Demystifying and Responding to CDC’s Hand Hygiene Guidelines

and JCAHO’s related Patient Safety Goal for 2004

Presentation to QMIC, 2/4/04

Noel Eldridge, MS

VHA National Center for Patient Safety

202 273-8878

Presentation Outline

• CDC Guidelines and JCAHO Patient Safety Goals for 2004

• Summary of the Evidence

• Letter from Dr. Roswell and Summary for VHA facilities

• Six Sigma Project with 3M Corporation

• Wrap-up

CDC Guidelines on Hand Hygiene

• Issued October 25, 2002• Issued by CDC and others: – “CDC Healthcare Infection Control Practices

Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force”

• Since the CDC Guidelines were issued, new IOM and NQF studies also give preventing nosocomial infections high priority

Recommendations (44) from CDC Guidelines

1. Indications for handwashing and hand antisepsis (14)

2. Hand-hygiene technique (4)

3. Surgical hand antisepsis (5)

4. Selection of hand-hygiene agents (5)

5. Skin care (2)

6. Other Aspects of Hand Hygiene (6)

7. Health-care worker educational and motivational programs (3)

8. Administrative measures (5)

Total Length: 1350 words in 45 page document

JCAHO Involvement

• JCAHO issued 6 Patient Safety Goals for 2003

• JCAHO added a new one (#7) for 2004: – 7a: “Comply with current CDC hand-hygiene

guidelines.” and – 7b: “Manage as sentinel events all identified

cases of unanticipated death or major permanent loss of function associated with a health care-acquired infection.”

“Comply with current CDC hand-hygiene guidelines”

Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.

Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale.

Category IC. Required for implementation, as mandated by federal or state regulation or standard.

Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.

No recommendation. Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist.

JCAHO Patient Safety Goals

• Resources:– December 2003 Topics in Patient Safety (TIPS)

Newsletter: www.patientsafety.gov/tips.html– December 2002 TIPS Newsletter – JCAHO Website:

www.jcaho.org/accredited+organizations/patient+safety/npsg.htm

– VHA NCPS Website: INSERT INTRANET URL

The Evidence

• 423 references in CDC Guidelines– From Laboratory Tests– From Hospitals– From Long-term Care Facilities– From Schools– On Bacteria, Viruses, Fungi– On Wild-type and Antibiotic-resistant Strains

• From VAMCs

Study of Alcohol Handrub use at a Long-Term Care Facility

• Compared the 2 units of the facility where alcohol hand-rubs were used with the rest of the facility. Key findings:– 30% fewer infections over a 34 month period

• 2.27 (alcohol) vs. 3.19 (soap) per 1000 pt-days• Primary infections were urinary tract with Foley

catheter, respiratory, and wound• 253,933 pt-days total; 81,036 in alcohol group

– Reference: Fendler et al, AJIC, June 2002

Study of Alcohol Handrub use at an Acute Care Facility

• Compared one unit (orthopedic surgery) of a hospital before and after introduction of alcohol handrubs in that unit.– 36% fewer infections (6 months before, 10 after).

• 8.2 vs. 5.3 infections per 1,000 patient days• “Teachable” patients given 4 oz. alcohol gel too• Primary infections: urinary tract and surgical site• Cost savings studied:

– Mean cost per infection: $4,828 +/- 4,868– Cost of 10 months of supplies for unit: $1,688

– Reference: Hilburn et al, AJIC, April 2003

VHA Summary

• Issued by Dr. Roswell in a memo to VISN Directors dated 12/15/03

• Also issued in December 2003 issue of TIPS Newsletter

• Memo and web site contain cross-reference to CDC Guidelines

VHA Summary of JCAHO-required CDC Recommendations (19)

I. All Health Care Workers with Direct Patient Contact (8)

II. Surgical Hand Hygiene (3)

III. Facility Management: Supplies (5)

IV. Facility Management: Administrative Action (3)

Total Length: 732 words (-45%)

