Download DVD answer key - Public Health Ontario

Hand Hygiene Training Scenarios for
Health Care Providers and Observers –
DVD Answer Key
Version 1.3
Instructions
•
The Training DVD is a tool included in the Just Clean Your Hands program
to provide practical demonstrations of each of the the 4 Moments for Hand
Hygiene
•
These slides are designed to accompany the DVD and provide answers to
the different scenarios
•
The DVD includes 5 menu items:
• Your 4 Moments for Hand Hygiene (animation)
• Training Scenarios (for health care providers and observers)
• Observer Scenarios (for observers)
• Hand Hygiene Techniques (for health care providers and observers)
• Acknowledgements
•
The menu bar allows you to freely switch between scenarios. It is
recommended that you follow the order as presented.The complexity of the
scenarios increases as you work through the scenarios.
2
Instructions
• The menu item Hand Hygiene Techniques includes the correct technique
for handwashing and handrubbing
• The scenarios have been separated into two sets. One for all health care
providers and one for observers.
• Training Scenarios 1 to 4 are intended to be used to train both health care
providers and observers. Each scenario is dedicated to one of the 4
Moments for Hand Hygiene.
• Observer Scenarios 5 to 8 are intended to be used by observers. These
scenarios show examples of sequences of health care during which
several indications for hand hygiene occur. Missed hand hygiene
indications are shown in some scenarios and duplicate scenarios are also
provided showing an example of 100 per cent compliance.
• After completing the Scenarios, it is recommended the observer practice
auditing in the clinical setting or a simulated environment followed by a
discussion.
3
SCENARIO 1
Before initial patient/patient environment contact
1a - Before initial patient environment contact
Content:
• The nurse opens the door (last contact with health care environment), enters
the room and goes towards the patient and introduces herself
• Before initial contact with patient environment, nurse performs hand
hygiene (handrubbing)*
• The nurse moves the bedside table (contact with object in patient environment)
• The nurse helps the patient to bring out his arm from under the sheets
(first patient contact)
Key messages: The nurse performs hand hygiene while approaching the
patient environment. The nurse handrubs before touching surfaces and
objects. As these are part of patient’s environment, it is not necessary to
perform hand hygiene again before touching the patient. The indication
remains “before initial patient/patient environment contact.”
*Note: Observers will time this indication.
4
SCENARIO 1
Before initial patient/patient environment contact
1a - Before initial patient environment contact
5
SCENARIO 1
Before initial patient/patient environment contact
1b - Before initial patient contact
Content:
• The nurse opens the door (last contact with health care environment), enters the
room and goes towards the patient
• The nurse performs hand hygiene (handrubbing) on entry to room*
• The nurse helps the patient to bring his arm from under the sheets (first patient
contact)
Key messages: Hand hygiene is required before patient contact to protect the
patient from harmful germs carried on hands from the health care environment
outside the patient’s environment. The indication remains “before initial
patient/patient environment contact”.
*Note: Observers will time this indication.
6
SCENARIO 1
Before initial patient/patient environment contact
1b - Before initial patient contact
7
SCENARIO 1
Before initial patient/patient environment contact
1c – Before initial patient/patient environment contact (missed)
Content:
• The nurse performs handrubbing in the corridor (hand hygiene action is useless)
• The nurse is on her way to the room and suddenly remembers she needs to
make a phone call. The nurse uses the phone in the waiting area (last contact
with health care environment) and then goes directly into the room towards
the patient
• The nurse helps the patient to bring his arm out from under the sheets
(hand hygiene action missed)
Key messages: After performing hand hygiene in the corridor (additional action
not corresponding to any recommended indication), the nurse then touches the
phone in the waiting area and thus potentially contaminates her hand with
germs belonging to the health care environment.The nurse then misses the
action before initial patient/patient environment contact, potentially
contaminating her with those germs.
