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Hand Hygiene Compliance: Observation

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Title: Hand Hygiene Compliance: Observation


1
Hand Hygiene ComplianceObservation
AnalysisThe Canadian Patient Safety Institute
would like to thank the Ontario Ministry of
Health and Long Term Care for their efforts
toward development of training materials
2
Instructions for Trainer
  • This presentation should be used to teach health
    care workers how to conduct observations.
  • Observers must complete training on Your 4
    Moments for Hand Hygiene before this presentation
  • Following the teaching session, practical
    sessions either at the patient bedside or by
    simulation, can be organized.
  • An Excel workbook is provided to enter and
    analyze data from the observation tool. The
    individual responsible for this activity should
    review the Instructions for Observation Tool
    analysis.

3
Overview
  • Practical training for observers on how to
    observe hand hygiene compliance and complete
    Observation Tool
  • Overview of audit process
  • Overview of analysis and reporting process

4
How to observe hand hygiene
  • Direct observation using a consistent approach
    and validated tool, is the most accurate
    methodology
  • The observer must familiarize him/herself with
    the methods and tools and must be trained to
    identify and distinguish the indications for hand
    hygiene occurring at the point of care
  • The observer must conduct observations openly,
    without interfering with the ongoing work, and
    keep the identity of the health care providers
    confidential
  • Compliance should be determined according to the
    four indications for hand hygiene

5
Key concepts Indication Opportunity
  • Health care activity a succession of tasks
    during which health care providers' hands touch
    different types of surfaces the patient, his/her
    body fluids, objects or surfaces located in the
    patient environment.
  • Each contact is a potential source of
    contamination for health care providers' hands
  • Indication the reason why hand hygiene is
    necessary at a given moment. It is justified by a
  • risk of organism transmission from one surface
    to another.

? contact 1 ? ?indication(s)? ? contact 2 ? ? indication(s) ? contact 3 ? ? indication(s)? ?
Opportunity the need to perform hand hygiene,
whether there are single or multiple indications.
Hand hygiene must correspond to each
opportunity. Multiple indications may come
together to create a single opportunity.
HAND HYGIENE
RISK OF TRANSMISSION
INDICATION
OPPORTUNITY
6
Indication and Opportunity
7
Preparing to Audit
  • General Recommendations for Observation
  • Determine how to best identify the types of
    health care providers you may be observing.
  • Accurate identification of health care provider
    is critical to ensure reliability of data.
  • Introduce yourself to the observed health care
    provider(s) and patients as appropriate and
    explain your role.

8
Preparing to Audit
  • Positioning for observation
  • Find a convenient place to observe without
    disturbing care activities
  • Move to follow the health care provider, but
    never interfere with their work.
  • You can also provide feedback after the session
    using On- the-Spot form.
  • Take into account any concerns the health care
    providers may have with your presence.
  • You should be as discreet as possible and in no
    way infringe on the actions of the health care
    provider.
  • If a health care provider feels uncomfortable
    with your presence he/she has the right to ask
    you to leave and you must do so if asked.

9
Preparing to Audit (continued)
  • You may observe up to three health care providers
    simultaneously (with experience)
  • Note Multiple health care providers performing
    sequential tasks quickly may interfere with audit
    accuracy.
  • You may include more health care providers
    sequentially during one observation session.
  • One observation session is for 20 minutes (/- 10
    minutes) prolong the session if you get the
    chance to observe a care sequence to its end.

10
Observation Tool
11
How to use the form
  • Use a pencil to fill in the form and an eraser to
    correct. Use a clipboard to hold the form.
  • Fill in the head of the form by indicating your
    ID number (Observer-ID), the date, the current
    time including am/pm (Start time), the number of
    the form used for a single session using the
    format 1, 2, 3, etc. (Form-No.)
  • See also point 19 on reverse of Observation
    Tool), the identity of the facility
    (Facility-ID), the identity of the patient care
    unit (Patient Care Unit)

12
How to use the form
  • Indicate any rooms where Additional/Isolation
    Precautions are in place by entering in the
    Comments section. (Observe outside the room.)
  • Indicate the type of health care provider being
    observed by entering the number that corresponds
    with the categories listed at the top of the
    form. The coding system is a number followed by a
    letter (e.g., first physician in the room is 1A,
    if second physician enters the room he/she is
    1B).

