Purpose: The purpose of this project was to improve the hand hygiene compliance among nursing staff in an acute medical-surgical unit, using an interprofessional team-developed intervention.
Relevance/significance: Hand hygiene is the most important means of preventing the spread of infection. Health care-associated infections affect nearly 687,000 patients annually in the United States of America and lead to about 72,000 deaths. One medical-surgical unit’s nurse council decided that increasing hand hygiene compliance was an opportunity for improvement.
Strategy/implementation/methods: Unit council met and decided on an interprofessional approach to tackling hand hygiene compliance. A team consisting of nursing and infection control was formed. The clinical nurses designed an interactive action plan to promote peer-to-peer accountability. The infection control preventionist (ICP) and nursing unit leaders provided educational sessions. The CNL provided ongoing peer-to-peer education on increasing accountability. Information, compliance scores, and statistics were shared on the bulletin board in the break room. Real-time peer-to-peer feedback was also utilized via the CNL and the CNS, throughout the 12-month period.
Evaluation/outcomes: The unit score for hand hygiene compliance prior to implementation was 84.2%; following the launch and implementation of the hand-washing action plan, it improved to 91.2%, a 7% increase in compliance. The unit also met the organizational goal of 95%, 5 out of 12 months. Nurses were able to monitor their compliance with the hand hygiene compliance board located in the breakroom. Posting the hand hygiene scores weekly and monthly on the unit’s quality board allowed the nurses to track their improvements.
Implications/conclusion: Getting staff involved is an improvement of outcomes by including them in the action plan and sharing the progress of scores reinforces the importance of hand hygiene. Real-time feedback improved engagement and accountability among the nursing staff.
Evidence-based references 1. Hillier MD (2020) Using effective hand hygiene practice to prevent and control infection. Nursing Standard. doi: 10.7748/ns.2020.e11552 2. Nohemi Sadule-Rios, G. A. (2017). Nurses’ perceptions of reasons for persistent low rates in hand hygiene compliance. Intensive and Critical Care Nursng, 17-21. 3. Olena Doronina RN1, D. J.-T. (2017). A Systematic Review on the Effectiveness of Interventions to Improve Hand Hygiene Compliance of Nurses in the Hospital Setting. Journal of Nursing Scholarship, 143-152.