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HOSPITAL AUTHORITY CONVENTION 2016 Service Enhancement Presentations
F7.7 Committed and Happy Staff 13:15 Room 421
Hand Hygiene Campaign in Siu Lam Hospital — a Participative and Transdisciplinary Approach
Tso S, Que TL, Mui HCJ, Au CNJ, Kan CH, Lee STC
Siu Lam Hospital, Hong Kong
Introduction
Siu Lam Hospital (SLH) is a 500-bed hospital providing infirmary services to adults with severe learning disabilities. They are
vulnerable to various kinds of infections. From 2013 to 2014, total number of confirmed cases requiring cohort nursing for
nosocomial or gastrointestinal infections increased from 52 to 71 with an average length of cohort duration raised from 14
days to 17 days. Besides, there were 5 and 11 staff being diagnosed with related infection during the outbreak period in 2013
and 2014 respectively. Hand hygiene is most effective in preventing healthcare-associated infections and the best strategy
to protect healthcare workers from infections. To foster a culture that values the importance of hand hygiene practice, we
developed and adopted a new strategy involving participation of the whole healthcare team of SLH with strong support from
hospital management and the Cluster Infection Control Team.
Objectives
(1) To prevent healthcare-associated infections through enhancement of hand hygiene practice; (2) to increase staff
awareness on the importance of hand hygiene in combating infections; (3) to establish role modelling in hand hygiene
practice; and (4) to foster a culture that treasures hand hygiene practice.
Wednesday, 4 May Methodology
(1) A task force including nurses, allied health colleagues, doctor and cluster Infection Control Nurses (ICNs) was formed
in July 2015. (2) Badge was designed and produced to signify the hand hygiene ambassadors. A hand hygiene song was
created by frontline staff. ICNs of New Territories West Cluster (NTWC) provided souvenirs to reinforce hand hygiene practice
and rendered timely feedback to clinical staff. (3) New staff was engaged to ensure succession of the new culture. (4) Hand
hygiene ambassadors were recruited to act as role models and buddies. (5) Presentations were held in various departmental
meetings. Kick-off ceremony was held in November 2015. NTWC CC(MHI) SLH Consultants, General Manager (N),
Department Operations Manager(P), Senior Nursing Officer (ICN) and NTWC Safety Coordinator led the handprint ceremony
that hallmarked support and commitment of top management. (6) Promotional activities including broadcasting hand hygiene
song in clinical areas, displaying poster, dispatching souvenir, taking photo and enhancing hand hygiene equipment/facility
were conducted.
Results
A hospital-wide staff opinion survey with 67% (260 staff) response rate was conducted in January 2016. 79% to 85% agreed
the hand hygiene song strengthened their memory on the “five moments” and “seven steps” of hand hygiene. 92% agreed
that the campaign enhanced hand hygiene practice and enriched their understanding on the importance of hand hygiene
practice. 88% replied that they liked the campaign. The number of hand hygiene ambassadors increased from 56 to 116
across different ranks and disciplines which indicated an increase of 107% within four months. Up till January 2016, we have
62 (27%) supporting workers, 33 (30%) frontline nurses, 11 (48%) nurse supervisors, 2 (33%) medical staff and 8 (38%) allied
health colleagues volunteered themselves to be the hand hygiene ambassadors. It represents 30% of the workforce of SLH.
The overall hand hygiene compliance increased from 82.8% (October 2015) to 97.5% (March 2016). The average number of
patients being infected during outbreaks was reduced by 69% and the average duration of cohort nursing was reduced by
30%. Thus, patient safety was also improved.
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