Summary of VHA Summary (1)

I. All Health Care Workers with Direct Patient Contact

• Decontaminate hands before and after touching a patient (regular soap doesn’t do it)

• Specific gloving recommendations• No artificial nails for HCWs contacting high

risk patients• Soap and water for soiled hands

Summary of VHA Summary (2)

II. Surgical Hand Hygiene• Guidance on surgical scrub with soap and water

(e.g., shorter scrub times)• Guidance on surgical scrub with no-rinse alcohol-

based products with ingredients for persistent action

Summary of VHA Summary (3)

III. Facility Management: Supplies• Alcohol at room entrance and/or bedside• Alcohol available in pocket-sized dispensers• Alcohol in other convenient locations (e.g., in

corridors is OK within limits)• Antimicrobial soap as an alternative to alcohol• Provide hand lotion to HCWs• Store alcohol safely -- it’s flammable

Summary of VHA Summary (4)

IV. Facility Management: Administrative Action

• Make HH a priority and provide financial and administrative support

• Solicit input from employees• Monitor adherence and provide feedback on

performance

Cross-reference

CDC Guidelines on Hand Hygiene

• If you only remember one thing, remember this: Alcohol hand-rubs are better than soap and water. Why?

1. They kill germs better (lab data) and produce better outcome for patients (hospital data)

2. They are easier to use correctly (forcing function)3. They are easier on hands (lab and hospital data)4. People only use soap 20-50% of when they should

(multiple hospital data)

Six Sigma Project with 3M Corporation

• DMAIC– Define: project charter– Measure: process map, cause and effect matrix, – Analyze: failure modes and effects analysis,

multi-variable studies– Improve: pilot studies– Control: control plan, hand-off training, final

capability, owner sign-off, final project report

What we’re measuring (in 3 VAMC ICUs)

• Staff compliance (observing staff with checklist and clipboard)

• Volume of product used (to be converted to “doses” of alcohol handrub and soap)

• Staff Attitudes and Perception of Compliance (questionnaire)

• Antimicrobial soap in use (percent yes/no)• Staff artificial nails (percent yes/no) • Staff satisfaction with HH practice (questionnaire)

3M-VHA Six Sigma Team Members

Dr. Robert Bonello, Minneapolis VAMC

Kay Clutter, Minneapolis VAMC

Linda Danko, Infectious Diseases

Dr. Edward Dunn, NCPS

Noel Eldridge, NCPS

Leann Ellingson, Minneapolis VAMC

Mary Ann Harris, Fayetteville (AR), VAMC

Barbara Livingston, Des Moines VAMC

Renee Parlier, VISN 23Cheryl Pederson, 3MKim Reichling, 3MDr. Gary Roselle, Infectious

Diseases Susan Woods, 3M Dr. Steven Wright, OQP

Preliminary Data

• Staff think they’re doing 90% when they’re doing 60%

• Nurses and doctors are better than others (e.g., chaplains, technicians)

• Number of HH opportunities doesn’t affect compliance

• HCWs believe in connection between HH and infections, but are simultaneously skeptical about some specifics

Some Tentative Opportunities for Improvement

• Improve availability of and access to appropriate supplies (make it easier to do it right)

• Involving patients and visitors• Providing scientific evidence to educated skeptics

(learning and unlearning)• Educating “others” of benefits of hand hygiene• HCWs reminding each other (culture change)• Feeding back real VAMC facility data on

compliance/performance

What to do now

• Get alcohol hand-rubs close to patients to make it convenient to use: in rooms or entrances to rooms, in hallways, and pocket size too.

• Get antimicrobial soap in soap dispensers• Tell staff that the alcohol hand-rub should be

primary method for hand decontamination• Don’t assume you know what the CDC Guidelines

say, if you haven’t read them you don’t. It’s not always “common sense”.– Start with 1-page VHA summary

Final Thought

• We know what doesn’t work: status quo of telling people to use soap and water and doing nothing when they don’t do it.