1. Exploring Hand Hygiene Knowledge and Practice
Training Module #1 for the CAUTI LTC Core Team
Welcome to the first training module for the Agency for Healthcare Research and Quality’s (or AHRQ’s) Safety Program for Long-term Care: Health care-Acquired Infections/CAUTI. Today’s training module titled, “Exploring Hand Hygiene: Knowledge and Practice” is intended for the project team lead and core team at your facility. We will review important basic hand hygiene principles and best practices to be reinforced with front-line staff to improve infection prevention at your facility.
Developed May 2015

2. Learning Objectives
Upon completion of this training, the facility core team members will be able to:
explain why hand hygiene is so important to prevent the spread of infections;
reinforce when and how to perform hand hygiene;
recognize challenges to hand hygiene in their facility, and identify possible solutions; and
discuss ways to monitor hand hygiene adherence and develop feedback reports.
When concerns are raised about a facility’s infection prevention program, hand hygiene education is often the first place we turn. However, it’s important to remember that knowledge of hand hygiene moments and technique is only half of the solution. During this presentation, we are going to review why hand hygiene is so important to prevent the spread of infections; reinforce when and how to perform hand hygiene; recognize challenges to hand hygiene and identify possible solutions and discuss ways to monitor hand hygiene adherence and develop feedback reports.

3. Front-line Staff Training Recap
Hand hygiene is one of the most important ways to prevent the spread of infections
Germs, especially gram-negative bacteria are frequently found on healthcare worker hands following routine resident care
The WHO 4 moments provide a simple framework for remembering when staff should perform hand hygiene during any resident interaction
You should recall from the All Staff training that healthcare-associated infections are a significant source of morbidity and mortality in long-term care facilities. And unfortunately, healthcare worker hands are a common way infections can be spread in healthcare settings. Hand hygiene is the key step to halting the spread of infection.
Bacteria often contaminate healthcare work hands following routine care, and it may not be the bacteria you’d guess. Gram negative bacteria, like E Coli and Proteus, which live in the GI tract and colonize the urinary tract, are more frequently found on hands compared to common skin bacteria like Staph aureus. These data highlight how important it is to think about what we are doing with our hands when providing care to our residents.
The World Health Organization, or W.H.O. has distilled hand hygiene practices into “4 moments” or opportunities for performing hand hygiene when interacting with residents in long-term care. If everyone remembers these four times for hand hygiene during care of residents, they will be maximize their efforts to prevent the spread of infections in your facility.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16 Mody et al Infect Control Hosp Epidemiol; 2003:24: Guide on Hand Hygiene in Outpatient and Home-based Care and Long-term Care Facilities. Just Clean Your Hands Educational Resources:

4. Hand Hygiene Technique
It is important to remind staff that proper hand hygiene technique is an essential part of hand hygiene and infection prevention. Whether you're using alcohol based hand rubs or rubbing soap on your hands during hand washing, the minimum amount of time that you should be rubbing your hands together is 15 seconds.
These posters developed by the WHO show each step of how to use alcohol based hand rubs and soap and water for hand hygiene. These are great tools to use during in-services or post as reminders to staff.

5. Front-line Staff Training Recap
Good
Better
Best
Plain soap
Antimicrobial soap
Alcohol-based hand rub
Alcohol-based hand products are preferred for hand hygiene during almost all routine patient care activities
Exceptions:
When hands are visibly soiled
After care of a resident with known or suspected infectious diarrhea
It’s important to clarify hand hygiene expectations during care of a resident with C.difficile.
Alcohol-based hand rubs are appropriate on entry to room; appropriate glove use to prevent hand contamination; washing with soup and water upon glove removal and exiting room
The diagram on this slide is a easy reminder for staff that alcohol-based hand rubs are more effective than antimicrobial soap or plain soap and water for reducing bacteria on health care workers’ hands. And alcohol-based hand rubs are preferred for hand hygiene during almost all routine patient care activities.
It is a combination of the product and our technique that makes the alcohol based hand rubs so effective at disinfecting hands. Alcohol based hand rub products don't need as much contact time to disinfect and kill organisms on hands. They also spread more easily into every crevice and surface of the hands.
Hand washing with soap and water is impacted more by poor technique for example, failing to coat every surface of the hands and fingers or inadequate contact time with soap on the hands. These problems with good technique reduce the efficacy of hand hygiene with soap and water. But, there are times when hand washing is preferred to alcohol-based hand rubs, including, when hands are visibly soiled and after care of a resident with known or suspected infectious diarrhea.
The most common situation when hand hygiene expectations need to be clarified for front-line staff is during care of a resident with C.difficile. The issue of hand hygiene and C.diff is a common source of confusion among healthcare staff. We know that hand washing with soap and water is preferred after caring for residents with infectious diarrhea, because soap and water remove germs, like C.diff more effectively than alcohol hand rubs. In addition, the spore form of the C.diff bacterium is protected by a hard shell which makes it more resistant to being killed by alcohol-based products. Soaping hands and rinsing with water is the most effective way to physically remove spores from hands.
But, we have to be careful not to lose the power of alcohol-based hand products to kill all the other germs because we are worried about C. diff. One approach that might work is use of alcohol-based hand rubs on room entry, appropriate use of gloves to prevent hand contamination during care of a resident with C.diff, and glove removal and hand washing with soap and water when ready to exit the room.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16Oughton MT et al. J Infect Hosp Epidemiol 2009;30(10):939–944. Dubberke E et al. SHEA/IDSA Practice Recommendation. J Infect Hosp Epidemiol 2014;35(6):

