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REVIEW My ve moments for hand hygiene a usercentred design approach to understand train monitor and report hand hygiene H

Sax B Allegranzi IUc 57528kay E Larson J Boyce D Pittet Infection Control Programme University of Geneva Hospitals Geneva Switzerland Global Patient Safety Challenge World Alliance for Patient Safety World Health Organization Geneva Switzerland S

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REVIEW My ve moments for hand hygiene a usercentred design approach to understand train monitor and report hand hygiene H






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Myvemomentsforhandhygiene:auser-centreddesignapproachtounderstand,train,monitorandreporthandhygieneH.Sax,B.Allegranzi,I.Uckay,E.Larson www.elsevierhealth.com/journals/jhin bridgesthegapbetweenscienticevidenceanddailyhealthpracticeandprovidesasolidbasistounderstand,teach,monitorandreporthandhy-gienepractices.2007TheHospitalInfectionSociety.PublishedbyElsevierLtd.Allrightsreserved.Healthcare-associatedinfections(HCAIs)repre-sentamajorrisktopatientsafetyandcontributetowardssuffering,prolongationofhospitalstay,costandmortality.HandhygieneisthecoreelementtoprotectpatientsagainstHCAIsandcol-onisationwithmulti-resistantmicro-organisms.Cleansinghandswithalcohol-basedhandrubisasimpleandundemandingprocedurethatrequiresonlyafewseconds.Ifhandrubiseasilyavail-ableateachpointofcare,handhygienecanalsoeasilybeintegratedinthenaturalworkoweveninhigh-densitycaresettings.However,mosthealthcareworkers(HCWs)practicehandhygienelessthanhalfasoftenastheyshould.Reasonsforneglectinghandhygienehavebeeninvestigatedandincludeforgetfulness,fearofskindamage,lackoftimeduetootherpatientcarepriorities,andscarceorinconvenientaccesstohandrubandsinks.However,oneessentialel-ementisfrequentlyoverlooked:thequalityoftheinformationandtrainingdispensedtoHCWstoex-plainwhy,whenandhowtoapplyhandhygieneduringroutinecareactivity.Yet,thereisaccumu-latingevidencethatfailuretocomplywithgoodpracticeisoftenduetopoordesign,whetheritbedevice-related,humanmachineinterfacesor,importantly,processdesign.Thisincludesmisleadinglanguage,complicateddescriptions,orpoordenitionoftargetoutcomes.Severaldisciplinessuchashumanfactorsengi-neeringandergonomics,socialmarketing,peda-gogy,andcommunicationsciencehavebeenfoundtobehelpfulinbridgingthegapbetweenscienticliteratureanduser-centred,error-proofproductsandprocesses.Whenmeasuredagainstthesestandards,theconceptofhandhygienehasbeenpoorlyassessedfromtheseperspectivesuntilnow.Eveninfectioncontrolexpertshavedifcul-tiesinreachingaconsensusontherelativerisklevelsofdifferentcareactivitiesandhowtobestdenekeymomentsforhandhygieneaction.BuildingonthelongstandingexperienceattheUniversityofGenevaHospitalsandworkontooldevelopmentintheframeworkoftheSwissna-tionalhandhygienecampaignandtheWHOGlobalPatientSafetyChallengeCleanCareisSaferCare,wedevelopedauser-centredconceptforrecognisingwhenhandhygieneshouldbedone,aswellastraining,performanceassessmentandreporting.Wedescribeherethedesignprocessoftheconcept,therationaleforelementsincluded,anditspotentialpracticaluse.RequirementsanddevelopmentRequirementspecicationsforauser-centredhandhygieneconceptThemainspecicationsfortheconceptaregivenTableI.Importantly,itmustresultinaminimalcomplexityanddensityofhandhygieneactions,integratewellintoanaturalworkow,butstillat-tainamaximumpreventiveeffect.Forapplicabil-ityacrossawiderangeofcaresettingsandhealthcareprofessions,itmustalsocreateauni-edapproachwithoutlosingthenecessarydetailtoproducemeaningfuldataforriskanalysisandfeedback.Theconceptshouldbeabsolutelycongruentindesignandmeaningtotrainers,observersandtheobservedHCWs.Thishasthedualpurposeofavoidinganylackofclaritybyanexpertpersongapandtocutdownontrainingtimerequirementandexpenditure.Moreover,thesharingofauniedvisionshouldleadtoastrongsenseofownership.Additionally,conceptrobust-nessisequallyinstrumentalbothtoavoidinter-observervariationandtoguaranteeintra-hospital, TableIRequirementspecicationsforauser-centredhandhygieneapplicationconceptConsistentwithevidence-basedriskassessmentofhealthcare-associatedinfectionsandspreadofmulti-resistantmicro-organismsStealthintegrationintoanaturalcareworkowEasytolearnLogicalclarityoftheconceptApplicableinawiderangeofhealthcaresettingsMinimisingthedensityoftheneedforhandhygieneMaximalconceptcongruencebetweentrainers,observers,andhealthcareworkers