Hand Hygiene Innovations – overcoming barriers in compliance and

conducting campaign promotion

WH Seto Hong Kong, China

HH HH

HH HH HH

HH

HH HH

2004

Good Infection Control practices…

But how do we keep it going?

It is important to have

First Global Patient Safety Challenge

Campaign spread and sustainability

21st January 2008 Hand Hygiene

HA – wide Launch

Symbol of conscientious patient care

50’ x 30’

Sustaining the campaign

1. Keep expanding the campaign

Hand hygiene compliance GOPC, n=3465

HH Program in TB & Chest Clinics

• 16 clinics • Baseline

direct HH observation

Results of HH Compliance

• 1st Baseline HH observation (n=575) – 52%

• 2nd HH observation (n=535): – 67.9% (p<0.05)

• 3rd HH observation (n=522): – 64% (p<0.05)

WHO Hand Hygiene Programmes along continnum of health care in Hong Kong

Visit of Professor Didier Pittet (Lead First GPSC) to Pilot Nursing Home in August 2008

8 pilot nursing homes

WHO Hand Hygiene Multimodal Strategy

� Hand hygiene compliance rate increases by 76% in 1 month and sustains over 80% at 4 months.

� Recourse to handrubbing in 4 months after intervention accounts for more than 70% of all hand hygiene actions, HH by alcohol-based hand rub increases substantially across the promotional period.

> 8000 HH opportunities observed in 3 phases Baseline Vs Post-1 mth (p<0.001) Baseline Vs Post-4 mth (p<0.001)

FIRST time with WHO HH Guidelines and Strategies adopted BEYOND conventional clinical settings

Overall Hand Hygiene Compliance in 8 Pilot Nursing Homes in Hong Kong

HH Promotion Further Extend in Long-term Care Facilities in 2009/2010 - over 140 Residential Care Homes providing skilled nursing care to over 10,000 elders -

Source: Surveillance & Research Team, Infection Control Branch, Centre for Health Protection, HKSAR Dept of Health Oral presentation to Members of Expert Group for WHO Finalization of Hand Hygiene Guidelines Meeting (29.9.08-1.10.08) Poster presentation at Health Protection Conference 2008 organised by UK Health Protection Agency (September 2008)

Dr Carole Tam Senior Medical and Health Officer

Centre for Health Protection Hong Kong SAR Department of Health

[Presentation Number 748]

“Nothing to Disclose”

Intervention in 18 LTCFs

Hand Hygiene in TCM

n=357 in six clinics

Sustaining the campaign

1.Keep expanding the campaign

2. Effective linkage to other healthcare programs

Link to bundles implementation

Central Line Bundle Elements

� Hand hygiene � Maximal barrier precautions

� One Piece Drape: Preliminary Evaluation

� Chlorhexidine skin antisepsis � 2% solution

� Optimal catheter site selection, � with subclavian vein as the preferred site for

� Daily review of line necessity with prompt removal of unnecessary lines

25 25

For the Patient:

Cover patient’s head and body with a large sterile drape

Jarvis

Good hand hygiene is very important

Alcohol Hand Rub for clean hands

Hand washing for visibly dirty hand

100 mls 500 mls

Introducing new UTI guideline for HK

Bladder Scan Ultrasound

Hand Hygiene • Before and after

manipulation of catheter

Introduction � Pilot scheme: 5 hospitals in

HK including QMH � Accreditation body:

Australian Council on Health Standards ( ACHS)

� Satisfy the peer reviewed standards grouped under 3 functions mandated by ACHS

Sustaining the campaign

1.Keep expanding the campaign

2. Effective linkage to other healthcare programs

3. Regular reinforcement

AHR Requisition by quarter(2007-2010)

7055

14486 17346 16850

13472

18427

26775

30934 31012

21151

38.29%

54.10% 56.07%

54.33%

63.69%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

0

5000

10000

15000

20000

25000

30000

35000

2007 2008 2009 2010 2011

Times hand hygiene performed

Observed hand hygiene indications

Hand hygiene compliance rate

Overall Hand Hygiene Compliance in HA

Year

38.29%

54.10% 56.07% 54.33%

63.69%

35.12%

51.51%

46.68% 47.96%

57.63%

47.92%

58.89%

73.52% 70.72%

77.15%

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

2007 2008 2009 2010 2011

All hospitals

Group 1

Non-group 1

Overall Hand Hygiene Compliance Rate in HA Group 1 Hospitals vs Non-group 1 Hospitals

(2007-2011 Q2)

Group 1 - General acute hospitals with 24 hour & A&E services

Non-group 1 includes: Group 2 - Hospitals with a mix of acute and non-acute services Group 3 - Non-acute or infirmary hospitals Group 4 - Psychiatric hospitals

