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www.ccnonline.org CriticalCareNurse Vol 37, No. 3, JUNE 2017 e1 Feature Patients’ Hand Washing and Reducing Hospital- Acquired Infection Stacy Haverstick, RN, BSN, PCCN Cara Goodrich, MS, AGPCNP-BC Regi Freeman, RN, MSN, ACNS-BC Shandra James, RN, DNP Rajkiran Kullar, MPH, CIC Melissa Ahrens, MPH, CIC Background Hand hygiene is important to prevent hospital-a\fquired infe\ftions\b Patients’ hand hygiene is just as important as hospital workers’ hand hygiene\b Hospital-a\fquired infe\ftion rates remain a \fon\fern a\fross health \fenters\b oBjectives BB iBnetviMdBtcsndksj BrckgBroundkdBsrvi urBsrdBtvieisnikBckgB jdBi BrckgB cjrnkuB nsrBjictB ckgB csdv BrckgBjcknsn dv Biv isrBckgBnetviMdBtcsndksj Bdg \fcsnikBsiBvdg \fdB rijtnschlc\f nvdgBnk d\fsnikj\bB Methods B k u js BtcsndksjBnkBcB\fcvgnisrivc\fn\fBtijsj vun\fchB jsdtlgi kB knsB dvdBtviMngdgB nsrB nkgnMng ch isshdjBi BrckgBjcknsn dv\b vjdjBckgBk vjnkuBsd\frkn\fnckjBtviMngdgBrckgBroundkdBdg \fcsnikBsiB dc\frBtcsndks\bB csndksjB\fiethdsdgBcB l djsnikBj vMdo d ivdBsrdBnksdvMdksnik BcsBrijtnschBgnj\frcvudBckg B Bckg BeiksrjBc sdvBsrdBnksdvMdksnik\bB aijtnschlc\f nvdgBnk d\fsnikBgcscB dvdBsvc\f dgBeiksrho oBnk d\fsnikB tvdMdksnikBjsc \b results Signifi\fant \forrelations were found between hand hygiene and rates of infe\ftion with van\fomy\fin- resistant entero\fo\f\fi (P = \b003) and methi\fillin-resistant Staphylococcus aureus ( P = \b01) after the interven - tion\b After the implementation of hand hygiene interventions, rates of both infe\ftions de\flined signifi\fantly and patients reported more staff offering opportunities for and en\fouraging hand hygiene\b conclusion BB rnjB chnsoBnetviMdedksBtvi d\fsBgdeikjsvcsdjBsrcsBnk\fvdcjdgBrckgBroundkdB\fiethnck\fd oB tcsndksjB\fckBn dk\fdBnk d\fsnikBvcsdjBnkBckBcg hsB\fcvgnisrivc\fn\fB jsdtlgi kB kns\bB rdBgd\fvdcjdgBnk d\fsnikB vcsdjBckgBnk\fvdcjdgB\fiethnck\fdB nsrBrckgBroundkdBceikuBsrdBtcsndksjBeco dBcssv sdgBsiBsrdBnethdedksc l snikBi BtcsndksBdg \fcsnikBckgBsrdBnk\fvdcjdgBc\f\fdjj nhnsoBckgB jdBi BrckgBjcknsn dv\b Critical Care Nurse\b 2017;37[3]:e1-e8) ©2017 American Association of Critical-Care Nurses doi: https://doi.org/10.4037/ccn2017694 H ospital-acquired infections (H\fIs) can lead to longer sta\bs, higher health care costs, and greater mortalit\b rates. A\f\fording to Magill et al, 1 who \fondu\fted a multistate point-prevalen\fe study of health \fare–asso\fiated infe\ftions, 1 in 25 patients in the a\fute \fare setting will develop a health \fare–asso\fiated infe\ftion during their hospital stay\b In 2011, roughly 722 000 patients had a HAI and around 75 000 of those patients died\b 1 Of those infe\ftions, pneumonia and surgi\fal site infe\ftions had the highest rates\b 1 Be\fause a \fommon mode of transmission is via \fontaminated hands, hand hygiene is e2 CriticalCareNurse Vol 37, No. 3, JUNE 2017 www.ccnonline.org the single best method to prevent the spread of infe\ftion\b Staff hand hygiene is always important, but providing a\f\fess and edu\fation to patients is equally important\b Cross-\fontamination shows the relationship between the environment, patients, and staff\b A majority of hospitals’ efforts to prevent infe\ftion are fo\fused on the attitudes and pra\fti\fes of staff members\b After many intera\ftions with patients on our \fardiothora\fi\f step- down unit, it be\fame obvious that in\freased fo\fus on patients’ hand hygiene pra\fti\fes and attitudes about hand hygiene was needed\b Local Problem While in the hospital, patients’ ability to pra\fti\fe hand hygiene in the room is limited by a\f\fessibility to soap and water or to hand sanitizer\b For example, in ea\fh patient’s room there is a sink by the door and a bottle of hand sanitizer that is pla\fed on the wall oppo- site the patient’s bed\b Many patients are unable to a\f\fess either of these without assistan\fe be\fause of mobility issues or postsurgi\fal intravenous \fatheters and drains\b These barriers \fan lead to de\freased hand hygiene \fom- plian\fe among patients\b Intended Improvement Our fo\fus was on providing tools for patients to prote\ft themselves against HAI\b Patients’ experien\fes and survey data demonstrated that the patient’s ability to pra\fti\fe hand hygiene in the hospital is limited and requires reinfor\fement by nursing staff\b Before the inter - vention, 75% of patients reported that they had been en\fouraged to wash their hands (Figure 1)\b In\freasing patients’ hand washing by edu\fating patients on the importan\fe of hand hygiene, as well as providing patients with a\f\fess to hand sanitizer, was proposed to redu\fe infe\ftion rates\b Reasons why patients were not able to perform hand hygiene in\fluded that patients did not know how import - ant hand hygiene was to preventing infe\ftion, that they did not usually wash their hands at home, and that they were unable to wash their hands be\fause they rely on Authors Stacy Ha\ferstick is a staff nurse on a car\biothoracic step-\bown unit at Uni\fersity of Michigan Health System, Ann Arbor, Michigan.

