Accepted Manuscript The ‘My five moments for hand hygiene’ concept for the overcrowded setting in resource-limited healthcare systems S. Salmon, D. Pittet, H. Sax, M.L. McLaws PII:
S0195-6701(15)00183-8
DOI:
10.1016/j.jhin.2015.04.011
Reference:
YJHIN 4539
To appear in:
Journal of Hospital Infection
Received Date: 1 March 2015 Accepted Date: 23 April 2015
Please cite this article as: Salmon S, Pittet D, Sax H, McLaws ML, The ‘My five moments for hand hygiene’ concept for the overcrowded setting in resource-limited healthcare systems, Journal of Hospital Infection (2015), doi: 10.1016/j.jhin.2015.04.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT S. Salmon et al. Review The ‘My five moments for hand hygiene’ concept for the overcrowded setting in resourcelimited healthcare systems a
RI PT
S. Salmona, D. Pittetb, H. Saxc, M.L. McLawsa,* School of Public Health and Community Medicine, UNSW Medicine, UNSW, Sydney, Australia
b
Infection Control Program and WHO Collaborating Centre on Patient Safety, University of
Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland c
Division of Infectious Diseases and Infection Control, University and University Hospital
SC
Zurich, Switzerland _________________________
Corresponding author. Address: Level 3 Samuels Building, School of Public Health and
M AN U
*
Community Medicine, UNSW Medicine, UNSW, Sydney, NSW 2052, Australia. Tel.: +61 2 9385 2586.
E-mail address: [email protected] (M.L. McLaws). SUMMARY
Hand hygiene is a core activity of patient safety for the prevention of healthcare-associated
TE D
infections (HCAIs). To standardize hand hygiene practices globally the World Health Organization (WHO) released Guidelines on Hand Hygiene in Health Care and introduced the ‘My five moments for hand hygiene’ concept to define indications for hand hygiene rooted in an evidence-based model for transmission of micro-organisms by healthcare workers’ (HCWs)
EP
hands. Central to the concept is the division of the healthcare environment into two geographical care zones, the patient zone and the healthcare zone, that requires the HCW to comply with
AC C
specific hand hygiene moments. In resource-limited, overcrowded healthcare settings inadequate or no spatial separation between beds occurs frequently. These conditions challenge the HCW’s ability to visualize and delineate patient zones. The ‘My five moments for hand hygiene’ concept has been adapted for these conditions with the aim of assisting hand hygiene educators, auditors, and HCWs to minimize ambiguity regarding shared patient zones and achieve the ultimate goal set by the WHO Guidelines – the reduction of infectious risks. Keywords: Alcohol-based hand rub Hand hygiene Healthcare-associated infections
ACCEPTED MANUSCRIPT Healthcare workers My five moments for hand hygiene Overcrowding Patient zone
RI PT
Introduction The World Health Organization (WHO) ‘My five moments for hand hygiene’ was
developed with a goal to standardize hand hygiene in clinical practice and reduce the burden of healthcare-associated infections (HCAIs).1,2 This clinician-centred concept delineates indications for hand hygiene by healthcare workers (HCWs) according to the risk for micro-organism cross-
SC
transmission to patients and their environment, and provides a resource for educators and auditors assessing performance.1,3‒11 Hand hygiene is critical for HCAI prevention and the availability of
M AN U
alcohol-based hand rub (ABHR) at the point of care has been pivotal to compliance with ‘My five moments’ during clinical practice.2,5‒7,12‒19 An important focus of the ‘My five moments’ concept is the visualization of the individual patient zone, which defines hand hygiene indications.17,19
In resource-limited healthcare settings, overcrowding in general wards means that it is common for patients to share a bed; furthermore, there is usually limited or no space between
TE D
beds. As a consequence, HCWs might have difficulties in identifying the patient zones and the healthcare zone and in recognizing the ‘My five moments for hand hygiene’ indications. This report discusses the practical application of the ‘My five moments for hand hygiene’ in overcrowded settings in accordance with the corresponding guidance by WHO to assist hand
EP
hygiene performance and monitoring.20
The ‘Five moments’ concept revisited
AC C
The central tenet of ‘My five moments for hand hygiene’ is the separation of microorganism from one patient zone to the next zone and from critical sites where contamination could lead to infection.17 Continuous contact with patients, surfaces, devices, medical documents and waste results in a large number of daily opportunities for HCWs’ hands to become colonized with potential pathogens.18,21,22 In the absence of correct hand hygiene, hand contamination has the potential for cross-transmission to other patients and healthcare surfaces or to cause HCAI in the presence of other risk factors.18,22,23 ‘My five moments for hand hygiene’ was developed around three important conditions necessary for cross-transmission.18,24 First, the patient zone that is colonized by patient flora includes the patient’s intact skin and inanimate surfaces that are exclusively dedicated to the patient within this zone. Second, the zone that is outside the patient’s
ACCEPTED MANUSCRIPT zone, the healthcare zone, includes the wider healthcare environment and other patient zones and contains a wide variety of micro-organisms, representing a key source for cross-transmission to patients.17,18,25‒29 Third, inside the patient zone pathogen transmission to or from critical sites such as skin breaks, invasive equipment, and mucous membranes represents a direct infectious risk. Therefore, the ‘My five moments for hand hygiene’ concept requires hand hygiene to be
RI PT
practised in accordance with the sequence of hand-to-surface exposures.17,18,24 The challenge for the zone concept in overcrowded hospital settings
During the trialling of ‘My five moments for hand hygiene’ in an overcrowded setting, we identified a unique challenge for hand hygiene trainers, the HCW, and hand hygiene monitors.
