2. Hand Hygiene Rapid Response Team (RRT) Infection Control Platform

3. Objectives 1)Define, and explain the impact and burden of Healthcare-Associated Infection (HAI) on the hospital and on the patients 2)Identify the modes of transmission of the healthcare-associated germs with particular focus on hand transmission 3)Name three infection control practices to prevent the transmission of these germs 4)Identify the “five moments” for Hand Hygiene 5)Demonstrate the proper techniques for handwashing and handrubbing 6)Explain the limitation of AHR use 7)Demonstrate the correct way of “Glove use and HH” Upon completion of this session, attendees should be able to:

4. Definitions : Infection: Invasion and multiplication of an infectious agent in the tissue of a host. Healthcare-Associated Infection: Infection associated with healthcare delivery in any setting Infections occurring in a patient during the process of care in a hospital or other health-care facility Not present or incubating at the time of admission. This includes infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility. Hospital Acquired Infection (Nosocomial Infection): Acquired in hospital after 72 hours of admission (not incubating nor present on admission. Community Acquired Infection: Infection that is present or incubating on admission to hospital that can be traced to a community source (during the first 72 hours of admission) Ducel G et al. Prevention of hospital-acquired infections. A practical guide. WHO 2002

5. Estimated Rates of Healthcare-Associated Infection (HAI) Worldwide  At any time, over 1.4 million people worldwide are suffering from infections acquired in hospitals  In modern hospitals in the “developed” world, 5-10% of patients acquire one or more infections  In “developing” countries, the risk of health care-associated infection is 2 to 20 times higher than in developed countries and the proportion of patients affected by HAI can exceed 25%  In Intensive Care Units, HAI affects about 30% of patients and the attributable mortality may reach 44%

6. Healthcare-Associated Infection: Scale and Costs Worldwide CountryN°of Cases/YearN°of Deaths/YearCosts/Year UK100,0005,000UK£ 1 billion USA2 millions90,000US$ 4.5 billion MEXICO450,00032/100,000 inhabitants US$ 1.5 billion

7. The Impact of Healthcare-Associated Infection (HAI) HAI Can Cause: ▪ More Serious Illness ▪ Prolongation of Hospital Stay (Availability of Beds) ▪ Long-Term Disability ▪ Excess Deaths ▪ High Personal Costs on Patients and their Families ▪ Reputation of the Hospital

8. The hip I had waited so long for got infected and had to be removed. I was devastated and so disappointed with it all. Now I have more pain than ever. My catheter caused an infection, which meant I spent another two weeks in hospital I'm afraid to go into hospital for my cancer treatment in case I pick up an infection again. My daughter went in to hospital for routine surgery but she developed an infection and died as a result. I’ll never trust hospitals anymore. I CAN BE YOUR MOM I CAN BE YOUR HUSBAND I CAN BE YOUR SON I CAN BE YOUR WIFE

10. Transmission of health care-associated germs with a particular focus on hand transmission

11. Hand Transmission Hands are the most common vehicle to transmit healthcare-associated pathogens Transmission of healthcare-associated pathogens from one patient to another via healthcare workers’ hands requires 5 sequential steps

12. Hand Transmission 1.Presence of Germs 2.Transmission on Hands 3.Germs Survival on Hands 4.Defective Hand Hygiene 5.Cross Transmission of Germs

13. Germs present on patient skin and environment surfaces Germs (S. aureus, P. mirabilis, Klebsiella spp and Acinetobacter spp.) present on intact areas of some patients’ skin: 100-1 million colony forming units (CFU)/cm 2 Nearly 1 million skin squames containing viable germs are shed daily from normal skin Patients immediate surroundings (bed linen, furniture, objects) become contaminated (especially by staphylococci and enterococci) by patient germs Hand Transmission: Step 1 The Lancet Infectious Diseases 2006

14. Germ transfer on healthcare workers’ hands – examples Nurses could contaminate their hands with 100-1,000 CFU of Klebsiella spp. during “clean” activities (lifting patients, taking the patient's pulse, blood pressure, or oral temperature) 15% of nurses working in an isolation unit carried a median of 10,000 CFU of S. aureus on their hands In a general hospital, 29% nurses carried S. aureus on their hands (median count, 3,800 CFU) and 17-30% carried Gram negative bacilli (median counts: 3,400-38,000 CFU) Hand Transmission: Step 2 The Lancet Infectious Diseases 2006

