Hand Hygiene Scenarios DVD Answer Key The Canadian Patient Safety Institute would like to thank the Ontario Ministry of Health and Long Term Care for.

Hand Hygiene Scenarios DVD Answer Key The 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 Stop! Clean Your Hands | Hand Hygene Toolkit

Instructions for Trainers
The Training DVD is a tool included to provide practical demonstrations of each of the the 4 Moments for Hand Hygiene These slides are designed to accompany the DVD and provide answers to the different scenarios The DVD includes 5 menu items: Your 4 Moments for Hand Hygiene (animation) Training Scenarios (for health care providers and observers) Observer Scenarios (for observers) Hand Hygiene Techniques (for health care providers and observers) Acknowledgements The menu bar allows you to freely switch between scenarios. For training it is recommended that you follow the order as presented.The complexity of the scenarios increases as you work through the scenarios.

The menu item Hand Hygiene Techniques includes the correct technique for handwashing and handrubbing The scenarios have been separated into two sets. One for all health care providers and one for observers. Training Scenarios 1 to 4 are intended to be used to train both health care providers and observers. Each scenario is dedicated to one of the 4 Moments for Hand Hygiene. Observer Scenarios 5 to 8 are intended to be used to train observers. Some trainers may find them helpful to reinforce training scenarios. These scenarios show examples of sequences of health care during which several indications for hand hygiene occur. Missed hand hygiene indications are shown in some scenarios and duplicate scenarios are also provided showing an example of 100 per cent compliance.

SCENARIO 1 Before initial patient/patient environment contact
1a - Before initial patient environment contact Content: The nurse opens the door (last contact with health care environment), enters the room and goes towards the patient and introduces herself Before initial contact with patient environment, nurse performs hand hygiene (handrubbing)* The nurse moves the bedside table (contact with object in patient environment) The nurse helps the patient to bring out his arm from under the sheets (first patient contact) Key messages: The nurse performs hand hygiene while approaching the patient environment. The nurse handrubs before touching surfaces and objects. As these are part of patient’s environment, it is not necessary to perform hand hygiene again before touching the patient. The indication remains “before initial patient/patient environment contact” *Note: Observers will time this indication.

SCENARIO 1 Before initial patient/patient environment contact 1a - Before initial patient environment contact

SCENARIO 1 Before initial patient/patient environment contact 1b - Before initial patient contact Content: The nurse opens the door (last contact with health care environment), enters the room and goes towards the patient The nurse performs hand hygiene (handrubbing) on entry to room* The nurse helps the patient to bring his arm from under the sheets (first patient contact) Key messages: Hand hygiene is required before patient contact to protect the patient from harmful germs carried on hands from the health care environment outside the patient’s environment. The indication remains “before initial patient/patient environment contact”. *Note: Observers will time this indication.

SCENARIO 1 Before initial patient/patient environment contact 1b - Before initial patient contact

SCENARIO 1 Before initial patient/patient environment contact 1c – Before initial patient/patient environment contact (missed) Content: The nurse performs handrubbing in the corridor (hand hygiene action is useless) The nurse is on her way to the room and suddenly remembers she needs to make a phone call. The nurse uses the phone in the waiting area (last contact with health care environment) and then goes directly into the room towards the patient The nurse helps the patient to bring his arm out from under the sheets (hand hygiene action missed) Key messages: After performing hand hygiene in the corridor (additional action not corresponding to any recommended indication), the nurse then touches the phone in the waiting area and thus potentially contaminates her hand with germs belonging to the health care environment.The nurse then misses the action before initial patient/patient environment contact, potentially contaminating her with those germs.

SCENARIO 1 Before initial patient/patient environment contact 1c – Before initial patient/patient environment contact (missed)

SCENARIO 1 Before initial patient/patient environment contact 1d - Repeated patient contacts Content: The nurse opens the door (last contact with health care environment), enters the room and goes towards the patient While entering, the nurse performs hand hygiene (handrubbing)* The nurse helps the patient to bring his arm out from under the sheets and measures his blood pressure (first patient contact) The nurse moves to the other side of the bed The nurse moves the bedside table (contact with patient environment) The nurse takes the patient’s right arm and assesses finger mobility (patient contact) The nurse bends down to examine the urine content in the bag without touching anything and then touches the bed while standing up (contact with patient environment) Key messages: The sequence shows several contacts with the patient and his environment, but with no aseptic procedure nor body fluid exposure risk. Hand hygiene is correctly performed only once, before the first patient contact/patient environment. There is no need for further hand hygiene actions because the nurse is always moving within the patient environment. *Note: Observers will time this indication.