SC
Identifying the delineation between patient zones was difficult. Distinct variations in the patient zone exist in the overcrowded settings because of bed sharing; it is common to have patients with
M AN U
varying medical conditions or infectious status sharing a single bed. Bed configurations may include a bed platform that provides bedding for as many as 10 patients, and single beds may be placed so closely together that the minimal spatial distance between beds makes delineation of patient zones for each individual patient impractical and irrelevant (see Figure 1). In overcrowded conditions, patients exchange their flora due to their frequent direct contact and contact with shared surfaces.
TE D
Still, the delineation of patient zones has to be clearly determined and communicated to HCWs and hand hygiene observers to allow for accurate hand hygiene performance and monitoring in accordance with the ‘My five moments for hand hygiene’ concept.1,17,24 This is in accordance with the original tenet of the concept: to serve usability with respect to understanding,
EP
training, monitoring and reporting hand hygiene performance. Infectious risk explained for shared patient zones
AC C
To understand the application of the ‘My five moments for hand hygiene’ concept to the overcrowded setting, it is useful to review the risk of hand transmission of pathogens. In the case of hand transmission of infectious agents, two negative events should be distinguished: crosstransmission of nosocomial pathogens between patients and HCAI. The ‘My five moments for hand hygiene’ concept addresses both negative events. Cross-transmission of pathogens between patients and within the healthcare environment is prevented mostly by hand hygiene moment 1, before touching a patient, and hand hygiene moments 4 and 5, after touching a patient and after touching the patient’s immediate surroundings, respectively. They occur at the transition between contact with the healthcare zone and the patient and vice versa. If patients share a common geographical space, transmission of
ACCEPTED MANUSCRIPT pathogens, including multidrug-resistant organisms, is likely to occur, due to their proximity. The sharing of a patient zone means that hand transmission by HCWs probably does not add a markedly increased risk of cross-transmission of pathogens, thereby limiting the effectiveness of systematic hand hygiene action between consecutive hand exposures to the intact skin or
RI PT
immediate surroundings of these patients. A significant proportion of HCAIs is associated with a breakdown in the host defences against micro-organisms that are part of the patient’s own flora, leading to endogenous infection. The major factors compromising host defences in a shared patient zone relate to procedures such as wound dressing, vascular or urinary catheter care, and endotracheal tube care. Hand
SC
transmission may contribute to this risk by transmitting pathogens from any surface to critical sites such as skin breaks, mucous membranes, and invasive equipment. In the majority of cases
M AN U
the origin of pathogens will be the patient’s own skin or immediate surroundings contaminated with the patient’s flora. Thus, in the case of shared patient zones, strict application of hand hygiene before invasive or clean/aseptic procedures should be the focus, as in the case of singleoccupancy patient zones, rather than focusing on hand hygiene action between consecutive hand exposures between patients in the shared zone.
It goes without saying that patient proximity is always associated with an important risk
TE D
for both cross-transmission and cross-infection. The adaptation of the ‘Five moments’ concept detailed in this article will not mitigate this inherent risk, which remains a pressing patient safety challenge to be addressed independently of hand hygiene promotion. The ‘Five moments for hand hygiene’ in shared patient zones
EP
The adaptation of the ‘My five moments for hand hygiene’ follows the description provided in the ‘WHO guidelines for hand hygiene in healthcare’ main document under the title
AC C
‘Two patients within the same patient zone’.30 This allows for two or more close patients being viewed as occupying a single patient zone. As in the case of ‘true’ single-patient zones, it is crucial to define patient zones wisely to avoid spread of pathogens. The necessary adaptations are listed in detail in Box 1.
Two patient care stories in an overcrowded hospital setting To further assist the comprehension of how to mitigate risk of infection or crosstransmission through the application of the ‘My five moments for hand hygiene’ concept in an overcrowded healthcare setting, it is helpful to imagine the following typical clinical stories. Story 1
ACCEPTED MANUSCRIPT A nurse enters a patient room and then closes the door. The nurse proceeds with conducting routine vital sign observations, e.g. measuring blood pressure and heart rate for two patients occupying a single bed. Then the nurse leaves the room. The hand hygiene auditor notes two hand hygiene opportunities in this scenario as
RI PT
follows: the door handle belongs to the healthcare zone and the two patients to the common shared patient zone. In this example, hand hygiene has to be performed after closing the door and immediately before touching the first patient (Moment 1). Then, a second hand hygiene
opportunity occurs after attending to the second patient and before opening the door (Moment 4). Hand hygiene action between touching the first patient and the second patient – within the shared
SC
patient zone ‒ does not constitute, in this case, a mandatory opportunity for hand hygiene, in contrast to the situation where two patients occupy two distinct beds (i.e. patient zones). Note that
M AN U
the blood pressure sphygmomanometer is temporarily dedicated to this shared patient zone and has to be cleaned once before and once after every use in this two-patient/single-patient zone scenario. Story 2
A doctor sees three patients in succession. The patients are lying on several joined beds. On entering the room the doctor uses ABHR located on the clinical trolley in the middle of the
TE D
room, to clean their stethoscope and then their hands (Moment 1). The doctor listens to the heart and chest of each patient without cleaning his/her own hands or stethoscope. Finally, it is decided to inject morphine into the peripheral line of one of the three patients whose pain has been aggravated over the past few hours. The doctor returns to the clinical trolley, cleans the
EP
stethoscope, and puts it in a pocket. The morphine (prepared by the nursing staff) is taken in a tray by the doctor to the patient, and administered into the hub of the peripheral line of the
AC C