8
SCENARIO 1
Before initial patient/patient environment contact
1c – Before initial patient/patient environment contact (missed)
9
SCENARIO 1
Before initial patient/patient environment contact
1d - Repeated patient contacts
Content:
• The nurse opens the door (last contact with health care environment), enters the room
and goes towards the patient
• While entering, the nurse performs hand hygiene (handrubbing)*
• The nurse helps the patient to bring his arm out from under the sheets and measures
his blood pressure (first patient contact)
• The nurse moves to the other side of the bed
• The nurse moves the bedside table (contact with patient environment)
• The nurse takes the patient’s right arm and assesses finger mobility (patient contact)
• The nurse bends down to examine the urine content in the bag without touching anything
and then touches the bed while standing up (contact with patient environment)
Key messages: The sequence shows several contacts with the patient and his
environment, but with no aseptic procedure nor body fluid exposure risk. Hand hygiene is
correctly performed only once, before the first patient contact/patient environment. There is
no need for further hand hygiene actions because the nurse is always moving within the
patient environment.
*Note: Observers will time this indication.
10
SCENARIO 1
Before initial patient/patient environment contact
1d - Repeated patient contacts
11
SCENARIO 2
Before aseptic procedure
2a - Aseptic procedure within a care sequence
Content:
• The nurse enters the room and places the equipment ready for giving an IV medication on
the overbed table (last contact with health care environment)
• The nurse performs hand hygiene by handrubbing (indication: before initial patient/
patient environment contact)*
• IMED pump alarms so nurse resets pump (contact with patient environment)
• The nurse moves the overbed table (contact with patient environment)
• The nurse performs hand hygiene by handrubbing (indication: before aseptic
procedure)
• The nurse cleans the IV port and injects the medication into the IV port (aseptic
procedure)
Key messages: The nurse has a first direct contact with the patient (she performs hand
hygiene as indicated) and the patient environment; she then repeats the hand hygiene
action before the aseptic procedure to protect the patient from her own organisms.
*Note: Observers will time this indication.
12
SCENARIO 2
Before aseptic procedure
2a - Aseptic procedure within a care sequence
13
SCENARIO 2
Before aseptic procedure
2b - Aseptic procedure only
Content:
• The nurse places the equipment ready for injection on the overbed table
• The patient is lying in bed with an IV catheter in her arm directly accessible
to the nurse
• The nurse performs hand hygiene by handrubbing (indication: before
aseptic procedure)
• The nurse cleans the IV port and injects the medication into the IV port
(aseptic procedure without direct patient contact)
Key messages: The aseptic procedure is the very first and unique indication
in this scenario. The nurse has no direct contact with the patient.
14
SCENARIO 2
Before aseptic procedure
2b - Aseptic procedure only
15
SCENARIO 3
After body fluid exposure risk
3a - Body fluid exposure risk within a care sequence (missed)
Content:
• The gloved nurse in the room punctures the patient’s finger and squeezes
drops of blood onto a strip and then tests with the glucometer (blood exposure
risk)
• When the nurse finishes, she places the lancet in the sharps container and
then places the alcohol swab in the garbage. She then takes off her gloves
and places them into the garbage (continuing blood exposure risk)
• Hand hygiene action missed (indication: after body fluid exposure risk)
• The nurse takes the patient's pulse (next patient contact)
Key messages: Hand hygiene must be performed immediately after body fluid
exposure risk, before touching either the patient again or any surface and
object within the patient environment or health care environment, to prevent
potential dissemination of organisms. Any care activity implying contact with
body fluids constitutes a risk because exposure may not be visible but may
have happened.
16
SCENARIO 3
After body fluid exposure risk
3a - Body fluid exposure risk within a care sequence (missed)
17
SCENARIO 3
After body fluid exposure risk
3b - Body fluid exposure risk within a care sequence
Content:
• The gloved nurse in the room punctures the patient’s finger and squeezes drops
of blood onto a strip and then tests with the glucometer (blood exposure risk)
• When the nurse finishes, she places the lancet in the sharps container and then
places the alcohol swab in the garbage. She then takes off her gloves and
places them into the garbage.
