This is not one of the 5 moments of hand hygiene

after touching a patient's surroundings

Moment 2 of Hand Hygiene is

after touching a patient's surroundings

after body fluid exposure/procedure

While auditing, you saw the doctor left the patient's bedside after examining the patient and threw his gloves on the rubbish bin. How would you report the scene in your auditing form?

D -> Moment 4 -> Missed -> Gloves Off

D -> Moment 4 -> Rub -> Gloves Off

D -> Moment 1 -> Wash -> Gloves On

D -> Moment 4 -> Missed -> Gloves On

While auditing, you saw the PSA carrying a patient's tray from the patient's bedside into the kitchen trolley. You saw the PSA removed her gloves then washed her hands after. How would you report the scene in your auditing form?

PSA -> Moment 5 -> Washed -> Gloves Off

PSA -> Moment 5 -> Rub -> Gloves Off

PSA -> Moment 4 -> Washed -> Gloves Off

PSA -> Moment 5 -> Washed -> Gloves On

While auditing, you saw the nurse emptying a stoma bag of a patient into a bottle. She places the bottle in the washer, removes her gloves then performed a hand wash. How would you report the scene in your auditing form?

N -> Moment 3 -> Wash -> Gloves Off

N -> Moment 3 -> Missed -> Gloves Off

N -> Moment 3 -> Rub -> Gloves Off

While auditing, you saw the PM nurse receiving handover to the AM nurse at the patient's bedside. The PM nurse inspects every tube connected to the patient during handover then proceeds to check the patient's folder. How would you report the scene in your auditing form?

N -> Moment 1 -> Missed -> Gloves Off -> N -> Moment 4 -> Missed -> Gloves Off

N -> Moment 1 -> Rub -> Gloves On -> N -> Moment 4 -> Missed -> Gloves Off

N -> Moment 1 -> Missed -> Gloves Off -> N -> Moment 4 -> Missed -> Gloves On

While auditing, I saw a nurse who missed to perform a hand hygiene after examining a patient. After I've placed my audit, my next responsibility is to

speak privately to the nurse and provide a brief reminder/education about hand hygiene

tell the NUM/ANUM that the nurse failed to perform hand hygiene

Hand Hygiene Audit

7.015 Hand Hygiene: Practice observation of hand hygiene compliance via the use of a hand hygiene survey tool to be reviewed quarterly at the QAPI committee. (Chapter 10.14 Handwashing & Surgical Antisepsis) Continue infection control education through ongoing orientation to center staff routinely and annual mandatory in-service. Continue to promote hand hygiene awareness for patients and staff by means of educational materials placed throughout the center which references the CDC/WHO guidelines. Needle-stick Injuries: (Refer to Exposure Control Plan) Use of designated safety engineered needles for injections (safety glide needles for injection and autoguard IV catheters) and blood draw. New employee and annual clinical competency for injections will be provided to all staff. The staff will be trained yearly on OSHA, blood borne pathogens and PPE. 7.016 Hand Hygiene Quality in the ASCs: based on AORN (Association of periOperative Registered Nurses) Standards and guidelines Policy: All ASC staff, including physicians, nurses, and other healthcare workers, are required to perform hand hygiene before and after any direct contact with patients, before and after any procedure, and after any contact with potentially contaminated items or surfaces. Hand hygiene must be performed using either an alcohol-based hand rub or soap and water. The alcohol-based hand rub must contain at least 60% alcohol. Staff members must ensure that their hands are free of debris and visible dirt before performing hand hygiene. Hand hygiene must be performed for a minimum of 20 seconds, and hands must be dried thoroughly after washing. Staff members must be trained on proper hand hygiene techniques and will be educated on a regular basis to ensure compliance with this policy. All staff members must comply with this policy and demonstrate compliance during inspections by ASC management and regulatory agencies. Any staff member who fails to comply with this policy will be subject to disciplinary action. ASC management will monitor compliance with this policy through regular inspections and audits and will take appropriate action to address any noncompliance issues. The ASC will maintain records of staff compliance with this policy as part of its infection control program. The ASC will review and update this policy on an annual basis or more frequently as needed to ensure that it remains current with the latest guidelines and standards for hand hygiene quality.

