UC DAVIS HEALTH
QUALITY IMPROVEMENT

MIND THE LINE
Performance Improvement of Hand Hygiene

Meredith Hansen MSN, RN, PH; Scott Prudhomme BSN, RN; Mag Browne McManus, MSN, RN Jill Hernandez, BS, RN, CCRN; Esther Muriithi BSN, RN; Doug Wright BSN, RN, CCRN; Diane Williams BSN, RN; Brad Barnes BSN, RN; Jennifer Ortiga Lamson BSN, RN; Connie Zasa BSN, RN; Katie Garson BSN, RN; Cynthia Elmido MSN, BSN, RN.

 
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POSTER - #PI1030

MIND THE LINE - Performance Improvement of Hand Hygiene

Meredith Hansen MSN, RN, PH; Scott Prudhomme BSN, RN; Mag Browne McManus, MSN, RN Jill Hernandez, BS, RN, CCRN; Esther Muriithi BSN, RN; Doug Wright BSN, RN, CCRN; Diane Williams BSN, RN; Brad Barnes BSN, RN; Jennifer Ortiga Lamson BSN, RN; Connie Zasa BSN, RN; Katie Garson BSN, RN; Cynthia Elmido MSN, BSN, RN
UC DAVIS HEALTH - QUALITY IMPROVEMENT

Background
Patient Care Services (PCS) Radiology reported a significant decrease in hand hygiene compliance from January 2019 to April 2019. Multiple problems with compliance were identified, such as lack of availability of hand sanitizers as well as education deficiencies among staff related to hand hygiene compliance. Additionally, patient care areas in the Radiology Department negatively impacted hand hygiene compliance being defined by curtains and not physical walls and clear barriers.

Purpose
The purpose of this project was to improve quality and safety to increase compliance of hand hygiene through:
•Education
•Increased availability of hand hygiene supplies
•Define and highlight patient care areas

Design & Methods
The first step was to define patient care areas with the placement of yellow tape on the floors. The yellow tape indicates that the area beyond the yellow line is a patient care area. Nursing staff should foam in and foam out when entering and exiting the patient care area. Signage stating “mind the line” was placed to remind staff how important hand hygiene is and to “Mind the Line” whenever they entered and exited the patient care area.

Implementation Plan
During the first two weeks of May, morning huddles consisted of educating staff about hand hygiene and implementation and goals of the project. During this time, questions and feedback from staff were encouraged. The input received helped guide the process of this project by identifying barriers to proper hand hygiene compliance.
Data was collected on a monthly bases by three hand hygiene auditors. The auditors were anonymous to nursing staff in order to capture data without any influence from auditors being present. Each auditor observed five RN’s a day with hand hygiene compliance.

Performance Data
(See poster)

Conclusions & Further Study
Since the project’s implementation, hand hygiene data indicates that compliance has improved. Radiology nursing’s hand hygiene compliance shows marked improvement from 39% in April to 93% in July and maintained a improved compliance rate for the remainder of 2019.
Clearly identifying patient care areas, making hand sanitizer more readily available, and emphasis on proper hand hygiene in daily huddles helped nurses be more aware of their hand hygiene compliance.
Identified limitations to this project are that anonymous hand hygiene auditors were eventually identified by staff, therefore influencing staffs hand hygiene practices. HH auditors will be rotated

References
1.Aziz, A. (2018). Hand hygiene compliance in the pre-hospital setting. Journal of Paramedic Practice, 10(6), 248-255.
2.Bingham, J., Abell, G., Kienast, L., Lerner, L., Matuschek, B., Mullins, … Kirk, J. (2016). Health care worker hand contamination at critical moments in out-patient care settings. American Journal of Infection Control, 44(11), 1198-1202.
3.Stackelroth, J., Sinnott, M., & Shaban, R. Z. (2015). Hesitation and error: Does product placement in an emergency departmentinfluence hand hygiene performance? American Journal of Infection Control, 43(9), 913-916. doi:10.1016/j.ajic.2015.04.199

Acknowledgements
PCS Radiology would like to acknowledge UC Davis Infection Prevention Department for their input developing this project.

Creative Commons License
This work is licensed under a Creative Commons Attribution-ShareAlike 4.0 International License.

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