Cara Goo\brich is a staff nurse on a car\biothoracic step-\bown unit at Uni\fersity of Michigan Health System.

Regi Freeman is a clinical nurse specialist in the car\bio\fascular intensi\fe care unit Uni\fersity of Michigan Health System.

Shan\bra James is a clinical assistant professor at Uni\fersity of Michigan, School of Nursing, Ann Arbor, Michigan.

Rajkiran Kullar is an infection pre\fentionist at Uni\fersity of Michigan Health System.

Melissa Ahrens is an infection pre\fentionist at Uni\fersity of Tole\bo Me\bical Center, Tole\bo, Ohio.

Correspon\bing author: Stacy Ha\ferstick, RN, BSN, PCCN, 4C Car\biac an\b Thoracic Surgery Unit, Uni\fersity of Michigan Health System, 1500 E. Me\bical Center Dr, Ann Arbor, MI 48109 (email: ha\[email protected]\bu).

To purchase electronic or print reprints, contact the American Association of Critical- Care Nurses, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 899-1712 or (949) 362-2050 (ext 532); fax, (949) 362-2049; email, [email protected] Figure 1 Patient survey results: were you offered to wash your hands during your stay? Percentage of responses 100 90 80 70 60 50 40 30 20 100 Ye s Before intervention 1 Month after intervention 2 Months after intervention 3 Months after intervention No Sometimes www.ccnonline.org CriticalCareNurse Vol 37, No. 3, JUNE 2017 e3 staff to offer the opportunity to do so\b 2 The typi\fal postsurgi\fal patient was not readily able to get to the sink without help\b With a fostering innovation grant provided by the University of Mi\fhigan, bed-bound patients re\feived al\fohol-based hand sanitizer, hand- sanitizer wipes, or both\b Staff were edu\fated and en\four - aged to be aware of patients’ a\f\fess to hand hygiene after any tasks that ne\fessitated hand hygiene, in\fluding after using the restroom, before meals, before tou\fhing in\fisions or wounds, and before leaving their room and upon returning to the room\b Study Question This study was done to determine if in\freased a\f\fess to hand hygiene produ\fts and patient edu\fation \fould improve patients’ hand hygiene and redu\fe the trans- mission of HAIs\b In parti\fular, rates of infe\ftion with methi\fillin-resistant Staphylococcus aureus (MRSA), van\fomy\fin-resistant entero\fo\f\fi (VRE), and Clostri\bium \bifficile were assessed to determine if rates were de\freased\b Methods Ethical Issues The proje\ft re\feived exempt status from the hospi- tal’s institutional review board\b Informed \fonsent was waived be\fause the proje\ft met \friteria for a quality improvement proje\ft\b No ethi\fal \fon\ferns were noted for this proje\ft\b A $2350 fostering innovation grant was provided by the University of Mi\fhigan Health System and was used to pur\fhase al\fohol-based hand sanitizer as well as hand-sanitizing wipes\b Setting The patient hand hygiene initiative was implemented in August 2013 on an adult 36-bed \fardiothora\fi\f surgi- \fal step-down unit at the University of Mi\fhi\fan Health System, a large a\fademi\f medi\fal \fenter in the Midwest\b The majority of patients were unable to get to the sink to wash their hands without assistan\fe\b Patients in the unit typi\fally arrive from the intensive \fare unit or the pos- tanesthesia \fare unit with \fhest tubes, nasogastri\f tubes, jejunostomy feeding tubes, epidurals, left ventri\fular assist devi\fes, and intravenous fluids and medi\fations\b Patients are taught not to get up without assistan\fe be\fause of the in\freased risk of falling, so getting up freely to wash their hands is not easily a\f\fomplished\b Unit staff nurses observed that patients need to have a\f\fess to al\fohol-based hand sanitizer, hand wipes, or soap and water at the bedside instead of relying on the hos- pital staff to give patients an opportunity to prote\ft themselves from HAIs\b Planning the Intervention/Planning the Study of the Intervention Before implementation of the patient hand-washing proje\ft, staff \fompleted an anonymous 6-question survey (Table 1)\b 3 Permission was granted to use a modified survey from the arti\fle, “Hand Hygiene: What About Our Patients?” 3 Unit staff were asked to \fomplete the questionnaire and return it within 1 week\b We re\feived a total of 33 staff responses\b Upon dis\fharge, patients also \fompleted a 6-question survey (Table 2) before the intervention, as well as 1, 2, and 3 months after Table 1 Staff questionnaire a Question Did you offer an opportunity to your patient to enable them to wash/clea\ n their hands?

Patients encouraged to carry out hand hygiene after going to the bathroom and before meals?

Patients who require assistance with hand washing are offered the opport\ unity?

I think hand hygiene is important to preventing infection in the hospita\ l.

I think staff feel their own hand hygiene is important part of preventing infection.

I think staff feel patients’ hand hygiene is an important part of preventing infection in the hospital.

In your opinion, what more could be done in order for patients to clean \ their hands in the hospital?

