Improving pre-meal patient hand hygiene compliance; A quality improvement collaborative.

As part of a health economy Gram negative ambition, we aim to improve patient PMHH compliance by a minimum of 20% over the 120 day collaborative period.

Objectives:

• Improve patient knowledge and understanding of hand hygiene, specifically PMHH. Facilitate the right environment to promote patient PMHH
• Establish a health economy approach and include patients throughout the project.
• Enable shared learning across organisations.

Personal Aim: As a NICE Fellow 2016-19 my aim is to promote the work of NICE in the Trusts I work with.

The project relates specifically to the following:

NICE Guideline PH36: Healthcare-associated infections: prevention and control.

QI statement 2: Be a learning organisation.

Statement - Trusts use information from a range of sources to inform and drive continuous quality improvement to minimise risk from infection.

Evidence that the trust promotes innovation to minimise harm from infection, for example by promoting research opportunities, practice development initiatives and action learning sets for staff.

QI statement 6: Multi-agency working to reduce HCAIs

Statement - Trusts work proactively in multi-agency collaborations with other local health and social care providers to reduce risk from infection.

QI statement 9: Patient and public involvement

Statement: Trusts use input from local patient and public experience for continuous quality improvement to minimise harm from HCAIs.

Evidence of:

• a range of mechanisms to involve patients and the public in the trust's decision making to ensure continuous quality improvement in infection prevention and control.
• a variety of information sources and participation methods are used to gain insight into patient experiences of infection prevention and control.
• patients' and the general public's perspective and priorities on infection
• prevention and control are taken into account in the trust's quality improvement programme.

NICE Guideline CG139: Healthcare-associated infections: prevention and control in primary and community care.

Educate patients and carers about: the benefits of effective hand decontamination the correct techniques and timing of hand decontamination when it is appropriate to use liquid soap and water or handrub the availability of hand decontamination facilities.

NICE Helping to prevent infection: A quick guide for managers and staff in care homes.

George Eliot NHS Trust is a small district general hospital with approximately 350 beds, serving its local community in Warwickshire. The QI project to improve patient PMHH compliance was identified to: 

• Support the National ambition to reduce Gram negative blood stream infections (https://improvement.nhs.uk/documents/822/2017-03-15_Letter_-_GNBSI_edits.pdf ).
• Improve awareness of PMHH as patient hand hygiene is often perceived as low risk (Banfeld and Kerr, 2006, Srigley et al; 2016).

The Patient Forum at GEH identified that patient compliance and knowledge of best practice associated with PMHH was poor. In a small sample study, 16 patients hand hygiene compliance pre-meal was observed

• Number of patients offered hand-hygiene by staff pre-meal; n=1 (6%)
• Patient understanding of the need to perform hand hygiene pre-meal n= 3 (19%)
• Patients undertaking pre-meal hand hygiene n=2. (13%)

Therefore, there is a potential heightened risk of enteric contamination if patients are not decontaminating their hands prior to eating, and an associated risk of acquiring a Gram-negative infection.

Patient involvement was pivotal to the project. The Patient Forum undertook the baseline assessment, the weekly audits for improvement measurements and were key advisors at each of the QI monthly meetings.

The National Gram-negative reduction plan has identified that a health economy approach is fundamental to its delivery. Therefore, as part of this collaborative stakeholders from the local Clinical Commissioning Group, a care home and a residential home were invited to participate.

Ref:

• Banfeld K and Kerr K. Could Hospital Patients’ Hands Constitute a Missing Link? Journal of Hospital Infection (2005) 61, 183–188
• Srigley J, Furness C, Gardam M. Interventions to improve patient hand hygiene: a systematic review. Journal of Hospital Infection (2016) 94, 23-29

The methodology chosen to deliver the change project was The Model for Improvement (MFI. Langley et al; 2009) as this has a proven track record for accelerating QI. In addition, the project team had undertaken formal QI training in its approach.

