1. Clinical Grand Rounds Wednesday, April 5 th, 2006

2. Semmelweiss, Ignaz (1818-1865) Hungarian physician who decided that doctors in Vienna hospitals were spreading childbed fever while delivering babies. He started forcing doctors under his supervision to wash their hands before touching patients. The doctors objected, however, and stopped washing despite the decrease in cases. Incidences of the disease skyrocketed, and it was not until Lister that doctors began routinely using antiseptics.

3. The Intervention: Hand scrub with chlorinated lime solution Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.

4. Hand Hygiene: Not a New Concept Semmelweis’ Hand Hygiene Intervention ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.

5. Has anything changed?

6. Most common mode of transmission of pathogens is via hands!  Infections acquired in healthcare  Spread of antimicrobial resistance So Why All the Fuss About Hand Hygiene? CDC

7. Nosocomial Infections 2 million/year in US 2 million/year in US 80,000 deaths/yr (IHI) 80,000 deaths/yr (IHI) Heavy colonization of patients Heavy colonization of patients –Intact skin as well –Environmental surfaces 10 6 squames shed daily Enterococcus and Staph aureus resist dessication HCW hands easily contaminate even after “clean” procedures HCW hands easily contaminate even after “clean” procedures

8. The Iceberg Effect Infected Colonized

9. Data for efficacy of hand hygiene Semmelweiss et al Semmelweiss et al 1960s prospective, controlled trial 1960s prospective, controlled trial –sponsored by the National Institutes of Health and the Office of the Surgeon General –demonstrated that infants cared for by nurses who did not wash their hands after handling an index infant colonized with S. aureus acquired the organism more often and more rapidly than did infants cared for by nurses who used hexachlorophene to clean their hands between infant contacts Mortimer EA Jr, Lipsitz PJ, Wolinsky E, Gonzaga AJ, Rammelkamp CH Jr. Transmission of staphylococci between newborns. Am J Dis Child 1962;104:289--95.

11. Factors affecting hand hygiene compliance Outbreak investigations have indicated an association between infections and understaffing or overcrowding Outbreak investigations have indicated an association between infections and understaffing or overcrowding association was consistently linked with poor adherence to hand hygiene. association was consistently linked with poor adherence to hand hygiene.

12. Self-Reported Factors for Poor Adherence with Hand Hygiene  Handwashing agents cause irritation and dryness  Sinks are inconveniently located/lack of sinks  Lack of soap and paper towels  Too busy/insufficient time  Understaffing/overcrowding  Patient needs take priority  Low risk of acquiring infection from patients Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386. a.k.a excuses

14. Hand Hygiene Adherence in Hospitals 1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88- 106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312. Year of StudyAdherence RateHospital Area 1994 (1) 29%General and ICU 1995 (2) 41%General 1996 (3) 41%ICU 1998 (4) 30%General 2000 (5) 48%General

15. Physician compliance Consistently, physicians score lower than other healthcare workers Consistently, physicians score lower than other healthcare workers Robert Weinstein (ID at Rush) Ann Intern Med. 2004 Jul 6;141(1):65-6 Robert Weinstein (ID at Rush) Ann Intern Med. 2004 Jul 6;141(1):65-6 –“..after more than 150 years of prodding, cajoling, educating, observing and surveying physicians, hand hygiene adherence rates remain disgracefully low…

16. Handwashing Guidelines As early as 1961, USPHS produced videos about hand washing As early as 1961, USPHS produced videos about hand washing –Wash hands for 1-2 minutes before and after each patient contact. –Antiseptics discouraged. 1975 CDC guidelines 1975 CDC guidelines 1985 CDC guidelines 1985 CDC guidelines 1988 APIC guidelines-start suggesting ABHG 1988 APIC guidelines-start suggesting ABHG 1995 HICPAC 1995 HICPAC 1996 HICPAC 1996 HICPAC

17. Handwashing Guidelines CDC CDC –Guidelines for Hand Hygiene in Healthcare settings (2002) –Forms basis for PHD policies WHO WHO –Guidelines on Hand Hygiene for Health Care (draft)

