Hand Hygiene Charissa Borja-Tabora, MD, FPPS, FPIDSP Chair, Infection Prevention and Control Committee RITM

Objective Objectives Suggested Reading: Hand out/materials Demonstrate correct Hand Hygiene technique Knowledge of multi-faceted plans to improve hand hygiene Understand appropriate Hand Hygiene practices when caring for patient with suspected or confirmed Ebola Suggested Reading: WHO Aide-Memoire: Hand Hygiene How to Hand Rub / How to Hand Wash Poster Hand out/materials See activities

Hand Hygiene basics

Hand Hygiene Quiz What is the number one way to prevent healthcare-associated infections?

Hand Hygiene… …the single most effective measure to reduce healthcare-associated infections Slide used with permission from World Health Organization

Where should hand hygiene be performed At the nurses’ station Hand Hygiene Quiz Where should hand hygiene be performed At the nurses’ station At the nearest sink At the point of care

…AT THE POINT-OF-CARE OPTIMAL HAND HYGIENE SHOULD BE PERFORMED… Point of care - refers to the place where three elements occur together: the patient, the health-care worker, and care or treatment involving patient contact. The concept refers to a hand hygiene product (e.g. alcohol-based handrub) which should be easily accessible to health-care workers by being as close as possible, e.g. within an arm’s reach (as resources permit) to where patient contact is taking place. Point of care products should be accessible without leaving the zone of care/treatment. This enables health-care workers to quickly and easily fulfill the 5 Moments for hand hygiene. The product must be capable of being used at the required moment, without leaving the zone of activity. …AT THE POINT-OF-CARE Slide used with permission from World Health Organization 7

What is the best way to achieve hand hygiene at the point of care? Hand Hygiene Quiz What is the best way to achieve hand hygiene at the point of care?

…with alcohol based hand rub unless visibly soiled OPTIMAL HAND HYGIENE SHOULD BE PERFORMED… …with alcohol based hand rub unless visibly soiled Alcohol-based hand rubs can be produced at the facility level by following the WHO recommendations and instructions it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better tolerated. Slide adapted and used with permission from World Health Organization 9

Examples of Hand Hygiene Products Easily Accessible at the Point-of-Care Slide adapted and used with permission from World Health Organization 10

What are the WHO 5 Moments for hand hygiene? Hand Hygiene Quiz What are the WHO 5 Moments for hand hygiene?

Your 5 Moments for Hand Hygiene Clean your hands immediately before accessing a critical site with infectious risk for the patient! To protect the patient against harmful germs, including the patient’s own, entering his/her body! Clean your hands when leaving the patient’s side, after touching a patient and his/her immediate surroundings, To protect yourself and the health-care environment from harmful germs! Clean your hands as soon as a task involving exposure risk to body fluids has ended (and after glove removal)! To protect yourself and the health-care environment from harmful germs! Clean your hands before touching a patient when approaching him/her! To protect the patient against harmful germs carried on your hands! Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving without having touched the patient! To protect yourself and the health-care environment against germ spread! Slide used with permission from World Health Organization

The 5 Moments Applies to all settings where direct contact with patients takes place. Slide adapted and used with permission from World Health Organization

For how many seconds to perform hand wash? Hand Hygiene Quiz For how many seconds to perform hand wash?

How to handwash To effectively reduce the growth of germs on hands, handwashing must last 40–60 secs and should be performed by following all of the illustrated steps. Slide used with permission from World health Organization

For how many seconds should you perform hand rub? Hand Hygiene Quiz For how many seconds should you perform hand rub?

How to handrub To effectively reduce the growth of germs on hands, handrubbing must be performed by following all of the illustrated steps. This takes only 20–30 seconds! Slide used with permission from World health Organization

Time Spent Cleansing Hands: one 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 The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis. More rapid access to hand hygiene materials could help improve adherence. Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often. ~ Alcohol-based handrubs reduce time needed for hand disinfection ~ Voss A and Widmer AF, Infect Control Hosp Epidemiology 1997:18;205-208.

Summary Alcohol-Based Handrubs: What benefits do they provide? Require less time More effective for standard handwashing than soap More accessible than sinks Reduce bacterial counts on hands Improve skin condition In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster. In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition.

