Questions and Answers

• What is hand hygiene?
• Why are hand hygiene rates being publicly reported?
• When should health care providers be cleaning their hands?
• Which moments of hand hygiene will be publicly reported?
• How are hand hygiene rates calculated?
• Why is the Ministry reporting hand hygiene rates annually and not monthly or quarterly?
• Do multi-site hospitals report hand hygiene compliance rates by corporation or by site?
• What will the health care system do with the rate information?
• How many observations are hospitals required to capture?
• Is there a specific time when the observations should be made?
• What are the elements of a hand hygiene program?

Hand hygiene is the action of cleaning hands. There are two ways to clean hands. Using an alcohol based hand rub which kills organisms in seconds or, when hands are visibly soiled, using soap and running water.

The single most common way of transferring health care-associated infections (HAIs) in a health care setting is on the hands of health care providers. Health care providers move from patient to patient and room to room while providing care and working in the patient environment. This movement provides many opportunities for the transmission of organisms on hands that can cause infections. Monitoring hand hygiene practices is vital to improving rates and, in turn, reducing HAIs.

There are four essential moments for hand hygiene :

• Before initial patient or patient environment contact
• Before aseptic procedure*
• After bodily fluid exposure risk
• After patient or patient environment contact

*An aseptic procedure could include: a) touching/manipulating a body site that should be protected against infections (e.g., wound care including dressing change and wound assessment); b) manipulating an invasive device that could result in infection of a body area (e.g. priming intravenous infusion set, inserting spike into opening of IV bag, flushing line, adjusting intravenous site, administering medication through IV port, changing IV tubing)

The Ministry of Health and Long-Term Care (MOHLTC) will be reporting two of the moments : before initial contact with the patient/patient’s environment (moment 1) and after contact with the patient/patient’s environment (moment 4). The reason the Ministry is not reporting moments 2 and 3 (before aseptic procedures and after body fluid exposure risk) is because they occur much less commonly than moments 1 and 4 and because it is relatively difficult to observe enough of them to ensure a statistically valid sample size.

The Ministry will report the above data as of April 30, 2009 on its Patient Safety website and this data will be refreshed annually.

Before Initial Patient/Patient Environment Contact :

After Patient/Patient Environment Contact :

Hand hygiene rates will be reported annually because behavioural and cultural change takes time. Therefore reporting hand hygiene rates more regularly than annually may not produce results that will indicate significant change or an impact on hand hygiene practices.

Hospitals that have multiple sites should be measuring, collecting, and reporting data for each site rather than providing an overall average for the corporation, as the rate can vary widely between sites. The MOHLTC website will report on hospitals by individual site.

Like the public reporting of other indicators, monitoring hand hygiene compliance rate is about overall performance improvement. The information gathered will assist hospitals in evaluating the effectiveness of their infection prevention and control interventions and make further improvements based on this information.

To ensure that the data is statistically valid, a hospital with 100 beds should complete at least 200 observations opportunities for hand hygiene. The minimum number of observation opportunities is 50 for any hospital that has 25 beds or less. The maximum number of hand hygiene observed opportunities will be a factor of the number of inpatient beds the facility has (i.e., 300 beds requires at least 600 observed hand hygiene opportunities).

Observed opportunities should be captured with observation sessions that vary across time (i.e. day of the week and time of day) and place (i.e. ward/unit) within the hospital.

The audits or observation sessions should take place over varying shifts, units, and days to more accurately capture what is happening within the facility.

An effective hand hygiene program is a multi-faceted approach and includes:

• Environmental changes and system supports – like alcohol-based hand rub at the point of care, which makes it easy for health care providers to clean their hands at the right time, and hand care programs;
• Education for health care providers about when and how to clean hands;
• Senior management support and commitment to make hand hygiene an organizational priority;
• Patient engagement;
• Opinion leaders and champions modeling the right behaviour; and
• Ongoing monitoring and observation of hand hygiene practices, with feedback to health care providers.