13
How to use the form (continued)
  • Each column is for recording hand hygiene
    opportunities of one health care provider only.
    Use additional columns for each additional health
    care provider being observed simultaneously or
    sequentially. The health care provider may
    interact with more than one patient during the
    time you are observing.
  • As soon as you observe the first indication for
    hand hygiene, indicate the corresponding
    information in the first of the numbered
    opportunity sections in the column corresponding
    to the health care provider being observed.

14
Before Initial Patient/Patient Environment Contact
  • BEF-PAT/ ENV before initial patient/patient
    environment contact
  • if the health care provider touches the patients
    environment and then touches the patient or
  • goes directly to touch the patient after having
    touched the hospital environment ( any other
    surface not in the patients environment) or
    another patients environment
  • if the health care provider enters the patients
    environment from the hospital environment and
    touches only the patients environment (does not
    touch patient) and then leaves the patients
    environment.

15
Before Aseptic Procedure
  • BEF-ASP before aseptic procedure if the
    health care provider is to perform any of the
    following after having touched any other surface
    including the concerned patient himself/herself
    and his/her environment
  • touch/manipulate a body site that should be
    protected against any colonization (e.g., wound
    care including dressing change and wound
    assessment)
  • manipulate an invasive device that could result
    in colonization of a body area that should be
    protected against colonization (e.g., priming
    intravenous infusion set, inserting spike into
    opening of IV bag, flushing line, adjusting
    intravenous site, administering medication
    through IV port, changing IV tubing).

16
After Body Fluid Exposure Risk
  • AFT-BFL after body fluid exposure risk if the
    health care provider has been engaged in a care
    activity involving a risk of body fluid exposure
    and before touching any other surface including
    the concerned patient himself/herself and his/her
    environment (e.g., contact with blood or blood
    products, emptying urinal/catheter bag and
    suctioning oral/nasal secretions).

17
After Patient/Patient Environment Contact
  • AFT-PAT/ ENV after patient/patient environment
    contact
  • if the health care provider is leaving the
    patient and his/her environment to go on working
    in the hospital environment or with another
    patient
  • if the health care provider is leaving the
    patient area after touching objects in the
    patient environment (without touching the
    patient) to go on working in the hospital
    environment or with another patient.

18
If there is more than one indication on one
opportunity, mark them all
  • Note If several indications fall together on the
    same hand hygiene opportunity, tick all.
  • Example 1 health care provider enters room,
    cleans hands with alcohol and immediately
    performs aseptic procedure this would result in
    checking
  • BEF-PAT/ENV and BEF-ASP.

19
For each opportunity, indicate the action of the
provider
  • Mark whether the health care provider used
    alcohol-based hand rub (RUB), soap and water
    (WASH) or did not do hand hygiene (MISSED)
  • If a health care provider used soap and water and
    then alcohol-based hand rub (or vice-versa), mark
    both.

20
Gloves
  • For each opportunity, tick if the health care
    provider was wearing gloves when the opportunity
    occurred.
  • In this audit, wearing gloves does not change the
    number of opportunities for health care providers
    to clean their hands.
  • Hand hygiene done with gloves on is incorrect
    therefore, it is marked as a missed opportunity.
  • Examples when gloves may be used when handling
    blood and body fluids, mucous membranes, wound
    care, contact with non-intact skin and where
    indicated for additional precautions/isolation.

21
Technique Nails, Rings and Bracelets
  • Tick the corresponding boxes if the health care
    provider does not meet the guidelines regarding
  • correct nail length (3-4 mm, ¼ inch)
  • no nail extensions/artificial nails
  • no rings or bracelets.
  • It is necessary to do this only once for each
    health care provider.