 The nurse performs hand hygiene by handrubbing (indication: after
body fluid exposure risk)
 The nurse takes the patient's pulse (next patient contact)
Key messages: The nurse performs correct and timely handrubbing
immediately after body fluid exposure risk; her hands are not visibly soiled
and she does not need to handwash.
18
SCENARIO 3
After body fluid exposure risk
3b - Body fluid exposure risk within a care sequence
19
SCENARIO 3
After body fluid exposure risk
3c - Body fluid exposure risk (handwashing)
Content:
• The nurse’s hands get wet with urine found on the sheets. The nurse discovers
that the Foley catheter has become disconnected. The nurse had not
anticipated there would be urine under the patient, therefore she did not have
gloves on (body fluid exposure risk).
• The nurse washes her hands with soap and water (after body fluid risk
exposure)
Key messages: The nurse performs correct and timely hand hygiene after
body fluid exposure risk.The nurse performs hand hygiene by handwashing.
Handwashing with soap and water is recommended when hands are visibly
soiled.
20
SCENARIO 3
After body fluid exposure risk
3c - Body fluid exposure risk (handwashing)
21
SCENARIO 4
After patient/patient environment contact
4a After patient/patient environment contact
Content:
• The Respiratory Therapist (RT) is at the patient’s bedside. The RT checks the
chest sounds on the patient (last patient contact)
• The RT performs hand hygiene (handrubbing) at the end of the bed*
• The RT leaves the patient and goes to record on the chart or computer on wheels
(C.O.W.) that is kept outside the patient environment
Key messages: The charting area is not part of the patient environment,
therefore hand hygiene is performed after patient/patient environment contact,
before leaving the patient environment and going to record in the chart.
*Note: Observers will time this indication.
22
SCENARIO 4
After patient/patient environment contact
4a After patient/patient environment contact
Note: On the Observation Tool for long term care homes
the HCP (category) code is 14 A
23
SCENARIO 4
After patient/patient environment contact
4b – After patient environment contact
Content:
• The pharmacist discusses with the patient the medications the patient was
on before coming to hospital. The pharmacist goes into the patient drawer
to verify what medications the patient has been taking
• The pharmacist performs hand hygiene (handrubbing) at the end of
the bed*
• The pharmacist leaves the room
Key messages: There is no contact with the patient, but hand hygiene must
still be performed after contact with objects and surfaces in the patient’s
environment when leaving patient environment.
*Note: Observers would time this indication if they could see the entire
time taken to do the handrub, but in this scenario they do not, so it is not
timed.
24
SCENARIO 4
After patient/patient environment contact
4b – After patient environment contact
Note: On the Observation Tool for long term care homes
the HCP (category) code is 14 B
25
SCENARIO 4
After patient/patient environment contact
4c - after patient contact
Content:
• The social worker (SW) is having a discussion with the patient
• The SW shakes the patient’s hands at the completion of the discussion
(first patient contact)
• The SW performs hand hygiene by handrubbing;(indication: after
patient/patient environment contact) as he leaves the room
Key messages: There is contact with the patient, so hand hygiene must
be performed when leaving patient’s environment. It is recorded as “after
patient/patient environment contact.”
*Note: Observers would time this indication if they could see the
entire time taken to do the handrub but in this scenario they do not,
so it is not timed.
26
SCENARIO 4
After patient/patient environment contact
4c - after patient contact
27
SCENARIO 5
Between patients
5a - Between patients (missed)
Content: (2 bed room)
• The doctor shakes patient X’s hand as he leaves bedside
• Hand hygiene action missed (indications: after patient/patient
environment contact and before initial patient/patient environment
contact, but it is one opportunity)
• He approaches patient Y, greets her and shakes her hand
Key messages: Two indications occur (after patient/patient environment
contact and before initial patient/patient environment contact) and correspond
to one single opportunity that requires one single hand hygiene action.
