Patient Hand Hygiene Protocol Project By Shannon Dembowske

Patient Hand Hygiene Protocol Project By: Shannon Dembowske

Project Overview • The Patient Hand Hygiene Protocol was implemented in the ICU to increase hand hygiene awareness to decrease the rates of hospital acquired infections (HAIs) • Patient hand hygiene was not being offered due to the lack in awareness, resources, and convenience. • Some studies show that patients hand washing compliance of patient’s decreases while they are in the hospital, than compared to at home. “The knowledge and attitudes of patients, and the accessibility of hand hygiene facilities, can influence their personal hand hygiene. ” (Drumright & Coffey, 2015) • A 2015 Patient hand hygiene protocol, using scheduled CHG cleansing showed a slight reduction in HAIs, and also showed a increase in staff compliance of hand hygiene as well. (Fox, et al, 2015, p. 216 -223)

Project Goals/ Objectives • The main goal of this project was to implement a patient hand hygiene process which includes action, education, and documentation. Objectives/Tasks- Completed/Met 1. 2. 3. 4. 1. 2. Literature Review 1. Literature research 2. Organize information to include in a Power. Point Method of education 1. Develop PPT presentation Pitch Project Presentation 1. Project approval from unit manager/educator 2. Present to UPC for project approval 3. Gain UPC resources and support Protocol Development 4. 2 Identify strategies for implementation 4. 3 Establish timing/ technique 4. Identify and obtain resources Educate/Implementation 1. Educate staff about new protocol 2. Implement protocol 3. Educate patients/visitors and reinforce Evaluate 2. Establish Barriers 3. Report results to UPC and unit educator Objectives/Tasks- Not Completed/ Not Met: 4. Protocol Development 4. 1 Pre-protocol hand-hygiene audit 4. 5 Finalize unit protocol 6. Evaluate 6. 1 Perform post-protocol audit

Quality and Safety • Quality Improvement Process – Aimed to reduce hospital acquired infections • (The Joint Commission’s National Patient Safety Goal) – Improve patient satisfaction scores – Education about the spread of infection and proper hand hygiene techniques. • Employee development, involvement, and direct patient care

Process, Progress, and Completion of Project • Idea for this project came from a lecture from NTI, along with the realization that my unit documented the hand hygiene was being taught, but it was not actually getting done. • Before presenting my project to the unit, I researched and developed a case for why patient hand hygiene was important. • After many meetings and emails, I was able to get support for the project through the UPC and unit manager with a few changes. – Patient Hand Hygiene Protocol > Patient Hand Hygiene Awareness • In the end, the ICU now stocks hand sanitizing wipe packets in every patient room along with staff education and reinforcement that the wipes are available.

Obstacles and challenges of project • Biggest Challenge– Nutritional services did not want to place individual hand wipes on each tray, claiming that it would just be a waste because patients never use them. • Smaller Challenges– Changing from a protocol to an awareness campaign – Documentation

Ethical/ Professional Issues • No ethical or professional issues to report. • Hand Hygiene Protocol Project can be related to the ethical principle of beneficence. – “The basic obligation to assist others” (Yoder. Wise, 2015, p. 92). These actions are taken to promote good. – This project requires actions by staff to assist patients with hand hygiene and promote good through the reduction in the spread of infection.

Lessons Learned as a Project Manager • Elements that shaped my role as a project manager and team leader – Leading by example – Building self-confidence – Having a positive attitude • Theory of Innovation-Decision Process – Five Stages for Creating Change • • • 1. Knowledge 2. Persuasion 3. Decision 4. Implementation 5. Confirmation (Yoder-Wise, 2015, p. 310). • Collaborative Leadership Role – “Collaborating involves a group of people working together to achieve a common goal”(Yoder-Wise, 2015, p. 580). – As a leader of this group keeping a positive attitude about the goal, set the tone for the other members of the group.

Conclusion • I think that this project was a success because I was able to make change in the ICU unit. – Hand hygiene resources now available • More awareness to patient hand hygiene throughout the entire hospital • Patient hand hygiene is now being talked about at the hand hygiene committee meetings

References: • Drumright, K. & Coffey, J. (2015). Patient hand hygiene: overlooked factor in the spread of healthcare-associated infections [Power. Point slides]. Retrieved from https: //ntinetwork 2015. pathable. com/meetings/239041 • Fox, C. , Wavra, T. , Ash Drake, D. , Mulligan, D. , Pacheco Bennett, Y. , Nelson, C. , Kirkwood, P. , Jones, L. , & Bader, M. (2015). Use of a Patient Hand Hygiene Protocol to Reduce Hospita-Aquired Infections and Improve Nurses' Hand Washing. American Journal of Critical Care, 24(3), 216 -224. • Yoder-Wise, P. S. (2015). Leading and managing in nursing, (6 th Ed. ). St. Louis, MO: Elsevier Mosby.