5 Moments for Hand Hygiene

Patient Refers to any part of the patient, their clothes, or any medical device that is connected to the patient If the patient were to get out of bed and walk off – what would still be attached to them?

Immediate Patient Surroundings A space temporarily dedicated to an individual patient for that patient’s stay Includes: Patient furniture and personal belongings Medical equipment – BP machine, monitor Medical chart Anything touched by HCW while caring for that patient

Patient Surroundings From Ontario Just Clean Your Hands Program The science behind Just clean your hands presentation

From Council for Remote Area Nurses of Australia

Moment 1 Before Touching a Patient

Moment 1 Touching a patient in any way When: Examples: Touching a patient in any way Shaking hands, Assisting a patient to move, most Allied health interventions, Touching any invasive medical device connected to the patient (eg. IV pump, IDC) Any personal care activities Bathing, Dressing, Brushing hair, Putting on personal eg. Glasses Any non-invasive observations Taking a pulse, Blood pressure, Oxygen saturation, Temperature, Chest auscultation, Abdominal palpation, Applying ECG electrodes, CTG Any non-invasive treatment Applying an oxygen mask or nasal cannula, Fitting slings/braces, Application of incontinence aids (including condom drainage)

Moment 1 Preparation and administration of oral medications When: Examples: Preparation and administration of oral medications Oral medications, Nebulised medications Oral care and feeding Feeding a patient, Brushing teeth or dentures Contacts with the patient’s surroundings before, during and after any of the above Bedside table, Medical chart

Education for Moment 1 Hand Hygiene before touching a patient When Hand Hygiene before touching a patient Where possible Hand Hygiene should occur in front of the patient so that they can observe it Hand Hygiene on entering the patient’s room Why To protect the patient against acquiring harmful germs from the hands of the HCW

Rule for Auditing Moment 1 HH Moment 1 should be performed prior to touching the patient Only record Moment 1 once the HCW touches the patient

Example: HCW walks in, helps the patient to sit up, moves the over bed table, folds down the sheets, moves the chair into position, then gets the patient out of bed Moment 1 – prior to touching patient

Moment 2 Before a Procedure

Procedure Is an act of care for a patient where there is a risk of direct introduction of a pathogen into the patient’s body.

Moment 2 When: Examples: Insertion of a needle into a patient’s skin, or into an invasive medical device Venipuncture, Blood glucose level, Arterial blood gas, Subcutaneous or Intramuscular injections, IV flush Preparation and administration of any medications given via an invasive medical device, or preparation of a sterile field IV medication, NGT feeds, PEG feeds, Baby feeds, Dressing trolley Administration of medications where there is direct contact with mucous membranes Eye drop installation, Suppository insertion, Vaginal pessary

Moment 2 When: Examples: Insertion of, or disruption to, the circuit of an invasive medical device Procedures involving the following: ETT, Tracheostomy, Nasopharyngeal airways, Suctioning of airways, Urinary catheter, Colostomy/ileostomy, Vascular access systems, Invasive monitoring devices, Wound drains, PEG tube, NGT, Secretion aspiration Any assessment, treatment and patient care where contact is made with non-intact skin or mucous membranes Wound dressings, Burns dressings, Surgical procedures, Digital rectal examination, Invasive obstetric and gynaecological examinations and procedures, Digital assessment of newborns palate

Education for Moment 2 Hand Hygiene immediately prior to a procedure When Hand Hygiene immediately prior to a procedure Once Hand Hygiene has been done, nothing else in the patient’s environment should be touched prior to the procedure starting Why To protect the patient from harmful germs (including their own) from entering their body during a procedure

Rule for Auditing Moment 2 HH Moment 2 must be performed immediately prior to any procedure

Example: HCW replaces an empty IV fluid bag with a new IV fluid bag Moment 2 – prior to disconnecting the IV line

Moment 3 After a Procedure or Body Fluid Exposure Risk

Body Fluid Exposure Risk Any situation where contact with body fluids may occur. Such contact may pose a contamination risk to either the HCW or the environment

Actual or potential contact with: Blood, Lochia Saliva or tears Mucous, wax, or pus Breast milk, Colostrum Vomitus Urine, faeces, semen, or meconium Pleural fluid, ascitic fluid or CSF Tissue samples, including biopsy specimens, organs, bone marrow, cell samples

