Recommended
More Related Content
What's hot
What's hot (20)
Similar to Monitoring and Evaluation Strategies for Hand Hygiene
Similar to Monitoring and Evaluation Strategies for Hand Hygiene (20)
Recently uploaded
Recently uploaded (20)
Monitoring and Evaluation Strategies for Hand Hygiene
- 1. Hand Hygiene: Monitoring and Evaluation Strategies Marion Aurellado Kwek, MD, FPCP, FPSMID 24 May 2019 PHICS Annual Convention Crowne Plaza Galleria, Manila
- 2. Disclosures • No relevant disclosures • Brands shown are not product endorsements
- 3. Objectives • Discuss strategies to monitor compliance to hand hygiene • Present strategies for improving compliance to hand hygiene • Discuss how to evaluate the implementation of hand hygiene program in the hospital
- 4. Hand Hygiene
- 5. • Observation: Maternal mortality rates were 16% vs 7% b/w 2 clinics • Hypothesis: Cadaverous particles transmitted via the hands of doctors caused puerperal fever • Recommendation: Use of chlorinated lime solution • Outcome: ↓ Mortality rate by 3% WHO Guidelines on Hand Hygiene in Health Care, 2009
- 6. WHO Guidelines on Hand Hygiene in Health Care, 2009 Was the change in practice sustained?
- 7. How can we make our HCWs do hand hygiene and how can we sustain it?
- 8. Ideal Measurement of Hand Hygiene (HH) • Unbiased & exact numerical measure • Does not interfere with the behavior of those observed • Assess microbiologic outcomes of each hand cleansing action • Real time • Reliable for EACH moment requiring HH • Does not require excessive staffing time or cost WHO Guidelines on Hand Hygiene in Health Care, 2009
- 9. Monitoring HH Performance • DIRECT • Direct observation • Patient assessment • HCW self-reporting • INDIRECT • Consumption of products • Automated monitoring of use of sinks and handrub dispensers WHO Guidelines on Hand Hygiene in Health Care, 2009 GOLD STANDARD
- 10. DIRECT OBSERVATION BY EXPERT OBSERVER • Only way to reliably capture all HH opportunities • Details can be observed • Unforeseen qualitative issues can be detected while observing HH • Time-consuming • Skilled and validated observers required • Prone to observation, observer, and selection bias WHO Guidelines on Hand Hygiene in Health Care, 2009
- 14. Covert vs Overt Observation • CO conducted simultaneously with OO during each 2-week session • Programs: HH resources, leadership commitment education, admin support & feedback • Overall HHC was 91.0% for OO, and 49.3% for CO. • CO reflects HHC change more reliably than does OO. However, it is uncertain whether CO will improve HHC. Yoo, et al. American Journal of Infection Control 47 (2019) 482−486
- 15. Self reporting Implementation of secret shoppers Infection Prevention & Control Unit, AHMC
- 16. DIRECT OBSERVATION BY PATIENT • Inexpensive • Potential negative impact on patient–HCW relationship • Reliability and validity required and remains to be demonstrated WHO Guidelines on Hand Hygiene in Health Care, 2009
- 17. DIRECT OBSERVATION: HCW SELF ASSESSMENT • Inexpensive • Overestimates true compliance • Not reliable WHO Guidelines on Hand Hygiene in Health Care, 2009
- 18. Bias in HH Observation BIAS DESCRIPTION Observation bias Presence of an observer induces better than usual hand hygiene behavior Observer bias Observers systematically interpret the observation method and definitions for hand hygiene opportunities and actions in their own way Selection bias Observers systematically select certain times, care situations, health-care sectors, HCWs or opportunities for their observations. Results do not reflect the overall hand hygiene compliance WHO Guidelines on Hand Hygiene in Health Care, 2009
- 19. INDIRECT METHODS: ALCOHOL CONSUMPTION • Inexpensive • Reflects overall hand hygiene activity (no selection bias) • Validity may be improved by surrogate denominators for the need for HH (patient-days, workload measures, etc.) •Does not reliably measure the need for HH (denominator) •No information about the timing of HH actions •Prolonged stocking of products at ward level complicates and might jeopardize the validity WHO Guidelines on Hand Hygiene in Health Care, 2009
- 20. ALCOHOL CONSUMPTION • Validity threatened by increased patient and visitor usage • No possibility to discriminate between individuals or professional groups WHO Guidelines on Hand Hygiene in Health Care, 2009
- 21. AUTOMATED MONITORING SYSTEMS • Absence of observer may reduce observation bias • May potentially produce valuable detailed information about HH behavior and infectious risks • Scarce real world experience so far • Potential ethical issues with tracking of individual activity • Unknown impact on staff and patient behavior • Systems may be costly and failure- prone WHO Guidelines on Hand Hygiene in Health Care, 2009
