Patient and Visitor Involvement:The Hand Hygiene Missing Link?Jim Gauthier, MLT, CICCHICA-Canada Past PresidentProvidence ...
Objectives• Review some of our issues with antibioticresistant organisms• Discuss the importance of keeping ourpatient’s h...
Courtesy of Ministry of Health and Long Term Care - Ontario3
Where Do We Spend Our Time?• Focus on– Reservoir– Mode of Transmission4
Reservoir• Patient Screening– Admission Screening• Isolation5
Admission Screening• MRSA– Nares, perianal or groin, wounds, exit sites• VRE– Stool or rectal swab• CDI– No screening read...
Admission Screening Problems• Cost– PCR can be pricey but quick - $75• Turn Around Time (TAT)– PCR is quick – same day– So...
Contact Precautions• Jim has problems with this!8
CONTACT PRECAUTIONSWE JUST FOUND OUT THAT THIS PATIENTHAS A BUG THAT COULD BE CARRIED TOTHE NEXT PATIENT.NOW WE REALLY MEA...
10
Mode of Transmission• Contact– Direct– Indirect• Droplet• Airborne11
Mode of Transmission – Contact• Hand hygiene– Alcohol hand rub– Soap and water• Variety of agents• Equipment cleaning– Sin...
http://www.hqontario.ca/public-reporting/patient-safety13
14
Infectious Agent• Bacteria• Fungi• Viruses• Parasites• Prions15
Acronyms on the Increase?• MRSA - Methicillin ResistantStaphylococcus aureus– stable to climbing• VRE - Vancomycin Resista...
http://www.hqontario.ca/public-reporting/patient-safety17
Newer Acronyms• NDM-1 – New Delhi metallo-betalactamase• CRE/CPE – Carbapenem resistant orcarbapenemase producingEnterobac...
19
Susceptible Host• Age• Immunosuppression• Diabetes• Burns• Surgery• Lines• Immunizations20
21
Portal of Exit• Body Fluids (Blood, etc.)• Skin• Feces• Mucous Membranes– Routine Practices22
WARNING!!This patient has:–Skin!–Feces!–Mucous Membranes!PERFORM HAND HYGIENE AFTER CONTACT WITHTHIS PATIENT OR THEIR ENVI...
Hi Healthcare PersonI haveSkin, Feces andMucous Membranes!Please sanitize yourhands after contactwith me or mysurroundings24
25
Portal of Entry - MRSA• Common colonization site of nares• HOW?• Healthcare workers and noses?• Patient and Nose?26
www.science.uva.nl/~robbert/zappa/files/jpg/collier1.jpg27
Portal of Entry - MRSA• Skin– Broken skin – opportunistic with ownorganism• Decolonization and SSI rates (Hacek 2008)– Per...
Portal of Entry - VRE• Two entrances– Rectal or oral• Rectal– Scopes– tubs– fingers– gloves29
Portal of Entry - VRE• Oral• Is it us?30
http://farm2.static.flickr.com/1276/1199717813_2fb6e1ef69.jpg?v=031
Portal of Entry – CDI• Same as previous slides– Oral, rectal– Possible food based (Rodriguez-Palacios2007)• Might explain ...
Portal of Entry – CDI• Proton Pump Inhibitors– Possible problem– Conclusion: Clean patient’s hands! (Metz2008)• Rates lowe...
Portal of Entry – CRE• Let me guess…oral, rectal• Can find in wounds, insertion sites34
Portal of Entry – Our Patients• Ward 2003 – ‘Improving Patient HandHygiene’• If they don’t wash at home, won’t wash inthe ...
Our Patients• Unable to access facilities– Immobile– Attached to equipment• IV, monitors• Ardizzone 2013– Surgical pain– S...
Our Patients• Patients want– More signs– Better Reminders– Personal hand sanitizers37
Hand Sanitizer Bottle LabelFOR PATIENT USEKeep on overbed tableIf necessary, please ask forassistance to use this product38
Portal of Entry – Our Patients• Banfield et al – 2005.• ‘Could hospital patients’ hands constitute amissing link?’• Excell...