a Adapted from Burnett et al, 3 with permission. Responses Yes, no Always, often, sometimes, rarely, never Always, often, sometimes, rarely, never Strongly agree, agree, disagree, strongly disagree, unsure Strongly agree, agree, disagree, strongly disagree, unsure Strongly agree, agree, disagree, strongly disagree, unsure Write your response… e4 CriticalCareNurse Vol 37, No. 3, JUNE 2017 www.ccnonline.org implementation to tra\fk progress of program parti\fipa- tion\b It was hypothesized that the unit results would mir- ror the results of Burnett et al, 3 where the staff aimed on the positive side of the s\fale and patients had the major - ity of rarely or never responses when asked if they were en\fouraged to wash their hands\b 3 Patient surveys were given and returned anony- mously at dis\fharge\b Surveys were in paper form, with a varying response rate dependent on how many patients were dis\fharged, as well as how many answered and returned the form\b Patient survey responses in\fluded (1) 16 responses before the intervention, (2) 39 responses 1 month after the inter - vention, (3) 63 responses 2 months after the intervention, and (4) 54 responses 3 months after the intervention\b Upon admission to the unit, ea\fh patient re\feived an al\fohol-based hand sanitizer or wipes and “The Impor - tan\fe of Hand Hygiene” bro\fhure \freated by the institu- tion’s infe\ftion prevention department, whi\fh was reviewed with the patient by the nurse\b Also in\fluded in the unit’s bro\fhure was a se\ftion dedi\fated to the importan\fe of hand hygiene for the patient that indi\fated when patients should wash their hands (after using the restroom, before meals, before tou\fhing in\fisions or wounds, before leaving their room, and upon return to the room)\b If the patient had a C \bifficile infe\ftion, they along with visi- tors were instru\fted to wash their hands with soap and water only\b Additionally, per the institution’s poli\fy, all al\fohol-based hand sanitizer was removed from the patient’s room\b Patients with existing infe\ftions of MRSA, VRE, and C \bifficile were also taught not to use the nutri- tion or linen rooms shared with all staff and patients\b It was expe\fted that the nurse and nurse te\fhni\fians would reinfor\fe patients’ hand hygiene when appropriate\b During daily rounds, the unit host asked patients if they had re\feived and were using the al\fohol-based hand sanitizer or wipes that were provided on admission\b If the patient did not re\feive or had mispla\fed the hand sani- tizer, the host provided additional sanitizer\b Unit leaders followed the trend in new \fases of HAI from the infe\ftion prevention department’s monthly report, whi\fh was then used to evaluate the impa\ft and effe\ftiveness of the proje\ft\b Methods of Evaluation and Analysis All patients admitted to the unit were in\fluded in the proje\ft\b HAI rates were \fompared during a 19-month period before and a 19-month period after the interven- tion\b Statisti\fal analyses were \fondu\fted by using SPSS version 21\b Rates of HAI (MRSA, VRE, and C \bifficile) were \fompared before and after the intervention\b A non- parametri\f Wil\foxon rank sum test was used be\fause of the small sample size and the underpowered study\b Sig- nifi\fan\fe was set at the \b05 level\b Results Outcomes Unit-spe\fifi\f infe\ftion \fontrol data showed that VRE infe\ftions de\freased by 70% (n = 33 before and n = 1 0 after) in a 19-month period after the intervention\b Table 2 Patient questionnaire a Question Were you offered to wash your hands during your stay?

Were you encouraged to carry out hand hygiene after going to the bathroom and before meals?

I think hand hygiene is important to preventing infection in the hospita\ l.

I think staff feel their own hand hygiene is important part of preventing infection.

I think staff feel patients’ hand hygiene is an important part of preventing infection in the hospital.

In your opinion, what more could be done in order for patients to clean \ their hands in the hospital?

