Clinical Grand RoundsClinical Grand Rounds

Wednesday, April 5Wednesday, April 5thth, 2006, 2006

Semmelweiss, Ignaz (1818-1865)

 

                                                                        

    

            

Hungarian physician who decided that doctors in Vienna hospitals were spreading childbed fever while delivering babies. He started forcing doctors under his supervision to wash their hands before touching patients.

The doctors objected, however, and stopped washing despite the decrease in cases. Incidences of the disease skyrocketed, and it was not until Lister that doctors began routinely using antiseptics.

The Intervention:The Intervention:Hand scrub with chlorinated lime Hand scrub with chlorinated lime

solutionsolution

Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.

Hand Hygiene: Not a New Hand Hygiene: Not a New ConceptConcept

Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850

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1841 1842 1843 1844 1845 1946 1847 1848 1849 1850

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MDs Midwives

Semmelweis’ Hand Hygiene Intervention

~ Hand antisepsis reduces the frequency of patient infections ~

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Has anything changed?

Most common mode of transmission of pathogens is via hands!

Infections acquired in healthcare

Spread of antimicrobial resistance

So Why All the Fuss About So Why All the Fuss About Hand Hygiene?Hand Hygiene?

CDC

Nosocomial InfectionsNosocomial Infections

• 2 million/year in US2 million/year in US• 80,000 deaths/yr 80,000 deaths/yr (IHI)(IHI)

• Heavy colonization of Heavy colonization of patientspatients– Intact skin as wellIntact skin as well– Environmental surfacesEnvironmental surfaces

• 101066 squames shed daily squames shed daily

• Enterococcus and Staph Enterococcus and Staph aureus resist dessicationaureus resist dessication

• HCW hands easily HCW hands easily contaminate even after contaminate even after “clean” procedures“clean” procedures

The Iceberg Effect

Infected

Colonized

Data for efficacy of hand Data for efficacy of hand hygienehygiene

• Semmelweiss et alSemmelweiss et al

• 1960s prospective, controlled trial 1960s prospective, controlled trial – sponsored by the National Institutes of Health and sponsored by the National Institutes of Health and

the Office of the Surgeon General the Office of the Surgeon General – demonstrated that infants cared for by nurses who demonstrated that infants cared for by nurses who

did not wash their hands after handling an index did not wash their hands after handling an index infant colonized with infant colonized with S. aureusS. aureus acquired the acquired the organism more often and more rapidly than did organism more often and more rapidly than did infants cared for by nurses who used infants cared for by nurses who used hexachlorophene to clean their hands between hexachlorophene to clean their hands between infant contacts infant contacts

Mortimer EA Jr, Lipsitz PJ, Wolinsky E, Gonzaga AJ, Rammelkamp CH Jr. Transmission

of staphylococci between newborns. Am J Dis Child 1962;104:289--95.

Factors affecting hand hygiene Factors affecting hand hygiene compliancecompliance

• Outbreak investigations have Outbreak investigations have indicated an association between indicated an association between infections and understaffing or infections and understaffing or overcrowdingovercrowding

• association was consistently linked association was consistently linked with poor adherence to hand with poor adherence to hand hygiene. hygiene.

Self-Reported Factors Self-Reported Factors for Poor Adherence for Poor Adherence with Hand Hygienewith Hand Hygiene

Handwashing agents cause irritation and drynessHandwashing agents cause irritation and dryness

Sinks are inconveniently located/lack of sinksSinks are inconveniently located/lack of sinks

Lack of soap and paper towelsLack of soap and paper towels

Too busy/insufficient timeToo busy/insufficient time

Understaffing/overcrowdingUnderstaffing/overcrowding

Patient needs take priorityPatient needs take priority

Low risk of acquiring infection from patientsLow risk of acquiring infection from patients

Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.

a.k.a excuses

Hand Hygiene Adherence in Hospitals

1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.

