1. PICO Presentation By Jamie Paiva, RN
In healthcare workers caring for patients with Clostridium difficile (C. difficile) infections, does washing hands with soap and water as compared to alcohol based hand rubs (ABHR) increase the removal of C. difficile spores from hands?
P – Clostridium difficile
I – Hand washing with soap and water
C – Hand washing with ABHR
O – Increased removal of C. difficile spores from hands
The incidence of acquiring a Clostridium difficile infection during a hospital stay has been steadily increasing over recent years (Jabbar et. al., 2009, p. 565). This microorganism is easily spread or transmitted by direct contact, the fecal-oral route, which is why there is a need to identify the best hand hygiene practices. The purpose of this presentation is represented by the PICO question: In healthcare workers caring for patients with Clostridium difficile infections, does washing hands with soap and water compared to alcohol based hand rubs increase the removal of C. difficile spores from hands?

2. Literature Search
Keywords: Clostridium difficile, hand hygiene, hand washing, hand sanitizer, alcohol based, alcohol, soap and water
Search engines: CIHNAL and PubMed
Results:
Many articles on C. difficile
Few articles on hand hygiene
Older articles
I performed my literature search starting with the CIHNAL database, and used the keywords listed on this slide. When I narrowed my search by using the advanced search option, I could not get any articles to pull up so I had to stick with a basic search. While this yielded many articles, I had a hard time finding the articles pertaining to best hand hygiene practices when dealing with C. difficile. I ended up having to play with different keywords in order to get the information I was after. For example, no results yielded when I used the term “hand sanitizer”. I noticed in other articles that it was referred to as an “alcohol based hand rub” so I used “alcohol based” instead of “hand sanitizer” which yielded many more results. When I simply used “alcohol” instead of “alcohol based” I was given even more results. As for search engines, PubMed pulled up all of the same articles as the CIHNAL database did. While there were many articles that pertained to C. difficile, there were only a very small number of articles that gave me data pertaining to best hand hygiene practices. Also, theses few articles are five and six years old and would have preferred to find more current information.

3. Citations
Article 1 Jabbar, U., Leischner, J., Kasper, D., Gerber, R., Sambol, S., Parada, J., … Gerding, D. (2010). Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands. Infection Control and Hospital Epidemiology, 31(6), doi: / Article 2 Oughton, M. T., Loo, V. G., Dendukuri, N., Fenn, S., & Libman, M. (2009). Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile. Infection control and hospital epidemiology, 30(10), doi: /605322
Here are the citations for my two research articles that performed quantitative studies on hand hygiene practices when dealing with C. difficile. Article one, by Jabbar et. al., is titled “Effectiveness of alcohol-based hand rubs for removal of Clostridium difficile spores from hands” and article two, by Oughton et. al., is titled “Hand hygiene with soap and water is superior to alcohol rub and antiseptic wipes for removal of Clostridium difficile”.

4. Rationales Quantitative studies Reduction in C. difficile spores
Alternative hand hygiene methods
Similar studies… do the results match?
I chose these two articles because they were the most current articles that were quantitative in nature. These two articles both performed similar tests in laboratories on human subjects that produced hard data on which methods of hand hygiene reduced the number of C. difficile spores from hands. The results were objective and measurable, and statistical data was produced, discussed, and used to definitively answer their research questions. These studies were also chosen because one went into depth on researching different types of soaps and different temperatures of water and which combinations worked best to remove C. difficile spores. The other article went into depth on comparing different brands of alcohol based hand rubs. These studies were also chosen because they both had the same goal so that I could compare their data to one another and see how well their results matched up.

5. Theory, Study Type, & Design
Article 1 (Jabbar et. al.)
Article 2 (Oughton et. al.)
Theoretical framework
2002 WHO Guidelines
Expert opinion
ABHR
Lack of experimental evidence
Study & Design
Clinical trial
Prospective design
Article 1 by Jabbar et al. built its theoretical framework around the 2002 World Health Organization’s Guidelines for Hand Hygiene in Healthcare Settings, which states alcohol based hand rubs are to be used before and after contact with persons with C. difficile infections. These guidelines also stated that these rubs are ineffective sporicides and hand washing with soap and water is the preferred method of decontamination. Jabbar et. al. (2010) stated, “Although the increased use of ABHRs in clinical practice could theoretically contribute to the increasing incidence of CDI, most studies have not shown increased rates of CDI temporally associated with ABHR introduction” (p. 566). Because of these two conflicting pieces of information, the authors of article 1 decided to investigate the efficacy of ABHRs on the reduction of C. difficile spores on hands.Article 2 by Oughton et. al. built the framework of this study based on there being a lack of experimental evidence on which hand hygiene methods work best to decontaminate hands of C. difficile spores. Oughton et. al. (2009) note that the current recommendations (at the time in 2009) were based on expert opinions, such from the Healthcare Infection Control Practices Advisory Committee (p. 939). We have learned in this class that expert opinion is the lowest level of evidence (level C), and these authors aimed to gather and interpret data to guide clinical decision making and recommendations on this matter.
Both studies performed clinical trials and used a prospective design, as these studies were planned in advance.

