Journal Article Presentation APIC Greater New York Chapter 13 June 19, 2019 Hand hygiene is a simple and effective measure to prevent the transmission of microorganisms and prevent patient acquisition of hospital acquired infections. It should be done at key points in time during the process of patient care. The World Health Organization (WHO) 5 moments of hand hygiene (HH) is a well-defined description of the times when HH should be performed. Arsenia Golfo, MSN, RN, CIC Infection Preventionist Burke Rehabilitation Hospital

This major article by Jennifer Woodard, Surbhi Leekha, Sarah Jackson, and Dr. Kerri Thom; Beyond entry and exit: Hand hygiene at the bedside was published in the American Journal of Infection Control, May 2019 edition. The study was done at the University of Maryland Medical Center, a 750-bed tertiary hospital in Baltimore, Maryland. While more studies focus on HH at entry and exit to patient rooms, just a few examine compliance at the bedside with the WHO 5 moments. Among those that do, rates of as low as 36% are reported.

Background The aim of the study is to assess compliance, knowledge, and attitudes regarding the World Health Organization (WHO) 5 moments for hand hygiene (HH).

Methods 302 HH observations - to assess HH compliance using a modified WHO 5 moments observation form 218 completed the electronic 26-question survey - to assess knowledge, opinions, and barriers to HH 14 participated in a 2-round focused survey to assign priority to the moments The authors included 3 study elements. HCP receive HH education, including education on the WHO 5 moments of HH during new employee orientation and annually with a brief online educational module. HCP compliance with HH and glove use according to the WHO 5 moments guidelines were conducted in the medical ICU, surgical ICU, and cardiac surgical ICU. The MICU is a 29 –bed unit where HCP are required to don gloves and gown for all patient interactions (i.e. universal contact precautions), the 19-bed SICU and 21-bed CSICU utilize contact precautions for patients colonized or infected with MDRO. Between July and August 2016, 302 observations were carried out by a single observer on weekdays during the day shift. The observer rotated at random between the different ICUs, did not announce presence, and if asked; reported they were observing HCP-patient interactions. In addition, routinely collected surveillance data on HH compliance at room entry and exit for the study units were obtained from their hospital’s infection control department. Based on routine infection prevention audits, the overall entry and exit HH compliance for the MICU, SICU, and CSICU was 90% during the time period of the observations. During the 104 HCP-patient encounters; 65 were nurses, 17 were physicians, 4 were technicians, 15 were classified under others, and 3 were unknown. Next, the authors developed a 26-question survey to assess knowledge, opinions, and barriers to HH. The survey was distributed electronically to all HCP responsible for patient care delivery. Section I collected demographics information and participant’s history of HH education. Section 2 assessed the most common methods used for HH. Section 3 & 4 assessed knowledge of the WHO 5 moments. Section 5 assessed opinions of the value of HH. The 3rd element was a focused survey of 14 respondents to the facility-wide survey. Participants were asked to answer a series of 2 additional surveys. The researchers sought to engage a variety of HCP types to respond to a set of questions aiming to identify and prioritize important HH opportunities prior to various patient care tasks.

Prioritizing procedure moments for HH in focused survey scenarios Before a sterile procedure Before insertion of a CVC line Before preparing sterile supplies Before insertion of a urinary catheter Before wound dressing (postoperative) Before opening a circuit or device (CVC line Before phlebotomy Before insertion into skin The tables included in this major article were: observation of HH behaviors in the ICU broken into the WHO 5 moments, the WHO 5 moments recalled by HCP, the important moments for HH as identified by HCP through focused survey, and on prioritizing procedure moments for HH in focused survey.

Results -HH Observation 302 HH opportunities observed in 104 unique HCP-patient interactions - HH was performed in 106 (35%) 37% (25 of 68) before touching a patient, 9% (6 of 70) before aseptic procedures, 5% (1 of 22) after body fluid exposure risk, 63% (55 of 88) after touching patient surroundings. Results -HH Observation

Result - Facility Survey 218 HCP completed the survey 63 (29%) were familiar with the WHO 5 moments 13 (21%) were able to recall all 5 moments Result - Facility Survey

Result – Focused Survey 46% (6 of 13) ranked “before aseptic procedures as the most important HH moment 85% (11 of 13) identified after touching patient surroundings as the least important Result – Focused Survey The fourteen HCP who participated in the focused survey consisted of 10 who responded to both surveys. Round 1 included 4 residents and fellow physicians, 1 nurse practitioner, 2 RNs, 2 respiratory technicians, 1 speech-language pathologi.st, and 1 three dimensional computer tomography technician. Forty six percent ranked “before aseptic procedures as the most important and 85% identified “after touching patient surroundings” as the least important.

Discussion Compliance with HH at the bedside was low @ 34%. Reported compliance at entry and exit was 90%. HCP recognized the importance of HH in infection prevention and perceived their own compliance as good. Only 33% were familiar with the 5 moments of HH. HCP prioritized HH before patient contact and before aseptic procedures over moments after patient contact and after exposure to body fluids or after contact with environment. Some of the discussion points in this article are the following: enumerate. There is a gap in compliance between the 5 moments bedside observation and the entry and exit observation by the infection control department. Infection prevention and control programs that focus on entry and exit only may want to evaluate observation based on the 5 moments.

Conclusions There were frequent opportunities for HH with infrequent compliance. There’s a lack of recognition of opportunities at the bedside. Frequent glove use may contribute to lower compliance. HH compliance may also be related to glove use. Gloves were observed to have been used in place of HH in 26% of the opportunities which is fairly consistent with available literature that identify gloves use as altering HH behavior. In the care of the critically-ill patients, H has the largest impact on infection prevention may be an effective approach to optimizing HH practices while realistically balancing the feasibility of compliance in critical or urgent situations.

The appraisal score I gave this study is B III due to its reasonably consistent result, sufficient sample size for the study design, conclusions that are fairly consistent with available studies, sufficient literature review that includes references to scientific evidence, and inclusion of qualitative data from interviews and focused survey.

Thank you