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Webinar 1: Ten barriers to hand hygiene


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Dr. Longtin will present the 10 principal factors which explain the poor compliance of health care workers to hand hygiene practices and will offer solutions to help resolve the issue. At the end of the lecture, the participant will have the background information to formulate arguments to promote good hand hygiene practices.

Published in: Health & Medicine, Business

Webinar 1: Ten barriers to hand hygiene

  1. 1. The 10 obstacles toYves Longtin, MDMicrobiologist-infectious disease specialistCHUQ-CHUL and IUCPQUniversité LavalHand hygiene
  2. 2. Once upon a time… in 1842
  3. 3. Rate of maternal mortality• 16% in division I– Residents• 7% in division II– Midwives• Very rare athome…
  4. 4. Ignaz Philipp Semmelweis,1818-65
  5. 5. A clue…• A pathologist cut hisfinger during anautopsy…• He died not longafter of an illnesssimilar to puerperalfeverJakob Kolletschka (1803-1847)
  6. 6. Sir William Osler, 1907
  7. 7. Pre-dated by 15 years Pasteur’s 1861 work“Mémoire sur les corpuscules organisés qui existent danslatmosphère. Examen de la doctrine des générationsspontanées”, which discussedstructured bodies present inthe atmosphere and the doctrine of spontaneousgeneration.
  8. 8. Robert TomAmerican, 1915-1979Semmelweis – Defender of MotherhoodOil on canvasCollection of the Universityof Michigan Health System472
  9. 9. Semmelweis’s before-and-afterstudy
  10. 10. Puerperal fever monthly mortality rates for the First Clinicat Vienna Maternity Institution 1841–1849. Rates dropmarkedly when Semmelweis implemented chlorine handwashing mid-May 1847
  11. 11. Semmelweis• Despite ↓in infection rate to < 1%– Idea conflicted with medical establishment of the time– Doctors offended at the idea of having to wash their hands– Semmelweis did not have a scientific explanation for themechanism– Deterioration in work relationships– Conflict with other scientists– Depression– Admission to psychiatric asylum
  12. 12. Importance recognizedPittet D et al., Lancet, 2000
  13. 13. The 10 obstacles toHand hygiene
  14. 14. Lack ofKNOWLEDGE1
  15. 15. Hand HygieneIndications
  16. 16. Hand Hygiene Indications2002Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16);1-44 2002
  17. 17. Hand Hygiene IndicationsBoyce JM Pittet D Morb Mort Weekly Rep 51(RR16);1-44 20022002 2006
  18. 18. WHO, 2009
  19. 19. IndicationsAdapted from Sax H. J Hosp Infect 2007
  20. 20. Many countries worldwide are committedto improving hand hygieneSource: WHO. Current status, March 2011Countries committed in 2005, 2006, 2007 and 2008Countries planning to commit in 2009
  21. 21. WHO’s indications…
  22. 22. The indications in Scotland…
  23. 23. The indications in Belgium…
  24. 24. The indications in Spain…
  25. 25. The indications in Brazil…
  26. 26. The indications in Canada???
  31. 31. Perform hand hygiene before touching a patient or his/her surroundings
  32. 32. Perform hand hygiene before touching a patient or his/her surroundings
  33. 33. Perform hand hygiene- before touching non-intact skin or mucous membranes- before handling invasive equipment
  34. 34. Perform hand hygiene- before touching non-intact skin or mucous membranes- before handling invasive equipment
  35. 35. Perform hand hygiene after contact with body fluids, excretions,mucous membranes, non-intact skin or bandages
  36. 36. Perform hand hygiene after contact with body fluids, excretions,mucous membranes, non-intact skin or bandages
  37. 37. The indications in Canada
  38. 38. Believing thatCOMPLIANCE ISEXCELLENT2
  39. 39. Compliance measurementRequired Organizational Practice Standardized by WHO
  40. 40. Compliance in Switzerland
  41. 41. Hand Hygiene Compliance
  42. 42. Institut de Cardiologie et dePneumologie de Québec
  43. 43. 30%(>2300 opportunities observed)44Overall compliance rate of caregiverswith regard to hand hygiene(2012-2013)
  44. 44. 266/85029/12794/215 424/999184/91418/14466/232520/12540102030405060708090100Avantle contactinitial avec lepatient ou son environnementAvantdeffectuer une procédureaseptiqueAprèsune exposition à des liquidesorganiquesAprèsle contactavec le patient ouson environnementTauxdobservance(%)Indications pourlhygiène des mainsTaux dobservance de lhygiène des mains par indicationpour lensemble des travailleurs de lIUCPQAnnée 2009-2010Année 2010-2011Année 2012-2013
  45. 45. * Indications: Fait référence aux4 indications pour procéder à lhygiène des mains:· Avant le contact initial avec le patient ou son environnement· Après une exposition avec des liquides organiques· Avant deffectuer un acte aseptique· Après le contact avec le patient ou son environnement
  46. 46. CHUQ2011-2012
  47. 47. 33% 43%82/250 153/353Compliance rateCHUQ
  48. 48. X HospitalProvince of Quebec
  49. 49. 23% 63%0%75%32/1416/8122/1920/9Compliance rateX Hospital
  50. 50. 23% 63%0%75%32/1416/8122/1920/9Compliance rateCHRDLMost room for improvementin terms of % and volume ofopportunities
  51. 51. PoorM O M E N T3
  52. 52. The ideal moment to perform hand hygiene
  53. 53. Not4B E L I E V I N G
  54. 54. FACT• A number of “before-and-after”-typestudies• Not many randomized controlled trials
  55. 55. MYTH!• A randomized controlled trial is the onlywayFALSE!!!! for infection prevention
  56. 56. Methodology for studies onhand hygiene
  57. 57. Proven effectivenessWHO, 2009
  58. 58. The “ultimate” study willprobably never take placeCompliance already highorLack of outcome indicators
  59. 59. Surgery in the 19th centuryCarbolic acid sprayerat the operating fieldJ. Lister (1867) Unpleasant smell for the surgeons…The solution??
