Sharing quality improvement experiences from the WHO SEARO region

Maternal, Newborn and Child Health

Improving hand hygiene practices in the NICU

30th August 2018

WEBINAR

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Webinar Roles

Dr Amlin Shukla, MD

Assistant Professor

Department of Neonatology

Dr. R.M.L. Hospital and PGIMER,

New Delhi, India

Dr. Sonali Vaid

Improvement

Advisor,

WHO – CC for

Newborn Care @

AIIMS, New Delhi,

India

Speaker Project Lead Moderators

Dr Arti Maria, DM

Prof. and Head of Department

Department of Neonatology

Dr. R.M.L. Hospital and PGIMER, New Delhi, India

Dr Surender Bisht

Senior Specialist &

In-charge, Neonatal ICU

Swami Dayanand Hospital,

New Delhi, India

Dr. R.M.L. Hospital and PGIMER

New Delhi, India

WEBINAR

Improving hand washing among parent-attendants

entering the NICU in a Family Centered Care Model

Hand washing

• WHO: Clean Care Is Safer Care: Ha ds are main pathways of germ tra s issio

• Hand hygiene – Most important measure to avoid transmission of harmful germs.

• Any caregiver or person involved in direct or indirect patient care (Health Care Providers, Family, Paramedical staff etc.)

Why?

Who?

http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf

• Dr. R.M.L Hospital and PGIMER has an

NICU providing tertiary level care

In a Family Centered care Model (FCC) in a

16 bedded unit in an area of about 2500sq ft

• This was the first quality improvement initiative that we

undertook

• We contacted a Quality improvement advisor–A good decision

Setting

• Poor compliance among Parent-Attendants to hand washing

despite of AV training sessions as a part of FCC

• This was the first quality improvement initiative that we

undertook

• We contacted Quality improvement advisor–A good decision

Problem

Step 1: Identifying a problem, forming a team and writing an

aim statement

Step 2: Analyzing the problem and measuring quality of care

Step 3: Developing and testing changes

Step 4: Sustaining improvement

Our steps to improve hand washing practices in

NICU

Poor Compliance (20%) to hand hygiene (6 areas for

30 seconds followed by gowning) by Parent-

Attendant before entering into NICU

To increase compliance towards Hand hygiene (6

areas for 30 seconds followed by gowning) by

Parent or attendants entering NICU from 20% to

80% with in 8 weeks (5thJu e 6 - 5th August

2016)

Step 1: Problem Statement

Step 1: Aim Statement

Team members Numbers

Senior resident 1

Nurse In-charge 1

Staff Nurses 2

Sr. Quality Improvement Advisor 1

Project Coordinator 1

Nurse Coordinator 1

Total 7

Step 1: Forming a quality improvement team

Step 2: Analysis using Fishbone Analysis

PROCEDURE

• Sequential

organization

of place

lacking

Non - compliance by

Parent-attendant

With hand hygiene

POLICY

• No

Regular

training

schedule

Parent-attendant

• Knowledge gap

• Lacking Self Motivation

Doctor-Nurse

• Role designation for

trainings lacking

PEOPLE

• No Regular

Supplies

(Water, Soap,

Gowns) PLACE

• Less interactive

training

• No-onsite

Demonstrations

• Parent-Attendants observed for

– Full Compliance to hand hygiene

– Null compliance to hand hygiene

• 10 observations (4 out of 10 at night) over 24 h

• Indicator:

Observations with full compliance

%Observations with full compliance = ---------------------------------------X 100

Total number of observations

Step 2: Data collection

Definition of Compliance

Coverage of all 6 critical hand areas

Duration of 30 secs

Gowning following handwashing

Six critical

hand areas

requiring

cleaning

Observations

Area 1

Area 2

Area 3

Area 4

Area 5 Area 6

Duration

30sec Gown

compliance

1 Yes NO Yes Yes NO Yes NO Yes NO

2 Yes Yes Yes Yes Yes Yes Yes Yes Yes

3 NO Yes Yes NO Yes Yes Yes Yes NO

4 Yes Yes Yes Yes Yes NO Yes Yes NO

5 Yes Yes Yes NO NO Yes NO Yes NO

6 Yes Yes Yes Yes Yes Yes Yes Yes Yes

7 Yes Yes Yes Yes Yes NO Yes Yes NO

8 Yes Yes NO NO Yes Yes Yes Yes NO

9 Yes Yes Yes NO NO NO NO Yes NO

10 Yes Yes NO Yes NO Yes Yes Yes NO

Observations with full compliance

Total number of Observations

% compliance to handwashing

2

10

20%

Baseline Data: Observation Checklist (5/6/17)