patient. The doctor then walks back to the clinical trolley, returns the tray, and cleans his/her hands (Moment 4) with ABHR on exiting the room. The hand hygiene auditor sees the doctor later in the office to discuss the results of the hand hygiene observation session. They agree that Moments 1 and 4 were correctly performed before patient contact, but acknowledge that additional hand hygiene actions were indicated before (Moment 2) and after (Moment 3) injecting the drug in the peripheral line of one of the three patients. The hand hygiene that was not performed by the doctor could have contaminated the peripheral line hub or cap with microorganisms originating from one of the three patients or environmental surfaces of the shared patient zone. In addition, the doctor could have been exposed to body fluids during the procedure. Discussion
ACCEPTED MANUSCRIPT The ‘My five moments for hand hygiene’ concept has been designed to be applicable to any healthcare context – including the overcrowded setting addressed here.1,17,24 This guideline provides details and rationale behind the application of ‘My five moments for hand hygiene’ to the overcrowded setting based on the instructions in the WHO Guidelines.30
RI PT
Yet, it is crucially important to recognize that overcrowded healthcare settings represent a high inherent risk for the spread of pathogens and multidrug-resistant micro-organisms and
occurrence of HCAI. In overcrowding, the ‘My five moments for hand hygiene’ concept cannot entirely mitigate risk; rather, the risk can only be alleviated by increasing the space between individual patients and where possible by cohorting patients with similar micro-organisms. In the
SC
meantime, using hand hygiene rationally and consistently in resource-deprived settings reduces the risk of transmission.31,32 During patient care, the rationale for hand hygiene must be clear to
M AN U
all HCWs so that they understand the economy of behaviour to reduce ambiguity.33,34 Using the ambiguity systems concept can help identify barriers to compliance and can be used as a diagnostic tool to tailor interventions based on specific contextual issues. Interventions to promote hand hygiene in hospitals should, wherever appropriate, be tailored for the contextual challenges. The ‘My five moments for hand hygiene’ concept has been trialled and adopted by the majority of United Nations member states with varying levels of
TE D
resources.1,32 The adaptations conveyed here have been refined and trialled in a practical context. These modifications aim to assist healthcare settings faced with similar overcrowded conditions and challenges so that hand hygiene actions focus specifically on Moments that have the greatest risk of pathogen transmission within this context. The WHO has had global success from the
EP
extensive efforts made to improve hand hygiene practices globally by reviewing, extending and adapting the ‘My five moments for hand hygiene’ concept.31,32 We have discussed the concept in
AC C
detail with respect to overcrowded settings so that all healthcare institutions, regardless of resources, can participate in the global effort to improve hand hygiene compliance and reduce global rates of HCAI. Acknowledgements
The authors would like to thank the World Health Organization First Global Patient
Safety Challenge ‘Clean Care is Safer Care’ Lead, Professor B. Allegranzi, and Technical Advisor, Ms C. Kilpatrick, for their valuable input. Conflict of interest statement None declared. Funding sources
ACCEPTED MANUSCRIPT The fieldwork undertaken in Vietnam for this research was not funded. References 1.
World Health Organization. Clean Care is Safer Care ‒ tools and resources. Geneva: WHO; 2009. Available from: http://www.who.int/gpsc/5may/tools/en/ [last accessed October,
2.
RI PT
2014]. Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of endemic health-care-
associated infection in developing countries: systematic review and meta-analysis. Lancet 2011;377:228‒224. 3.
Pessoa-Silva CL, Posfay-Barbe K, Pfister R, Touveneau S, Perneger TV, Pittet D. Attitudes
SC
and perceptions toward hand hygiene among healthcare workers caring for critically ill neonates. Infect Control Hosp Epidemiol 2005;26:305‒311.
Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to
M AN U
4.
improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307‒1312. 5.
Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162:1037‒1043.
6.
Pessoa-Silva CL, Hugonnet S, Pfister R, et al. Reduction of health care associated infection
7.
TE D
risk in neonates by successful hand hygiene promotion. Pediatrics 2007;120:382‒390. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126‒130. 8.
Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of
EP
the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morb Mortal Wkly Rev
9.
AC C
2002;51:1‒45.
Pittet D, Sax H, Hugonnet S, Harbarth S. Cost implications of successful hand hygiene promotion. Infect Control Hosp Epidemiol 2004;25:264‒266.
10. Pessoa-Silva CL, Dharan S, Hugonnet S, et al. Dynamics of bacterial hand contamination during routine. Infect Control Hosp Epidemiol 2004;25:192‒197. 11. Pittet D, Donaldson L. Clean Care is Safer Care: a worldwide priority. Lancet 2005;366:1246‒1247. 12. Grayson ML, Jarvie LJ, Martin R, et al. Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand
ACCEPTED MANUSCRIPT hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust 2008;188:633‒640. 13. Whitby M, McLaws ML. Handwashing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect 2004;58:247‒253.
RI PT
14. Gould DJ, Hewitt-Taylor J, Drey NS, Gammon J, Chudleigh J, Weinberg JR. The CleanYourHandsCampaign: critiquing policy and evidence base. J Hosp Infect 2007;65:95‒101.
15. McLaws ML, Pantle AC, Fitzpatrick KR, Hughes CF. Improvements in hand hygiene across New South Wales public hospitals: clean hands save lives, part III. Med J Aust
SC
2009;19:S18‒24.
16. Marjadi B, McLaws ML. Hand hygiene in rural Indonesian healthcare workers: barriers
M AN U
beyond sinks, hand rubs and in-service training. J Hosp Infect 2010;76:256‒260. 17. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9‒21.
18. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641‒652.
TE D
19. Longtin Y, Sax H, Allegranzi B, Schneider F, Pittet D. Videos in clinical medicine. Hand hygiene. N Engl J Med 2011;364:e24.
20. World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge. Clean care is safer care. Geneva: WHO; 2009. Available from:
EP
http://www.who.int/gpsc/5may/tools/en/ [last accessed December 2014]. 21. Salmon S, Truong AT, Nguyen VH, Pittet D, McLaws ML. Health care workers’ hand
AC C
contamination levels and antibacterial efficacy of different hand hygiene methods used in a Vietnamese hospital. Am J Infect Control 2013;42:178‒181. 22. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med 1999;159:821‒826. 23. Bonten MJ, Weinstein RA. The role of colonization in the pathogenesis of nosocomial infections. Infect Control Hosp Epidemiol 1996;17:193‒200. 24. Sax H, Allegranzi B, Chraïti M-N, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37:827–834. 25. Boyce JM, Opal SM, Chow JW, et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol 1994;32:1148‒1153.