28
SCENARIO 5
Between patients
5a - Between patients (missed)
29
SCENARIO 5:
Between patients
5b - Between patients (100 per cent compliance)
Content: (2 bed room)
• The doctor shakes patient X’s hand as he leaves her bedside
• The doctor performs hand hygiene by handrubbing (indications: after
patient/patient environment contact and before initial patient/patient
environment contact,* but it is one opportunity)
• The doctor approaches patient Y, greets her and then lifts the sheets to
examine her
Key messages: same sequence as 6a, but with properly performed hand
hygiene (100 per cent compliance).
*Note: Observers will time this indication.
30
SCENARIO 5:
Between patients
5b - Between patients (100 per cent compliance)
31
SCENARIO 6
Care sequence break
6a - Care sequence break (missed)
Content:
• The doctor enters the room and goes towards the patient
• While entering, the doctor performs hand hygiene by handrubbing (indication:
before initial patient/patient environment contact)* (less than 15 seconds)
• The doctor shakes the patient's hand and is about to examine her knee
• The pager beeps, the doctor excuses herself and leaves the room to answer the phone
in the corridor (hand hygiene action missed; indication: after patient/patient
environment contact)
• The doctor comes back through the open door
• The doctor carries on with the physical examination (hand hygiene action missed;
indication: before initial patient/patient environment contact)
Key messages: A care sequence break occurs (the doctor answering the phone in the
corridor, outside the patient’s environment).Therefore, the doctor should perform hand
hygiene after leaving the patient (to prevent transmission of germs from the patient to the
health care environment), and before touching the patient again (to prevent transmission
of germs from the health care environment to the patient).These care breaks should be
avoided as much as possible.
*Note: Before initial patient/patient environment contact to be timed.
32
SCENARIO 6
Care sequence break
6a - Care sequence break (missed)
33
SCENARIO 6
Care sequence break
6b - Care sequence break (100 per cent compliance)
Content:
• The doctor enters the room and goes towards the patient
• While entering she performs hand hygiene by handrubbing (indication: before
initial patient/patient environment contact)*
• The doctor shakes the patient's hand and is about to examine her knee
• The pager beeps, the doctor excuses herself to answer the phone
• The doctor leaves the room while performing hand hygiene by handrubbing
(indication: after patient/patient environment contact)*
• The doctor comes back through the open door while performing hand hygiene by
handrubbing (indication: before initial patient/patient environment contact)*
• The doctor carries on with the physical examination
Key messages: Same sequence as 6a, but with correctly performed hand hygiene (100
per cent compliance). Assess and plan care sequences to decrease the number of times
hands must be cleaned.
*Note: Observers will time before initial patient/patient environment and after
patient/patient environment contact.
34
SCENARIO 6
Care sequence break
6b - Care sequence break (100 per cent compliance)
35
SCENARIO 7
Patient examination
7a - Patient examination (missed)
Content: Scene: 2 bed room
• The doctor is beside the patient and listens to his heartbeat
• The nurse comes into the room
• The nurse performs hand hygiene by handrubbing (indication: “before initial patient /patient environment
contact”)
• The nurse helps the doctor to prop the patient up in bed
• The doctor examines the patient's lungs
• The doctor puts on gloves to examine the patient's mouth using a tongue depressor and a pen light
• Hand hygiene action missed by doctor (indication: “before aseptic procedure”)
• The nurse performs hand hygiene by handrubbing (additional hand hygiene action, unnecessary)
• The doctor helps the patient to open his mouth and examines the mucous membrane (contact with mucous membrane)
• Some saliva drips and the doctor wipes away the saliva (body fluid exposure)
• The doctor throws the wipes and tongue depressor into the garbage and then takes off his gloves
and throws them into the same garbage
• Nurse leaves room
• The doctor completes his examination
• Hand hygiene action missed (indication: “after body fluid exposure”)
• The doctor leaves the patient’s room
Open discussion - only record what you see
36
SCENARIO 7
Patient examination
7a - Patient examination (missed)
37
SCENARIO 7
Patient examination
7b - Patient examination (100 per cent compliance)
Content: Scene: 2 bedroom
• The doctor is beside the patient and listens to his heartbeat
• The nurse comes into the room
• The nurse performs hand hygiene by handrubbing (indication: before initial patient /patient environment
contact)*
• The nurse helps the doctor to prop the patient up in bed
• The doctor examines the patient's lungs
• The doctor performs hand hygiene by handrubbing (indication: before aseptic procedure)
• The doctor puts on gloves to examine the patient's mouth using a tongue depressor and a pen light
• The doctor helps the patient to open his mouth and examines the mucous membrane (contact with mucous
membrane)
• Some saliva drips and the doctor wipes away the saliva (body fluid exposure)
• The doctor throws the wipes and tongue depressor into the garbage and takes off his gloves and throws them
into the same garbage.
