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‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene

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Summary

Hand hygiene is a core element of patient safety for the prevention of healthcare-associated infections and the spread of antimicrobial resistance. Its promotion represents a challenge that requires a multi-modal strategy using a clear, robust and simple conceptual framework. The World Health Organization First Global Patient Safety Challenge ‘Clean Care is Safer Care’ has expanded educational and promotional tools developed initially for the Swiss national hand hygiene campaign for worldwide use. Development methodology involved a user-centred design approach incorporating strategies of human factors engineering, cognitive behaviour science and elements of social marketing, followed by an iterative prototype test phase within the target population. This research resulted in a concept called ‘My five moments for hand hygiene’. It describes the fundamental reference points for healthcare workers (HCWs) in a time–space framework and designates the moments when hand hygiene is required to effectively interrupt microbial transmission during the care sequence. The concept applies to a wide range of patient care activities and healthcare settings. It proposes a unified vision for trainers, observers and HCWs that should facilitate education, minimize inter-individual variation and resource use, and increase adherence. ‘My five moments for hand hygiene’ bridges the gap between scientific evidence and daily health practice and provides a solid basis to understand, teach, monitor and report hand hygiene practices.

Introduction

Healthcare-associated infections (HCAIs) represent a major risk to patient safety and contribute towards suffering, prolongation of hospital stay, cost and mortality.1, 2 Hand hygiene is the core element to protect patients against HCAIs and colonisation with multi-resistant micro-organisms.3 Cleansing hands with alcohol-based hand rub is a simple and undemanding procedure that requires only a few seconds.4, 5 If hand rub is easily available at each point of care, hand hygiene can also easily be integrated in the natural workflow – even in high-density care settings.6, 7, 8 However, most healthcare workers (HCWs) practice hand hygiene less than half as often as they should.9, 10

Reasons for neglecting hand hygiene have been investigated and include forgetfulness, fear of skin damage, lack of time due to other patient care priorities, and scarce or inconvenient access to hand rub and sinks.11, 12 However, one essential element is frequently overlooked: the quality of the information and training dispensed to HCWs to explain why, when and how to apply hand hygiene during routine care activity. Yet, there is accumulating evidence that failure to comply with good practice is often due to poor design, whether it be device-related, human–machine interfaces or, importantly, process design.13, 14, 15 This includes misleading language, complicated descriptions, or poor definition of target outcomes.16

Several disciplines such as human factors engineering and ergonomics, social marketing, pedagogy, and communication science have been found to be helpful in bridging the gap between scientific literature and user-centred, error-proof products and processes.17, 18, 19, 20 When measured against these standards, the concept of hand hygiene has been poorly assessed from these perspectives until now. Even infection control experts have difficulties in reaching a consensus on the relative risk levels of different care activities and how to best define key moments for hand hygiene action.

Building on the longstanding experience at the University of Geneva Hospitals and work on tool development in the framework of the Swiss national hand hygiene campaign and the WHO Global Patient Safety Challenge ‘Clean Care is Safer Care’, we developed a user-centred concept for recognising when hand hygiene should be done, as well as training, performance assessment and reporting.6, 7, 8, 11, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32 We describe here the design process of the concept, the rationale for elements included, and its potential practical use.

Section snippets

Requirement specifications for a user-centred hand hygiene concept

The main specifications for the concept are given in Table I. Importantly, it must result in a minimal complexity and density of hand hygiene actions, integrate well into a natural workflow, but still attain a maximum preventive effect. For applicability across a wide range of care settings and healthcare professions, it must also create a unified approach without losing the necessary detail to produce meaningful data for risk analysis and feedback.

The concept should be absolutely congruent in

‘My five moments for hand hygiene’ explained

The geographical representation of the two zones and the two critical sites (Figure 2A) is useful to introduce the five moments for hand hygiene. The correlation between these five moments and the indications for hand hygiene according to WHO Guidelines on Hand Hygiene in Healthcare27 is given in Table II. To further facilitate ease of recall and expand the ergonomic dimension, the five moments for hand hygiene are numbered according to the habitual care workflow (Figure 2B).

Moment 1: Before patient contact

From the two-zone

Discussion

Hand hygiene as it is understood today requires three to 30 applications of hand rub per hour during patient care which translates to one hand rub application up to every 2 min during intensive care activities.3, 4, 6, 7, 8, 11, 21, 27, 59 The reality, however, is that unobserved HCWs only perform very few hand hygiene actions during their work day. The magnitude of the task of fixing this substandard quality of care has challenged infection control professionals worldwide for many years.60, 61

Acknowledgements

The authors wish to thank all members of the Infection Control Programme, University of Geneva Hospitals, in particular M.-N. Chraiti and P. Herrault; Swiss Hand Hygiene participating hospitals and SwissNOSO members; G. Teague for fruitful exchange on social marketing strategies; B. Gordts, MD, for discussion; R. Sudan for outstanding editorial assistance; members of the WHO ‘Clean Care is Safer Care’ core group: D. Goldmann, H. Richet, W.H. Seto, A. Voss; the Global Patient Safety Challenge

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