ACCEPTED MANUSCRIPT 26. Hota B. Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clin Infect Dis 2004;15:1182‒1189. 27. Noble WC. Dispersal of skin microorganisms. Br J Dermatol 1975;93:477‒485. 28. Boyce JM. Environmental contamination makes an important contribution to hospital
RI PT
infection. J Hosp Infect 2007;6:50‒54. 29. Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 2004;25:164‒167.
30. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First
SC
Global Patient Safety Challenge. Clean care is safer care. 2009. Chapter 21: The WHO Multimodal Hand Hygiene Improvement Strategy. Available from:
M AN U
http://www.who.int/gpsc/5may/tools/en/ [last accessed January 2015].
31. Allegranzi B, Sax H, Bengaly L, et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 2010;31:133–141.
32. Allegranzi B, Gayet-Ageron A, Damani N, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet
TE D
Infect Dis 2013;13:843–851.
33. Gurses AP, Seidl, KL, Vaidya V, et al. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008;17:351–359.
EP
34. Sax H, Clack L. Mental models: a basic concept for human factors design in infection
AC C
prevention. J Hosp Infect 2015;89:335‒339.
ACCEPTED MANUSCRIPT Box 1 ‘My five moments for hand hygiene’ for shared patient zones in overcrowded settingsa •
Moment 1. Before touching a patient in the shared patient zone Moment 1 occurs before touching a patient within the shared patient zone after having
RI PT
touched a surface in the healthcare zone. Hand hygiene at this indication will prevent potential cross-colonization with pathogens external to the group of patients within the
concerned shared patient zone. Further hand hygiene between patients in the shared patient zone is not necessary if no touching of critical sites is involved. •
Moment 2. Before a clean/aseptic procedure in the shared patient zone
SC
Exactly as in single-patient zones, hand hygiene action in shared patient zones will take place between the last exposure to any surface (whether skin, mucosal, or environmental) and •
M AN U
before contact with any critical site.
Moment 3. After body fluid exposure risk in the shared patient zone In line with single patient zones, hand hygiene is required after any task involving a risk of hand contamination with body fluids. This reduces the risk of infection with blood-borne pathogens and spread of pathogens from highly colonized body sites.1,29 Glove use with Moments 2 and 3 is frequently necessary, requiring the following sequence: touching a
TE D
surface within the patient zone > hand hygiene (Moment 2) > donning gloves > task > removing gloves > hand hygiene (Moment 3) > touching the next surface. •
Moment 4. After touching one or several patients in the shared patient zone Moment 4 occurs when the healthcare worker (HCW) leaves a shared patient zone and
EP
before touching a surface in the healthcare zone, avoiding spread of pathogens into the healthcare setting. Touching an object within the shared patient zone before leaving the zone •
AC C
requires compliance with hand hygiene (equivalent to Moment 4 and Moment 5 combined). Moment 5. After contact with patient surroundings in the shared patient zone Moment 5 occurs after contact with any surface within the shared patient zone in the absence of the patient or in the absence of any patient contact in the concerned care sequence and before touching a surface outside of the shared patient zone. •
Coincidence of two moments for hand hygiene between shared patient zones Two indications for hand hygiene may coincide in a single hand hygiene opportunity. This is in accordance with the monitoring of compliance undertaken in patient zones with single occupancy.1 Two frequent situations of this kind, where only one hand hygiene action is
ACCEPTED MANUSCRIPT required despite two indications, are worth citing: (i) when the HCW moves from one patient located within a shared patient zone to another patient in a different shared patient zone without touching any surface outside the two shared patient zones (Moment 4 coincides with Moment 1); (ii) when the HCW leaves a patient zone (performs Moment 4 or 5) and enters
coincides with Moment 2). a
RI PT
another patient zone and directly handles a critical site without touching a surface (Moment 1
Overcrowded setting refers to multiple patients in a single bed or single or multiple patient/s
AC C
EP
TE D
M AN U
SC
with two or more beds with minimal or no spatial separation.
ACCEPTED MANUSCRIPT Figure 1. Applying ‘My five moments for hand hygiene’ in overcrowded settings. Patient zone 1, single-patient occupancy situation; Patient zone 2, situation where two patients are sharing one bed in a unified patient zone; Patient zone 3; situation with several close beddings with inadequate spacing where a common patient zone is established. Circle: hand-to-surface
RI PT
exposure; arrow with number: hand transition with corresponding moment for hand hygiene (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 (without touching the patient); dotted arrow: hand transition with no indication for hand hygiene; dashed arrow: hand transition before Moment 5, indicating that no patient is touched during the entire care sequence in this
SC
patient zone; grey line: infusion tube leading to peripheral venous access that is exemplifying a
AC C
EP
TE D
M AN U
critical site (the touching of which is associated with Moments 2 and 3).
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0195-6701(15)00183-8
DOI:
10.1016/j.jhin.2015.04.011
Reference:
YJHIN 4539
To appear in:
Journal of Hospital Infection
Received Date: 1 March 2015 Accepted Date: 23 April 2015
Please cite this article as: Salmon S, Pittet D, Sax H, McLaws ML, The ‘My five moments for hand hygiene’ concept for the overcrowded setting in resource-limited healthcare systems, Journal of Hospital Infection (2015), doi: 10.1016/j.jhin.2015.04.011. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT S. Salmon et al. Review The ‘My five moments for hand hygiene’ concept for the overcrowded setting in resourcelimited healthcare systems a
RI PT
S. Salmona, D. Pittetb, H. Saxc, M.L. McLawsa,* School of Public Health and Community Medicine, UNSW Medicine, UNSW, Sydney, Australia
b
Infection Control Program and WHO Collaborating Centre on Patient Safety, University of
Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland c
Division of Infectious Diseases and Infection Control, University and University Hospital
SC
Zurich, Switzerland _________________________
Corresponding author. Address: Level 3 Samuels Building, School of Public Health and
M AN U
*
Community Medicine, UNSW Medicine, UNSW, Sydney, NSW 2052, Australia. Tel.: +61 2 9385 2586.
