orm_mar_apr-2025 - 27

Sterilization & Infection Prevention
Compliance rates by role
WHO's Five
Moments
Moment 1
(Before entering OR)
Moment 2
(Before assessment
/ procedure)
Moment 3
(After body fluid
exposure)
Moment 4
(After exiting OR)
Moment 5
(After patient surroundings
contact)
Personnel title
Anesthesia
OR Assistive Personnel
RN
Surgical
Anesthesia
OR Assistive Personnel
RN
Surgical
Anesthesia
OR Assistive Personnel
RN
Surgical
Anesthesia
OR Assistive Personnel
RN
Surgical
Anesthesia
OR Assistive Personnel
RN
Surgical
The project recorded 179 observations
of non-scrubbed personnel, revealing
remarkable improvements (sidebar,
Compliance rates by role). The most
significant impact was observed in the
compliance rate at Moment 2 of the
WHO's Five Moments.
Most notably, anesthesia personnel
saw the most compliance rate increase
of all observed roles in four of the five
Moments:
* 90% compliance rate at the end of
the project (post-intervention) at Moment
1, up from 10% at the start
(baseline)
* improvement from zero to 100% at
Moment 2
* 87.5% compliance rate post-intervention
at Moment 3, up from
12.5% baseline
www.ormanager.com
Baseline
1 (10%)
11(39.29%)
17 (44.74%)
3 (9.38%)
7 (29.17%)
13 (41.94%)
3 (16.67%)
1 (12.50%)
5 (22.73%)
12 (37.50%)
3 (27.27%)
1 (16.67%)
7(29.17%)
13 (39.39%)
1 (10%)
12 (50%)
10 (50%)
1 (16.67%)
* improvement from zero to 100% at
Moment 5.
Surgical was the next group to show
the most compliance rate increase,
beating Anesthesia at Moment 4 with a
90% compliance rate post-intervention,
up from 10% baseline.
Also of note:
* Moment 2 showed statistically significant
improvement in HHC for all
roles.
* Circulating nurses showed the most
comparable rates from beginning to
end, seeing the least fluctuation in
HHC.
* The combined interventions of education
and visual cues were particularly
effective, with monthly compliance
rates showing steady upward
trends across all roles.
Post-intervention
9 (90%)
17 (60.71%)
21 (55.26%)
7 (70%)
10 (100%)
17 (70.83%)
18 (58.06%)
15 (83.33%)
7 (87.50%)
17 (32.69%)
20 (62.50%)
8 (72.73%)
5 (83.33%)
17 (70.83%)
20 (60.61%)
9 (90%)
6 (100%)
12 (50%)
10 (50%)
5 (83.33%)
0.23
p-value
0.04
0.52
0.34
0.07
Sustaining HHC culture
As with any behavioral change initiative,
challenges arose. For instance, initial visual
cue reminders featuring " watching
eyes " were perceived as threatening.
Replacing them with emojis resolved
the issue-a result of implementing
staff feedback.
While the project achieved short-term
gains, toward the end, some staff became
less engaged. Sustaining compliance
remains a challenge and will require
ongoing accountability. To mitigate
this, establishing a steering committee
as a dedicated task force to monitor
compliance, address barriers,
implement
adjustments, and provide regular
feedback is a key recommendation to
maintain momentum.
Leadership buy-in proved critical,
OR Manager | Mar/Apr 2025 27
http://www.ormanager.com
orm_mar_apr-2025

Table of Contents for the Digital Edition of orm_mar_apr-2025
