Innovative Approaches to Promote Nursing Hand Hygiene Success in an Emergency Department

Proper hand hygiene is known to be highly effective in reducing the spread of infection between patients. Compliance monitoring in the emergency department, however, presents unique challenges. Patient acuity, rapid serial patient contact, in-patient boarding, and overcrowding issues contribute to this complexity. In 2008, a quality improvement project in the Johns Hopkins Hospital Emergency Department was launched to educate, support and empower staff to achieve higher rates of hand hygiene. Barriers specific to emergency care were identified by an inter-professional team of emergency department and infection prevention staff. Identified barriers included: implementing a sustainable practice model; access to necessary hand sanitizer and sinks; multi-patient rooms; proactive mitigation of skin breakdown; educating “secret shopper” observers on ED processes; and the need for consistent coaching and feedback. Different practice approaches were tested, with hand hygiene at room entry/exit resulting in higher observed compliance than immediately prior to physical contact with the patient. Other solutions to barriers were initiated, such as additional hand sanitizer dispensers, visual cues, and weekly internal observations and feedback to providers and staff by the departmental safety officer, nurse educator and clinical nurse specialist. Over time, monthly compliance observations showed improvement from an initial low of 30% to a consistent 70%. Progress then plateaued, resulting in an innovative method to track and trend individual staff compliance, with rapid feedback to team leaders for reinforcement coaching, and transitioning of internal observations to the nursing supervisor team. This, along with transition to a new clinical space with private patient rooms, allowed additional momentum to be achieved, resulting in sustainment of 90% compliance via secret shopper observations. Additional inventive methods have included individual and team recognition, availability of results for team comparisons, and engaging student volunteers to help with real-time feedback. Lessons learned thus far have included the need for: early engagement of “nay-sayers,” a continued inter-professional approach, the power of physical cues (i.e. door frames), and continued and frequent staff performance feedback.