Three fundamental questions are asked in the process:

• What is to be accomplished?
• How will we know a change is an improvement?
• What changes will result in improvement?

Plan-Do-Study-Act (PDSA) cycles  then guided the tests of a change to determine if the change was an improvement or not.

A 120 day rapid QI programme was developed based around the MFI principles of QI and the NICE guidelines, as discussed above. This included; forming the Project Team, enrolling clinical areas and care providers, developing four face to face learning sessions and supporting four action periods (Figure 1).

The project started small; three wards, a care home and a residential home. At the end of the programme, learning was gathered and successful interventions which had the greatest impact, were further developed and scaled-up across the organisation.

The Project Team was set up:

• Dr. Debra Adams: Senior IP Advisor NHS Improvement
• June Ayre: Lead IP Nurse GEH
• Natalie Carvelle: Admin support.
• David Carr: Chair of Patient Forum
• Dilly Wilkinson: Deputy Director of Nursing GEH

Supported by:

• Elaine Whitby: Adviser, NICE Fellows & Scholars Programme

The project did not face any initial obstacles to its development and introduction. There was a palpable energy to improve patient awareness and develop change. However, after Day 30 the care home had to withdraw from the project due to a change in management. Therefore, the scale of learning was reduced. However, it was not felt that this impacted on this programme but was a lesson to be learnt for future programmes.

Financial costs were limited for this project as this was about change to existing methods of communication where costs already existed e.g. meal tray fliers, patient information leaflets, documentation, hand wipes, branding.

Ref: Langley GL, Moen R, Nolan KM, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009 

Aim: As part of our health economy Gram negative ambition, we aim to improve pre-meal patient hand hygiene compliance by a minimum of 20% over the four-month collaborative period.

Outcome: The project excelled. Over the duration of the project, patient PMHH compliance increased from 13% to 97% (Figure2). The next stage is to determine which of the interventions to scale up and then to monitor sustainability.

Objectives:

• Improve patient knowledge and understanding of hand hygiene, specifically PMHH:The results demonstrated that patients and relatives became more aware of the need for PMHH as opposed to only post meal hand hygiene. In addition, staff reported that relatives became more involved with their relatives at meal times
• Facilitate the right environment to promote patient PMHH: Staff altered their practices to facilitate PMHH e.g. where meal trays were laid up, whether to use individual hand wipes or tubs of wipes, designing meal tray information, placement of gel dispensers and the future placement of handwash basins, developed patient newsletters, amended patient food chart documentation to record PMHH.
• Establish a health economy approach and include patients throughout the project. This broadened staff awareness of issues across the health economy e.g. the specific needs for patient PMHH for those who are; bed bound, those with limited mobility/arthritis, fully mobile, reduced sight etc. Discussions enabled the development of products/tools which could be used generically
• Enable shared learning across organisations. The project developed networks across the health economy which have garnered shared learning for not only this project but are facilitating future projects.

Personal Aim: As a NICE Fellow 2016-19 my aim is to promote the work of NICE in the Trusts with which I work.

• The project has enabled me to promote the QI tools which NICE has developed to a wider audience than the specialised teams which generally access those relating to Infection Prevention. Furthermore, my mentor has supported the project by facilitating one of the project support days and the final celebration day, thus promoting the accessibility and public face of NICE.

Increase the number of participating teams in the collaborative in-order to reduce the impact that dropout can have on the development of ideas. Notwithstanding, the small number of participants facilitated group interaction, and did not negatively impact on this project.

• Patient and social care involvement ensured that the whole patient journey was covered across the health economy. This raised awareness of other perspectives and challenges and not those just faced in an acute NHS Trust.
• The Model for Improvement rapid improvement methodology facilitated innovative ideas and ownership. This was an ideal approach, we would use this again to garner buy in at all levels.
• Due to the limited timescale of the intervention it was not possible to identify an impact on the Gram-negative ambition on the four areas chosen. However, this will be monitored over the next 12 months to identify whether any improvement has been identified to which this and the other interventions also being introduced could be attributed to.