Our Patients• Studies did find potentially pathogenicbacteria on patient’s hands (Hedin 2012,Istenes 2013)• Outbreak strai...
Our Patients• If not given the chance, won’t be able todo their hands• Need to make sure patients can do it!• Hand wipes a...
Patients/Volunteers• Study looking at education methods forparents visiting PICU (Chen 2007)• Used video versus poster• Vi...
Children/Visitors• Observation on paediatric unit• General and Oncology• No education over the presence of ABHR• Visitors ...
Staff Awareness• Surveys recognize that staff think patienthand hygiene is a good idea (Burnett2008, 2009)• Staff felt HH ...
Does it Work?• Gagne 2010• Could not get rates down• 4 full time and 4 part time attendants hired• Met patients and visiti...
Results Impressive2002-3 2003-4 ReductionMRSA Infections per1000 Admissions10.6 5.2 51%MRSA BSI 1.3 0.2 85%MRSA Resp 4.9 1...
Projected Savings• $688,843!• May have prevented 51 infections– MRSA infection ~ $14,360– MRSA BSI ~ $27,083– Staffing was...
Patient MomentsLanders 20121. After using the toilet, bedpan, orcommode2. When returning to room after test orprocedure3. ...
Patient Moments4. When visibly dirty5. Before touching any breaks in the skin(wounds, dressing, tubes or any careprocedure...
Patient Moments7. After coughing, sneezing, or touchingnose or mouth8. Before interacting with visitors and afterthey leav...
Jim’s Additional Moments1. Leaving a wheelchair- New pamphlet for patients2. After pet therapy (Lefebvre 2006)51
CPSI• “How to help prevent healthcare-associated infections: a patient and familyguide”• www.handhygiene.ca52
Patient Assessment• Alcohol hand rub on overbed table• Observe if they can depress plunger• Observe if they can adequately...
Our Patients• Use of volunteers?http://images.buycostumes.com/mgen/merchandiser/17757.jpg54
55
Summary• We need more emphasis on patient handhygiene• We need more incentive (Schweon 2011)– Joint Commission, Centers fo...
http://www.hqontario.ca/public-reporting/patient-safetyThis looks good!57
http://www.hqontario.ca/public-reporting/patient-safetyThis Should Look Better!58
Super Patient Hand Hygiener59
References• Ardizzone LL, et al. Patient hand hygiene practices insurgical patients. AJIC 2013 – in press• Banfield KR, et...
References• Drudy D, et al. Emergence and control offluoroquinolone-resistant, toxin a–negative, toxin b–positive Clostrid...
References• Hedin G. et al. Occurrence of potentially pathogenicbacteria on the hands of hospital patients before andafter...
References• Lefebvre SL, et al. Prevalence of zoonotic agents indogs visiting hospitalized people in Ontario: implications...
References• Rodriguez-Palacios A, et.al. Clostridium difficile in retailground meat, Canada. Emerg Infect Dis 2007:13(3):4...
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Webinar 2 - Patient and Visitor Involvement: The Hand Hygiene Missing Link?

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Examine the rise in Antibiotic Resistant Organisms and review the Chain of Transmission with emphasis on the portal of entry, and how a focused patient hand hygiene program may be what’s missing in our goal of lower healthcare associated infections and colorizations.

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Webinar 2 - Patient and Visitor Involvement: The Hand Hygiene Missing Link?