Moment 3 After any Moment 2 See Moment 2 When: Examples: After any Moment 2 See Moment 2 After any potential body fluid exposure Contact with a used urinary bottle / bedpan, Contact with sputum either directly or indirectly via a cup or tissue, Contact with used specimen jars / pathology samples, Cleaning dentures, Cleaning spills of body fluid from patient surroundings, After touching the outside of a drain

Education for Moment 3 When Hand Hygiene immediately after a procedure or a body fluid exposure risk As hands are likely to be contaminated with body fluid Why To protect yourself and the healthcare surroundings from harmful patient germs

Rule for Auditing Moment 3 HH Moment 3 must be performed immediately after a procedure or body fluid exposure risk Touching the outside of a drain or drainage bag even when the circuit is not broken, is considered a Moment 3 since there is a risk of body fluid exposure

Rule for Auditing Moment 3 Moment 3 will usually be paired with a Moment 2 except that: Moment 3 may be recorded as a stand alone HH Moment when there is a body fluid exposure risk, but the HCW has not touched the patient Cleaning up a spill of vomit, urine or faeces Moving pathology specimens Moving items contaminated with body fluids Sputum cup, urinal bottle, incontinence pad / nappy

Example: HCW replaces an empty IV fluid bag with a new IV fluid bag Moment 2 – prior to disconnecting IV Moment 3 – after reconnecting IV

Example: HCW walks into the room, empties IDC drainage bag, disposes of urine in pan room Moment 2 – before opening IDC Moment 3 – after disposing of urine (exposure risk)

Moment 4 After Touching a Patient

Education for Moment 4 Hand Hygiene after touching a patient When Hand Hygiene after touching a patient This completes the education of Hand Hygiene before you enter the patient room, and before you leave the patient room Why To protect yourself and the healthcare surroundings from harmful patient germs

Rules for Auditing Moment 4 HH Moment 4 should be performed after touching the patient Moment 4 will usually be proceeded by a Moment 1 Touching the patient surroundings after touching the patient is recorded as a single Moment 4. If after a Moment 3 there is touching of the patient surroundings, this is recorded as a Moment 4

Example: HCW walks in, helps the patient to sit up, folds down the sheets, moves the chair into position, then gets the patient out of bed, then leaves the room Moment 1 – prior to touching patient Moment 4 – after touching the patient

Moment 5 After touching a patient’s immediate surroundings when the patient has not been touched

Moment 5 When: Examples: After touching the patient’s immediate surroundings when the patient has not been touched Patient surroundings include: Bed, Bedrails, Linen, Table, Bedside chart, Bedside locker, Call bell/TV remote control, Light switches, Personal belongings, Chair, Foot stool, Monkey bar

Education for Moment 5 When Hand hygiene after touching the patient’s surroundings Why To protect yourself and the healthcare surroundings from harmful patient germs

Rule for Auditing Moment 5 HH Moment 5 is performed when there has been no touching of the patient but there has been touching of the patient’s immediate surroundings When multiple items in the patient surroundings are touched, only one Moment 5 is recorded

Example: HCW walks into patient room, moves the over bed table closer to the patient, then leaves Moment 5 – after touching the patient surroundings (without touching the patient) If patient had been touched, then this would have been recorded as: Moment 1 and Moment 4

Note 1 Generally for every “before” Moment there should be an “after” Moment recorded Moment 1 can either be followed by a Moment 4 or a Moment 3 Moment 2 is generally followed by Moment 3 Moment 5 is a stand alone Moment as there is no patient contact There are a few situations when two “afters” may be recorded sequentially

Example: HCW walks in, picks up drain bottle to view it, puts it down, writes on the medical chart, then leaves Moment 1 – prior to touching the drain (patient) Moment 3 – after drain (body fluid exposure risk) Moment 4 – after chart (continuum of patient care)

Note 2 For every procedure there should be a Moment 2 and Moment 3 recorded

Example: HCW checks blood glucose level of patient Moment 2 – Immediately prior to pricking finger with lancet Moment 3 – Immediately after disposing of sample strip & used lancet, prior to touching anything else

Note 3 The HCW must be observed to perform HH as they approach the patient. If HH is not observed it should be recorded as a “missed” action (i.e. HH not performed). In such circumstances the HCW can be asked (at the conclusion of the sequence of care) if they performed HH immediately prior to entering the room If they did then the Moment should be scored as HH performed

Moment 1 – before touching the patient HH action missed Example: HCW walks in and touches the patient on the shoulder without being observed to perform hand hygiene Moment 1 – before touching the patient HH action missed

Note 4 No “before” Moment can be recorded if auditing commences after a HCW is already touching a patient, or in the process of performing a procedure. No “after” Moment can be recorded unless the Moment is observed.