15. Germ survival on hands Following contact with patients and/or contaminated environment, germs can survive on hands for differing lengths of time (2-60 minutes) In the absence of hand hygiene action, the longer the duration of care, the higher the degree of hand contamination Hand Transmission: Step 3 The Lancet Infectious Diseases 2006

16. Defective hand cleansing results in hands remaining contaminated Insufficient amount of product and/or insufficient duration of hand hygiene action lead to poor hand decontamination Transient microorganisms are still recovered on hands following handwashing with soap and water, whereas handrubbing with an alcohol-based solution has been proven significantly more effective Hand Transmission: Step 4 The Lancet Infectious Diseases 2006

17. Hand Transmission: Step 5 The Lancet Infectious Diseases 2006 Contaminated hands cross- transmit germs In many outbreaks, germ transmission between patients and the environment (both the care setting and patient surroundings) to patients through healthcare workers’ hands has been demonstrated

18. Prevention of Healthcare-Associated Infection (HAI) Validated and standardized prevention strategies are available to reduce HAI At least 50% of HAI could be prevented Most solutions are simple and not resource-demanding, and can be implemented in developed, as well as in transitional and developing countries

19. Strategies for Infection Control General Measures Surveillance Standard Precautions Transmission-based Precautions Specific Measures Specifically targeted against: - Urinary tract infections - Surgical site infections - Respiratory infections - Bloodstream infections Antibiotic Control

20. Standard and Transmission-based Precautions (CDC, 1996) FeaturesStandard PrecautionsContact PrecautionsDroplet PrecautionsAirborne Precautions Patient roomStandardPrivate Private; door closed; negative pressure; 6-12 air changes/hour; appropriate discharge of air outdoors or air filtration Hand hygieneAfter contact with body fluids and contaminated items, after glove removal, between patients; with plain soap or alcohol-based handrub Standard; with antiseptic soap or alcohol-based handrub Standard GlovesBefore contact with body fluids and contaminated items; clean, non- sterile Before entering the room; clean, non-sterile Standard GownBefore procedures likely to generate projections of body fluids Standard; before entering the room when substantial patient contact is anticipated, or if the patient has diarrhoea, open wound drainage, secretions Standard Mask/eye protection/face shield Before procedures likely to generate projections of body fluids Standard Mask if within 1 metre of patient Before entering the room; possibly N95 respirator ExamplesAll patientsMultidrug-resistant bacteria (MRSA, VRE), Clostridium difficile, diarrhoea, RSV infection Meningitis, pertussis, influenza, mumps, rubella, diphteria Tuberculosis, varicella, measles

21. Simple evidence… Hand Hygiene is the single most effective measure to reduce healthcare-associated infections

22. Vienna, Austria General Hôpital, 1841-1850 Fighting Puerperal Fever Ignaz Philipp Semmelweis: The Pioneer of Hand Hygiene

24. Maternal Mortality Rates, First and Second Obstetrics Clinics, General Hospital of Vienna Semmelweis IP, 1861 Intervention May 15, 1847 Maternal Mortality

25. Evidence of Relationship Between Hand Hygiene and Healthcare-Associated Infections Substantial evidence that hand hygiene reduces the incidence of infections Historical study: Semmelweis More recent studies: rates lower when antiseptic handwashing was performed Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

26. What are the TOP 10 carriers of infectious agents?

28. How Can We Overcome Problems Associated with Handwashing? Washing hands frequently with soap and water is ▪ inconvenient ▪ time-consuming ▪ often causes skin irritation and dryness Experts recommended that healthcare workers routinely clean their hands with an alcohol-based hand rub (a gel, rinse or foam) Faster More convenient Less skin irritating

29. Handrubbing is the Solution to Obstacles to Improve Hand Hygiene Compliance Handwashing with soap and water only when hands are visibly dirty or following visible exposure to body fluids (and dealing with spores forming germs) Adoption of alcohol-based handrub is the gold standard in all other clinical situations

30. Are Alcohol-Based Hand Rubs Really Effective? Numerous published studies have shown that alcohol-based hand rubs remove bacteria from hands more effectively than washing hands with plain soap and water In most studies, alcohol-based hand rubs removed bacteria from the hands to a greater degree than did washing hands with an antimicrobial soap and water Boyce JM, Pittet D et al. MMWR 2002;51 (RR-16):1-45

