Identifying the World Health Organization’s fifth moment for hand hygiene: Infection prevention in the operating room

Abstract

Background:

The World Health Organization have designed the fifth of their ‘5 moments’ for hand hygiene to account for microbial transfer from patients to equipment in a narrow area around that patient, known as the patient zone. The study was prompted by emerging local confusion about application of the patient zone in the operating room (OR).

Aim/Objectives:

In two phases, we aimed to create a ‘5 moments’ style poster displaying an OR patient zone: phase 1, quantify equipment, in direct contact with the patient and, touched by non-scrubbed staff immediately after touching the patient; and phase 2, categorise equipment identified in phase 1 into patient zone and healthcare zone. An objective is to produce a ‘5 moments’ poster for the OR.

Methods:

The first phase used non-participant direct overt observation. In phase 2, phase 1 data were collaboratively assigned to patient zone or healthcare zone. Photography and graphic design were used to produce the OR ‘5 moments’ poster.

Results:

In 11 full-length surgeries, 20 pieces of equipment were in direct contact with the patient and 57 pieces of equipment were touched. In phase 2, a ‘5 moments’ poster showing an OR patient zone was designed.

Discussion:

Content of the patient zone was identified and displayed in a novel resource. Having shared understanding of the patient zone has potential to sustain hand hygiene compliance and equipment cleaning in the OR.

Conclusion:

Limitations in methods were balanced by collaboration with frontline staff. The study has been used as a teaching tool in the OR and similar settings.

Introduction

Prevention of surgical infection is a global priority, to which applying the World Health Organization’s (WHO) hand hygiene (HH) campaign is of critical importance in the operating room (OR) (Abbas and Pittet, 2016). Despite high design specification of the OR and equipment, with exception of sterile surgical instruments in the surgical field, the OR is a clean, not a sterile environment (Loftus, 2016). The focus of this study is non-sterile equipment, which will be referred to as equipment. Multi-drug resistant bacterial transmission around an OR from patient to non-scrubbed staff hands and equipment to the next patient has been associated with healthcare-associated infection (HAI) (Loftus et al., 2012).

Responding to the risk of HAI associated with bacterial transmission around equipment (Loftus, 2016), which occurs in as little as 30 min (Rowlands et al., 2014), the research team introduced the WHO HH guidelines (Smith et al., 2016). The core of these guidelines is the concept of ‘My five moments for hand hygiene’ (Figure 1). In our ORs, monthly HH audit based upon the WHO method had not dropped below the required standard of 95% compliance (Smith et al., 2016). Concern that reported local confusion about the practical content of the patient zone would lead to erosion of HH compliance and equipment cleaning prompted infection prevention and OR collaboration on this quality improvement project.

Figure 1.

‘My five moments for Hand Hygiene’. (WHO, 2009).

Source: reproduced with permission from World Health Organization (WHO, 2009).

The literature defines the patient zone as a narrow area around the patient that is dedicated to that patient wherever the patient receives care (Sax et al., 2007). It is represented in Figure 1 as equipment inside the dashed black line. The patient zone is composed of three elements, each within the narrow geographical area around the patient. The first of these is equipment in direct contact with the patient. The second is equipment touched by healthcare staff while caring for the patient. Finally, equipment within the same narrow area touched by the patient completes the WHO definition of the patient zone. Equipment outside the patient zone is in the healthcare zone.

HH and equipment cleaning are embedded into the WHO fifth moment for HH (Figure 1) (Sax et al., 2007). HH at ‘moment 5’ interrupts transmission of microorganisms from equipment included in the patient zone into the healthcare zone (Sax et al., 2007), which is the rest of the OR. Equipment included in the patient zone is cleaned between patients, complementing HH in disruption of microbial transmission (WHO, 2009).

The fifth moment’s reliance on understanding of two geographical areas (the patient and healthcare zones) is a challenge for reducing microbial spread (Sax and Clack, 2015). Where confusion exists around which pieces of equipment are included in the patient zone, both HH at ‘moment 5’ and cleaning equipment between patients in the OR may be missed, thus increasing the risk of HAI (Hopf, 2015). While the patient zone is clearly defined in the literature, practical application of it is not. Our study aimed to build upon current evidence by quantifying the WHO definition of the patient zone and developing a useful resource to help frontline staff practically identify the OR patient zone from the healthcare zone.

Methods

This quality improvement project was divided into two phases. In phase 1, we planned to quantify two of the three elements of the WHO definition of the patient zone; the equipment in direct contact with the patient and touched by non-scrubbed staff in the OR. In our hospitals, the patient, brought into and out of the OR on a bed/trolley (The Association for Perioperative Practice, 2016) is not free to touch equipment outside of the bed/trolley or operating table. Therefore, this element of the WHO patient zone definition, the patient touching equipment, was not quantified. Phase 1 data were used in phase 2 to assign by collaboration, equipment into the patient zone or healthcare zone. Equipment, categorised in the typical OR patient zone, was photographed and embedded into the WHO ‘5 moments’ poster (WHO, 2016).

Data collection (study phase 1)

Data collection occurred during June–August 2016 in ORs in an adult acute hospital (21 ORs) and a children’s acute hospital (4 ORs). Both are large NHS teaching hospitals in a Scottish city. In our ORs, the patient arrives via the anaesthetic room. Children are usually anaesthetised in the anaesthetic room and transferred into the OR where they are connected to another anaesthetic machine. Adults are usually anaesthetised in the OR. Both children and adults are brought into and out of the OR on their hospital bed/trolley and transferred by the non-scrubbed team onto the operating table. The bed/trolley is then removed from the OR. Postoperatively, the patient is transferred back onto their bed/trolley and transferred to the recovery room.

Observation method (study phase 1)

Quantitative overt non-participant structured observation was conducted by an experienced Infection Prevention and Control (IPC) nurse trained and validated in HH observation and known to the OR team. Unannounced observations started and ended at patient entry and exit from the OR. Observations did not take place outside of the OR.

Selection of surgical disciplines and ORs (study phase 1)

All surgical disciplines in the adult and children’s acute hospitals were available for phase 1 observation. Evidence (Munoz-Price et al., 2014; Rowlands et al., 2014) and local experience indicated the peak of hand contact between non-scrubbed intraoperative staff, the patient and equipment occurred at the beginning and end of the operation. Therefore, surgical disciplines were limited by non-probability judgement sampling to those with a planned operative case length of ⩽ 2 h.

Using password access to an electronic OR booking system, surgical specialties planned over a four-week period (March 2016) with scheduled case lengths of ⩽ 2 h were identified. These were Urology, Ear Nose and Throat, Gynaecology, Ophthalmology and Maxillofacial. The minimum quota was one full-length surgery planned to last ⩽ 2 h for each of the specialties. Observations were conducted during office hours. Participating ORs were drawn at random from a list of surgeries, meeting the inclusion criteria, available on the electronic scheduling system. Phase 1 observations ended when repeating themes indicated saturation of data.

Recording hand contact events (HCE) (study phase 1)

To enable one observer to accurately capture all HCE, the first time a piece of equipment was touched by non-scrubbed staff after contact with the patient was listed. Subsequent HCE with the same piece of equipment were tallied. One HCE was defined as one non-scrubbed staff touching the patient with any part of one or both of their hands then touching a piece of equipment. If two non-scrubbed staff performed a task together, and each meets the definition of an HCE, two HCEs were recorded. Non-scrubbed staff were counted as many times as they performed an HCE.

Exclusion from phase 1 observations

Having performed surgical hand preparation, scrubbed staff were excluded. In a busy OR, to enable one observer to capture an HCE for the non-scrubbed team, the anaesthesia provider’s HCE within the anaesthetic machine were excluded. The anaesthetic machine has been demonstrated to be frequently touched after contact with the patient meets the WHO definition of the patient zone and is a source of HAI (Loftus et al., 2012). HCEs with HH dispensers were excluded. If the first non-sterile object touched after contact with a patient was an HH dispenser, the next non-sterile object touched was recorded.

