Infection Prevention Manual

& +$//(1*(6 72 $1' 6 75$7(*,(6 )25 , 03529(0(17 It is important to investigate the reasons for non-adherence to hand hygiene guidelines before deciding on one or more improvement strategies. It is also useful to examine the Agency context of health care delivery, which may facilitate or inhibit adherence. Such organizational factors include the following: • The Agency’s physical capacity for making products available • The presence of written hand hygiene policies and procedures • The active involvement of leadership “from the top down” • The presence of role models • The degree of accountability for non-adherent staff • The presence of a culture of safety • The active involvement of staff in improvement efforts • The awareness and involvement of patients and families Staff hand hygiene practices will be improved in our Agency through efforts such as the following: • Education, training, in-services • Timely feedback, supervisors reports • Reminders, evaluations, assessments, direct observation • Structured approaches to performance improvement CENTER FOR DISEASE CONTROL AND PREVENTION (CDC) HAND HYGIENE Recommendations Categories These recommendations are designed to improve handhygiene practices of HCWs (Healthcare workers) and to reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. As in previous CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. The CDC/HICPAC system for categorizing recommendations is as follows: Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies. Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale. Category IC. Required for implementation, as mandated by federal or state regulation or standard. Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale. No recommendation. Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist. A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items (IA) . Alternatively, wash hands with an antimicrobial soap and water in all clinical situations. C. Decontaminate hands before having direct contact with patients (IB) D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB) E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB) F. Decontaminate hands after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient) (IB) G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) H. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care (II) I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) J. Decontaminate hands after removing gloves (IB) Your Agency Name (PN System)