Areas Frequently Missed by Healthcare workers Hand hygiene activity

Golden Rules: Summary Performed at the point-of-care exactly where you are delivering health care to patients Performed when any of the 5 Moments (indications) occurs Using the appropriate technique and time duration Performed with an alcohol-based formulation if available Performed with soap and water when visibly soiled

After using gloves there is no need for hand hygiene. True or False? Hand Hygiene Quiz After using gloves there is no need for hand hygiene. True or False?

Hand Hygiene and Glove Use GLOVES PLUS HAND HYGIENE = CLEAN HANDS GLOVES WITHOUT HAND HYGIENE = GERM TRANSMISSION Slide used with permission from World Health Organization

Hand Hygiene Improving Compliance

Obstacles to Hand Hygiene Do healthcare workers perform Hand Hygiene 100% of the time? Average reported compliance with hand hygiene is about 39% Why is Compliance so poor? WHO 2009 Photo used with permission from WHO

Self-Reported Factors for Poor Adherence with Hand Hygiene 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 Adherence not typically tracked individually Not rewarded Adverse events aren’t immediate and their relationship to the missed HH opportunity isn’t always clear Healthcare workers have reported several factors that may negatively impact their adherence with recommended practices including; handwashing agents cause irritation and dryness, sinks are inconveniently located, lack of soap and paper towels, not enough time, understaffing or overcrowding, and patient needs taking priority. Lack of knowledge of guidelines/protocols, forgetfulness, and disagreement with the recommendations were also self reported factors for poor adherence with hand hygiene. Perceived barriers to hand hygiene are linked to the institution and HCWs colleagues. Therefore, both institutional and small-group dynamics need to be considered when implementing a system change to secure and improve HCWs hand hygiene practice. Adapted from Pittet D, Infect Control Hosp Epidemiology 2000;21:381-386.

Obstacles to Hand Hygiene Discussion: What are the main obstacles to preforming 100% hand hygiene? Photos used with permission from World health Organization

Overcoming Obstacles Multifaceted interventions can lead to improvements and good HH performance Adequate hand hygiene products at point of care Frequent Training Reminders in workplace Rigorous monitoring and feedback with rewards/recognition Accountability Institutional safety climate Achieving improvement requires: Ongoing education, Communication, Perseverance and dedication, Engagement, Leadership support, Creativity and adaptability Pittet, 1999; Boyce Editorial

Room set up to make hand hygiene easy Improving Hand Hygiene Compliance: Supplies, Equipment and the Environment Point of use supplies Sinks Soap Paper towels Alcohol hand rub Room set up to make hand hygiene easy

Education/Motivation Programs Monitor healthcare workers (HCWs) adherence with recommended hand hygiene practices and give feedback Implement a multidisciplinary program to improve adherence to recommended practices Encourage patients and their families to remind HCWs to practice hand hygiene One strategy to promote improved hand hygiene behavior is to monitor healthcare worker adherence with recommended hand hygiene practices and to give feedback. Strategies to improve adherence to hand hygiene practices should be both multimodal (i.e. use several different methods or strategies) and multidisciplinary (i.e. involve several different areas of the institution, and types of HCWs). Patients and their families can be involved in reminding HCWs to wash their hands. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Improving Hand Hygiene Compliance: Communications Campaigns Raise awareness Educate Remind Demonstrate leadership commitment Clarify institutional priorities Define HH as the “norm” and an expectation Materials available from WHO… or from other sources!

Administrative Measures to Improve Hand Hygiene Make improved hand hygiene an institutional priority Place alcohol-based handrubs at entrance to patient room, or at bedside Provide HCWs with pocket-sized containers Make improved hand hygiene an institutional priority and provide appropriate administrative support and financial resources. Several administrative measures may help improve hand hygiene adherence among personnel who work in areas where high workloads and high intensity of patient care are anticipated. These include placing alcohol-based handrubs at the entrance to patients’ rooms, or at the bedside and providing healthcare workers with individual pocket-sized containers. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Improving Hand Hygiene Compliance: Tools WHO Guidelines on Hand Hygiene in Health Care Based on evidence and expert consensus (>100 international experts) Summary translated in the UN official languages Implementation strategy and tool package tested in 2007-2008 Final version including evidence update and lessons learned from testing Slide used with permission from World Health Organization

Improving Hand Hygiene Compliance: Measurement Why Measure Hand Hygiene Compliance? To understand performance To use data to change behaviors To assess impact of interventions How to Measure Hand Hygiene Compliance Direct observation of practice Alcohol hand rub utilization Technology monitoring Healthcare-associated infection (HAI) rates