Year of Study Adherence Rate Hospital Area

1994 (1) 29% General and ICU

1995 (2) 41% General

1996 (3) 41% ICU

1998 (4) 30% General

2000 (5) 48% General

Physician compliancePhysician compliance

• Consistently, physicians score lower Consistently, physicians score lower than other healthcare workersthan other healthcare workers

• Robert Weinstein (ID at Rush) Robert Weinstein (ID at Rush) Ann Intern Med. 2004 Jul Ann Intern Med. 2004 Jul

6;141(1):65-66;141(1):65-6 – ““..after more than 150 years of prodding, ..after more than 150 years of prodding,

cajoling, educating, observing and cajoling, educating, observing and surveying physicians, hand hygiene surveying physicians, hand hygiene adherence rates remain disgracefully adherence rates remain disgracefully low…low…

Handwashing GuidelinesHandwashing Guidelines

• As early as 1961, USPHS produced videos As early as 1961, USPHS produced videos about hand washingabout hand washing– Wash hands for 1-2 minutes before and after Wash hands for 1-2 minutes before and after

each patient contact. each patient contact. – Antiseptics discouraged.Antiseptics discouraged.

• 1975 CDC guidelines1975 CDC guidelines

• 1985 CDC guidelines1985 CDC guidelines

• 1988 APIC guidelines-start suggesting ABHG1988 APIC guidelines-start suggesting ABHG

• 1995 HICPAC1995 HICPAC

• 1996 HICPAC1996 HICPAC

Handwashing GuidelinesHandwashing Guidelines

• CDCCDC– Guidelines for Hand Guidelines for Hand

Hygiene in Hygiene in Healthcare settings Healthcare settings (2002)(2002)

– Forms basis for PHD Forms basis for PHD policiespolicies

• WHOWHO– Guidelines on Hand Guidelines on Hand

Hygiene for Health Hygiene for Health Care (draft)Care (draft)

RegulationRegulation

• Multiple regulatory agencies have added Multiple regulatory agencies have added hand hygiene to their list of goalshand hygiene to their list of goals– IHIIHI

• The 100,000 Lives CampaignThe 100,000 Lives Campaign– initiative to engage U.S. hospitals in a commitment to initiative to engage U.S. hospitals in a commitment to

implement changes in care proven to improve patient implement changes in care proven to improve patient care and prevent avoidable deaths (zero tolerance).care and prevent avoidable deaths (zero tolerance).

• Endorsed by CDC, APIC, and SHEAEndorsed by CDC, APIC, and SHEA• Component of the central line bundleComponent of the central line bundle

– JACHO patient safety goal #7- Reduce Hospital JACHO patient safety goal #7- Reduce Hospital Acquired InfectionsAcquired Infections• Comply with CDC guidelinesComply with CDC guidelines• Manage as sentinel events all identified cases of Manage as sentinel events all identified cases of

unanticipated death or major permanent loss of unanticipated death or major permanent loss of function associated with a health care-associated function associated with a health care-associated infection.infection.

IHI campaignIHI campaign

• 4 components4 components– Demonstrate knowledgeDemonstrate knowledge– Demonstrate competenceDemonstrate competence– Enable employees (provide equipment)Enable employees (provide equipment)– Monitor compliance and provide feedbackMonitor compliance and provide feedback

• Random observationsRandom observations• Record % time all 3 components followedRecord % time all 3 components followed

– Wash beforeWash before– Wash afterWash after– Proper glove useProper glove use

• Goals of Goals of zerozero incidence incidence

IHI tipsIHI tips• Empower nursing to enforce use of a central line Empower nursing to enforce use of a central line

checklist checklist • Include hand hygiene as part of your checklist for Include hand hygiene as part of your checklist for

central line placement.central line placement.• Keep soap/alcohol-based handwashing dispensers Keep soap/alcohol-based handwashing dispensers

prominently placed and make universal prominently placed and make universal precautions equipment, such as gloves, only precautions equipment, such as gloves, only available near hand sanitation equipment.available near hand sanitation equipment.

• Post signs at the entry and exits to the patient Post signs at the entry and exits to the patient room as reminders.room as reminders.

• Initiate a campaign using posters including Initiate a campaign using posters including photos of celebrated hospital doctors/employees photos of celebrated hospital doctors/employees recommending handwashing.recommending handwashing.

• Create an environment where reminding each Create an environment where reminding each other about handwashing is encouraged.other about handwashing is encouraged.