Analysis of data (phase 1)

Simple descriptive statistics were used. In phase 1a, equipment in direct contact with the patient was listed according to observation session. In phase 1b, HCEs were ranked by frequency. Frequency was calculated by dividing the total number of HCEs for that equipment by the total number of HCEs.

Identification of OR patient zone (study phase 2)

In phase 2, an IPC nurse and frontline nursing staff reviewed phase 1 study results to collaboratively assign equipment into the patient or healthcare zones. Intraoperative workflow, practical application of HH, time to clean and ease of cleaning equipment were all considered when assigning equipment into the geographical zones. Equipment agreed, in the typical OR, patient zone was staged in an OR. Our Medical Illustration team professionally photographed and electronically embedded it into the WHO ‘5 moments’ poster (WHO, 2016). Ethical review for staff observation in the adult and children’s ORs was provided by the University of Dundee. Ethical review concluded Sponsorship / NHS REC or UREC favourable ethics opinion or NHS Research and Development permission were not required. Verbal consent for staff observation was considered sufficient. Verbal staff consent was requested following opportunity to study a review board approved handout. Observation sessions were not conducted if staff refused consent.

Results

Phase 1 observations were conducted during 11 full-length surgeries, lasting a total of 12 h 50 min. Surgical disciplines were in line with methodology (Table 1). Equipment in direct contact with the patient (Table 1) identified in phase 1a varied according to patient need.

Table 1.

Non-sterile equipment in direct contact with the patient in each of the 11 observation sessions and surgical specialties indicating adult or children’s hospitals.

Non-sterile equipment in direct contact with the patient	Ear Nose and Throat 1 Adult	Ear Nose and Throat 2 Adult	Ear Nose and Throat 3 Adult	Gynaecology 1 Adult	Maxillofacial Facial 1 Adult	Maxillofacial Facial 2 Children	Ophthalmology 1 Adult	Ophthalmology 2 Adult	Urology 1Adult	Urology 2 Children	Urology 3 Children
IV bag/line	-	Yes	Yes	Yes	Yes	-	Yes	Yes	Yes	Yes	-
Suction tubes	-	Yes	Yes	Yes	Yes	Yes	-	Yes	Yes	-	Yes
Positioning supports	Yes	Yes	Yes	Yes	Yes	-	Yes	Yes	Yes	Yes	-
Ward bed upper surface	Yes	Yes	Yes	Yes	Yes	-	Yes	Yes	Yes	Yes	Yes
Patient notes	Yes	-	-	Yes	-	Yes	Yes	-	Yes	-	-
Bedding/gown	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Breathing circuit/airway	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Operating table top	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Moving and handling glide board/sheet	Yes	Yes	Yes	Yes	Yes	-	Yes	Yes	Yes	Yes	Yes
Oxygen mask/tubing	-	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
ECG pads/cables	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Oxygen cylinder	-	-	-	Yes	-	-	Yes	-	Yes	-	Yes
BP cuff/cable	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Oxygen saturation probe/cable	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Urinary catheter	-	-	-	Yes	-	-	-	Yes	Yes	-	-
Warming blanket	-	-	-	-	-	-	-	Yes	-	-	-
Vascular compression garment	-	-	-	Yes	-	-	-	Yes	Yes	-	-
Nappy	-	-	-	-	-	-	-	-	-	-	Yes
Diathermy pad	-	-	-	Yes	-	-	-	-	Yes	-	Yes
Stethoscope	-	-	-	-	-	-	-	-	-	-	Yes

Identification of non-sterile equipment touched (phase 1b)

A total of 591 HCEs were observed. Of these, the top 20 pieces of equipment touched (n = 57) accounted for 78% of all (n = 591) HCEs by the non-scrubbed OR team (Figure 2). These 57 pieces of equipment were each considered for inclusion in the patient or healthcare zones. Of these, 37 were included in the patient zone and the remainder (n = 20) in the healthcare zone (Figure 3).

Figure 2.

The equipment frequently touched by non-scrubbed staff, excluding the anaesthetist at the anaesthetic workstation, in the operating room during 11 full-length (12 h 50 min) surgical operations.

Figure 3.