35.12%

51.51%

46.68% 47.96%

57.63%

0.098

0.087

0.076

0.068 0.064

0

0.02

0.04

0.06

0.08

0.1

0.12

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

2007 2008 2009 2010 2011

Hand hygiene compliance rate(%)

Hospital-apportioned MRSAbacteremia/ 1,000 patient days

Rate of Hospital-apportioned MRSA Bacteremia and

Year Hospital-apportioned cases refer to those detected or after 2 days of hospital admission

Detailed analysis of one hospital

HKBH

Hong Kong Baptist Hospital 850 beds

2009 2010 2011

� HH poster design competition with hospital- wide display of winner

� HH talks � HH promotions

related to 2009 swine flu pandemic

� Role models promotion with posters & election of top 10 personnel

� Election of best HH department

� Hospital-wide ceremony with presentation of the 10 role models with special lecture

� HH talks � Starts HH day

celebration

� Special HH workshop

� New hospital-wide posters

� Enhancement program for hand rub locations

� HH talks

2009 (95% CI) n = 347

2010 (95% CI) n =166

2011 (95% CI) n = 599

(2008- 2011)

p 53 (48−58) 55 (47−63) 50 (46−54) 0.3

Doctors 25 (9−49) 5 (0−24) 23 (12−37) 0.16

Nurses 57 (45−67) 63 (51−74) 59 (54−65) 0.72

Health care assistants

62 (49−73) 54 (39−69) 45 (37−53) 0.05

Advertisement fatigue: where a user tires of an advertisement as it is seen more often. Zo¨e Abrams and Erik Vee

Campaign fatigue is when there is evidence that promotional activities are

being ignored

Definition

• Received 2-days training course on infection control.

• Awarded a certificate and badge on passing the course assessment.

• ICLNs has the full routine of workload in the ward.

• Frontline staff to first encounter IC problems and representative to liaise with ICN

• Report all important events.

Link Nurse strategy – first published in HK Seto et al: Am. J of Infection Control 1991:19:86-91. Ching, Seto:Journal of Advanced Nursing.1990;15:1128-1131.

Focus group and survey of link nurse on enhancing HH strategy in HKBH

A Significant factors in hindering compliance to hand hygiene % Yes

1 Doctors’ noncompliance widespread and affects the entire ward/area 53.9*

2. Agree with hand hygiene, but not enough reminders in the ward area. 53.9*#

3. Concern for allergic and adverse reactions 38.5

4. Found incompatibility of ABHR with the use of hand creams 26.9

5. Still believe that hand hygiene must involve hand washing by the tap 26.9

6. Don’t understand that ABHR can enhance practice in a busy ward 23.1

7. ABHR rubs not generally available at point of care 19.2

8. Number of key strong resisters hindering the process 15.4

9. Turned off by the smell or content of ABHR 15.4

Table 2. Survey of infection control link nurses on enhancing hand hygiene strategy in Hong Kong Baptist Hospital, July 2012 (n=26 clinical areas with patient admissions)

B. Further educational or improvement activities in

your ward/area (Prioritize top 3 from list with scores†)

Priority

scores

1. Develop special program to remind doctors of hand

hygiene during rounds

49*#

2. A special program to remind staff other than nurses and

doctors of hand hygiene

30*

3. Review to ensure that ABHR is fully available at strategic

points of care

29*

4. Special 15-min talk by an expert in your ward 26

5. Put up more hospital-wide posters for good hand hygiene

practice

16

6. Special section for high resisters 9

Total of 21 suggestions

AJIC 2013: July

2009 (95% CI) n = 347

2010 (95% CI) n =166

2011 (95% CI) n = 599 2012

53 (48−58) 55 (47−63) 50 (46−54) Doctors 25 (9−49) 5 (0−24) 23 (12−37) 72%

Nurses 57 (45−67) 63 (51−74) 59 (54−65) 89%

Health care assistants

62 (49−73) 54 (39−69) 45 (37−53) 84%

All participants must follow hand hygiene seven steps observed by official witness and signed by participants.

For 5th May Hand Hygiene Day 2014

We have break the Guinness World Records: ‘MOST PARTICIPANTS IN A HAND SANITISING RELAY’. Total participants 277 Time started -12:45 and completed at 14:05. Total time:1 hour 20mins.

“Why re-invent the wheel….. Let’s learn from management science”

Ref: JHI 1995: 30 (supp) 241-247

The field of Change Management

Change management is a systematic approach to dealing with change, both from the perspective of an organization and on the individual level. CMC.com