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Volume 10, 2010

So what’s the best way to get people to learn about infection prevention and control practices? Or more appropriately, will knowledge of these practices, guidelines, expectations, etc translate into modified behaviour, and thence to reduced infection rates? Good questions all, and questions over which people have been agonizing since the time of Semmelweis, Lister, and others. Will health-care professionals respond better to voluntary training and passive promotion, or is making in-fection control training mandatory the better way. This question was addressed a fascinating article in the Canadian Journal of Infectious Diseases & Medical Microbiology (Vol 20, No 1, Spring 2009) where the authors sought to evaluate the impact of a making an on-line training program in infec-tion control mandatory.

“It is not known whether the objective of improving infection control, occupational health and safety climate in the hospital environment would be better served by requiring all health professionals to suc-cessfully complete a course in infection control as opposed to encourag-ing them to do so. Therefore, the objective of the present study was to compare the perception of safety culture and intention to comply with infection control guidelines in health professionals who were required by their supervisors to take an online learning course, and those who did so voluntarily, based on having seen promotional material.”

The study was undertaken with all health care professionals within an urban health region - who were working in acute, rehabilitation, resi-dential, community and pediatric facilities – all of whom had taken the 30 minute on-line infection control course. Some were mandated to take the course as a supervisor requirement, others did so volun-tarily, having been exposed to promotional posters, pay cheque in-serts, word of mouth, etc. No other concurrent standardized infection control course was offered within the health region, although the in-fection control program provided in-services regularly.

The authors - Annalee Yassi, Elizabeth Bryce, Deirdre Maultsaid, Helen Novak Lauscher, and Kun Zhao, all of Vancouver – conclude that re-quiring that health professionals complete a 30 min interactive on-line infection control module generates a higher intention to comply with infection control guidelines compared with those who volun-tarily access this material. Moreover they recommend that training of this sort should be an important requirement for all healthcare workers.

It’s an interesting and revealing study, and well worth the time to read and discuss. If we extrapolate that to larger society, just imagine the impact on community-based infectious disease if all workplaces required, as a component of workplace health and safety, that their employees undergo a brief training in socially recognizable infection prevention activities. Imagine …

Impact of Mandatory Online Training on Intentions to Comply With Infection Control GuidelinesDavid Green, Deb Canada

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It’s often said that two heads are better then one. An idea is converted into a project or major initiative and solutions to roadblocks are found. So ask yourself what would happen if several national organizations with many committed individuals partner to support patient safety initiatives. That is exactly what CHICA-Canada, the Canadian Patient Safety Institute (CPSI) and Accreditation Canada are doing. They are part-nering to support the efforts of health care organiza-tions across Canada to maximize their hand hygiene programs and increase patient safety.

Each year in Canada, 8,000 to 12,000 patients die as a result of complications of healthcare-associated in-fections. Through the simple act of practicing optimal hand hygiene, healthcare facilities can reduce that number by half and prevent the spread of healthcare related infections to our patients who have entrusted us with their health and well-being.

CHICA-Canada, CPSI and Accreditation Canada each bring a differ-ent perspective to the initiative but we share a common goal and

that is to ensure that Canadians receive the safest healthcare they can. On April 14th, 2010 the leaders of each of the organizations announced at the CPSI National Conference that the first ever national Stop! Clean Your Hands Day would take place on May 5, 2010. This national event will coincide with a global initiative of the World Health Organization’s: Save Lives, Clean Your Hands Day. Tools and resources are available to assist organizations in promoting optimal hand hygiene practices in organizations are avail-able on the CPSI and CHICA- Canada websites. This is a complementary initiative to the Ontario Just Clean Your Hands campaign.

CHICA-Canada is proud to be a part of this initiative. It is grounded on the extraordinary work of the WHO and dedicated hand hygiene experts from around the

world whose research has helped us to understand how to support optimal hand hygiene. We know that if healthcare providers are pro-vided with the tools to enable them to use the right technique in the right way, at the right place, and at the right time that all Canadians will benefit.

