Taking Practical Approach to Hand Hygiene

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 VOL. 8, ISSUE 4

Taking a Practical
                                          Taking a Practical Approach to Hand Hygiene
Approach to Hand                          By Judith Anderson, M.D., patient safety fellow
Hygiene                                        The Ann Arbor (Michigan) VA Healthcare                  was the manufacturer’s name. In addition, the
Pages 1 and 2                             System has developed a hand hygiene initia-                  off-white alcohol rub dispensers blended in
New Challenges                            tive focused on creating practical solutions to              with the walls of the facility, making them
in Acute Mental Health                    challenges faced by VA and non-VA hospitals                  difficult to find.
Wards                                     nationwide.                                                       All dispensers are now labeled. The alco-
Page 3                                         The facility’s patient safety manager, Cindy            hol dispensers carry an additional, more color-
Hospital and Nursing                      Paterson, R.N., M.S.A., Ph.D., first assembled               ful label designed to make them stand out from
Home Bed Safety                           a 10-person interdisciplinary hand hygiene                   their surroundings. Permanent alcohol foam
Page 4                                    team whose members ranged from the infec-                    dispensers have also been ordered for all
                                          tion control nurse to a representative from the              medication carts.
VA National                               medical media department. The team contin-
Center for                                ues to meet on a regular basis to address ongo-
Patient Safety                            ing hand hygiene issues.
P.O. Box 486
                                               One of Ann Arbor’s challenges was the
Ann Arbor, MI 48106-0486
                                          physical appearance of the soap and alcohol-
Phone: ................(734) 930-5890
                                          based hand rub dispensers. Neither dispenser
Fax: ....................(734) 930-5899
E-mail: ................
                                          was marked in a way that identified what it
                                          contained – the only label on the dispensers
Web sites:
VHA Chief Patient Safety Officer
James P. Bagian, MD, PE

Joe Murphy, APR
Deb Royal
Copy Editing
Amy Carmack
Deb Royal
TIPS is published bimonthly
by the VA National Center for
Patient Safety. As the official                                                                        Clean Hands
patient safety newsletter of the
Department of Veterans Affairs,
                                                                                                             A week-long contest for a campaign slogan drew 188
it is meant to be a source of                                                                          entries from staff and 12 from patients.
patient safety information for
all VA employees. Opinions of             Dispenser “Before” (left)
contributors are not necessarily
                                                                                                       Summary of Team Actions
those of the VA. Suggestions              	    It	was	difficult	to	tell	soap	and	alcohol-based	hand	
                                          rub	dispensers	apart	with	just	the	manufacturer’s	name	          The team’s initial action was to hold a
and articles are always welcome.
                                          appearing.	Is	this	soap?	Or	hand	rub?	                       week-long contest for a hand hygiene cam-
Thanks to all contributors and
those NCPS program managers                                                                            paign slogan. The contest drew 188 entries
and analysts who offered their            Dispenser “After” (right)                                    from staff and 12 from patients. The prize-
time and effort to review and                                                                          winning entry, “Clean Hands – The Best Gift
comment on these TIPS articles                  Alcohol dispensers now carry an additional, more
prior to publication.                     colorful	label	designed	to	make	them	stand	out	from	their	   You Can Give,” can now be seen on posters
                                          surroundings and from soap dispensers.                       throughout the hospital.
                                                                                                                                    Continued on Page 2
Taking a Practical Approach to Hand Hygiene
Continued from page 1

