Clinical Grand Rounds

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Clinical Grand Rounds

• Wednesday, April 5th, 2006

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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.
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The InterventionHand scrub with chlorinated
lime solution
Hand hygiene basin at the Lying-In Womens
Hospital in Vienna, 1847.
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Hand Hygiene Not a New Concept
Semmelweis Hand Hygiene Intervention
Hand antisepsis reduces the frequency of
patient infections
Adapted from Hosp Epidemiol Infect Control, 2nd
Edition, 1999.
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Has anything changed?
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So Why All the Fuss About Hand Hygiene?

• Most common mode of transmission of pathogens is
  via hands!
• Infections acquired in healthcare
• Spread of antimicrobial resistance

CDC
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Nosocomial Infections

• 2 million/year in US
• 80,000 deaths/yr (IHI)
• Heavy colonization of patients
• Intact skin as well
• Environmental surfaces
• 106 squames shed daily
• Enterococcus and Staph aureus resist dessication
• HCW hands easily contaminate even after clean
  procedures

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The Iceberg Effect
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Data for efficacy of hand hygiene

• Semmelweiss et al
• 1960s prospective, controlled trial
• sponsored by the National Institutes of Health
  and the Office of the Surgeon General
• demonstrated that infants cared for by nurses who
  did not wash their hands after handling an index
  infant colonized with S. aureus acquired the
  organism more often and more rapidly than did
  infants cared for by nurses who used
  hexachlorophene to clean their hands between
  infant contacts

Mortimer EA Jr, Lipsitz PJ, Wolinsky E, Gonzaga
AJ, Rammelkamp CH Jr. Transmission of
staphylococci between newborns. Am J Dis Child
1962104289--95.
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Factors affecting hand hygiene compliance

• Outbreak investigations have indicated an
  association between infections and understaffing
  or overcrowding
• association was consistently linked with poor
  adherence to hand hygiene.

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Self-Reported Factors for Poor Adherence with
Hand Hygiene
a.k.a excuses

• Handwashing agents cause irritation and dryness
• Sinks are inconveniently located/lack of sinks
• Lack of soap and paper towels
• Too busy/insufficient time
• Understaffing/overcrowding
• Patient needs take priority
• Low risk of acquiring infection from patients

Adapted from Pittet D, Infect Control Hosp
Epidemiol 200021381-386.
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Hand Hygiene Adherence in Hospitals

• 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
• (5) 48 General

1. Gould D, J Hosp Infect 19942815-30. 2.
Larson E, J Hosp Infect 19953088-106. 3.
Slaughter S, Ann Intern Med 19963360-365. 4.
Watanakunakorn C, Infect Control Hosp Epidemiol
199819858-860. 5. Pittet D, Lancet
20003561307-1312.
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Physician compliance

• Consistently, physicians score lower than other
  healthcare workers
• Robert Weinstein (ID at Rush) Ann Intern Med.
  2004 Jul 6141(1)65-6
• ..after more than 150 years of prodding,
  cajoling, educating, observing and surveying
  physicians, hand hygiene adherence rates remain
  disgracefully low

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Handwashing Guidelines

• As early as 1961, USPHS produced videos about
  hand washing
• Wash hands for 1-2 minutes before and after each
  patient contact.
• Antiseptics discouraged.
• 1975 CDC guidelines
• 1985 CDC guidelines
• 1988 APIC guidelines-start suggesting ABHG
• 1995 HICPAC
• 1996 HICPAC

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Handwashing Guidelines

• CDC
• Guidelines for Hand Hygiene in Healthcare
  settings (2002)
• Forms basis for PHD policies
• WHO
• Guidelines on Hand Hygiene for Health Care (draft)

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Regulation

• Multiple regulatory agencies have added hand
  hygiene to their list of goals
• IHI
• The 100,000 Lives Campaign
• initiative to engage U.S. hospitals in a
  commitment to implement changes in care proven to
  improve patient care and prevent avoidable deaths
  (zero tolerance).
• Endorsed by CDC, APIC, and SHEA
• Component of the central line bundle
• JACHO patient safety goal 7- Reduce Hospital
  Acquired Infections
• Comply with CDC guidelines
• Manage as sentinel events all identified cases of
  unanticipated death or major permanent loss of
  function associated with a health care-associated
  infection.

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IHI campaign

• 4 components
• Demonstrate knowledge
• Demonstrate competence
• Enable employees (provide equipment)
• Monitor compliance and provide feedback
• Random observations
• Record time all 3 components followed
• Wash before
• Wash after
• Proper glove use
• Goals of zero incidence

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IHI tips

• Empower nursing to enforce use of a central line
  checklist
• Include hand hygiene as part of your checklist
  for central line placement.
• Keep soap/alcohol-based handwashing dispensers
  prominently placed and make universal precautions
  equipment, such as gloves, only available near
  hand sanitation equipment.
• Post signs at the entry and exits to the patient
  room as reminders.
• Initiate a campaign using posters including
  photos of celebrated hospital doctors/employees
  recommending handwashing.
• Create an environment where reminding each other
  about handwashing is encouraged.