Step 3: Developing and Testing Change Ideas

• Team came up with several change ideas for improvement

• Tested each of the ideas one by one with PDSA cycles

• This provision had a positive impact on

hand hygiene compliance

• ADOPT! Sequential arrangements of amenities around NICU continued

• NICU shifted to new premises, Provision of

Lockers, Sequential arrangement of

supplies

• Structural Changes and Sequential Arrangement of the Supplies

Plan Do

Study Act

PDSA Cycle-1 Structural Change(5th to 16th June 2016)

LOCKER & FOOT WEAR CHANGE

AREA

HAND WASHING

AREA

HAND DRYING

GOWNS ENTRY

INTO THE NICU

Nursing

Station

Intensive Care Area

EN

TR

Y

PA

SS

AG

E

Footwear

(inside

and

outside )

Nursing

station

Hand

Drying

Area

Hand

washing

Area Gowning

Area

Intensive Care Area

3

1 4 2

5

Process Flow: BEFORE QI

RANDOM

Sequence at

ENTRY AREA

Remove bangles, watch, rings, etc. tie your hair

Remove footwear; put on NICU slippers kept at

entrance

Washing hands (6 areas) for atleast 30 seconds.

Wearing a Gown

NICU Entry process flow

NICU Entry area pics : After reorganization of space

2 1

3

4

5

6 7

1-3 4 5 7 6

Box depicts Step number to be followed before entering inside the NICU

Breast

Feeding

Room

Step down Area

Intensive Care Area

1st

EN

TR

Y

Do

or

FCC Training Area

Gowning Area

PA

SS

AG

E

Ou

tsid

e

Foo

twe

ar

Hand washing Area

TV

Insi

de

Fo

otw

ea

r

Are

a

Ha

nd

Dry

ing

Are

a

2

Lock

ers

1

3

4

5

6

Locker & Foot Wear

Change Area

Hand Washing

Area

Hand Drying Area

Gowning area

Entry Into NICU

Change idea-1 AFTER reorganizing space(5th to 16th June 2016)

2n

d

EN

TR

Y

Do

or

0%

10%

20%

30%

40%

50%

60%

Results after PDSA 1(5th to 16th June 2016)

% o

bse

rva

tio

ns

wit

h f

ull

co

mp

lia

nce

Date

• This Intervention had a positive impact and

hand hygiene compliance increased

to 40%

• ADOPT! Daily training sessions rotation wise were undertaken by nurses

• Training roster with rotational duties to be made by the nursing in-charge and trainings to be done accordingly

• To engage staff nurses in FCC training according to Nurses training roster.

Plan Do

Study Act

PDSA Cycle-2 Change Of Trainer (17/6/16-21/6/16)

Results After PDSA 2 (17th to 21st June 2016)

Date

0%

10%

20%

30%

40%

50%

60%

% o

bse

rva

tio

ns

wit

h f

ull

co

mp

lia

nce

PDSA Cycle- 3 Peer Learning (22nd to 30th June 2016)

• This Intervention had a positive impact and hand

hygiene compliance increased to about 50%

• ADOPT! Interactive sessions were continued

• Peer to peer learning was encouraged

• Training sessions more interactive.

• Also Peer learning among mothers is encouraged

• Improving communication among trainers and mothers and peer learning

Plan Do

Study Act

Results after PDSA 3 (22nd to 30th June 2016)

Date

% o

bse

rva

tio

ns

wit

h f

ull

co

mp

lia

nce

0%

10%

20%

30%

40%

50%

60%

70%

06

/05

/16

06

/06

/16

06

/07

/16

06

/08

/16

06

/09

/16

06

/10

/16

06

/11

/16

06

/12

/16

13

/6/1

6

14

/6/1

6

15

/6/1

6

16

/6/1

6

17

/6/1

6

18

/6/1

6

19

/6/1

6

20

/6/1

6

21

/06

/16

22

/06

/16

23

/06

/16

24

/06

/16

25

/06

/16

26

/6/1

6

27

/6/1

6

28

/6/1

6

29

/6/1

6

30

/6/1

6

PDSA Cycle-4 Use of Glogerm (1st to 7th July 2016)

PDSA Cycle-4 Use of Glogerm (1st to 7th July 2016)

• This had a mixed impact and the

product was expensive

• ABANDONED!Discontinued

• Use of glo germ after training

• To introduce glogerm as a tool to demonstrate the importance of the Hand hygiene.