  1. 1. Patient and Visitor Involvement:The Hand Hygiene Missing Link?Jim Gauthier, MLT, CICCHICA-Canada Past PresidentProvidence Care, Kingston, ONCPSIApril 20131
  2. 2. Objectives• Review some of our issues with antibioticresistant organisms• Discuss the importance of keeping ourpatient’s hands clean2
  3. 3. Courtesy of Ministry of Health and Long Term Care - Ontario3
  4. 4. Where Do We Spend Our Time?• Focus on– Reservoir– Mode of Transmission4
  5. 5. Reservoir• Patient Screening– Admission Screening• Isolation5
  6. 6. Admission Screening• MRSA– Nares, perianal or groin, wounds, exit sites• VRE– Stool or rectal swab• CDI– No screening readily available• Other ARO’s– Problems with culture media orstandardization, what to look for?6
  7. 7. Admission Screening Problems• Cost– PCR can be pricey but quick - $75• Turn Around Time (TAT)– PCR is quick – same day– Some culture techniques can take up to 5 or 7days if mixed culture• Snap shot of that day, that site7
  8. 8. Contact Precautions• Jim has problems with this!8
  9. 9. CONTACT PRECAUTIONSWE JUST FOUND OUT THAT THIS PATIENTHAS A BUG THAT COULD BE CARRIED TOTHE NEXT PATIENT.NOW WE REALLY MEAN YOU HAVE TOPERFORM HAND HYGIENE AND TRY NOTTO SOIL YOUR UNIFORM!WE ARE NOT SURE ABOUT THE GUY NEXTDOOR, YET, SO DO WHATEVER YOU WANT!9
  10. 10. 10
  11. 11. Mode of Transmission• Contact– Direct– Indirect• Droplet• Airborne11
  12. 12. Mode of Transmission – Contact• Hand hygiene– Alcohol hand rub– Soap and water• Variety of agents• Equipment cleaning– Single patient use– Fomites such as toilets, tubs, etc.12
  13. 13. http://www.hqontario.ca/public-reporting/patient-safety13
  14. 14. 14
  15. 15. Infectious Agent• Bacteria• Fungi• Viruses• Parasites• Prions15
  16. 16. Acronyms on the Increase?• MRSA - Methicillin ResistantStaphylococcus aureus– stable to climbing• VRE - Vancomycin Resistant Enterococci• CDI - Clostridium difficile Infection– still causing outbreaks• ESBL – Extended Spectrum Beta-lactamase producing organisms16
  17. 17. http://www.hqontario.ca/public-reporting/patient-safety17
  18. 18. Newer Acronyms• NDM-1 – New Delhi metallo-betalactamase• CRE/CPE – Carbapenem resistant orcarbapenemase producingEnterobacteriaceaehttp://en.wikipedia.org/wiki/New_Delhi_metallo-beta-lactamase_118
  19. 19. 19
  20. 20. Susceptible Host• Age• Immunosuppression• Diabetes• Burns• Surgery• Lines• Immunizations20
  21. 21. 21
  22. 22. Portal of Exit• Body Fluids (Blood, etc.)• Skin• Feces• Mucous Membranes– Routine Practices22
  23. 23. WARNING!!This patient has:–Skin!–Feces!–Mucous Membranes!PERFORM HAND HYGIENE AFTER CONTACT WITHTHIS PATIENT OR THEIR ENVIRONMENT!23
  24. 24. Hi Healthcare PersonI haveSkin, Feces andMucous Membranes!Please sanitize yourhands after contactwith me or mysurroundings24
  25. 25. 25
  26. 26. Portal of Entry - MRSA• Common colonization site of nares• HOW?• Healthcare workers and noses?• Patient and Nose?26
  27. 27. www.science.uva.nl/~robbert/zappa/files/jpg/collier1.jpg27
  28. 28. Portal of Entry - MRSA• Skin– Broken skin – opportunistic with ownorganism• Decolonization and SSI rates (Hacek 2008)– Perineum / perianal – GI tract?• Tubs• Linen• Patient hands28
  29. 29. Portal of Entry - VRE• Two entrances– Rectal or oral• Rectal– Scopes– tubs– fingers– gloves29
  30. 30. Portal of Entry - VRE• Oral• Is it us?30
  31. 31. http://farm2.static.flickr.com/1276/1199717813_2fb6e1ef69.jpg?v=031
  32. 32. Portal of Entry – CDI• Same as previous slides– Oral, rectal– Possible food based (Rodriguez-Palacios2007)• Might explain some of the community relatedillness32
