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HHNZ implementation

What is Hand Hygiene New Zealand (HHNZ)?

Hand Hygiene New Zealand (HHNZ) is a national programme aiming to improve hand hygiene practice among healthcare workers in New Zealand hospitals. This programme was initially established by the Quality Improvement Committee (QIC) in 2008 and delivered to District Health Boards throughout the country. In 2011, the QIC was superseded by the Health Quality & Safety Commission New Zealand (HQSC), which now holds overall responsibility for the national Infection Prevention and Control programme. This programme seeks to reduce healthcare associated infections in New Zealand through three different infection prevention initiatives, one of which is the national hand hygiene programme (HHNZ). The HQSC has partnered with a project team based at Auckland District Health Board to deliver the HHNZ programme.

What is the goal of HHNZ?

The HHNZ programme supports DHBs to improve hand hygiene practice among healthcare workers so that they can reduce healthcare associated infections and enhance the quality and safety of patient care. HHNZ is working towards a national hand hygiene performance rate of 80% by end June 2015.

Why do we need a national hand hygiene programme in New Zealand?

Numerous studies have shown that improved hand hygiene practice by healthcare workers can lead to a reduction in healthcare associated infections (HAI). As in many other countries, HAI are a major issue cause of morbidity in New Zealand hospitals. In June 2003, a report from New Zealand’s Controller and Auditor-General – “Management of Hospital-acquired Infection” – noted that up to 10 per cent of patients admitted to modern hospitals acquire one or more HAI. These infections are a significant cause of avoidable patient mortality, morbidity and financial expense to the New Zealand health system. In 2003 it was estimated that the annual cost of HAI in New Zealand could be almost $140m nationally (Graves, Nicholls, & Morris, 2003). Moreover, baseline data suggest there is substantial room for improvement in hand hygiene practice in New Zealand District Health Boards (DHBs). The HHNZ programme is one of three initiatives happening in the New Zealand health sector aimed at reducing HAI. Having a hand hygiene programme that operates at a national level will allow relevant resources and expertise to be shared efficiently between DHBs and will also allow compliance data to be compared between DHBs as a mechanism to motivate culture change.

How will my District Health Board be expected to participate in the HHNZ programme?

HHNZ seeks to achieve participation by all DHBs in New Zealand. A key aspect of the programme is to achieve a system whereby hand hygiene compliance data are collected, submitted and reported in a consistent manner across all DHBs. This will enable quality data to be used as a tool to both identify areas of need and to motivate behavioural change. To achieve this, each DHB will require “gold auditors” – individuals who will be specially trained to monitor, record and submit hand hygiene compliance data to the national hand hygiene database in a consistent manner. If your DHB is already implementing a hand hygiene programme, including undertaking standardised audits of hand hygiene compliance, then little will change for you, except you will now have access to greater support, information and resources. Each DHB should have a designated hand hygiene coordinator who will be responsible for coordinating the programme within each DHB. HHNZ will provide centralised support and resources for local programmes and will facilitate the sharing of experiences and expertise between DHBs via the HHNZ website.

Patient safety

What is a healthcare associated infection?

Healthcare associated infections are infections acquired by patients while receiving treatment for other conditions whilst accessing health care. Examples include central line associated bloodstream infections, catheter-associated UTIs, surgical wound infections and ventilator-associated pneumonias.

For more detailed information about HAIs please visit the Center for Disease Control and Prevention or the Health Protection Agency.
Who is at risk from a healthcare associated infection?

Anyone who is a patient in a hospital is at risk of acquiring a healthcare associated infection. However, some patients are more vulnerable than others. These include:
•    Very young or very old patients.
•    Patients with underlying medical conditions such as diabetes, cancer and heart disease.
•    Patients who have a weak or compromised immune system, such as those who are receiving chemotherapy.

How important are clean hands to the overall patient safety agenda?

Hand hygiene is considered to be one of the most important measures in the fight against healthcare associated infections (HAI), making it a key patient safety issue within New Zealand hospitals.

Scientific evidence shows that microbes causing HAI are most frequently spread between patients via the hands of healthcare workers. Hand hygiene is a simple, low-cost action to prevent the spread of all microbes that cause HAI. While hand hygiene is not the only measure to counter HAI, compliance with it alone can dramatically enhance patient safety.

The selection of hand hygiene as the first pillar to promote the Global Patient Safety Challenge of the World Health Organization World Alliance for Patient Safety signifies its importance in the patient safety agenda.
What types of microbes can be spread due to lapses in hand hygiene?

