Evidence-informed best practices are based on quality evidence and should be implemented into practice to optimize outcomes.9 Listed below you will find best practices graded according to the type of evidence. To view a description of the types of evidence, click here.
To help you move from best evidence to best practice, click on the + button next to each best practice to find details on how to implement, as well as change ideas to test using a PDSA approach.
Change ideas are specific and practical changes informed by experience and research that focus on improving specific aspects of a system, process or behaviour. To learn more about change ideas see the QI: Getting Started tab.
Evidence-Informed |
How To Implement |
Toolbox |
Hand hygiene
Effective hand hygiene kills or removes transient bacteria on the skin and minimizes risk of infection. (Provincial Infectious Diseases Advisory Committee (PIDAC), December 2010.) |
There are two methods of killing/removing microorganisms on hands:
The mechanical action of washing, rinsing and drying is the most important contributor to the removal of bacteria that might be present. |
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Type of Evidence: IV (Expert Opinion)*
REFERENCES:
Guidelines
Canadian Patient Safety Institute. Your 4 Moments for Hand Hygiene. Government of Ontario; [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Tools and Templates/Your 4 Moments for Hand Hygiene (Poster).pdf
Hand Hygiene Self-Assessment Framework (adapted from WHO Hand Hygiene Self-Assessment Framework 2010). Safer Healthcare Now!; [cited 2012 Nov 19]. Available from: https://shn.med.utoronto.ca/hh/
Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement. Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 19]. Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf
How to Help Prevent Healthcare-Associated Infections: A Patient and Family Guide. Canadian Patient Safety Institute; 2012 Apr [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Patients and Families/Patient Family Guide.pdf
Institute for Healthcare Improvement (IHI). Hand Hygiene [Internet]. Institute for Healthcare Improvement; [cited: 2012 Nov 19]. Available from: http://app.ihi.org/imap/tool/#Process=f0e22d9b-e08d-4d96-9f5b-181fe63743d8
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Hand Hygiene in All Health Care Settings. Toronto: Ontario Ministry of Health and Long-Term Care/Public Health Division; 2010 Dec [cited: 2012 Nov 19]. Available from: http://www.publichealthontario.ca/en/eRepository/2010-12 BP Hand Hygiene.pdf
World Health Organization. Prevention of hospital-acquired infections: A Practical Guide. 2nd ed. World Health Organization; 2002 [cited 2012 Nov 19]. Available from: http://www.who.int/csr/resources/publications/whocdscsreph200212.pdf
TYPES OF EVIDENCE
A literature review of relevant studies was conducted to present the state of evidence that currently exists in support of each best practice presented in this resource. Where available, studies that are characterized by good methodological quality and rigorous scientific design, such as systematic reviews (e.g., Cochrane reviews) and meta-analyses, were included. Additional types of evidence were considered and presented, including primary research studies such as randomized control trials, correlation and case-controlled studies, and observational research. Where studies were not found, other evidence that supported the change idea were presented, including expert guidelines, clinical experience of respected authorities, or other reports. Each best practice included in this resource was then assigned a type of evidence in accordance with the classification outlined below in Table 1:
*Table 1: Description of Types of Evidence
Type of Evidence | Grade | Description |
---|---|---|
High |
I |
High quality evidence including systematic reviews/Cochrane systematic reviews or meta-analyses |
Medium |
II |
Medium quality evidence including primary research studies such as randomized control trials, case control studies |
Low |
III |
Low quality evidence including descriptive studies, controlled study without randomization, correlation, case studies, grey literature |
Expert Opinion |
IV |
Guidelines, Expert committee reports, clinical experience of respected experts in the field |
Experience |
V |
Locally driven ideas that have shown promise and emerging innovations |
Evidence-Informed |
How To Implement |
Toolbox |
4 Moments of Hand Hygiene
A hand hygiene indication points to the reason hand hygiene is necessary at a given moment. |
The 4 Moments for Hand Hygiene for Health Care Professionals include:3
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Type of Evidence: IV (Expert Opinion)*
REFERENCES:
Guidelines
Canadian Patient Safety Institute. Your 4 Moments for Hand Hygiene. Government of Ontario; [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Tools and Templates/Your 4 Moments for Hand Hygiene (Poster).pdf
