Impact of hand hygiene on healthcare associated infections.  Joshua Freeman.  Clinical Microbiologist, Auckland, NZ
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Impact of hand hygiene on healthcare associated infections. Joshua Freeman. Clinical Microbiologist, Auckland, NZ

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Evidence for the benefit of hand hygiene practices in health care

Evidence for the benefit of hand hygiene practices in health care

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Impact of hand hygiene on healthcare associated infections.  Joshua Freeman.  Clinical Microbiologist, Auckland, NZ Impact of hand hygiene on healthcare associated infections. Joshua Freeman. Clinical Microbiologist, Auckland, NZ Presentation Transcript

  • Impact of hand hygiene on healthcare associated infections: Four key studies Josh Freeman Department of Clinical Microbiology ADHB
  • • Before-after intervention study (Quasi-experimental) – “Before” - 1994 – “After” - 1995-1998 • Large teaching hospital (University of Geneva Hospitals) • Standardisation of outcome measures – auditing of hand hygiene compliance (5 moments) – nosocomial infections (NNISS definitions) measured by annual prevalence surveys – MRSA attack rate – new hospital acquired cases per 100 admissions
  • HH compliance HH compliance improved overall from 47.6% at baseline in 1994 to 66.2% in December 1997 (p<0.001)
  • Impact on nosocomial infections and MRSA attack rate Between 1994 and 1998, MRSA infections decreased from 2.16 /10000 PD to 0.93 / 10000 PD (p<0.001) MRSA bacteraemia decreased from 0.74 to 0.24 / 10000 PD (p<0.001)
  • Evidence that HH affects healthcare-associated infections: Strengths and Weaknesses Strengths • Large hospital with large sample size • Temporal associaton between improved hand hygiene practice and reduced nosocomial infections and MRSA attack rate • Extended time frame post intervention Weaknesses • Other interventions targeting MRSA carried out simultaneously • Few data points for nosocomial infection rates (particularly pre- intervention) • “Nosocomial infections” may be subject to classification bias despite standardised definitions
  • • Before-after intervention study – Before: Jan 1999-May 2001 – After: May 2001- April 2004 • Five wards at Austin Health, Melbourne • Intervention – HH programme – Mupirocin / triclosan for MRSA colonised patients on admission • Outcomes – Standardised HH compliance auditing (“5 moments”) – Standardised definitions • MRSA bacteraemia • MRSA clinical isolates • ESBL-E. coli and K. pneumoniae clinical isolates
  • HH compliance pre and post intervention Overall – 21% pre-intervention to 42% post intervention
  • MRSA rates pre and post intervention Slope<0; p<0.001 Slope<0;p=0.003
  • ESBL rates pre and post intervention
  • Evidence that HH affects healthcare-associated infections: Strengths and Weaknesses Strengths • Substantial and significant association between program onset, improved HH compliance and improved trends in MRSA bacteraemia; MRSA clinical isolates; and ESBL clinical isolates • Large number of data points pre and post intervention Weaknesses • Intervention included decolonisation for MRSA, therefore difficult to estimate relative impact of HH on MRSA rates
  • • Before-after study (Quasi-experimental study) – Standardised process and outcome measures • auditing of HH compliance 4 monthly (5 moments) • Standardised definitions of MRSA bacteraemia / clinical isolates • Pilot study – 6 Victorian healthcare institutions over 24 month period • Statewide study – 75 Victorian hospitals over 12 month period – Rolled out in two stages: Stage 1 – March 2006-April 2007 and stage 2 July 2006-June 2007
  • HH Compliance: Pilot program
  • MRSA bacteraemia rates: Pilot program
  • MRSA clinical isolates: Pilot program
  • HH compliance: Statewide rollout
  • MRSA bacteraemia rates: Statewide rollout
  • MRSA clinical isolates: Statewide rollout
  • Evidence that HH affects healthcare-associated infections: Strengths and Weaknesses Strengths • Large, multicentre study • Improved HH practice temporally associated with significant reductions in MRSA bacteraemia in both the pilot and statewide studies • Large number of data points before and after the intervention • MRSA bacteraemia–less vulnerable to classification bias than many endpoints (“hard” endpoint) Weaknesses • Quasi-experimental, non- randomised study with historical controls– therefore intrinsically vulnerable to confounding • Concurrent MRSA-specific measures not documented • MRSA clinical isolates started to decrease prior to commencing the program (raising possibility that factors other than the HH program may have been driving change)
  • 24 month Outcomes from the Australian National Hand Hygiene Initiative (MJA -in press) • National HH initiative (Hand Hygiene Australia) • Quasi-experimental study (2009-2010) – “Before” - Jan 2007-Dec 2008 – “After” - Jan 2009-Dec 2010 • Nationally standardised – Auditing of HH compliance (“5 moments”) – MRSA bacteraemia – Hospital-onset SA/MRSA bacteraemia
  • HH compliance by state: 2009-2010 (post intervention) Overall 43.6% at baseline to 67.8% post intervention
  • National MRSA bacteraemia rates pre and post intervention 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Apr-07 Nov-07 Jun-08 Dec-08 Jul-09 Jan-10 Aug-10 Feb-11 RateofMRSAbacteraemiaper10,000PD's Month Pre NHHI Post NHHI Implementation Slope<0;p=0.008
  • Hospital-onset S. aureus bacteraemia rates post intervention 0 0.2 0.4 0.6 0.8 1 1.2 1.4 RateofS.aureusbacteraemiasper10,00PD's Month MRSA /10,000 MSSA/10,000 SAB/10,000 Linear (MRSA /10,000) Linear (MSSA/10,000) Linear (SAB/10,000)
  • Evidence that HH affects healthcare-associated infections: Strengths and Weaknesses Strengths • First nationwide before-after intervention study for HH programme with outcome data • Large multi centre study • Utilises a “hard” endpoint (MRSA bacteraemia) • Strong temporal association with improved compliance and reduced MRSA bacteraemia • Large number of data points pre and post intervention Weaknesses • Vulnerable to confounding (like all quasi-experimental studies) • No reduction in “hospital- onset” S. aureus bacteraemia or “hospital- onset” MRSA bacteraemia
  • HH compliance infection: Association versus causality Bradford Hill Criterion Supports improved HH compliance as a means to reduce infection? Association is strong? YES – Statistically significant association between HH and infection rates Association is seen consistently? YES – Consistent association in four well designed studies Cause precedes effect? YES – Improvements in hand hygiene have preceded / coincided with reduced infections Biological gradient (dose- response between cause and effect)? YES - Inverse correlation between HH compliance rates and rates of infection Biologically plausible? YES – Hands of healthcare workers known to be frequently contaminated with potential pathogens including MRSA Coherence (compatible with existing knowledge)? YES- A causal relationship would be consistent with accepted models of pathogenesis of healthcare-associated infections Subject to experiment? NO – experimental studies not feasible / ethical Alternate explanations for association? YES – Difficult to rationalise temporal association between HH compliance and infectious endpoints based on alternative explanations