Hand Hygiene and Bare Below the

Elbow Audit (Trust‐wide)

Audit Period: 11th February –1st March 2019

Report Date: 14th March 2019

Authors

Alice Page – Senior Information Analyst

Dawn Westmoreland – Senior Infection Prevention Nurse

 Executive Summary

Key Findings – Trustwide

Q2 18/19 Q4 18/19
Question
N % N %
5 Moments of Hand Hygiene Compliance 744 63% 982 62%
Before patient contact? 220 64% 336 62%
After patient contact or contact with 524 62% 646 62%
patient surroundings or completion of the
task?

Hand Sanitiser Compliance

Hand Sanitiser Availability 1750 94% 1852 89%
Hand Sanitiser Accessibility 1750 93% 1852 94%

Bare Below the Elbow Compliance 709 95% 793 95%

Areas of exemplary practice

Wards G14, GDCM, R05, R10, R12, R19, RKIN, and RSCB all achieved 100% compliance.

Key Actions
Give positive feedback to staff where good practice has been demonstrated
Feedback audit results to clinical staff to encourage a team approach to
service improvement and patient safety
Clinicians and senior nursing staff are expected to lead by example and
demonstrate compliance with the uniform and dress code policy
Discuss and promote hand hygiene activities at ward level, particularly around
observation and drug round
Action taken to be discussed at CMG IP meetings and evidence recorded on the IP
scorecard

Re‐audit period
April 2019
Page 2 of 13
Table of Contents
Executive Summary ......................................... Findings ...............................................................
2 5
Key Findings – Trustwide....................................... Thresholds of compliance......................................
2 5
Areas of exemplary practice.................................. Trustwide...............................................................
2 5
Key Actions Results by Staff Group .....................................
............................................................ 2 6
Re‐audit period...................................................... Breakdown by CMG ..........................................
2 7
Table of Contents .............................................. Comments ...........................................................
3 8
Abbreviations Summary................................................................
........................................................ 3 8
Introduction ....................................................... Recommendations.................................................
4 8
Why the audit was undertaken Action Plans ...........................................................
............................. 4 8
How the audit was carried out Detailed table of results ..............................
.............................. 4 10
Method Appendix 1: Audit tool .................................
.................................................................. 4 13
Sample ..................................................................
4

Abbreviations
CHUGS‐ Cancer, Haematology, Urology, Gastrology and Surgery
CMG – Clinical Management Group
EM – Emergency Medicine
HCA‐ Health Care Assistant
IPN – Infection Prevention Nurse
IPT‐ Infection Prevention Team
ITAPS‐ Intensive Therapy and Pain Management Services
MRSA – Meticillin‐Resistant Staphylococcus aureus
MSS‐ Musculoskeletal and Specialist Surgery
PPE – Personal Protective Equipment
RN – Registered Nurse
RRCV – Renal, Respiratory, Cardiac and Vascular Surgery
SM – Specialist Medicine
W&C – Womens and Childrens
Page 3 of 13
 Introduction

Why the audit was undertaken

To demonstrate compliance with the Health and Social Care Act 2010, compliance with policies to
reduce the risk of infection must be audited regularly and performance results fed back to clinical
teams. The wards audit their own hand hygiene practice on a monthly basis and the aim of this
audit is to provide a quality check on a biannual basis.
Please note ‘bare below the elbows’ has been added to the audit to monitor compliance with the
recently reviewed UHL Uniform and Dress Code Policy B30/2010v2. This is reported as a
single element and does not affect the overall hand hygiene compliance score.

How the audit was carried out

The audit is carried out by the Infection Prevention Team. A data collection tool has been
developed in order to record the compliance information which can be captured during
observed practice and/or review of the environment documentation. The elements measured
have been revised in line with findings from significant US reviews of audit processes and
accuracy. The recommendation discussed at the 2016 Infection Prevention Society conference
was that ‘moments’ 2 and 3 are not easily observed as these activities generally take place behind
curtains or closed doors. Moments 4 and 5 are interchangeable therefore have been combined as
a single observation following contact with a patient.

Method

This audit was carried out by the Infection Prevention Team. A tool was developed in FORMIC by
a Senior Information Analyst and tested by the team prior to use. The data collection tool is
reviewed annually to ensure the elements measured are in line with current best practice
guidance. The audit data collection was conducted over a three week period in order to observe a
representative sample of staff groups across the three UHL sites. This information is collated
and analysed in Microsoft Excel and the report is produced.

