Transcript Clinical Grand Rounds

Clinical Grand Rounds
Wednesday, April 5th, 2006
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.
The Intervention:
Hand scrub with chlorinated lime
solution
Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.
Hand Hygiene: Not a New
Concept
Maternal Mortality due to Postpartum Infection
General Hospital, Vienna, Austria, 1841-1850
Semmelweis’ Hand
Hygiene Intervention
Maternal Mortality (%)
18
16
14
12
10
8
6
4
2
0
1841
1842
1843
1844
1845
MDs
1946
1847
1848
1849
1850
Midwives
~ Hand antisepsis reduces the frequency of patient infections ~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
Has anything changed?
So Why All the Fuss About Hand
Hygiene?
Most common mode of transmission of
pathogens is via hands!
 Infections acquired in healthcare
 Spread of antimicrobial resistance
CDC
Nosocomial Infections
• 2 million/year in US
• 80,000 deaths/yr (IHI)
• Heavy colonization of patients
– Intact skin as well
– Environmental surfaces
• 106 squames shed daily
• Enterococcus and Staph aureus
resist dessication
• HCW hands easily
contaminate even after
“clean” procedures
The Iceberg Effect
Infected
Colonized
Data for efficacy of hand hygiene
• Semmelweiss et al
• 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.
Factors affecting hand hygiene
compliance
• Outbreak investigations have indicated an
association between infections and
understaffing or overcrowding
• association was consistently linked with
poor adherence to hand hygiene.
Self-Reported Factors for
Poor Adherence with Hand
Hygiene
a.k.a excuses
 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.
Hand Hygiene Adherence in
Hospitals
Year of Study
Adherence Rate Hospital Area
1994 (1)
29%
General and ICU
1995 (2)
41%
General
1996 (3)
41%
ICU
1998 (4)
30%
General
2000 (5)
48%
General
1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88106. 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.
Physician compliance
• Consistently, physicians score lower than
other healthcare workers
• 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…
Handwashing Guidelines
• 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
1985
1988
1995
1996
CDC guidelines
CDC guidelines
APIC guidelines-start suggesting ABHG
HICPAC
HICPAC
Handwashing Guidelines
• CDC
– Guidelines for Hand
Hygiene in Healthcare
settings (2002)
– Forms basis for PHD
policies
• WHO
– Guidelines on Hand
Hygiene for Health
Care (draft)
Regulation
• Multiple regulatory agencies have added hand
hygiene to their list of goals
– IHI
• 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
• Component of the central line bundle
– JACHO patient safety goal #7- Reduce Hospital
Acquired Infections
• 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.
IHI campaign
• 4 components
–
–
–
–
Demonstrate knowledge
Demonstrate competence
Enable employees (provide equipment)
Monitor compliance and provide feedback
• Random observations
• Record % time all 3 components followed
– Wash before
– Wash after
– Proper glove use
• Goals of zero incidence
IHI tips
•
•
•
•
•
•
Empower nursing to enforce use of a central line
checklist
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.
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.
Create an environment where reminding each other
about handwashing is encouraged.
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.
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.
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.
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.
Vignette:
• Patients still think they can’t question their
doctors
• Other HCW’s still think they can’t question
the doctor
• Lawyers are happy to question the doctor
Partners in Your Care
• Program designed at Penn to encourage
patients to speak up
• Focus on patient, not healthcare worker
• 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.
Still, compliance is very low.
Solution?
More research!!
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.
Specific Indications for
Hand Hygiene
• Before:
– Patient contact
– Donning gloves when inserting a CVC
– Inserting urinary catheters, peripheral
vascular catheters, or other invasive devices
• After:
– Contact with a patient’s skin
– Contact with body fluids or excretions, nonintact skin, wound dressings
– Removing gloves
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;
vol. 51, no. RR-16.
Which hand hygiene method is best
at killing bacteria?
1. Plain soap and water
2. Antimicrobial soap and
water
3. Alcohol-based handrub
Efficacy of Hand Hygiene
Preparations in Killing Bacteria
Good
Better
Plain Soap
Antimicrobial
soap
Best
Alcohol-based
handrub
Bacterial Reduction
Ability of Hand Hygiene
Agents to Reduce Bacteria on
Hands
%
99.9
Time After Disinfection
log
0 60
180 minutes
3.0
99.0
2.0
90.0
1.0
0.0
0.0
Alcohol-based handrub
(70% Isopropanol)
Antimicrobial soap
(4% Chlorhexidine)
Baseline
Plain soap
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
Effect of Alcohol-Based Handrubs
on Skin Condition
Dry
Healthy
Self-reported skin score
Epidermal water content
6
5
4
3
2
1
0
27
25
23
21
19
17
15
Baseline
Alcohol rub
2 weeks
Soap and water
Healthy
Baseline
Alcohol rub
2 weeks
Dry
Soap and water
~ Alcohol-based handrub is less damaging to the skin ~
Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.
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
~ Alcohol-based handrubs reduce time
needed for hand disinfection ~
Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.
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
VRE1

VRE were recovered from a
number of environmental
surfaces in patient rooms

VRE survived on a countertop
for up to 7 days2
1
Hayden MK, Clin Infect Diseases 2000;31:1058-1065.
2 Noskin
G, Infect Control and Hosp Epidemi 1995;16:577-581.
The Inanimate Environment Can
Facilitate Transmission
X represents VRE culture positive sites
~ 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.
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%
Fingernails and Artificial
Nails
• 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)
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002;
vol. 51, no. RR-16.
% Recovery of gram negative
bacteria
Can a Fashion Statement
Harm the Patient?
40
35
30
Natural (n=31)
Artificial (n=27)
Polished (n=31)
ARTIFICIAL
20
10
10
0
5
POLISHED
NATURAL
p<0.05
Avoid wearing artificial nails, keep natural nails
<1/4 inch if caring for high risk patients (ICU, OR)
Edel et. al, Nursing Research 1998: 47;54-59
What about gloves?
• Do increase patient
•
•
protection
Protects HCW from BBP
exposure
Proper use essential
– Change between patients
– Change between sites
• Not a substitute for hand
hygiene!
– Micropunctures in gloves
can allow contamination
– Glove removal risks
contamination
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.
• controversial
• Current PHD policy is to use soap and water in
known cdiff patients (sign on ABHG dispenser)
Influence of Role Models and Hospital Design on Hand Hygiene
of Healthcare Workers
Lankford, et al Emerg Infect
Dis 2003 Feb
•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.
PREVENTION
IS PRIMARY!
Protect patients…protect healthcare personnel…
promote quality healthcare!