Performance Indicators Monitor and record adherence to hand hygiene by ward or service Provide feedback to healthcare workers about their performance Monitor the volume of alcohol-based handrub used per 1,000 patient days Monitor adherence to policies on wearing artificial nails These performance indicators are recommended for measuring improvements in HCWs hand-hygiene adherence. Monitor and record adherence to hand hygiene by ward or service. Provide feedback to healthcare workers about their performance. Monitor the volume of alcohol-based handrub used per 1,000 patient days. Monitor adherence to policies on wearing artificial nails. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Improving Hand Hygiene Compliance: Tools Key tools recommended for rapid understanding of hand hygiene and Ebola Links are on reference page Slide used with permission from World Health Organization

When caring for A patient in Ebola isolation Hand Hygiene When caring for A patient in Ebola isolation

Hand Hygiene and Ebola 100% compliance Suggested Products & Techniques Meticulous hand hygiene required to remove potential contamination Neglecting to perform hand hygiene after removing PPE will reduce or negate any benefits of the protective equipment Suggested Products & Techniques Use an alcohol-based hand rub or soap and running water Alcohol-based hand rubs if hands are not visibly soiled Soap and water if hands are visibly soiled or sanitizers are unavailable Use the correct technique Availability of hand hygiene supplies Make alcohol-based hand rubs available where needed Alcohol-based hand rubs can be produced at the facility level by following the WHO recommendations and instructions Slide adapted from World Health Organization

Perform hand hygiene Hand Hygiene: Ebola BEFORE: Putting on gloves and wearing PPE before entry to the isolation room/area IMMEDIATELY AFTER Removal of PPE, upon leaving the care area Note: Cleaning gloved hands with 0.5% chlorine solution between removing each item of PPE is a common practice in Ebola Care Centers and Ebola Treatment Units.

Do Not Remove Gloves in High Risk Area HEALTH-CARE AREA PATIENT ZONE Critical site with infectious risk for the patient health care activity may be described as a succession of tasks during which health-care workers' hands touch different types of surfaces: the patient, his/her body fluids, objects or surfaces located in the patient surroundings and patients and surfaces within the health-care area. Each contact is a potential source of contamination for health-care workers' hands. Elements or areas that are involved in hand transmission of health care-associated germs: PATIENT: the transmission risk is especially related to critical sites. Critical sites can either correspond to body sites or medical devices that have to be protected against microorganisms potentially leading to HCAI (called critical sites with infectious risk for the patient), or body sites or medical devices that potentially lead to hand exposure to body fluids and blood borne pathogens (called critical sites with body fluid exposure risk). Both pre-cited risks may also occur simultaneously. Critical site with infectious risk for the patient: where there is a risk of germs being inoculated into the patient during a care activity through contact with a mucous membrane, non-intact skin or an invasive medical device. Critical site with infectious risk for the health-care worker: where there is a risk of potential or actual exposure to a patient’s blood or another body fluid for the health-care worker. PATIENT SURROUNDINGS: space temporarely dedicated to a patient, including all inanimate surfaces that are touched by or in direct physical contact with the patient (e.g. bed rails, bedside table, bed linen, cHCAIrs, infusion tubing, monitors, knobs and buttons, and other medical equipment). health-care ZONE: all those elements beyond the patient surroundings, which make up the care environment (other patients, objects, medical equipment and people present in a health-care facility, clinic or ambulatory setting). Therefore, focusing on a single patient, two virtual geographical areas can be identified from the “transmission risk point of view”, the patient zone (including the patient and his/her surroundings) and the health-care zone (containing all surfaces outside the patient zone, i.e. all other patients and their surroundings and the health-care facility environment). Sax H, et al. “My 5 Moments for Hand Hygiene”: a user-centred design approach to understand, train, monitor and report hand hygiene. J Hosp Infect 2007 Critical site with body fluid exposure risk Slide used with permission from World Health Organization 41

Hand Hygiene: Ebola IN HIGH RISK AREA: Avoid touching contaminated or potentially contaminated surfaces/items/equipment when possible If gloves become visibly soiled wipe or clean off with 0.5% chlorine solution If gloves become torn or damaged leave isolation area Note: Cleaning gloved hands with 0.5% chlorine solution between patients is a common practice in Ebola Care Centers and Ebola treatment units