Plan Do

Study Act

Results after PDSA 4 (1/7/16-7/7/16)

Date

% o

bse

rva

tio

ns

wit

h f

ull

co

mp

lia

nce

0%

10%

20%

30%

40%

50%

60%

70%

PDSA Cycle-5 Peer Monitoring (8th to 15th July 2016)

• Had a negative impact lead to disharmony among attendants

• Abandoned!Discontinued

• experienced mothers were asked to check the compliance of new mothers

• To ask competent mothers to check on compliance towards hand washing of new mothers. (Peer Monitoring)

Plan Do

Study Act

Results after PDSA 5 (8th to 15th July 2016) %

ob

serv

ati

on

s w

ith

fu

ll c

om

pli

an

ce

Date

0%

10%

20%

30%

40%

50%

60%

70%

06

/05

/16

06

/07

/16

06

/09

/16

06

/11

/16

13

/6/1

6

15

/6/1

6

17

/6/1

6

19

/6/1

6

21

/06

/16

23

/06

/16

25

/06

/16

27

/6/1

6

29

/6/1

6

07

/01

/16

07

/03

/16

07

/05

/16

07

/07

/16

07

/09

/16

07

/11

/16

13

/07

/16

15

/7/1

6

PDSA Cycle-6 Selected CCTV footage (16th to 18th July 2016)

• Had a negative impact , lead to naming and shaming

• Abandoned!

• Discontinued

• Shown selected CCTV footage of correct and incorrect hand washing to a group of mothers.

• To show selected CCTV footage to a group of mothers doing 1)correct hand washing 2)Incorrect hand-washing Plan Do

Study Act

Result after PDSA 6(16th to 18th July 2016)

Date

% o

bse

rva

tio

ns

wit

h f

ull

co

mp

lia

nce

0%

10%

20%

30%

40%

50%

60%

70%0

6/0

5/1

6

06

/07

/16

06

/09

/16

06

/11

/16

13

/6/1

6

15

/6/1

6

17

/6/1

6

19

/6/1

6

21

/06

/16

23

/06

/16

25

/06

/16

27

/6/1

6

29

/6/1

6

07

/01

/16

07

/03

/16

07

/05

/16

07

/07

/16

07

/09

/16

07

/11

/16

13

/07

/16

15

/7/1

6

17

/7/1

6

PDSA Cycle-7 Random CCTV footage (19th July to 15th August 2016)

• Positive impact

• Adopted! This method was continued

• Shown random CCTV footage to a group.

• To show random CCTV footage to a group from a past date

Plan Do

Study Act

0%

20%

40%

60%

80%

100%

06

/05

/16

06

/08

/16

06

/11

/16

14

/6/1

6

17

/6/1

6

20

/6/1

6

23

/06

/16

26

/6/1

6

29

/6/1

6

07

/02

/16

07

/05

/16

07

/08

/16

07

/11

/16

14

/7/1

6

17

/7/1

6

20

/7/1

6

23

/7/1

6

26

/7/1

6

29

/7/1

6

08

/01

/16

08

/04

/16

08

/07

/16

10

/08

/16

13

/08

/16

Results after PDSA 7 (19th July to 15th August 2016) %

ob

serv

ati

on

s w

ith

fu

ll c

om

pli

an

ce

Date

Run Chart(Weekly)

Results:

The compliance to all six steps of hand washing for

30 sec followed by gowning among

parents/attendants of newborns admitted in the

NICU improved from 20% to 80% over a period of 9

weeks

PDSA 1: Structural changes and sequential arrangement of supplies Adopted

PDSA 2: Regular training with more of demonstrations and practice

sessions at real site

Adopted

PDSA 3: change in training methodology by ensuring a dedicated trainer

and reinforcement by peer learning

Adopted

PDSA 4: cross checking among mothers , but this lead to negative impact on

compliance

Abandoned

PDSA 5: Use of Glo Ger , did t have u h of i pa t Abandoned

PDSA 6: Use of CCTV footage where we identified a mother who is non

compliant, this bought negative impact on compliance

Abandoned

PDSA 7: Use of CCTV footage , where random footage of any attendant is

shown , made huge impact

Adopted

Conclusion

Key messages • Achieving hand hygiene compliance among parent-attendant is

Challenging yet Achievable

• Sequential reorganisation of entry area is important & effective

• Capacity building by healthcare providers is central but peer group

learning should be encouraged: is empowering

• Compliance is enhanced by encouragement & Impeded by punitive

methods

• Contacting QI coach or mentor is essential

• Continuing interventions that yield positive results lead to

sustenance of achievements

Acknowledgement

• USAID-ASSIST

• Our unit staff

/doctors and RML

Hospital

• Babies and their

families for

participation

Thank you!

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