1. Can improving patient hand hygiene impact Clostridium difficile infection events at an academic medical center?
AJIC Sept Volume 45, Issue 9, p , e91-e102
APIC Greater NYC Meeting – November 15, 2017
Steve Bock RN CIC FAPIC

3. Study Intent / Design – study led by IPs
Survey inpatients at a 500 bed academic medical center about their hand hygiene practices
Train nursing staff to teach patients about Patient Hand Hygiene (PHH)
Have nursing staff coach patients to perform hand hygiene (and assist as needed)
Survey patients after education/coaching is ongoing
Compare hospital-onset (HO) C. difficile infection (CDI) rates before and after the PHH program is implemented
Analyze PHH rates and HO-CDI rates to see if changes in one led to changes in the other

4. Study Intent / Design Two main phases in study (11/2013 – 12/2015)
Phase 1 – limited to four inpatient med-surg units
Phase 2 – throughout all inpatient hospital units
Quasi-experimental design
No control groups
No random selection of study participants
No comparison of units’ populations as a confounding variable
Attempt to make causal link between PHH and HO-CDI rates

5. Patient Survey Questions

6. Study Methods Phase 1 Survey patients: 30/unit x 4 med-surg units
Patients had to be able to participate in survey
No PHH was observed by surveyor, only patient recall of PHH was collected
Train unit nursing staff to educate patients
Initial survey results
Importance of staff and patient HH
When patients should perform HH (prior to meals, after using the toilet or bedpan, prior to touching dressings and incisions, after returning from testing or a procedure, before and after having visitors)

7. Study Methods Phase 1 Nursing staff asked to verbally educate patients
On admission
At key times, before meals, when leaving/returning from tests off the unit, after toileting, etc.
No patient HH return demonstrations were done
In-room Signs posted – for patients and staff
For patients – HH supplies/wipes placed in rooms
For staff – reminders (nursing station signage, screen savers)
Patients re-surveyed (time interval between education roll-out and survey not stated)
Surveyed 3:1 over initial survey = 90 pts/nursing unit

8. Study Results Phase 1
Post-education/practice change PHH rates analyzed
99% of patients surveyed ranked HH as a 4 or 5 (out of 5) in importance to prevent infections

9. Study Methods Phase 2 No IRB approval sought/reported
Study expansion to entire hospital based on Nursing Admin approval/IP Input (e.g., rehab, Observation, OB, ICUs)
Phase 2 modeled on Phase 1
Baseline patient surveys (not as many/nursing unit)
Education to staff
Staff educate patients
Follow-up patient HH surveys (1 year later) (not as much over-sampling
80 baseline surveys, 189 post-program surveys (2.4:1 ratio)
Total # of nursing units not reported, nor # patient surveys per unit, nor whether original 4 units were re-surveyed

10. Study Results Phase 2
PHH changed very little in Phase 2: 2.4/day at baseline, 2.6 at study completion (1 year later, March 2015 vs. March 2016)
Authors stated there were differences between types of units (OB vs med-surg) without presenting data
Statistical analyses not given on Phase 2 data; authors state “no change” in PHH during Phase 2

11. Discussion / C. difficile Issues
Nursing Leadership/staff were apparently not aware the of the study aim to link PHH with HO-CDI rates
CDI practices include
Prompt testing of symptomatic patients
Cases counted as HO by CDC definition (>3 days in hosp)
PCR-based C. difficile testing
Contact Precautions at the time of CD testing
Staff perform HH with soap and water for CDI patients
Use sporicidal H2O2-based environmental cleaner
UV-C room irradiation of CDI rooms
Active Antibiotic Stewardship program
CDI Practices did not change during the study period

12. Discussion / C. difficile Issues
Traditional IP efforts focus on HCW HH practices
Literature suggests PHH may play an important role on infection prevention
Improving PHH may have a positive impact on HO-CDI rates
A VAMC study (ICHE 2015;36:986-9) suggested four key times for PHH
before and after touching wounds
before eating *
after using the restroom
on entering or leaving their room
* perhaps the most important opportunity for PHH

13. Discussion / C. difficile Issues
Why don’t patients do good hand hygiene? Barriers include
Patients’ lack of knowledge about PHH benefit
Physical barriers, room layout, access to bathroom or other means for PHH
Patients need assistance during acute illness
Article presented good review of the topic of PHH and HAI risks
However, relationship between PHH and HAI rates not strongly shown in existing literature

14. Analysis of HO-CDI Rates
Quarterly Hospital HO CD Rates compared during study
* P < 0.05
Red text indicates when Phase 2 occurred throughout hospital
HO CD rates improved significantly for two quarters, then increased
Maintaining an intensive program over a long time is difficult
Rate/1000 Pt days
HO-CDI cases
Pt Days
SIR
SIR P value
Q4 2014
0.897 19
21185
0.85
.4928
Q1 2015
0.842 22
26135
0.834
.4021
Q2 2015
0.622 16
25743
0.572
.0157*
Q3 2015
0.436 11
25253
0.497
.0103*
Q4 2015
0.762 18
23613
0.813
.3844

15. Limitations / Confounding Issues
Survey bias is possible
Only alert patients interviewed
Patients may be reluctant to give honest answers
Relied on patient memory / recall of HH activity
No direct HH teaching was performed, no return demonstration to validate good HH technique
Patient education by nursing was neither measured nor validated
Final patient surveys were conducted after time period used for HO CD rate analysis (end of Q vs. Q4 2015)
Ongoing hospital efforts focusing on HCW HH occurred during study, found to be increasing about 5% / year

16. Limitations / Confounding Issues
Patients’ hands were not tested for microorganisms
Patients’ hands were not tested for effectiveness of cleaning
Patients were free to choose alcohol-based hand rub (ABHR) or soap and water
No data collected on PHH methods (theoretical benefit from soap and water vs. ABHR?)
No breakdown of PHH or HO CD rates by nursing unit or hospital service
No literature shows direct connection between PHH and HAI rates; all articles cited merely infer causal link
No data to show same or differences in patient populations during lengthy study period

17. Limitations / Confounding Issues
Phase 1 HO CD rates for initial study nursing units not presented yet PHH increased significantly in this part of the study
Phase 2 PHH rates did not change appreciably, yet HO CD rates decreased
Perhaps affirms the null hypothesis – no link between PHH and HO CD rates
Suggests that efforts to increase PHH were ineffective
Suggests that other variables not studied or identified led to decreased HO CD rates
Suggests that other factors may affect HO CD rates (possibly seasonal increase in Abx use w/fall/winter months)

18. Final Thoughts
Program sustainability must be considered carefully before implementation
PHH is definitely important and may reduce HAI rates
Studies should seek to make clear causal link between data collected and outcomes
More research is needed!