Example: Observation commences whilst HCW is emptying IDC drainage bag Example: Observation commences whilst HCW is emptying IDC drainage bag. The HCW then leaves the room to dispose of the urine in panroom No Moment can be recorded as the start of the procedure and the end of the procedure/body fluid exposure risk have not been observed.

Note 5 Patient bed curtains are outside the patient zone and are frequently contaminated Touching the curtains is considered to be leaving the patient zone HH should be performed between touching the curtains and touching the patient

Example: HCW walks into patient room opens the curtains up, then walks out No Moment - as the curtain is outside the patient zone

“Bonus” Moments The Aussie 5 Moments audit tool rewards staff who clean their hands at the most important times Eg1. Moving between patients One HH is recorded as two Moments – M4 and M1 Eg2. Moving from touching a patient to doing a procedure One HH is recorded as two Moments – M4 and M2 and vice versa M3 and M1

“Bonus” Moments

More examples

HCW walks in, silences IV alarm that is connected to the patient, then leaves Moment 1 – prior to touching the “patient” Moment 4 – after touching the “patient”

HCW walks in, picks up IDC to read it, puts it down, then leaves Moment 1 – pre IDC as IDC is considered to be a part of the patient Moment 3 – after IDC (potential body fluid risk)

HCW walks into the room, picks up the IDC to read it, puts it down, writes on the medical chart, then leaves Moment 1 – pre IDC as the IDC is considered to be a part of the patient Moment 3 – after IDC (potential body fluid risk) Moment 4 – after chart – after continuum of patient care

HCW changes IV fluid bag that is connected to the patient, then leaves Moment 2 – prior to disconnecting IV Moment 3 – after reconnecting IV

HCW prepares oral medications with medications sitting on the patient’s medical chart, signs the chart whilst giving the medications, then moves the curtain aside 1 – pre-giving the medications to the patient 4 – prior to moving the curtain

Moment 1 – prior to touching patient HCW walks in, shakes the patient’s hand, does hand hygiene, picks up the chart to read it, then leaves Moment 1 – prior to touching patient Moment 4 – on leaving (after chart – after continuum of patient care) The hand hygiene that was done in the scenario was not required at that time

HCW walks into the room opens the patient’s curtains, then leaves the room Nil as the curtains are external to the patient’s surroundings and are not a Moment

Moment 4 – after patient pre curtain HCW walks into patient room, helps the patient out of bed, moves the curtain back, then helps the patient to walk out of the room Moment 1 – pre patient Moment 4 – after patient pre curtain Moment 1 – after curtain pre patient No Moment 4 is recorded as HCW has not left the patient

HCW walks in, cleans up urine from the floor, then leaves Moment 3 – after clean up due to the body fluid exposure risk

Moment 1 – before touching first patient HCW assists a patient back to bed, then assists another patient to stand up, then leaves Moment 1 – before touching first patient Moment 4 – after touching first patient Moment 1 – prior to touching second patient Moment 4 – after touching second patient

HCW picks up the medication chart and walks out of the room with it Nil as the Moment has not finished

Moment 1 – prior to touching the patient HCW walks in, moves the overbed table, does Hand Hygiene, helps the patient out of bed, does hand hygiene, then leaves Moment 1 – prior to touching the patient Moment 4 – after touching the patient Hand hygiene was done correctly

Moment 1 – prior to touching the patient HCW walks in, does Hand Hygiene, moves the overbed table, helps the patient out of bed, does hand hygiene, then leaves Moment 1 – prior to touching the patient Moment 4 – after touching the patient Hand hygiene was done correctly

Food services worker walks in with food trolley, places tray on patient’s table then walks back to trolley and leaves the room Nil as Food services worker has not touched the patient’s surroundings

Food services worker walks in with food trolley, moves patient’s belongings off the overbed table, goes back to trolley to get food tray, places tray on patient’s table then walks back to trolley and leaves the room Moment 5 – after touching patient’s surroundings (before getting food tray out of trolley)

Moment 1 – prior to touching the patient HCW walks in, helps the patient to adjust position in bed, empties IDC, takes urinal to pan room, then leaves Moment 1 – prior to touching the patient Moment 4 – after touching the patient Moment 2 – prior to opening the IDC Moment 3 – after disposing of body fluid