a Adapted from Burnett et al, 3 with permission. Responses Yes, no Always, often, sometimes, rarely, never Strongly agree, agree, disagree, strongly disagree, unsure Strongly agree, agree, disagree, strongly disagree, unsure Strongly agree, agree, disagree, strongly disagree, unsure Write your response… Each patient received an alcohol-based hand sanitizer or wipes. www.ccnonline.org CriticalCareNurse Vol 37, No. 3, JUNE 2017 e5 MRSA infe\ftions de\freased by 63% (n = 1 9 before and n = 7 after) in a 19-month period after the intervention\b A Wil\foxon rank sum test revealed no signifi\fant differ - en\fe in the rates of C \bifficile infe\ftion before (median, 0\b73) and after (median, 0\b78) the intervention (U = 175, z = -0\b171, P = \b86, r = 0\b02)\b Conversely, C \bifficile infe\ftions in\freased 31% in a 19-month period\b A Wil\foxon rank sum test revealed a signifi\fant differen\fe in the VRE infe\ftion rates from before (median, 1\b6) and after (median, 0\b50) the intervention (U = 83\b50, z = -2\b975, P = \b003, r = 0\b48)\b A Wil\foxon rank sum test revealed a signifi\fant differ - en\fe in the MRSA rates before (median, 0\b82) and after (median, 0\b50) the intervention (U = 102\b500, z = -2\b484, P = \b01, r = 0\b40; Table 3)\b Staff Survey At the time of the preintervention survey, nursing staff believed that they en\fouraged patients to \fomplete hand hygiene 97% of the time\b Ideas that staff listed to help with patients’ hand hygiene were as follows: having preprinted signs for alerting patients to wash their hands before leaving room and when returning, giving patients a personal sanitizer at the bedside, a sign in patients’ restrooms stating: “Did you remember to wash your hands?”, in\freased patient edu\fation, in\freased prompt - ing of patients to wash their hands, infe\ftion \fontrol pamphlets on admission, patient \fontra\fts, hand wipes at the bedside for those unable to stand to wash, visual reminders for patients on the wall, having doors that open without tou\fhing them, and having automati\f sinks and toilets\b Patient Survey Results of the patient survey querying: “Were you offered to wash your hands during your stay?” (Table 2) indi\fated that the data improved from 75% before the intervention to 94% by 3 months after the intervention\b Patients’ suggestions to in\frease patient hand hygiene in\fluded the following: having staff en\fourage all patients to perform hand hygiene, giving ea\fh patient his or her own hand sanitizer, re\fognizing that patients would be more apt to use hand sanitizer than hand wipes, having hand wipes at the bedside, explaining that the wipes pro- vided with meals are for sanitizing, pla\fing a small \fon- tainer on the side of the tray table with individual hand sanitizer wipes\b Comments from patients \folle\fted on the survey indi\fated: “Well, I think you guys are doing a good job with hand hygiene, very good staff,” “Every need for hygiene is provided,” “Staff is really good about washing their hands\b” Other survey questions in\fluded, “Were you en\four - aged to \farry out hand hygiene after going to the bathroom and before meals?” (Figure 2)\b Before the intervention, 53% of patients responded “always” but that per\fentage had de\freased to 46% by 3 months after the intervention\b When talking with staff, patients said that they thought that when working with an adult population, nurses should not have to remind patients to wash their hands\b Another bar - rier was that the nurse and/or te\fh- ni\fian was not always with the patient during a\ftivities that would ne\fessitate hand hygiene\b In the unit bro\fhure and the hand-washing bro\fhure, the importan\fe of hand hygiene after using the bathroom and before meals was outlined and en\fouraged\b The patient survey also asked patients about their level of agreement with the statement, “I think hand hygiene is important to preventing infe\ftion in the hospital\b” Before the intervention, 93% strongly agreed and 6% agreed\b One month after the intervention, 90% strongly agreed and 9% agreed\b Two months after the Table 3 Overall outcomes for infection rates Organism Clostridium difficile Vancomycin-resistant enterococci Methicillin-resistant Staphylococcus aureus P .86 .003 .01 After intervention February 2015 (n = 38) 0.78 0.50 0.50 Before intervention January 2012 (n = 38) 0.73 1.60 0.82 Median infection rate MRSA and VRE infection rates declined significantly. e6 CriticalCareNurse Vol 37, No. 3, JUNE 2017 www.ccnonline.org intervention, opinion de\freased to 84% strongly agreed and 15% agreed\b Three