Clean In, Clean Out

Clean in, Clean Out is UNC Hospitals' program to achieve 90% hand hygiene compliance.

Background

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Hand hygiene is of paramount importance to the health and safety of our patients. When health care employees properly wash their hands, we can reduce infections and save lives.

UNC Hospitals' Clean In, Clean Out program asks all employees to clean in and clean out every time they enter and exit a patient room. This goal applies to both clinical and non-clinical colleagues because we all can help keep our patients safe by practicing proper hand hygiene. Please read the Hand Hygiene Program Overview for more information.

Although UNC Hospitals has improved its hand hygiene compliance rate to 80-90% in recent years, The Joint Commission now requires health care facilities to show continued improvement.

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Sustaining 90% compliance requires cooperation and participation from all UNC Hospitals employees, including nurses, physicians, and all of our support services. Each employee is responsible for cleaning in and cleaning out any time s/he enters and exits a patient’s room.

To measure compliance, we ask each employee to observe other employees and report on proper (or improper) hand hygiene. The compliance results are updated on the Intranet on a monthly basis. Data is made available collectively, as a hospital, by individual unit, and by occupational group. The measurement period for FY17 begins on July 1, 2016, and ends on June 30, 2017.

For more information about the importance of hand hygiene and to learn more about the rationale for the Clean In, Clean Out program, how it impacts patient safety, and the incentives associated with participation and success, please read the information under the "Why Clean In, Clean Out" tab above.

For an overview tutorial on how to participate, please read our How To document. For more information about how you can record observations through the iScrub App or via paper-based forms, as well as how to collect and submit that information, please read the Hand Hygiene Program Details. To learn more about what is expected of you as a participant in the campaign, please read the Program Expectations.

The important information gathered throughout this site helps you better understand hand hygiene and how we measure it, and in so doing helps us reduce infections, save lives, and reach our goal of sustaining hand hygiene compliance -- Clean In, Clean Out -- at least 90 percent of the time.

Tools to Measure Hand Hygiene

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You will find the following tools useful as you prepare to make hand hygiene observations, and record and submit your observations using either iScrub or the paper forms:

  • iScrub/Setting Up and Making Observations - Read for instructions on setting up the iScrub App on your Apple device and on how to observe hand hygiene compliance using iScrub. All iScrub observations will be submitted directly by the observer to the Hospital Epidemiology department via the hand@unch.unc.edu email address (see Setting up iScrub for details).
  • iScrub/Setting Up and Making Observations in the ORs - Read for instructions on setting up the iScrub App on your Apple device for use in the ORs and on how to observe hand hygiene compliance using iScrub in the ORs. All iScrub observations will be submitted directly by the observer to the Hospital Epidemiology department via the hand@unch.unc.edu email address (see Setting up iScrub for details).
  • Hand Hygiene Observation Paper Tool - Single Location - Read for instructions on recording observations from a single location; these forms will be submitted to by returning to the unit communication bulletin board. (The Spanish-language version of the tool is also available.) Hand Hygiene champions will enter data from paper forms at least monthly via online survey tool: Survey - Single Location Data
  • Hand Hygiene Observation Paper Tool for the ORs - Single LocationRead for instructions on recording observations from a single location in the ORs; these forms will be submitted to by returning to the unit communication bulletin board. Hand Hygiene champions will enter data from paper forms at least monthly via online survey tool: Survey for the ORs - Single Location Data
  • Hand Hygiene Observation Paper Tool - Multiple Locations - For those who service multiple locations in a single day: please read for instructions on recording observations from locations around the hospital; these forms will be submitted to the departmental communication bulletin board. Hand Hygiene champions will enter data from paper forms at least monthly via online survey tool: Survey - Multiple Locations Data
  • Providing Feedback After Observation - When you notice someone using improper hand hygiene techniques, you may approach that person to alert him/her about his/her oversight. Please remember to do so as respectfully as possible. The following script is an essential tool that offers suggestions for approaching someone who has not cleaned in nor cleaned out and for providing positive feedback for those who have displayed proper hand hygiene.
  • Real-time Compliance Data for Display: Each area bulletin board will host a paper graph where observers can chart the percentage of compliance observed on that unit. Compliance reports will be updated on the Intranet on a monthly basis and will detail compliance performance hospital-wide, collectively and by location and group. Please note that the overall, hospital-wide rate will be shown on the graphic at the top right of this page.
  • Hand Hygiene Action PlanAreas/departments can use this action planning tool to develop specific action steps to improve participation, compliance or feedback with hand hygiene. Specific strategies are provided on the sample tool as well.  