JCAHO Speak upJCAHO Speak up• SSpeak up if you have questions or concerns, and peak up if you have questions or concerns, and

if you don't understand, ask again. It's your body if you don't understand, ask again. It's your body and you have a right to know.and you have a right to know.

• PPay attention to the care you are receiving. ay attention to the care you are receiving. Make sure you're getting the right treatments Make sure you're getting the right treatments and medications by the right health care and medications by the right health care professionals. Don't assume anything.professionals. Don't assume anything.

• EEducate yourself about your diagnosis, the ducate yourself about your diagnosis, the medical tests you are undergoing, and your medical tests you are undergoing, and your treatment plan.treatment plan.

• AAsk a trusted family member or friend to be sk a trusted family member or friend to be your advocate. your advocate.

• KKnow what medications you take and why you now what medications you take and why you take them. Medication errors are the most take them. Medication errors are the most common health care errors.common health care errors.

• UUse a hospital, clinic, surgery center, or other se a hospital, clinic, surgery center, or other type of health care organization that has type of health care organization that has undergone a rigorous on-site evaluation against undergone a rigorous on-site evaluation against established state-of-the-art quality and safety established state-of-the-art quality and safety standards, such as that provided by Joint standards, such as that provided by Joint Commission.Commission.

• PParticipate in all decisions about your treatment. articipate in all decisions about your treatment. You are the center of the health care team.You are the center of the health care team.

Vignette:Vignette:

• Patients still think they can’t Patients still think they can’t question their doctorsquestion their doctors

• Other HCW’s still think they can’t Other HCW’s still think they can’t question the doctorquestion the doctor

• Lawyers are happy to question the Lawyers are happy to question the doctordoctor

Partners in Your CarePartners in Your Care

• Program designed at Penn to Program designed at Penn to encourage patients to speak upencourage patients to speak up

• Focus on patient, not healthcare Focus on patient, not healthcare workerworker

• Studies in Europe reported 40-50% Studies in Europe reported 40-50% improvement in HH complianceimprovement in HH compliance

McGuckin M et al. Patient Education Model for Increasing Handwashing Compliance. Am J. Infect Control, 1999:27;309-314.

McGuckin M et al Evaluation of a patient-empowering hand hygiene programme in the UK. Journal of Hospital Infection, 2002 48: 222-227.

McGuckin M, Taylor A, Martin V, Porten,Salcido R, Evaluation of a Patient Education Model for Increasing Hand Hygiene compliance in an in-patient Rehabilitation Unit. Astract presented at SHEA, January 2003 American Journal of Infect Control. In press - 2004.

Still, compliance is very low. Still, compliance is very low. Solution?Solution?

More research!!

Indications for Hand Indications for Hand HygieneHygiene

If hands are not If hands are not visiblyvisibly soiled, soiled, use an use an alcohol-based handrubalcohol-based handrub for routinely decontaminating for routinely decontaminating hands.hands.

When hands are When hands are visibly soiledvisibly soiled, , wash with non-antimicrobial or wash with non-antimicrobial or antimicrobial antimicrobial soap and water.soap and water.

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Specific Indications Specific Indications for Hand Hygienefor Hand Hygiene

•Before:Before:– Patient contact Patient contact – Donning glovesDonning gloves when inserting a CVC when inserting a CVC– Inserting urinary catheters, peripheral vascular Inserting urinary catheters, peripheral vascular

catheters, or other invasive devicescatheters, or other invasive devices

•After:After:– Contact with a patient’s skin Contact with a patient’s skin – Contact with body fluids or excretions, non-Contact with body fluids or excretions, non-

intact skin, wound dressingsintact skin, wound dressings– Removing glovesRemoving gloves

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

1.1. Plain soap and waterPlain soap and water

2.2. Antimicrobial soap and Antimicrobial soap and waterwater

Which hand hygiene method is Which hand hygiene method is best at killing bacteria?best at killing bacteria?

3. Alcohol-based handrub3. Alcohol-based handrub

Efficacy of Hand Hygiene Efficacy of Hand Hygiene Preparations in Killing Preparations in Killing

BacteriaBacteria

Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

Ability of Hand Hygiene Agents to Reduce Bacteria on

Hands

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

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Alcohol-based handrub(70% Isopropanol)

Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

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Baseline 2 weeks

Alcohol rub Soap and water

1517

192123

2527

Baseline 2 weeks

Alcohol rub Soap and water

Epidermal water contentSelf-reported skin scoreDry

Healthy Dry

Healthy

Effect of Alcohol-Based Handrubs on Skin Condition

~ Alcohol-based handrub is less damaging to the skin ~

Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.