     The team then began the hand                    of hand hygiene, senior staff members                 Unannounced in-house audits of
hygiene awareness campaign with a two-               readily participated, including the chief        hand washing practices are scheduled to
day “blitz,” during which team members               of staff and hospital administrator.             be conducted on an ongoing basis. The
visited all floors and all shifts. Laminat-               Large signs are being posted at the         auditors will also distribute cards that
ed cards outlining critical hand hygiene             entrance to all patient care areas that          either remind caregivers to wash their
practices were distributed. The cards                state “Mandatory Hand Washing Area.”             hands if they have been observed not
were specifically tailored for different                  A universal signal was adopted to           doing so; or, to thank staff members
audiences – health care providers, EMS               promote hand hygiene awareness. “You             who are seen as practicing good hand
personnel, SPD employees, and those                  simply raise your hands in front of you          hygiene. A monthly drawing will be held
who work in all phases of food produc-               at shoulder level to indicate that you           and a prize given for those collecting
tion and distribution.                               didn’t see a caregiver wash his or her           the “thank you” cards.
     “We also distributed 900 bottles of             hands,” said Kushiner. “It’s neither a                “We also conducted a ‘Continued
alcohol-based hand rub and some 500                  rude way to get another’s attention nor          Readiness Fair’ in early April to pro-
buttons,” said Paterson. She and Risk                a way of finger-pointing.”                       mote compliance with Joint Commis-
Manager Judith Kushiner, R. N., hand-                                                                 sion guidelines,” said Paterson. Hand
made all the buttons. “I was floored by                                                               hygiene compliance was prominently
the amount of people who participated                                                                 reinforced at the fair. In addition, a pa-
in the contest and who saw the blitz as                                                               tient health education fair was held dur-
a critical boost to hand hygiene aware-                                                               ing which the importance of hand hy-
ness,” she added.                                                                                     giene was emphasized, including proper
                                                                                                      techniques for hand washing and using
                                                                                                      alcohol-based products.
                                                     Hand Signal                                           A hand washing LMS module will
                                                                                                      soon be mandatory for all hospital em-
                                                          A neutral hand signal was adopted to pro-
                                                     mote hand hygiene awareness.                     ployees. “Simply put,” said Paterson,
                                                                                                      “everyone must be involved.”
                                                                                                           Want further information on the
                                                          Glo Germ kits were found to be              team and their project? Email me:
                                                     an additional aid in teaching good hand
                                                     washing technique. These kits offer a
                                                     lotion containing plastic that simulates
                                                     germs and is rubbed on the hands be-
                                                     fore washing. After washing, an ultra-
                                                     violet light illuminates residual “germs”
                                                     to test the effectiveness of the employ-
                                                     ee’s hand washing technique.
                                                          A brochure explaining the impor-
                                                     tance of clean hands is being placed
                                                     in the patient admittance package. The
                                                     material also provides tips to patients on
                                                     hand washing and sanitizing techniques.
                                                     Patients will also be offered cards that
Kill a Germ                                          question whether or not a provider               Glo Germ Hands
                                                     washed his or her hands. “They will be
	      Posters	have	been	placed	throughout	the	      able put them in box, so patient identifi-       	     Glo	Germ	kits	were	found	to	be	an	addi-
facility	–	many	that	depict	senior	staff 	members	                                                    tional aid in teaching good hand washing
promoting hand hygiene efforts.                      cation will be unknown,” said Kushiner.
                                                          Alcohol-based hand rub dispensers           techniques. The lotion simulates germs. After
                                                                                                      washing, an ultra-violet light illuminates residual
     A series of posters have been                   are being moved inside patient rooms to          lotion	to	test	the	effectiveness	of 	the	employee’s	
placed throughout the facility that                  promote patient involvement. “The pa-            hand washing technique.
depicts a number of staff members                    tient can tell whether or not the provid-
encouraging others to “Make my day!                  er is using the hand rub,” said Paterson.
Kill a germ” by using alcohol-based                  “This is not the case when the dispenser
hand rub. Because of the importance                  is placed outside a patient’s room.”
Page 2
New Challenges in Acute Mental Health Wards
By	Joe	Murphy,	NCPS	public	affairs	officer

