Infection Control Today

SEP 2018

ICT delivers to infection preventionists & their colleagues in the operating room, sterile processing/central sterile, environmental services & materials management, timely & relevant news, trends & information impacting the profession & the industry

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41 September 2018 ICT Garcia-Houchins says that despite the current emphasis on education and training around hand hygiene, facilities should instead focus on individual and institutional accountability and human factors engineering. "Studies are showing that education and training around hand hygiene is not enough," she says. "In the organizations that are very successful in improving their hand hygiene rates, it's more of a self-awareness among staff members that has been developed. At one facility I visited, the medical director used the Kubler-Ross stages of death and dying to describe the process of improving hand hygiene. He explained the facility's hand hygiene rates and provided the data to staff — the data showed that staff is only washing their hands 50 percent of the time — and the frst reaction from healthcare personnel is denial: 'No, that wasn't me, that was her.' Or, 'I wash my hands all the time, it's the doctors.' Or 'No, we wash our hands all the time, it's the nurses.' Then they may proceed to the anger stage, then the bargaining stage, where they may ask, 'If I walk into one room and wash my hands after coming out of that room and I walk straight into the next room, does that count for the next room?' They go through all those Kubler-Ross stages until they reach the point of acceptance; it is what it is, you must wash your hands. Personnel are in all those stages at some point, and teaching people to wash their hands is not going to improve their hand hygiene. Everyone pretty much knows how to wash their hands, and most healthcare workers have been taught when to wash their hands — after all, it's one of the frst topics addressed during infection prevention and control orientation on the frst day of work. The Five Moments are covered, or at the very least, the importance of pumping in and out with hand sanitizer and washing your hands with soap and water when they are visibly soiled." Garcia-Houchins continues, "It's not usually a matter of teaching, it's usually a matter of healthcare personnel accepting their role in performing hand hygiene and also recognizing that not only must they hold themselves accountable, but their peers as well. And that's usually when units start to see a difference in behavior. Hand hygiene compliance rates go up when a group of people decides that it needs to make a change. So, success is related to achieving buy-in from staff. As an IP I used to tell people, 'I can't wash your hands for you; only you can decide to wash your hands.' Most facilities these days provide an abundant amount of alcohol-based hand sanitizer, and there are electronic pumps that indicate when it runs out of product, but we cannot make people wash their hands unless they are holding themselves accountable. I have been to facilities that achieved this by listing everyone's names on a chalkboard scoreboard in the breakroom. If personnel saw anyone not washing their hands, they would put a little hash mark next to that person's name. I have visited healthcare organizations where a 'clicker' was sounded every time someone didn't wash his/her hands. There are a variety of tactics that can help raise awareness, but holding each other accountable for hand hygiene is what makes a real and lasting difference." Breaking Down Barriers Countering the known barriers to hand hygiene compliance is critical. For example, if hand hygiene compliance data are not collected or reported accurately or frequently, the Joint Commission recommends that facilities begin using data as a framework for a systematic approach for improvement. It is essential that facilities utilize a sound measurement system to determine the real score in real time, that they scrutinize and question the data, and that they measure the specifc, high-impact causes of hand hygiene failures and target solutions to those causes. A lack of accountability can be countered with the institution requiring its leadership to commit to hand hygiene as an organizational priority and demonstrate support by role modeling consistent hand hygiene compliance. Additionally, hospital leaders can be trained as just-in-time coaches to intervene to reinforce compliance. The Joint Commission says that healthcare facilities should consider implementing employee contracts to be signed by all healthcare workers to reinforce their commitment to hand hygiene. An institution may also weigh the application of progressive disciplinary action against repeat offenders. Expectations should be applied equally to all healthcare workers. If an institution lacks a safety culture, or if the culture does not emphasize hand hygiene at all levels, the Joint Commission advises that the facility make hand hygiene a habit as automatic as looking both ways when crossing the street or fastening the seat belt in a vehicle. Hospital leadership should consider making a commitment to achieve hand hygiene compliance of 90-plus percent and be prepared to serve as a role model by practicing proper hand hygiene. Finally, everyone in the facility — doctors, nurses, food service staff, housekeepers, chaplains, technicians, therapists — must be held accountable and responsible for upholding good infection prevention practices. If healthcare workers are distracted and forget to wash their hands, the Joint Commission recommends using a code word among healthcare workers to signal to a peer that they missed an opportunity and need to wash. Also, facilities should identify new technologies to make it easy for healthcare workers to remember to clean their hands, such as RFID, automatic reminders, and warning systems. Visual cues reinforce hand hygiene messages and training. These include stickers, colors, and posters. Visual cues need to be changed periodically so that they continue to be effective. Systems should be evaluated and revised to help suppor t proper hand hygiene practices. Focus on the system, not just on people, the Joint Commission says, by: ✦ Making it easy; examine work fow of healthcare workers to ensure ease of washing hands: ✦ Providing easy access of hand hygiene equipment and dispensers ✦ Creating a place for everything: for example, a healthcare worker with full hands needs a dedicated space where he or she can place items while washing hands ✦ Limiting entries and exits from a patient's room – make supplies available in room References: Dunne CP, Kingston L, Slevin B and O'Connell NH. Editorial: Hand hygiene and compliance behaviors are the under-appreciated human factors pivotal to reducing hospital-acquired infections. Journal of Hospital Infection. Vol. 98, No. 4. Pages 328-330. April 2018. Joint Commission. Accreditation and Certifcation. Effective Jan. 1, 2018: Individual hand hygiene failures to be cited under IC, NPSG standards. Dec. 20, 2017. Joint Commission Center for Transforming Healthcare. Hand hygiene storyboard: Identifying Causes, Targeting Solutions. Jan. 14, 2015. Reilly J, Price L, Lang S, Robertson C, Cheater F, Skinner K and Chow A. A pragmatic randomized controlled trial of 6 step versus 3 step hand hygiene technique in acute hospital care. Web: Infection Control & Hospital Epidemiology. March 31, 2016. Ò It's not usually a matter of teaching , it's usually a matter of healthcare personnel accepting their role in performing hand hygiene and also recognizing that not only must they hold themselves accountable, but their peers as well.

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