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Demystifying and Responding to CDC’s Hand

Hygiene Guidelines and JCAHO’s Related Patient

Safety Goal for 2004

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

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Presentation OutlinePresentation Outline

• CDC Guidelines and JCAHO Patient Safety Goals for 2004

• Summary of the Evidence • Memo from Dr. Roswell and

Summary of Requirements for VHA facilities

• Pilot Six Sigma Project with 3M Corporation and Three VAMCs

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The Big PictureThe Big Picture

• Patients are getting infections that can be avoided by following the CDC Guidelines

• My goal today here is to provide:• a comprehensive and comprehensible

introduction to the CDC Guidelines• summary information on how to

address the CDC Guidelines and JCAHO requirements

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CDC Guidelines on Hand Hygiene

CDC Guidelines on Hand Hygiene

• Issued October 25, 2002• Issued by CDC and others:

“CDC Healthcare Infection Control Practices Advisory Committee (HICPAC) and the HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force”

• New IOM and NQF studies also give preventing nosocomial infections high priority

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CDC Guidelines Recommendations - 44 in 8 Categories

CDC Guidelines Recommendations - 44 in 8 Categories

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

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Why the Big Deal?Why the Big Deal?• Studies cited by CDC and/or IOM:

• Nosocomial infections are the most frequent major “complication” for inpatients -- 5% contract a nosocomial infection

• 88,000 deaths annually from nosocomial infections

• 350,000 years of life lost annually – almost 1,000 years a day!

• Most common mode of transmission of pathogens is via hands

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JCAHO InvolvementJCAHO Involvement

• New JCAHO Patient Safety Goal for 2004: • 7a: “Comply with current CDC hand-

hygiene guidelines.”

• Making it a Patient Safety “Goal” for 2004 has transformed the CDC “Guidelines” into JCAHO “Requirements”

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The EvidenceThe 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

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

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

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Study of Alcohol Handrub use at an Acute Care Facility

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. Key Findings:

• 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

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Memo from Dr. Roswell and Summary of VHA Requirements

Memo from Dr. Roswell and Summary of VHA Requirements

• Memo from Dr. Roswell to VISN Directors• Special VHA guidance, e.g., alcohol hand-rub in

corridors is OK• One-page VHA Summary of the CDC Hand

Hygiene Guidelines required by JCAHO• One-page Cross-reference between VHA

Summary and CDC Guidelines• See also: Dec. 2003 issue of TIPS Newsletter• All these documents were written after clarifying

discussions with top CDC and JCAHO officials

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VHA Summary of JCAHO-required CDC Recommendations

(19 in 4 categories)

VHA Summary of JCAHO-required CDC Recommendations

(19 in 4 categories)

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%)

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Summary of VHA Summary (1)Summary of VHA Summary (1)

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

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

• Specific gloving recommendations• Soap and water for soiled hands

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Summary of VHA Summary (2)Summary of VHA Summary (2)

II. Surgical Hand Hygiene• Guidance on surgical scrub with

soap and water (e.g., shorter scrub times are OK)

• Guidance on surgical scrub with no-rinse alcohol-based products with additional compounds for persistent action

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Summary of VHA Summary (3)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 is flammable

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Summary of VHA Summary (4)Summary of VHA Summary (4)

IV. Facility Management: Administrative Action

• Make HH a priority and provide financial and administrative support

• Solicit input from employees on products

• Monitor adherence and provide feedback on hand hygiene performance

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CDC Guidelines on Hand HygieneCDC 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 outcomes -- fewer infections -- for patients (hospital data)

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

(multiple hospital data). Some studies as low as 4 or 5%

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CDC Slide on EffectivenessCDC Slide on EffectivenessAbility of Hand Hygiene

Agents to Reduce Bacteria on Hands

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

0.0

1.0

2.0

3.0 0 60 180 minutes

0.0

90.0

99.0

99.9log%

Ba

cte

rial

Red

ucti

on

Alcohol-based handrub(70% Isopropanol)

Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

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CDC Slide on Skin ConditionCDC Slide on Skin Condition

0

12

3

45

6

Baseline 2 weeks

Alcohol rub Soap and water

1517

192123

2527

Baseline 2 weeks

Alcohol rub Soap and water

Epidermal water contentSelf-reported skin scoreDry

Healthy Dry

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.

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Six Sigma Pilot Project with 3M: What we’re measuring in 3 VAMC ICUs

Six Sigma Pilot Project with 3M: What we’re measuring in 3 VAMC ICUs

1. Staff compliance (observing practices with checklist and clipboard)

2. Volume of product used (converting to “doses” of alcohol handrub and soap)

3. Staff Attitudes and Perception of Compliance (questionnaire)

4. Antimicrobial soap in use (percent yes/no)

5. No artificial nails on HCWs (percent yes/no)

6. Staff satisfaction with HH practices (questionnaire)

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3M-VHA Six Sigma Team Members3M-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, VHACO (10NC)

Cheryl Pederson, 3MKim Reichling, 3MDr. Gary Roselle, Infectious

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

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Very Preliminary Data from Questionnaire or Pilot Site(s)Very Preliminary Data from

Questionnaire or Pilot Site(s)• Staff think they’re doing 90% when they’re doing

60%.• Nurses and doctors at about 50% -- but 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 skeptical about specifics.• Almost all VAMCs providing alcohol handrubs.• Over 40 VAMCs using only antimicrobial soap in

patient care areas. • ICU staff are not wearing artificial nails.

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What to do now (short list)What to do now (short list)1. Get alcohol hand-rubs close to patients

and make it convenient to use: put in rooms or entrances to rooms, in hallways, and pocket size too.

2. Get antimicrobial soap in soap dispensers.3. Tell staff that the alcohol hand-rub should

be primary method for hand decontamination.

4. Read the CDC Guidelines and VHA Summary. Start with TIPS article and memo from Dr. Roswell (see final slide)

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Final ThoughtsFinal Thoughts1. What doesn’t work: Telling people to use

soap and water.2. It’s not always common sense, for

example:• Evidence suggests that shorter surgical

scrub times and not using a brush are same or better

• Alcohol products easier on hands than soaps

• Cleaner-feeling hands may have more microorganisms (soap vs. alcohol handrub)

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Recommended On-line ResourcesRecommended On-line Resources

• December 2003 VHA NCPS Topics in Patient Safety (TIPS) Newsletter: vaww.ncps.med.va.gov/TIPSarchive.html

• Special VHA NCPS Website on Hand Hygiene: vaww.ncps.med.va.gov/Hand_Hygiene/

• CDC Website: www.cdc.gov/handhygiene/• JCAHO Website:

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

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How EAs Can HelpHow EAs Can Help

• Work with me to send a tailored e-mail to your national list(s)

• Invite me to give a short presentation on this topic on a monthly call or staff meeting

• Other ways that I haven’t thought of? Let me know!