WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE
all new potential observers in a given setting. It is advisable to
perform validation in each care setting that is to be monitored
by the future observer. The <strong>WHO</strong> Training Film provides visual
examples of the five moments for HCWs and observers.
Observers can be trained and tested through the use of the
scenarios, which include different sequences of health care
where hand hygiene is necessary. Observers are asked to
complete the form while watching the film, and the trainer can
then judge their performance by comparing the results with the
those provided in a slide show presentation that accompanies
the film. The subsequent discussion is usually very valuable
for learning purposes. If a time grid of opportunities can be
established in a scenario, kappa statistics can be calculated to
quantify the level of coincidence between two observers.
1.2.4 Understanding the five moments for hand hygiene
The concept of “My five moments for hand hygiene” has been
created as a robust framework for understanding, training,
measuring, and communicating hand hygiene performance. 1
Understanding this concept (see Part I, Section 21.4) is a
prerequisite for any future observer. It is a simple concept
that should not leave any knowledge gap between the insight
of observers and observed HCWs once they are adequately
trained in hand hygiene. It is essential, however, that local
specificity related to the application of the “five moments”
is established and known by everyone. For example, the
delimitation of the patient zone in a given setting needs to be
specifically determined.
Health-care activity must be imagined as a succession of tasks
during which the HCWs’ hands touch different types of surfaces
prior to and after patient contact. Each contact is a potential
source of contamination for HCW’s’ hands.
A crucial point specific to observations is the distinction
between indications and opportunities, which is more
extensively described in the Hand Hygiene Reference
Technical Manual. The indication is the reason why hand
hygiene is necessary at a given moment to effectively interrupt
microbial transmission during care, and it corresponds to
precise moments in patient care. Very close to the concept
of indication, the term opportunity is much more relevant to
the observer: it determines the need to perform the hand
hygiene action, whether the reason (the indication that leads
to the action) be single or multiple. From the observer point of
view, the opportunity exists whenever one of the indications
for hand hygiene occurs and is observed. Several indications
may arise simultaneously and create a single opportunity. Very
importantly, the opportunity constitutes the denominator for
calculating compliance, i.e. the proportion of times that HCWs
perform hand hygiene action of all observed moments when this
was required.
For this purpose, hand hygiene action is defined as either
rubbing hands with an alcohol-based handrub accepted by
the institution or handwashing with soap and water. Neither the
duration nor other quality aspects of hand hygiene such as the
quantity of product used, glove use, length of fingernails, or the
presence of jewellery are assessed.
It is important to understand that hand hygiene actions not
corresponding to an opportunity, and therefore “additional” and
not required, should not be taken into account by the observer.
1.2.5 Understanding the observation form
Observations are noted on a paper form using a pencil
and rubber. Each form represents a separate observation
session. Experience shows that this material is ergonomic for
observations. The surface of a sheet of paper provides the
necessary overview of the past evolution of observed activity in
several, simultaneously observed HCWs. Using a pencil and an
eraser, errors can easily be corrected.
The form has three main sections: 1) a header contains
information on the institutional level (country, city, hospital,
site identity); 2) a second header contains information on the
session (observer identity, date, start and end time, duration,
period number, session number, form number, department,
service name, ward name); and 3) four columns below the
header represent the sequence of actions for different HCWs
observed during the same session. Each column is usually
dedicated to one HCW and therefore the form can include up
to four HCWs. Alternatively, in situations with low activity, each
column can be dedicated to a different professional category
and therefore the HCWs belonging to the same professional
category can be grouped within one column. This method can
be practical when the observer chooses to observe more than
four HCWs during the same session. This results, however, in a
loss of the possibility to calculate a per person density of hand
hygiene opportunities and individual feedback after the session.
The header of each column contains information about the
observed HCW (professional category, code, number). The rest
of the column consists of equal blocks that are incrementally
numbered from 1 to 8 from top to bottom. Each block
represents one of the sequentially occurring opportunities for
hand hygiene. For each opportunity, the observer notes in the
corresponding block all the applicable indications and if hand
hygiene was executed by handrubbing, handwashing or missed.
1.2.6 Determining the scope of an observation period
Before starting an observation period, the investigators and
project coordinators must determine the scope of observations.
Possible scopes are listed in Table III.1.3. If the scope is to build
a comparison between two or more observation periods to
assess the evolution of hand hygiene compliance over time,
special attention should be paid to control for the potential
confounding factors. This can be achieved by predefining a
target number of opportunities by profession, wards, and time
of day. To minimise inter-observer variability, the observer or the
team of observers should remain the same across the different
periods of the project. The best unit for calculation is the
denominator, i.e. opportunities for hand hygiene, because this
will directly influence the results.
1.2.6.1 Selection of location and time
A representative mix of wards and time of day should be sought.
Naturally, observers tend to undertake their activity at times
and in locations with a high density of care to gather a higher
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