By Linda Weld, RN, MSN, CIC, and Jane Kirk, MSN, RN, CIC
Hand hygiene compliance and the prevention of healthcare-associated infections (HAIs) is a challenge in any healthcare setting. Pediatric hospitals have both unique issues and opportunities in the performance of hand hygiene. Many of the patients are unable to understand or comply with hand hygiene due to their age or physical condition.
Children may have chronic conditions that impact their resistance to infection, such as cystic fibrosis and medications for conditions such as arthritis or asthma, and their lack of previous exposure to a specific pathogen. Parents and other family members play a critical role in the care of the child. They may assist with care measures while the child is hospitalized to both learn the activities they will need to perform at home and to provide a familiar and comforting presence while the child is in the facility.
Texas Scottish Rite Hospital for Children (TSRHC) in Dallas, Texas is an orthopedic children’s hospital performing spinal and other surgical procedures. TSRHC is one of the nation's leading pediatric centers for the treatment of orthopedic conditions, certain related neurological disorders and learning disorders, such as dyslexia. The hospital was recently awarded by U.S. News & World Report the No. 1 ranking for 2013-14 to the combined TSRHC and Children’s Medical Center (CMC) pediatric orthopedic program. The program includes 18 TSRHC orthopedic surgeons who care for children with a range of orthopedic conditions at TSRHC, and in collaboration with University of Texas Southwestern Medical School at two CMC facilities. TSRHC treats children with orthopedic conditions such as scoliosis, club foot, hand disorders, and hip disorders. The facility sees patients from the state of Texas and has links in the international community. The patient population includes those that may be staying for two to four months for staged procedures and physical therapy. Often times the parents stay with the child for the duration of the hospitalization. This provides an opportunity for hand hygiene and infection control education as parents participate in the care of their child and continue the care after taking the child home. Many of the international patients are from areas with very different cultural beliefs and knowledge on the importance of hygiene measures. Some of these patients come from areas where basic services which we take for granted, such as electricity or running water inside the home, are not available.
Preventing the patients from acquiring infections post-surgery is a challenge that TSRHC takes very seriously. The most common HAIs following surgical procedures are surgical site infections (SSIs), complicating up to 22 percent of all operative procedures.(1) A study done of HAIs in 61 PICUs in the United States, an SSI incidence of approximately 6 percent in 110,000 patients studied was reported. The study reported that on average, the length of stay and financial costs were significantly increased (10.6 days and $27,288, respectively) for each pediatric patient with a potentially preventable SSI.(2)
Recently TSRCH adapted electronic hand hygiene compliance monitoring as part of their process to improve hand hygiene and prevent HAIs. According to the Centers for Disease Control and Prevention (CDC) hand hygiene is the number one way to prevent HAIs.(3) The system chosen was the GOJO SMARTLINK™ Hand Hygiene Solutions which incorporates innovative measurement tools to track and report real-time hand hygiene compliance rates as a stand- alone system.
The system works by providing a sensor above the patient doorway that tracks entry/exits as hand hygiene "opportunities", while the SMARTLINK™ Technology in the soap/sanitizer dispensers calculate the hand hygiene "events." All information is sent via an internet gateway to the software system. The software calculates the hand hygiene events over opportunities into the "compliance rate." These measurements are provided by way of feedback screens to the staff and provide constant awareness of their hand hygiene compliance. These measurements are group based and capture everyone who walks into the patient’s room, including visitors.
After several weeks of baseline measurement, a GOJO clinician-based support team partnered with TSRHC to implement processes to improve the electronic measurements. This included ensuring administrative and leadership support, and guiding frontline caregivers to determine how they wanted to improve hand hygiene compliance. Using the Six Sigma DMAIC process, the multidisciplinary performance improvement team determined their strategy to improve hand hygiene compliance. Some of these strategies included competition between the clinic staff, parent and patient education and developing a pamphlet for them, a Hand Hygiene Awareness Day, hand hygiene coloring books for the patients, Staff education – both individual and group, individual feedback, and ongoing communication between the hospital and the vendor.
Observations were done to determine the percentage of entries and exits into the room that were related to families and visitors. This demonstrated that between 25 percent to 30 percent of the activity in and out of the rooms were related to families and visitors and validated a need for family and visitor education. Families are more aware of the need for hand hygiene and are being encouraged to remind all people who enter the room to clean their hands before caring for their child.
The changing of hand hygiene behaviors is not something that can be accomplished quickly. It requires frequent feedback to staff and celebrating small victories. Systems that can assist in giving feedback to the staff are important in changing practices and should be a part of the activities in a program to improve hand hygiene.
Linda Weld, RN, MSN, CIC, is an infection preventionist at Texas Scottish Rite Hospital.
Jane Kirk, MSN, RN, CIC, is clinical director at GOJO Industries, Inc.
1. Rosenthal, A. et al (2013). Text of Infection Control and Epidemiology 3rd Edition Chapter 39, Pediatrics. Association for Professionals in Infection Control and Epidemiology.
2. Sparling, K.W. et. al. (2007). Financial Impact of failing to prevent surgical site infections. Quality Management in Health Care 16(3)219-225.
3. Boyce, JM.et al (2002).Guideline for Hand Hygiene in Health-Care Settings. Morbidity and Mortality Weekly Report 51: No.RR16.