31. Pittet and Boyce, Lancet Infectious Diseases 2001 Application time of Hand Hygiene (handwashing and handrubbing) and Reduction of Bacterial Contamination Hand Hygiene with: Handwashing Handrubbing

32. Won’t Frequent Use of Alcohol Dry Out My Skin? Several studies have proven that nurses who routinely cleaned their hands between patients by using an alcohol-based hand rub had less skin irritation and dryness than nurses who washed their hands with soap and water Alcohol-based hand rubs contain skin conditioners (emollients) that help prevent the drying effects of alcohol Boyce JM et al. Infect Control Hosp Epidemiol 2000;21:442 Winnefeld M et al. Br J Dermatol 2000;143:546

33. The Golden Rules for Hand Hygiene Hand hygiene must be performed exactly where you are delivering health care to patients (at the point of care) During healthcare delivery, there are 5 moments when it is essential that you perform hand hygiene You must perform hand hygiene using the appropriate technique and time duration

34. The geographical conceptualization of the transmission risk Clean site Body fluid site

35. THE 5 STEPS OF HAND TRANSMISSION Pittet D et al, Lancet Infect Dis, Oct 2006

36. YOUR 5 MOMENTS FOR HAND HYGIENE 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 immediately after an exposure risk to body fluids (and after glove removal)! To protect yourself and the health-care environment from harmful germs! Clean your hands immediately before an aseptic task! To protect the patient against harmful germs, including the patient’s own, entering his/her body! Clean your hands after touching a patient and his/her immediate surroundings, when leaving the patient’s side! To protect yourself and the health-care environment from harmful germs! Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving- even if the patient has not been touched! To protect yourself and the health-care environment from harmful germs!

37. Can you identify the main examples of this indication during your everyday practice of health care? Some examples may be: shaking hands, stroking an arm helping a patient to move around, get washed, giving a massage taking pulse, blood pressure, chest auscultation, abdominal palpation

38. Some examples may be: secretion aspiration skin lesion care, wound dressing catheter insertion, opening a vascular access system or a draining system preparation of medication, dressing sets Can you identify the main examples of this indication during your everyday practice of health care?

39. Some examples may be: oral/dental care, giving 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 (lavatories, medical instruments) Can you identify the main examples of this indication during your everyday practice of health care?

40. Some examples may be: shaking hands, stroking an arm helping a patient to move around, get washed, giving a massage taking pulse, blood pressure, chest auscultation, abdominal palpation Can you identify the main examples of this indication during your everyday practice of health care?

41. Some examples may be: changing bed linen perfusion speed adjustment monitoring alarm holding a bed rail clearing the bedside table Can you identify the main examples of this indication during your everyday practice of health care?

42. BUT… We should not forget the moments where Hand Hygiene is indicated and falls under hygienic or social practices i.e: after using the toilet preparing food and eating, after coughing etc…

43. To effectively reduce the growth of germs on hands, handwashing must last 40-60 secs and should be performed by following all steps illustrated on the left

44. To effectively reduce the growth of germs on hands, handrubbing must be performed by following all steps illustrated on the left. This takes only 20-30 secs!

45. Hand hygiene and glove use

46. Hand Hygiene and Glove Use The use of gloves does not replace the need of cleaning your hands! You should wear gloves only when indicated

47. Skin Care Dry skin ??? REMEMBER THAT YOU LIVE IN RIYADH If hand skin problems following use of antiseptic hand hygiene, seek medical assistance USE /LOTION HAND MOISTURIZER

48. More Tips on How to Use an Alcohol-Based Hand Rub If you feel a “build-up” of emollients on your hands after cleaning your hands 5 to 10 times with an alcohol- based hand rub, wash your hands with soap and water If you clean your hands with an alcohol-based hand rub before putting on gloves, make sure the alcohol has dried completely before putting on gloves

50. In Summary At MOH Hand Hygiene is an EXPECTATION not an OPTION. We will never be able to improve our Hand Hygiene compliance if not each and everyone of us presumes that the patient to be touched might be his/her father, mother, sister, brother or child

51. 50 THANK YOU THANK YOU