Hand hygiene matters at Sunnybrook

Seeing is believing. Germs can’t readily be seen on hands and surfaces but when hand hygiene is not top-of-mind, hospitals have undoubtedly seen related outbreaks.

“Our goal is to help make the seemingly invisible, proactively ‘visible’ for staff and physicians so that performing proper hand hygiene remains a central and consistent part of everyday practice,” says Dr. Mary Vearncombe, Medical Director, Infection Prevention and Control (IP&C), Sunnybrook Health Sciences Centre.

Sunnybrook is one of the early adopters of the “Four Moments of Hand Hygiene” based on Ontario’s Just Clean Your Hands (JCYH) initiative that began in late 2007.  The hospital is now 91 percent Hand Hygiene compliant, or more than double its rate at the start of this provincial initiative.

Says President and CEO, Dr. Barry McLellan, “Hand Hygiene is a priority at Sunnybrook. Our Infection Prevention and Control team has done a tremendous job in propelling this priority across the organization. Our high rates of good practice are testament to staff and physicians across all disciplines who have literally had a hand in our achievement thus far.”

Hand Hygiene compliance is part of Sunnybrook’s Quality Improvement Plan for 2013/2014, and a Ministry Publicly Reported Safety Indicator for all hospitals.

To facilitate success, Infection Prevention and Control together with Quality and Patient Safety, employ strategies Dr. Vearncombe refers to as “a multi-modal, multidisciplinary approach” in line with the Ontario Just Clean Your Hands toolkit. JCYH recommended strategies include senior management support and program leadership, environmental changes, monitoring and observation, engaging champion and opinion leaders, and education for health care providers.

“Our Hand Hygiene education activities are targeted across all groups and are a frequent and integrated component within, for example, orientation, in-service sessions, on-line modules, and training for students including nurses and physicians,” says Sandra Callery, Director, Infection Prevention and Control, Sunnybrook.

Internal awareness campaigns are another education component. Staff mentors are highlighted, discussing the importance of Hand Hygiene in their specific roles. Another campaign directed to staff physicians, residents, fellows and medical students, features physician champions with their quotes and published evidence related to the efficacy of Hand Hygiene compliance.

All activities are supported with infrastructure and resources to ensure point-of-care placement of alcohol-based hand rub product, and individualized assessments of patient care units and work areas in collaboration with staff. Human factors analysis is also used to better understand workflow, patient type, and types of healthcare professionals within each area.

Another part of the proactively visible strategy, says Dr. Vearncombe, involves recognizing good Hand Hygiene ‘in the moment’. This reinforces what she calls ‘positive deviance’.  While on the units, staff and physicians are routinely audited by Hand Hygiene nurse observers (originally funded through late-career or modified work programs).

“The approach is educational, non-punitive,” Dr. Vearncombe notes.  Observers give immediate and personalized feedback using a report card that highlights areas of good technique and suggested improvements.  For demonstrating excellent Hand Hygiene compliance, staff and physicians at Sunnybrook get uniquely ‘Caught Clean-Handed’ with special recognition stickers.

To gather data consistently, observers use a validated JCYH tool formatted as an input program for laptops. This allows IP&C to provide timely analysis and feedback to units, programs and Sunnybrook senior leadership. IP&C also generates quarterly reports for leadership and the Sunnybrook Board’s Quality Committee.

The IP&C team also conducts Hand Hygiene compliance research and regular literature reviews for the latest strategies. In a 2009 study of an outbreak at Sunnybrook, the team found Hand Hygiene compliance inversely related to infection attack rates, reporting units with higher Hand Hygiene compliance had lower numbers of cases.

“Hand Hygiene matters,” says Dr. Vearncombe, extending Sunnybrook’s tagline of ‘When It Matters Most’.

“At Sunnybrook, Hand Hygiene compliance has become more tangible, achievable and acknowledged, as critically supported by our senior leaders and with the resources and infrastructure to make it all work.”