All employees who enter patients' rooms, no matter the purpose, will be eligible to be observed. It is therefore critical that no matter what role you serve at UNC Hospitals, you must clean in and clean out each time you enter a patient's room.

We encourage each of you to record and submit observations monthly (a minimum of 50 observations for an area per month) using either the iScrub App for Apple products or a paper form that you will enter into a web-based survey tool. For those areas without regular access to computers, you may submit the paper forms to your area's hand hygiene bulletin board for a unit champion to enter into the web-based survey tool.

Why Clean In, Clean Out?

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What is hand hygiene?

  • The process of decontaminating the hands
  • A general term that applies to either hand washing, antiseptic hand wash, antiseptic hand rub, or surgical hand antisepsis

How do I perform proper hand hygiene?

  • Wash your hands with soap and water for 15 to 20 seconds
  • Use an alcohol based hand rub (continue rubbing hands for 15-20 seconds until dry)

Why should I perform hand hygiene?

    • To prevent infections among patients, employees and visitors in the hospital
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When should I perform hand hygiene?

  • Before
    • Entering a patient’s room
    • Direct patient contact (with or without gloves)
    • Putting on sterile gloves
    • Inserting a device
    • Eating and drinking
  • After
    • Leaving a patient’s room
    • Direct patient contact
    • Removing gloves
    • Contact with equipment near the patient
    • Contact with body fluids, wound dressings (use soap and water if hands visibly soiled)
    • Moving from a contaminated body site to a clean site

What about my finger nails?

  • Nails should be kept clean and well-manicured
  • Nail polish should not be peeling or chipped
  • The use of artificial nails is prohibited for staff providing direct patient care

What if I have a rash below my elbows?

  • You should not work if the skin below your elbows is not intact
  • You should be seen by Occupational Health Service

Can I use lotions?

  • A list of approved lotions are available on the infection control webpage under FAQs
  • Some lotions interfere with the way that the antimicrobial soaps work and render them less effective

Click here to view this information as a flyer.

FAQs

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General Questions:

Is this a UNC Health Care goal or just a UNC Hospitals goal?
Although hand hygiene compliance is a priority at our other facilities, the details of this program are unique to UNC Hospitals.

How can I comply with Clean In, Clean Out?
Every employee must clean their hands upon entry and exiting a patient’s room or bedspace.

In addition, all employees entering patient rooms  or bedspace are encouraged to record and submit observations of their co-workers each month.

Conducting Observations:

How do I record my observations?
Employees may use the free iScrub app available on Apple products or paper forms available in patient areas (hand hygiene bulletin boards) and on the Intranet. Directions for setting up and using the iScrub app are available from the Tools tab above.

What should I look for when doing observations?
Each employee must clean their hands upon entry and exiting a patient’s room or bedspace.

One observation is defined as the employee moving in one direction (either entry or exit). You should record the occupational group of the person, the location of the observation (i.e., name of the patient area) and whether or not they complied with the Clean In, Clean Out requirement and whether feedback was given.

What if I could not tell if the employee cleaned his/her hands inside the patient room?
If you are not able to observe the entire opportunity for compliance (e.g., patient room’s door closed and you could not observe whether or not employee cleaned hands upon entry), you should not count this observation.

What if someone cleans on their way out and immediately enters another room without washing in?
An observation of staff who clean hands as they exit one room/bedspace and immediately enter another patient room/bedspace should be included as only one observation of compliance. Staff who go directly from one patient room/bedspace to another are not required to clean out of the first room and clean in to the next room/bedspace.

What if an employee enters a room/bedspace with gloves on?
Employees should wear a new pair of gloves for each patient room/bedspace entry and should have clean hands prior to donning gloves, although cleaning does not need to occur immediately prior to donning gloves. If you are not able to observe the entire opportunity for compliance (e.g., you did not observe what activities happened prior to donning gloves), you should not count this observation.

