Clean Care is Safer Care

Case study

Ramsay Health Care, Indonesia

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Submitted by:

Rosdelima Simarmata
Ramsay Health Care
Tangerang, Indonesia

What type of health-care facility or organization are you?

Three Ramsay Health Care Hospitals, situated in Indonesia.

What was the situation at your facility with respect to hand hygiene and HAI before you initiated the hand hygiene initiatives?

The reason to initiate hand hygiene promotion was that there was inconsistent hand washing before and after caring for patients, particularly if staff touched the environment around patients, and there was a risk of transmission.

We planned to measure hand hygiene compliance by hospital hand hygiene teams and made it as a quality project for the three hospitals. The project was supported by management who helped by improving and providing more hand basins. Some hand basins had touchable tap handles and this contaminated the hands of staff and patients who used it.

The project started in October 2007 and continued to 2009.

What were the goals of your initiative?

The objectives were:
- to determine level of staff hand hygiene compliance;
- to evaluate hand hygiene items usage as this also had a financial impact;
- to evaluate effectiveness of education that was given related to hand hygiene practices;
- to encourage nursing staff to improve hand hygiene practice and increase awareness;
- to reduce cross infection rates related to inadequate hand hygiene;
- to encourage evidence based practice e.g. WHO Advance Draft within the hospitals.

The project included both clinical and non clinical staff.

What actions have you planned or already put in place to improve hand hygiene at your facility?

- Constituted a hand hygiene team at each hospital;
- Developed and implemented hand hygiene questionnaires (clinical staff and non clinical staff) and a check list for observation for clinical staff and focused on technique.
- Used WHO questionnaire in Bahasa language and also observation check list;
- Performed compliance surveys in October 2007, January 2008, April 2008 and March 2009;
- Conducted education sessions in class rooms;
- Provided hand rub at each bed in high risk areas such as ICU, High care, Emergency unit, Recovery room and dialysis unit and also on each trolley;
- Provided WHO poster "5 Moments for Hand Hygiene" in each nurse station and entry area and hand hygiene information as screen saver on each computer in Bahasa language;
- Participated in 5 May 2009 initiative by encouraging staff, doctors, patients and visitors to perform hand hygiene by using ' WHO 5 Moments for Hand Hygiene' at point of care.

Did you encounter any particular problems while planning and implementing your strategy?

- inconsistency of practice is still found occasionally;
- lack of compliance particularly if busy.

Strategies to overcome the barriers:
- remind staff of the importance of good hand hygiene for the health of patients, themselves and family;
- promote a "no-blame culture" through ongoing development of positive relationships.
- Encourage staff to perform hand hygiene routinely.
- Provide hand rub at point of care such as each trolley, each bed, as well as at high risk areas.

What were the outcomes of your initiatives?

- Surveys showed that there was improvement in nurse/midwife hand hygiene from 40% to 88%.
- The last survey showed an increase in paper towel usage by 20%; hand rub, and hand soap usage increased by over 100%.
- Infections reduced from 2007 - August 2009: SSI from 12 to 3 cases, UTI from 4 to 2 cases, phlebitis from 57 to 13 cases bacteraemia from 31 to 2 cases and VAP from 9 to 3 cases.
- Task force to ensure good hand hygiene established within 3 hospitals;
- Full support by each hospital's management particularly financial commitment in respect to facilities such as additional hand basins, long handle taps, hand rubs, paper towels and soap at each hand basins;
- Strong recommendation from Australian Infection Control Auditors (Health Infection Control Management Resources (HICMR)) the hospitals infection control auditors for the past 8 years as part of quality project for patient safety. This is a requirement by the Indonesian Department of Health; - Ongoing development of a good relationship with all staff.

What were your key learning points?

- Continuous improvement belongs to everybody all the time;
- All feedback was positive from staff, doctors and visitors.

What are your future directions?

- We will continue surveys, focus on busy hours and increase sample size, and consider involving doctors in these.
- We have recommended adding additional hand rub stations in public areas such as waiting rooms, admissions desk and OPD if possible.
- One day a month is nominated to be "hand hygiene day".
- We are considerubg using CCTV as a monitor to observe hand hygiene practices.