H.Saxetal. inter-hospitalandinternationalcomparisonsandcommunication.Finally,characteristicsknowntoneurosciencetoincreaselearningandfacilitateuptakesuchaslimitednumberofitems,clusteringofitems,sym-metry,rhythm,plainandmeaningfulterminology,colourcodes,clarityandlogic,highsignal-to-noiseratio,andcorrespondencetopre-existingconceptsintheconcernedpopulationwereappliedduringthedesignprocesswheneverpossible.Healthcare-associatedcolonisationandinfection:thenegativeoutcometargetsForconceptualclarity,itisusefultorevisittwodistinctoutcomesoftransmissionpathways.Colo-nisationdenotesthepresenceofmicro-organismsonbodysiteswithoutinvadingthetissueandwithouttriggeringasymptomatichostdefencereaction;infectiondenotestissueinvasionofmicro-organismstriggeringaninammatoryhostresponse.Transmissionofmicro-organismsfromthehealth-careenvironment(e.g.furniture,equipment,walls,doors,documents,neighbouringpatients,etc.)toapatientmostoftenresultsincross-colonisationandnotininfection.38,39Cross-colonisationwithmulti-resistantmicro-organismsrepresentsanimportanttargetforpreventionbecauseitcontributestoin-creasingantimicrobialresistanceandthereservoirofpotentialpathogens.40,41Withrespecttocross-colonisation,itisimpor-tanttorecognisethreefacts:rst,colonisedorinfectedpatientsrepresentthemainreservoirforhealthcare-associatedmicro-organisms;second,theenvironmentinthehealthcarefacilitycontainsawidevarietyofdifferenthealthcare-associatedmicro-organismsandrepresentsasecondarysourcefortransmission;andthird,theimmediatepatientenvironmentbecomescolonisedbythepatientora.Cross-transmissioncanresultinexogenousHCAI,inparticularifthepatientsdefenceagainsttheimplicatedmicro-organismisloworifitisdirectlyintroducedintoavulnerablebodysite,ormucousmembrane.MostHCAIs,however,areofanendogenousnature,andduetomicro-organismsalreadycolo-nisingthepatientbeforetheonsetofinfec-Thisimpliesthathandsmayplayaroleinthisprocessbytransferringmicro-organismsfromacolonisedbodysitetoacleanoneinthesamepatient,e.g.fromtheperineumtoatrachealtube,orfromthelegskintoacatheterhub.inducedbreaksofphysicalandbiologicaldefencemechanismsbyinvasiveproceduresanddevicesrepresentriskfactorsforinfection.Inadditiontopatientcolonisationand/orinfec-tion,twoadditionalnegativeoutcomesaretargetedbyhandhygiene:infectioninHCWswithpathogenscontainedinbodyuidsandcross-colonisationofinanimateobjectsinthehealthcareenvironmentandcolonisationofHCWsbypatientora.Insummary,fournegativeoutcomesconstitutethepreventiontargetforhandhygiene:(i)cross-colonisationofpatients;(ii)endogenousandex-ogenousinfectioninpatients;(iii)infectioninHCWs;and(iv)cross-colonisationofthehealthcareenvironmentincludingHCWs.ThecoreelementofhandtransmissionDuringdailypractice,HCWshandstypicallytouchacontinuoussequenceofsurfacesandsubstancesincludinginanimateobjects,patientsintactornon-intactskin,mucousmembranes,food,waste,bodyuidsandtheHCWsownbody.Thetotalnumberofhandexposuresinahealthcarefacilitymightreachasmanyasseveraltensofthousandsperday.Witheachhand-to-surfaceexposureabidirec-tionalexchangeofmicro-organismsbetweenhandsandthetouchedobjectoccursandthetransienthand-carriedoraisthuscontinuouslychanging.Inthisway,micro-organismscanspreadthroughoutahealthcareenvironmentwithinafewhours.Anevidence-basedhandtransmissionmodelhasbeendescribedelsewhere.Inbrief,weillus-tratethecoreelementsstrippeddowntotheirsimplestlevelinFigure1.Effectivehandcleansingcanpreventtransmissionofmicro-organismsfromsurfaceAtosurfaceBifappliedatanymomentduringhandtransitionbetweenthetwosurfaces.Typically,surfaceAcouldbeadoorhandlecolon-isedbymeticillin-resistantStaphylococcusaureus(MRSA)andsurfaceBtheskinofapatient.Iftrans-missionofmicro-organismsbetweenAandBwouldresultinoneofthefournegativeoutcomesde-tailedabove,thecorrespondinghandtransitiontimebetweenthesurfacesisusuallycalledahandhygieneopportunity.Ifavoidable,nottouchingAorBorbothwouldbeanotherveryef-fectivewayofpreventingcross-contaminationandinfection.TouchingtwiceinarowsurfaceBwouldequallynotgenerateaneedforhandhygiene.Hence,itfollowsclearlythatthenecessityforhandhygieneisdenedbyacoreelementofhandtransmissionconsistinginadonorsurface,areceptorsurfaceandhandtransitionfromthersttothesecond.Merelydescribingahandhy-gieneopportunityasamomentbeforeexecutingacertaincaretaskisanoversimplicationandwillbediscussedinafurthersection. Myvemomentsforhandhygiene11 Conceptualisationoftherisk:twozones,twocriticalsitesToachievetheobjectiveofcreatingauser-centredconcept,weoptedforadirecttranslationoftheevidence-basedhandtransmissionmodeldescribedabovetoapracticaldescriptionofhandhygieneindications.Thetermszoneandcriticalsiteswereintroducedtoallowageographicalvisual-isationofkeymomentsforhandhygiene(Figure2Focusingonasinglepatient,thehealthcaresettingisdividedintotwovirtualgeographicalareas,thepatientzoneandthehealthcarezoneFigure2AandB).ThepatientzonecontainsthepatientXandhis/herimmediatesurroundings.Thistypicallyin-cludestheintactskinofthepatientandallinanimatesurfacesthataretouchedbyorindirectphysicalcontactwiththepatientsuchasthebedrails,bedsidetable,bedlinenandinfusiontubingandothermedicalequipment.ItfurthercontainssurfacesfrequentlytouchedbyHCWswhilecaringforthepatientsuchasmonitors,knobsandbuttons,andotherhighfrequencytouchsurfaceswithinthepatientzone.Themodelassumesthatthepatientorarapidlycontaminatestheentirepatientzone,butthatitisbeingcleanedbetweenpatientadmissions.ThehealthcarezonecontainsallsurfacesoutsidethepatientzoneofpatientX,i.e.allotherpatientsandtheirpatientzonesandthehealthcarefacilityenvironment.Conceptually,thehealthcarezoneiscontaminatedwithmicro-organismsthatmightbeforeignandpotentiallyharmfultopatientX,eitherbecausetheyaremulti-resistantorbecausetheirtransmissionmightresultinexogenousinfection. Figure1Coreelementofhandtransmission.(1)DonorsurfaceAcontainsmicro-organismsa;receptorsurfaceBmicro-organismsb.(2)Ahandpicksupamicro-organismafromdonorsurfaceAandcarriesitovertoreceptorsurfaceB,nohandhygieneactionperformed.(3)ReceptorsurfaceBisnowcross-contaminatedwithmicro-organismainadditiontooriginalorab.Thearrowmarkstheopportunityforhandhygiene,e.g.thetimeperiodandgeographicaldislocationwithinwhichhandhygienewillpreventcross-transmission;theindicationsforhandhygienearedeterminedbytheneedtoprotectsurfaceBagainstcolonisationwithathepreventablenegativeoutcomeinthisexample. H.Saxetal. PATIENT ZONEHEALTHCARE ZONEPATIENTCONTACTPATIENTCONTACTCONTACTS WITHPATIENTSURROUNDINGSTASKAFTER BODY FLUID Figure2UniedvisualsforMyvemomentsforhandhygiene.Patientzonedenedasthepatientsintactskinandhis/herimmediatesurroundingscolonisedbythepatientoraandhealthcarezonecontainingallothersurfaces.(A)Symbolsforcleansiteandbodyuidsite,twocriticalsitesforhandhygienewithinthepatientzone.