Authors (including presenting author) :
Ng WF (1), Lau SY (1), Yu PL (1), To KY(1), Yung HC(1)
Affiliation :
(1) United Christian Hospital
Introduction :
Hand Hygiene compliance rate of a surgical ward was the lowest in United Christian Hospital in 2017 which was 59.8%. The hand hygiene compliance rate of nurses was 63.89% and supporting staff was 59.09%. An improvement project for a surgical ward with poor hand hygiene compliance implemented which used the root cause analysis, lean management, education program and hand hygiene observation through the Plan–Do–Study–Act continuous improvement cycle (Deming, 1993).
Objectives :
To improve the hand hygiene compliance of nurse and PCA was implemented from April to July 2018
Methodology :
Root cause analysis-No data entry to the infection control hand hygiene(HH)compliance system from7/2017-4/2018due to busy clinical work. Ward infection control link nurse(ICNLN) didn’t familiarize with system. HH observation by duty in charge&ICNLN but required observations were not done. No routine for refilling hand rub.HH observation form was not user friendly.Infection Control Nurse observed the poor HH compliance of PCA after body fluid exposure.Heavy workload of emptying urinary bag was found.Ward crowded &occupancy was high.Survey on the perception of nurse,PCA&TUNS by 7 interventions to increase HH compliance was conducted with the result applied.PDSA cycle was used.HH observation was shared by designated nurses.HH observation form was simplified.Data entry of HH observation could be done by WM,APN, ICNLN &clerk.Routine for refilling the alcohol hand rub & environmental checking added.Procedure of empty urinary bag was lean with appropriate frequency.Education program was held.
Result & Outcome :
Hand hygiene compliance rate would be improved when comparing with 2017 data 1. Hand hygiene compliance rate from May to July 2018 (Data from ward observation and Infection Control team observation). The hand hygiene compliance rate was higher than the data of 2017.
Month/2018 Nurse PCA
May 71.4% 66%
June 90% 88%
July 96% 92% 2. The data of hand hygiene observation was submitted on time.
3. Sufficiency of alcohol hand rub was available in ward by random environmental checking.
4. PCAs satisfied with the modified procedure in emptying the urinary bag.
5. Nurse and PCA satisfied with the education program.
Co-location with:
