i. e. time, rings, watches, nails are not calculated in the rate) Timing indications 1 and 4 (chosen arbitrarily) is optional but can provide helpful data on technique which can be used to inform ongoing education. HCP : _____ 1 £ BEFP - AT/ £ AFTP - AT/ ENV T: T: BEF A SP AFTB - FL £ £ Rub £ Missed ™ Wash £ Gloves Nails £ £ Bracelets £Rings £ HCP : _____ 1 £ BEFP - AT/ £ AFTP - AT/ ENV T: T: BEF A SP AFTB - FL £ £ Rub £ Missed ™ Wash £ Gloves £ Nails £ Bracelets £ Rings £ HCP : _____ 1 £ BEFP - AT/ £ AFTP - AT/ ENV T: T: BEF A SP AFTB - FL £ £ Rub £ Missed ™ Wash £ Gloves Nails £ £ Bracelets £ Rings £ HCP : _____ 1 £ BEFP - AT/ £ AFTP - AT/ ENV T: T: BEF A SP AFTB - FL £ £ Rub £ Missed ™ Wash £ Gloves £ Nails £ Bracelets £ Rings £ 32

Observation Analysis Tool – Data and Reports 33

Observation Analysis Tool – Data Entry Page 34

Methods of analysis Data can be analyzed as follows: 1. Analyzing one type of “indication” for each health care provider category at a time to provide for accurate information to compare over time (most accurate method) 2. Combine health care providers, categories for a specific “indication” to obtain a generalized compliance rate for that “indication” 3. Combine the opportunities for each category of health care provider (HCP) to obtain a generalized compliance rate for each HCP category 4. Compare alcohol-based hand rub with soap and water to assess behaviour change *Note: for 2 and 3 the information may not be comparative over time as the mix of “type of indication” gathered in opportunities in “ 2” or the category of health care provider” in “ 3“may vary and therefore not provide for accurate comparative rates. 35

Calculating reliable hand hygiene compliance rates • An overall hand hygiene compliance rate does not provide for reliable and comparative rates over time as compliance rates for the different types of health care provider and for the each of the four indications are frequently different. • If a generalized rate is to be provided, reliability will increase if the same number is used for the overall analysis: § for each category of health care provider and § for the number of observations of each indication 36

Reports 1 a – d: Preferred Method: Calculating reliable hand hygiene compliance rates • Compliance rates are to be calculated separately for each type of indication and each health care provider category (e. g. , Nurses BEFPAT/ENV 70 per cent; Physicians AFT-PAT/ENV 70 per cent; Respiratory Therapist AFT-BFL-85 per cent) § Compliance rates must be reported by: √ Each hand hygiene indication √ Each health care provider (HCP) category # times hand hygiene was performed for a specific indication /specific HCP category x 100% # observed hand hygiene indications for specific indication/specific HCP category (The number of observations to make the information meaningful will depend on unit size, patient population and hospital size) • Breakdown of the compliance rates by indication and health care provider category provides data for developing targeted and appropriate interventions to improve compliance. • Overall generalized compliance rate combining health care providers and/or combining types of indications will not provide for reliability. 37

Report 1 a - sample Calculation: # times hand hygiene was performed for BEF-PAT/ENV by specific HCP category X 100 = % # observed hand hygiene indications for BEF-PAT/ENV by specific HCP category Note: Categories of provider differ for LTC homes. 38

Report 1 b – sample Calculation: # times hand hygiene was performed for BEF-ASP by specific HCP category X 100 = % com # observed hand hygiene indications for BEF-ASP by specific HCP category Note: Categories of provider differ for LTC homes. 39

Report 1 c - sample Calculation: # times hand hygiene was performed for AFT-BFL by specific HCP category X 100 = % com # observed hand hygiene indications for AFT-BFL by specific HCP category Note: Categories of provider differ for LTC homes. 40

Report 1 d - sample Calculation: # times hand hygiene was performed for AFT-PAT/ENV by specific HCP category X 100 = % # observed hand hygiene indications for AFT-PAT/ENV by specific HCP category Note: Categories of provider differ for LTC homes. 41

Report 2 – Hand Hygiene by type of indication – sample Calculation: # times hand hygiene was performed for a specific indication by all categories of HCP x 100 = % compliance # observed hand hygiene indications for a specific indication by all categories of HCP 42

Report 2 – table detail Example: Compliance for Before initial patient/patient environment contact: 3 x 100 = 75% compliance for BEF-PAT/ENV Compliance 4 Denominator Numerator % Compliance # times hand hygiene was performed # observed hand hygiene indications Before initial patient/patient environment contact 75% 3 4 Before aseptic procedure 25% 1 4 After body fluid exposure risk 50% 2 4 After patient/patient environment contact 75% 3 4 Type of Indications 43

Report 3 – Compliance by health care provider type – combined indications Calculation: # opportunities hand hygiene performed by specific HCP category = % compliance Total # observed hand hygiene opportunities for a specific HCP category x 100 Note: Categories of provider differ for LTC homes. 44

Report 3 - table detail Provides detail on numbers of providers observed as well as total number of observed hand hygiene opportunities Sum of column 4 will provide total number of observed hand hygiene opportunities (1) Type of Health Care Provider (2) % Compliance (3) # Opportunities hand hygiene performed by HCP (4) Total # observed hand hygiene opportunities by HCP Allied HCPs* 0% 0 0 Environmental Services 0% 0 0 Medical Students 0% 0 0 Nurses 0% 0 0 Nursing Students 0% 0 0 PSA, PSW, PCA 0% 0 0 Patient Transporters 0% 0 0 Physicians 0% 0 0 Other 0% 0 0 Note: Categories of provider differ for LTC homes. 45

Report 4 - sample Hand Hygiene Technique 20% 5% rub wash both 75% Calculation: # of opportunities hand rub was used to clean hands x 100 = % rub Total number of opportunities hand hygiene was observed # of opportunities soap and water was used to clean hands X 100 = % wash Total number of opportunities hand hygiene was observed # of opportunities hand rub and soap and water were both used to clean hands X 100 = % both Total number of opportunities hand hygiene was observed 46

Acknowledgement • The Ministry of Health and Long-Term Care would like thank the WHO World Alliance for Patient Safety for sharing its Clean Care is Safer Care materials. This presentation includes slides from annex 16 and concepts from the Observers Manual of Clean Care is Safer Care, the WHO multimodal hand hygiene improvement strategy developed by the World Alliance for Patient Safety. 47