6. Methods Article 1 (Jabbar) Sample and population 10 volunteers
Hospital lab workers
Non-medical
448 observations
Water temp. variations, 2 soaps, hand wipe, ABHR, water
Variables used
3 ABHR, soap & water, water
Analytical approach
Differences between groups
Article 2 (Oughton)
Both studies used 10 volunteers to perform their experiments on. Article one used non-medical volunteers and article two used volunteers that are workers in a hospital laboratory. Volunteers in neither study were not coached how to wash their hands, but had time limits for washing, rinsing, and drying their hands. While article one used each volunteer only one time, article two had its volunteers come back and perform multiple tests on a number of different days for a total of 448 different observations. Both studies randomly selected five donors (those who’s hands would be inoculated with nontoxigenic C. difficile spores) and five recipients (those who would shake hands with the donors after the donors hands were inoculated). Recipients then had their hands cultured by stamping it on a culture plate. Article one focused on using different brands of ABHR, one type of soap and water, and just plain water as a control. Article two focused on using plain soap and water, and antimicrobial soap and water and combining these soaps with warm and cold water washings. Article two also tested the efficacy of one AHBR, one antiseptic hand wipe, and just plain water as a control.

7. Findings
The hand hygiene method most effective for removing C. difficile spores:
Article 1 (Jabbar et. al.)
Washing hands with soap and water
Article 2 (Oughton et. al.)
So which method of hand hygiene works best when dealing with the removal of C. difficile spores? Both studies concluded the same finding: that washing hands with soap and water works most effectively. Oughton et. al. (2009) also concluded that the temperature of the water did not have an impact on the reduction of the number of C. difficile spores (p. 941). Oughton et. al. (2009) went on to say that “the effect of alcohol based hand rubs was not significantly different from the effect of not washing [one’s hands]” (p. 941).

8. Ethical Considerations
Article 1 (Jabbar et. al.)
Article 2 (Oughton et. al.)
IRB approved
Informed consents obtained
Ethical approval from a Research Ethics Board
Informed consents obtained
Although nontoxigenic C. difficile spores were used in both studies, they were still using a live microorganism and using them on the surface of the skin on human subjects. Because of this, both studies needed to be ethically approved. Jabbar et. al. obtained approval from the Internal Review Board or IRB and Oughton et. al. obtained ethical approval from the Research Ethics Board from McGill University Health Centre. Once these boards gave their approval, participants in both studies signed informed consents to take part in the experiments.

9. Strength & Quality Both articles: Peer-reviewed Level of Evidence: B
Quantitative studies
Rationales
Generalizable findings
Both of these articles are strong and high quality. They are peer-reviewed to ensure credibility and high standards of quality by those of similar expertise. Both articles are at the B level of evidence, which is neither the highest nor the lowest level of evidence, but ensures a good standard of quality. These articles are both quantitative in nature, which means measurable, hard data was produced and calculated to produce objective results. Both articles provided rationales as to why they were performing their studies, as previously discussed on slide number 5. These findings are also generalizable to any person who has C. difficile or any person taking care of someone with C. difficile. It is generalizable in the sense that all healthcare facilities should put this into policy and practice to ensure the highest quality of practice and safety in being implemented.

10. Article 2 (Oughton et. al.)
Credibility
Article 1 (Jabbar et. al.)
Article 2 (Oughton et. al.)
Peer-reviewed
Credible authors
Reputable journal
Journal is published by SHEA
This article was used as a reference by the CDC (Ref. 3 in PDF)
(CDC’s website)
Peer-reviewed
Credible authors
Reputable journal
Journal is published by SHEA
This article was used as a reference by the CDC (Ref. 4 )
(The PDF)
Both of these articles are credible because of the same reasons. Both articles have been peer-reviewed and both have credible authors. Article one has eight authors, six of which are M.D.s that are affiliated with Loyola University’s School of Medicine and the others are affiliated with Edward Hines Jr. Veteran’s Hospital. Article two has five authors, 3 of which are MDs and all five are affiliated with different universities and hospitals that range from Departments of Medicine of Infectious Disease, to Departments of Epidemiology and Biostatistics, to Departments of Microbiology. Both of the articles were published in a journal called Infection Control and Hospital Epidemiology which is published for the Society for Healthcare Epidemiology for America, or SHEA. SHEA’s mission is to “prevent and control healthcare-associated infections and advance the field of healthcare epidemiology.” SHEA is a valuable resource of the Centers for Disease Control and Prevention or CDC and often refers to SHEA in creating guidelines for healthcare workers to follow to reduce the rates of various infections. Both of my articles were cited in the CDC’s guidelines for clinicians pertaining to hand hygiene and C. difficile under the PDF titled, “Rationale for Hand Hygiene Recommendations after Caring for Patients with Clostridium difficile infection.” Seeing the SHEA and the CDC cite these article as part of their reasons for the guidelines they have created, this shows that these article are credible.