Time Spent Cleansing Time Spent Cleansing Hands:Hands:

one nurse per 8 hour one nurse per 8 hour shiftshift

Hand washing with soap and water: 56 minutesHand washing with soap and water: 56 minutes

– Based on seven (60 second) handwashing Based on seven (60 second) handwashing episodes per hourepisodes per hour

Alcohol-based handrub: 18 minutesAlcohol-based handrub: 18 minutes

– Based on seven (20 second) handrub Based on seven (20 second) handrub episodes per hourepisodes per hour

Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.

~ Alcohol-based handrubs reduce time needed for hand disinfection ~

Recovery of VRE from Hands and Environmental Surfaces

Up to 41% of healthcare worker’s hands sampled (after patient care and before hand hygiene) were positive for VRE1

VRE were recovered from a number of environmental surfaces in patient rooms

VRE survived on a countertop for up to 7 days2

1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065.2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581.

The Inanimate Environment Can Facilitate Transmission

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents VRE culture positive sites

Estimate how often Estimate how often YOUYOU clean your hands after clean your hands after touching a patient or a touching a patient or a

contaminated surface in contaminated surface in the hospital?the hospital?

1.1. 25%25%

2.2. 50%50%

3.3. 75%75%

4.4. 90%90%

5.5. 100%100%

Fingernails and Fingernails and Artificial NailsArtificial Nails

•Natural nail tips should be kept Natural nail tips should be kept to ¼ inch in lengthto ¼ inch in length

•Artificial nails should not be worn Artificial nails should not be worn when having direct contact with when having direct contact with high-risk patients (e.g., ICU, OR)high-risk patients (e.g., ICU, OR)

Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Can a Fashion Statement Harm the Patient?

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Artificial (n=27)

Polished (n=31)

ARTIFICIAL

POLISHEDNATURAL

Edel et. al, Nursing Research 1998: 47;54-59

Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for high risk patients (ICU, OR)

What about gloves?What about gloves?

• Do increase patient Do increase patient protectionprotection

• Protects HCW from BBP Protects HCW from BBP exposureexposure

• Proper use essentialProper use essential– Change between patientsChange between patients– Change between sitesChange between sites

• Not a substitute for Not a substitute for hand hygiene!hand hygiene!– Micropunctures in gloves Micropunctures in gloves

can allow contaminationcan allow contamination– Glove removal risks Glove removal risks

contaminationcontamination

What about cdiff?What about cdiff?

• None of the agents used in antiseptic None of the agents used in antiseptic handwash or antiseptic hand-rub handwash or antiseptic hand-rub preparations are reliably sporicidal against preparations are reliably sporicidal against ClostridiumClostridium spp. or spp. or BacillusBacillus spp. spp.

• controversialcontroversial• Current PHD policy is to use soap and Current PHD policy is to use soap and

water in known cdiff patients (sign on water in known cdiff patients (sign on ABHG dispenser)ABHG dispenser)

•assessed the effect of medical staff role models and the number of sinks on hand-hygiene compliance before and after construction of a new hospital designed for increased access to handwashing sinks. •721 hand-hygiene opportunities•Hand-hygiene compliance was significantly better in the old hospital (161/304; 53%) compared to the new hospital (97/417; 23.3%) (p<0.001). •Health-care workers in a room with a senior medical staff person or peer who did not wash hands were significantly less likely to wash their own hands (odds ratio 0.2; confidence interval 0.1 to 0.5); p<0.001). •health-care worker hand-hygiene compliance is influenced significantly by the behavior of other health-care workers•increased number of hand-washing sinks did not increase hand-hygiene compliance.

Influence of Role Models and Hospital Design on Hand Hygiene of Healthcare Workers

Lankford, et al Emerg Infect Dis 2003 Feb

PREVENTIONIS PRIMARY!

Protect patients…protect healthcare personnel…

promote quality healthcare!