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JCAHO Speak up

• Speak up if you have questions or concerns, and
  if you don't understand, ask again. It's your
  body and you have a right to know.
• Pay attention to the care you are receiving. Make
  sure you're getting the right treatments and
  medications by the right health care
  professionals. Don't assume anything.
• Educate yourself about your diagnosis, the
  medical tests you are undergoing, and your
  treatment plan.
• Ask a trusted family member or friend to be your
  advocate.
• Know what medications you take and why you take
  them. Medication errors are the most common
  health care errors.
• Use a hospital, clinic, surgery center, or other
  type of health care organization that has
  undergone a rigorous on-site evaluation against
  established state-of-the-art quality and safety
  standards, such as that provided by Joint
  Commission.
• Participate in all decisions about your
  treatment. You are the center of the health care
  team.

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Vignette

• Patients still think they cant question their
  doctors
• Other HCWs still think they cant question the
  doctor
• Lawyers are happy to question the doctor

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Partners in Your Care

• Program designed at Penn to encourage patients to
  speak up
• Focus on patient, not healthcare worker
• Studies in Europe reported 40-50 improvement in
  HH compliance

McGuckin M et al. Patient Education Model for
Increasing Handwashing Compliance. Am J. Infect
Control, 199927309-314. 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.
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Still, compliance is very low. Solution?
More research!!
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Indications for Hand Hygiene

• If hands are not visibly soiled, use an
  alcohol-based handrub for routinely
  decontaminating hands.
• When hands are visibly soiled, wash with
  non-antimicrobial or antimicrobial soap and
  water.

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

• Before
• Patient contact
• Donning gloves when inserting a CVC
• Inserting urinary catheters, peripheral vascular
  catheters, or other invasive devices
• After
• Contact with a patients skin
• Contact with body fluids or excretions,
  non-intact skin, wound dressings
• Removing gloves

Guideline for Hand Hygiene in Health-care
Settings. MMWR 2002 vol. 51, no. RR-16.
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Which hand hygiene method is best at killing
bacteria?

1. Plain soap and water
2. Antimicrobial soap and water

3. Alcohol-based handrub
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Efficacy of Hand Hygiene Preparations in Killing
Bacteria
Better
Good
Best
Antimicrobial soap
Plain Soap
Alcohol-based handrub
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Ability of Hand Hygiene Agents to Reduce Bacteria
on Hands
Adapted from Hosp Epidemiol Infect Control, 2nd
Edition, 1999.
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Effect of Alcohol-Based Handrubs on Skin Condition
Epidermal water content
Self-reported skin score
Dry
Healthy
Healthy
Dry
Alcohol-based handrub is less damaging to the
skin
Boyce J, Infect Control Hosp Epidemiol
200021(7)438-441.
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Time Spent Cleansing Handsone nurse per 8 hour
shift

• Hand washing with soap and water 56 minutes
• Based on seven (60 second) handwashing episodes
  per hour
• Alcohol-based handrub 18 minutes
• Based on seven (20 second) handrub episodes per
  hour

Alcohol-based handrubs reduce time needed for
hand disinfection
Voss A and Widmer AF, Infect Control Hosp
Epidemiol 199718205-208.
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Recovery of VRE from Hands and Environmental
Surfaces

• Up to 41 of healthcare workers 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
2000311058-1065. 2 Noskin G, Infect Control and
Hosp Epidemi 199516577-581.
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The Inanimate Environment Can Facilitate
Transmission
X represents VRE culture positive sites
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.
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Estimate how often YOU clean your hands after
touching a patient or a contaminated surface in
the hospital?

1. 25
2. 50
3. 75
4. 90
5. 100

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Fingernails and Artificial Nails

• Natural nail tips should be kept to ¼ inch in
  length
• Artificial nails should not be worn when having
  direct contact with high-risk patients (e.g.,
  ICU, OR)

Guideline for Hand Hygiene in Health-care
Settings. MMWR 2002 vol. 51, no. RR-16.
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Can a Fashion Statement Harm the Patient?
ARTIFICIAL
POLISHED
NATURAL
Avoid wearing artificial nails, keep natural
nails lt1/4 inch if caring for high risk patients
(ICU, OR)
Edel et. al, Nursing Research 1998 4754-59
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What about gloves?

• Do increase patient protection
• Protects HCW from BBP exposure
• Proper use essential
• Change between patients
• Change between sites
• Not a substitute for hand hygiene!
• Micropunctures in gloves can allow contamination
• Glove removal risks contamination

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What about cdiff?

• None of the agents used in antiseptic handwash or
  antiseptic hand-rub preparations are reliably
  sporicidal against Clostridium spp. or Bacillus
  spp.
• controversial
• Current PHD policy is to use soap and water in
  known cdiff patients (sign on ABHG dispenser)

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Influence of Role Models and Hospital Design on
Hand Hygiene of Healthcare Workers
Lankford, et al Emerg Infect Dis 2003 Feb

• 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) (plt0.001).
• 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) plt0.001).
• 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.

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PREVENTION IS PRIMARY!
Protect patientsprotect healthcare
personnel promote quality healthcare!
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