Hand Hygiene - How To For The Inpatient Setting

 

 

 

 

 

• Paper hand hygiene form 
• Systemwide Inpatient Hand Hygiene Program Staff Education Presentation 
• Hand Hygiene Policy 
• Ambulatory Patient Feedback Hand Hygiene Monitoring Education
• Single Point and Facility Contact Info

 

Record observations

Click on the frog or this link to get started:  https://carilion.ca1.qualtrics.com/jfe/form/SV_esQ0pPc74nZZUR

HAND HYGIENE OBSERVATION UPDATE:

The Hand Hygiene committee meets monthly, and we need to alert everyone regarding new patient quality initiatives for 2021 regarding hand hygiene.

In the past, the average number of monthly observed submissions for hand hygiene was 40 observations. With the new 2021 Leap Frog changes, it will be necessary to submit more monthly observations based on your department's average daily census or average monthly procedures.
For Example: 200 hand hygiene observations will be required monthly for many of our departments.

Below is the table from Leapfrog that includes information regarding the exact number of hand hygiene observations your department should be submitting monthly.  If your unit does not currently have a hand hygiene representative, please work on assigning someone.  Hand Hygiene is important for patient safety and quality.

T. (2021, March 8). Summary of Changes to the 2021 Leapfrog Hospital Survey. Retrieved March 29, 2021, from https://www.leapfroggroup.org/sites/default/files/Files/LeapfrogHospitalSurvey_ProposedChanges_2021_FINAL.pdf

Helpful Hand Hygiene Observation Guidelines before completing observations:

1. Complete at least the required number of observations per month per area (see table above). 
2. Observe and record compliance and non-compliance, noting if a reminder was needed and what the response was. 
3. Gently remind all staff who you see may potentially become noncompliant or have been noncompliant. Feel free to use ‘Ribbit’ as a fun way to remind. While you should be professional, (we are all a team and need to work together, especially if we forget things) we expect the response to be professional as well. We want to communicate openly to ensure patient safety initiative and because if you remind someone and they clean their hands, it ultimately counts as compliant for them.  
4. Hand Hygiene compliance is the use soap and water or use of waterless product. 
5. HH opportunities should only be counted if there is no doubt that the individual did or did not perform HH. If the observer’s view is obstructed and the individual may have done HH while out of the observer’s view, the opportunity should not be counted unless you ask them to verify that they did or did not clean their hands. 
6. Observation can be made either going into the patient’s room, coming out of the patient’s room or prior to procedure. HH going into the patient’s room and coming out of the patient’s room will be counted as 2 observations. If only observed going into patient’s room count as one observation.  
7. If you see noncompliance mark ‘no’ for compliance, even if you remind them, but then mark that you reminded them and whether they did or did not clean their hands afterward. If they refuse to clean their hands, please do an event report.  
8. An employee who does HH on the way out of a room and goes immediately into another room does not need to do HH again if they DO NOT touch anything, unless the patient/visitor asks them to.   
9. A good way to get unbiased observations is to choose a room(s) that you can see well and mark anyone who goes into or out of the room during the time that you can watch. You can observe anyone, not just people who work in your area. Be sure to mark where each person works (physicians are marked as physician always, residents as residents, etc. but for others mark their department).  

To be a part of this growing committee where your hands count, please contact: 

• Angela Moore, amslough@carilionclinic.org 
• Bray Studtmann, bknemetzgardner@carilionclinic.org

To order pump hand sanitizer

• Lawson# 1520241
• Product Description
• SNTZR HND 535 mL FM WKCR​

To order pocket size hand sanitizer

• Lawson# 602419​
• Product Description
• Pocket size Ecolab hand sanitizer 1.25 oz bottle of, 60% alcohol

To order pocket size hand lotion

• Lawson# 1520380
• Product Description
• Revitalizing Skin Lotion 4oz