Building Partnerships- Enhancing Patient SafetyAnne Bialachowski, President, CHICA-Canada, www.chica.org

Perceptions, Attitudes, and Behaviour Towards Patient Hand HygieneEmma Burnett, MSc, PGCert, BN, SPQ, RGNUniversity of Dundee, School of Nursing and Mid-wifery, United Kingdom

We all know that healthcare associated infection remains one of the world’s leading causes of morbidity and mortality. The importance of hand hygiene has been recognized for centuries, from the early work of Oliver Wendell Holmes in 1843 and Dr Ignaz Semmelweis in 1847. Over the past few decades, research continues to demonstrate that healthcare environments provide a major reservoir for pathogenic micro-organisms. Hand contact surfaces such as patient clothing, patient associated equipment and furniture, such as beds, tables, lockers and curtains, shared and used between individuals can eas-

ily become contaminated with blood, other bodily fluids, secretions and excretions. Outbreaks of pathogenic micro organisms such as MRSA and Clostridium difficile yield extensive contamination in single rooms, ward areas and bathrooms.

Evidence shows that patient’s hands are at risk of frequent contami-nation via direct contact and from the environment and healthcare equipment and failing to carry out effective hand hygiene practices can result in the development of infection and further transmission of pathogenic micro organisms. While there is a plethora of research exploring hand hygiene practices of healthcare workers, little atten-tion has been paid to patient hand hygiene. Patient safety predomi-nantly lies in the hands of healthcare workers, especially in terms of patient hand hygiene. Many patients are unable, for various reasons, to carry out their own hand hygiene, therefore whether or not they are encouraged and assisted to do so is often determined by the perceptions, attitudes and behaviour of healthcare workers. Despite continuing research, development of policies and the implementa-tion of intervention strategies, the unrelenting rise in the incidence of healthcare associated infection indicates that significant links in the chain of infection have been neglected. It could therefore be argued

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that patient hand hygiene practices may indeed be one of those neglected links.

This study employed a de-scriptive, cross-sectional survey using questionnaires to explore perceptions, at-titudes and self reported behaviour of clinical ward nurses towards patient hand hygiene. It also gained fur-ther understanding of why nurses behave the way they do towards patient hand hygiene. (American Journal of Infection Control, October 2009). A questionnaire was developed from previously validated questionnaires of other published studies, consisting of 4 main sections (participant characteristics and demographics; perceptions towards patient hand hygiene; attitudes towards patient hand hygiene and behaviour to-wards patient hand hygiene). A final open-ended question also asked participants to suggest how patient hand hygiene practices could be improved. In total, 444 clinical nurses participated in the study, which provided a wide variety of characteristics such as age, grade, clinical speciality, experience and education and training received.

It was found that the majority of nurses had good perceptions of patient hand hygiene and felt that this task was an important part of preventing and controlling healthcare associated infection. They also believed that poor patient hand hygiene could contribute to the acquisition and transmission of healthcare associated infection. Fur-thermore, the majority of nurses displayed very positive attitudes to-wards patient hand hygiene, which reinforced the value of their per-ceptions. Despite this however, nurses reported that they frequently failed to encourage and provide patients with facilities in order to decontaminate their hands. This was especially so after visiting the toilet and prior to meal times. Statistically significant predictors of behaviour included age, grade of staff and infection prevention and control training received. Nurses aged 56 years and over displayed the most positive perceptions and attitudes. However, nurses of 26 years and under reported better behaviour. Highest qualified nurses were also significantly more likely to demonstrate positive behav-iour, with those who were unqualified least likely. Nurses who had received local infection prevention and control training were statisti-cally more likely to demonstrate positive behaviour towards patient hand hygiene.