Please note the Infection Prevention Team have altered the order of their audit programme.
The team now audit Standard Precautions in Q1 and Q3 and audit Hand Hygiene in Q2 and
Q4. This enables them to have assurance of hand hygiene practices during the winter months,
when we are more likely to see outbreaks of infections such as Norovirus and Influenza.

Sample
982 observations were carried out across 90
wards.
CMG Number Descriptive of wards
of
Wards

CHILDREN’S 9 F30, FPIC, R10, R11, R12, R14, R19, R27, RCIC
CHUGS 14 G20, G22, G23, G26, G27, G28, G29, R08, R22, R39, R40, R41, R42, R43
EM 10 ED, GPAU, R34, RACB, RAFU, RAMU, RCED, RCSSU, REDU, REFU
ITAPS 3 AICU, GDCM, RITU
MSS 9 G14, G18, G19, R09, R17, R18, R32, RASU, RKIN

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 F15, F16, F17, F20, F23, F26, F27, F28, F29, F31, F32, F33, F33a, FCCU, FCDU, G10, G15A,
RRCV 19
G15N, G17
SM 16 G3, GBIU, GNRU, R21, R23, R24, R25, R26, R29, R30, R31, R33, R36, R38, RHAMP, RIDU
WOMEN’S 10 G11, G30, G31, GSCB, R05, R06, RGAU, RMAU, RNNU, RSCB

Page 5 of 13
 Findings

Thresholds of compliance
Key: Adherence Adherence Adherence
> 90% 60% – 90% < 60%

Trustwide
Remedial action required for areas below 90%
Q2 18/19 Q4 18/19
Question
N % N %
5 Moments of Hand Hygiene Compliance 744 63% 982 62%
Before patient contact? 220 64% 336 62%
After patient contact or contact with 524 62% 646 62%
patient surroundings or completion of the
task?

Hand Sanitiser Compliance

Hand Sanitiser Availability 1750 94% 1852 89%
Hand Sanitiser Accessibility 1750 93% 1852 94%

Bare Below the Elbow Compliance 709 95% 793 95%

Page 6 of 13
Results by Staff Group

A total of 769 staff members were observed carrying out 782 hand hygiene opportunities
Staff Group Previous Overall Number Hand Hygiene Before After patient
audit Q4 of Staff Opportunities patient contact or
Overall Q2 contact? contact with
patient
surroundings or
completion of
the task?
Medical Staff 51% 55% 149 177 56% 54%
RN 69% 66% 256 333 61% 69%
Student Nurse 70% 48% 41 50 52% 45%
HCA 59% 56% 158 194 62% 53%
Bank Staff 29% 0% 2 3 0% 0%
Support Staff 65% 78% 75 87 81% 77%
Medical Student 0% 63% 12 19 63% 64%
Housekeeper 77% 87% 26 31 100% 83%
Domestic 50% 55% 24 22 0% 57%
Midwife 100% 75% 6 8 33% 100%
ODP 0% N/A 0 0 N/A N/A
Agency Staff 100% N/A 0 0 N/A N/A
Other 51% 64% 49 58 61% 65%

Page 7 of 13
 Breakdown by CMG
Remedial action required for areas below 90%

Questions Children’s CHUGS EM ITAPS MSS RRCV SM Women’s

Q2 Q2 Q2 Q4 Q4 Q2 Q2
18/19 Q4 18/19 Q4 18/19 18/19 Q2
18/ 18 /19 18/19 Q4 Q2 Q4 18/ 19 Q4
18/ Q2 Q4
18/19 18/19 19 18/19 18/19 18/19 19 18/19 18/19
Overall Hand Hygiene
Compliance 69% 82% 67% 65% 47% 57% 64% 86% 58% 73% 67% 42% 59% 61% 75% 74%

Before patient contact? 72% 82% 76% 71% 34% 50% 46% 81% 64% 71% 76% 46% 60% 55% 86% 75%
After patient contact or contact
with patient surroundings 67% 82% 65% 62% 53% 61% 73% 90% 56% 73% 64% 40% 58% 65% 72% 73%
or completion of the task?

Hand Sanitiser Compliance

Hand Sanitiser Availability 99% 100% 98% 96% 90% 82% 100% 100% 89% 77% 95% 91% 93% 87% 98%
81% Hand Sanitiser Accessibility 98% 90% 98% 99% 90% 95% 90% 100% 86% 100% 93% 92% 92% 89% 97%
99%

Bare Below the Elbow Compliance 92% 97% 97% 91% 93% 92% 97% 83% 97% 98% 94% 97% 95% 97% 97%
94%

Page 7 of 13
Comments

Summary
Trust‐wide there has been a 1% decrease in compliance of the trust‐wide hand hygiene
moments observed in this audit since Q2 18/19.