- 22. Strategies to Improve HH Compliance WHO Guidelines on Hand Hygiene in Health Care, 2009 System Change Monitoring & Feedback Training & Education Workplace Reminders Safety Culture
- 23. System Change • Availability of hand hygiene facility at point of care • At least 1 sink : 10 beds • Soap AND fresh towels at every sink
- 25. Training and Education • Programs to update training over the short-, medium- and long-term • Traditional educational sessions • Interactive sessions • Practical sessions • Brochures/leaflets • Training films
- 26. Educational & Training Program for HH • Global burden of health care-associated infections • Transmission of pathogens • Strategy to prevent the transmission of pathogens • Indications for hand hygiene
- 27. Monitoring & Feedback • Close the loop! • Feedback - raise awareness and acknowledge results achieved • Slide presentation during educational sessions • Immediate compliance feedback • Written reports to staff and the hospital directorate • Be ready for violent reactions
- 28. Real Time Prompting and HH Behaviors • Changing the prompt duration on HH • Prompts: Badge prompts, LED indicators, graphs of aggregate nursing unit performance • HH performance ↓ from 62.61% to 24.94% (OR, 0.36; 95% CI, 0.34- 0.38) when the prompting feature was removed • Electronic monitoring with real-time prompts of 20 seconds’ duration nearly doubles handwashing activity and causes handwashing to occur sooner after entering a patient room. Pong, S et al. American Journal of Infection Control 46 (2018) 768-74
- 29. Real Time Audit & Feedback Apps
- 30. Workplace Reminders • “How to” and “5 Moments” posters are displayed in all test wards (e.g. patients’ rooms; staff areas; out-patient/ambulatory departments)
- 31. Safety Culture • Chief executive officer • Chief medical officer • Medical superintendent • Chief nurse • ALL make a visible commitment to support hand hygiene improvement
- 32. How can we make our HCWs do hand hygiene and how can we sustain it?
- 33. Increasing and Sustaining HH Compliance • Availability and accessibility of HH products • Knowledge & perception of HH principles & importance • Multimodal approach • Continued audit and feedback • Behavior change/cultural change program Moro ML, et al. Euro Surveill. 2017;22(23):pii=30546. Neo et al. American Journal of Infection Control 44 (2016) 691-704 Qasmi, S. et al. American Journal of Infection Control 46 (2018) 1026-31
- 34. Increasing and Sustaining HH Compliance • Well received and engaging hand hygiene interventions • Continued commitment from opinion leaders & interdisciplinary teams • HH training in the curricula of medical students Moro ML, et al. Euro Surveill. 2017;22(23):pii=30546. Neo et al. American Journal of Infection Control 44 (2016) 691-704 Qasmi, S. et al. American Journal of Infection Control 46 (2018) 1026-31
- 35. Evaluating your Hand Hygiene Program Implementations • Random/scheduled audits on hand hygiene facility • Regular hand hygiene monitoring and feedback • Staff knowledge & skills assessment • No artificial nails or extenders • Outcomes: • HAI rates • MDRO Rates • Transmission rates • Product tolerance and acceptability
- 36. Top 5 Trends in Hand Hygiene 2019 • Beginning Jan. 1, 2018, any observation by surveyors of individual failure to perform HH citation • Show stopper Hermann, C. Top 5 Hand Hygiene Trends for 2019, Infection Control Today Increased Pressure & Penalties
- 37. Top 5 Trends in Hand Hygiene 2019 Less reliance on Direct Observation Hermann, C. Top 5 Hand Hygiene Trends for 2019, Infection Control Today
- 38. Top 5 Trends in Hand Hygiene 2019 More reliance on Actionable Data Hermann, C. Top 5 Hand Hygiene Trends for 2019, Infection Control Today
- 39. Top 5 Trends in Hand Hygiene 2019 Real Time Intervention Hermann, C. Top 5 Hand Hygiene Trends for 2019, Infection Control Today
- 40. Top 5 Trends in Hand Hygiene 2019 Lower Costs Hermann, C. Top 5 Hand Hygiene Trends for 2019, Infection Control Today
- 41. Conclusion • Hand Hygiene is a safety concern of everyone • Compliance to hand hygiene is a performance indicator • Methods to measure compliance have limitations • Multimodal strategies are effective • Continued audit and feedback and behavior change are needed for a sustained hand hygiene program • Hard outcomes like HAI rates can be used to evaluate the true hand hygiene performance
- 42. @Mars_IDS
Editor's Notes
- Good morning. So as stated in the earlier announcement, which we play in our hospital, it is now 8 o’clock, our hand hygiene hour. So for the next hour let us talk about hand hygiene. Before I start, I would like to thank the organizing committee for the invitation to speak today.