18. Regulation Multiple regulatory agencies have added hand hygiene to their list of goals Multiple regulatory agencies have added hand hygiene to their list of goals –IHI The 100,000 Lives Campaign The 100,000 Lives Campaign –initiative to engage U.S. hospitals in a commitment to implement changes in care proven to improve patient care and prevent avoidable deaths (zero tolerance). Endorsed by CDC, APIC, and SHEA Endorsed by CDC, APIC, and SHEA Component of the central line bundle Component of the central line bundle –JACHO patient safety goal #7- Reduce Hospital Acquired Infections Comply with CDC guidelines Comply with CDC guidelines Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection. Manage as sentinel events all identified cases of unanticipated death or major permanent loss of function associated with a health care-associated infection.

19. IHI campaign 4 components 4 components –Demonstrate knowledge –Demonstrate competence –Enable employees (provide equipment) –Monitor compliance and provide feedback Random observations Random observations Record % time all 3 components followed Record % time all 3 components followed –Wash before –Wash after –Proper glove use Goals of zero incidence Goals of zero incidence

20. IHI tips Empower nursing to enforce use of a central line checklist Empower nursing to enforce use of a central line checklist Include hand hygiene as part of your checklist for central line placement. Include hand hygiene as part of your checklist for central line placement. Keep soap/alcohol-based handwashing dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment. Keep soap/alcohol-based handwashing dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment. Post signs at the entry and exits to the patient room as reminders. Post signs at the entry and exits to the patient room as reminders. Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending handwashing. Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending handwashing. Create an environment where reminding each other about handwashing is encouraged. Create an environment where reminding each other about handwashing is encouraged.

21. JCAHO Speak up Speak up if you have questions or concerns, and if you don't understand, ask again. It's your body and you have a right to know. Speak up if you have questions or concerns, and if you don't understand, ask again. It's your body and you have a right to know. Pay attention to the care you are receiving. Make sure you're getting the right treatments and medications by the right health care professionals. Don't assume anything. Pay attention to the care you are receiving. Make sure you're getting the right treatments and medications by the right health care professionals. Don't assume anything. Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan. Educate yourself about your diagnosis, the medical tests you are undergoing, and your treatment plan. Ask a trusted family member or friend to be your advocate. Ask a trusted family member or friend to be your advocate. Know what medications you take and why you take them. Medication errors are the most common health care errors. Know what medications you take and why you take them. Medication errors are the most common health care errors. Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by Joint Commission. Use a hospital, clinic, surgery center, or other type of health care organization that has undergone a rigorous on-site evaluation against established state-of-the-art quality and safety standards, such as that provided by Joint Commission. Participate in all decisions about your treatment. You are the center of the health care team. Participate in all decisions about your treatment. You are the center of the health care team.

22. Vignette: Patients still think they can’t question their doctors Patients still think they can’t question their doctors Other HCW’s still think they can’t question the doctor Other HCW’s still think they can’t question the doctor Lawyers are happy to question the doctor Lawyers are happy to question the doctor

23. Partners in Your Care Program designed at Penn to encourage patients to speak up Program designed at Penn to encourage patients to speak up Focus on patient, not healthcare worker Focus on patient, not healthcare worker Studies in Europe reported 40-50% improvement in HH compliance Studies in Europe reported 40-50% improvement in HH compliance McGuckin M et al. Patient Education Model for Increasing Handwashing Compliance. Am J. Infect Control, 1999:27;309-314. McGuckin M et al Evaluation of a patient-empowering hand hygiene programme in the UK. Journal of Hospital Infection, 2002 48: 222-227. McGuckin M, Taylor A, Martin V, Porten,Salcido R, Evaluation of a Patient Education Model for Increasing Hand Hygiene compliance in an in-patient Rehabilitation Unit. Astract presented at SHEA, January 2003 American Journal of Infect Control. In press - 2004.