      With acute mental health admis-        this point, far exceeding expectations.                       assessed every 24 hours by nursing,”
sions rising and a new mix of patients       “Patient safety, as related to staff-                         said Kersten. “The assessment looks
requiring a higher level of care, Elaine     ing demands, trumps budget con-                               at changes in such areas as eating,
Kersten has had to begin rethink-            straints,” Kersten noted. “Fortunately                        socialization, appearance and mood.”
ing patient safety challenges at the         at Northampton, patient safety issues                         Depending on the daily results of the
Northampton (Mass.) VA Medical               receive ongoing support from senior                           assessment, patients can be further as-
Center’s acute mental health ward.           leadership.”                                                  sessed by a ward psychiatrist.
      Kersten, Ed.D., CAGS, is the                To include ward staff in continu-                              Results from the monthly meet-
facility’s patient safety manager.           ing patient safety challenges, Kersten                        ings are beginning to create greater
      During the past three years, she       and the facility suicide prevention                           ward efficiency. For instance, one of
has noticed a considerable change in         coordinator offer monthly in-service                          the aims of those involved has been
the patient population. “We now have         training and dialogue sessions.                               to streamline paperwork so that nurses
patients ranging in age from 20 to                                                                         can spend more time on the floor.
80,” said Kersten, “and many require                  Northampton                                                “We also wanted to significantly
a much higher level of care and of               VA Medical Center Nursing                                 improve the treatment environment.
                                                     Daily “Change”
direct supervision than in the past.”                                                                      As a result of Mental Health Environ-
                                                     Risk Assessment
      Previously, most patient admis-                                                                      ment of Care Check List reviews, we
sions were associated with detoxifica-         Feeling                                                     stripped down the whole ward for
tion or chronic psychiatric conditions.        Comments:                                                   safety reasons over time,” she said.
Admissions were mostly World War               Verbalize                                                   “Consequently, it has begun to look
II, Korean, or Vietnam veterans – and          Comments:                                                   very barren and institutional.”
almost all of them were men.                   Acting                                                            Re-evaluating the ward from a
      “We had 11 admissions in one day         Comments:                                                   patient’s point of view led to rethink-
alone recently,” she said, “including          Physiology                                                  ing its appearance. “When we started
three veterans in active suicide states.”      Comments:                                                   discussing the overall appearance and
She also noted a growing frequency             Referral to physician/psychiatrist                          comfort level of the care environment,
of female veteran admissions, with at          Comments:                                                   we thought about adding wall murals,”
least one or more women on the ward                                                                        said Kersten. “We’re working aggres-
on a regular basis. This can complicate              The	assessment	is	straightforward.	It’s	done	every	   sively to improve the look and feel
security and care issues (e.g., additional   24	hours	by	an	R.N.	Any	positive	findings	trigger	            of the ward so that we can raise the
                                             an immediate communication to the ward psychiatrist,
staffing hours/overtime to ensure                                                                          comfort level of our patients.”
                                             who	conducts	a	suicide	assessment.	Positive	findings	are	
privacy, etc.).                              defined	as	changes	in	observed	behavior	in	any	one	of 	             The facility is considering pursu-
      “Our acute ward is in an old           the criteria.                                                 ing a grant from the Johnson & John-
building that has narrow hallways and             The safety topics concern veterans                       son Foundation in an effort to provide
a poor structural layout. As we engage       in the acute mental health ward. “The                         funding for this effort. “As we work
in the ward reconstruction process,          suicide prevention coordinator deals                          to reduce vulnerabilities related to the
meeting the life safety standards is a       with a specific topic at our monthly                          complex mix of patients, we must also
real challenge,” Kersten said. “As a         in-service meetings,” Kersten said. “We                       pay attention to the comfort level in
result, we require more staff due to         review acute ward cases and environ-                          the environment of care,” she said.
the increase in our admissions rate and      mental challenges relative to safety.”                              “The way a ward looks and feels
changes in types of patients than in              A newly developed behavioral                             is as important in some ways as other
the past.”                                   “change” risk assessment is completed                         focus areas, and must be conducive
      Additional staffing is required        by RN staff on a daily basis. She said                        to becoming ‘better,’ ” Kersten noted.
because of the current patient acuity        the staff assesses how individuals relate                     “We need to create a comfortable envi-
and mix. This is creating a strain on        to one another in what has become a                           ronment to stabilize and care for those
the existing ward’s staffing budget.         more dynamic care environment, based                          with acute needs. Many won’t come
      The requirement to provide one-        on higher admittance levels.                                  to us if they feel they are coming to a
to-one staffing is a daily constant at            “Patient behavioral change is                            cold, hostile environment.”