  33. 33. Portal of Entry – CDI• Proton Pump Inhibitors– Possible problem– Conclusion: Clean patient’s hands! (Metz2008)• Rates lower with hand hygiene programfor both staff and patients (Drudy 2007)33
  34. 34. Portal of Entry – CRE• Let me guess…oral, rectal• Can find in wounds, insertion sites34
  35. 35. Portal of Entry – Our Patients• Ward 2003 – ‘Improving Patient HandHygiene’• If they don’t wash at home, won’t wash inthe hospital• Educate staff• Provide information– Pamphlet, Verbally, Posters35
  36. 36. Our Patients• Unable to access facilities– Immobile– Attached to equipment• IV, monitors• Ardizzone 2013– Surgical pain– Surgical dressings36
  37. 37. Our Patients• Patients want– More signs– Better Reminders– Personal hand sanitizers37
  38. 38. Hand Sanitizer Bottle LabelFOR PATIENT USEKeep on overbed tableIf necessary, please ask forassistance to use this product38
  39. 39. Portal of Entry – Our Patients• Banfield et al – 2005.• ‘Could hospital patients’ hands constitute amissing link?’• Excellent review article• Not a lot of studies that look at patienthands39
  40. 40. Our Patients• Studies did find potentially pathogenicbacteria on patient’s hands (Hedin 2012,Istenes 2013)• Outbreak strains present• Bed-ridden patients have higher numbers• Patients help patients! (Tomic 2008)40
  41. 41. Our Patients• If not given the chance, won’t be able todo their hands• Need to make sure patients can do it!• Hand wipes a good idea (Burnett 2008)41
  42. 42. Patients/Volunteers• Study looking at education methods forparents visiting PICU (Chen 2007)• Used video versus poster• Video group had better technique– Overall no significant difference in compliance• Patients and Visitors better thanphysicians at 57% (Randle 2010)42
  43. 43. Children/Visitors• Observation on paediatric unit• General and Oncology• No education over the presence of ABHR• Visitors lower at 23%• Need program for children (Randle 2012)43
  44. 44. Staff Awareness• Surveys recognize that staff think patienthand hygiene is a good idea (Burnett2008, 2009)• Staff felt HH more important after going tothe toilet than before meals– Need to explain concept of fecal oral spreadand the role of the environment44
  45. 45. Does it Work?• Gagne 2010• Could not get rates down• 4 full time and 4 part time attendants hired• Met patients and visiting relatives at door• Verbal and pamphlet• Encourage to clean hands at least twiceper day• Used 70% with 0.5% Chlorhexidine45
  46. 46. Results Impressive2002-3 2003-4 ReductionMRSA Infections per1000 Admissions10.6 5.2 51%MRSA BSI 1.3 0.2 85%MRSA Resp 4.9 1.5 69%Ratio MRSA BSI / MSSABSI59% (13/22) 14% (2/14) 76%MRSA Mortality 0.7 0.2 71%46
  47. 47. Projected Savings• $688,843!• May have prevented 51 infections– MRSA infection ~ $14,360– MRSA BSI ~ $27,083– Staffing was $170,00047
  48. 48. Patient MomentsLanders 20121. After using the toilet, bedpan, orcommode2. When returning to room after test orprocedure3. Before eating, drinking, taking medicine,or putting anything in your mouth48
  49. 49. Patient Moments4. When visibly dirty5. Before touching any breaks in the skin(wounds, dressing, tubes or any careprocedure (dialysis, IV drug administration,injections)6. Before dialysis, contact with IV lines orother tubes49
  50. 50. Patient Moments7. After coughing, sneezing, or touchingnose or mouth8. Before interacting with visitors and afterthey leave9. When there is concern about whetherhand are clean50
  51. 51. Jim’s Additional Moments1. Leaving a wheelchair- New pamphlet for patients2. After pet therapy (Lefebvre 2006)51