6. Front-line Staff Training Recap
Gloves play a key role in preventing hand contamination – but, do NOT replace hand hygiene
Perform hand hygiene and wear gloves immediately before:
Placing or removing an indwelling catheter
Accessing the drainage system to empty the drainage bag or collecting a urine sample
Remove gloves and perform hand hygiene immediately after:
Handling an indwelling catheter
Accessing the drainage system to empty the drainage bag or collecting a urine sample
As discussed with C. difficile, gloves play a key role in preventing hand contamination, but they should NEVER be considered a substitute for hand hygiene. Let’s consider this in the context of CAUTI prevention …
To help prevent catheter-associated urinary tract infections and the spread of MDROs to residents with urinary catheters, it is critical to emphasize both hand hygiene and glove use when in contact with the indwelling urinary catheter or the drainage system. We will spend more time discussing gown and glove use in the context of standard precautions during Training Module 3.
Staff should perform hand hygiene and wear gloves immediately before placing or removing an indwelling catheter, or accessing the drainage system to empty the drainage bag or collecting a urine sample. This is very important because interacting with the resident or the environment before handling the urinary device may contaminate your hands. Also, reaching for gloves with unclean hands may contaminate the glove box and outside of the gloves. Then, your gloves will contaminate the urinary catheter or urine collection system.
It is also critical to perform hand hygiene after handling an indwelling catheter, or accessing the drainage system to empty the drainage bag or collecting a urine sample. Hand contamination may occur as a result of small, undetected holes in your gloves or during glove removal. Performing hand hygiene after using gloves to perform catheter care helps to protect your hands and the environment from being contaminated.

7. Health Care Worker Challenges with Hand Hygiene
Belief that Hand Hygiene guidelines aren’t applicable
30% wouldn’t change current practices; 20% said guidelines were impractical
Lack of access to appropriate Hand Hygiene supplies
16.2% lack of available sink; 27.5% lack of alcohol-based hand rub
No Hand Hygiene because of glove use
23% nurses, 17% CNAs, 26% other HCWs
Forgot about Hand Hygiene because of workload
35% of nurses, 22% CNAs, 44% other HCWs
Lack of access to Hand Hygiene feedback and/or education
55% never to rarely received personal feedback on HH practices
Other HCWs less often received periodic education on HH (86.8% vs. 92% of nurses and CNAs, p=0.03)
But knowledge about hand hygiene opportunities and technique is not enough. A survey of front-line nursing staff in nursing homes found lots of reasons for why hand hygiene was a challenge or why hand hygiene wasn't performed. About 30% of respondents thought that the 2002 CDC hand hygiene guidelines weren't applicable to them and 20% said that these guidelines aren't practical for use in long term care settings. About 16% said they didn't have access to a sink, but almost twice as many, 30%, said they didn't have access to alcohol based hand rubs. Roughly a quarter said they didn’t perform hand hygiene because of glove use. Forgetting hand hygiene because of heavy workload was a universal problem reported among all healthcare staff.
Interestingly when you look at the responses about hand hygiene feedback and education, it's not necessarily that they didn't get in services on hand hygiene, but over 50% of these health care workers surveyed said they never or rarely received any personal feedback on their hand hygiene practices. Non-nursing staff health care workers felt they received a little less education on hand hygiene, compared to the nursing staff respondents. That's interesting finding as far as who are we training and where do we emphasize hand hygiene. Are we training all of the staff in our building or are we mostly focusing on our front line nursing staff?
Ashraf MS et al. ICHE 2010; 31(7):

