A multifaceted approach
For health care providers to improve their hand hygiene, clean hands must become part of their workplace culture. The Just Clean Your Hands program was developed to overcome the barriers to proper hand hygiene and improve compliance with hand hygiene best practices in hospitals. The program expanded to include long-term care and retirement homes.
It takes more than a single intervention such as a poster campaign to change hand hygiene behaviour. It takes a multifaceted intervention.
Why should hand hygiene be a priority?
Because it's the right thing to do. Proper hand hygiene will protect patients and providers, reduce the spread of infections and the costs associated with treating infections, reduce hospital lengths of stay and readmissions, reduce wait times, and prevent deaths.
Health care-associated infections are a real and growing safety problem:
- In Canada, about 250,000 people or one out of every nine patients admitted to hospital each year -- pick up infections while being treated for something else.
- Every year, more than 8,000 patients die from those infections.
- Antibiotic resistant organisms add $40 to $52 million to the annual direct and indirect costs of providing care.
- The average cost of managing a patient infected with methicillin-resistant Staphylococcus aureus (MRSA) has increased from $14,360 in 1997 to $25,661 in 2007.
- The incremental cost to prevent a case of health care-associated infection is less than $20 per patient.
- Proper hand hygiene - the use of alcohol-based hand rub or soap and water by health care providers to clean their hands is one of the most effective ways of preventing health care-associated infections
- Most health care settings report less than 50 per cent adherence to hand hygiene and compliance among Ontario health care providers is estimated to be less than 32 per cent.
- Under the proposed new standards for infection prevention and control developed by Canadian Council on Health Services Accreditation (March 2007), hospitals are required to monitor infection rates and participate in hand hygiene initiatives in order to maintain their accreditation.
In March 2006, Ontario began its effort to find out why health care provider hand hygiene compliance was so low. We invited provincial, national and international experts to a two-day workshop to share their experiences and expertise.
Here’s what we learned about making hand hygiene a priority.
- There is a gap between health care providers’ perception of their hand hygiene practices and their actual practice. Health care providers don’t clean their hands as often or as thoroughly as they think they do.
- Leadership and a hospital-wide commitment to hand hygiene – with visible role models – is key to success.
- Hand hygiene compliance rates improved steadily over the duration of the pilot project. By using a multifaceted program, it is possible to create a culture and environment that promotes hand hygiene, and to significantly improve health care providers’ hand hygiene practices.
- Education is essential to teach “when and how” to do appropriate hand hygiene in health care settings – which is different from personal hand hygiene.
- Alcohol-based hand rub is more convenient, faster and healthier for health care providers’ hands than soap and water. The type, quality, user input, availability and location of alcohol hand rub has a direct impact on hand hygiene practices.
- Visual reminders at point of care reinforce the importance of hand hygiene and lead to better adherence to best practices.
- Hand hygiene is not just an issue for those providing direct patient care; it involves everyone who works in or provides support for patient care areas in the hospital.
- Patients are more confident about their care when a hospital has a hand hygiene program. Patients should be engaged in hand hygiene in a way that does not transfer responsibility from health care providers to patients or visitors.
- Ongoing promotion and measurement (observational audits) of hand hygiene practices, using a valid tool and timely feedback, are key to continuous quality improvement.
The pilot approach
There were two phases to the pilot project. In December 2006, the Ontario Ministry of Health and Long-Term Care began a three-month preparation phase to prepare 10 hospital sites for testing its Hand Hygiene Improvement Program. This was followed by a six-month test phase that began in March 2007 and concluded in August 2007.
The purpose of the pilot was to evaluate the implementation process and the effectiveness of the program in changing the hand hygiene behaviour of health care workers. The program ran in two to three units (approximately 80 beds) in 10 test hospitals. The hospitals were selected from over 50 applications.
Third party evaluation
The pilot was evaluated to assess its implementation and effectiveness, and to identify ways of improving the program prior to its wider implementation. The primary evaluation methods included:
- Surveys of patients and health care providers
- Focus groups with health care providers
- Interviews with key informants
- Review of hospital records related to product use and infection rates
- Three observational audits of health care providers hand hygiene compliance, made by trained observers using a validated tool. Measures were taken at baseline prior to implementation of the program at interim (two months after launch), and at final (five months after launch).
Additional evaluation methods:
- Each hospital received two site visits from the ministry during the pilot
- On site project coordinators provided daily logs
- Minutes of hand hygiene meetings
Hospitals in the pilot
The following hospitals were selected from over 50 applications to participate in the pilot study.
Kirkland and District Hospital
Lake of the Woods District Hospital
London Health Sciences Centre
Niagara Health System
Quinte Health Care
South Lake Regional Health Centre
St. Thomas Elgin General Hospital
The Ottawa Hospital
Toronto Rehabilitation Institute
University Health Network
A Quick Guide to Just Clean Your Hands [PDF]
Third Party Evaluation Report [PDF]
Globally, the World Health Organization challenged countries around the world to improve practices and reduce health care associated infections through its Global Patient Safety Challenge entitled "Clean Care is Safer Care".
This program aims to:
- raise awareness of the impact of health care-associated infections
- build commitment from countries to give priority to reducing health care-associated infections
- test the implementation of the newly developed WHO Guidelines on Hand Hygiene in Health Care (advanced draft).
Find out what other countries are doing to improve hand hygiene
National Patient Safety Agency
World Health Organization
In October 2006, Canada pledged support for this international challenge during the second annual Canadian Patient Safety Week, a national campaign to raise awareness of patient safety. Hand hygiene was the theme for the 2006 celebrations with the focus on communicating the importance of hand hygiene as a means of reducing infections in healthcare settings.
For more information