It is positive to see that trust‐wide the bare below the elbow criteria has remained above
90%. However when reviewing the CMG individual results slight improvement is still required
to get all areas above 90%.

There has been a drop in the availability of hand sanitiser from 94% to 89%. Please continue
to ensure that the availability of hand sanitisers is checked at the start of each shift and that
staff are aware it is everyone’s responsibility to replace any missing sanitisers.

Childrens, EM, ITAPS, MSS and SM have all made an improvement when reviewing at their overall
CMG hand hygiene score since quarter 2.

Recommendations
Give positive feedback to staff where good practice has been demonstrated

Feedback audit results to all clinical staff to encourage a team approach to

service improvement and patient safety

Clinicians and senior nursing staff are expected to lead by example and
demonstrate compliance with the uniform and dress code policy

All staff are expected to challenge poor practice if witnessed

Ward staff who carry out local hand hygiene audits should book onto a hand hygiene
audit training session. These sessions are currently available on HELM.

It has been agreed by the Chief Nurse that wards scoring less than 60% are expected to
improve practice in their area to achieve 60% or above. Wards scoring 60‐90% are
expected to make at least 5% incremental increases to their hand hygiene compliance
by the re‐audit. Please use action plan template below to document your wards agreed
actions.

Action Plans
The audit results must be fed back at ward level. Results should be discussed at the CMG IP
meetings and where compliance is below 90% remedial actions with a completion date and
named lead identified and recorded on the IP scorecard. These will be reviewed at the
quarterly Trust Infection Prevention Assurance Committee meeting.

Page 8 of 13
 Objective Agreed Action By Whom By
When

Feed results back to all staff at

ward level
Share audit report within your CMG
meeting
Wards scoring less than 60% to
achieve above 60% by the following
audit. Wards scoring between 60‐90%
to achieve a 5% incremental increase
in their hand hygiene compliance
CMG’s to provide assurance to the
next TIPAC of measureable actions to
improve areas of low compliance.

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 Detailed table of results
After patient
contact or
contact with
patient Bare
Before surroundings Below Availability Accessibility
Overall Overall Patient or completion the of Hand of Hand
Q2 18/19 Q4 19/20 Contact? of the task? Elbow Sanitiser Sanitiser

UHL 63% 62% 62% 62% 95% 89%

94% Childrens 69% 82% 82% 82% 97% 100%
90% F30 70% 69% 50% 86% 88% 100%
100% FPIC 57% 82% 100% 71% 100% 100%
0% R10 83% 100% 100% 100% 100% 100%
100% R11 83% 70% 0% 78% 90% 100%
100% R12 100% 100% 100% 100% 100% 100%
100% R14 N/A 70% 100% 50% 100% 100%
100% R19 83% 100% 100% 100% 100% 100%
100% R27 N/A 70% 75% 67% 100% 100%
100% RCIC 42% 90% 100% 83% 100% 100%
0% CHUGS 67% 65% 71% 62% 91% 96%
99% G20 100% 44% 100% 29% 100% 94%
94% G22 25% 25% 17% 33% 100% 95%
95% G23 NC 67% 67% 67% 83% 100%
100% G26 69% 64% 50% 71% 88% 100%
100% G27 83% 71% 50% 88% 100% 100%
100% G28 100% 73% 100% 63% 80% 100%
100% G29 82% 89% 100% 86% 90% 100%
100% R08 78% 50% 33% 57% 80% 93%
100% R22 100% 62% 100% 44% 100% 100%
100% R39 33% 63% N/A 63% 90% 100%
100% R40 36% 69% 100% 50% 100% 95%
100% R41 38% 77% 100% 70% 78% 100%
100% R42 80% 61% 67% 56% 89% 86%
100% R43 NC 88% 88% 88% 100% 86%
100% EM 47% 57% 50% 61% 92% 82%
95% ED 55% 20% 0% 22% 80% N/A
N/A GPAU 67% 44% 0% 80% 100% N/A
N/A R34 22% 75% 67% 80% 90% 81%
95% RACB 58% 46% 0% 60% 90% 100%
100% RAFU 70% 56% 67% 44% 100% 63%
70% RAMU 36% 70% 0% 78% 100% N/A
N/A RCED 25% 50% 67% 44% 70% 100%
100% RCSSU 100% 78% 100% 67% 100% 58%
86% REDU 50% 44% 0% 67% 100% 92%
Page 10 of 13
100% REFU 46% 72% 67% 78% 100% 75%
100%