• The doctor performs hand hygiene by handrubbing (indication: after body fluid exposure)
• The doctor palpates the patient's abdomen
• The nurse performs hand hygiene by handrubbing (indication: after patient/patient environment contact)*
• The doctor performs hand hygiene by handrubbing on the way out of the room (indication: after
patient/patient environment contact)*
Key messages: same sequence as 7a, but with correctly performed hand hygiene (100 per cent
compliance). *Note: Observers will time before initial patient/patient environment contact. Observers
would time after patient/patient environment if they could see the entire time taken to do the handrub, but
in this scenario they do not, so it is not timed.
38
SCENARIO 7
Patient examination
7b - Patient examination (100 per cent compliance)
39
SCENARIO 8
Starting an IV
Content:
• 2 nurses are entering the room. A senior nurse has the equipment to start an IV.
• The senior nurse (A) explains the procedure to the patient
• The new grad nurse (B) then comes into the room through an open door and cleans hands at the end
of the bed (before patient/patient environment contact) *
• The new grad nurse touches the environment/equipment
• The senior nurse positions the patient and puts the blue pad under the arm
• The new grad nurse assesses the equipment for doing the procedure without touching it
• The senior nurse performs hand hygiene by handrubbing (indication: before aseptic procedure).
• The senior nurse dons gloves The new grad nurse opens the pack of sterile swabs
• The new grad nurse opens the pack containing the syringe
• The senior nurse disinfects the puncture site
• The senior nurse inserts the IV catheter into the vein
• The senior RN’s pager goes off, so she asks the new grad nurse to find out what the page is about
• The new grad nurse leaves the room, but cannot be observed
• The senior nurse applies a sterile dressing over the IV site
• The senior nurse takes used equipment and pad and disposes of them
• The senior nurse takes off gloves
• Senior nurse starts to perform hand hygiene by handrubbing (indication: after body fluid
exposure risk.)
*Note: Observers will time before patient/patient environment contact.
40
SCENARIO 8
Starting an IV
Key messages:
• The senior nurse goes over and touches the patient without performing hand
hygiene. Since it cannot be observed whether the senior nurse had performed
hand hygiene on entering the room, a missed hand hygiene action should not
be recorded
• The new grad nurse cleaned hands before touching the patient/patient
environment
• Subsequently, the senior nurse correctly performed hand hygiene before
aseptic procedure
• The senior nurse correctly performs hand hygiene after body fluid exposure
risk following starting the IV
• Since it cannot be observed whether the new grad nurse had performed hand
hygiene on leaving the room, a missed hand hygiene action should not be
recorded
41
SCENARIO 8
Starting an IV
42
Acknowledgement
•
The Ministry of Health and Long-Term Care would like thank the WHO World Alliance
for Patient Safety for sharing its Clean Care is Safer Care materials. This presentation
includes concepts from “Instructions to Use Training Films” of Clean Care is Safer Care,
the WHO multimodal hand hygiene improvement strategy developed by the World
Alliance for Patient Safety.
43