22
Technique Timing of hand hygiene
  • Timing of the duration of hand hygiene
  • T timing This is the duration of hand hygiene
    performed by the health care provider when hand
    hygiene occurs for
  • BEF-PAT/ ENV and AFT-PAT/ ENV opportunities.
  • Use a wristwatch or stopwatch to record duration
    (seconds) of hand hygiene before patient/patient
    environment contact and after patient/patient
    environment contact.
  • Begin timing when the health care provider starts
    rubbing his/her hands with the product, and stops
    timing when he/she completes the motion of
    rubbing their hands with the product.
  • Note Rinsing of hands with water does not
    constitute a hand wash this would be coded as a
    missed opportunity.

23
Important Notes
  • Each column is for recording hand hygiene
    opportunities of one health care provider only.
    Use additional columns for each additional health
    care provider being observed simultaneously or
    sequentially. The health care provider may
    interact with more than one patient during the
    time you are observing.
  • Note Multiple health care providers sequentially
    performing tasks quickly may make it difficult to
    maintain accurate observation of missed hand
    hygiene opportunities.
  • If you observe more than four opportunities for
    one health care provider, use another form,
    numbering them sequentially in the variable
    Form-No. Remember to code the health care worker
    in the same way (e.g., if they were 2A on the
    first form, they are 2A on the second form).
  • At the end of the session, do not forget to fill
    in the End time and check the form(s) for missing
    values before handing it in.
  • End the observation if the privacy curtain is
    drawn around the patients bed or if a health
    care worker asks you to leave.
  • Record any additional qualitative data in the
    Comments section E.g., Additional
    Precautions/Isolation.

24
Activities for Observers
  • .
  • Review Training Scenarios 1-4 on Training DVD and
    record the appropriate observation results for
    each scenario.
  • Debrief with others when first learning how to
    use the Observation Tool, to assist with
    consistency and understanding of the audit
    process.
  • Review Observer Scenarios 5-8 on Training DVD and
    record the appropriate observation results for
    each scenario.
  • Discuss your results as a group or compare your
    recorded observations with the answers for each
    scenario in the Hand Hygiene DVD Answer Key

25
Planning Observation Schedule
  • Observation Suggestions
  • Eight 20-minute observations/day
  • At least seven different days of eight periods of
    observation
  • At different times of the day (different shifts
    and different times within the shift)
  • Therefore, there will be approximately 56
    observation sessions for calculating the
    aggregate data.

26
Feedback Aggregate Data
  • An Excel workbook tool has been provided to enter
    and analyze observation results
  • The data entry can be done by the observer or
    another resource may be assigned
  • Predefined reports have been included to analyze
    data using four different methods
  • Report table and charts can be pasted into
    presentations to support feedback of progress to
    health care providers, management and hospital
    board

27
Observation Analysis ToolData Entry Page
28
Methods of analysis
  • Data can be analyzed as follows
  • Analyzing one type of indication for each
    health care provider category at a time to
    provide for accurate information to compare over
    time (most accurate method)
  • combine health care providers, categories for a
    specific indication to obtain a generalized
    compliance rate for that indication
  • combine the opportunities for each category of
    health care provider (HCP) to obtain a
    generalized compliance rate for each HCP category
  • Compare alcohol-based hand rub with soap and
    water to assess behaviour change
  • Note for 2 and 3 the information may not
    be comparative over time as the mix of type of
    indication gathered in opportunities in 2 or
    the category of health care provider in 3may
    vary and therefore not provide for accurate
    comparative rates.

29
Calculating Reliable Compliance Rates
  • An overall hand hygiene compliance rate does not
    provide for reliable and comparative rates over
    time as compliance rates for the different types
    of health care provider and for the each of the
    four indications are frequently different.
  • If a generalized rate is to be provided,
    reliability will increase if the same number is
    used for the overall analysis
  • for each category of health care provider and
  • for the number of observations of each indication