(B)ZonesandsiteswithinsertedtimespacerepresentationofMyvemomentsforhandhygiene. Myvemomentsforhandhygiene13 Withinthepatientzone,twocriticalsitesshouldbedistinguished(Figure2A):cleansitescorre-spondingtobodysitesormedicaldevicesthathavetobeprotectedagainstmicro-organismspo-tentiallyleadingtoHCAIs,andbodyuidsiteslead-ingtohandexposuretobodyuidsandblood-bornepathogens.Criticalsitesmayco-exist:drawingbloodforexamplewouldresultinacleansiteandabodyuidsiteatthesametimeatthesiteofneedleperforationoftheskin.Theaddedvalueofcriticalsitesliesintheirpotentialuseinvisualmaterialandtraining:risk-pronetasksbecomegeographicallylocatedandhencemorepalpable.TheconceptanditspracticalMyvemomentsforhandhygieneThegeographicalrepresentationofthetwozonesandthetwocriticalsites(Figure2A)isusefultoin-troducethevemomentsforhandhygiene.ThecorrelationbetweenthesevemomentsandtheindicationsforhandhygieneaccordingtoWHOGuidelinesonHandHygieneinHealthcaregiveninTableII.Tofurtherfacilitateeaseofrecallandexpandtheergonomicdimension,thevemo-mentsforhandhygienearenumberedaccordingtothehabitualcareworkow(Figure2Moment1:BeforepatientcontactFromthetwo-zoneconcept,amajormomentforhandhygieneisnaturallydeduced.Itoccursbetweenthelasthand-to-surfacecontactwithanobjectbelongingtothehealthcarezoneandtherstwithinthepatientzonebestvisualisedbycrossingthevirtuallinebetweenthetwozones.Handhygieneatthismomentwillmainlypreventcross-colonisationofthepatientand,occasionally,exogenousinfection.Aconcreteexamplewouldbethetemporalperiodbetweentouchingthedoorhandleandshakingthepatientshand:thedoorhandlebelongstothehealthcarezoneandthepatientshandtothepatientzone.Moment2:BeforeanaseptictaskOncewithinthepatientzone,usuallyafterahandexposuretothepatientsintactskin,clothesoranyotherobject,theHCWmightengageinanaseptictaskonacleansitesuchasopeningavenousaccessline,givinganinjection,orperformingwoundcare.Importantly,handhygienerequiredatthismomentaimsatpreventingcolonisationandHCAI.Inlinewiththepredominantlyendogenousaetiologyoftheseinfections,handhygieneistakingplacebetweenthelastexposuretoasurface,evenwithinthepatientzoneandimmediatelybeforeaccesstoacleansite.ThisisimportantbecauseHCWscustomarilytouchanothersurfacewithinthepatientzonebeforecontactwithacleansite.Forsometasksoncleansites,e.g.lumbarpuncture,surgicalprocedures,trachealsuction-ing,etc.,theuseofglovesisstandardprocedure.Inthiscase,handhygieneisrequiredbeforedonningglovesbecauseglovesalonemaynotpreventcontaminationentirely.Moment3:AfterbodyuidexposureriskAfteracaretaskassociatedwitharisktoexposehandstobodyuids,e.g.afteraccessingabodyuidsite,handhygieneisrequiredinstantlyandmusttakeplacebeforeanyhand-to-surfaceexpo-sure,evenwithinthesamepatientzone.Thishasadoubleobjective.Firstandmostimportantly,itreducestheriskofcolonisationorinfectionofHCWswithinfectiousagentswhichcanoccurevenintheabsenceofvisiblesoiling.Second,itreducestheriskofatransmissionofmicro-organismsfromacolonisedtoacleanbodysitewithinthesamepatient.Thisroutinemomentforhandhygieneconcernsallcareactionsassociatedwithariskofbodyuidexposureandisnotidenticaltothehopefullyveryrarecaseofaccidentalvisiblesoil-ingcallingforimmediatehandwashing.cleansitescoincidewithbodyuidsites(TableIIDisposableglovesaremeanttobeusedasasecondskintopreventexposureofhandstobodyuids.However,handsarenotsufcientlyprotectedbyglovesandhandhygieneisstronglyrecommendedaftergloveremoval.Evenifgloveremovalrepresentsastrongcuetohandhygieneac-tion,theconceptchoosestoidentifythismomentforhandhygienewiththeassociatedrisk(e.g.ex-posuretobodyuids)ratherthanwiththeaddi-tionalprotectiveaction(e.g.gloveuse).Thishasthedoubleadvantageofbeingmoreconsistentwiththerisk-drivenlogicoftheoverallconceptandtocoveralltimeswhenglovesarenotworn.Moment4:AfterpatientcontactAfteracaresequence,whenleavingthepatientzoneandbeforetouchinganobjectinthehealth-carezone,handhygieneactionsubstantiallyre-ducescontaminationofHCWshandswiththeora