SCENARIO 1 Before initial patient/patient environment contact 1d - Repeated patient contacts

Before aseptic procedure 2a – Aseptic procedure within a care sequence
SCENARIO 2 Before aseptic procedure 2a – Aseptic procedure within a care sequence Content: The nurse enters the room and places the equipment ready for giving an IV medication on the overbed table (last contact with health care environment) The nurse performs hand hygiene by handrubbing (indication: before initial patient/ patient environment contact)* IMED pump alarms so nurse resets pump (contact with patient environment) The nurse moves the over bed table (contact with patient environment) The nurse performs hand hygiene by handrubbing (indication: before aseptic procedure) The nurse cleans the IV port and injects the medication into the IV port (aseptic procedure) Key messages: The nurse has a first direct contact with the patient (she performs hand hygiene as indicated) and the patient environment; she then repeats the hand hygiene action before the aseptic procedure to protect the patient from her own organisms. *Note: Observers will time this indication.

SCENARIO 2 Before aseptic procedure 2a – Aseptic procedure within a care sequence

SCENARIO 2 Before aseptic procedure 2b – Aseptic procedure only
Content: The nurse places the equipment ready for injection on the overbed table The patient is lying in bed with an IV catheter in her arm directly accessible to the nurse The nurse performs hand hygiene by handrubbing (indication: before aseptic procedure) The nurse cleans the IV port and injects the medication into the IV port (aseptic procedure without direct patient contact) Key messages: The aseptic procedure is the very first and unique indication in this scenario. The nurse has no direct contact with the patient.

Before aseptic procedure 2b – Aseptic procedure only
SCENARIO 2 Before aseptic procedure 2b – Aseptic procedure only

After body fluid exposure risk 3a –
SCENARIO 3 After body fluid exposure risk 3a – Body fluid exposure risk within a care sequence (missed) Content: The gloved nurse in the room punctures the patient’s finger and squeezes drops of blood onto a strip and then tests with the glucometer (blood exposure risk) When the nurse finishes, she places the lancet in the sharps container and then places the alcohol swab in the garbage. She then takes off her gloves and places them into the garbage (continuing blood exposure risk) Hand hygiene action missed (indication: after body fluid exposure risk) The nurse takes the patient's pulse (next patient contact) Key messages: Hand hygiene must be performed immediately after body fluid exposure risk, before touching either the patient again or any surface and object within the patient environment or health care environment, to prevent potential dissemination of organisms. Any care activity implying contact with body fluids constitutes a risk because exposure may not be visible but may have happened.

SCENARIO 3 After body fluid exposure risk 3a – Body fluid exposure risk within a care sequence (missed)

SCENARIO 3 After body fluid exposure risk 3b –
Body fluid exposure risk within a care sequence Content: The gloved nurse in the room punctures the patient’s finger and squeezes drops of blood onto a strip and then tests with the glucometer (blood exposure risk) When the nurse finishes, she places the lancet in the sharps container and then places the alcohol swab in the garbage. She then takes off her gloves and places them into the garbage. The nurse performs hand hygiene by handrubbing (indication: after body fluid exposure risk) The nurse takes the patient's pulse (next patient contact) Key messages: The nurse performs correct and timely handrubbing immediately after body fluid exposure risk; her hands are not visibly soiled and she does not need to handwash.

Body fluid exposure risk within a care sequence

SCENARIO 3 After body fluid exposure risk 3c –
Body fluid exposure risk (handwashing) Content: The nurse’s hands get wet with urine found on the sheets. The nurse discovers that the Foley catheter has become disconnected. The nurse had not anticipated there would be urine under the patient, therefore she did not have gloves on (body fluid exposure risk). The nurse washes her hands with soap and water (after body fluid risk exposure) Key messages: The nurse performs correct and timely hand hygiene after body fluid exposure risk.The nurse performs hand hygiene by handwashing. Handwashing with soap and water is recommended when hands are visibly soiled.

Body fluid exposure risk (handwashing)

SCENARIO 4 After patient/patient environment contact 4 a -
Content: The Respiratory Therapist (RT) is at the patient’s bedside. The RT checks the chest sounds on the patient (last patient contact) The RT performs hand hygiene (handrubbing) at the end of the bed* The RT leaves the patient and goes to record on the chart or computer on wheels (C.O.W.) that is kept outside the patient environment Key messages: The charting area is not part of the patient environment, therefore hand hygiene is performed after patient/patient environment contact, before leaving the patient environment and going to record in the chart. *Note: Observers will time this indication.