30
Reports 1ad Preferred Method
Calculating reliable hand hygiene compliance
rates
  • Compliance rates are to be calculated separately
    for each type of indication and each health care
    provider category (e.g., Nurses BEF-PAT/ENV 70
    per cent Physicians AFT-PAT/ENV 70 per cent
    Respiratory Therapist AFT-BFL-85 per cent)
  • Compliance rates must be reported by
  • Each hand hygiene indication
  • Each health care provider (HCP) category
  • times hand hygiene was performed for a
    specific indication /specific HCP category x
    100
  • observed hand hygiene indications for
    specific indication/specific HCP category
  • (The number of observations to make the
    information meaningful will depend on unit size,
    patient population and hospital size)
  • Breakdown of the compliance rates by indication
    and health care provider category provides data
    for developing targeted and appropriate
    interventions to improve compliance.
  • Overall generalized compliance rate combining
    health care providers and/or combining types of
    indications will not provide for reliability.

31
Report 1 a - sample
Calculation times hand hygiene was performed
for BEF-PAT/ENV by specific HCP category X 100
compliance observed hand hygiene indications
for BEF-PAT/ENV by specific HCP category
32
Report 1 b sample
Calculation times hand hygiene was performed
for BEF-ASP by specific HCP category X 100
compliance observed hand hygiene indications
for BEF-ASP by specific HCP category

33
Report 1 c - sample
Calculation times hand hygiene was performed
for AFT-BFL by specific HCP category X 100
compliance observed hand hygiene indications
for AFT-BFL by specific HCP category
34
Report 1 d - sample
Calculation times hand hygiene was performed
for AFT-PAT/ENV by specific HCP category X 100
compliance observed hand hygiene indications
for AFT-PAT/ENV by specific HCP category
35
Report 2 - sample
Calculation times hand hygiene was performed
for a specific indication by all categories of
HCP x 100 compliance observed hand hygiene
indications for a specific indication by all
categories of HCP
36
Report 3 - sample
Calculation opportunities hand hygiene
performed by specific HCP category
x 100 compliance Total observed hand
hygiene opportunities for a specific HCP category
37
Report 4 - sample
Calculation of opportunities hand rub was used
to clean hands x 100 rub Total number of
opportunities hand hygiene was observed
of opportunities soap and water was used to
clean hands X 100 wash Total number of
opportunities hand hygiene was observed
of opportunities hand rub and soap and
water were both used to clean hands X 100
both Total number of opportunities hand hygiene
was observed
38
Instructions for Trainer
  • This presentation should be used to teach health
    care workers how to conduct observations.
  • Observers must complete training on Your 4
    Moments for Hand Hygiene before this presentation
  • Following the teaching session, practical
    sessions either at the patient bedside or by
    simulation, can be organized.
  • An Excel workbook is provided to enter and
    analyze data from the observation tool. The
    individual responsible for this activity should
    review the Instructions for Observation Tool
    analysis.

39
Overview
  • Practical training for observers on how to
    observe hand hygiene compliance and complete
    Observation Tool
  • Overview of audit process
  • Overview of analysis and reporting process

40
How to observe hand hygiene
  • Direct observation using a consistent approach
    and validated tool, is the most accurate
    methodology
  • The observer must familiarize him/herself with
    the methods and tools and must be trained to
    identify and distinguish the indications for hand
    hygiene occurring at the point of care
  • The observer must conduct observations openly,
    without interfering with the ongoing work, and
    keep the identity of the health care providers
    confidential
  • Compliance should be determined according to the
    four indications for hand hygiene

41
Key concepts Indication Opportunity
  • Health care activity a succession of tasks
    during which health care providers' hands touch
    different types of surfaces the patient, his/her
    body fluids, objects or surfaces located in the
    patient environment.
  • Each contact is a potential source of
    contamination for health care providers' hands
  • Indication the reason why hand hygiene is
    necessary at a given moment. It is justified by a
  • risk of organism transmission from one surface
    to another.

? contact 1 ? ?indication(s)? ? contact 2 ? ? indication(s) ? contact 3 ? ? indication(s)? ?
Opportunity the need to perform hand hygiene,
whether there are single or multiple indications.
Hand hygiene must correspond to each
opportunity. Multiple indications may come
together to create a single opportunity.
HAND HYGIENE
RISK OF TRANSMISSION
INDICATION
OPPORTUNITY
42
Indication and Opportunity
43
Preparing to Audit
  • General Recommendations for Observation
  • Determine how to best identify the types of
    health care providers you may be observing.
  • Accurate identification of health care provider
    is critical to ensure reliability of data.
  • Introduce yourself to the observed health care
    provider(s) and patients as appropriate and
    explain your role.

