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« My five moments for Hand Hygiene » Carolina Fankhauser Ermira Tartari Infection Control Programme
« My five moments for Hand Hygiene »
Carolina Fankhauser Ermira Tartari
Infection Control Programme
The Hand Hygiene Technical Reference Manual
– For health-care workers, trainers and observers
– The manual helps to understand:
- the importance of HCAI
- the dynamics of cross-transmission
- the "My five moments for hand hygiene" approach
- the correct procedures for handrubbing and handwashing
- the WHO observation method
Why observe hand hygiene practices?
– The purpose of observing hand hygiene is to determine the degree of compliance with hand hygiene practices by health-care workers
– The results of the observation should help to identify the most appropriate interventions for hand hygiene promotion, education and training
– The results of observation (compliance rates) can be reported to health-care workers, either to explain the current practices of hand hygiene in their health-care setting and to highlight the aspects that need improvement, or to compare baseline with follow-up data to show possible improvements resulting from the promotion efforts
How to observe hand hygiene?
– Direct observation is the most accurate methodology
– The observer must familiarize him/herself with the methods and tools used in a promotion campaign and must be trained (and validated) to identify and distinguish the indications for hand hygiene occurring during health care practices at the point-of-care
– The observer must conduct observations openly, without interfering with the ongoing work, and keep the identity of the health-care workers confidential
– Compliance should be detected according to the "My 5 Moments for Hand Hygiene" approach recommended by WHO
« My 5 Moments for Hand Hygiene » approach at point-of-care
Minimising the complexity of hand hygiene
Logically integrated into the workflow
Easy to remember
Unified vision for trainer, observer and HCW
Applicable in any healthcare setting
Consistent with evidenced-based risk assessment of HCAI and spread of MDRO
• xxxxx1
The approach
The “My 5 Moments for Hand Hygiene” approach
HEALTH-CARE AREA
PATIENT ZONE
The geographical conceptualization of the transmission risk
Critical site with infectious risk for the patient
Critical site with body fluid
exposure risk
OPTIMAL HAND HYGIENE
AT THE POINT-OF-CARE
SHOULD BE PERFORMED
Definition of point-of-care
– Point-of-care – refers to the place where three elements occur together: the patient, the health-care worker, and care or treatment involving patient contact (within the patient zone)
– The concept embraces the need to perform hand hygiene at recommended moments exactly where care delivery takes place
– This requires that a hand hygiene product (e.g. alcohol-based handrub, if available) be easily accessible and as close as possible (e.g. within arm’s reach), where patient care or treatment is taking place. Point-of-care products should be accessible without having to leave the patient zone
– This enables health-care workers to quickly and easily fulfil the 5 indications (moments) for hand hygiene xxxx2
Examples of hand hygiene products easily accessible at the point-of-care
Observation Form
– Detailed instructions are available on the back of the form, to be consulted during observation
Crucial concepts for observing hand hygiene
Indication and opportunity – Health care activity = a succession of tasks during which health-care workers'
hands touch different types of surfaces: the patient, his/her body fluids, objects or surfaces located in the patient surroundings and within the care environment
– Each contact is a potential source of contamination for health-care workers' hands
– Indication: the reason why hand hygiene is necessary at a given moment. It is justified by a risk of germ transmission from one surface to another
– Opportunity: moment when a hand hygiene action is necessary during health-care activities, to interrupt germ transmission by hands
– A hand hygiene action must correspond to each opportunity
– Multiple indications may come together to create a single opportunity
RISK OF TRANSMISSION INDICATION OPPORTUNITY ACTION
… contact 1 indication(s) contact 2 indication(s)] contact 3 indication(s) …
The observer point of view Indications and opportunity for hand hygiene
– The opportunity is the number of times hand hygiene is necessary
■ Indications are the reasons for hand hygiene
■ Indications are not exclusive and may be single or multiple at a time
■ At least one indication defines the opportunity
■ Multiple indications may define one opportunity
Coincidence of two indications
Care activity Care activity Care activity Care activity
Key points for the observer about coincidence of indications
■ All double, triple, quadruple indications combinations may be observed
■ Except one! The indications after patient contact and after contact with patient surroundings can never coincide in the same opportunity
X X
X
X X X
X
X X
Example: Moment 5 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
The observer point of view Opportunity and hand hygiene action
■ The observer must detect at least one indication to count an opportunity (multiple indications simultaneously occur and determine one opportunity)
■ The hand hygiene action should correspond to a counted opportunity
■ The hand hygiene action is performed either by handrubbing or handwashing; if it is not performed when indicated, it must be recorded as "missed"
■ An observed hand hygiene action not corresponding to an actual indication should not be recorded
The observer point of view Compliance with hand hygiene (1)
performed hand hygiene actions (x 100)
-------------------------------------------- required hand hygiene actions
(opportunities)
COMPLIANCE
Coincidence of two indications
Care activity Care activity Care activity Care activity
= 50%
?