SCENARIO 4 After patient/patient environment contact 4a -

After patient/patient environment contact 4b –
SCENARIO 4 After patient/patient environment contact 4b – After patient environment contact Content: The pharmacist discusses with the patient the medications the patient was on before coming to hospital. The pharmacist goes into the patient drawer to verify what medications the patient has been taking The pharmacist performs hand hygiene (handrubbing) at the end of the bed* The pharmacist leaves the room Key messages: There is no contact with the patient, but hand hygiene must still be performed after contact with objects and surfaces in the patient’s environment when leaving patient environment. *Note: Observers would time this indication if they could see the entire time taken to do the handrub, but in this scenario they do not, so it is not timed.

SCENARIO 4 After patient/patient environment contact 4b – After patient environment contact

SCENARIO 4 After patient/patient environment contact 4c –
After patient contact Content: The social worker (SW) is having a discussion with the patient The SW shakes the patient’s hands at the completion of the discussion (first patient contact) The SW performs hand hygiene by handrubbing; (indication: after patient/patient environment contact) as he leaves the room Key messages: There is contact with the patient, so hand hygiene must be performed when leaving patient’s environment. It is recorded as “after patient/patient environment contact.” *Note: Observers would time this indication if they could see the entire time taken to do the handrub but in this scenario they do not, so it is not timed.

SCENARIO 4 After patient/patient environment contact 4c - After patient contact

Between patients (missed)
SCENARIO 5 Between patients 5a – Between patients (missed) Content: (2 bed room) The doctor shakes patient X’s hand as he leaves bedside Hand hygiene action missed (indications: after patient/patient environment contact and before initial patient/patient environment contact, but it is one opportunity) He approaches patient Y, greets her and shakes her hand Key messages: Two indications occur (after patient/patient environment contact and before initial patient/patient environment contact) and correspond to one single opportunity that requires one single hand hygiene action.

SCENARIO 5 Between patients 5a – Between patients (missed)

SCENARIO 5 Between patients 5b – Between patients (100% compliance)
Content: (2 bed room) The doctor shakes patient X’s hand as he leaves her bedside The doctor performs hand hygiene by handrubbing (indications: after patient/patient environment contact and before initial patient/patient environment contact,* but it is one opportunity) The doctor approaches patient Y, greets her and then lifts the sheets to examine her Key messages: same sequence as 6a, but with properly performed hand hygiene (100 per cent compliance). *Note: Observers will time this indication.

SCENARIO 5 Between patients 5b – Between patients (100 % compliance)

SCENARIO 6 Care sequence break 6a – Care sequence break (missed)
Content: The doctor enters the room and goes towards the patient While entering, the doctor performs hand hygiene by handrubbing (indication: before initial patient/patient environment contact)* (less than 15 seconds) The doctor shakes the patient's hand and is about to examine her knee The pager beeps, the doctor excuses herself and leaves the room to answer the phone in the corridor (hand hygiene action missed; indication: after patient/patient environment contact) The doctor comes back through the open door The doctor carries on with the physical examination (hand hygiene action missed; indication: before initial patient/patient environment contact) Key messages: A care sequence break occurs (the doctor answering the phone in the corridor, outside the patient’s environment). Therefore, the doctor should perform hand hygiene after leaving the patient (to prevent transmission of germs from the patient to the health care environment), and before touching the patient again (to prevent transmission of germs from the health care environment to the patient). These care breaks should be avoided as much as possible. *Note: Before initial patient/patient environment contact to be timed.

SCENARIO 6 Care sequence break 6a – Care sequence break (missed)

SCENARIO 6 Care sequence break 6b –
Care sequence break (100 % compliance) Content: The doctor enters the room and goes towards the patient While entering she performs hand hygiene by handrubbing (indication: before initial patient/patient environment contact)* The doctor shakes the patient's hand and is about to examine her knee The pager beeps, the doctor excuses herself to answer the phone The doctor leaves the room while performing hand hygiene by handrubbing (indication: after patient/patient environment contact)* The doctor comes back through the open door while performing hand hygiene by handrubbing (indication: before initial patient/patient environment contact)* The doctor carries on with the physical examination Key messages: Same sequence as 6a, but with correctly performed hand hygiene (100 per cent compliance). Assess and plan care sequences to decrease the number of times hands must be cleaned. *Note: Observers will time before initial patient/patient environment and after patient/patient environment contact.