The statistical model within this study accounted for only 10% of the variation in self reported behaviour, which confirmed that 90% of the variability was accounted for by other variables. It found that significant predictors of behaviour were percep-tions, attitudes, gender, age, qualification level and local infection prevention and control training received. The qualitative data gener-ated from the final question may provide some indica-tion as to further predictors of behaviour, which included both individual and organi-sational factors. One of the

main suggestions was the provision of better hand hygiene facili-ties such as ‘nicer soap’, ‘softer hand towels’, ‘patient hand wipes’ and ‘more sinks’. A large proportion of nurses also suggested providing better infection prevention and control education, and others felt it was necessary to employ more nurses to allow them time to assist patients with hand hygiene.

This study not only identified that patient hand hygiene is funda-mental in the prevention and control of healthcare associated infec-tion but gained further understanding as to why practices are poor. It supported other research findings in that human behaviour is ex-tremely complex in nature, and is the consequence of multiple in-terdependent influences from biology, the environment, education and culture. It reinforced the need to gain further understanding of why people behaviour in a particular way in relation to patient hand hygiene and demonstrated the variety of issues that require consid-eration when developing and implementing infection control inter-vention strategies in order to achieve a sustainable, positive behav-ioural change.

By allowing themselves to be put in the hands of the healthcare professionals, patients rely and trust them to manage risks for them, make good decisions and protect them from harm. This trust has the potential to be undermined if patients are not protected. By investi-gating patient hand hygiene from clinical ward nurses perspectives, it identified gaps in current practice and should allow healthcare pro-fessionals to utilise these findings, evaluate current practice and take necessary action in a bid to address increasing incidences of health-care associated infection.

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Health care associated infections (HAIs) can have a significant impact on the health of residents in long-term care facilities and their overall quality of life.

A recent study at Sunnybrook Health Sciences Centre, Long-Term Care, in Toronto demonstrated the higher the hand hygiene compliance rate the low-er the norovirus attack rate - meaning fewer people with diarrhea or vomit-ing.

Hand hygiene is universally accepted as the single most important way to prevent the spread of infections and outbreaks – while reducing the need for expensive, time consuming precautions.

The Just Clean Your Hands program was created by the Ministry of Health and Long-Term Care (MOHLTC) to help hospitals overcome the barriers to proper hand hygiene and improve compliance. An ef-fective hand hygiene program can reduce the burden of illness and associated costs in long-term care homes.

Transmission of OrganismsIn an average day, caregivers and healthcare workers do a range of tasks with many residents and patients. Simple tasks like helping a resident become more comfortable in bed can result in thousands of microorganisms being transferred onto the hands of the caregiver. Without a proper hand hygiene protocol – those microorganisms canbe easily transferred from one resident to another.

Hand hygiene works and it works differently dependent on the method used. Alcohol based hand rubs with at least 70-90% alcohol, kills organisms in seconds and is the preferred method when hands are not visibly soiled. Additionally, soap and water with friction will remove these organisms and wash them down the drain.

Four Moments of Hand HygieneIn the resident’s environment, where care is taking place – the essen-tial indications of hand hygiene can be simplified into 4 moments:

1. BEFORE initial resident / resident environment contact

2. BEFORE aseptic procedures3. AFTER body fluid exposure risk4. AFTER resident / resident environ-

ment contact.

In long term care homes, residents gather for shared or group activi-ties, such as meal time and social ac-tivities. It is recommended thatresi-dents, staff, volunteers and family members clean their hands before and after these group activities to re-duce the spread of micro organisms.

So what’s the bottom line? Simply put, “Improving hand hygiene compliance saves lives.” In fact, an increase of hand hygiene ad-herence of only 20% can result in a 40% reduction in the rate of healthcare associated infections.

The MOHLTC Just Clean Your Hands program contains all the nec-essary tools to help improve hand hygiene and compliance includ-ing a step-by-step implementation guide, training and education materials. For more information on the Just Clean Your Hands Pro-gram for Long Term Care, visit the Ontario Ministry of Health and Long Term Care website at www.health.gov.on.ca

To learn more about Deb Canada’s healthcare skin safetyprogram and products, please visit www.debgroup.com

Just Clean Your HandsFor Long-Term Care Homes