Summary It is NECESSARY and possible to improve hand hygiene in your facility, to protect patients and yourself! You have the tools to make the change. Now is the time! BASIC infection control for everyone… this simple measure save lives! Meticulous hand hygiene is essential for prevention of Ebola

Activities Practice Hand Hygiene Technique Thinking Through the 5 Moments Hand Hygiene Competency

Practice Hand Hygiene Technique 1 Supplies Red paint (water-based) or similar Sterile gloves, one pair per person How to hand rub instructions on screen

Practice Hand Hygiene Technique 2 Put on sterile gloves Hold out your hand, you will receive a small amount of paint Close your eyes Perform hand hygiene Open your eyes and see if you covered all areas of your hand

Thinking Through the 5 Moments Use the following slides to help participants discuss how actual events in their day to day interaction with patients fit into the 5 moments

Can you identify some examples of this indication during your everyday practice of health care? Situations illustrating direct contact: shaking hands, stroking a child’s forehead helping a patient to move around, get washed applying oxygen mask, giving physiotherapy taking pulse, blood pressure, chest auscultation, abdominal palpation, recording ECG Slide used with permission from World Health Organization

Can you identify some examples of this indication during your everyday practice of health care? Situations illustrating clean/aseptic procedures: brushing the patient's teeth, instilling eye drops skin lesion care, wound dressing, subcutaneous injection catheter insertion, opening a vascular access system or a draining system, secretion aspiration preparation of food, medication, pharmaceutical products, sterile material. Slide used with permission from World Health Organization

Can you identify some examples of this indication during your everyday practice of health care? Situations illustrating body fluid exposure risk: brushing the patient's teeth, instilling eye drops, secretion aspiration skin lesion care, wound dressing, subcutaneous injection drawing and manipulating any fluid sample, opening a draining system, endotracheal tube insertion and removal clearing up urines, faeces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning of contaminated and visibly soiled material or areas (soiled bed linen lavatories, urinal, bedpan, medical instruments) Slide used with permission from World Health Organization

Can you identify some examples of this indication during your everyday practice of health care? Situations illustrating direct contact : shaking hands, stroking a child forehead helping a patient to move around, get washed applying oxygen mask, giving physiotherapy taking pulse, blood pressure, chest auscultation, abdominal palpation, recording ECG Slide used with permission from World Health Organization

Can you identify some examples of this indication during your everyday practice of health care? Situation illustrating contacts with patient surroundings: changing bed linen, with the patient out of the bed perfusion speed adjustment monitoring alarm holding a bed rail, leaning against a bed, a night table clearing the bedside table Slide used with permission from World Health Organization

Hand Hygiene Competency 1 Supplies Alcohol-based hand rub How to hand rub poster printed Pen/Pencil

Hand Hygiene Competency 2 Get supplies Find a partner Check off your partner as they perform hand hygiene Make corrections to their technique if needed

PREVENTION IS PRIMARY! Protect patients…protect healthcare personnel… promote quality healthcare!

Resources WHO 2014 Interim Infection Prevention and Control Guidance for Care of Patients with Suspected or Confirmed Filovirus Haemorrhagic Fever in Health-Care Settings, with Focus on Ebola http://apps.who.int/iris/bitstream/10665/130596/1/WHO_HIS_SDS_2014.4_eng.pdf?ua=1&ua=1 WHO 2011 Aide-Memoire Infection Control: Core components of infection prevention and control programmes in health care http://www.who.int/csr/resources/publications/AM_CoreCom_IPC.pdf WHO Standard Precautions in Health Care http://www.who.int/csr/resources/publications/EPR_AM2_E7.pdf

Resources World Health Organization Hand Hygiene Resources http://www.who.int/gpsc/5may/Hand_Hygiene_Why_How_and_When_Brochure.pdf http://www.who.int/gpsc/5may/Glove_Use_Information_Leaflet.pdf http://www.who.int/gpsc/5may/Guide_to_Local_Production.pdf http://www.who.int/gpsc/country_work/hhsa_framework.pdf http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf http://www.who.int/gpsc/tools/HAND_WASHING.pdf www.who.int/gpsc/5may/Observation_Form.doc New England Journal of Medicine Hand Hygiene Video (multiple languages) http://www.who.int/gpsc/5may/hand_hygiene_video/en/