44
Preparing to Audit
  • Positioning for observation
  • Find a convenient place to observe without
    disturbing care activities
  • Move to follow the health care provider, but
    never interfere with their work.
  • You can also provide feedback after the session
    using On- the-Spot form.
  • Take into account any concerns the health care
    providers may have with your presence.
  • You should be as discreet as possible and in no
    way infringe on the actions of the health care
    provider.
  • If a health care provider feels uncomfortable
    with your presence he/she has the right to ask
    you to leave and you must do so if asked.

45
Preparing to Audit (continued)
  • You may observe up to three health care providers
    simultaneously (with experience)
  • Note Multiple health care providers performing
    sequential tasks quickly may interfere with audit
    accuracy.
  • You may include more health care providers
    sequentially during one observation session.
  • One observation session is for 20 minutes (/- 10
    minutes) prolong the session if you get the
    chance to observe a care sequence to its end.

46
Observation Tool
47
How to use the form
  • Use a pencil to fill in the form and an eraser to
    correct. Use a clipboard to hold the form.
  • Fill in the head of the form by indicating your
    ID number (Observer-ID), the date, the current
    time including am/pm (Start time), the number of
    the form used for a single session using the
    format 1, 2, 3, etc. (Form-No.)
  • See also point 19 on reverse of Observation
    Tool), the identity of the facility
    (Facility-ID), the identity of the patient care
    unit (Patient Care Unit)

48
How to use the form
  • Indicate any rooms where Additional/Isolation
    Precautions are in place by entering in the
    Comments section. (Observe outside the room.)
  • Indicate the type of health care provider being
    observed by entering the number that corresponds
    with the categories listed at the top of the
    form. The coding system is a number followed by a
    letter (e.g., first physician in the room is 1A,
    if second physician enters the room he/she is
    1B).

49
How to use the form (continued)
  • Each column is for recording hand hygiene
    opportunities of one health care provider only.
    Use additional columns for each additional health
    care provider being observed simultaneously or
    sequentially. The health care provider may
    interact with more than one patient during the
    time you are observing.
  • As soon as you observe the first indication for
    hand hygiene, indicate the corresponding
    information in the first of the numbered
    opportunity sections in the column corresponding
    to the health care provider being observed.

50
Before Initial Patient/Patient Environment Contact
  • BEF-PAT/ ENV before initial patient/patient
    environment contact
  • if the health care provider touches the patients
    environment and then touches the patient or
  • goes directly to touch the patient after having
    touched the hospital environment ( any other
    surface not in the patients environment) or
    another patients environment
  • if the health care provider enters the patients
    environment from the hospital environment and
    touches only the patients environment (does not
    touch patient) and then leaves the patients
    environment.

51
Before Aseptic Procedure
  • BEF-ASP before aseptic procedure if the
    health care provider is to perform any of the
    following after having touched any other surface
    including the concerned patient himself/herself
    and his/her environment
  • touch/manipulate a body site that should be
    protected against any colonization (e.g., wound
    care including dressing change and wound
    assessment)
  • manipulate an invasive device that could result
    in colonization of a body area that should be
    protected against colonization (e.g., priming
    intravenous infusion set, inserting spike into
    opening of IV bag, flushing line, adjusting
    intravenous site, administering medication
    through IV port, changing IV tubing).

52
After Body Fluid Exposure Risk
  • AFT-BFL after body fluid exposure risk if the
    health care provider has been engaged in a care
    activity involving a risk of body fluid exposure
    and before touching any other surface including
    the concerned patient himself/herself and his/her
    environment (e.g., contact with blood or blood
    products, emptying urinal/catheter bag and
    suctioning oral/nasal secretions).