The observer point of view Compliance with hand hygiene (2)
1 hand hygiene action x 100 -----------------------------------------
2 indications ?
X
X
X
= 50%
The observer point of view Compliance with hand hygiene (3)
1 hand hygiene action x 100 -----------------------------------------
2 indications
= 100% 1 hand hygiene action x 100
----------------------------------------- 1 opportunity
X
X
?
X
X
X
X
Recording the information: the header of the Observation Form
– The header allows observations to be precisely located in time and place (setting, date, session duration and observer) and the data to be classified and recorded (period, session)
– Before observing, the header should be completed – After observing data should be complemented and checked – Period and session numbers may be completed at the data entry
moment
Recording the information: the grid of the Observation Form (1)
– Each column can be dedicated either to a professional category (in this case different health-care workers of that category are recorded in the column) or to an individual health-care worker whose category is mentioned
– The codes of professional categories are listed on the back of the form
– Where data is classified by professional category, the number of health-care workers observed in each category during each session must be specified. This is done by inserting a vertical mark (I) in the item “No" each time a new health-care worker in the category is observed
– Where data is classified by health-care worker, a maximum of four can be included in the same form
– Several health-care workers may be observed at the same time (when they are working with the same patient or in the same room). Nevertheless, it is not advisable to simultaneously observe more than three health-care workers; in Intensive Care Units, it is recommended to observe only 1–2 health-care workers at once
Recording the information: the grid of the Observation Form (2)
Each row of the column corresponds to an opportunity where the indications (the 5 indications recommended by WHO) and actions (hand hygiene) observed are entered
means that no item is exclusive (if several indications apply to
the opportunity, they should all be marked)
means that the action (hand hygiene) was missed
Recording the information: summary of the Observation Form
Determining the time and scope of the observation: – Period: the time window during which compliance is measured in a
certain setting – Session: the time when the observation takes place in a precise
setting (ward); it is numbered and timed (start and end times) in order to calculate its duration. It should last 20 minutes (+10 min)
■ Setting: institution-wide, department, service, ward sectors ■ Professional category: observed health-care workers are classified according to four
main professional categories ■Number of opportunities: sample size should be sufficient to undertake stratification
and compare results from different periods in the same setting ■ Indications: all 5 indications or selected ones only ■ Action: hand hygiene action performed (handrubbing or handwashing) or missed
Donning gloves Change napkin Remove gloves Settle pt To Bed 2 …
… Donning gloves Change napkin Remove gloves Settle pt To counter
BEF-PAT AFT-BFL AFT-PAT
BEF-PAT
AFT-BFL AFT-PAT
BED 1 PATIENT SURROUNDINGS
BED 2 PATIENT SURROUNDINGS
Example
Napkin Changing
Take blood pressure Prop up pt To Bed 2 patient …
… Take blood pressure Give a cup of water to pt To Bed 4 pt …
BEF-PAT AFT-PAT
BEF-PAT
AFT-PAT
BED 1 PATIENT SURROUNDINGS
BED 2 PATIENT SURROUNDINGS
Example
Take vital signs
Don gloves insert film case X-Ray Take out film settle patient remove glove
insert film case take X-Ray Take out film settle patient remove glove
BEF-PAT AFT-PAT
BEF-PAT AFT-BFL AFT-PAT
PATIENT SURROUNDINGS
PATIENT SURROUNDINGS
Example
Portable X-Ray
with assistant
BEF-PAT
No assistant
From Ontario Just Clean Your Hands Program
The science behind Just clean your hands presentation
Patient Zone
Possible cross contamination between Patient A and Patient B
Two Zones
•The Patient Zone:
•The patient’s immediate surroundings
•The patient &
Two Critical Sites
•Clean site
•Body fluid site
•The Healthcare Zone •The Healthcare Zone
Patient Zone
• Assumptions
– Patient flora rapidly contaminates entire patient zone
– Patient zone is cleaned between patients
Critical sites
• Clean sites
– Have to be protected against microorganisms
• Body fluid sites
– Lead to hand exposure of body fluids
Moment 1 Before touching a Patient
« My five moments » (1)
This indication is determined by the occurrence of the last contact with the health-care area and the next contact with the patient.
