Carbapenem-Resistant Enterobacteriaceae (CRE) Control and Prevention Toolkit

Background: Efforts to prevent HAI often benefit from the collection, comparison, and sharing of data on fundamental infection control practices such as hand hygiene.

Instructions: This observation tool can be used to systematically collect data about hand hygiene compliance during multiple hand hygiene opportunities. The tool itself contains instructions about how to best carry out such observations.

Use: Data can be used to identify baseline hand hygiene practices, and then later to see how education and awareness activities may have changed behaviors.

Hand Hygiene Compliance Report

Instructions for Using the Hand Hygiene Observation Tool

1. This tool will be used for quality improvement purposes only. Not to be used for punitive purposes.
2. The purpose of this tool is to collect baseline data about current compliance with the CDC Hand Hygiene Guideline. Hand hygiene means using an alcohol-based antiseptic or soap before and after contact of any kind with a patient or his/her immediate environment. Under certain circumstances, the guideline calls for the use of nonsterile gloves. There is also a circumstance in which an alcohol-based antiseptic is not sufficient and actual hand washing must take place.
3. Data collection needs to be done discreetly, ideally by someone who would normally be in the unit, so that the person's presence is not thought to be unusual. Keep observation tools in a discreet location to minimize influence on current behaviors. It is important to have reliable baseline data.
4. Some suggestions for completing this tool:
   1. Identify your unit and date.
   2. Under staff category, identify the job category of the person you are observing.
   3. A key is listed at the bottom of the tool. For example, a staff physician code is MD, a nurse code is RN, chaplain is CHAP, and so on.
   4. Each category has a column for yes and no. Yes means the individual observed proper hand hygiene as specified on the left side of the tool, or no the individual did not. Make a hash mark for each yes or no. You may have multiple hash marks for each person you are observing in both columns and even within one category of patient contact. Each hash mark represents a discreet observation.
   5. Try to observe the behavior of every job category, not just nurses and doctors. This includes any employee who may have contact with the patient, including x-ray technicians, social workers, respiratory therapists, etc.
   6. Try to get a representative sample that reflects the true number of opportunities for hand hygiene in your unit. This means you could expect more hash marks for nurses than doctors and more for doctors than chaplains. One way to do this is to try to observe a single room for 5 minutes at a time.
   7. This tool can be completed at different times.

Send completed forms to the Infection Control Unit.

Hand Hygiene Compliance Report—Please Fax To [Fax number] (Infection Prevention Office) When Completed

Instructions: Observe practice. Include a variety of disciplines. NOTE: Hand Hygiene refers to use of alcohol foam hand rub or washing hands with soap and water for a least 15 seconds. Make a CHECK (√) for each hand hygiene opportunity. Please submit a minimum of 30 observations per month per unit.

Name of person completing observation sheet: _________________________________________________________

Date(s):______________________________________

Specify which campus i.e., for example: ___ Main Hospital ___ Amb Site [specify site & address or unit]: ________________________________________

Staff Titles: MD=Attending/Resident/Fellow; MS=Medical Student; RN = Registered Nurse; NA = Nursing Assistant; RT=Respiratory Therapy; XR=X ray; IVT=IV Team; DT=Dietitian; CHAP=Chaplain; SW=Social Worker: Other=identify.

Developed by Montefiore Medical Center for the Agency for Healthcare Research and Quality.