Hand Hygiene Self-Assessment Framework (adapted from WHO Hand Hygiene Self-Assessment Framework 2010). Safer Healthcare Now!; [cited 2012 Nov 19]. Available from: https://shn.med.utoronto.ca/hh/
Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement. Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 19]. Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf
How to Help Prevent Healthcare-Associated Infections: A Patient and Family Guide. Canadian Patient Safety Institute; 2012 Apr [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Patients and Families/Patient Family Guide.pdf
Institute for Healthcare Improvement (IHI). Hand Hygiene [Internet]. Institute for Healthcare Improvement; [cited: 2012 Nov 19]. Available from: http://app.ihi.org/imap/tool/#Process=f0e22d9b-e08d-4d96-9f5b-181fe63743d8
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Hand Hygiene in All Health Care Settings. Toronto: Ontario Ministry of Health and Long-Term Care/Public Health Division; 2010 Dec [cited: 2012 Nov 19]. Available from: http://www.publichealthontario.ca/en/eRepository/2010-12 BP Hand Hygiene.pdf
World Health Organization. Prevention of hospital-acquired infections: A Practical Guide. 2nd ed. World Health Organization; 2002 [cited 2012 Nov 19]. Available from: http://www.who.int/csr/resources/publications/whocdscsreph200212.pdf
TYPES OF EVIDENCE
A literature review of relevant studies was conducted to present the state of evidence that currently exists in support of each best practice presented in this resource. Where available, studies that are characterized by good methodological quality and rigorous scientific design, such as systematic reviews (e.g., Cochrane reviews) and meta-analyses, were included. Additional types of evidence were considered and presented, including primary research studies such as randomized control trials, correlation and case-controlled studies, and observational research. Where studies were not found, other evidence that supported the change idea were presented, including expert guidelines, clinical experience of respected authorities, or other reports. Each best practice included in this resource was then assigned a type of evidence in accordance with the classification outlined below in Table 1:
*Table 1: Description of Types of Evidence
Type of Evidence | Grade | Description |
---|---|---|
High |
I |
High quality evidence including systematic reviews/Cochrane systematic reviews or meta-analyses |
Medium |
II |
Medium quality evidence including primary research studies such as randomized control trials, case control studies |
Low |
III |
Low quality evidence including descriptive studies, controlled study without randomization, correlation, case studies, grey literature |
Expert Opinion |
IV |
Guidelines, Expert committee reports, clinical experience of respected experts in the field |
Experience |
V |
Locally driven ideas that have shown promise and emerging innovations |
Evidence-Informed |
How To Implement |
Toolbox |
Remove impediments to hand hygiene |
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Remove Impediments to Hand Hygiene
Type of Evidence: IV (Expert Opinion)*
REFERENCES:
Guidelines
Canadian Patient Safety Institute. Your 4 Moments for Hand Hygiene. Government of Ontario; [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Tools and Templates/Your 4 Moments for Hand Hygiene (Poster).pdf
Hand Hygiene Self-Assessment Framework (adapted from WHO Hand Hygiene Self-Assessment Framework 2010). Safer Healthcare Now!; [cited 2012 Nov 19]. Available from: https://shn.med.utoronto.ca/hh/
Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement. Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 19]. Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf
How to Help Prevent Healthcare-Associated Infections: A Patient and Family Guide. Canadian Patient Safety Institute; 2012 Apr [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Patients and Families/Patient Family Guide.pdf
Institute for Healthcare Improvement (IHI). Hand Hygiene [Internet]. Institute for Healthcare Improvement; [cited: 2012 Nov 19]. Available from: http://app.ihi.org/imap/tool/#Process=f0e22d9b-e08d-4d96-9f5b-181fe63743d8
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Hand Hygiene in All Health Care Settings. Toronto: Ontario Ministry of Health and Long-Term Care/Public Health Division; 2010 Dec [cited: 2012 Nov 19]. Available from: http://www.publichealthontario.ca/en/eRepository/2010-12 BP Hand Hygiene.pdf
World Health Organization. Prevention of hospital-acquired infections: A Practical Guide. 2nd ed. World Health Organization; 2002 [cited 2012 Nov 19]. Available from: http://www.who.int/csr/resources/publications/whocdscsreph200212.pdf
TYPES OF EVIDENCE