H.Saxetal. TableIIMyvemomentsforhandhygiene:explanationsandlinktoevidence-basedrecommendationsMomentEndpointsofhandPreventedExamplesLinktoWHOGuidelinesforHandHygieneinHealthCareWHOrecommendation(rankingforscientic1BeforeDonorsurface:anysurfaceinthehealthcarezone.Patientcross-rarelyexogenousShakinghands,helpingapatienttomovearound,gettingwashed,takingpulse,bloodpressure,chestauscultation,abdominalpalpationBeforeandaftertouchingpatients(IB)Thetwomomentsbeforeandaftertouchingapatientwereseparatedbecauseoftheirspecicsequentialoccurrenceinroutinecareandunequalnegativeoutcomeincaseoffailuretoadhere,andusualadherencelevel.Receptorsurface:anysurfaceinthepatientzone2BeforeDonorsurface:anyothersurfacePatientinfection;rarelyOral/dentalcare,secretionaspiration,skinlesioncare,wounddressing,subcutaneousinjection;catheterinsertion,openingavascularaccesssystem;preparationoffood,medication,dressingsetsBeforehandlinganinvasivedeviceforpatientcare,regardlessofwhetherornotglovesareused(IB)Thisconceptwasenlargedtocoveralltransferofmicro-organismstovulnerablebodysitespotentiallyresultingininfection.Receptorsurface:cleansiteIfmovingfromacontaminatedbodysitetoacleanbodysiteduringpatientcare(IB)Sinceitisnotpossibletodeterminethesebodysitesobjectively,thisindicationwasnotretainedasaseparateitem,butcoveredbywithin-patient-zonemoments.3AfterbodyDonorsurface:bodyuidsiteworkerinfectionOral/dentalcare,secretionaspiration;skinlesioncare,wounddressing,subcutaneousinjection;drawingandmanipulatinganyuidsample,openingdrainingsystem,endotrachealtubeinsertionandremoval;clearingupurines,faeces,vomit,handlingwaste(bandages,napkin,incontinencepads),cleaningofcontaminatedandvisiblysoiledmaterialorareas(lavatories,medicalAfterremovinggloves(IB)Afterbodyuidexposureriskcoversthisrecommendation;seetextforfurthercomments.Receptorsurface:anyothersurfaceAftercontactwithbodyuidsorexcretions,mucousmembranes,non-intactskin,orwounddressings(IA)Thisriskwasgeneralisedtoincludealltasksthatcanpotentiallyresultinhandexposuretobodyuids.AparadoxofbodyuidexposurewasresolvedbyincludingthenotionofexposureriskinsteadofactualIfmovingfromacontaminatedbodysitetoacleanbodysiteduringpatientcare(IB)Seecomment(2)Beforeasepticcontinuedonnextpage Myvemomentsforhandhygiene15 TableIIMomentEndpointsofhandPreventedExamplesLinktoWHOGuidelinesforHandHygieneinHealthCareWHOrecommendation(rankingforscientic4AfterpatientDonorsurface:anysurfaceinthepatientzonewithtouchingapatient.workercross-Shakinghands,helpingapatienttomovearound,gettingwashed,takingpulse,bloodpressure,chestauscultation,abdominalpalpationBeforeandaftertouchingpatients(IB)Seecomment(1)BeforepatientReceptorsurface:anysurfaceinthehealthcarezone5AftercontactwithpatientDonorsurface:anysurfaceinthepatientzonethepatient.workercross-Changingbedlinen,perfusionspeedadjustment,monitoringalarm,holdingabedrail,clearingthebedsidetableAftercontactwithinanimateobjects(includingmedicalequipment)intheimmediatevicinityofthepatient(IB)RetainedtocoverallsituationswherethepatientsimmediateandpotentiallycontaminatedenvironmentistouchedbutnottheReceptorsurface:anysurfaceinthehealthcarezoneRankingsystemforevidenceaccordingtoWHOguidelines:categoryIA,stronglyrecommendedforimplementationandstronglysupportedbywell-designedexperimental,clinical,orepidemiologicalstudies;categoryIB,stronglyrecommendedforimplementationandsupportedbysomeexperimental,clinical,orepidemiologicalstudiesandastrongtheoreticalrationale. H.Saxetal. frompatientX,minimisestheriskofdisseminationtothehealthcareenvironment,andprotectstheHCWsthemselves.ItisnoteworthythatHCWsusuallytouchanobjectwithinthepatientzoneandnotthepatientbeforeleaving.Hence,thetermafterpatientcontactissomewhatmislead-ingandshouldbeunderstoodasaftercontactwiththepatientorhis/herimmediatesurroundings.Moment5:AftercontactwithpatientThefthmomentforhandhygieneisavariantofmoment4.Itoccursafterhandexposuretoanysurfaceinthepatientzonebutwithouttouchingthepatient.Thistypicallyextendstoobjectscontaminatedbythepatientorathatareex-tractedfromthepatientzonetobedecontami-natedordiscarded.Becausehandexposuretopatientobjectswithoutphysicalcontactwiththepatientsisassociatedwithhandcontamination,handhygieneisrequired.CoincidenceoftwomomentsforhandTwomomentsforhandhygienemaysometimesfalltogether.Typicallythisoccurswhengoingfromonepatienttoanotherwithouttouchinganysurfaceoutsidethecorrespondingpatientzones.Naturally,asinglehandhygieneactionwillcoverthetwomomentsforhandhygiene.PracticalapplicationsofthemodelAmulti-modalapproachtohandhygienepro-motionhasbeenfoundtobethemostefcienttechniquetoincreasepatientsafetyinasustainedway.Arobustdescriptionofthecriticalmomentsforhandhygieneisimportantforthevariouselementsofamulti-modalstrategyin-cludingtraining,workplacereminders,ergonomiclocalisationofhandrubatthepointofcare,per-formanceassessmentbydirectobservations,andreporting.UnderstandingandvisualsAcriticalfeaturetofacilitatetheunderstandingandcommunicationofMyvemomentsforhandhygieneliesinitsstrongvisualmessage(Figure2Theobjectivewastorepresenttheever-changingsituationsofcareintopictogramsthatcouldserveawidearrayofpurposesandhealthcaresettings.Themodeldepictsasinglepatientinthecentreofauniedvisualtorepresentthepointofcareofanytypeofpatient.Thezones,criticalsitesandmomentsforhandhygieneactionarearrangedaroundthispatienttodepicttheinfectiousrisksandthecorrespondingmomentsforhandhygieneactionintimeandspace.TrainingThereareimportantinterpersonaldifferencesinthemosteffectivelearningstyles.Someindivid-ualsrespondbettertoconceptualgroupingandwillrespondwelltotherisk-basedconstructofzonesandcriticalsitesandthevemomentsforhandhygiene.Formost,however,therationalbackgroundofaconceptisastrongmotivator.Itisthushelpfultomakeveryclearthereasonforeachofthevemomentsforhandhygiene(TableIIOthersrespondbettertocircumstantialcuesanditisusefultolistthemostfrequentexamplesoc-curringinthespeciccaresetting.Theapproachalsooffersmanypossibilitiesforthedevelopmentoftrainingtools,includingon-siteaccompaniedlearningkits,computer-assistedlearning,andoff-sitesimulators.Directobservationisthegoldstandardtomonitorcompliancewithoptimalhandhygienepractice.Theve-momentsmodelcanbeinstrumentalinseveralways.Manycareactivitiesdonotfollowastandardoperatingprocedure.Thus,itisdifculttodenethecrucialmomentforhandhygiene.Theconceptlaysareferencegridovertheseactiv-itiesandminimisesinter-observervariation.OnceHCWsareprocientintheconcept,theyareabletobecomeobserverswithminimaladditionaleffort,thuscuttingdownontrainingcosts.Furthermore,theconceptsolvesthetypicalprob-lemsofclearlydeningthedenominatorasanopportunityandthenumeratorasahandhygieneReportingresultsofhandhygieneobservationtoHCWsisanessentialelementofmulti-modalstrategiestoimprovehandhygieneprac-Therefore,reportingdetailsonrisk-specichandhygieneperformancemayincreasetheimpactofanyfeedbackandmakeitpossibletomonitorprogressinameaningfulwaythatfullycorrespondstotrainingandpromotionalmaterial. Myvemomentsforhandhygiene17 Handhygieneasitisunderstoodtodayrequiresthreeto30applicationsofhandrubperhourduringpatientcarewhichtranslatestoonehandrubapplicationuptoevery2minduringintensivecareactivities.Thereality,how-ever,isthatunobservedHCWsonlyperformveryfewhandhygieneactionsduringtheirworkday.Themagnitudeofthetaskofxingthissubstan-dardqualityofcarehaschallengedinfectioncon-trolprofessionalsworldwideformanyyears.Variousindicationsforhandhygieneduringcarehavebeendescribedinthescienticliteraturebut,todate,therearefewstudieswhichfocusindetailonpracticalissueswithintheframeworkofobser-vation.Wedescribeanewmodelforhandhygienethatisintendedtomeettheneedsfortraining,observation,andperformancereportingacrossallhealthcaresettingsworldwide.ThemodelMyvemomentsforhandhygienewascre-atedtobridgethegapbetweentheresultsofscien-ticstudiesandevidence-basedguidelinesandthenecessitytoprovideuser-centred,practicaltools.Itisbasedonavailableevidenceintheeldsofmi-crobiologyandinfectiousdiseases,along-standingpracticalexperienceinhandhygieneresearchandpromotion,andseveralyearsofatrial-and-errorprocess.Principlesandrecentinsightinthethreeoverlappingdomainsofhumanfactorsengineering,behaviourscienceandsocialmarketingwereusedtocrafttheconceptforoptimalperformanceatminimalcost.Theimportanceofhumanfactorsdesignandergonomicsforpatientsafetyisincreasinglybeingrecognized.Whathasledtoa100-foldde-creaseinaeroplanecrashesisnowbeingprogres-sivelyimplementedinhealthcare:adeliberatedesignprocesstoavoidhumanerrorbystreamlin-ingprocessesandworkenvironmenttointuitivehumanunderstanding,behaviourandlimitations.Buildingonthisunderstanding,weprovideacon-ceptthatappliestothecomplexandunpredictabletaskofhealthcaredeliveryandservesasasolidba-sisfortheengineeringofthenecessaryimplemen-tationtools.Behaviouralscienceisusedinhumanfactorsengineering.Accordingtocognitivebehaviourmodels,intentiontoperformanyactionismotivatedbypositiveoutcomeevaluation,socialpressure,andtheperceptionofbeingincontrol.conceptofMyvemomentsofhandhygienetries:(i)tofosterpositiveoutcomeevaluationbylinkingspecichandhygienetospecicinfectiousout-comesinpatientsandHCWs(positiveoutcomebeliefs);and(ii)toincreasethesenseofbeingincontrolbygivingHCWsclearadviceonhowtointe-gratehandhygieneinthecomplextaskofcare(positivecontrolbeliefs).Successfulexamplesofpowerfulcommercialmarketingstrategiestransferredtotherealitiesofhealthcareexist.Ithasbeensuggestedthatscience-basedworkandguidelinesregularlyfailtotranslateintodailypracticebecauseoflackofap-pealtothetargeteduser.Weusedtheconceptofbranding,termcoining,simplewordingandvis-ualstofacilitatethemarketingofhandhygienetoHCWsasusers.Whiledevelopingthisconcept,wefacedsomefundamentaldifcultieswhichweremainlyrootedinthelackofdetailedscien-ticevidenceonhandtransmissionanditsimpli-cationintheaetiologyofspecicinfectiousoutcomes.Iftherelativerisklevelofspeciccaretasksremainsunknown,asafesystemhastotreatthemonanequallevel.Thisprohibitedfurtherconceptsimplication,whichwouldhavebeenpossiblehadwebeenabletoeliminatethelessimportantmomentsforhandhygiene.Itispossiblethataccumulatingevidencemightmakefutureadaptationsoftheconceptnecessary.Webelieve,however,thatgapsindetailedevidenceshouldnotpreventtheconstructionofanapplica-bleholisticapproach.Inthisrespect,Myvemomentsforhandhygienecanbecomparedtowearingasafetybeltwhiledriving.Althoughtheriskthroughneglectingasinglepreventivegesturemaybeverylow,cumulativenegligenceresultsinahightotalnumberoffataloutcomesduetothesheerfrequencyoftherisksituation.Furthermore,someassumptionsmadeinthismodelmightnotbefullledatallfacilities.Ahighstandardofcleaningofthehealthcareenvironmentandallobjectsbroughtinclosecontactwithpatientsisrequirediftheproposedhandhygieneconceptistomakesense.Standardisationisessentialtotherobustnessoftheconcept,i.e.itsapplicabilitytoalargerangeofhealthcaresettings.Forthis,however,wehadtoomitcertainpotentiallyusefulconceptfeatures.Forexample,powerfulcuesforactionsuchasgloveuse,catheterinsertion,orotherfrequentlyde-scribedmomentsincarewerediscarded.Further-more,weoptedagainsteducatingHCWstorecognizethetransmissionriskthemselvesandtousehandhygienewhenevertheyconsideredthatmicro-organismsontheirhandscouldbeharmfultopatients.Inconclusion,effortstoimprovehandhygienepracticesofHCWshavealreadytravelledfaroverthepastfewyearsbytheapplicationofhuman H.Saxetal. factorsengineering:handwashingatthesinkhasbeenreplacedbyalcohol-basedhandrubbingasthequickerandmoreeffectivemethod,andhandrublocationatthepointofcarehasbeenadvo-catedtomakeitevenmoreconvenient.Inthiswork,werevisitedthemainnegativeoutcomesandtheircausalmechanismstodesignauser-centred,out-of-the-boxconcepttomakeunderstanding,training,andmonitoringofhandhygieneinhealth-careatopselleramongHCWsworldwide.AcknowledgementsTheauthorswishtothankallmembersoftheInfectionControlProgramme,UniversityofGenevaHospitals,inparticularM.