Hospital and Nursing Home Bed Safety
By	Christine	M.	Olney,	Ph.D.,	RN,	inter-professional	patient	safety	fellow
Introduction                                                Measurement of the bed entrap-          necessarily for size and fit to the bed
     While death or injury due to en-                  ment zones is accomplished with a            frame. The purchasing agent was not
trapment is rare, it’s important to rec-               validated instrument – the B4000 bed         aware that the dimensions of the mat-
ognize that part of our veteran popula-                measurement device.1                         tress were so important.
tion is at risk, in particular the elderly.                 The device is designed to emulate            To overcome this barrier, as a
     Concern about entrapment has                      the head and neck measurements of a          group, we have developed recommen-
been evidenced by the FDA’s 1995                       small elderly person. It is manipulated      dations for bed systems and replace-
safety alert “Entrapment Hazards with                  through the zone areas to determine          ment mattress purchases. A copy of
Hospital Bed Side Rails,” 1 one of the                 if those spaces could possibly allow         this can be found on our web site.4
first VHA Patient Safety Alerts devel-                 for entrapment of the head or neck of             Most importantly, we recommend
oped by NCPS 2 (published July 2001),                  a patient. A pass or fail is assigned to     a knowledgeable person, such as the
and the 2002 Joint Commission’s alert                  each zone.                                   PSM, advise the bed/mattress purchas-
on bed entrapment deaths.3                                  VISN 8 medical centers maintain         ers to ensure that all purchases are
     The FDA developed guidelines                      a database with information on the           in compliance with the “2006 FDA
for hospital bed safety in partnership                 following: the type of injury (i.e., bed-    Hospital Bed System Dimensional and
with stakeholder groups. Based on the                  related fall or entrapment); the level of    Assessment Guidance to Reduce En-
recommendations, the FDA issued the                    injury (i.e., minor, moderate, major, or     trapment.” 1
“2006 FDA Hospital Bed System Di-                      death); and, if available, the unit, date,        We also recommend that each
mensional and Assessment Guidance                      time, and location. (We will only exam-      facility develop a plan for replacing all
to Reduce Entrapment.” The guide-                      ine rates in nursing homes.)                 noncompliant, outdated bed systems.
lines describe seven potential entrap-                      The 2007 adverse event data will
                                                       be compared with the 2001 VISN 8             Final Thoughts
ment zones.1
     Aware since 2001 that guidelines                  data to predict the probability of ad-            Not all hospital beds need to be
were being created, manufacturers have                 verse events per 100,000 bed days            upgraded to meet entrapment criteria.
been increasingly designing beds that                  of care.5                                    Patients can be assessed for entrap-
meet the dimensional criteria. These                                                                ment risk and placed in an appropriate
                                                       Summary                                      bed. If the bed has a noncompliant
newer beds are often designed with
other safety features, such as:                            Knowledge gained through a               entrapment zone, it can be corrected
                                                       project of this type can:                    by using stuffers, wedges, etc.
• Varying heights from the floor.                                                                        Many bed types are also exempt
• Smaller bed rails.                                   • Guide the purchase of beds and             from the FDA entrapment criteria,
• Built-in bed exit alarms.                              replacement mattresses.                    including specialty mattresses.
                                                       • Provide a method to interpret                   We believe that it is important to
Our VISN 8 Quality                                       whether or not compliance can re-          consider the advantages of conduct-
Improvement Project                                      duce adverse events or close calls.        ing a quality improvement program
     Recognizing that some VISN 8                      • Potentially reduce the risk of injury      concerning entrapment issues, as we
facilities have purchased new beds, we                   to patients.                               are doing at VISN 8.
are conducting a project to examine                                                                      The road to bed safety is a long
compliance with the 2006 FDA guid-                     A Collaborative Effort                       one that requires lots of team work
ance previously noted. We will com-                                                                 and effort – but it is one that must be
                                                            When we first began, the PSMs           traveled.
pare the new data to that collected                    were using a data-gathering instrument
in 2001.                                               we developed called the “Guidelines          References
Procedure                                              for Bed Safety Measurement” tool, but        1.   For this and a wide range of other issues
                                                       found the process too burdensome.
     The bed safety compliance data are                     The PSMs worked with us to de-
                                                                                                         discussed by the FDA: http://www.fda.
being collected from each VISN 8 hos-                  velop a more user-friendly spreadsheet
pital and nursing home by designated                   that has streamlined the verification of
                                                                                                    2.   To read all VHA Patient Safety Alerts and
employees; in most cases, the patient                                                                    Advisories:
                                                       the bed compliance process. You can          3.   For more information from the Joint
safety manager (PSM). Those involved                   find this spreadsheet on our web site.4
were specially trained in bed assess-                                                                    Commission: http://www.jointcommis-
                                                            As we progressed through the       
ment and data collection at a workshop                 project, the PSMs, with whom we
in September 2007.                                                                                       ert/sea_27.htm
                                                       phone-conference every month, dis-           4.   VISN 8:
    If your VISN or facility decides to                covered that the replacement mattress
undertake a similar project, we have                                                                     patientsafetycenter/bedSafe
                                                       purchasing process can be a barrier to       5.   Hoffman, S., Powell-Cope, G., Rathvon,
posted information about the bed as-                   compliance.
sessment and data collection training                                                                    L., & Bero, K. (2003). BedSAFE: Evaluat-
                                                            With a bit of investigative work,            ing a program of bed safety alternatives
on our web site.4 The focus of the                     one PSM found that the replacement
assessment and data collection were                                                                      for frail elder. Journal of Gerontological
                                                       mattresses were not purchased                     Nursing,	29(11), 34-42.
potential entrapment zones 1-4.
Page 4

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