how to implement a systems and behavior approach to improve hand...
TRANSCRIPT
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How to Implement a Systems and Behavior Approach to
Improve Hand Hygiene
June 25, 2015 Sharon Bradley, RN, CIC
Senior Infection Prevention Analyst
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Objectives
• Review the history and effectiveness of hand hygiene compliance in Pennsylvania
• Assess the effectiveness of current hand hygiene methods
• List and review the components of a multimodal approach for hand hygiene compliance
• Describe and demonstrate the process outlined in “Decision-Making Map to Improve Hand Hygiene Behavior”
• Discuss disruptive behavior intervention
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Historical Perspective
• First handwashing studies
1843
Holmes
• Chlorinated lime solution 1846
Semmelweiss
• Carbolic acid (phenol) 1867
Lister
1961
US Public Health Service
• Handwashing with soap and water for 1-2 minutes
(CDC “Guideline”)
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Guidelines and Regulations • Centers for Disease Control and Prevention
– Guideline for Hand Hygiene in Health-Care Settings - 2002
• World Health Organization
– Global Safety Challenge: Clean Care Is Safer Care
• The Joint Commission
– Patient Safety Goal #7
• Centers for Medicare and Medicaid Services
– 42 CFR § 482.42. CMS Conditions of Participation: infection control
(CDC “Guideline”; WHO “About”; Joint Commission; 42 CFR § 482.42)
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(Reprinted with permission: My 5 Moments for Hand Hygiene Based on “My 5 Moments for Hand Hygiene” http://www.who.int/gpsc/5may/background/5moments/en/index.html)
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PA Patient Safety Report Narratives • Nurse did not clean hands or wear gloves while
accessing a cancer patient’s port, left room twice and no hand hygiene or using clean gloves either time.
• Nurse inserted rectal suppository in patient and then performed a blood draw without washing hands between procedures.
• Nurse did not wash hands or wear gloves before or after a dressing change
• X-ray tech ignored isolation precaution-no gloves or hand sanitizing after touching the patient.
(The details of the Pennsylvania Patient Safety Reporting System event narratives in this presentation
have been modified to preserve confidentiality.)
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PA Patient Safety Report Narratives • Anesthesia suctioned patient’s airway without
gloves, wiped hands on his jacket, and administered intravenous medication without hand hygiene or gloves. Refused offer of hand sanitizer prior to giving medication.
• Surgeon did not do surgical scrub before gowning for first case, used foam soap before scrubbing for the second case and touched drapes on the sterile table without being sterile.
(The details of the Pennsylvania Patient Safety Reporting System event narratives in this presentation
have been modified to preserve confidentiality.)
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Alcohol-Based Handrub (ABHR)
Improves the availability of the product at the point of care
Shortens the time to clean hands
Decreases skin irritability with emollient-enriched formulas
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(Ellingson et al.)
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Effectiveness of ABHR
• Point-of-Care Approach:
– Systematic review of 15 studies from 2002 to 2012
– Dispensers at point of care, workflow consideration, and dispenser design
– Variety of practice settings
– Study investigated impact on product consumption, hand hygiene compliance, and healthcare-associated infection (HAI)
– Improved compliance
– Decreased HAI rates (Kendall et al.)
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Poll #1
Select one or more of the processes used in your facility to monitor hand hygiene compliance:
• Direct observation
• Electronic badge monitoring
• Product measurement
• Resource assessment
• Staff perception assessment
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Compliance Monitoring
Direct Observation
• Gold standard
• Labor intensive
• Method variation
• Observer bias
• Hawthorne effect
• Technical challenges
Product Measurement
• No verification of technique
• No verification of WHO 5 Moments
• Subject to care area variances
Electronic Monitoring
• No validation of technique
• No validation of WHO 5 Moments
• Expensive
• Technical challenges
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(Ellingson et al.)
Status of Hand Hygiene Compliance • Systematic review of 96 studies
– Compliance with hand hygiene in hospital care
– Overall compliance median of 40%
• Lowest compliance is associated with:
– ICU, physicians, before patient contact, high activity level
• Highest compliance is associated with:
– Dirty tasks, the introduction of ABHR, performance feedback, accessibility of materials
(Erasmus et al.)
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Closing the Practice Gap
• Focus resources
• Healthcare delivery workflow
• Influence healthcare worker behavior
• Multimodal approach
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(De Wandel et al.)