All 57 pieces of equipment touched in an HCE are indicated by dots. Thirty-seven pieces of equipment included in the patient zone are indicated by green dots; 20 pieces of equipment included in the operating room healthcare zone are indicated by red dots.

Equipment assigned to the typical OR patient zone were staged in an OR, photographed and displayed in the form of the WHO’s ‘My 5 moments for hand hygiene’ poster (Figure 4).

Figure 4.

‘My 5 moments for hand hygiene’ in the OR. Equipment included in the typical patient zone in an operating room embedded into a ‘My 5 moments for hand hygiene’ poster.

Source: reproduced with permission from World Health Organization (WHO, 2016).

Discussion

Responding to emerging local confusion around application of the patient zone at the fifth moment for HH in the OR, we applied the WHO definition to produce a unique resource which practically demonstrates the OR patient zone. Quantifying equipment using the WHO definition of the patient zone in phase 1 (Table 1 and Figure 2) enabled objective consideration of application of the typical patient zone and healthcare zone in phase 2 (Figure 3). Equipment touched in the 12 h 50 min of observation were similar to recent studies which have quantified non-sterile equipment touched by anaesthesia providers in the anaesthetic workstation (Munoz-Price et al., 2013; Rowlands et al., 2014). Differences may be explained by methods; we quantified HCEs of the entire non-scrubbed team excluding anaesthesiologists HCE with the anaesthetic machine.

In times of high touch intensity for staff hands, continuous HH is not a practical solution to interrupt microbial transmission (Munoz-Price et al., 2014). We have addressed this by inclusion of equipment (n = 37) to the patient zone. This enables, within the five moments model, a continuous episode of care without interruption of HH. HH after contact with the patient zone at moment 5 disrupts microbial transfer to equipment outside of the patient zone. Microbial spread is interrupted when the equipment in the patient zone is cleaned before use with the next patient (Loftus et al., 2012) When assigning equipment into the patient zone, we considered time to clean during tight time limits between operative cases (Vassell, 2016). Cleaning the equipment assigned within the patient zone between patients is local practice to prevent HAI.

While all the equipment shown in Figure 4 complies with the WHO definition of the patient zone, all of these will not be present in every operative case. Figure 4 shows the content of the typical OR patient zone to enable discussion and understanding of the fifth moment for HH. Collaborative understanding of the fifth moment for HH is essential for infection prevention in healthcare settings (Sax et al., 2007), including the OR.

Use of collaboration in phase 2 between infection prevention and the frontline OR team has enabled workflow to inform content of both OR patient and healthcare zones. Local understanding of application of the fifth moment for HH in an OR has been helped by using the phase 1 observation method followed by discussion in workshops to teach the concept of the patient zone. This approach to practically identify the patient zone has been locally applied in similar settings such as radiology and endoscopy. In practice, understanding the concept of the geographical areas to interrupt microbial transmission helps teams use the poster (Figure 4) as an example of a patient zone which adapts to include specialist equipment.

Conclusion

Limitations

Non-randomly selecting a small target population using judgement sampling could limit external validity of the research results. Use of a single observer may have introduced bias. However, validity was strengthened by collaboration with the OR staff, as consumers of the research, to identify typical content of the OR patient zone (Figure 4). Excluding equipment touched by the patient was due to local practice, thus the results may not be transferable to other facilities. We did not consider the influence of OR airflow on microbial transmission between patient zone and healthcare zones. Further research into the influence of airflow on microbial transmission between equipment in each zone would be of interest.

Infection prevention is undermined by confusion about evidence-based guidelines (Sax and Clack, 2015) such as the WHO fifth moment. We have built upon our HH campaign (Smith et al., 2016) by addressing emerging confusion. To our knowledge, we have created a unique useful resource. We have successfully identified the patient zone for the ‘fifth moment’ for HH in the OR. Embedding a shared universal understanding of the OR patient zone across all specialties will help sustain learning and application in clinical practice (Sax et al., 2007). Sustainability will be further aided because frontline staff were involved throughout, facilitating ownership and ensuring practical workflow was addressed when assigning equipment into the patient zone and healthcare zone.