  60. 60. CultureL A I S S E Z - FA I R E5
  61. 61. Laissez-faire culture• The importance of hand hygiene nottaken seriously• Systematic errors are tolerated• Hand hygiene not taken seriously
  62. 62. Ponce de Leon Rosales S et al. Lancet Infect Dis. 2005 Mar;5(3):131-2.0.2% compliance
  63. 63. • 29 videos released2006-2009– 206 minutes in total– 66 indications in which hand hygienementioned or illustrated were identified• 16/66 mentioned only• 14/16 washing with water rather thanABHRs
  64. 64. Confusing6ABHRs AND SOAP
  65. 65. Numberofgermsonhands5 10 15 20 25 secondsDuration of handrubbingApplication of solution-99.99%ABHRs are• more effective• quickerABHRs vs. Soap-99%
  66. 66. Specific indications for washing with soap and water•Visible contamination with bloodor other body fluids•Hands visibly dirty•Exposure to spore-formingbacteria•Clostridium difficile•Bacillus anthracis•After using the restroomChoice of hygiene technique
  67. 67. Handwashing with ABHR after 7-10 HHopportunities?•Not a real indication•A myth that persists in hospitals•Invented by ABHR companies•To avoid sticky handsand build-up of residue•Misinterpreted by caregivers•Greater effectiveness of handwashing!Choice of hygiene technique
  68. 68. ↑ History of atopy↑ Winter− GlovesABHRs causeless irritation than soapWITH EQUAL USE
  69. 69. All of these products containGlycerine
  70. 70. dermatitisDamaged skin is more difficult to disinfestHigher bacterial load
  71. 71. ComplicationsStrategies for preventing irritation•Use protective creams•Use ABHRs rather thansoap and water•Do not use water that is too hot•Do not wear gloves unnecessarily•Dry your hands completely beforeputting on gloves
  72. 72. 7
  73. 73. Competing forA T T E N T I O N7
  74. 74. Doctors’ schedules• Multi-tasking…….. 24% of the time– E.g. Patient documentation and talkingto colleague• Interruptions and problems1.12 times/hour• Telephone calls7/day• Pager– 1 page / 6.9 minutes for surgeonson dutyChiu T et al. N Z Med J 2006 Mar 31
  75. 75. Not making it aREFLEX8
  76. 76. How tocompete witha host ofotherpriorities?
