NUR 3220 Module 2 Infection Prevention Paper: Hand Hygiene Compliance and the Five Moments Example

Forty Percent of the Time: Hand Hygiene on a New Brunswick Medical Unit and What the Evidence Says Would Help

Student Name

B.S.N., Accelerated Second Degree, Thomas Edison State University

NUR-3220: Fundamentals of Nursing

Mentor Name

Month Day, Year

Forty Percent of the Time: Hand Hygiene on a New Brunswick Medical Unit and What the Evidence Says Would Help

Why Hand Hygiene

The unit, the staff and the observations in this paper are invented. Hospital-acquired infections harm patients and add days to hospital stays, and staff hands are one of the main routes by which germs pass between patients. Hand hygiene is the simplest measure against this spread, and also one of the most often skipped. During a clinical rotation on a medical unit at a hospital in New Brunswick, a BSN student was asked by her instructor to observe hand hygiene for two hours, using a structured tool, and to write about what she found.

The Five Moments

International guidelines on hand hygiene in health care (World Health Organization, 2009) describe five moments for cleaning hands. Two come before care, as a nurse approaches the patient and just before a clean or aseptic procedure. Three come after: once body fluids may have been touched, once the patient has been touched and once anything in the patient's space has been touched. The guidelines recommend alcohol-based hand rub as the main method in most situations, because it is faster and more effective than soap and water against most organisms and can be placed at the point of care, and soap and water when hands are visibly dirty or after caring for a patient with an organism alcohol does not kill reliably, Clostridioides difficile being the usual example.

The five moments give observers a way to count opportunities and to see which moments are missed most often.

How Often It Happens

Erasmus et al. (2010) systematically reviewed 96 studies of hand hygiene compliance in hospitals. Median compliance was about 40 percent. Intensive care units did worse than other wards, physicians did worse than nurses, and staff cleaned their hands less often on the way in to a patient than on the way out. The authors noted that health care workers seemed more likely to clean their hands to protect themselves, after contact, than to protect patients, before contact.

What a Program Can Do

Pittet et al. (2000) reported on a campaign across the whole of Geneva's university hospitals that combined promotion of bedside alcohol hand rub, posters, feedback of compliance results to staff and support from hospital leaders. In three years, the observed rate of hand hygiene climbed to 66 percent from 48. During those years, the share of patients with an infection caught in the hospital dropped to 9.9 percent, down from 16.9, and the transmission of methicillin-resistant Staphylococcus aureus declined. The study was not randomized, but it showed that a multimodal program could change behavior and was followed by fewer infections.

What the Student Observed

Over two hours, the student observed 62 hand hygiene opportunities involving nurses, patient care technicians, physicians and a phlebotomist. Hand hygiene was performed at 27 of them, about 44 percent. Compliance after touching a patient was 61 percent, but before touching a patient it was 30 percent. Moments after touching the surroundings, such as adjusting an IV pump or bed rail, were most often missed. Staff more often cleaned hands when leaving a room than when entering. Two of the six alcohol rub dispensers in the hallway were empty, and in four rooms the dispenser was inside the door, out of view from the bedside.

Why Moments Were Missed

The student talked briefly with two nurses and a technician afterward. They described rushing between call lights, carrying supplies into rooms with full hands and believing that gloves made hand hygiene unnecessary. One nurse said that alcohol rub dried and cracked her hands, so she avoided it.

Proposed Improvements

The student proposed five changes based on the Geneva program and the WHO guidelines. First, check and refill dispensers each shift and move in-room dispensers to where staff can reach them on the way to the bed. Second, teach staff that gloves do not replace hand hygiene and that hands should be cleaned before putting gloves on and after taking them off. Third, offer a hand rub with moisturizers and supply hand cream, since skin damage reduces compliance. Fourth, share monthly compliance results with the unit by moment, so staff can see where they miss most. Fifth, ask the nurse manager and a physician leader to model and remind, since leadership was part of the Geneva program.

Sharing the Findings

With her instructor's guidance, the student presented her findings at the unit's monthly staff meeting, without naming anyone. She showed compliance by moment rather than a single number, which surprised staff who had assumed they missed hand hygiene mostly on the way out of rooms. The nurse manager agreed to a trial of moving dispensers in four rooms and asked the environmental services supervisor to add dispenser checks to the shift routine. Two nurses volunteered to observe a sample of opportunities each month and post the results by the time clock. The infection preventionist offered to bring the moisturizing hand rub the hospital already stocked on another unit.

The Student's Own Practice

Observing others made the student watch her own hands. She noticed that she cleaned her hands reliably when entering a room but sometimes forgot after touching the bed rail before writing on a chart. She began cleaning her hands each time she moved from the patient zone to a computer.

Patients as Partners

The student also considered the patient's role. Some hospitals invite patients to ask staff whether they have cleaned their hands, but patients often feel uncomfortable doing so. The student suggested a small sign in each room that thanks staff for cleaning their hands, which makes the expectation visible without asking frail patients to confront their caregivers.

Limits

Two hours is a small sample, and people who know they are observed tend to behave better. Observations by one student may be less reliable than those of a trained observer. The Geneva study was not a trial, so other changes during the same years may have contributed to fewer infections.

Conclusion

Compliance on the unit was close to the median found in the systematic review and lowest before patient contact. The five moments gave a framework for observing, and the Geneva program showed that a combination of access, education, feedback and leadership can raise compliance and is followed by fewer infections. The student's proposals target the reasons staff gave for missing moments.

References

Erasmus, V., Daha, T. J., Brug, H., Richardus, J. H., Behrendt, M. D., Vos, M. C., & van Beeck, E. F. (2010). Systematic review of studies on compliance with hand hygiene guidelines in hospital care. Infection Control & Hospital Epidemiology, 31(3), 283-294. https://doi.org/10.1086/650451

Pittet, D., Hugonnet, S., Harbarth, S., Mourouga, P., Sauvan, V., Touveneau, S., & Perneger, T. V. (2000). Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet, 356(9238), 1307-1312. https://doi.org/10.1016/S0140-6736(00)02814-2

World Health Organization. (2009). WHO guidelines on hand hygiene in health care. World Health Organization.