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  • Measure Summary
  • NQMC:008528
  • Mar 2011

Nursing care: percentage of hand washes carried out.

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

View the original measure documentation External Web Site Policy

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in May 2016.

Primary Measure Domain

Clinical Quality Measures: Process

Secondary Measure Domain

Does not apply to this measure

Description

This measure is used to assess the percentage of hand washes carried out.

Rationale

The aim of intensive care medicine is to provide critical patients with the healthcare that they need, ensuring the quality and safety of care. Intensive care medicine is one of the principal components of modern healthcare systems. There is an increasing demand for this resource, which involves high costs.

The quality of care has gradually come to be the central focus of healthcare, and in recent years patient safety has come to represent one of the key aspects of quality. In the case of intensive care medicine, this interest in quality is even more evident, not only because of its social and economic impact, but also because some of the dimensions involved in the quality of care of critical patients take on greater importance: critical patients are more vulnerable, access to critical care is more limited so efforts to distribute resources equitably are more important, scant scientific evidence is available, and the efficiency is limited.

Hand washing is the most important measure for reducing nosocomial infections. These infections increase morbidity, mortality, and the costs of care. Using alcohol-based solutions reduces the incidence of nosocomial infections by 40%.

Evidence for Rationale

Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep. 2002 Oct 25;51(RR-16):1-45, quiz CE1-4. PubMed External Web Site Policy

Elola-Vicente P, Aroca-Palencia J, Huertas-Paredero MV, Díez-Sebastián J, Rivas-Bellido L, Martínez-Martínez G, Nájera-Santos MC, Muñoz-García ML. [A hand hygiene education program. Comparison between handwashing and the use of alcohol solutions]. Enfermeria Clin. 2008 Jan-Feb;18(1):5-10. PubMed External Web Site Policy

Kampf G, Löffler H, Gastmeier P. Hand hygiene for the prevention of nosocomial infections. Dtsch Arztebl Int. 2009 Oct;106(40):649-55. PubMed External Web Site Policy

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

The Joint Commission. Measurement hand hygiene adherence: overcoming the challenges. Oakbrook Terrace (IL): The Joint Commission; 2009. 234 p.

World Health Organization (WHO). WHO guidelines on hand hygiene in health care. Geneva (Switzerland): World Health Organization; 2009. 270 p.

Primary Health Components

Nursing care; hand washing

Denominator Description

Number of opportunities for hand washes in the department (see the related "Denominator Inclusions/Exclusions" field)

Numerator Description

Number of hand washes carried out

Type of Evidence Supporting the Criterion of Quality for the Measure

  • A clinical practice guideline or other peer-reviewed synthesis of the clinical research evidence
  • A formal consensus procedure, involving experts in relevant clinical, methodological, public health and organizational sciences
  • One or more research studies published in a National Library of Medicine (NLM) indexed, peer-reviewed journal

Additional Information Supporting Need for the Measure

Unspecified

Extent of Measure Testing

Unspecified

State of Use

Current routine use

Current Use

Internal quality improvement

Measurement Setting

Hospital Inpatient

Intensive Care Units

Professionals Involved in Delivery of Health Services

Nurses

Physicians

Least Aggregated Level of Services Delivery Addressed

Single Health Care Delivery or Public Health Organizations

Statement of Acceptable Minimum Sample Size

Unspecified

Target Population Age

Age greater than or equal to 18 years

Target Population Gender

Either male or female

National Quality Strategy Aim

Better Care

National Quality Strategy Priority

Health and Well-being of Communities
Prevention and Treatment of Leading Causes of Mortality

IOM Care Need

Getting Better

Staying Healthy

IOM Domain

Effectiveness

Case Finding Period

Unspecified

Denominator Sampling Frame

Professionals/Staff

Denominator (Index) Event or Characteristic

Health Professional Characteristic

Denominator Time Window

Does not apply to this measure

Denominator Inclusions/Exclusions

Inclusions
Number of opportunities for hand washes in the department

Note:

  • Evidence-based recommendations:
    • Hygienic wash:
      • Procedure: With water and neutral soap. Duration: 20 seconds.
      • Indicated: Before: Starting the shift, going to eat, having contact with the patient, manipulating systems that should be sterile, preparing medication or food, performing procedures of short duration (less than 10 minutes), and whenever dirt is visible. After: using the lavatory, eating, manipulating material contaminated with secretions, touching a patient, and finishing the shift. Before and after: contact with wounds and handling drainage systems. Between: contact with different patients.
    • Antiseptic wash:
      • Procedure: Alcohol-based solution. Duration: 2 minutes.
      • Indicated: Before performing invasive procedures of long duration (20 minutes) and any maneuver in immunodepressed patients. Wearing gloves does NOT mean hand washing is unnecessary.
  • Population: All healthcare staff during the period reviewed (physicians, registered nurses, nurse's aides, and all others)

Exclusions
Unspecified

Exclusions/Exceptions

Unspecified

Numerator Inclusions/Exclusions

Inclusions
Number of hand washes carried out

Exclusions
Unspecified

Numerator Search Strategy

Fixed time period or point in time

Data Source

Other

Type of Health State

Does not apply to this measure

Instruments Used and/or Associated with the Measure

Unspecified

Measure Specifies Disaggregation

Does not apply to this measure

Scoring

Rate/Proportion

Interpretation of Score

Desired value is a higher score

Allowance for Patient or Population Factors

Unspecified

Standard of Comparison

Internal time comparison

Prescriptive standard

Prescriptive Standard

Standard: 90%

Evidence for Prescriptive Standard

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Original Title

Compliance with hand-washing protocols.

Measure Collection Name

Quality Indicators in Critically Ill Patients

Measure Set Name

Nursing Care

Submitter

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Developer

Spanish Society of Intensive and Critical Care and Units Coronary - Clinical Specialty Collaboration

Funding Source(s)

Boehringer Laboratories

Composition of the Group that Developed the Measure

Work Group for Nursing (SEEIUC)

  • Rosa García Díez
  • Mar Sánchez Sánchez
  • Juan Carlos Muñoz Camargo
  • Mónica Vázquez Calatayud
  • Rosa Jam Gatell
  • Rosana Goñi Viguria
  • Emilia Romero de San Pío
  • Susana Arias Rivera
  • Alicia Robas Gómez
  • Juan Ángel Hernández
  • Susana Arias Rivera

Scientific Coordination:

  • Maria Cruz Martín Delgado
  • Jesús Blanco Varela
  • Lluís Cabré Pericas
  • Pedro Galdos Anuncibay
  • Federico Gordo Vidal

Financial Disclosures/Other Potential Conflicts of Interest

Unspecified

Adaptation

This measure was not adapted from another source.

Date of Most Current Version in NQMC

2011 Mar

Measure Maintenance

Unspecified

Date of Next Anticipated Revision

2016 Jul

Measure Status

This is the current release of the measure.

The measure developer reaffirmed the currency of this measure in May 2016.

Source(s)

Quality indicators in critically ill patients. Madrid (Spain): Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC); 2011. 185 p.

Measure Availability

Source available in English External Web Site Policy and Spanish External Web Site Policy from the Spanish Society of Intensive and Critical Care and Units Coronary (SEMICYUC) Web site.

For more information, contact SEMICYUC at Paseo de la Reina Cristina, 36, 4o D, Madrid, Spain; Phone: +34-91-502-12-13; Fax: +34-91-502-12-14; Web site: www.semicyuc.org External Web Site Policy; E-mail: secretaria@semicyuc.org.

NQMC Status

This NQMC summary was completed by ECRI Institute on March 20, 2014. The information was verified by the measure developer on April 25, 2014.

The information was reaffirmed by the measure developer on May 10, 2016.

Copyright Statement

This NQMC summary is based on the original measure, which is subject to the measure developer's copyright restrictions.

The Quality Indicators in Critically Ill Patients update 2011 can be used by any private or public body only for the purposes of research, clinical management, teaching and education, and will not be used for any other purpose. In all cases, full credit to the Spanish Society of Intensive Care Medicine (SEMICYUC) will be granted. The commercial use of the Quality Indicators in Critically Ill Patients update 2011 is explicitly forbidden.

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