53
After Patient/Patient Environment Contact
  • AFT-PAT/ ENV after patient/patient environment
    contact
  • if the health care provider is leaving the
    patient and his/her environment to go on working
    in the hospital environment or with another
    patient
  • if the health care provider is leaving the
    patient area after touching objects in the
    patient environment (without touching the
    patient) to go on working in the hospital
    environment or with another patient.

54
If there is more than one indication on one
opportunity, mark them all
  • Note If several indications fall together on the
    same hand hygiene opportunity, tick all.
  • Example 1 health care provider enters room,
    cleans hands with alcohol and immediately
    performs aseptic procedure this would result in
    checking
  • BEF-PAT/ENV and BEF-ASP.

55
For each opportunity, indicate the action of the
provider
  • Mark whether the health care provider used
    alcohol-based hand rub (RUB), soap and water
    (WASH) or did not do hand hygiene (MISSED)
  • If a health care provider used soap and water and
    then alcohol-based hand rub (or vice-versa), mark
    both.

56
Gloves
  • For each opportunity, tick if the health care
    provider was wearing gloves when the opportunity
    occurred.
  • In this audit, wearing gloves does not change the
    number of opportunities for health care providers
    to clean their hands.
  • Hand hygiene done with gloves on is incorrect
    therefore, it is marked as a missed opportunity.
  • Examples when gloves may be used when handling
    blood and body fluids, mucous membranes, wound
    care, contact with non-intact skin and where
    indicated for additional precautions/isolation.

57
Technique Nails, Rings and Bracelets
  • Tick the corresponding boxes if the health care
    provider does not meet the guidelines regarding
  • correct nail length (3-4 mm, ¼ inch)
  • no nail extensions/artificial nails
  • no rings or bracelets.
  • It is necessary to do this only once for each
    health care provider.

58
Technique Timing of hand hygiene
  • Timing of the duration of hand hygiene
  • T timing This is the duration of hand hygiene
    performed by the health care provider when hand
    hygiene occurs for
  • BEF-PAT/ ENV and AFT-PAT/ ENV opportunities.
  • Use a wristwatch or stopwatch to record duration
    (seconds) of hand hygiene before patient/patient
    environment contact and after patient/patient
    environment contact.
  • Begin timing when the health care provider starts
    rubbing his/her hands with the product, and stops
    timing when he/she completes the motion of
    rubbing their hands with the product.
  • Note Rinsing of hands with water does not
    constitute a hand wash this would be coded as a
    missed opportunity.

59
Important Notes
  • Each column is for recording hand hygiene
    opportunities of one health care provider only.
    Use additional columns for each additional health
    care provider being observed simultaneously or
    sequentially. The health care provider may
    interact with more than one patient during the
    time you are observing.
  • Note Multiple health care providers sequentially
    performing tasks quickly may make it difficult to
    maintain accurate observation of missed hand
    hygiene opportunities.
  • If you observe more than four opportunities for
    one health care provider, use another form,
    numbering them sequentially in the variable
    Form-No. Remember to code the health care worker
    in the same way (e.g., if they were 2A on the
    first form, they are 2A on the second form).
  • At the end of the session, do not forget to fill
    in the End time and check the form(s) for missing
    values before handing it in.
  • End the observation if the privacy curtain is
    drawn around the patients bed or if a health
    care worker asks you to leave.
  • Record any additional qualitative data in the
    Comments section E.g., Additional
    Precautions/Isolation.

60
Activities for Observers
  • .
  • Review Training Scenarios 1-4 on Training DVD and
    record the appropriate observation results for
    each scenario.
  • Debrief with others when first learning how to
    use the Observation Tool, to assist with
    consistency and understanding of the audit
    process.
  • Review Observer Scenarios 5-8 on Training DVD and
    record the appropriate observation results for
    each scenario.
  • Discuss your results as a group or compare your
    recorded observations with the answers for each
    scenario in the Hand Hygiene DVD Answer Key

61
Planning Observation Schedule
  • Observation Suggestions
  • Eight 20-minute observations/day
  • At least seven different days of eight periods of
    observation
  • At different times of the day (different shifts
    and different times within the shift)
  • Therefore, there will be approximately 56
    observation sessions for calculating the
    aggregate data.

