Ambulatory Surgery Centers Hand Hygiene: Quest for Consistency

Background:  

Centers for Medicare and Medicaid Services (CMS) issued a 16-page surveyor tool to inspect infection control practices in Ambulatory Surgery Centers (ASCs) (Centers for Medicaid & Medicare Services (CMS), 2009). Barriers have been observed that limit healthcare workers (HCW) compliance with hand hygiene (HH) practices:

• knowledge of guidelines for HH
• recognition of HH opportunities
• acknowledgement of gaps in individual practice

Objective:  

Create detailed observation guidelines and tool for the 5 Moments of HH.  Educate HCWs on the HH observation criteria.  Establish standardization and consistency among all participating ASCs. Use Hawthorne effect to increase awareness of HH expectations.

Methods:  

This study collected observational data on HCW HH within four ASCs.   2010 HH observation guidelines, tool, and education were created using existing compliance percentages, feedback from staff members, and the monograph for Measuring HH Adherence (The Joint Commission (TJC), 2009). The convenience sample comprised non-randomly selected HCW from four ASCs.  Each ASC collected facility-specific HH observations during daily work activities. Compliance was determined using “2009 HH Observation Guidelines” until the “2010 HH Observation Guidelines” were implemented in January.  Facility HH compliance percentages and number of observations by area were calculated.

 

1. Calculation:

HH Compliance = # of compliant HH actions/Total # of  HH observations X 100

Results:  

Four ASC facilities collected observational HH data over an 21-month period.  HH Compliance (Graph 1); Compliance in HH among ASC HCW increased steadily over the 21 month observational time period.  After the implementation of the 2010 HH Observation Guidelines, HH compliance was more consistent.

 

Graph 1. 21 month comparison of 4 ASC HH Compliance

Conclusions:  

Four ASC facilities collected observational HH data over an 21-month period.  HH Compliance (Graph 1); Compliance in HH among ASC HCW increased steadily over the 21 month observational time period.  After the implementation of the 2010 HH Observation Guidelines, HH compliance was more consistent.

 

Graph 1. 21 month comparison of 4 ASC HH Compliance

References:

Centers for Medicare & Medicaid Services. (2009). State Operations Manual (SOM) appendix L, Ambulatory Surgical Centers (ASC) comprehensive revision: Retrieved fromhttps://www.cms.gov/SurveyCertificationGenInfo/downloads/SCLetter09_37.pdf.

The Joint Commission. (2009). Measuring Hand Hygiene Adherence: Overcoming the Challenges. Oakbrook Terrace, Illinois: Retrieved from http://www.jointcommission.org/NR/rdonlyres/68B9CB2F-789F-49DB-9E3F-2FB387666BCC/0/hh_monograph.pdf.