8. Addressing Barriers to Hand Hygiene
Let’s Chat!
What challenges do you experience performing hand hygiene in your facility?
What solutions do you propose to address these challenges in your facility?
How can you support a culture of safety around hand hygiene?
One of our recommended hand hygiene exercises is to lead a discussion with staff to identify challenges to hand hygiene that staff might experience in your facility and collaboratively identify solutions to those challenges that will work in your facility. Here are 3 specific questions you can use to initiate the discussion. You could also review the barriers reported in the NH survey on the previous slide to initiate a dialogue with your team about why individuals miss opportunities to perform hand hygiene appropriately.
In addition to the barriers described on that slide, other issues to explore include:
Do staff like the hand hygiene products available to them? If staff feel that the alcohol-based or soap product is unpleasing, then they are less likely to use it.
Availability and accessibility within your building is a very important piece of your hand hygiene program. You may want to just walk around and ask yourself, "How easy is it for my staff members to get to hand hygiene dispensers or sinks during their regular resident care activities?" That's an important issue to address. In particular, looking at the access in the resident care rooms. Often we'll have some alcohol based hand dispensers sort of posted in the hallways scattered through the building, but they may not be right as you're entering a room, or somewhere close to the glove box. For example, when I would be about to start reaching for those gloves. Having a dispenser right there at my fingertips might be very helpful.
Another strategy that people are considering more and more are pocket sized hand products, and in particular the pocket sized alcohol based hand rubs. This may be especially useful in wards or units where you're concerned about residents with cognitive impairment and you want to make sure that it's not unsafe for your residents. Having your staff members carrying alcohol based hand products in their pockets allows them to basically be the point of care. They can always use product as they're about to interact with a resident, whether they're in the room, or in the dining hall, or in the activities room, which are all places where we interact with residents in long term care settings.
Have staff think of ways that they can support each other to develop a culture of safety around hand hygiene. Possible ideas could be to identify champions for hand hygiene to serve as mentors/role models; develop a phrase or signal as a friendly supportive reminder for others to perform hand hygiene; monitor hand hygiene compliance with feedback to each unit/individual on their performance and you can make it a contest with prizes.
From these discussions identify a plan that includes 3 simple actions that staff/administration can implement to improve the hand hygiene program at your facility.

9. Hand Hygiene Adherence Monitoring Options
Method
Pros
Cons
Direct observation of hand hygiene technique
Educational moment
Does not measure adherence during patient care
Direct observation of hand hygiene adherence
Captures information on product, technique
Data summarized by staff type, shift, unit
Time and resource intensive
Can influence performance
Measurement of volume of AHBR or soap used
Easy to track consistently
Consumption may not correlate with appropriate use
Could be biased by purchasing patterns
Survey/self-report of hand hygiene adherence
Captures perceptions and barriers
Rates often inflated
Monitoring hand hygiene compliance can be a powerful tool to help improve your hand hygiene program. There are several different methods that you can use to monitor which are outlined in this table. Direct observation of technique is a popular method for assessing competency and providing education about hand hygiene – the problem though is watching someone wash their hands or apply alcohol rub correctly doesn’t guarantee that he or she will adhere to those best-practice during a busy work day. Therefore, direct observation of technique by itself may not be adequate for really knowing that staff members are doing hand hygiene appropriately.
Direct observation of hand hygiene adherence on the units, either by a designated hand hygiene monitor or by using a secret shopper, is the best way to capture the most information. It tells you what products staff and information about technique for example, how well people coat their hands with hand rub or how long they stand at the sink. You can also see who is performing hand hygiene appropriately at the bedside, whether it's nursing staff, CNAs, physicians, rehab therapists, social workers, or dietary. The problem with this methodology is it's very time and resource intensive and you can spend quite a bit of time up on the units, on the floors, and it's very hard to get data from all the shifts, especially off-hour shifts like overnight and weekends. In addition, if you have designated a hand hygiene monitor in your building, then you may find that people know to pay attention to their adherence whenever that individual is on the unit – then you can’t be certain their practice reflects what they truly do when not being watched. Using secret shoppers, (unknown peers who are observing hand hygiene compliance) can overcome the “Hawthorne effect” which is when performance might be influenced by the fact that it’s being watched. Despite the challenges of direct observation of adherence, I would encourage all of us in long term care settings and nursing homes to start looking at that as a way to provide feedback on hand hygiene practices. Remember, 55% of the health care workers surveys in that hand hygiene they never or rarely received feedback on their hand hygiene practices.
Measuring the volume or product being used is certainly a way that you can track your consumption and it's a way you can track your information in a consistent way. However, the problem with measuring consumption of product, is that it may not actually correlate with appropriate use. Increased consumption may not only reflect improvements in staff hand hygiene adherence, if residents, families and visitors increase their use of HH products, that could also increase the volume of product being used.
You can also survey staff to self-report hand hygiene adherence. I don't think anyone is using this as a method for tracking their hand hygiene practices, because we often self-report we're doing a little better than we actually are. But what we can do with these surveys is understand staff perceptions of barriers and challenges to doing hand hygiene. That can actually give you some insights into what your staff might be finding are obstacles to performing hand hygiene.