62
Feedback Aggregate Data
  • An Excel workbook tool has been provided to enter
    and analyze observation results
  • The data entry can be done by the observer or
    another resource may be assigned
  • Predefined reports have been included to analyze
    data using four different methods
  • Report table and charts can be pasted into
    presentations to support feedback of progress to
    health care providers, management and hospital
    board

63
Observation Analysis ToolData Entry Page
64
Methods of analysis
  • Data can be analyzed as follows
  • Analyzing one type of indication for each
    health care provider category at a time to
    provide for accurate information to compare over
    time (most accurate method)
  • combine health care providers, categories for a
    specific indication to obtain a generalized
    compliance rate for that indication
  • combine the opportunities for each category of
    health care provider (HCP) to obtain a
    generalized compliance rate for each HCP category
  • Compare alcohol-based hand rub with soap and
    water to assess behaviour change
  • Note for 2 and 3 the information may not
    be comparative over time as the mix of type of
    indication gathered in opportunities in 2 or
    the category of health care provider in 3may
    vary and therefore not provide for accurate
    comparative rates.

65
Calculating Reliable Compliance Rates
  • An overall hand hygiene compliance rate does not
    provide for reliable and comparative rates over
    time as compliance rates for the different types
    of health care provider and for the each of the
    four indications are frequently different.
  • If a generalized rate is to be provided,
    reliability will increase if the same number is
    used for the overall analysis
  • for each category of health care provider and
  • for the number of observations of each indication

66
Reports 1ad Preferred Method
Calculating reliable hand hygiene compliance
rates
  • Compliance rates are to be calculated separately
    for each type of indication and each health care
    provider category (e.g., Nurses BEF-PAT/ENV 70
    per cent Physicians AFT-PAT/ENV 70 per cent
    Respiratory Therapist AFT-BFL-85 per cent)
  • Compliance rates must be reported by
  • Each hand hygiene indication
  • Each health care provider (HCP) category
  • times hand hygiene was performed for a
    specific indication /specific HCP category x
    100
  • observed hand hygiene indications for
    specific indication/specific HCP category
  • (The number of observations to make the
    information meaningful will depend on unit size,
    patient population and hospital size)
  • Breakdown of the compliance rates by indication
    and health care provider category provides data
    for developing targeted and appropriate
    interventions to improve compliance.
  • Overall generalized compliance rate combining
    health care providers and/or combining types of
    indications will not provide for reliability.

67
Report 1 a - sample
Calculation times hand hygiene was performed
for BEF-PAT/ENV by specific HCP category X 100
compliance observed hand hygiene indications
for BEF-PAT/ENV by specific HCP category
68
Report 1 b sample
Calculation times hand hygiene was performed
for BEF-ASP by specific HCP category X 100
compliance observed hand hygiene indications
for BEF-ASP by specific HCP category

69
Report 1 c - sample
Calculation times hand hygiene was performed
for AFT-BFL by specific HCP category X 100
compliance observed hand hygiene indications
for AFT-BFL by specific HCP category
70
Report 1 d - sample
Calculation times hand hygiene was performed
for AFT-PAT/ENV by specific HCP category X 100
compliance observed hand hygiene indications
for AFT-PAT/ENV by specific HCP category
71
Report 2 - sample
Calculation times hand hygiene was performed
for a specific indication by all categories of
HCP x 100 compliance observed hand hygiene
indications for a specific indication by all
categories of HCP
72
Report 3 - sample
Calculation opportunities hand hygiene
performed by specific HCP category
x 100 compliance Total observed hand
hygiene opportunities for a specific HCP category
73
Report 4 - sample
Calculation of opportunities hand rub was used
to clean hands x 100 rub Total number of
opportunities hand hygiene was observed
of opportunities soap and water was used to
clean hands X 100 wash Total number of
opportunities hand hygiene was observed
of opportunities hand rub and soap and
water were both used to clean hands X 100
both Total number of opportunities hand hygiene
was observed
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