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A PROBLEM WE MUST FACE TOGETHER The Importance of Hand Hygiene Educational Media

Each year in the United States, more people die from bacterial infections they caught while receiving care in their own local, community and private hospitals than from: AIDS, Breast Cancer and automobile accidents combined.

 

It’s a national disgrace that annually, more than 99,000 people never survive the infections they accidentally catch while being cared for as patients in American hospitals.

 

The Center for Disease Control and Prevention says that in all, over 1,700,000 people in the U.S. are becoming infected every year while in the hospital receiving medical care for other things.

 

That number equates to 3 people becoming newly infected every minute, 4,600 people every day and of those infected, approximately 271 people per day actually die.

 

The numbers speak for themselves. Every 2 weeks that go by, more Americans will die from complications of their own medical care than the sum of all Americans who died on 911.

 

There is an urgent need for the American people to be re - educated about the hospital experience. When we enter a hospital, we are engaging a completely different environment than the one existing outside of those glass doors.

 

Patients must become as aware and proactive as possible and caregivers must become vigilant in technique and procedure so that we may all experience healthy, acceptable medical outcomes we can be sure of receiving and proud of administering.

 

This cultural change is crucial and must ultimately manifest in a new, safer standard of care as well as better stewardship of our financial resources.

 

It has been estimated that the average cost of a hospital stay for patients who acquired infections was approximately $50,000 more than for those who did not acquire infections.  This is unacceptable.

OVERVIEW AND HISTORICAL PERSPECTIVE

For generations, hand washing with soap and water has been considered a measure of personal hygiene. The concept of cleansing hands with an antiseptic agent probably emerged in the early 19th century.

 

As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odors associated with human corpses and that such solutions could be used as disinfectants and antiseptics.

 

In a paper published in 1825, this pharmacist stated that physicians and other persons attending patients with contagious diseases would benefit from moistening their hands with a liquid chloride solution.

Ignaz Semmelweis

Oliver Wendell Holmes

In 1846, Ignaz Semmelweis observed that women whose babies were delivered by students and physicians in the First Clinic at the General Hospital of Vienna consistently had a higher mortality rate than those whose babies were delivered by midwives in the Second Clinic. He noted that physicians who went directly from the autopsy suite to the obstetrics ward had a disagreeable odor on their hands despite washing their hands with soap and water upon entering the obstetrics clinic.

 

 

He postulated that the puerperal fever that affected so many parturient women was caused by "cadaverous particles" transmitted from the autopsy suite to the obstetrics ward via the hands of students and physicians. Perhaps because of the known deodorizing effect of chlorine compounds, as of May 1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient in the clinic. The maternal mortality rate in the First Clinic subsequently dropped dramatically and remained low for years.

 

This intervention by Semmelweis represents the first evidence indicating that cleansing heavily contaminated hands with an antiseptic agent between patient contacts may reduce health care associated transmission of contagious diseases more effectively than hand washing with plain soap and water.

 

In 1988 and 1995, guidelines for hand washing and hand antisepsis were published by the Association for Professionals in Infection Control. Recommended indications for hand washing were similar to those listed in the CDC guidelines. The 1995 APIC guideline included more detailed discussion of alcohol-based hand rubs and supported their use in more clinical settings than had been recommended in earlier guidelines. In 1995 and 1996, the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleaning hands upon leaving the rooms of patients with multi-drug-

This CDC video teaches the importance of Hand Hygiene and how patients must insist on it from every single person who touches them.

New research shows that patients can have a role in promoting hand hygiene among doctors and nurses. Hand hygiene video empowers patients to remind hospital caregivers to clean their hands, a strategy that is critical in the fight to prevent infections.

 

The research tested the effectiveness of a CDC video called "Hand Hygiene Saves Lives" co-produced by the CDC, APIC, and Safe Care Campaign in 2007. The video encourages patients, family and visitors to play a role in theirt own care by helping healthcare professionals remember to clean their hands before and after touching patients. After the video was shown to patients in 17 CHP facilities, patients were twice as likely to report reminding nurses to was their hands, and doctors were twice as likely to report being asked by patients to wash their hands.

 

"Hand Hygiene Saves Lives" available in English and Spanish, teaches two key points to hospital patients and visitors to help prevent infections: the importance of practicing hand hygiene while in the hospital and that it is appropriate to ask or remind their healthcare providers to practice hand hygiene as well.