Five Components of a Multimodal Approach
Assess barriers to
hand hygiene compliance
Survey stuff on hand hygiene
behaviors and beliefs
Map specific strategies for compliance to behaviors
Institute a hand
hygiene “bundle”
Intervene to address disruptive behaviors
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Hand Hygiene Self-Assessment • Framework targets problems with compliance
• Hand hygiene systems
• Training and education
• Evaluation and feedback on resources
• Workplace reminders
• Safety climate
• Leadership gaps
• Sample on the WHO website at: http://www.who.int/gpsc/country_work/hhsa_framework.pdf
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(WHO “WHO Hand Hygiene Self-Assessment”)
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(Reprinted with permission :World Health Organization Hand Hygiene Self-Assessment) http://www.who.int/gpsc/5may/hhsa_framework/en/
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Hand Hygiene Behavior and Belief Survey
• Perception Survey for Health-Care Workers
• Target internal and external motivators
– Attitude and social norms
– Perceived control and intention
– Activity level in work setting
– Prompts: hand hygiene stations and signs
– Sample on WHO website at: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en
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(WHO “Perception Survey”)
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(Reprinted with permission: World Health Organization Perception Survey)
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Source: Pennsylvania Patient Safety Authority. Educational Tools: http://patientsafetyauthority.org/EducationalTools/PatientSafetyTools/handhygiene/Pages/map.aspx
Behavioral Beliefs
• The person believes that:
– Hand hygiene at the point of care prevents spread of organisms and patient harm from HAIs.
– Hand hygiene compliance is expected and valued by peers, supervisors, and patients.
– He or she has control over resources necessary to comply with hand hygiene and can remove barriers to performance.
(Huis et al.; O’Boyle et al.; Whitby et al.)
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Behavioral Beliefs
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Assess Staff Motivational Beliefs
• Do HAIs harm patients?
• Does good hand hygiene prevent HAIs if practiced:
– Before touching a patient?
– Before clean and aseptic procedures?
– After touching a patient?
– After body fluid exposure?
– After touching the patient’s environment?
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(Huis et al.; O’Boyle et al.; Whitby et al.)
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Does Hand Hygiene Prevent HAI?
Hospital-based studies 1975 to 2008
• Validated correlation between adherence with hand hygiene practice and HAI rates
• Demonstrated impact of multimodal hand hygiene promotion on healthcare-associated pathogen cross-transmission and infection rates
(Pittet et al.; Allegranzi et al.)
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Influence Motivational Beliefs
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Motivational Strategies
• Require job-specific, evidence-based education by a role model; use visual aids to simulate organism transfer.
• Define administrative goals and targets for hand hygiene for all staff.
• Educate staff on the science behind the WHO Five Moments for Hand Hygiene.
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(Huis et al.; O’Boyle et al.; Whitby et al.)
Motivational Strategies • Institute one-to-one persuasive
communication moments on the value of proper hand hygiene.
• Post various changeable visual reminders on the intranet and by sinks, mirrors, doors, and/or charts.
• Provide feedback on patient harm from HAIs at staff meetings and group sessions.
(Huis et al.; O’Boyle et al.; Whitby et al.)
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Poll #2 Which of the following educational approaches are used in your facility?
• Video
• Live in-service
• Pre- and post-test
• Competency checklists
• Fluorescent marker
• Simulation
• Interviews
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Behavioral Beliefs
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Assess Hand Hygiene Value Beliefs
• Does administration value hand hygiene as a patient safety issue?
• Do patients, colleagues, supervisors, and the person who most influences your professional behavior expect you to perform hand hygiene?
• Does your unit have a high level of hand hygiene compliance?
• Does your personal hand hygiene practice set a good example for others?
(Huis et al.; O’Boyle et al.; Whitby et al.)
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Influence Value Beliefs
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Strategies to Influence Value Beliefs
• Require staff to sign a contract committing to formulated hand hygiene goals.
• Develop, distribute, and practice talking points to implement peer-pressure communication.
• Engage staff and physicians as role models.
• Be visible with praise, encouragement, and material rewards.
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(Huis et al.; O’Boyle et al.; Whitby et al.)
Strategies to Influence Value Beliefs
• Include hand hygiene compliance in annual performance and competency evaluations.
• Institute hand hygiene compliance as a credentialing requirement.
• Empower patients to speak up, using patient report cards and “Ask me if I’ve washed my hands” buttons.
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(Huis et al.; O’Boyle et al.; Whitby et al.)
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Behavioral Beliefs
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Assess Resource Control Perceptions
• How much effort does it take to perform hand hygiene at all five WHO moments?
• Is there personal control over hand hygiene performance during an intensive patient care activity?
• Are sufficient hand hygiene resources available?
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(Huis et al.; O’Boyle et al.; Whitby et al.)
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Influence Resource Beliefs
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Strategies to Influence Resource Control
• Observe hand hygiene opportunities in high-workload situations.
• Simulate integration of hand hygiene into high-workload situations.
• Demonstrate how various levels of staff are able to integrate hand hygiene into their workflows while keeping up with the workload.
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(Huis et al.; O’Boyle et al.; Whitby et al.)
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Strategies to Influence Resource Control
• Ensure availability of alcohol-based handrub stations at the point of care in all patient care areas.
• Develop a system to ensure soap, alcohol-based handrub, and towels are stocked.