Care sequence break (100 % compliance)

Open discussion - only record what you see
SCENARIO 7 Patient examination 7a – Patient examination (missed) Content: Scene: 2 bed room The doctor is beside the patient and listens to his heartbeat The nurse comes into the room The nurse performs hand hygiene by handrubbing (indication: “before initial patient /patient environment contact”) The nurse helps the doctor to prop the patient up in bed The doctor examines the patient's lungs The doctor puts on gloves to examine the patient's mouth using a tongue depressor and a pen light Hand hygiene action missed by doctor (indication: “before aseptic procedure”) The nurse performs hand hygiene by handrubbing (additional hand hygiene action, unnecessary) The doctor helps the patient to open his mouth and examines the mucous membrane (contact with mucous membrane) Some saliva drips and the doctor wipes away the saliva (body fluid exposure) The doctor throws the wipes and tongue depressor into the garbage and then takes off his gloves and throws them into the same garbage Nurse leaves room The doctor completes his examination Hand hygiene action missed (indication: “after body fluid exposure”) The doctor leaves the patient’s room Open discussion - only record what you see

SCENARIO 7 Patient examination 7a – Patient examination (missed)

SCENARIO 7 Patient examination 7b –
Patient examination (100 % compliance) Content: 2 bed room The doctor is beside the patient and listens to his heartbeat The nurse comes into the room The nurse performs hand hygiene by handrubbing (indication: before initial patient /patient environment contact)* The nurse helps the doctor to prop the patient up in bed The doctor examines the patient's lungs The doctor performs hand hygiene by handrubbing (indication: before aseptic procedure) The doctor puts on gloves to examine the patient's mouth using a tongue depressor and a pen light The doctor helps the patient to open his mouth and examines the mucous membrane (contact with mucous membrane) Some saliva drips and the doctor wipes away the saliva (body fluid exposure) The doctor throws the wipes and tongue depressor into the garbage and takes off her gloves and throws them into the same garbage. The doctor performs hand hygiene by handrubbing (indication: after body fluid exposure) The doctor palpates the patient's abdomen The nurse performs hand hygiene by handrubbing (indication: after patient/patient environment contact)* The doctor performs hand hygiene by handrubbing on the way out of the room (indication: after patient/patient environment contact)* Key messages: same sequence as 7a, but with correctly performed hand hygiene (100 per cent compliance). *Note: Observers will time before initial patient/patient environment contact. Observers would time after patient/patient environment if they could see the entire time taken to do the handrub, but in this scenario they do not, so it is not timed.

Patient examination (100 % compliance)

SCENARIO 8 Starting an IV Content:
2 nurses are entering the room. A senior nurse has the equipment to start an IV. The senior nurse (A) explains the procedure to the patient The new grad nurse (B) then comes into the room through an open door and cleans hands at the end of the bed (before patient/patient environment contact) * The new grad nurse touches the environment/equipment The senior nurse positions the patient and puts the blue pad under the arm The new grad nurse assesses the equipment for doing the procedure without touching it The senior nurse performs hand hygiene by handrubbing (indication: before aseptic procedure). The senior nurse dons gloves The new grad nurse opens the pack of sterile swabs The new grad nurse opens the pack containing the syringe The senior nurse disinfects the puncture site The senior nurse inserts the IV catheter into the vein The senior RN’s pager goes off, so she asks the new grad nurse to find out what the page is about The new grad nurse leaves the room, but cannot be observed The senior nurse applies a sterile dressing over the IV site The senior nurse takes used equipment and pad and disposes of them The senior nurse takes off gloves Senior nurse starts to perform hand hygiene by handrubbing (indication: after body fluid exposure risk.) *Note: Observers will time before patient/patient environment contact.

SCENARIO 8 Starting an IV Key messages:
The senior nurse goes over and touches the patient without performing hand hygiene. Since it cannot be observed whether the senior nurse had performed hand hygiene on entering the room, a missed hand hygiene action should not be recorded The new grad nurse cleaned hands before touching the patient/patient environment Subsequently, the senior nurse correctly performed hand hygiene before aseptic procedure The senior nurse correctly performs hand hygiene after body fluid exposure risk following starting the IV Since it cannot be observed whether the new grad nurse had performed hand hygiene on leaving the room, a missed hand hygiene action should not be recorded

SCENARIO 8 Starting an IV

The Training DVD is a tool included to provide practical demonstrations of each of the the 4 Moments for Hand Hygiene These slides are designed to accompany the DVD and provide answers to the different scenarios The DVD includes 5 menu items: Your 4 Moments for Hand Hygiene (animation) Training Scenarios (for health care providers and observers) Observer Scenarios (for observers) Hand Hygiene Techniques (for health care providers and observers) Acknowledgements The menu bar allows you to freely switch between scenarios. For training it is recommended that you follow the order as presented.The complexity of the scenarios increases as you work through the scenarios.