 

Modeled after the video that airline passengers are required to view prior to take-off on a flight, this video is intended to be shown to patients upon admission to the hospital. The goal is that the video will inform patients at the beginning of their hospital stay about what they can do to help prevent infections throughout the duration of their stay.

Access both the IHI Guide to Improving Hand Hygiene as well as the CDCs GUIDELINE for Hand Hygiene in Health-Care Settings.

For your patients:

Show them this VIDEO from The Patient Channel and Safe Care Campaign.

CLICK HERE

to access the World Health Organization's Guidelines on Hand Hygiene in Healthcare (PDF)

CLICK HERE

to access the Joint Commission's Center for Transforming Healthcare (PDF)

resistant pathogens (e.g., vancomycin-resistant enterococci and methicillin-resistant Staphylococcus aureus. These guidelines also provided recommendations for hand washing and hand antisepsis in other clinical settings, including routine patient care. Although the APIC and HICPAC guidelines have been adopted by the majority of hospitals, adherence of HCWs to recommended hand washing practices has remained low.

 

Recent developments in the field have stimulated a review of the scientific data regarding hand hygiene and the development of new guidelines designed to improve hand-hygiene practices in health-care facilities. This literature review and accompanying recommendations have been prepared by a Hand Hygiene Task Force, comprising representatives from HICPAC, the Society for Healthcare Epidemiology of America (SHEA), APIC, and the Infectious Diseases Society of America (IDSA).

2009 STUDY OF HAND HYGIENE COMPLIANCE IN HEALTH CARE SETTINGS

According to a study published in the American Journal of Medical Quality in May, 2009, hand hygiene compliance in health care settings remains unsatisfactory even though hand hygiene (HH) is the single most important factor in the prevention of health care acquired infections.

 

Hand Hygiene Compliance Rates in the United States - A One-Year Multicenter Collaboration Using Product/Volume Usage Measurement and Feedback Maryanne McGuckin, ScEd, MT (ASCP)

 

The article presents the results of a 12-month multi center collaboration assessing HH compliance rates at US health care facilities by measuring product usage and providing feedback about HH compliance. Through:

American Journal of Medical Quality. Vol. 24, No. 3, 205-213 (2009)

(1) direct observation,

(2) self-reporting by health care workers (HCWs), and

(3) indirect calculation based on HH product usage

The results showed that HH compliance at baseline was 26% for intensive care units (ICUs) and 36% for non - ICUs. After 12 months of measuring product usage and providing feedback, compliance increased to 37% for ICUs and 51% for non -ICUs. (ICU, P = .0119; non-ICU, P < .001). HH compliance in the United States can increase when monitoring is combined with feedback.

However, HH still occurs at or below 50% compliance for both ICUs and non-ICUs.

RELATION OF HAND HYGIENE, OVERCROWDING, UNDERSTAFFING AND HEALTH CARE ASSOCIATED PATHOGENS

Excerpted from the CDC Guideline for Hand Hygiene in Health-Care Settings / Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force

In the 1960s, a 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. This trial provided evidence that, when compared with no hand washing, washing hands with an antiseptic agent between patient contacts reduces transmission of health care associated pathogens.

Hand antisepsis reduces the incidence of health care associated infections. An intervention trial using historical controls demonstrated in 1847 that the mortality rate among mothers who delivered in the First Obstetrics Clinic at the General Hospital of Vienna was substantially lower when hospital staff cleaned their hands with an antiseptic agent than when they washed their hands with plain soap and water.

 

Evidence that hand hygiene compliance reduces transmission of pathogens

 

Trials have studied the effects of hand washing with plain soap and water versus some form of hand antisepsis on health care associated infection rates. Health care associated infection rates were lower when antiseptic hand washing was performed by personnel. In another study, antiseptic hand washing was associated with lower health care associated infection rates in certain intensive-care units, but not in others.

 

Health care associated infection rates were lower after antiseptic hand washing using a chlorhexidine - containing detergent compared with hand washing with plain soap or use of an alcohol-based hand rinse. However, because only a minimal amount of the alcohol rinse was used during periods when the combination regimen also was in use and because adherence to policies was higher when chlorhexidine was available, determining which factor (i.e., the hand -hygiene regimen or differences in adherence) accounted for the lower infection rates was difficult. Investigators have determined also that health care associated acquisition of MRSA was reduced when the antimicrobial soap used for hygienic hand washing was changed.

