Himpunan Perawat Pencegah dan Pengendali Infeksi Indonesia (HIPPII) Cabang Banten POKOK BAHASAN I. ACUAN II. TUJUAN PELAPORAN III. LAPORAN KEPATUHAN CUCI TANGAN 1. OVERALL HAND HYGIENE COMPLIANCE 2. HAND HYGIENE COMPLIANCE BY MOMENTS 3. HAND HYGIENE COMPLIANCE BY HEALTHCARE WORKER CATEGORY IV. PENYAJIAN DATA V. KESIMPULAN I. ACUAN 1. WHO Guidelines on Hand Hygiene In Health Care Provide Health Care (Revised Aug 2009). 2. Peraturan Menteri Kesehatan Republik Indonesia Nomor 27 Tahun 2017 Tentang Pedoman Pencegahan dan Pengendalian Infeksi di Fasilitas Pelayanan Kesehatan 3. Peraturan Menteri Kesehatan Republik Indonesia Nomor 34 Tahun 2017 Tentang Akreditasi Rumah Sakit 4. Standar Nasional Akreditasi Rumah Sakit Edisi 1, Efektif 1 Januari 2018 PENDAHULUAN Hand washing prevents the spread of germs. CDC recommends cleaning hands in a specific way to avoid getting sick and spreading germs to others. 1. Nose, mouth, or eyes to hands to others 2. Hands to food 3. Food to hands to food 4. Infected child to hands to other children: 5. Animals to people DISEASES AND HAND WASHING
Hands are the most
exposed part of the body to germs. Touching the eyes, mouth, nose or food transfers the germs into the body. KEEPING UPDATE!
SAVE LIVES: Clean Your Hands
(SL:CYH) 5 May 2017 - 'Fight antibiotic resistance - it's in your hands' STANDAR NASIONAL AKREDITASI RUMAH SAKIT EDISI 1 II. TUJUAN PELAPORAN HASIL AUDIT
Untuk Edukasi dan Umpan balik
Evaluasi terhadap Keberhasilan / Kegagalan suatu Kegiatan Sebagai bukti Kegiatan Kualitas Hasil pencapaian dapat dipergunakan untuk publikasi secara internal Marketing III. LAPORAN KEPATUHAN CUCI TANGAN
1. OVERALL HAND HYGIENE
COMPLIANCE Berdasarkan target/Pilot Area, seperti Rawat Inap Rawat Jalan Hospital Wide Intensive Care Unit Bagaimana Figur Kepatuhan? Periode Laporan 3 bulan, 6 bulan, 1 tahun, dst 2. Hand Hygiene Compliance by Moments The 5 Moments 1. Before touching a patient 2. Before clean / aseptic procedure
3. After body fluid exposure risk
4. After touching a patient 5. After touching patient surroundings 3. Hand Hygiene Compliance by Healthcare Worker Category
1) Perawat & Bidan
2) Dokter Spesialis dan dr Umum 3) Petugas Farmasi 4) Petugas Radiologi 5) Petugas Laboratorium 6) Petugas Kesehatan lainnya, misalnya: House Keeping Petugas Pelayanan Makanan Nurse Aid Petugas Administrasi dll IV. PENYAJIAN DATA
Beberapa cara penyajian data Kepatuhan:
• Tabel • Garis / Line Chart • Batang / Bar Chart • Pie Chart • Control Chart • dll Compliance Rate by Moment - Tabel
Correct Total Compliance Lower 95% Upper 95%
Moment Moments Moments Rate CI CI 1 - Before Touching A 136,344 168,930 80.7% 80.5% 80.9% Patient
2 - Before Procedure 51,621 58,782 87.8% 87.6% 88.1%
3 - After a Procedure 63,741 69,954 91.1% 90.9% 91.3%
or Body Fluid Exposure Risk
4 - After Touching a 147,019 167,266 87.9% 87.7% 88.1%
Patient
5 - After Touching A 95,948 121,627 78.9% 78.7% 79.1%
Patient's Surroundings
Source: http://www.hha.org.au/LatestNationalData.aspx - National Hand Hygiene Compliance Rate By Moment
- Australia Compliance Rate by Moment – Bar Chart
Source: http://www.hha.org.au/LatestNationalData.aspx - National Hand Hygiene Compliance Rate By Moment
- Australia Hand Hygiene Compliance by Profesi
Prosentasi Kategori Responden - Audit Cuci Tangan
25 35
Doctor Nurse/Midwife Otherhealcatre Workers 40 Overall Hand Hygiene Compliance by Year What is the WHO Multimodal Hand Hygiene Improvement Strategy?
Based on the ONE System change
Alcohol-based handrubs at point of care evidence and and access to safe continuous water supply, soap and towels
recommendations from the WHO TWO Training and education Guidelines on Providing regular training to all health-care workers
Hand Hygiene in Health Care THREE Evaluation and feedback (2009), Monitoring hand hygiene practices, infrastructure, perceptions, & knowledge, while providing results feedback to health-care workers made up of 5 core FOUR Reminders in the workplace components, to Prompting and reminding health-care workers improve hand hygiene in health- FIVE Institutional safety climate care settings Individual active participation, institutional support, patient participation Change Tap Water Touch tap water Non touch/long handle tap water
Automatic tap water
Pelaporan Kegiatan Program HH
Kegiatan terkait Program Kebersihan Tangan,
termasuk: Edukasi Pasien & Keluarga, Petugas, Pengunjung Audit - Kepatuhan Cuci Tangan Pemakaian Sabun, Hand rub, Tisu Audit Ketersediaan Sarana Cuci tangan poster, leaflet, baner, dll Kampanye Seputar Cuci Global Campaign 5th May LAPORAN DISAJIKAN KEPADA
Petugas Kesehatan terkait dan Petugas
Kesehatan Lainnya Bagian Terkait Komite / Tim PPI RS Komite Mutu dan Keselamatan Kerja RS Manajer dan Direktur RS EVALUASI LAPORAN
Evaluasi Laporan dapat dilakukan:
Setiap 3 bulan Setiap 6 bulan Setiap 12 bulan Jika dibutuhkan Evaluasi jika ada Penurunan Trend yang significant Bersama dengan Evaluasi Program Kerja PPI V. KESIMPULAN
Pelaporan data sangat penting dilakukan sebagai
bagian dari edukasi dan umpan balik bagi petugas terkait Laporan audit dapat digunakan sebagai salah indikator keberhasilan dan atau kegagalan yang dapat digunakan sebagai bukti kegiatan mutu internal RS. Pecapaian target audit dapat digunakan oleh marketing dengan tujuan publikasi Penyajian data audit yang baik memudahkan petugas dalam memahami data tersebut Thank you
