POSTER - #PI1043

Improving Hand Hygiene in the CTICU: Unconventional Interventions for a Challenging Problem

Stacey Camposagrado RN BSN CCRN
UC DAVIS HEALTH - QUALITY IMPROVEMENT

Background
According to The Centers for Disease Control and Prevention (CDC), hand washing is the single most important procedure for preventing healthcare acquired infections. Up to 80% of all infections are transmitted by touch. 1 in 25 patients a day are affected by a hospital acquired infection. In a 12-hour shift, healthcare workers enter patient's room over 100x a shift.

Purpose
The purpose of this project was to improve the unit's overall hand hygiene compliance. The hospital compliance standard is 93% and pre-intervention our unit's compliance was as low as 82%.

Design & Methods:
After brainstorming, the UBPC decided on four interventions that have not have not been attempted on our unit before.
• Educate bedside RN's how to complete hand hygiene audit form and learn how to perform just in time coaching.
• Increase hand sanitizer replacement par level and educate staff on the process to refill empty dispensers.
• Improve visibility of hand sanitizer dispensers.
• Glow germ demonstration with staff indicating quality of
hand hygiene.
Flashy Signs: (see poster)
Motion Sensor Lights: (see poster)
Glow Germ Demo: (see poster)

Analysis:
Hand Hygiene compliance was measured by using the hospital hand hygiene audit tool and by covert audits. Both of which were done by a variety of auditors.
(see poster)

Results:
For the current fiscal year, the CTICU hand hygiene compliance rate increased from 82% to 90.6%. For the same time period, the average compliance score of 4 other units in the hospital is 86%, which is a gap of 4.6%.

References:
Centers for Disease Control and Prevention, (2015) http://www.cdc.gov/HAI/surveillance/index.html

Conclusions:
Hand Hygiene compliance has improved by nearly 10% after implementing new interventions.

Further Study: What's Next?
• Hand Hygiene compliance survey emailed to staff, and nearly 70% of surveys completed.
• Continue covert audits, rotating out auditors, increase number of auditor to help maintain accuracy and increase the total number of audits.
• Elimination of 5 workstation on wheels (WOW) noted to
be blocking the hand hygiene dispensers with the goal
being increased visibility and accessibility.

Acknowledgements:
Thank you to the CTICU UBPC and leadership for your hard work on this and many other projects with a common goal to improve our unit and patient outcomes.