Hand Hygiene Observations and Compliance in the Operative Setting

Background: Northwestern Memorial Hospital is an 854 bed academic medical center in Chicago with three surgical pavilions  with 56 operating rooms performing over 36,0000 surgical procedures annually. A hand hygiene (HH) initiative began in 2007 and extended to include Surgical Services (SS) areas in 2009.

Objective: To implement HH education and compliance monitoring in SS areas to mirror efforts in other inpatient settings.

Methods: First, preliminary HH data were collected through direct observation in the operating room, pre and post-operative areas. The audits did not include surgical scrub. Education detailing HH compliance indications and a HH audit tool were created through meetings and with feedback from area managers, anesthesia and nursing. The indications and audits were revised and refined to only include entry and exit of the patient’s care space and before and after contact with the patient, which were the same expectations on the inpatient units. These were then shared with SS staff, including physicians, during departmental meetings and via e-mail.  A physician champion was identified. Additional alcohol hand gel dispensers were installed due to recognition of lack of adequate numbers. HH signage was placed on the OR doors and outside patient bays in the pre and post-operative areas.  Auditors were identified and trained by Infection Control personnel; inter-rater reliability was validated. Ten weekly audits per area are required from each auditor. Compliance data is stratified by location and job type to include nurses, physicians and ancillary staff.  After data collection and review, ongoing monthly compliance results are shared with all SS staff.

Results: Prior to project implementation, 366 baseline HH observations collected by multiple auditors in three SS areas revealed a compliance of 65%. The main reasons for noncompliance were lack of knowledge of HH expectations, unawareness of what indications were audited and availability of product. After education and addition of alcohol hand gel dispensers, the compliance rate improved to 80% with 624 observations in ten SS areas. Rates increased dramatically in December 2009 as there was increased focus and education in Labor and Delivery. Data stratified by job type allows specific intervention with groups that have the lowest compliance. The project continues with weekly audits, monthly compliance reporting and education to all staff.

Conclusions: Intensive education and timely data sharing with stakeholders significantly improved HH compliance in SS. A multi-disciplinary approach, identification of physician champions and standardization of hand hygiene indications attribute to improved practices. Installation of additional dispensers helped with accessibility of products and HH signage served as a reminder.  Continual engagement of staff, education of newcomers and consistent monitoring and feedback all contribute to a successful hand hygiene program.