  52. 52. CPSI• “How to help prevent healthcare-associated infections: a patient and familyguide”• www.handhygiene.ca52
  53. 53. Patient Assessment• Alcohol hand rub on overbed table• Observe if they can depress plunger• Observe if they can adequately coverhands• ‘Flag’ patient if they require assistance53
  54. 54. Our Patients• Use of volunteers?http://images.buycostumes.com/mgen/merchandiser/17757.jpg54
  55. 55. 55
  56. 56. Summary• We need more emphasis on patient handhygiene• We need more incentive (Schweon 2011)– Joint Commission, Centers for Medicare andMedicaid Services• We need more studies (Banfield 2005,Burnett 2008, 2009, Schweon 2010, Randle2012, Landers 2012, Istenes 2013)56
  57. 57. http://www.hqontario.ca/public-reporting/patient-safetyThis looks good!57
  58. 58. http://www.hqontario.ca/public-reporting/patient-safetyThis Should Look Better!58
  59. 59. Super Patient Hand Hygiener59
  60. 60. References• Ardizzone LL, et al. Patient hand hygiene practices insurgical patients. AJIC 2013 – in press• Banfield KR, et al. Could hospital patients’ handsconstitute a missing link? J Hosp Infect 2005;61:183–188• Burnett E, et al. Hand hygiene: what about our patients?Br J Infect Control 2008;9(1):19-24• Burnett E. Perceptions, attitudes, and behavior towardspatient hand hygiene. AJIC 2009;37:638-42• Chen YC, et al. Effectiveness of hand-washing teachingprograms for families of children in paediatric intensivecare units. J Clin Nurs 2007;16:1173-960
  61. 61. References• Drudy D, et al. Emergence and control offluoroquinolone-resistant, toxin a–negative, toxin b–positive Clostridium difficile. Infect Control HospEpidemiol 2007; 28:932-940• Gagne D, et al. Systematic patients’ hand disinfection:impact on meticillin-resistant Staphylococcus aureusinfection rates in a community hospital. J Hosp Infect2010;75:269-72• Hacek DM, et al. Staphylococcus aureus nasaldecolonization in joint replacement surgery reducesinfection. Clin Orthop Relat Res. 2008;466(6):1349-135561
  62. 62. References• Hedin G. et al. Occurrence of potentially pathogenicbacteria on the hands of hospital patients before andafter the introduction of patient hand disinfection. APMIS2012;120:802-7• Istenes N, et al. Patients’ potential role in thetransmission of health care-associated infections:prevalence of contamination with bacterial pathogensand patients attitudes toward hand hygiene. AJIC 2013In Press.• Landers T, et al. Patient-centered hand hygiene: the nextstep in infection prevention. AJIC 2012;40:S11-S17.62
  63. 63. References• Lefebvre SL, et al. Prevalence of zoonotic agents indogs visiting hospitalized people in Ontario: implicationsfor infection control. J Hosp Infect 2006;62:458–466• Metz DC. Clostridium difficile Colitis: Wash your handsbefore stopping the proton pump inhibitor. Am JGastroenterol 2008;103:2314–16• Randle J, et al. Twenty-four-hour observational study ofhospital hand hygiene compliance. J Hosp Infect2010;76:252-5• Randle J, et al. An observational study of hand hygienecomplaince in paediatric wards. J Clin Nurs 2012;doi: 10.1111/j.1365-2702.2012.04103.x63
  64. 64. References• Rodriguez-Palacios A, et.al. Clostridium difficile in retailground meat, Canada. Emerg Infect Dis 2007:13(3):485-7• Schweon SJ, et al. A realistic approach towards handhygiene for long-term care residents and health carepersonnel. AJIC 2011;39:336-8• Tomic V. Has the time come to recommend the use ofalcohol-based hand rub to hospitalized patients? ICHE2008;29(10): 987-8• Ward D. Improving patient hand hygiene. NursingStandard 2003;17(35):39-4264
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