1. Georgia Hospital Engagement Network HAI Affinity Group October 8th, 2014 11:00 – 11:30 AM

2. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 2 Hospital Sharing Share one success story or one thing that went well in reducing Healthcare Acquired Infections this past month... CAUTI CLABSI SSI VAE C difficile 2

3. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 3 Hand Hygiene continues to be one of the most important processes to prevent HAI Review a synopsis of the recent August SHEA document to encourage facilities to review their Hand Hygiene programs to ensure best practice recommendations are in place. Reference: Infection Control & Epidemiology Volume 35, Number I August 2014 Commentary: Strategies to Prevent Healthcare- Associated Infections through Hand Hygiene

4. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 4 SHEA / IDSA PRACTICE RECOMMENDATIONS Infection Control and Hospital Epidemiology August 2-14, Vol. 35, No. 8 Strategies to Prevent Healthcare-Associated Infections through Hand Hygiene – Purpose: “The intent of this document is to highlight practical recommendations in a concise format, update recommendations with the most current scientific evidence, and elucidate topics that warrant clarification or more robust research. Additionally, this document is designed to assist healthcare facilities in implementing hand hygiene adherence improvement programs, including efforts to optimize hand hygiene product use, monitor and report back hand hygiene adherence data, and promote behavior change.”

5. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 5 Recommendation Sections Section I: Rationale and Statements of Concern Section 2: Background – Strategies To Measure Hand Hygiene Adherence Section 3: Background – Strategies to Prevent HAI Through Hand Hygiene Section 4: Recommended Hand Hygiene Improvement Strategies Section 5: Performance Measures Section 6: Examples of Implementation Strategies

6. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 6 Section 1 Rationale and Statements of Concern I. “For more than 150 years, the association between hand hygiene improvement and HAI reduction has been demonstrated in a variety of settings, and hand hygiene is widely accepted as a foundational component of infection prevention and control programs.” – Adherence remains low (approximately 40%)

7. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 7 Section 1 Rationale and Statements of Concern II. Controversial issues – pathogen specific efficacy of products (e.g., efficacy of alcohol against C. difficile and norovirus) – warrant attention – Integration of glove use and hand hygiene protocols – Deficiencies in hand hygiene technique

8. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 8 Section 1 Rationale and Statements of Concern III. Improvement strategies not consistently implemented – Abundance of tools and methods, from direct observation to volume- based measurement to emerging automated oversight technologies. – No national standards exist, guidance on optimal implementation is needed – Historically, the quality of studies evaluating the implementation of hand hygiene improvement programs was suboptimal, with little evidence-based guidance. More recently, some specific bundles of intervention are possibly effective.

9. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 9 Section 2 Background – Strategies to measure Adherence Defining Opportunities – WHO’s 5 Hand Hygiene Moments Variation Before and After Care Canada combines moments 4 and 5 into “after patient/patient environment contact.” CDC’s protocol for MDRO and CDI surveillance includes hand hygiene measurement as a “supplemental prevention process measure.” For simplification of measurement, the protocol stipulates observation of hand hygiene opportunities after contact with a patient or with inanimate objects in the vicinity of the patient. Methods Direct Observation, Indirect volume or event count measurement, and advanced technologies for automated adherence monitoring. Each method has strengths and weaknesses. Gould recommended that the feasibility and acceptability of a combined approach should be explored. In the U.S., no national standard for HH measurement is in place

10. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 10 Section 3 Background – Strategies to Prevent HAI through Hand Hygiene I. Existing guidelines and recommendations for hand hygiene – 2002 CDC Guideline for Hand Hygiene in Healthcare Settings – 2009 WHO Guidelines on Hand Hygiene in Health Care (largely consistent with CDC guidelines) – 2007 CDC Guidelines for Isolation Precautions – 2011 Guideline for the Prevention and Control of Norovirus Gastroenteritis Outbreaks in Healthcare Settings – Other Guidelines for the prevention of specific device- and procedure- associated HAIs. – Numerous strong (IA and IB) recommendations, few are based on randomized trials or epidemiologically rigorous observational studies. – This lack of rigor occurs in part because of ethical considerations

11. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 11 Section 3 Background – Strategies to Prevent HAI through Hand Hygiene II. Clarifications and updates to literature Hand Hygiene Product efficacy Efficacy versus bacteria ABHRs (with alcohol concentrations between 62% and 95%) are described as being more effective than either plain or antimicrobial soaps over a broad range of testing conditions One issue of concern is that study conditions may not always be reflective of clinical situations because artificial contamination with microorganisms and controlled hand hygiene regimens are sometimes used. Efficacy versus viruses The majority of available studies who that ABHRs have significantly better efficacy than soap and water, overall, there are fewer studies on hand hygiene products against viruses. Efficacy based on dispensing mechanism 2002 CDC guidelines stated that alcohol containing hand wipes were not a substitute for gel or foam, since that time, alcohol-containing wipes have been reported to have similar efficacy to ABHR gel and foam against influenza virus. Some formulations with at least 65% alcohol are now comparable to alcohols delivered by other dispensing methods.

12. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 12 Section 3 Background – Strategies to Prevent HAI through Hand Hygiene II. Clarifications and updates to literature – Technique – Tolerability – Toxicity and Fire Risk – Integration of glove use into routine hand hygiene protocols – Glove use reduces transmission of CDI and carriage of VRE on healthcare worker hands. Hand hygiene is recommended after removing gloves. – Triclosan

13. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 13 Section 3 Background – Strategies to Prevent HAI through Hand Hygiene – Hand hygiene and norovirus prevention Debated area regarding effectiveness of HH, especially with alcohol-based sanitizers Conflicting results in studies CDC guidelines do not discuss which products to use after caring for norovirus patients in routine settings, However, in addition to glove use as part of contact precautions, they do recommend use of soap and water for care of patients with known, suspected, or proven norovirus during norovirus outbreaks. (low-quality evidence)

14. – Hand hygiene and CDI prevention Use of soap and water versus ABHR for hand hygiene while caring for patients with CDI is controversial. WHO and SHEA recommend preferential use of soap and water over ABHR for HH while caring for CDI patients in outbreak or hyper endemic settings. CDC Vital Signs report “Wear gloves and gowns when treating patients with CDI, even during short visits. Hand sanitizer does not kill C. difficile, and hand washing may not be sufficient.” The relationship between hand hygiene methods and CDI rates over time is not definitive. Inconclusive evidence has created confusion about appropriate hand hygiene during care of patients with CDI. Although in vivo studies show slight advantages for soap and water over ABHR, there are no clinical studies suggesting the superiority of soap and water to ABHR for reducing CDI transmission; however, use of gloves has been associated with decreased CDI transmission, suggesting that appropriate use of gloves should be emphasized over hand hygiene methods when targeting prevention of CDI via contact transmission.

15. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 15 Section 3 Background – Strategies to Prevent HAI through Hand Hygiene – Hand preparation for surgery – Artificial nails and nail length

16. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 16 Section 4 Recommended Hand Hygiene Improvement Strategies Recommendations are categorized as either – (1) basic practices that should be adopted by all acute care hospitals, or – (2) special approaches that can be considered for use under specific circumstances (e.g., outbreaks) when HAIs are not controlled by use of basic practices.

17. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 17 Recommendations Each recommendation is given a quality of evidence ranking based on the Grades of Recommendation, Assessment, Development, and Evaluation system. None of the recommendations listed achieve a category I ranking, which requires a wide range of studies. The lack of randomized trials to test recommendations that have become standard of care is likely to persist, largely due to ethical concerns.

18. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 18 Section 5 Performance Measures I. Internal Reporting II. External Reporting

19. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 19 Section 6 Examples of Implementation Strategies I. Engage II. Educate III. Execute IV. Evaluate

20. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 20 In Summary Read, Review most current recommendations Ensure your Hand Hygiene Program is where it needs to be to support HAI prevention. Discuss best practice recommendations with your Interdisciplinary Team 20

21. Learn. Act. Improve. Spread. Keep the Drum Beat Going. 21 GAPP / LEAPT Updates/ Deadlines SPREAD OF LEAPT TOPICS Data Submission: – Due 3 rd or each month – send to Lynne Hall (lhall@gha.org)lhall@gha.org TOC November 3 rd End Date(1 for sepsis and 1 for additional topic area) Checklist (1 per hospital) – Worker Safety Data (if in WS group) Send to Jean Allred (jallred@gha.org)jallred@gha.org due 15 th of month (about 45 days after end of reporting month). 21