E-mail address: [email protected] (M.L. McLaws). SUMMARY
Hand hygiene is a core activity of patient safety for the prevention of healthcare-associated
TE D
infections (HCAIs). To standardize hand hygiene practices globally the World Health Organization (WHO) released Guidelines on Hand Hygiene in Health Care and introduced the ‘My five moments for hand hygiene’ concept to define indications for hand hygiene rooted in an evidence-based model for transmission of micro-organisms by healthcare workers’ (HCWs)
EP
hands. Central to the concept is the division of the healthcare environment into two geographical care zones, the patient zone and the healthcare zone, that requires the HCW to comply with
AC C
specific hand hygiene moments. In resource-limited, overcrowded healthcare settings inadequate or no spatial separation between beds occurs frequently. These conditions challenge the HCW’s ability to visualize and delineate patient zones. The ‘My five moments for hand hygiene’ concept has been adapted for these conditions with the aim of assisting hand hygiene educators, auditors, and HCWs to minimize ambiguity regarding shared patient zones and achieve the ultimate goal set by the WHO Guidelines – the reduction of infectious risks. Keywords: Alcohol-based hand rub Hand hygiene Healthcare-associated infections
ACCEPTED MANUSCRIPT Healthcare workers My five moments for hand hygiene Overcrowding Patient zone
RI PT
Introduction The World Health Organization (WHO) ‘My five moments for hand hygiene’ was
developed with a goal to standardize hand hygiene in clinical practice and reduce the burden of healthcare-associated infections (HCAIs).1,2 This clinician-centred concept delineates indications for hand hygiene by healthcare workers (HCWs) according to the risk for micro-organism cross-
SC
transmission to patients and their environment, and provides a resource for educators and auditors assessing performance.1,3‒11 Hand hygiene is critical for HCAI prevention and the availability of
M AN U
alcohol-based hand rub (ABHR) at the point of care has been pivotal to compliance with ‘My five moments’ during clinical practice.2,5‒7,12‒19 An important focus of the ‘My five moments’ concept is the visualization of the individual patient zone, which defines hand hygiene indications.17,19
In resource-limited healthcare settings, overcrowding in general wards means that it is common for patients to share a bed; furthermore, there is usually limited or no space between
TE D
beds. As a consequence, HCWs might have difficulties in identifying the patient zones and the healthcare zone and in recognizing the ‘My five moments for hand hygiene’ indications. This report discusses the practical application of the ‘My five moments for hand hygiene’ in overcrowded settings in accordance with the corresponding guidance by WHO to assist hand
EP
hygiene performance and monitoring.20
The ‘Five moments’ concept revisited
AC C
The central tenet of ‘My five moments for hand hygiene’ is the separation of microorganism from one patient zone to the next zone and from critical sites where contamination could lead to infection.17 Continuous contact with patients, surfaces, devices, medical documents and waste results in a large number of daily opportunities for HCWs’ hands to become colonized with potential pathogens.18,21,22 In the absence of correct hand hygiene, hand contamination has the potential for cross-transmission to other patients and healthcare surfaces or to cause HCAI in the presence of other risk factors.18,22,23 ‘My five moments for hand hygiene’ was developed around three important conditions necessary for cross-transmission.18,24 First, the patient zone that is colonized by patient flora includes the patient’s intact skin and inanimate surfaces that are exclusively dedicated to the patient within this zone. Second, the zone that is outside the patient’s
ACCEPTED MANUSCRIPT zone, the healthcare zone, includes the wider healthcare environment and other patient zones and contains a wide variety of micro-organisms, representing a key source for cross-transmission to patients.17,18,25‒29 Third, inside the patient zone pathogen transmission to or from critical sites such as skin breaks, invasive equipment, and mucous membranes represents a direct infectious risk. Therefore, the ‘My five moments for hand hygiene’ concept requires hand hygiene to be
RI PT
practised in accordance with the sequence of hand-to-surface exposures.17,18,24 The challenge for the zone concept in overcrowded hospital settings
During the trialling of ‘My five moments for hand hygiene’ in an overcrowded setting, we identified a unique challenge for hand hygiene trainers, the HCW, and hand hygiene monitors.
SC
Identifying the delineation between patient zones was difficult. Distinct variations in the patient zone exist in the overcrowded settings because of bed sharing; it is common to have patients with
M AN U
varying medical conditions or infectious status sharing a single bed. Bed configurations may include a bed platform that provides bedding for as many as 10 patients, and single beds may be placed so closely together that the minimal spatial distance between beds makes delineation of patient zones for each individual patient impractical and irrelevant (see Figure 1). In overcrowded conditions, patients exchange their flora due to their frequent direct contact and contact with shared surfaces.
