Improving Hand Hygiene Compliance Through a Cultural Intervention in the Cardiovascular Intensive Care Unit (CVICU)
CCCF ePoster library. Mustard M. 10/02/17; 198121; 21
Mary Mustard
Mary Mustard
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Improving Hand Hygiene Compliance Through a Cultural Intervention in the Cardiovascular Intensive Care Unit (CVICU)

Mustard, M 1; Parkes, J 1; Bhuptani, P 1; Harris, D 1; Lewis, E 1; Glen, J 1; Kataoka, M 1; Williams, M 1

1 CVICU, St Michael's Hospital, Toronto, ON, Canada


Introduction: Good hand hygiene (HH) is integral to improving patient safety and outcomes through prevention of Healthcare Associated Infections1.  The complexity of the critical care environment and workload factors pose unique challenges to maintaining HH compliance. Despite a steady rise in compliance rates over the past 5 years, the CVICU remains below hospital targets. The literature identifies multimodal and interprofessional interventions as the most successful strategies for change2. Previous approaches included education, simulation, product placement and staff engagement, however years of quality improvement (QI) initiatives have led to initiative fatigue amongst frontline staff3. Change theory authors suggest that a culture shift within a work environment drives sustainable change4.  
Objectives:  (1) Increase moment 1 hand hygiene compliance by 5% in 12 months; (2) Design an intervention to facilitate culture shift towards HH compliance.
Methods:  An interprofessional, local-leadership team from the CVICU participated in a QI Fellowship.  The fellowship program deconstructed the roles and responsibilities of team members within the terms of a QI Plan project and introduced all members to the St. Michael’s QI Framework.  The Current state of HH was examined through the use of the A3 worksheet, the development of SMART goals, and process mapping.  Deeper examination of root causes included use of the following tools:  Root Cause Analysis, the 5 Why’s, and; construction of a Fishbone Diagram.  Driver diagrams were then utilized to identify key factors that influenced the performance of the system and to select change ideas that addressed those key drivers.
Results:  Using the driver diagram, culture that supports HH was determined to be the primary driver. Interventions were targeted at all members/disciplines within the CVICU team and consulting services/visitors.  A poster was mounted at each entrance to the unit, demonstrating expectations for the perform moments one & four of hand hygiene for anyone entering the patient room.  A question was also added to the daily rounding checklist with goal of identifying missed opportunities and fostering interprofessional discussion of HH.  Preliminary results demonstrated that our original goal was exceeded. Missed opportunities were identified at 20% of bedsides. The checklist quantified the impact of unplanned activities and identified concrete examples of factors contributing to missed opportunities such as: forgetting (5), CXR (3), patient safety (2), glove use (2) etc. The frequency of use was reduced from daily to 2-3x/week due to identification of initiative fatigue during an initial Plan Do Study Act (PDSA) cycle. Sustainability was demonstrated at decreased frequency.
Conclusion: HH compliance is integral to patient safety. The use of a cultural intervention in the CVICU was a novel intervention to increase compliance. Incorporating the interventions into pre-existing work flow contributed to sustainability, while providing time for cultural change to occur. Interprofessional discussion helped dispel myths, foster reflective practice and emphasize HH as integral to the daily routine.  Future use of data generated from the checklist will facilitate more focused approaches to improvement strategies.

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