Page 11 of 13
 After patient
contact or
contact with
patient Bare
Before surroundings Below Availability Accessibility
Overall Overall Patient or completion the of Hand of Hand
Q2 18/19 Q4 19/20 Contact? of the task? Elbow Sanitiser Sanitiser

ITAPS 64% 86% 81% 90% 83% 100% 100%

AICU 43% 75% 67% 83% 100% 100% 100%
GDCM 92% 100% 100% 100% 60% 100% 100%
RITU 62% 80% 83% 75% 89% 100% 100%
MSS 58% 73% 71% 73% 98% 77% 100%
G14 50% 100% 100% 100% 100% 90% 100%
G18 N/A 57% 100% 40% 100% 94% 100%
G19 86% 80% 75% 83% 100% 0% N/A
R09 100% 55% 0% 60% 90% 100% 100%
R17 50% 92% 75% 100% 100% 100% 100%
R18 64% 67% 0% 75% 100% 50% 100%
R32 36% 57% 75% 50% 90% 100% 100%
RASU 100% 50% 67% 40% 100% 100% 100%
RKIN N/A 100% N/A 100% 100% 50% 100%
RRCV 67% 42% 46% 40% 97% 91% 92%
F15 67% 36% 33% 38% 100% 97% 97%
F16 75% 36% 0% 44% 100% 73% 100%
F17 50% 42% 33% 44% 100% 77% 100%
F20 100% 40% N/A 40% 100% 86% 100%
F23 38% 10% 17% 0% 89% 79% 91%
F26 67% 36% 100% 13% 100% 100% 100%
F27 NC 57% 50% 63% 100% 100% 100%
F28 67% 8% 0% 13% 90% 100% 100%
F29 11% 43% 20% 56% 100% 96% 100%
F31 90% 36% 63% 0% 100% 100% 97%
F32 100% 50% 100% 38% 100% 88% 93%
F33 58% 29% 20% 33% 94% 97% 100%
F33a 100% 55% 100% 44% 100% 100% 100%
FCCU 63% 33% 100% 25% 88% 100% 100%
FCDU 50% 50% 40% 57% 100% 79% 15%
G10 92% 67% 60% 71% 100% 100% 89%
G15A 100% 80% 100% 75% 100% 78% 100%
G15N 89% 67% 100% 57% 100% 100% 100%
G17 17% 42% 43% 40% 88% 93% 100%

Page 12 of 13
 After patient
contact or
contact with
patient Bare
Before surroundings Below Availability Accessibility
Overall Overall Patient or completion the of Hand of Hand
Q2 18/19 Q4 19/20 Contact? of the task? Elbow Sanitiser Sanitiser

SM 59% 61% 55% 65% 97% 87%

89% G3 83% 88% 100% 80% 100% 100%
100% GBIU N/A 75% 75% 75% 90% 100%
100% GNRU 38% 70% 67% 71% 100% 88%
100% R21 56% 50% N/A 50% 100% 89%
100% R23 67% 90% 100% 88% 100% 89%
100% R24 60% 70% 67% 71% 90% 96%
100% R25 54% 56% 33% 100% 100% 56%
0% R26 42% 45% 50% 40% 100% 61%
100% R29 67% 43% 50% 38% 100% 76%
100% R30 64% 64% 40% 83% 100% 86%
100% R31 73% 55% 50% 60% 100% 90%
100% R33 64% 82% 100% 80% 90% 100%
100% R36 71% 40% 0% 44% 100% 71%
100% R38 50% 69% 71% 67% 100% 93%
0% RHAMP NC 67% 83% 50% 100% 100%
100% RIDU 0% 40% 20% 60% 90% 89%
100% Womens 75% 74% 75% 73% 94% 81%
99% G11 N/A 42% 50% 38% 78% 100%
100% G30 67% 54% 67% 50% 100% 96%
95% G31 70% 78% 100% 71% 89% N/A
N/A GSCB 67% 80% 80% 80% 100% 100%
92% R05 88% 100% 100% 100% 100% 100%
100% R06 100% 67% 33% 83% 100% 100%
100% RGAU 67% 88% 100% 75% 83% 83%
100% RMAU 100% 80% 50% 100% 100% N/A
N/A RNNU 71% 90% 83% 100% 100% 100%
100% RSCB 50% 100% 100% 100% 100% 100%
100%

Page 13 of 13
Appendix 1: Audit tool

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