TE D
Still, the delineation of patient zones has to be clearly determined and communicated to HCWs and hand hygiene observers to allow for accurate hand hygiene performance and monitoring in accordance with the ‘My five moments for hand hygiene’ concept.1,17,24 This is in accordance with the original tenet of the concept: to serve usability with respect to understanding,
EP
training, monitoring and reporting hand hygiene performance. Infectious risk explained for shared patient zones
AC C
To understand the application of the ‘My five moments for hand hygiene’ concept to the overcrowded setting, it is useful to review the risk of hand transmission of pathogens. In the case of hand transmission of infectious agents, two negative events should be distinguished: crosstransmission of nosocomial pathogens between patients and HCAI. The ‘My five moments for hand hygiene’ concept addresses both negative events. Cross-transmission of pathogens between patients and within the healthcare environment is prevented mostly by hand hygiene moment 1, before touching a patient, and hand hygiene moments 4 and 5, after touching a patient and after touching the patient’s immediate surroundings, respectively. They occur at the transition between contact with the healthcare zone and the patient and vice versa. If patients share a common geographical space, transmission of
ACCEPTED MANUSCRIPT pathogens, including multidrug-resistant organisms, is likely to occur, due to their proximity. The sharing of a patient zone means that hand transmission by HCWs probably does not add a markedly increased risk of cross-transmission of pathogens, thereby limiting the effectiveness of systematic hand hygiene action between consecutive hand exposures to the intact skin or
RI PT
immediate surroundings of these patients. A significant proportion of HCAIs is associated with a breakdown in the host defences against micro-organisms that are part of the patient’s own flora, leading to endogenous infection. The major factors compromising host defences in a shared patient zone relate to procedures such as wound dressing, vascular or urinary catheter care, and endotracheal tube care. Hand
SC
transmission may contribute to this risk by transmitting pathogens from any surface to critical sites such as skin breaks, mucous membranes, and invasive equipment. In the majority of cases
M AN U
the origin of pathogens will be the patient’s own skin or immediate surroundings contaminated with the patient’s flora. Thus, in the case of shared patient zones, strict application of hand hygiene before invasive or clean/aseptic procedures should be the focus, as in the case of singleoccupancy patient zones, rather than focusing on hand hygiene action between consecutive hand exposures between patients in the shared zone.
It goes without saying that patient proximity is always associated with an important risk
TE D
for both cross-transmission and cross-infection. The adaptation of the ‘Five moments’ concept detailed in this article will not mitigate this inherent risk, which remains a pressing patient safety challenge to be addressed independently of hand hygiene promotion. The ‘Five moments for hand hygiene’ in shared patient zones
EP
The adaptation of the ‘My five moments for hand hygiene’ follows the description provided in the ‘WHO guidelines for hand hygiene in healthcare’ main document under the title
AC C
‘Two patients within the same patient zone’.30 This allows for two or more close patients being viewed as occupying a single patient zone. As in the case of ‘true’ single-patient zones, it is crucial to define patient zones wisely to avoid spread of pathogens. The necessary adaptations are listed in detail in Box 1.
Two patient care stories in an overcrowded hospital setting To further assist the comprehension of how to mitigate risk of infection or crosstransmission through the application of the ‘My five moments for hand hygiene’ concept in an overcrowded healthcare setting, it is helpful to imagine the following typical clinical stories. Story 1
ACCEPTED MANUSCRIPT A nurse enters a patient room and then closes the door. The nurse proceeds with conducting routine vital sign observations, e.g. measuring blood pressure and heart rate for two patients occupying a single bed. Then the nurse leaves the room. The hand hygiene auditor notes two hand hygiene opportunities in this scenario as
RI PT
follows: the door handle belongs to the healthcare zone and the two patients to the common shared patient zone. In this example, hand hygiene has to be performed after closing the door and immediately before touching the first patient (Moment 1). Then, a second hand hygiene
opportunity occurs after attending to the second patient and before opening the door (Moment 4). Hand hygiene action between touching the first patient and the second patient – within the shared
SC
patient zone ‒ does not constitute, in this case, a mandatory opportunity for hand hygiene, in contrast to the situation where two patients occupy two distinct beds (i.e. patient zones). Note that
M AN U
the blood pressure sphygmomanometer is temporarily dedicated to this shared patient zone and has to be cleaned once before and once after every use in this two-patient/single-patient zone scenario. Story 2
A doctor sees three patients in succession. The patients are lying on several joined beds. On entering the room the doctor uses ABHR located on the clinical trolley in the middle of the
TE D
room, to clean their stethoscope and then their hands (Moment 1). The doctor listens to the heart and chest of each patient without cleaning his/her own hands or stethoscope. Finally, it is decided to inject morphine into the peripheral line of one of the three patients whose pain has been aggravated over the past few hours. The doctor returns to the clinical trolley, cleans the
EP
stethoscope, and puts it in a pocket. The morphine (prepared by the nursing staff) is taken in a tray by the doctor to the patient, and administered into the hub of the peripheral line of the
AC C
patient. The doctor then walks back to the clinical trolley, returns the tray, and cleans his/her hands (Moment 4) with ABHR on exiting the room. The hand hygiene auditor sees the doctor later in the office to discuss the results of the hand hygiene observation session. They agree that Moments 1 and 4 were correctly performed before patient contact, but acknowledge that additional hand hygiene actions were indicated before (Moment 2) and after (Moment 3) injecting the drug in the peripheral line of one of the three patients. The hand hygiene that was not performed by the doctor could have contaminated the peripheral line hub or cap with microorganisms originating from one of the three patients or environmental surfaces of the shared patient zone. In addition, the doctor could have been exposed to body fluids during the procedure. Discussion
ACCEPTED MANUSCRIPT The ‘My five moments for hand hygiene’ concept has been designed to be applicable to any healthcare context – including the overcrowded setting addressed here.1,17,24 This guideline provides details and rationale behind the application of ‘My five moments for hand hygiene’ to the overcrowded setting based on the instructions in the WHO Guidelines.30
RI PT
Yet, it is crucially important to recognize that overcrowded healthcare settings represent a high inherent risk for the spread of pathogens and multidrug-resistant micro-organisms and
occurrence of HCAI. In overcrowding, the ‘My five moments for hand hygiene’ concept cannot entirely mitigate risk; rather, the risk can only be alleviated by increasing the space between individual patients and where possible by cohorting patients with similar micro-organisms. In the
SC
meantime, using hand hygiene rationally and consistently in resource-deprived settings reduces the risk of transmission.31,32 During patient care, the rationale for hand hygiene must be clear to
M AN U
all HCWs so that they understand the economy of behaviour to reduce ambiguity.33,34 Using the ambiguity systems concept can help identify barriers to compliance and can be used as a diagnostic tool to tailor interventions based on specific contextual issues. Interventions to promote hand hygiene in hospitals should, wherever appropriate, be tailored for the contextual challenges. The ‘My five moments for hand hygiene’ concept has been trialled and adopted by the majority of United Nations member states with varying levels of
TE D
resources.1,32 The adaptations conveyed here have been refined and trialled in a practical context. These modifications aim to assist healthcare settings faced with similar overcrowded conditions and challenges so that hand hygiene actions focus specifically on Moments that have the greatest risk of pathogen transmission within this context. The WHO has had global success from the
EP
extensive efforts made to improve hand hygiene practices globally by reviewing, extending and adapting the ‘My five moments for hand hygiene’ concept.31,32 We have discussed the concept in
AC C
detail with respect to overcrowded settings so that all healthcare institutions, regardless of resources, can participate in the global effort to improve hand hygiene compliance and reduce global rates of HCAI. Acknowledgements
The authors would like to thank the World Health Organization First Global Patient
Safety Challenge ‘Clean Care is Safer Care’ Lead, Professor B. Allegranzi, and Technical Advisor, Ms C. Kilpatrick, for their valuable input. Conflict of interest statement None declared. Funding sources
ACCEPTED MANUSCRIPT The fieldwork undertaken in Vietnam for this research was not funded. References 1.