 

Increased hand washing frequency among hospital staff has been associated with decreased transmission of Klebsiella spp. among patients; these studies, however, did not quantitate the level of hand washing among personnel. In a recent study, the acquisition of various health care associated pathogens was reduced when hand antisepsis was performed more frequently by hospital personnel; both this study and another documented that the prevalence of health care associated infections decreased as adherence to recommended hand-hygiene measures improved.

 

Clear relationship between overcrowding and/or understaffing

Outbreak investigations have indicated an association between infections and under staffing or overcrowding; the association was consistently linked with poor adherence to hand hygiene.

 

During an outbreak investigation of risk factors for central venous catheter-associated bloodstream infections, after adjustment for  confounding factors, the patient-to-nurse ratio remained an independent risk factor for bloodstream infection, indicating that nursing staff reduction below a critical threshold may have contributed to this outbreak by jeopardizing adequate catheter care.

 

The understaffing of nurses can facilitate the spread of MRSA in intensive-care settings through relaxed attention to basic control measures (e.g., hand hygiene).

In an outbreak of Enterobacter cloacae in a neonatal intensive-care unit, the daily number of hospitalized children was above the maximum capacity of the unit, resulting in an available space per child below current recommendations. In parallel, the number of staff members on duty was substantially less than the number necessitated by the workload, which also resulted in relaxed attention to basic infection-control measures. Adherence to hand-hygiene practices before device contact was only 25% during the workload peak, but increased to 70% after the end of the understaffing and overcrowding period.

 

Surveillance documented that being hospitalized during this period was associated with a fourfold increased risk of acquiring a health care associated infection. This study not only demonstrates the association between workload and infections, but it also highlights the intermediate cause of antimicrobial spread: poor adherence to hand-hygiene policies.

THE CENTERS FOR DISEASE CONTROL AND PREVENTION HAND HYGIENE GUIDELINES FACT SHEET

When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. Alcohol-based hand rubs significantly reduce the number of microorganisms on skin, are fast acting and cause less skin irritation.

 

Health care personnel should avoid wearing artificial nails and keep natural nails less than one quarter of an inch long if they care for patients at high risk of acquiring infections (e.g. Patients in intensive care units or in transplant units.)

When evaluating hand hygiene products for potential use in health care facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel. Characteristics of a product that can affect acceptance and therefore usage include its smell, consistency, color and the effect of dryness on hands.

 

As part of these recommendations, CDC is asking health care facilities to develop and implement a system for measuring improvements in adherence to these hand hygiene recommendations.

 

Some of the suggested performance indicators include: periodic monitoring of hand hygiene adherence and providing feedback to personnel regarding their performance, monitoring the volume of alcohol-based hand-rub used/1000 patient days, monitoring adherence to policies dealing with wearing artificial nails and focused assessment of the adequacy of health care personnel hand hygiene when outbreaks of infection occur.

Improved adherence to hand hygiene (i.e. hand washing or use of alcohol-based hand rubs) has been shown to terminate outbreaks in health care facilities, to reduce transmission of antimicrobial resistant organisms (e.g. methicillin resistant staphylococcus aureus) and reduce overall infection rates.

 

CDC is releasing guidelines to improve adherence to hand hygiene in health care settings. In addition to traditional hand washing with soap and water, CDC is recommending the use of alcohol-based hand rubs by health care personnel for patient care because they address some of the obstacles that health care professionals face when taking care of patients.

 

Hand washing with soap and water remains a sensible strategy for hand hygiene in non-health care settings and is recommended by CDC and other experts. When health care personnel's hands are visibly soiled, they should wash with soap and water.

 

The use of gloves does not eliminate the  need for hand hygiene. Likewise, the use of hand hygiene does not eliminate the need for gloves.

 

Gloves reduce hand contamination by 70 percent to 80 percent, prevent cross-contamination and protect

patients and health care personnel from infection.

 

Hand rubs should be used before and after each patient just as gloves should be changed before and after each patient.

Allergic contact dermatitis due to alcohol hand rubs is very uncommon. However, with increasing use of such products by health care personnel, it is likely that true allergic reactions to such products will occasionally be encountered.

