1. H AND H YGIENE C OMPLIANCE : “G OING B ACK TO B ASICS ” Greater NY York APIC Chapter 13 November 19, 2014 Presented by: Saungi McCalla, MSN, MPH, RN, CIC Director of Infection Prevention and Control White Plains Hospital

3. WPH H AND H YGIENE P ROGRAM We have a very robust hand hygiene program at our institution which targets patients, staff and visitors. Staff Program Education Compliance monitoring via observation Observation done through objective observers (college interns) Patient Program Education (role and responsibility in hand hygiene and infection prevention)

4. B ACKGROUND According to the Centers for Disease Control and Prevention (CDC), hand hygiene is the single most important means of preventing the spread of infection Hand Hygiene compliance among healthcare workers is poor, less than 40% globally with many healthcare-acquired infections being transmitted on the hands of health care workers. Since many disease causing germs are spread by the hands, patients are also at risk from themselves and visitors.

5. I SSUE Hand Hygiene compliance is monitored for staff and rates published. In 2010-2011, our rates were 84% and 91% respectively. We were not meeting our goal of 95%.

6. O BJECTIVE To increase our hand hygiene rate to >95% quarterly and sustain it.

7. P ROJECT In 2012, we developed the Hand Hygiene Task Force which was designed to re-energize all hospital staff around hand hygiene, re-educate on the principles of hand hygiene and to engage everyone in the process. We also wanted to identify the barriers to hand hygiene which were: not enough dispensers dispensers were only mounted in patients’ room where they were not readily accessible to staff dispensers were often empty dried cracked hands from frequent hand hygiene staff not taking performing hand hygiene seriously

8. P LAN /S OLUTION 1. Addressing the barriers: hand hygiene dispensers were made available throughout the hospital we collaborated with EVS to ensure that rounding was being done to prevent dispensers from being empty Lotion dispensers were also made available to staff to keep their hands moisturized in an effort to prevent dried cracked hands.

9. 2. E DUCATION All staff were re-educated on hand hygiene The new Slogan: “Wash In, Wash Out” in alignment with The Joint Commission was adopted.

10. 3. A CCOUNTABILITY All staff re-committed themselves to the principles and policy through reading and signing of the hand hygiene pledge including new hires. The staff is charged with the responsibility to intervene when anyone was found to be non- compliant with the policy, thereby holding everyone accountable. Compliant staff is rewarded with a “Great Job!” sticker and a lollipop

12. R ESULTS The initiatives were successful. Our hand hygiene compliance rate increased to 97% in 2012 and was sustained in 2013. The 2013 3 rd and 4 th quarter data shows an increase in our compliance rate to 99.9%. Our current rate is 100%. In addition, as hand hygiene compliance rates increased, infections were noted to decrease in several categories such as central lines and ventilator associated pneumonia (VAPs). This resulted in cost savings and substantial reduction in patient morbidity and mortality.

17. R EWARD Hospital-wide celebration with Ice Cream Socials for achieving 100% compliance in a quarter We have had 3 so far in 2014

18. Questions?