World Health Organization. Clean Care is Safer Care ‒ tools and resources. Geneva: WHO; 2009. Available from: http://www.who.int/gpsc/5may/tools/en/ [last accessed October,
2.
RI PT
2014]. Allegranzi B, Bagheri Nejad S, Combescure C, et al. Burden of endemic health-care-
associated infection in developing countries: systematic review and meta-analysis. Lancet 2011;377:228‒224. 3.
Pessoa-Silva CL, Posfay-Barbe K, Pfister R, Touveneau S, Perneger TV, Pittet D. Attitudes
SC
and perceptions toward hand hygiene among healthcare workers caring for critically ill neonates. Infect Control Hosp Epidemiol 2005;26:305‒311.
Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to
M AN U
4.
improve compliance with hand hygiene. Infection Control Programme. Lancet 2000;356:1307‒1312. 5.
Hugonnet S, Perneger TV, Pittet D. Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162:1037‒1043.
6.
Pessoa-Silva CL, Hugonnet S, Pfister R, et al. Reduction of health care associated infection
7.
TE D
risk in neonates by successful hand hygiene promotion. Pediatrics 2007;120:382‒390. Pittet D, Mourouga P, Perneger TV. Compliance with handwashing in a teaching hospital. Infection Control Program. Ann Intern Med 1999;130:126‒130. 8.
Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings. Recommendations of
EP
the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morb Mortal Wkly Rev
9.
AC C
2002;51:1‒45.
Pittet D, Sax H, Hugonnet S, Harbarth S. Cost implications of successful hand hygiene promotion. Infect Control Hosp Epidemiol 2004;25:264‒266.
10. Pessoa-Silva CL, Dharan S, Hugonnet S, et al. Dynamics of bacterial hand contamination during routine. Infect Control Hosp Epidemiol 2004;25:192‒197. 11. Pittet D, Donaldson L. Clean Care is Safer Care: a worldwide priority. Lancet 2005;366:1246‒1247. 12. Grayson ML, Jarvie LJ, Martin R, et al. Significant reductions in methicillin-resistant Staphylococcus aureus bacteraemia and clinical isolates associated with a multisite, hand
ACCEPTED MANUSCRIPT hygiene culture-change program and subsequent successful statewide roll-out. Med J Aust 2008;188:633‒640. 13. Whitby M, McLaws ML. Handwashing in healthcare workers: accessibility of sink location does not improve compliance. J Hosp Infect 2004;58:247‒253.
RI PT
14. Gould DJ, Hewitt-Taylor J, Drey NS, Gammon J, Chudleigh J, Weinberg JR. The CleanYourHandsCampaign: critiquing policy and evidence base. J Hosp Infect 2007;65:95‒101.
15. McLaws ML, Pantle AC, Fitzpatrick KR, Hughes CF. Improvements in hand hygiene across New South Wales public hospitals: clean hands save lives, part III. Med J Aust
SC
2009;19:S18‒24.
16. Marjadi B, McLaws ML. Hand hygiene in rural Indonesian healthcare workers: barriers
M AN U
beyond sinks, hand rubs and in-service training. J Hosp Infect 2010;76:256‒260. 17. Sax H, Allegranzi B, Uckay I, Larson E, Boyce J, Pittet D. ‘My five moments for hand hygiene’: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007;67:9‒21.
18. Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006;6:641‒652.
TE D
19. Longtin Y, Sax H, Allegranzi B, Schneider F, Pittet D. Videos in clinical medicine. Hand hygiene. N Engl J Med 2011;364:e24.
20. World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge. Clean care is safer care. Geneva: WHO; 2009. Available from:
EP
http://www.who.int/gpsc/5may/tools/en/ [last accessed December 2014]. 21. Salmon S, Truong AT, Nguyen VH, Pittet D, McLaws ML. Health care workers’ hand
AC C
contamination levels and antibacterial efficacy of different hand hygiene methods used in a Vietnamese hospital. Am J Infect Control 2013;42:178‒181. 22. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med 1999;159:821‒826. 23. Bonten MJ, Weinstein RA. The role of colonization in the pathogenesis of nosocomial infections. Infect Control Hosp Epidemiol 1996;17:193‒200. 24. Sax H, Allegranzi B, Chraïti M-N, Boyce J, Larson E, Pittet D. The World Health Organization hand hygiene observation method. Am J Infect Control 2009;37:827–834. 25. Boyce JM, Opal SM, Chow JW, et al. Outbreak of multidrug-resistant Enterococcus faecium with transferable vanB class vancomycin resistance. J Clin Microbiol 1994;32:1148‒1153.