 

Alcohol-based hand rubs take less time to use than traditional hand washing. In an eight hour shift, an estimated one hour of an ICU nurse's time will be saved by using an alcohol based hand rub.

 

These guidelines should not be construed to legalize product claims that are not allowed by an FDA product approval by FDA's Over-the-Counter Drug Review.

 

The recommendations are not intended to apply to consumer use of the products discussed.

CDC HAND WASHING AND HAND ANTISEPSIS RECOMMENDATIONS

I.  Indications for hand washing and hand antisepsis

 

A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.

 

B. If hands are not visibly soiled, use an alcohol based hand rub for routinely decontaminating hands in all other clinical situation described in items I C J.  Alternatively, wash hands with an antimicrobial soap and water in all Clinical Situations described in items I C J.

 

C. Decontaminate hands before having direct contact with patients.

 

D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter.

 

E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure.

 

F. Decontaminate hands after contact with a patient’s intact skin (e.g., when taking a pulse or blood pressure and lifting a patient).

 

G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non intact skin, and wound dressings if hands are not visibly soiled.

 

H. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care.

 

I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.

 

J. Decontaminate hands after removing gloves.

 

K. Before eating and after using a restroom, wash hands with a non antimicrobial soap and water or with an antimicrobial soap and water.

 

L. Antimicrobial impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non antimicrobial soap and water.  Because they are not as effective as alcohol based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs they are not a substitute for using an alcohol based hand rub or antimicrobial soap.

 

M. Wash hands with non antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis suspected or proven.  The physical action of washing and rinsing bands under such circumstances is recommended because alcohols, chlorhexidine iodophors, and other antiseptic agents have poor activity against spores.

 

N. No recommendation can be made regarding the routine use of non-alcohol based hand rubs for hand hygiene in health care settings.  Unresolved issue.

II.  Hand hygiene technique

 

A. When decontaminating hands with an alcohol based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer’s recommendations regarding the volume of product to use.

 

B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel.

Use towel to turn off the faucet.  Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.

 

C. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non -antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used.

 

D. Multiple use cloth towels of the hanging or roll type are not recommended for use in health care settings.

 

III.  Surgical hand antisepsis

 

A. Remove rings, watches, and bracelets before beginning the surgical hand scrub.

 

B. Remove debris from underneath fingernails using a nail cleaner under running water.

 

C. Surgical hand antisepsis using either an antimicrobial soap or an alcohol based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures.

 

D. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 to 6 minutes.  Long scrub times (e.g., 10 minutes) are not necessary.

 

E. When using an alcohol based surgical hand scrub product with persistent activity, follow the manufacturer’s instructions. Before applying the alcohol solution, pre-wash hands and forearms with a non antimicrobial soap and dry hands and forearms completely. After application of the alcohol based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.

 

IV.  Selection of hand-hygiene agents

 

A. Provide personnel with efficacious hand hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift.

 

This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel.

 

B. To maximize acceptance of hand hygiene products by HCWs, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration.  The cost of hand-hygiene products should not be the primary factor influencing product selection.

 

C. When selecting non antimicrobial soaps, antimicrobial soaps, or alcohol based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution.

 

D.Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product.

 

E. Do not add soap to a partially empty soap dispenser.  This practice of “topping off” dispensers can lead to bacterial contamination of soap.

 

V.  Skin care

 

A. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washing.

 

B. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution.

 

VI.  Other aspects of hand hygiene

 

A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive care units or operating rooms).

 

B. Keep natural nails tips less than ¼  inch long.

 

C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur.

 

D. Remove gloves after caring for a patient.  Do not wear the same pair of gloves for the care of more than one patient and do not wash gloves between uses with different patients.

 

E. Change gloves during patient care if moving from a contaminated body site to a clean body site.

 

F. No recommendation can be made regarding wearing rings in health care settings.  Unresolved issue.

 

VII.  Health care worker educational and motivational programs

 

A. As part of an overall program to improve hand-hygiene practices of HCWs, educate personnel regarding the types of patient care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their hands.

 

B. Monitor HCWs’ adherence with recommended hand hygiene practices and provide personnel with information regarding their performance.