months after the intervention, 93% strongly agreed and 6% agreed\b An evaluation of these results indi\fated that we needed to improve our patient edu\fation\bThe patient survey also queried patients’ level of agreement with the statement, “I think staff feel their own hand hygiene is an important part of preventing infe\ftion\b” Before the intervention, 100% of patients strongly agreed\b One month after the intervention, 93% strongly agreed, 4% agreed, and 1% disagreed\b Two months after the intervention, 79% strongly agreed and 20% agreed\b Three months after the intervention, 94% strongly agreed and 5% agreed\b Another survey statement was, “I think staff feel patient hand hygiene is an important part of preventing infe\ftion in the hospital\b” Before the intervention, 68% of patients strongly agreed, 25% agreed, and 6% were unsure\b One month after the intervention, the per\fent - ages had in\freased to 81% strongly agreed and 18% agreed\b Two months after the intervention, 84% strongly agreed, 14% agreed, and 1% were unsure\b Three months after the intervention, 93% strongly agreed and 6% agreed\b Discussion After the intervention, patients’ knowledge about the importan\fe of hand hygiene and the availability of hand hygiene supplies in\freased\b Patients’ responses indi\fated that they were offered the opportunity to wash their hands before meals and after using the restroom with in\freas- ing frequen\fy in the months following the intervention\b Therefore, \fomplian\fe with patient hand hygiene would have in\freased\b Patients’ perspe\ftive of staff hand hygiene being important to prevent infe\ftion showed a slight de\fline during the months of the study\b This de\frease \fould be related to the in\freasing knowledge and atten- tion to hand hygiene that patients experien\fed after implementation of these interventions\b In a review of our fa\filities’ HAIs, unit-spe\fifi\f infe\ftion \fontrol data indi\fated that VRE infe\ftions de\freased by 70% and MRSA infe\ftions de\freased by 63% in a 19-month period\b These de\freased infe\ftion rates \fould be affe\fted by several fa\ftors, in\fluding in\freased awareness of and knowledge about hand hygiene that resulted in improved hand hygiene pra\f - ti\fes among both patients and staff\b As noted earlier, C \bifficile infe\ftions in\freased 31% in a 19-month period\b Asso\fiated fa\ftors may have in\fluded the use of al\fohol- based hand sanitizer and sanitizer wipes, as hand hygiene with soap and water is re\fommended for use to prevent the spread of C \bifficile infe\ftions\b Relation to Other Evidence Survey findings were \fonsistent with out\fomes reported by Ward\b 2 Patients did not perform hand hygiene for a multitude of reasons su\fh as la\fk of Figure 2 Patient survey results: were you encouraged to carry out hand hygiene after going to the bathroom and before meals? Percentage of responses 70 60 50 40 30 20 10 0 Always Before intervention 1 Month after intervention 2 Months after intervention 3 Months after intervention Sometimes Often Never Rarely www.ccnonline.org CriticalCareNurse Vol 37, No. 3, JUNE 2017 e7 knowledge, not routinely washing hands at home, inabil- ity to a\f\fess supplies for hand hygiene, la\fk of en\four - agement by staff, and staff being too busy to be bothered\b Before these interventions, it was surmised that hand hygiene was simply overlooked by nursing staff, as reported by Fox et al\b 4 The essential times for hand hygiene used in this proje\ft were \forroborated by Sunkesula et al 5 as being before meals, after using the restroom, before \fonta\ft with in\fisions or wounds, and before leaving and after returning to the hospital room\b Limitations This quality improvement proje\ft had some limita- tions\b Primarily, this study was \fondu\fted on 1 unit in 1 medi\fal \fenter, whi\fh limits the generalizability of the findings to other settings\b Plans to expand these pra\fti\fes to other units within the fa\fility are ongoing\b Results were \fompared with results for a group of patients from before the intervention instead of with results from a randomized \fontrol group, and the demographi\fs of the 2 groups were not evaluated\b Patients’ learning was assessed upon admission; how- ever, edu\fation of patients about hand washing was done via verbal instru\ftion and printed bro\fhure\b This method may not have taken into \fonsideration the learning needs and health litera\fy of the patients\b Staff members on this unit were engaged to do this work and to assist patients to \fomplete hand hygiene even though the unit is very busy and