Hand Hygiene/Glove Use Monitoring Tool



Hand Hygiene/Glove Use Observation Tool (Developed for VA-3M Six Sigma Project)

INSTRUCTIONS: Observe practice. Include a variety of disciplines. NOTE: Hand Hygiene refers to use of alcohol foam hand rub or washing hands with soap and water for at least 15 seconds

Date(s): ________________________________ Unit: Completed by:_______________________________________

Staff Title | | | | | | | | | | | | | | | | | | | | | | |Yes |No |Yes |No |Yes |No |Yes |No |Yes |No |Yes |No |Yes |No |Yes |No |Yes |No |Yes |No | |

HAND HYGIENE | | | | | | | | | | | | | | | | | | | | | |Before clean and aseptic procedures, including medication prep and prior to prep, gown & glove for sterile procedures. | | | | | | | | | | | | | | | | | | | | | |After contact with blood, body fluids, secretions or excretions, mucous membranes, non-intact skin. | | | | | | | | | | | | | | | | | | | | | |After handling objects and devices such as soiled linen, trash, equipment. | | | | | | | | | | | | | | | | | | | | | |After removing gloves or other PPE used for contact with body substances. | | | | | | | | | | | | | | | | | | | | | |Before patient contact. * | | | | | | | | | | | | | | | | | | | | | |After patient contact upon exiting patient’s room. * | | | | | | | | | | | | | | | | | | | | | |Upon entering patient’s room before equipment contact. ** | | | | | | | | | | | | | | | | | | | | | |After equipment contact upon exiting patient’s room. **

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GLOVE USE | | | | | | | | | | | | | | | | | | | | | |Whenever potential for hand contact with blood/body substance. | | | | | | | | | | | | | | | | | | | | | |Gloves removed immediately after use to avoid contaminating the environment. | | | | | | | | | | | | | | | | | | | | | |

Staff Titles: MD attending (MDA); MD resident/fellow (MR/F); Med Student (MS); RN; NA; Respiratory Therapy (RT); X ray (XR); IV team (IVT); Dietitian (DT); Chaplain (Chap); Social Worker (SW); other-identify. Make a single hash mark for each hand-hygiene opportunity. * Use of hand-hygiene between patients (as on rounds) is acceptable if no other activity intervenes(e.g. use of a telephone.) **Hand-hygiene is recommended before entering and upon exiting a patient’s room even if the only contact is with equipment in the room (CDC Level II). It is NOT necessary to repeat hand-hygiene when moving between the patient and equipment WITHIN the same patient’s room (e.g. patient to computer to ventilator to monitor to patient). Document Revised: 2/3/2004

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