Since the HCW has not left the patient zone and on condition of no other indication for HH, further contact with patient’s skin, clothes and surroundings do not requires any furthermore hand hygiene action
Situations illustrating the contact:
• shaking hand
• taking pulse, blood pressure
• chest auscultation
• abdominal palpation
• helping to move around xxxx3 Reference point BEFORE touching a patient when approaching her/him
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?
Moment 1 When: Examples:
Touching a patient in any way Shaking hands, Assisting a patient to
move, most Allied health interventions,
Touching any medical device connected to
the patient (e.g. IV pump, IDC)
Any personal care activities Bathing, Dressing, Brushing hair, Putting
on personal aids e.g. 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
When: Examples:
Preparation and administration of oral
medications
Oral medications, Nebulised medications
Oral care and feeding Feeding a patient, Brushing teeth or
dentures
Key Message for Moment 1
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
Example Moment 1
• HCW walks in ,helps patient to sit up, moves over bed table, folds down sheets, moves the chair into position, then assists patient out of bed
• Moment 1-prior to touching the patient
Moment 2 Before a Procedure
« My five moments » (2)
This indication is determined by the occurrence of the last contact with any surface in the health-care area or in the patient zone, and any procedure involving any direct and indirect contact with mucous membranes, non-intact skin or an invasive medical device.
Reference point: IMMEDIATELY BEFORE a contact with a critical site with infectious risk for the patient
Situations associated with an aseptic task:
• drawing blood sample
• opening a vascular line
• endotracheal suctionning
• oro-dental care
• rectal examination
• eye drop instillation
• wound dressing
• preparing food, medication xxxx4
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 tube 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
Key Message for Moment 2
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
Example: Moment 2
HCW replaces an empty IV fluid bag with a new IV fluid bag
• Moment 2 – prior to disconnecting the IV line
Key points on clean/aseptic procedure
Clean/ aseptic procedure
Refers to the medical asepsis definition
= no pathogen introduced into the body during the procedure
≠ sterile condition or sterile body site
xxx5
Moment 3 After a Procedure or 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
Body Fluid Exposure Risk
« My five moments » (3)
This indication is determined by the occurrence of contact (even if minimal and not clearly visible) with blood or another body fluid and the next contact with any surface, including the patient, the patient surroundings or the health-care area
Reference point: IMMEDIATELY AFTER the task involving exposure risk to body
fluids has ended
Situations associated to a potential or effective exposure to a body fluid :
• drawing blood sample
• oro-dental care
• vaginal examination
• removing a wound dress
• manipulating fluid sample
• clearing excreta
• cleaning soiled material and areas xxx6
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
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
Key Message for Moment 3
Hand Hygiene immediately after a procedure or a body fluid exposure risk
– As hands are likely to be contaminated with body fluid
Example: Moment 3
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: Moment 3
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
« My five moments » (4)
This indication is determined by the occurrence of the last contact with intact skin or the patient’s clothing or a surface in the patient’s surroundings (following contact with the patient), and the next contact with a surface in the health-care area
Situations illustrating the contact:
• shaking hand
• taking pulse, blood pressure
• chest auscultation
• abdominal palpation
• helping to move around xxxx7 Reference point: AFTER
having touched the patient, when
leaving the patient’s side Situations containing the indication “before touching a patient contact” will contain the indication “after touching a patient” necessarily
Key Message for Moment 4
Hand Hygiene after touching a patient
– This completes the basic message of Hand Hygiene before you enter the patient room, and before you leave the patient room
Example: Moment 4
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
« My five moments » (5)
The indication occurs between the last contact with the patient surroundings, without having touch the patient, and any contact with a surface in healthcare environement without having touched the patient
Reference point: AFTER touching any object or furniture when
leaving the patient surroundings Situations illustrating the limited contact with inanimates:
• ajusting perfusion speed
• clearing monitoring alarm
• changing bed linen
• holding a bed rail
• clearing the bedside table
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
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
Key Message for Moment 5
Hand hygiene after touching the patient’s surroundings when the patient has not been touched
Example: Moment 5
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
A HH Moment is only documented when : • The field observer can accurately observe the HCW • Moment that has been completed. • If an auditor is unsure whether the observed HCW
performed HH, then such Moments should not be recorded.
• The only exception is when a HCW is observed to enter a room and go directly to the patient.
A Moment finishes when a HCW: • Moves from one patient to another • Leaves the room on completion of patient
care • Touches the curtain partition in a multi-
patient room • HCW moves from touching a patient to doing
a procedure or vice versa
A Moment can finish in another area outside a patient room if patient care is not yet completed e.g. transporting a bedpan to the pan room
Nurses - 70% Allied health - 20% Dr. - 10