fast pa\fed\b This arrangement may limit the appli\fability of our results to other units or areas where engagement is not high and \fhange is diffi\fult\b Some \fosts were asso\fiated with obtaining supplies to assist with enabling patients to perform hand hygiene, whi\fh may limit the implementa- tion of this proje\ft in other areas or fa\filities\b Fa\ftors asso\fiated with the methods, in\fluding the use of sur - veys, may have led to lower response rates than if other methods of data \folle\ftion had been used\b Thus an addi- tional limitation of this quality improvement study is the small sample size\b Survey responses from the patients and staff may have exhibited bias be\fause of intera\ftion with the nursing staff \fondu\fting this quality improvement work\b Many fa\ftors \fome into play when \fonsidering infe\ftion rates; thus it is diffi\fult to generalize that infe\ftion rates de\freased ex\flusively as a result of the patient hand hygiene interventions implemented\b During this time, no other interventions spe\fifi\fally related to prevention of HAIs were implemented on the unit, in an effort to determine the impa\ft of the interventions related to patients’ hand hygiene\b Interpretation As is well do\fumented in the literature, hand hygiene is the single best method to prevent the spread of infe\f - tion\b Edu\fation of staff and patients is essential to engage stakeholders in hand hygiene\b Survey results indi\fated that patients were not well informed about the impor - tan\fe of hand hygiene and were not given the opportu- nity to perform hand hygiene\b Informing the nursing staff of these findings and engaging the staff to empower the patient to \fomplete hand hygiene and provide the patient with resour\fes were essential to the su\f\fess of this quality improvement proje\ft\b Even though this study had a small sample size, it indi\fated a redu\ftion in HAIs on the \fardiothora\fi\f step-down unit, whi\fh \fould in turn potentially lead to a de\freased length of stay, lower health \fare \fosts, and a de\frease in mortality\b Conclusions Further studies should be fo\fused on observations of patients’ hand hygiene before and after interventions are implemented\b Observations of patients’ hand hygiene pra\fti\fes should o\f\fur at the most essential times, in\fluding after the patient uses the restroom, before meals, before tou\fhing in\fisions or wounds, before leav- ing the room, and upon return to the room\b This spe\fifi\f type of surveillan\fe would assist with providing knowl - edge about where nursing staff should fo\fus their efforts to engage patients to \fomplete hand hygiene\b The pra\f - ti\fes of other multidis\fiplinary team members relative to hand hygiene and empowerment of patients to \fomplete hand hygiene \fould be studied to assist in further inte- grating patients’ hand hygiene pra\fti\fes\b CCN A\fknowledgmentsThe authors thank the staff of 4C at University of Mi\fhigan Health System\b Finan\fial Dis\flosuresThis proje\ft was funded by a fostering innovation grant for $2350 that was provided by the University of Mi\fhigan Health System\b Now that you’ve read the arti\fle, \freate or \fontribute to\- an online dis\fussi\-on about this topi\f using eL\-etters\b Just visit \-www\b\f\fnonline\borg and s\-ele\ft the arti\fle you want to \fomment on\b In t\-he full-text or PDF view of the arti\fle, \fli\fk “Responses” in the middle \folumn and t\-hen “Submit a response\b” e8 CriticalCareNurse Vol 37, No. 3, JUNE 2017 www.ccnonline.org Referen\fes1\b Magill S, Edwards J, Bamberg W, et al\b Multistate point-prevalen\fe survey of health \fare-asso\fiated infe\ftions\b N Engl J Me\b. 2014;370:1198-1208 \b 2\b W ard D\b Improving patient hand hygiene\b Nurs Stan\b. 2003;17(35):39-42\b 3\b Burnett E, Lee K, Kydd P\b Hand hygiene: what about our patients? Br J Infect Control. 2008;9(1):19-24\b 4\b F ox C, Wavra T, Drake D, et al\b Use of a patient hand hygiene proto\fol to redu\fe hospital-a\fquired infe\ftions and improve nurses’ hand wash- ing\b Am J Crit Care. 2015;24(3):216-224\b 5\b S unkesula V, Knighton S, Zabarsky T, et al\b Four moments for patient hand hygiene: a patient-\fentered, provider-fa\filitated model to improve patient hand hygiene\b Infect Control Hosp Epi\bemiol. 2015;36(8):986-989 \b Copyright ofCritical CareNurse isthe property ofAmerican Association ofCritical- Care Nurses anditscontent maynotbecopied oremailed tomultiple sitesorposted toalistserv without thecopyright holder'sexpresswrittenpermission. However,usersmayprint, download, oremail articles forindividual use.