  77. 77. Armenillo D et al. Clin Infect Dis 2012;54(1):1–7
  78. 78. Hand Hygiene and Remote VideoAuditing• 17-bed ICU– Cameras placed in front of every sink and ABHRSdispenser– Sensors in doorways to detect HCW movement– Monitoring 24/7 (outsourcing of evaluation)– 107 week before-and-after study– Feedback to HCWs provided in real-time• Electronic boards• EmailsArmenillo D et al. Clin Infect Dis 2012;54(1):1–7
  79. 79. Armenillo D et al. Clin Infect Dis 2012;54(1):1–7
  80. 80. Hand Hygiene and Remote VideoAuditingArmenillo D et al. Clin Infect Dis 2012;54(1):1–775-week maintenance period298 860 HH opportunities262 826 in compliance (87.9%)16 prefeedback weeks60 542 hand hygiene opportunities3933 in compliance (6.5%)
  81. 81. Hand Hygiene and Remote VideoAuditing• Why this study matters– The most effective way to improve HH compliance– The most HH observations made– The highest compliance rate ever observed– Very long maintenance phase• Took a pragmatic approach to HH indications– Not WHO recommendations– Maybe key to success
  82. 82. GLOVES9
  83. 83. Gloves
  84. 84. Proper use of gloves2 uses for procedure gloves
  85. 85. GlovesProtection in case ofaccidental prickingReduce the amount ofblood at the surface ofthe needle by 86%But no change inside theneedle…
  86. 86. Proper Use of GlovesBlood Mucous membranesBody fluids Damaged skin
  87. 87. Wear gloves when you are taking care of patientscarrying multi-resistant germs(MRSA, VRE, ESBL…)Proper Use of Gloves
  88. 88. Proper Use of GlovesALWAYS perform HH BEFORE and AFTER removing glovesDefectsor re-contamination
  89. 89. Wearing gloves and HH• Wearing of gloves associated with lowerHH compliance– OR, 0.65 (95% CI, 0.54-0.79)Fuller C et al. Infect Control Hosp Epidemiol 2011;32(12):1194-1199
  90. 90. Wearing glovesIS NOT a substitute forhand hygiene
  91. 91. 10A bonus…
  92. 92. MicrobesI N V I S I B L E10
  93. 93. ObjectiveSet an objectiveof systematicallyperforming HH in front of eachpatient• Not too soon, but not too late• Even if wearing gloves• Theywill see you as very good and very competent!
  94. 94.  There are those who notice but don’t day say anything Perception is a matter of details– think about electioncampaigns.Don’t believe theydon’t realizeyouaren’t doing it
  95. 95. The stethoscopeA vector oftransmissionin care settings?
  96. 96. Medical equipment• Any medical equipment used for apatient must be cleaned anddisinfected before being used for asecond patient– Sphygmomanometers– Thermometers– Stethoscopes• If the patient is carrying amulti-resistant germ– Dedicated device or disinfection afteruse
  97. 97. The problem…70-90% of doctors do notdisinfect their stethoscopesafter each use…Wood, M.W. et al. Am J Infect Control, 2007. 35(4): p. 263-6.Bernard, L., et al., Infect Control Hosp Epidemiol, 1999. 20(9): p. 626-8.Fenelon, L., et al. The Journal of hospital infection, 2009. 71(4): p. 376-8.Muniz, J., et al., American journal of infection control, 2012.
  98. 98. • Multiple limitations– A piece of equipment’s “past” cannot bedetermined• Number of uses today? This week?• Microbiological status of patients? (MRSA?C.difficile?)• Exactly how equipment was used?– Full physical examination?• If bacteria is present, so what? Is thisimportant?– Does the equipment need to be sterile?Prevalence studies
  99. 99. “Ideal” methodologySystematic culture of hands andstethoscope following a standardizedphysical examination
  100. 100. Contamination of stethoscopesCultures from Rodac agar contact plates83 patients recruited and examined
  101. 101. Assessment of microbial loadMeanlog(CFU)/25cm2Level of Contamination of Physician’s Hand and Stethoscope Following a SinglePhysical ExaminationGloved Hand Stethoscope
  102. 102. DIAPHRAGM – FINGERTIPS ASSOCIATIONPearson’s r =0.81; r2= 0.65β=1.15; 95% CI 0.84-1.46; p<0.001
  104. 104. Fingertips Thenar Hypothenar Diaphragm Tube
  105. 105. How to remember?CleanContaminated
  106. 106. RECAP
  107. 107. Lack ofKNOWLEDGE1
  108. 108. Believing thatCOMPLIANCE ISEXCELLENT2
  109. 109. PoorM O M E N T3
  110. 110. NotBELIEVING4
  111. 111. CultureL A I S S E Z - FA I R E5
  112. 112. Confusing6ABHRs and SOAP
  113. 113. Competing forA T T E N T I O N7
  114. 114. Not making it aREFLEX8
  115. 115. GLOVES9
  116. 116. MicrobesI N V I S I B L E10
  117. 117. THANK YOU FOR YOUR ATTENTION!Any questions?
  118. 118. CONCLUSIONS
  119. 119. Lack ofK N OW L ED G E1
  120. 120. RESULTS• 83 patients recruited and examined– 33 patients to evaluate total CFU– 50 patients to evaluate MRSA CFU– 52% males– Average age ( 64.2 (14.8)– Average length of hospital stay (IQR): 7 (3-9)
  121. 121. Objectives• Review the rationale for HH• Review the indications for HH• Understand the factors that influencenon-compliance with HH• Propose solutions for improvingcompliance by doctors
  122. 122. 10 problems relating to HH1. Not being aware of the indications1. Teach about the patient zone2. Show indications2. Not realizing how HH is not being complied with1. Show rate of compliance1. Also talk about the number of opportunitiesfor enhancingunderstandingof how to improveoverall rates2. Manage by a metric and that metric will improve (HBR)3. Recontamination1. NEJM video on recontamination4. Not believing in the effectiveness of HH1. Show the studies2. Explain that it is important not to w ait for RCT (Europe and North America: compliance already high; Africa: no indicator)3. Parachute analogy5. Impunity and laissez-faire culture towards non-compliance1. Surgical mask analogy: Would w e allow a particular hospital to get rid of them because they “don’t believe in them”?6. Not distinguishing betweenABHRs and soap1. MORE effective than soap!2. QUICKER3. The rule of w ashing at every X HH: misunderstood!7. Contact dermatitis as a result of HH8. People are busy and have a lot on their hands other than HH1. Aw areness test9. Not making it a habit1. Seatbelt analogy2. Paper on video cameras10. Wearing of gloves11. C.difficiile and HH with soap and water
  123. 123. Will we be able to eliminate nosocomialinfections one day?