24. Still, compliance is very low. Solution? More research!!

25. Indications for Hand Hygiene  If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands.  When hands are visibly soiled, wash with non-antimicrobial or antimicrobial soap and water. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

26. Specific Indications for Hand Hygiene Before: Before: –Patient contact –Donning gloves when inserting a CVC –Inserting urinary catheters, peripheral vascular catheters, or other invasive devices After: After: –Contact with a patient’s skin –Contact with body fluids or excretions, non- intact skin, wound dressings –Removing gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

27. 1.Plain soap and water 2.Antimicrobial soap and water Which hand hygiene method is best at killing bacteria? 3. Alcohol-based handrub

28. Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub

29. Ability of Hand Hygiene Agents to Reduce Bacteria on Hands Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999. 0.0 1.0 2.0 3.0 060180minutes 0.0 90.0 99.0 99.9 log% Bacterial Reduction Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Time After Disinfection Baseline

30. Epidermal water contentSelf-reported skin score Dry HealthyDry Healthy Effect of Alcohol-Based Handrubs on Skin Condition ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.

31. Time Spent Cleansing Hands: one nurse per 8 hour shift  Hand washing with soap and water: 56 minutes – Based on seven (60 second) handwashing episodes per hour  Alcohol-based handrub: 18 minutes – Based on seven (20 second) handrub episodes per hour Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208. ~ Alcohol-based handrubs reduce time needed for hand disinfection ~

32. Recovery of VRE from Hands and Environmental Surfaces  Up to 41% of healthcare worker’s hands sampled (after patient care and before hand hygiene) were positive for VRE 1  VRE were recovered from a number of environmental surfaces in patient rooms  VRE survived on a countertop for up to 7 days 2 1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065. 2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581.

33. The Inanimate Environment Can Facilitate Transmission ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents VRE culture positive sites

34. Estimate how often YOU clean your hands after touching a patient or a contaminated surface in the hospital? 1.25% 2.50% 3.75% 4.90% 5.100%

35. Fingernails and Artificial Nails Natural nail tips should be kept to ¼ inch in length Natural nail tips should be kept to ¼ inch in length Artificial nails should not be worn when having direct contact with high-risk patients (e.g., ICU, OR) Artificial nails should not be worn when having direct contact with high-risk patients (e.g., ICU, OR) Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

36. Can a Fashion Statement Harm the Patient? ARTIFICIAL POLISHED NATURAL Edel et. al, Nursing Research 1998: 47;54-59 Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for high risk patients (ICU, OR)

37. What about gloves? Do increase patient protection Do increase patient protection Protects HCW from BBP exposure Protects HCW from BBP exposure Proper use essential Proper use essential –Change between patients –Change between sites Not a substitute for hand hygiene! Not a substitute for hand hygiene! –Micropunctures in gloves can allow contamination –Glove removal risks contamination

38. What about cdiff? None of the agents used in antiseptic handwash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium spp. or Bacillus spp. None of the agents used in antiseptic handwash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium spp. or Bacillus spp. controversial controversial Current PHD policy is to use soap and water in known cdiff patients (sign on ABHG dispenser) Current PHD policy is to use soap and water in known cdiff patients (sign on ABHG dispenser)

39. assessed the effect of medical staff role models and the number of sinks on hand-hygiene compliance before and after construction of a new hospital designed for increased access to handwashing sinks. 721 hand-hygiene opportunities Hand-hygiene compliance was significantly better in the old hospital (161/304; 53%) compared to the new hospital (97/417; 23.3%) (p<0.001). Health-care workers in a room with a senior medical staff person or peer who did not wash hands were significantly less likely to wash their own hands (odds ratio 0.2; confidence interval 0.1 to 0.5); p<0.001). health-care worker hand-hygiene compliance is influenced significantly by the behavior of other health-care workers increased number of hand-washing sinks did not increase hand-hygiene compliance. Influence of Role Models and Hospital Design on Hand Hygiene of Healthcare Workers Lankford, et al Emerg Infect Dis 2003 Feb

40. PREVENTION IS PRIMARY! Protect patients…protect healthcare personnel… promote quality healthcare!