• Stock a hand lotion dispenser in all work areas to prevent skin irritation from multiple hand washings.
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Sample Hand Hygiene Bundle Components
• Integrate administrative and leadership support with the healthcare facility quality improvement effort.
• Institute a multidisciplinary team to coordinate implementation.
• Determine effectiveness of preventive strategies with ongoing monitoring and timely feedback about HAI rates and hand hygiene compliance.
• Implement methods to reinforce behavior, including education, reminders, and support for appropriate hand hygiene.
(Pincock et al.)
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Poll #3 Which of the following approaches are used to structure your facility’s hand hygiene program?
• Written infection control plan
• Hand hygiene annual goals
• Written policies and procedures
• Education programs for all staff levels
• Hand hygiene resource assessment
• Compliance accountability is assigned
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When All Else Fails
Informal conversation
Nonpunitive awareness
intervention
Leader-developed action plan
Corrective action
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Four escalating
interventions
Disruptive Behavior Pyramid (Hickson et al.)
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Summary
• Reliance on ABHR stations, monitoring, standards, and guidelines is problematic.
• Credible hand hygiene programs do the following:
– Target healthcare delivery workflow
–Map specific interventions to internal and external motivators of behavior
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Summary
• A multimodal framework of system infrastructure and behavioral strategies is vital to:
– Investigate, understand, and mitigate gaps in hand hygiene compliance
– Remove obstacles to hand hygiene performance
– Convince healthcare workers that compliance prevents HAIs and is expected and important
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patientsafetyauthority.org
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Questions?
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Like the Authority on Facebook
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References • 42 CFR § 482.42 (2011). http://www.gpo.gov/fdsys/granule/CFR-2011-title42-vol5/CFR-2011-
title42-vol5-sec482-42
• Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. J Hosp Infect 2009 Dec;73(4):305-15.
• Centers for Disease Control and Prevention (CDC). 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 [online]. MMWR Morbid Mortal Week Rep 2002 Oct 25 http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf
• De Wandel D, Maes L, Labeau S, et al. Behavioral determinants of hand hygiene compliance in intensive care units. Am J Crit Care 2010 May;19(3):230-39.
• Ellingson K, Haas JP, Aiello AE. Strategies to prevent healthcare-associated infections through hand hygiene. ICHE 2014 Aug;35(8):937-60.
• Erasmus V, Daha TJ, Richards JH. Systematic Review of studies on compliance with hand hygiene guidelines in hospital care. ICSE Mar 2010.
• Hickson G, Pichert JW, Webb LE. A complementary approach to promoting professionalism: identifying, measuring, and addressing unprofessional behaviours. Academic Medicine 2007 Nov;82(11):1040-8.
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References
• Huis A, van Achterberg T, de Bruin M et al. A systematic review of hand hygiene improvement strategies: a behavioral approach. Implement Sci 2012 Sep 14;7:92. http://www.implementationscience.com/content/7/1/92
• Joint Commission. 2015 national patient safety goals [online]. http://www.jointcommission.org/standards_information/npsgs.aspx
• Kendall A, landers T, Kirk J. Point-of-care hand hygiene: preventing infection behind the curtain. Am J Infect Control 2012 May;40(4):53-9.
• O’Boyle C, Henley S, Larson E. Understanding adherence to hand hygiene recommendations: the theory of planned Behavior. Am J Infect Control 2001;29:352-60
• Pennsylvania Department of Health. 2012 Report: Healthcare associated infections (HAI) in Pennsylvania hospitals [online]. http://www.portal.state.pa.us/portal/server.pt/document/1417904/pennsylvaniahaireport2012_2014-05-19_pdf
• Pennsylvania Patient Safety Authority. Annual Reports 2010, 2011, 2012, 2013 [online]. http://patientsafetyauthority.org/PatientSafetyAuthority/Pages/AnnualReports.aspx
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References
• Pincock T, Bernstein P, Warthman S, eta l. Bundling hand hygiene interventions and measurement to decrease healthcare-associated infections. Am J Infect Control 2012 May;40(4 Suppl 1):S18-S27.
• Pittet D, Allegranzi B, Sax H. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641-52.
• Whitby M, Pessoa-Silva CL, McLaws M.L, et al. Behavioural considerations for hand hygiene practices: the basic building blocks. J Hosp Infect 2007;65:1-8.
• World Health Organization. About SAVE LIVES: clean your hands: My 5 Moments for Hand Hygiene [online]. http://www.who.int/gpsc/5may/background/5moments/en/index.html
• World Health Organization. WHO Hand hygiene self-assessment framework [online]. 2010 http://www.who.int/gpsc/5may/hhsa_framework/en
• World Health Organization. Perception survey for health-care workers [online]. 2009 Aug. http://www.who.int/gpsc/5may/tools/evaluation_feedback/en
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