Can an individual submit too many observations?
We have encouraged employees to submit observations monthly, but there is no maximum number of observations allowed for each employee. However, we prefer that areas and departments work to maximize the number of unique observers rather than only the number of observations because we believe that widespread participation from frontline staff is the key component to achieving and sustaining a high level of hand hygiene compliance.   

What should I do with the multiple locations/traveling form when I have collected observations?
The Multiple Location Form (also called the Traveling Form) was developed for departments that move from one patient area to another (e.g., Radiology, Respiratory Therapy, EVS, Patient Transportation). If individual employees are unable to enter their own data into the web-based survey tool, their departments should have a central location for collecting these forms (hand hygiene bulletin board) and designated champions for the department will input their paper data forms into the Multiple Locations/Traveling Form web-based survey tool. 

Data Submission:

How can I enter more than one paper form into either the web-based Single Location or Multiple Locations/Traveling Form survey tool most efficiently?
After you enter up to 10 observations made by a single observer and you click the “Done” button on the bottom of the screen, the next screen thanks you for your submission and offers a “Continue” button which will restart the survey for a new batch of up to 10 observations. 

Assessing Participation and Compliance:

How will I know whether or not my area/department is submitting hand hygiene compliance observations?
A summary of observation data received for the previous month (i.e., total observations and number of unique observers by unit and department) will be shared with hand hygiene champions in each area, and at least one area/department will be highlighted each month for their outstanding participation.  

How will my area know what our hand hygiene compliance is?
Compliance data (% compliance with Clean In, Clean Out) will be also summarized and shared with champions in the summary. 

Program Inclusion:

Do non-clinical employees have to participate?
All UNC Hospitals staff entering patients rooms are eligible to be observed for their hand hygiene compliance and will be asked to provide five observations per month. All staff regardless of direct patient interactions should be aware of the Clean In, Clean Out hand hygiene campaign.

Will the UNC School of Medicine participate?
Any School of Medicine employees (e.g., attending physicians) or students who enter patients' rooms/bedspaces are eligible to be observed for their hand hygiene compliance and will be encouraged to provide observations.

Will visitors/families participate? Should I report on their compliance?
Visitors and families can be educated about our Clean In, Clean Out hand hygiene program. Feedback may be provided to and by visitors and families, but you should not report on their compliance as part of the program.

Will volunteers participate? Should I report on their compliance?
Volunteers can be educated about our Clean In, Clean Out hand hygiene program. Feedback may be provided to volunteers and by volunteers, but you should not report on their compliance as part of the program.

How should I document compliance for Nursing Assistants?
Nursing assistants should be included in the broad category of Nursing Staff. The hand hygiene forms and documentation has been changed to use the abbreviation “NURS” rather than “RN” to reflect this more general category.

How should I document compliance for Recreational Therapy staff?
Recreational therapy staff should be classified in the general grouping of OT/PT.

Are procedural areas, outpatient areas, and observation areas included in the Clean In, Clean Out program?
For FY15, inpatient areas and selected procedural and outpatient areas will be included in the measurement and 90% goal of the Clean In, Clean Out program, although all areas are encouraged to participate as we may consider an expansion of this program to additional areas in upcoming years. For non-included areas that do submit data, we will provide summary compliance reporting data to them routinely so they can initiate improvement strategies as well.

Immediate Feedback:

What do we say to someone who doesn’t clean in or clean out?
Immediate feedback scripting is provided for guiding conversations with our co-workers about non-compliance. Feedback should be offered in a non-threatening and private manner and if you have difficult interactions with providing immediate feedback, please speak with your supervisor.

What if we witness someone not complying who is not in our unit?
Immediate feedback can be provided to any UNC Hospitals co-worker, including medical students, residents, and attending physicians. Feedback should be offered in a non-threatening and private manner and if you have difficult interactions with providing immediate feedback, please speak with your supervisor.

Hand Hygiene Products and Occupational Health Issues:

What hand hygiene products are available?
At UNC Hospitals, we use Purell, an alcohol-based hand rub product, and EcoLab, an antimicrobial soap with 2% chlorhexidine gluconate. Our public restrooms have a non-antimicrobial soap available for non-clinical use.