 

C. Encourage patients and their families to remind HCWs to decontaminate their hands.

 

VIII.  Administrative measures

 

A. Make improved hand hygiene adherence an Institutional priority and provide appropriate administrative support and financial resources.

 

B. Implement a multidisciplinary program designed to improve adherence of health personnel to recommended hand hygiene practices.

 

C. As part of a multidisciplinary program to improve hand hygiene adherence, provide HCWs with a readily accessible alcohol based hand rub product.

 

D. To improve hand hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol based hand rub available at the entrance to the patient’s room or at the bedside, in other convenient locations, and in individual pocket sized containers to be carried by HCWs.

 

E. Store supplies of alcohol based hand rubs in cabinets or areas approved for flammable materials.

 

IX. Performance Indicators

 

The following performance indicators are recommended for measuring improvements in HCWs’ hand hygiene adherence:

 

A. Periodically monitor and record adherence as the number of hand hygiene episodes performed by personnel/number of hand hygiene opportunities, by ward or by service.  Provide feedback to personnel regarding their performance.

 

B. Monitor the volume of alcohol based hand rub (or detergent used for hand washing or hand antisepsis) used per 1,000 patient days.

 

C. Monitor adherence to policies dealing with wearing of artificial nails.

 

D. When outbreaks of infection occur, assess the adequacy of health care worker hand hygiene.

CDC’S “HAND HYGIENE SAVES LIVES” VIDEO SHOWN TO PATIENTS MAKES THEM TWICE AS LIKELY TO ASK CAREGIVERS TO SANITIZE THEIR HANDS

New research shows that patients can have a role in promoting hand hygiene among doctors, nurses. Hand hygiene video empowers patients to remind hospital caregivers to clean their hands, a strategy that is critical in the fight to prevent infections

 

In December 2009, The Centers for Disease Control and Prevention (CDC), Catholic Healthcare Partners (CHP) and the Premier healthcare alliance released research showing that a video can be an effective tool for encouraging patients to remind healthcare staff to wash their hands.

 

The research tested the effectiveness of a CDC video called “Hand Hygiene Saves Lives”, co-produced by the CDC, APIC and Safe Care Campaign in 2007. The video encourages patients, family and visitors to play a role in their own care by helping healthcare professionals remember to clean their hands before and after touching patients. After the video was shown to patients in 17 CHP facilities, patients were twice as likely to report reminding nurses to wash their hands, and doctors were twice as likely to report being asked by patients to wash their hands.

 

“Research has shown that hand hygiene adherence among medical professionals is less than optimal, despite long-standing evidence showing that it helps prevent healthcare-associated infections (HAIs),” said Dr. John Jernigan of the CDC. “This video is a tool hospitals can use to empower patients to participate in their own care and reduce their risk of acquiring an infection by reminding care givers to perform hand hygiene.”

 

There are approximately 1.7 million HAIs and nearly 100,000 associated deaths among hospitalized patients each year. In addition, infections cost the healthcare system between $35-45 billion annually.

 

“Preventing HAIs is a high priority goal at all CHP hospitals, and we believe that patients can partner with us to assure safe and high-quality care,” said Carolyn Wieging RN, BSN, CIC, Infection Prevention and Control Manager, St. Rita's Medical Center. “This video encourages that partnership by making it clear that it is perfectly acceptable to ask care givers to wash their hands to reduce their risk of infection.”

 

“We are pleased to see that the video we developed with the CDC is having such a positive impact on patient empowerment,” said Christine Nutty, RN, MSN, CIC, 2009 President of the Association for Professionals in Infection Control and Epidemiology (APIC) which helped to create Hand Hygiene Saves Lives. “Hand hygiene is the number one way to prevent the spread of infection, so these are really encouraging results. We hope this leads to increased hand hygiene compliance and improved patient outcomes.”

 

“Before every airline flight, passengers are shown a safety video so they know how to respond in an emergency,” said Victoria  Nahum, Executive Director of the Safe Care Campaign, which helped to develop Hand Hygiene Saves Lives. “We need the same safety resources in healthcare. This video teaches patients how to minimize the risk of infection and is providing tools to take action and advocate for highest quality care.”

After watching the video, the majority of patients:

 

            - Reported that the video increased their knowledge about hand hygiene;

            - Reported that the video is a useful tool to educate patients about hand hygiene; and

            - Recommended that the video be shown to other patients.