  124. 124. What role does medicalequipment play in thetransmission of germs at thehospital?
  125. 125. Previous studies suggest thatmedical equipmentA) Is a major source of germtransmissionB) Is NOT a major source ofgerm transmissionC) Don’t know
  126. 126. Previous studies suggest thatmedical equipmentA) Is a major source of germtransmissionA) Is NOT a major source ofgerm transmissionB) Don’t know
  127. 127. • Multiple limitations– A piece of equipment’s “past” cannot bedetermined• Number of uses today? This week?• Microbiological status of patients? (MRSA?C.difficile?)• Exactly how equipment was used?– Full physical examination?• If bacteria is present, so what? Is thisimportant?– Does the equipment need to be sterile?Prevalence studies
  128. 128. Mediate Auscultation 1894
  129. 129. • 1816– Difficulty during auscultation of a youngwoman– Bundle of 24 sheets of paper– Surprise! The sounds travelled very well– “The cylinder”
  130. 130. Only 2 Francs, with a bonus stethoscope
  131. 131. •Immediate Auscultation
  132. 132. And where do microbes fit in with all this????
  133. 133. Region sampled % recoveryStethoscope diaphragm 56% (28/50) Any stethoscope60% (30/50)Stethoscope tube 34% (17/50)Fingertips 66% (33/50)Any hand74% (37/50)Thenar region 56% (28/50)Hypothenar region 62% (31/50)Dorsum 28% (14/50)N=50P=0.14Proportion of MRSA recovered from Physician’s Hand and StethoscopeFollowing Physical Examination of an MRSA-Colonized PatientPRESENCE OF MRSA
  134. 134. Can stethoscopestransmit germs?
  135. 135. “Ideal” MethodologySystematic culture of hands andstethoscope following a standardizedphysical examination
  136. 136. CONCLUSIONS• Stethoscope contamination following a physicalexamination is not negligible• Need to disinfest a stethoscope after each use?– Not just the diaphragm!• One option: not allowing doctors to wearstethoscopes around their necks?
  137. 137. Contain 60-80% ethanol, isopropanolor n-propanolAddition of emollientsLess irritating than soap and water withequal use!Liquid, gel or mousse solutionsABHRsEquipment
  138. 138. DetergentsDislodge bacteria from the skinthrough the effect of rinsingwith waterSometimes chlorhexidine is addedEquipmentSoap
  139. 139. • N Engl J Med. 1988 Dec 15;319(24):1585-9.• The soundsof the hospital.Paging patterns in three teaching hospitals.• Katz MH, SchroederSA.• Source• Department of Medicine, University of California, San Francisco.• Abstract• To examine the influence of hospital paging systems on residency training, nursingservices,and patient care, we asked medical interns (first-year residents)in threeteaching hospitals to keep logs of pages they received during a three-day period.Thirty-one logs from 26 interns were completed;a total of 1206 pages were recorded on 91days (1095 hours). Interns were paged an average of once an hour; on 24 occasions,interns were paged five or more times an hour. The majority of pages (65 percent)occurred when interns were engaged in patient care. Only 34 percent of the pages werejudged both to require a response within one hour and to result in a change in patientcare. Twenty-four percent were clinically indicated and required a response within onehour but did not result in a change in patient care. Sixteen percent of pages resulted in achange in patient care or were clinically indicated but could have been postponed formore than an hour. An additional 26 percent of pages neither resulted in a change inclinical management nor were clinically indicated. Reducing the number of unnecessarypages and postponing nonurgent ones could result in as much as a 42 percent decreasein disruptions of patient care and more rest for interns.Katz MH, Schroeder SA. N Engl J Med. 1988;319:1585-9.
  140. 140. Hand hygiene promotion –Time to use a stick?
  141. 141. Choice of hygiene techniqueHand hygiene with ABHRs is preferable in almost every situation…Advantages•Available at point of care•More effective•Quicker•Less irritatingDisadvantage•No activity against spore-formingbacteria (C.difficile)
  142. 142. D E R M A T I T I S7