10. Feedback and Dissemination of Hand Hygiene Rates
Providing feedback on hand hygiene adherence to front-line staff is a key component to raising awareness and maintaining high compliance rates.
Also consider opportunities for “just in time” education when incorrect practices are observed.
If you monitor hand hygiene with direct observation of adherence at the bedside, where you can actually track compliance by staff person, the type of provider or staff person walking in the room, or by the units that you are observing, this allows you to provide some of that feedback and sharing of information to the front line staff, which we know is a very key component to keeping their awareness and attention on the importance of hand hygiene. And also it allows you to maybe stimulate a little bit of friendly competition among your staff. For example, the top graph breaks down compliance by type of provider. The nurses are doing very well, and the CNAs are not far behind them, but the physicians are sort of lagging. You can try to get your physicians to do a little bit better job with hand hygiene by showing them how different their adherence looks compared to their peers and their colleagues in the building. Another way to do it, is looking at the data by unit. In the bottom graph you can compare unit 1 and unit 2 and try to get them to sort of compete if you will from month to month to see if staff improve their compliance.

11. Interactive Activities
Demonstration of hand hygiene technique
Culture staff hands before and after hand hygiene
Demonstration of germ transfer
Use glow powder on commonly touched objects to see how and where “germs” travel
Before After
Interactive activities are always a great way to get staff engaged, and visual interactions can be exceptionally powerful.
Culturing staff hands before and after hand hygiene can show them how many germs are present on their hands, and how well their technique is when using alcohol based hand rubs or soap and water. The top picture demonstrates fairly good hand hygiene technique – almost all of the bacteria have been killed or removed. The bottom picture however shows that maybe some additional training on technique is warranted.
You can also use glow powder on commonly touched objects (the phone at the nurse’s station for example), and after a specified amount of time you can use a black light to see where the ‘germs’ may have traveled (staff hands and/or clothing, computer keyboards, door knobs, etc.)

12. Hand Hygiene Videos WHO - SAVE LIVES: Clean Your Hands
Hand Hygiene Video New England Journal of Medicine
Hand Hygiene Training Films and Slides
O les mains Hand Hygiene Dance
CDC—Hand Hygiene Interactive Education Video
Public Health Ontario—Just Clean Your Hands (based on WHO 5 Moments)
NPSA Wi-Five Hand Hygiene Video Game
Here are examples of training and educational web-based video resources available on hand hygiene.

13. Hand Hygiene Posters Create your own! Other Resources:
Have staff role model positive behaviors
Other Resources:
CDC and WHO Hand Hygiene Resources
Additional posters
Public Health Ontario – Just Clean Your Hands
You can display eye-catching, informative posters to remind staff about hand hygiene. You can personalize these posters by taking photographs of your health care professionals engaging in positive behaviors. Laminate and hang them up in key common areas.
Additional links for posters from CDC, WHO, and Ontario are included as well.

14. Take the Pledge…
Along with the Association for Professionals in Infection Control and Epidemiology (APIC) the LTC program has developed an infection prevention tool titled “Take the Pledge.” This tool contains information on the four infection prevention skills covered in the LTC Program Training Modules, including Hand Hygiene skills. The content is designed to be accessible to a broad audience, including facility team leaders, front-line staff and residents and family members. We encourage all facility leaders to share this tool with all staff in their long-term care facility. The tool can even be personalize with individual facility logos and guidelines. Instructions for personalization are available to download along with the tool on the project website. This tool can be printed, displayed or disseminated as appropriate in your facility to encourage proper infection prevention skills.

15. Stay Updated with Useful Resources
Take the Pledge… (to practice all infection prevention skills)
World Health Organization How to Handrub Poster
World Health Organization How to Handwash Poster
Finally, these and many other educational resources are available on the AHRQ Safety Program CAUTI project website. I would encourage you to explore these materials to find other ways to support your front-line staff in improving hand hygiene and all their infection prevention practices. Many thanks for your time and good luck with addressing the hand hygiene opportunities in your facility.