11. Contribution to Evidence-Based Practice
Results used in CDC guideline rationales
Used in hospitals/healthcare facilities
Impact patient care
People at home with C. difficile infections
These studies did contribute to evidence-based practice. As mentioned in the credibility section of this PowerPoint, these studies have been cited in literature from the CDC’s recommendations for hand hygiene for healthcare workers dealing with C. difficile positive patients. These recommendations impact hospital and other healthcare facilities’ policy on hand hygiene which makes a direct impact on patient care. These recommendations also given to people living at home that are dealing with active C. difficile infections, as we always teach our patients and their families to wash their hands with soap and water often and after any direct contact.

12. Communication & Implications for Practice
Communicated at all levels
Some potential for change
Healthcare facilities follow CDC guidelines
CDC guidelines recommend ABHR, NOT soap & water
Update needed on CDC’s patient FAQ sheet
The finding that washing hands with soap and water instead of using alcohol based hand rubs should be communicated at all levels, which include professional levels, standard of care level, written into healthcare facility policies, and even the individual level for family caring for a family member who is C. difficile positive. As for the potential for change, there is some room for improvement. We have learned that hand washing with soap and water works best for spore removal, yet the CDC recommends that healthcare workers use ABHR for hand hygiene (which we will discuss more on the next slide). My hospital follows CDC guidelines and our policy tells us to use ABHR as well, so some healthcare facilities may want to change their policies. Also, the CDC’s FAQ sheet on C. difficile that we give our patients and their families when someone has been diagnosed does not make a point to emphasize hand washing with soap and water over ABHR. The FAQ sheet says to frequently “clean your hands” and mentions both soap and water and ABHR as a method of hand hygiene. This sheet should clearly tell people that soap and water hand washing is the main method, especially when not using personal protection equipment such as gloves when caring for a person with a C. difficile infection.

13. Potential Barriers
CDC/SHEA Guidelines recommend ABHR for healthcare workers caring for C. difficile positive patients.
Rationale:
Prevents confusion
Hand washing with soap and water decreases hand hygiene compliance
ABHR increases hand hygiene compliance
PPE use/gloves
Updated CDC FAQ sheet needed
There are many actual and potential barriers to implementing the preferred hand hygiene method of soap and water. One of the biggest barriers is that the CDC/SHEA actually recommends the use of ABHR for healthcare workers caring for patients with C. difficile infections, with the exception of outbreak situations (then soap and water is recommended.) The reasons cited include: 1) less confusion on when to use which hand hygiene method, 2) requiring hand washing with soap and water has compliance rates of less than 40 percent, 3) ABHR increases hand hygiene compliance, 4) ABHR use is associated with decreased rates of methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant enterococcus (VRE), 5) with proper use of gloves as PPE any benefit of soap and water instead of ABHR is negated, and 6) there is no evidence of increased rates of C. difficile infections with ABHR use or a decrease in C. difficile infections with the use of soap and water. A barrier to the public is the CDC’s C. difficile FAQ sheet. This sheet should clearly inform the public that hand washing with soap and water is the most effective way to clean their hands.

14. Additional PICO Questions
In healthcare workers caring for patients with a Clostridium difficile infection, how does wearing gloves as compared to not wearing gloves reduce the number of Clostridium difficile spores on hands?
In healthcare workers caring for patients with C. difficile infections, after taking off gloves does hand washing with soap and water as compared to ABHR, increase the removal of C. difficile spores from hands?

15. Conclusion
PICO Question: In healthcare workers caring for patients with Clostridium difficile (C. difficile) infections, does washing hands with soap and water as compared to alcohol based hand rubs (ABHR) increase the removal of C. difficile spores from hands?
Gold Standard: Soap and water
ABHR not effective
So, in healthcare workers caring for patients with C. difficile infections, does washing hands with soap and water as compared to alcohol based hand rubs (ABHR) increase the removal of C. difficile spores from hands? We have learned today that washing hands with soap and water is the gold standard of hand hygiene when caring for patients with a C. difficile infection. Alcohol based hand rubs are not able to kill C. difficile spores and are not effective at reducing the number of spores on hands. However, the CDC recommends that healthcare workers use alcohol based hand rubs because proper use of Personal Protection Equipment such as gloves reduce the risk of hand contamination, and because of the potential barriers listed on slide 13 (such as decrease hand hygiene compliance with soap and water policies). The CDC does, however, recommend hand washing with soap and water in outbreak situations.