The following are examples of the types of microbes that can be spread on the hands of healthcare workers:
•    Staphylococcus aureus  (including MRSA)
•    Streptococcus pyogenes (Group A Strep)
•    Vancomycin-resistant Enterococcus (VRE)
•    Klebsiella (including ESBL-producing Klebsiella)
•    E. coli (including ESBL-producing E. coli)
•    Enterobacter spp
•    Pseudomonas spp (including multidrug-resistant Pseudomonas spp)
•    Clostridium difficile
•    Candida spp
•    Rotavirus
•    Adenovirus
•    Hepatitis A virus
•    Norovirus

Microbes such as Staphylococcus aureus and Klebsiella spp. can be present on intact skin in numbers ranging from 100 to 1,000,000 per square cm.
The hands of healthcare workers can become contaminated even after seemingly ‘clean’ procedures such as:
•    Taking a pulse
•    Taking blood pressure readings
•    Taking a temperature
•    Touching a patient’s hand, shoulder or groin.

Furthermore, several studies have presented dramatic evidence that microbes have an impressive ability to survive on the hands, sometimes for hours, if hands are not cleaned. All of the studies clearly demonstrate that contaminated hands can be vehicles for the spread of microbes.

What other initiatives fall within the overall Infection Prevention and Control programme?

Three patient safety initiatives fall into the overall Infection Prevention and Control programme. These are the Hand Hygiene New Zealand programme, the catheter-related blood stream infections prevention programme and a surgical site infection surveillance programme. The Health Quality & Safety Commission New Zealand (HQSC) holds overall responsibility for these initiatives.  For more information visit: www.hqsc.govt.nz

Hand hygiene

What are the “5 moments” of hand hygiene?

The key message from HHNZ is that hand hygiene with an alcohol-based hand rub (AHBR) should be performed before and after patient contact; after contact with the patient’s environment and before and after any type of procedure (including accessing or manipulation of any indwelling device). This simple message aligns with the internationally recognised “5 moments” of hand hygiene that are recommended by the World Health Organization (WHO). The “5 moments” concept will be used by HHNZ for the purposes of auditing hand hygiene compliance in a standardised manner across DHBs.


What is the underlying theory of the "My 5 Moments for Hand Hygiene" approach?


Indications for hand hygiene depend on the risk of germs transmission and are closely connected with the activities of healthcare workers within the geographical area surrounding each patient zone, and with tasks they perform.

Healthcare activity is made up of a succession of tasks during which healthcare workers’ hands touch different types of surfaces (patient, object, body fluid, etc). Depending on the order in which these contacts occur, pathogen transmission from one surface to another must be interrupted, as each contact is a potential source of contamination. It is during the interval between two contacts that the indication or indications for hand hygiene occur.

The “before” indications are present when there is a risk of microbial transmission to the patient; the hand hygiene actions that correspond to these indications protect the patient.

The “after” indications are present when there is a risk of microbial transmission to the health-care worker and/or to the health-care environment (and to any other person present); the hand hygiene actions that correspond to these indications protect health-care workers and the health-care environment and ultimately other patients.

The right hand hygiene action at the right moment will contribute significantly to the maintenance of clean and safe care in the context of pathogens transmitted by hands.

What are the barriers to performing good hand hygiene?

Barriers to performing correct hand hygiene procedures include:

•    Heavy workloads - the busier healthcare workers are the less likely they are to perform hand hygiene.
•    Traditional hand washing techniques are time consuming.
•    Hands don’t appear dirty – the germs are still there even if you can’t see them.
•    Skin irritation – frequent washing with soap and water removes skin lipids, and in some health care workers causes dryness, skin irritation and damaged skin.
•    Poor location of sinks – if it is hard to get to a sink healthcare workers are less likely to wash their hands.
•    Poor location of alcohol-based hand rubs – not at the point of care.

Why does HHNZ place more emphasis on the use of alcohol-based hand rubs than washing hands with soap and water?

Having a product available to make hands safe at the point of care, the place where pathogens are transmitted, has revolutionised hand hygiene improvement strategies. For this reason, alcohol-based hand rubs are considered to fulfil the highest standards of safety in relation to the prevention of cross-transmission.

At the present time, the most efficacious, well-tolerated and well-researched product that can be placed ergonomically and safely at the point of care is an alcohol-based hand rub. This facilitates the right action to occur at the right time and in the right way. Soap and water hand washing is less efficacious, more time-consuming, and less well tolerated by skin than alcohol-based hand rubs.

Is HHNZ suggesting that healthcare workers are no longer required to use soap and water?

No. There will always be a place for hand washing with soap and water, particularly when hands are visibly soiled with blood or other body fluids, or after using the toilet.

