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Improving hand hygiene in the hospital setting

Hand hygiene is a term that incorporates the decontamination of the hands by methods including routine hand washing, surgical hand washing and the use of alcohol hand rubs and gels. Although recognised as an essential practice for infection control and patient safety, healthcare workers do not necessarily comply with prescribed hand hygiene protocols. This article presents evidence-based approaches to improving hand hygiene in the hospital setting.
by Dr C. Day

It has been a challenge to get healthcare workers (HCWs) to consistently comply with hand hygiene practices. This is despite the abundance of scientific evidence to demonstrate that poor HCW hand hygiene puts hospitalised patients at risk. Leaders in healthcare organisations cannot assume that all staff consistently perform proper hand hygiene routines as studies have indicated a wide range compliance with hand hygiene practices. 

Practitioners including nurses, physicians and other ancillary staff, cite numerous reasons for not complying with hand hygiene protocols. Self-reported reasons for poor hand hygiene include product related issues such as skin irritation or hand dryness, inconvenient placement of sinks, lack of soap and towels, inaccessibility of hand gel or alcohol-based hand rub (AHR), understaffing, lack of time, prioritisation of other patient needs over the time it would take to perform hand hygiene, and practitioner belief that the risk of transmitting infection to a patient is low [1].

An evidence-based guideline was developed and some of its recommendations and strategies were utilised in an academic medical centre as a useful tool to improve hand hygiene of workers, patients, and families. Five areas, each with at least two strategies supported by the literature, were identified in the guideline.  The five recommendations included a programme or campaign to draw awareness of HCWs and patients to the importance of hand hygiene; education regarding protocols and techniques; performance feedback; product selection and availability; and organisational commitment and leadership. Understanding the organisation-specific reasons for non-compliance, designing a programme founded on evidence-based interventions, and strong leadership commitment were keys to the success of a programme that resulted in improved performance [2]. An evidence-based approach to improvement can be successfully applied in other organisations.

Improvement approach
In order to implement a programme to improve hand hygiene, an effective approach is to first identify a small multi-disciplinary team to champion and lead the initiative. Membership should include staff from nursing and ancillary disciplines, infection control, quality control and medical staff, and administration.  A team leader, or co-leaders, from the highest levels of clinical leadership is important in setting the stage and importance of the project. Team education, and a review of the literature and most current guidelines for practice are important. Identification of the team’s objectives, target improvement goal and timelines, along with a framework such as the ‘nursing process’ (assessment, diagnosis, planning, implementation and evaluation) to guide the work are also important. 

Utilising the nursing process framework, assessment is a first step in order to effectively determine the current state. An assessment of the risks and barriers to hand hygiene should be conducted. Determining whether the policies and procedures regarding hand hygiene are evidence-based and clearly written and the staff’s level of knowledge and understanding of those policies, as well as assessing the availability and placement of hand hygiene products including AHR, are examples of basic information required for an assessment related to hand hygiene. Collection of baseline hospital-acquired infection (HAI) rates and surveillance of HCW hand hygiene practice would provide baseline data and information upon which to help determine appropriate recommendations.  Assessment at the organisational, nursing unit  and departmental levels will lead to identification and implementation of evidence-based recommendations that are the most likely to result in improved performance.

The second step of the nursing process is diagnosis. Based on the data gathered in the assessment phase, the team should next analyse the assessment data, and clearly identify the discrete problems and their causes. Determination of whether the problems are related to a HCW knowledge deficit, product or environmental factors, lack of awareness, time constraints, individual accountability, or leadership is important. Key variables to consider before planning an intervention strategy are; a clear definition of the problem, the causative factors, and where and how pervasive the problems are in the organisation.

The third step of the nursing process is planning. This step involves taking the problems that were identified in the diagnosis step and identifying the specific evidence-based recommendations and strategies that are most likely to effect an improvement. Some recommendations might be appropriate to implement house-wide (e.g. an institutional hand hygiene campaign); others might be more appropriate at a unit level (e.g. the Intensive Care Unit (ICU) sink availability is not adequate therefore AHR is needed at the bedside, or staff education regarding the policy needs to be reinforced). Becoming a stakeholder (nurse, physician, ancillary, leadership) in the planning process can be an effective way to gain insight into the development of plans and strategies that will work in the organisation but that the staff will also engage in and support.
The planning step should include the development of detailed written plans specific to each problem identified, including a goal, the guideline recommendation identified to address the problem, the individual(s) who will be accountable for implementation, metrics and a date for completion. The plan should also include a comprehensive communication plan, dates for follow-up evaluation and a budget.

Implementation follows the planning phase and should include the communication and implementation of the specific recommendations. Periodic team meetings throughout the process should be conducted in order to ensure that implementation is progressing as planned, or that appropriate course corrections and problem solving are conducted in a timely manner. Barriers to implementation – real or potential - should be anticipated and contingencies identified. 

The final step is ongoing evaluation of the programme. Building metrics into the organisational and departmental dashboards is important for ongoing monitoring and accountability. Reporting structure, frequency for reporting and accountability expectations should be built into the plan along with feedback, recognition and celebration plans.

Challenges
Numerous organisational issues, including resistance, should be anticipated. Improving hand hygiene may not be perceived as an exciting or even necessary initiative and engagement of staff champions and team members could be difficult. A second challenge may be the time taken to systematically assess and plan the initiative. Many organisations and healthcare leaders are eager to find a “quick fix” rather than taking the time to assess a problem and then strategically implement well-planned interventions.

A key strategy for success is to ensure leadership commitment to the initiative. Presentation of the plan to the senior executives, senior leadership and to the governing body of the organisation for endorsement and support is important to success. Periodic progress reports to each of these levels, including barriers, successes and outcomes are important.  Management team commitment and involvement would also be key for the achievement of successful outcomes.

An additional challenge could be resources, both in labour requirements (e.g. additional expenses related to training and staff participation on an implementation team) and in materials and supplies (e.g. AHR, posters, educational materials, etc). Finally, one of the most difficult challenges might be competing priorities in the institution and the availability of resources to be dedicated to the project.

Conclusion
Healthcare organisations and healthcare workers have a responsibility and an obligation to protect patients from harm, including prevention of hospital-acquired infections. The development and application of evidence-based policies and procedures, along with evidence-based approaches to improving hand hygiene in the hospital setting can lower infection rates and thus positively impact on patient care outcomes.

References
1. Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol 2000; 21(6):381-386.
2. Day C. Engaging the Nursing Workforce: An Evidence-Based Tool Kit. Nurs Admin Q 2009: 33(3): 238-244.

The author
Cindy Day, DNP, RN, NEA, BC
Stanford Hospital and Clinics
Stanford, CA, USA
e-mail: cday@stanfordmed.org


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