- I have no conflict of interest related to this talk.
- For the next hour, I would present different strategies to improve compliance to hand hygiene. <> I will also discuss strategies to monitor compliance to hand hygiene <> And discuss how to evaluate the implementation of hand hygiene program in the hospital
- Hand hygiene, as we all know, is a general term referring to any action of hand cleansing whether through the use of alcohol based hand rubs, or hand washing with soap and water.
- The first time that the association of hand hygiene with infection was first noted by Dr. Ignaz Philipp Semmelweis in 1847 when he noticed that childbed fever or infections were higher in one clinic compared with the other (16% versus 7%), with one facility operated by midwives and the other by doctors. He also noted that doctors and medical students often went directly to the delivery suite after performing autopsies and hypothesized therefore that “cadaverous particles” were transmitted via the hands of doctors and students from the autopsy room to the delivery theatre and caused the puerperal fever. As a consequence, Semmelweis recommended that hands be scrubbed in a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room.
- Despite various publications of results where hand washing reduced mortality, his observations conflicted with the established scientific and medical opinions of the time and his ideas were rejected by the medical community. He could not offer an acceptable scientific explanation for his findings, and some doctors were offended at the suggestion that they should wash their hands and mocked him for it. He was eventually committed to an asylum and died 2 weeks later. His practice earned widespread acceptance only years after his death, when Louis Pasteur confirmed the germ theory and Joseph Lister, acting on the French microbiologist's research, practiced and operated, using hygienic methods, with great success.
- Before we can say that our HCWs are doing hand hygiene, we should be able to measure this as a performance indicator. An ideal indicator of hand hygiene performance would produce an unbiased and exact numerical measure of how appropriately HCWs practise hand hygiene so that its preventive effect on negative infectious outcomes is maximized. <> Ideally, the technology does not interfere with the behaviour of those observed, <> assesses the microbiological outcome of each hand cleansing action <> in real time, and <> reliably captures each moment requiring hand hygiene even during complex care activities. Furthermore, the method used should not require excessive staffing time and other costs to provide sufficient data to exclude selection bias and underpowering. Bias and insufficient sample size represent the two major threats to meaningful monitoring outputs. Does such a method exist? <> Like the unicorn and other mythical creatures, such a method does not exist. All current measurement approaches produce approximate information on real hand hygiene performance.
- Detection of hand hygiene compliance by a validated observer (direct observation) is currently considered the gold standard in hand hygiene compliance monitoring. It is the only method available to detect all occurring hand hygiene opportunities and actions and to assess the number of times and appropriate timing when hand hygiene action would be required in the sequence of care. Observations are usually performed by trained and validated observers who observe care activity directly and count the occurring hand hygiene opportunities and determine the proportion being met by hand hygiene actions. It is essential that hand hygiene opportunities, indications, and actions are clearly defined
- You observe for the hand hygiene opportunities with the different moments of hand hygiene to measure compliance.
- This study was designed to evaluate whether simultaneous CO and direct overt observation (OO) can improve and sustain HHC as a method of hospital-wide monitoring. Additionally, we validated whether CO reflects changes in HHC more reliably than OO. HHC in phase 1 was not changed by repeated CO (34.7% & 34.0%, P = .70). HHC based on CO ↑ to 66.9% in phase 2 after intervention (P < .01), but decreased to 57.5% in phase 3 (P < .01) HHC based on OO ↑ significantly between only the 1st & 2nd sessions in phase 2 (90.8% and 94.5%, respectively, P = .01).
- Patients could be observers of HCWs’ hand hygiene compliance. In two studies, patients were encouraged to find out if HCWs had washed their hands before patient contact.804,805 Patient monitoring of hand hygiene compliance is not well documented, however, and has never been objectively evaluated.1036 Patients may not feel comfortable in a formal role as observers and are not always physically or mentally able to execute this task.737,1037
- The use of sinks and handrub dispensers can be monitored electronically.699,710,852,986 Systems that are even able to identify HCWs when using a sink or a handrub dispenser are under
- The WHO Guidelines on hand hygiene recommends a multimodal approach to Hand Hygiene Improvement. This approach consists of 5 essential elements
- Obstacles: limited time availability of HCWs beyond the work shifts and the reluctance of doctors to attend training sessions.