A literature review of relevant studies was conducted to present the state of evidence that currently exists in support of each best practice presented in this resource. Where available, studies that are characterized by good methodological quality and rigorous scientific design, such as systematic reviews (e.g., Cochrane reviews) and meta-analyses, were included. Additional types of evidence were considered and presented, including primary research studies such as randomized control trials, correlation and case-controlled studies, and observational research. Where studies were not found, other evidence that supported the change idea were presented, including expert guidelines, clinical experience of respected authorities, or other reports. Each best practice included in this resource was then assigned a type of evidence in accordance with the classification outlined below in Table 1:
*Table 1: Description of Types of Evidence
Type of Evidence | Grade | Description |
---|---|---|
High |
I |
High quality evidence including systematic reviews/Cochrane systematic reviews or meta-analyses |
Medium |
II |
Medium quality evidence including primary research studies such as randomized control trials, case control studies |
Low |
III |
Low quality evidence including descriptive studies, controlled study without randomization, correlation, case studies, grey literature |
Expert Opinion |
IV |
Guidelines, Expert committee reports, clinical experience of respected experts in the field |
Experience |
V |
Locally driven ideas that have shown promise and emerging innovations |
Evidence-Informed |
How To Implement |
Toolbox |
Incentives |
|
Type of Evidence: IV (Expert Opinion)*
REFERENCES:
Guidelines
Canadian Patient Safety Institute. Your 4 Moments for Hand Hygiene. Government of Ontario; [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Tools and Templates/Your 4 Moments for Hand Hygiene (Poster).pdf
Hand Hygiene Self-Assessment Framework (adapted from WHO Hand Hygiene Self-Assessment Framework 2010). Safer Healthcare Now!; [cited 2012 Nov 19]. Available from: https://shn.med.utoronto.ca/hh/
Health Quality Ontario. 2012/13 Quality Improvement Plans: An Analysis for Improvement. Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 19]. Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf
How to Help Prevent Healthcare-Associated Infections: A Patient and Family Guide. Canadian Patient Safety Institute; 2012 Apr [cited 2012 Nov 19]. Available from: http://www.handhygiene.ca/English/Documents/Patients and Families/Patient Family Guide.pdf
Institute for Healthcare Improvement (IHI). Hand Hygiene [Internet]. Institute for Healthcare Improvement; [cited: 2012 Nov 19]. Available from: http://app.ihi.org/imap/tool/#Process=f0e22d9b-e08d-4d96-9f5b-181fe63743d8
Provincial Infectious Diseases Advisory Committee (PIDAC). Best Practices for Hand Hygiene in All Health Care Settings. Toronto: Ontario Ministry of Health and Long-Term Care/Public Health Division; 2010 Dec [cited: 2012 Nov 19]. Available from: http://www.publichealthontario.ca/en/eRepository/2010-12 BP Hand Hygiene.pdf
World Health Organization. Prevention of hospital-acquired infections: A Practical Guide. 2nd ed. World Health Organization; 2002 [cited 2012 Nov 19]. Available from: http://www.who.int/csr/resources/publications/whocdscsreph200212.pdf
TYPES OF EVIDENCE
A literature review of relevant studies was conducted to present the state of evidence that currently exists in support of each best practice presented in this resource. Where available, studies that are characterized by good methodological quality and rigorous scientific design, such as systematic reviews (e.g., Cochrane reviews) and meta-analyses, were included. Additional types of evidence were considered and presented, including primary research studies such as randomized control trials, correlation and case-controlled studies, and observational research. Where studies were not found, other evidence that supported the change idea were presented, including expert guidelines, clinical experience of respected authorities, or other reports. Each best practice included in this resource was then assigned a type of evidence in accordance with the classification outlined below in Table 1:
*Table 1: Description of Types of Evidence
Type of Evidence | Grade | Description |
---|---|---|
High |
I |
High quality evidence including systematic reviews/Cochrane systematic reviews or meta-analyses |
Medium |
II |
Medium quality evidence including primary research studies such as randomized control trials, case control studies |
Low |
III |
Low quality evidence including descriptive studies, controlled study without randomization, correlation, case studies, grey literature |
Expert Opinion |
IV |
Guidelines, Expert committee reports, clinical experience of respected experts in the field |
Experience |
V |
Locally driven ideas that have shown promise and emerging innovations |
Lancet. 2003 Oct 11;362(9391):1225-30.