Will alcohol-based hand rubs be readily available?
All areas have been assessing the accessibility of hand hygiene agents in their area. If you feel there are areas of the hospital that do not have hand hygiene agents easily accessible, please work with nurse managers of those locations and the infection prevention department to evaluate solutions. In addition, all departments should make available pocket-sized alcohol-based hand rubs (1.5 oz) for staff to use (Lawson # 050887).

What if I have dermatologic problems?
Personnel with cracked skin or dermatitis pose an infectious risk and should be evaluated by the Occupational Health Service as to work status and methods to relieve the condition. Occupational Health Service can provide additional hand creams that are compatible with our hand hygiene products.

What should I do about my dry hands?
Staff should use hand lotion in order to minimize the occurrence of irritant contact dermatitis associated with hand hygiene. However, hand lotions/creams must be compatible with both the antimicrobial agents in our hand hygiene products.

We have hand lotion available (Lawson #050939) which is compatible with the hand hygiene product. If staff prefer to use their personally purchased product they must review the list of approved agents on the infection control website to ensure compatibility.

Need Help?/Contacts

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Infection Control and Epidemiology

Emily Sickbert-Bennett, PhD, MS, CIC
Director | 984-974-47621 | pager: 919-347-1970 | Emily.Vavalle@unchealth.unc.edu

David J. Weber, MD, MPH
Medical Director | 984-974-7632 | pager: 919-347-0639 | David.Weber@unchealth.unc.edu

Lauren DiBiase, MS, CIC
Associate Director | 984-974-7629 | pager: 919-216-3891 | Lauren.Dibiase@unchealth.unc.edu

Lisa Teal, BSN, RN, CIC
Associate Director | 919-974-7628 | pager: 123-6941 | Lisa.Teal@unchealth.unc.edu

Brooke Brewer, MS, BSN, RN, CNML
Infection Preventionist (IP) | 984-974-7500 | pager: 123-7982 | Brooke.Brewer@unchealth.unc.edu

Christa Clark, BSN, RN, CCRN
Infection Preventionist (IP) | 984-974-7625 | pager: 123-4904 | Christa.Clark@unchealth.unc.edu

Cyndi Culbreth, BSN, RN, RN-BC
Infection Preventionist (IP) | 984-974-7627 | pager: 123-4538 | Cynthia.Culbreth@unchealth.unc.edu

Kate Schultz, MPH, BSN, RN
Infection Preventionist (IP) | 984-974-7624 | pager: 123-4718 | Katherine.Schultz@unchealth.unc.edu

Karen Croyle, BSN, RN, CIC
Infection Preventionist (IP) & Occupational Health Nurse| 984-215-2352 | pager: 919-216-0770 | Karen.Croyle@unchealth.unc.edu

Mark Buchanan, BS, BSN, RN, RN-BC
Clinical Quality Assurance Specialist | 984-974-6033 | pager: 123-6781 | Mark.Buchanan@unchealth.unc.edu

Shelley Summerlin-Long, MPH, MSW, BSN, RN
Quality Improvement Lead | 984-974-6036 | pager: 123-6782 | Shelley.Summerlin-long@unchealth.unc.edu

Maria Gergen, MT (ASCP)
Senior Medical Technologist | 984-974-7623 | pager: 123-2440 | Maria.Gergen@unchealth.unc.edu

Sherie Goldbach
Infection Prevention Registrar | 984-974-7622 | sherie.goldbach@unchealth.unc.edu

Judie Bringhurst, MSN, RN, CIC
Outpatient Infection Preventionist & Instrument Reprocessing Specialist | 984-974-7626 | cell: 919-951-4158 | Judie.Bringhurst@unchealth.unc.edu

Pamela Del Monte, MS, RN-BC
Outpatient Infection Preventionist | 984-215-2356| cell: 919-370-2989 | Pamela.DelMonte@unchealth.unc.edu

Pamela B. Miller, BSN, RN
Outpatient Infection Preventionist | 984-215-2354 | cell: 919-923-2685 | Pamela.Miller3@unchealth.unc.edu