ACCEPTED MANUSCRIPT 26. Hota B. Contamination, disinfection, and cross-colonization: are hospital surfaces reservoirs for nosocomial infection? Clin Infect Dis 2004;15:1182‒1189. 27. Noble WC. Dispersal of skin microorganisms. Br J Dermatol 1975;93:477‒485. 28. Boyce JM. Environmental contamination makes an important contribution to hospital
RI PT
infection. J Hosp Infect 2007;6:50‒54. 29. Bhalla A, Pultz NJ, Gries DM, et al. Acquisition of nosocomial pathogens on hands after contact with environmental surfaces near hospitalized patients. Infect Control Hosp Epidemiol 2004;25:164‒167.
30. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First
SC
Global Patient Safety Challenge. Clean care is safer care. 2009. Chapter 21: The WHO Multimodal Hand Hygiene Improvement Strategy. Available from:
M AN U
http://www.who.int/gpsc/5may/tools/en/ [last accessed January 2015].
31. Allegranzi B, Sax H, Bengaly L, et al. Successful implementation of the World Health Organization hand hygiene improvement strategy in a referral hospital in Mali, Africa. Infect Control Hosp Epidemiol 2010;31:133–141.
32. Allegranzi B, Gayet-Ageron A, Damani N, et al. Global implementation of WHO’s multimodal strategy for improvement of hand hygiene: a quasi-experimental study. Lancet
TE D
Infect Dis 2013;13:843–851.
33. Gurses AP, Seidl, KL, Vaidya V, et al. Systems ambiguity and guideline compliance: a qualitative study of how intensive care units follow evidence-based guidelines to reduce healthcare-associated infections. Qual Saf Health Care 2008;17:351–359.
EP
34. Sax H, Clack L. Mental models: a basic concept for human factors design in infection
AC C
prevention. J Hosp Infect 2015;89:335‒339.
ACCEPTED MANUSCRIPT Box 1 ‘My five moments for hand hygiene’ for shared patient zones in overcrowded settingsa •
Moment 1. Before touching a patient in the shared patient zone Moment 1 occurs before touching a patient within the shared patient zone after having
RI PT
touched a surface in the healthcare zone. Hand hygiene at this indication will prevent potential cross-colonization with pathogens external to the group of patients within the
concerned shared patient zone. Further hand hygiene between patients in the shared patient zone is not necessary if no touching of critical sites is involved. •
Moment 2. Before a clean/aseptic procedure in the shared patient zone
SC
Exactly as in single-patient zones, hand hygiene action in shared patient zones will take place between the last exposure to any surface (whether skin, mucosal, or environmental) and •
M AN U
before contact with any critical site.
Moment 3. After body fluid exposure risk in the shared patient zone In line with single patient zones, hand hygiene is required after any task involving a risk of hand contamination with body fluids. This reduces the risk of infection with blood-borne pathogens and spread of pathogens from highly colonized body sites.1,29 Glove use with Moments 2 and 3 is frequently necessary, requiring the following sequence: touching a
TE D
surface within the patient zone > hand hygiene (Moment 2) > donning gloves > task > removing gloves > hand hygiene (Moment 3) > touching the next surface. •
Moment 4. After touching one or several patients in the shared patient zone Moment 4 occurs when the healthcare worker (HCW) leaves a shared patient zone and
EP
before touching a surface in the healthcare zone, avoiding spread of pathogens into the healthcare setting. Touching an object within the shared patient zone before leaving the zone •
AC C
requires compliance with hand hygiene (equivalent to Moment 4 and Moment 5 combined). Moment 5. After contact with patient surroundings in the shared patient zone Moment 5 occurs after contact with any surface within the shared patient zone in the absence of the patient or in the absence of any patient contact in the concerned care sequence and before touching a surface outside of the shared patient zone. •
Coincidence of two moments for hand hygiene between shared patient zones Two indications for hand hygiene may coincide in a single hand hygiene opportunity. This is in accordance with the monitoring of compliance undertaken in patient zones with single occupancy.1 Two frequent situations of this kind, where only one hand hygiene action is
ACCEPTED MANUSCRIPT required despite two indications, are worth citing: (i) when the HCW moves from one patient located within a shared patient zone to another patient in a different shared patient zone without touching any surface outside the two shared patient zones (Moment 4 coincides with Moment 1); (ii) when the HCW leaves a patient zone (performs Moment 4 or 5) and enters
coincides with Moment 2). a
RI PT
another patient zone and directly handles a critical site without touching a surface (Moment 1
Overcrowded setting refers to multiple patients in a single bed or single or multiple patient/s
AC C
EP
TE D
M AN U
SC
with two or more beds with minimal or no spatial separation.
ACCEPTED MANUSCRIPT Figure 1. Applying ‘My five moments for hand hygiene’ in overcrowded settings. Patient zone 1, single-patient occupancy situation; Patient zone 2, situation where two patients are sharing one bed in a unified patient zone; Patient zone 3; situation with several close beddings with inadequate spacing where a common patient zone is established. Circle: hand-to-surface
RI PT
exposure; arrow with number: hand transition with corresponding moment for hand hygiene (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 (without touching the patient); dotted arrow: hand transition with no indication for hand hygiene; dashed arrow: hand transition before Moment 5, indicating that no patient is touched during the entire care sequence in this
SC
patient zone; grey line: infusion tube leading to peripheral venous access that is exemplifying a
AC C
EP
TE D
M AN U
critical site (the touching of which is associated with Moments 2 and 3).
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