Available from: http://www.ncbi.nlm.nih.gov/pubmed/14568747
Government of Ontario; [cited 2012 Nov 19].
Available from: http://www.handhygiene.ca/English/Documents/Tools and Templates/Your 4 Moments for Hand Hygiene (Poster).pdf
How will we know if a change is an improvement? Measurement is one of the critical steps in a quality improvement (QI) initiative that assesses the impact of your tests of change. Quality indicators are used to measure how well something is performing. There are three types of quality indicators used to measure your QI efforts: outcome (indicators that capture clinical outcomes and or system performance), process (indicators that track the processes that measure whether the system is working as planned), and balancing indicators (indicators that ensure that changing one part of the system does not cause new problems in other parts of the system).
Key Measurement Guidelines |
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Suggested measures for QI initiatives in hand hygiene are listed in the table below:
Type of Measure | Measure |
---|---|
Process Measure | Hand hygiene compliance before initial patient/patient environment contact |
Process Measure | Hand hygiene compliance before aseptic procedure |
Process Measure | Hand hygiene compliance after body fluid exposure risk |
Process Measure | Hand hygiene compliance after patient/patient environment contact |
Process Measure | Hand hygiene compliance across all four moments - previously mentioned see above |
Outcome Measure | Hospital-acquired infection rates |
Health care associated infections kill between 8,000 and 12,000 Canadians every year, of which 40% occur in Ontario.1 Patients seeking help for other health issues may inadvertently get an infection at the health care facility, leading to more serious illness, prolonged hospital stays, and possibly induce long-term disability or death. These preventable infections inflict an unexpected complication on the patients and their families, as well as a substantial financial burden on the health care system.2 Proper hand hygiene is a key part of an effective infection control and prevention program, and can help prevent unnecessary cost, illness and death.
It has been estimated that 220,000 health care associated infections occur in Canada each year, meaning that one in nine patients admitted to Canadian hospitals will acquire an infection as a consequence of their stay.2 About twenty years ago, hospital-acquired infection was the 11th leading cause of death in Canada. Today, it is the fourth leading cause of death in the country.2
It is recommended that there are four important moments of hand hygiene compliance: before initial patient/patient environment contact, before aseptic procedures, after body fluid exposure risk, and after patient/patient environment contact.2,3 The overall rate of hand hygiene compliance before patient contact in Ontario hospitals in 2012 was 72% (all hospitals, a slight improvement since 2011 where it was about 66%) and the rate of hand hygiene compliance after patient contact was 83%.4 In 2011, acute teaching hospitals had a lower rate of hand hygiene compliance before patient contact (57%) compared to other hospitals (small community, 51%; large community, 70%; mental health, 63%; chronic/rehabilitation 69%).6 In Ontario, eighty-five hospitals chose hand hygiene as their number one priority in 2012.5 There has been some improvement in this rate of compliance but compliance is too low, leaving room for improvement in Ontario hospitals.6
Ontario Council of Hospital Unions; 2011 Oct 11 [cited 2012 Nov 19].
Available from: http://www.ochu.on.ca/hai_tour.html
The College of Physicians and Surgeons of Ontario; 2009 July [cited 2012 Nov 19].
Available from: http://www.cpso.on.ca
Government of Ontario; [cited 2012 Nov 19].
Available from: http://www.handhygiene.ca/English/Documents/Tools and Templates/Your 4 Moments for Hand Hygiene (Poster).pdf
Toronto: Health Quality Ontario; 2012 Sept [cited 2012 Nov 19]
Available from: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2012-en.pdf
Toronto: Health Quality Ontario; 2012 Nov [cited 2012 Nov 19].
Available from: http://www.hqontario.ca/Portals/0/Documents/qi/qip-analysis-for-improvement-2012-en.pdf
Toronto: Health Quality Ontario; 2011 Sept [cited 2012 Nov 19]
Available from: http://www.hqontario.ca/portals/0/Documents/pr/qmonitor-full-report-2011-en.pdf