- Global Burden of HAI – Global Patient Safety Challenge, Morbidity, mortality and costs of HAIs Transmission of pathogens – route of transmission, consequences for the patient AND the HCW Strategies to break the chain of infection – standard precautions, hand hygiene and care associated precautions Indications for Hand Hygiene - Concept of health-care area and patient zone, five moments for hand hygiene, Hand hygiene agents and procedures, Care of hands, Glove use
- It is important to close the loop! Feedback was noted as being very important to raise awareness and to acknowledge the results achieved. The method used most frequently was a slide presentation during educational sessions; in some cases, immediate compliance feedback and a written report were given to staff and the hospital directorate. In some facilities, the reaction of HCWs to reported low rates of compliance was not positive; in others, when data were disseminated to other units, they generated much interest to take part in the implementation.
- Quasi experimental study. Prompts: Badge prompts (vibration for missed opportunities), LED indicators, graphs of aggregate nursing unit performance on a screen at the nurse’s station, performance graphs of other stations
- According to several studies, hand hygiene compliance tend to return to baseline unless sustained with continued audit and feedback. Improving awareness with education (knowledge transfer, evaluation, mentoring, and feedback),
- According to several studies, hand hygiene compliance tend to return to baseline unless sustained with continued audit and feedback. Improving awareness with education (knowledge transfer, evaluation, mentoring, and feedback),
- Random audits on hand hygiene facility includes checking your sinks, availability of soap, water? Towels, alcohol handrubs, trolleys for clinical use have hand rubs, <> Regular hand hygiene monitoring and feedback, showing adherence of staff and leadership, prominent display of trends. Electronic, unit meetings, quality boards <> Staff knowledge and skills assessment includes answering a standard questionnaire, demonstrating proper method of hand hygiene
- Beginning Jan. 1, 2018, any observation by surveyors of individual failure to perform hand hygiene in the process of direct patient care citation
- Partially the result of increased pressure from the Joint Commission, healthcare organizations are less likely to use secret shoppers when monitoring hand hygiene performance with direct observation. Most of them have known for years that direction observation doesn’t work, but it was easier to continue with the status quo (as flawed as it was) than investing energy and time in making a change. There are many reasons direct observation doesn’t work. A multitude of human biases are involved, such as the Hawthorne Effect in which providers who know they’re being watched (and they always figure it out) are three times more likely to clean their hands. In addition, the sample sizes are too small. And as we like to say, “you don’t make a chicken fatter by weighing it.” That is, any method to simply monitor hand hygiene performance – direct observation or otherwise – does not change nor improve the results. Many hospitals continue to submit misleading data that shows hand hygiene performance rates above 95 percent, yet their HAI rates have not dropped and some of these hospitals are even on the HAC (Hospital-Acquired Conditions) list. If the nationwide average for hand hygiene is below 50 percent and you say you’re at 95 percent, but you’re also on the HAC list, in reality your hand hygiene data is not accurate. Most leading organizations are becoming more willing to face the fact that this data is seriously flawed and getting leadership support to fix it.
- ore Reliance on Actionable Data. The Internet of Things (IoT) and big data have revolutionized a number of industries and they’re beginning to transform healthcare as well. When used to monitor hand hygiene performance, IoT sensors and other technology can capture hand hygiene performance data without bias, unlike direct observation. This data can be analyzed in new and exciting ways, with cutting edge visualization that makes it easy for healthcare managers to identify the highest risk individuals, patient conditions and hospital rooms on a granular level. Many electronic hand hygiene technologies integrate with electronic medical record systems, so there’s a seamless flow of information between the two, automatically syncing patient condition with hand hygiene protocols in the system. This combined data can be used to identify the most at-risk patients for targeted interventions.
- A growing number of healthcare organizations are relying on real-time interventions to improve hand hygiene performance in the moment. This includes reminding providers to sanitize their hands by using lights, beeps, vibrations and/or a human voice that are activated when a healthcare worker fails to clean their hands. These can be remarkably effective in changing behavior and improving performance. We’re seeing increasing adoption of these technologies. Real-time interventions can also take the form of text messages that warn unit managers of hotspots – patient rooms where hand hygiene is unusually low, particularly for patients in isolation or with C. diff. This type of intervention can alert managers to high-risk situations, so they can intervene before a problem can spread.
- 5. Lower Costs. Electronic hand hygiene systems that gather and analyze reams of actionable data, provide real-time interventions and reduce the chance of a Joint Commission citation, have come down in price. While there appears to be a misconception in the marketplace that this technology is expensive, it’s surprisingly affordable and becoming more so as time goes on. Most of these systems provide a tremendous ROI due to reducing infections, reducing HAC and readmission penalties, and eliminating the need for staff to spend precious time doing direct observation. With these financial advantages, hospitals are adopting electronic hand hygiene systems at a faster pace than ever before. The Bottom Line With dropping prices, a solid return on investment and mounting pressure to improve hand hygiene, we’ll see more hospitals in 2019 moving away from direct observation to leverage actionable data and real-time interventions that change clinical behavior.