1000. Hand Hygiene External Observation Program Raises Compliance at a Pediatric Hospital
Session: Poster Abstract Session: Hand Hygiene 2012
Friday, October 19, 2012
Room: SDCC Poster Hall F-H
Background: Hand hygiene is the single most important infection prevention action that healthcare workers (HCWs) can do to prevent the spread of pathogens.  However, it remains a challenge to measure accurately and to improve performance.  Our objective is to describe a rigorous hand hygiene observation program at a 480 bed urban, tertiary care children’s hospital, based upon the World Health Organization’s (WHO) My 5 Moments for Hand Hygiene.

Methods: We designed and implemented a hand hygiene program consisting of observers who underwent rigorous initial and monthly refresher training using materials adapted from the WHO.  Every observer must be 100% concordant with the trainer on at least 20 observations covering all 5 moments before submitting monthly data.  The minimum number of required observations for each unit was determined by weighting the number of beds and typical acuity of each unit. The monthly expectation for the hospital is greater than 1000 total observations. Data is collected and managed using REDCap electronic data capture survey tool.  Data is exported and analyzed using SAS 9.2.  Strategies to overcome barriers to hand hygiene compliance included education, rapid feedback and institution-wide transparency of data, immediate performance feedback, and institutional culture change.

Results: Over 16 months, we have collected 15,218 hand hygiene observations in 18 inpatient units.  Initial hospital-wide hand hygiene compliance was 84% (range 60% to 100%) and is now 95% (April 2012 range 90% to 100%).  We have demonstrated sustained compliance of ≥95% for the past 3 months. Differences in hand hygiene compliance by provider type persist; in April 2012, physician hand hygiene was 90% as compared to nurse hand hygiene of 96%. 

Conclusion: A rigorous program on hand hygiene observations based upon the WHO’s My 5 Moments for Hand Hygiene can be implemented and can drive significant and sustained improvements in hand hygiene performance.  The long-term sustainability of these achievements will rely upon a culture change across the institution.

Sarah Smathers, MPH, CIC1, Eileen Sherman, MS, CIC1, Catherine Ntabadde, BS1, Julia Szymczak, MA1, Kelly Fischbein, MS1 and Susan Coffin, MD, MPH2, (1)Children's Hospital of Philadelphia, Philadelphia, PA, (2)The Children's Hospital of Philadelphia, Philadelphia, PA


S. Smathers, None

E. Sherman, None

C. Ntabadde, None

J. Szymczak, None

K. Fischbein, None

S. Coffin, None

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