When an alcohol-based hand rub is available, it should be used as the first choice for hand hygiene of non-visibly soiled hands. This provides a quick and effective way for healthcare workers to clean their hands when they are with their patient, enabling them to optimally comply with recommended indications at the point and moment of care. It also means that patients can see the healthcare worker clean their hands, which is important for patient confidence.

Are there times when I should not use a hand rub?

If your hands are visibly soiled we strongly recommend you wash them in the nearest hand basin. The same advice may be recommended following known or suspected exposure to patients with Clostridium difficile infection. However, the use of alcohol-based hand rubs in this setting has not resulted in increased rates of transmission of C. difficile.

In an outbreak of viral gastroenteritis, each DHB should have specific policies for hand hygiene and these should be followed.

How do I hand rub or hand wash correctly?

A detailed guide illustrating the correct hand hygiene procedure can be found on our Promotional materials page or by downloading our “how-to” hand rub and hand wash promotional posters.
Will it matter if my hands are wet when I apply the alcohol hand product?

Yes, having wet hands dilutes the solution thus decreasing its effectiveness. The product should be applied to dry hands.

Can I use too much?

No. The bottles used provide a metered amount with one pump, which should be sufficient to clean your hands.

Does hand rub sting when applied?

Stinging demonstrates pre-damaged epidermal tissue, most commonly caused by the frequent use of soap and water. The use of an alcohol hand product may lead to an improvement in the condition of your hands because it contains an emollient, does not remove skin lipids and does not require a paper towel for drying. However, if symptoms persist, advice should be sought from your occupational health service.

Allergic contact dermatitis due to alcohol-based hand rubs is extremely rare in contrast to reactions to soaps. Alcohol-based hand rubs should not be used concomitantly to detergents or soaps for routine hand hygiene.

Will the hand rub dry my hands out if I use it too often?

Modern alcohol-based hand rubs should not dry the hands (if used correctly). The products used in the hospital have an emollient incorporated into them. Several studies have shown that nurses who routinely use alcohol rubs have less skin irritation and dryness than those using soap and water.
Can I bring my own moisturising cream from home?

No. Some hand creams may reduce the effectiveness of the alcohol hand product. The hand products used by your hospital will have been chosen specifically for their compatibility with the alcohol hand product.

Can the alcohol be absorbed through my skin?

Tests undertaken have shown that if used correctly intensive use of alcohol hand products have not been associated with legally or clinically relevant levels of cutaneous alcohol absorption.

What if the hand rub gets in my eyes?

The bottles should be placed at a height where the risk of eye splashes is minimised, but in cases of accidental splashing, don’t rub your eye but carefully irrigate your eye with sterile saline solution (0.9% sodium chloride – if readily available) or clean water; and seek help as soon as possible from another healthcare professional.

What happens if someone accidentally drinks the alcohol hand product?

Most hand rubs on the market contain very unpleasant tasting products, which make drinking it unlikely. The risk of poisoning from ingestion of alcohol hand products is relatively uncommon, but diarrhoea and vomiting have been reported where accidental ingestion has occurred. It is recommended that care be taken with the placement of alcohol hand product in high risk areas (such as paediatrics, drug and alcohol units, psychiatric units, and psycho-geriatric units).

What are the recommendations in relation to jewellery and fingernails?

Artificial nails are more likely than natural nails to harbour gram-negative pathogens. Recommendations regarding fingernails are that healthcare workers do not wear artificial fingernails or extenders when having direct contact with patients and natural nails should be kept short (≤0.5 cm long or approximately ¼ inch long).

Several studies have shown that skin underneath rings is more heavily colonised than comparable areas of skin on fingers without rings. The consensus recommendation is to strongly discourage the wearing of rings or other jewellery during healthcare. If religious or cultural influences strongly condition the healthcare worker’s attitude, the wearing of a simple wedding ring (band) during routine care may be acceptable.

Do I need to perform hand hygiene if I am going to/have been wearing gloves?

The use of gloves does not replace the need for hand decontamination. Gloves will decrease the number of germs you acquire on your hands, but they will not totally prevent the spread of germs from your hands. Hand hygiene should be performed regardless of the use of gloves when an indication for hand hygiene applies.

Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, or non-intact skin will occur. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to either another body site (including non-intact skin, mucous membrane or medical device) within the same patient or the environment. The reuse of gloves is not recommended.

Auditing

Should we collect some data on hospital-associated infection rates?

The outcome measure collected for HHNZ is the number of healthcare associated Staphylococcus aureus bacteraemia per quarter. The definition of healthcare associated S. aureus bacteraemia can be found in the HHNZ guidelines, along with the reporting requirements.

HHNZ would like to acknowledge the use of World Health Organization and Hand Hygiene Australia FAQ resources in the development of this FAQ document.