7.018 Safe Injection Practices (Refer to 7.07 Safe Injection Policy) Environment of Care: Active participation with all identified projects to assess compliance with infection control standards. . Surveillance, Control, and Reporting includes: Baseline information about the frequency and type of nosocomial infections. Identification of patients and/or staff with communicable or potentially communicable infections. Patients identified with a communicable disease will be isolated from other patients in the facility or, if this is not possible, they will be transferred to a local hospital for care or rescheduled. Identification of clusters of microorganisms or significant deviations from endemic level. Reporting to committees and outside agencies, when required. Investigation of infections as needed. Immediate implementation of corrective and preventive measures that result in improvements. The Infection Control nurse or designated staff member will perform facility audits and report results to the QI committee and Board of Managers. EVALUATION Evaluation and improvement of the infection prevention and control activities are important steps in the Center’s efforts to control and prevent infection. Infection prevention and control practices should become a routine part of the care, treatment, or services the center provides to patients. Patients expect and deserve hygienic and safe care even if their contact with the Center does not extend beyond a single visit. Continuous review of the goals, activities, and outcomes of the Center’s initiative are therefore followed by improvement activities that are realistic in expectation and, above all, effective. Evaluation of the plan shall include but not be limited to: Evaluation of the infection prevention and control activities annually and whenever risks significantly change. The evaluation includes a review of the following: The infection prevention and control prioritized risks The infection prevention and control goals. Implementation of infection prevention and control Outcomes of infection prevention and control activities. Findings from the evaluation are communicated at least annually to the Quality Management Committee References: http://oneandonlycampaign.org/content/what-are-they-why-follow-them. Centers for Disease Control and Prevention (CDC). (2004). Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings. Retrieved January 29, 2015 from www.cdc.gov/niosh/topics/bbp/sharps.html. Centers for Disease Control and Prevention (CDC). (2003). Guidelines for Environmental Infection Control in Health-Care Facilities 52(RR10);1-42. Retrieved January 29, 2015 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5210a1.htm. Centers for Disease Control and Prevention (CDC). (2002). Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR. 51(RR-16). Retrieved January 29, 2015 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm. Centers for Disease Control and Prevention (CDC). (2008). Sharps Safety Workbook. Retrieved April 24 2014 from http://www.cdc.gov/sharpssafety/pdf/workbookcomplete.pdf. Guideline for Infection Control in Healthcare Personnnel available at: Guideline for Infection Control in Healthcare Personnel available at: http://www.cdc.gov/hicpac/pdf/InfectControl98.pdf Immunization of HealthCare Personnel, guidance available at: http://www.cdc.gov/vaccines/spec-grps/hcw.htm Occupational Safety & Health Administration (OSHA) Bloodborne Pathogens and Needlestick Prevention Standards available at: http://www.osha.gov/SLTC/bloodbornepathogens/index.html Sax H, et al. (2007). My five moments for hand hygiene: A user-centered design approach to understand, train, monitor and report hand hygiene. For the World Health Organization. J Hosp Infect 67(1):9–21. World Health Organization (WHO). (2005). World Alliance for Patient Safety. WHO Guidelines on Hand Hygiene in Health Care. Retrieved January 29 , 2015 from http://www.who.int/patientsafety/events/05/HH_en.pdf.

Hand hygiene

Hand Hygiene Policies @ CSC

Hand Hygiene Principles

7.017 Fingernail Policy for ASC Personnel with Direct Patient Contact The surgical center applies this policy equitably and inclusively, and management expects staff to do so in good faith. Purpose: To prevent infection by ensuring proper hand and nail hygiene among ASC staff with direct patient contact. Policy: All ASC staff with direct patient contact must maintain clean and well-groomed fingernails and a healthy hand skin condition. Artificial Nails The ASC defines Artificial nails as press-on, extenders, studs, stones, or other objects positioned on top of the natural nail that are elevated and irregular. These are not allowed as they can be a potential source of infection and can also inhibit proper hand hygiene. Nail Enhancements The ASC defines Nail enhancements as nail paint, gel, and shellac. These are allowed, as evidence against them is weak/moderate and inconsistent, as long as they are undamaged, free of chipping, adequately maintained, and do not interfere with proper hand hygiene, job performance, or glove integrity. Staff must ensure that their nails are trimmed, clean, rounded, and at a length that does not inhibit them from performing their duties or putting themselves or their patient at risk for exposure. Staff must wash their hands with soap and water or use an alcohol-based hand rub before and after each patient encounter and after any activity that may contaminate the hands. Staff must report any cuts, sores, or other skin conditions that may prevent them from maintaining proper hand hygiene to the supervisor. Implementation: The infection Control Nurse or designee will educate staff on hand and nail hygiene, proper hand-washing techniques, and alcohol-based rubs. Supervisors will monitor staff compliance with the policy and provide corrective action as needed. The ASC will provide hand hygiene products and education materials for staff. Evaluation: The infection Control Nurse or designee will evaluate the effectiveness of this policy annually and through regular staff education and monitoring of staff compliance. Nurses are reminded of the standards of nursing practice specified in 22 Texas Administrative Code Rule 217.11 (B)(O), which includes Implementing measures to promote a safe environment for clients and others and Implementing measures to prevent exposure to infectious pathogens and communicable conditions. Reference: AORN INC. (2022). Guidelines for perioperative practice.

Grundlagen der Händehygiene

hand

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