-N.ChraitiandP.Her-rault;SwissHandHygieneparticipatinghospitalsandSwissNOSOmembers;G.Teagueforfruitfulexchangeonsocialmarketingstrategies;B.Gordts,MD,fordiscussion;R.Sudanforoutstand-ingeditorialassistance;membersoftheWHOCleanCareisSaferCarecoregroup:D.Gold-mann,H.Richet,W.H.Seto,A.Voss;theGlobalPatientSafetyChallengeteam:G.Dziekan,A.Leotsakos,J.Storr;andtheWHOHandHygieneEducationTaskForce:B.Cookson,N.Damani,M.-L.McLaws,Z.Memish,M.Rotter,S.Sattar,M.Whitby,A.Widmer.ConictofintereststatementNone.FundingsourcesNone.1.CosgroveSE.Therelationshipbetweenantimicrobialresis-tanceandpatientoutcomes:mortality,lengthofhospitalstay,andhealthcarecosts.ClinInfectDis(Suppl.2):2.GravesN,WeinholdD,TongE,etal.Effectofhealthcare-acquiredinfectiononlengthofhospitalstayandcost.fectControlHospEpidemiol3.PittetD,AllegranziB,SaxH,etal.Evidence-basedmodelforhandtransmissionduringpatientcareandtheroleofimprovedpractices.LancetInfectDis4.VossA,WidmerAF.Notimeforhandwashing!?Handwashingversusalcoholicrub:canweafford100%compliance?ControlHospEpidemiol5.WidmerAF,ConzelmannM,TomicM,FreiR,StrandenAM.Introducingalcohol-basedhandrubforhandhygiene:thecriticalneedfortraining.InfectControlHospEpidemiol6.HugonnetS,PernegerTV,PittetD.Alcohol-basedhandrubimprovescompliancewithhandhygieneinintensivecareArchInternMed7.PittetD,StephanF,HugonnetS,AkakpoC,SouweineB,ClergueF.Hand-cleansingduringpostanesthesiacare.esthesiology8.Pessoa-SilvaCL,HugonnetS,PsterR,etal.Reductionofhealthcare-associatedinfectionriskinneonatesbyhandhygienepromotion.Pediatrics(inpress).9.PittetD,BoyceJM.Handhygieneandpatientcare:pursuingtheSemmelweislegacy.LancetInfectDis2001April:910.LarsonEL,CimiottiJ,HaasJ,etal.Effectofantiseptichandwashingvsalcoholsanitizeronhealthcare-associatedinfectionsinneonatalintensivecareunits.ArchPediatrAdolescMed11.PittetD,MourougaP,PernegerTV.Compliancewithhand-washinginateachinghospital.InfectionControlProgram.AnnInternMed12.LarsonE,KillienM.Factorsinuencinghandwashingbehav-iorofpatientcarepersonnel.AmJInfectControl13.VicenteKJ.Whatdoesittake?Acasestudyofradicalchangetowardpatientsafety.JtCommJQualSaf14.LinL,VicenteKJ,DoyleDJ.Patientsafety,potentialadversedrugevents,andmedicaldevicedesign:ahumanfactorsengineeringapproach.JBiomedInform15.LeapeLL,WoodsDD,HatlieMJ,KizerKW,SchroederSA,LundbergGD.Promotingpatientsafetybypreventingmed-icalerror.JAmMedAssoc16.ObradovichJH,WoodsDD.Usersasdesigners:howpeoplecopewithpoorHCIdesignincomputer-basedmedicalde-HumFactors17.FormosoG,MarataAM,MagriniN.Socialmarketing:shoulditbeusedtopromoteevidence-basedhealthinformation?SocSciMed18.SmithWA.Socialmarketing:anoverviewofapproachandInjPrev(Suppl.1):3819.GordonR,McDermottL,SteadM,AngusK.Theeffectivenessofsocialmarketinginterventionsforhealthimprovement:whatstheevidence?PublicHealth20.MahMW,DeshpandeS,RothschildML.Socialmarketing:abehaviorchangetechnologyforinfectioncontrol.AmJInfectControl21.PittetD,HugonnetS,HarbarthS,etal.Effectivenessofahospital-wideprogrammetoimprovecompliancewithhandhygiene.InfectionControlProgramme.22.BoyceJM,PittetD.Guidelineforhandhygieneinhealth-caresettings.RecommendationsoftheHealthcareInfectionControlPracticesAdvisoryCommitteeandtheHICPAC/SHEA/APIC/IDSAHandHygieneTaskForce.SocietyforHealthcareEpidemiologyofAmerica/AssociationforProfes-sionalsinInfectionControl/InfectiousDiseasesSocietyofAmerica.MorbidMortalWklyRep.Recommendationsandreports/CentersforDiseaseControl23.PittetD,SimonA,HugonnetS,Pessoa-SilvaCL,SauvanV,PernegerTV.Handhygieneamongphysicians:performance,beliefs,andperceptions.AnnInternMed24.PittetD,SaxH,HugonnetS,HarbarthS.Costimplicationsofsuccessfulhandhygienepromotion.InfectControlHosp25.Pessoa-SilvaCL,DharanS,HugonnetS,etal.Dynamicsofbacterialhandcontaminationduringroutineneonatalcare.InfectControlHospEpidemiol26.Pessoa-SilvaCL,Posfay-BarbeK,PsterR,TouveneauS,PernegerTV,PittetD.Attitudesandperceptionstowardhandhygieneamonghealthcareworkerscaringforcriticallyillneonates.InfectControlHospEpidemiol 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