1. Hand Hygiene What it’s all about…

2. Hand Hygiene Hand Hygiene (HH) is generally poorly adhered to across the board by all levels of Health Care Worker’s

3. THE UNWASHED HAND!

4. Hand Hygiene The problem:  HAIs / MRSA, ESBLs, VRE etc  Majority are preventable  Costly to patient  Costly to health service

5. Ignaz Philipp Semmelweis

6. Semmelweis IP, 1861 (%) Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1846

7. Intervention Students and doctors were required to: clean their hands with a chlorinated lime solution when entering the labour room in particular when moving from the autopsy to the labour room May 1847

8. Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1850 Intervention Semmelweis IP, 1861 May 15, 1847

9. Ignaz Philipp Semmelweis before and after he insisted that students and doctors clean their hands with a chlorine solution between each patient

10. 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 hand washing was performed Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

11. What we Know  In summary we know:  Bugs are on our hands  Bugs can be washed off  Washing bugs off our hands saves lives  HCWs don’t wash their hands!!!  So what is the problem???

12. Why we don’t wash our hands  Too busy/insufficient time  Patient needs take priority  Understaffing/overcrowding Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386. HCW are not bad just busy! Poor design Poor product More education  Sinks are inconveniently located or lack of sinks  Lack of soap and paper towels  Hand washing agents cause irritation and dryness  Low risk of acquiring infection from patients

13. What can we do to help change this  Provide easy access to hand hygiene materials  Handrub solution  Conveniently located:  at the patient’s bedside  at the patient’s room entrance  in convenient / appropriate locations  in high traffic public areas  Working appropriately  Full of product  Within use by date

14. What the Austin did Full culture change program in 3 parts  Alcohol Based Hand Rub(ABHR)  Moisturiser  Alcohol impregnated wipes Aim:  Increase HH compliance  Reduce HAIs

15. How we did it  Rolled out in one area (zone) at a time, then all hospital  Education/learning packages  “Talking Walls” = participation, ownership,fun & reminders  Monitoring before and after  Handrub supply  Hand hygiene compliance  MRSA rates  Feedback of results  Recruitment of area champions  Launch days, t-shirts,BBQ,wine etc  Strong support from management

16. ABHR’s are literally the solution Pittet Geneva Sample products only

17. Time Spent Cleansing Hands  One nurse per 8 hour shift  Hand washing with soap and water: 56 minutes  Based on seven (60 second) hand washing episodes per hr  Alcohol-based hand rub: 18 minutes  Based on seven (20 second) hand rub episodes per hr Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208. ~ Alcohol-based hand rubs reduce time needed for hand hygiene ~

18. Hand Hygiene Definitions Hand washing  The application of non-antimicrobial soap and water to the surface of the hands Antiseptic hand wash  Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based hand rub  an alcohol-containing preparation designed for application to the hands in order to reduce the number of viable organisms with maximum efficacy and speed Surgical hand hygiene/antisepsis  Hand washing or using an alcohol-based hand rub before operations by surgical personnel

19. Indications for Hand Hygiene  When hands are visibly dirty, contaminated, or soiled, wash with non-antimicrobial or antimicrobial soap and water.  If hands are visibly clean, use an alcohol- based hand rub for routinely decontaminating hands. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

20. Hand Hygiene Compliance  Compliance = using hand hygiene products appropriately  Non compliance = failure to apply hand hygiene products at the appropriate time  Is when HH is considered necessary & classified according to one of the 5 Moments  Total moments observed=Y  Actual moments performed=X  X/Y x100%=% rate of HH compliance

21. Product Choice HHA is non product specific  ABHR more effective than either medicated/non medicated soap  Isopropanol alcohol has slightly greater activity against bacteria than ethanol  Chlorhexidine has persistent activity  HCWs happy to use

22. Why Use ABHR ??  Reduces bacterial count on hands  More effective for standard hand wash  Reduces adverse outcomes and cost associated with HAI’s  Requires less time  Less irritating  Can be readily accessible/ portable

23. What to use and When  When hands are visibly soiled use soap and water to wash  If your hands are visibly CLEAN use ABHR  Before and after touching a patient  Before and after a procedure  After touching a patient’s surroundings  Before and after glove use

24. Program Organiser  Organise product selection  Product placement  Education  Marketing/promotions  Meeting (internal/external)  Funding  Reports(Gantt charts), proformas  Launch  Passion/energy/dedication

25. Steering Committee  High level chair/executive support  Heads of depts  Sentinel wards NUMs  Champions  Regular meeting  Minutes/agendas/meeting planners

26. Education  Varies depending on whom  Grand rounds/medical support  Handovers  Team meetings  NUMs groups  Allied health  Hospital orientation  Newsletters  Flyers/payslips/magazine

27. RUB apply to palm ROLL rub hands together covering all aspects of your fingers & hands until dry SQUIRT one squirt (1-3 ml) to your hands Easy Message

28. Basic message always the same “Clean you hands before and after every patient touch” Instructions always the same  Squirt  Rub  Roll

29. Champions  Ward liaison/link nurses  Staff with interest  Doctors with passion  Consultants  Dept heads  CEO  Involve all areas

30. “Healthcare workers in a room with a senior staff member or peer who DID NOT wash their hands were significantly less likely to wash their own hands” EMERGING INFECTIOUS DISEASES FEB 2003 Role Models

31. Promotion  Area ownership  Area specific  Strap lines/slogans  Keep changing  Rewards/incentives  Posters,poetry and song competitions  Newsletters,payslips,local media  T-shirts,food,stickers,badges,giveaways

32. Accessibility

33. - is an important barrier to compliance - is more frequent with soap and water than with handrubs - is reduced and can be treated by emollient-containing solutions Skin irritation Boyce et al. Inf Contr Hosp Epi 2000;21:442 Kramer et al. J Hosp Infect 2002; 51:114 Larson et al. Heart Lung 2000; 29:139 Pittet. Emerging Inf Dis 2001; 2:234

34. Consolidating Culture  Learning package mandatory for new staff  Annual Learning Package planned for all current staff - to be linked to performance appraisal  Website: www.hha.org.auwww.hha.org.au

35. Glove use  Hand hygiene is required regardless of whether gloves are used or changed  Failure to remove gloves after patient contact or between dirty and clean body site care in the same patient has to be regarded as noncompliance with recommendations  Gloves should not be washed or reused  Gloved HCWs can cause cross infections

36. Mythbusters Absorption  Local studies have demonstrated minimal rates of cutaneous alcohol absorption.  You cannot absorb enough through your skin to lose you drivers license Fire  The overall risk of fires associated with ABHR is extremely low  Consult MSDS,local OH&S requirements & HHA guidelines for placement of product

37. Mythbusters Ingestion  Unlikely as ABHR tastes unpleasant  Risk of poisoning uncommon but some diarrhoea/vomiting has been reported Splashes  Product should be placed at a height to minimise risk of splashes  If splash occurs don’t rub,flush eye and seek help ASAP Children need to be supervised at all times in hospitals

38. References  Guideline for Hand Hygiene in Health-Care Settings.MMWR 2002:vol,51,no RR-16  Pittet D,Inf.Control Hospital Epidemiology 200:21:381-386  Voss A and Widmer AF,Inf. Control Hospital Epidemiology 1997:18:205-208  HHA 5 Moments for Hand Hygiene,Advanced draft, August 2008  WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft) April 2006  Boyce et al.Inf. Control Hospital Epidemiology 2000:21:442  Kramer et at,Journal Hospital Inf. 2002:51:114  Larson et al.Heart Lung 2000:29:139  Pittet.D.Emerging Inf Dis 2001:2:234