Demystifying and
Responding to CDC’s Hand
Hygiene Guidelines and
JCAHO’s Related Patient
Safety Goal for 2004
Presentation...
Presentation Outline
• CDC Guidelines and JCAHO
Patient Safety Goals for 2004
• Summary of the Evidence
• Memo from Dr. Ro...
The Big Picture
• Patients are getting infections that
can be avoided by following the
CDC Guidelines
• My goal today here...
CDC Guidelines on Hand
Hygiene
• Issued October 25, 2002
• Issued by CDC and others:
“CDC Healthcare Infection Control
Pra...
CDC Guidelines Recommendations 44 in 8 Categories
1. Indications for handwashing and hand
antisepsis (14)
2. Hand-hygiene ...
Why the Big Deal?
• Studies cited by CDC and/or IOM:
• Nosocomial infections are the most
frequent major “complication” fo...
JCAHO Involvement
• New JCAHO Patient Safety Goal
for 2004:
• 7a: “Comply with current CDC handhygiene guidelines.”

• Mak...
The Evidence
• 423 references in CDC Guidelines
•
•
•
•
•
•

From Laboratory Tests
From Hospitals
From Long-term Care Faci...
Study of Alcohol Handrub use at
a Long-Term Care Facility
• Compared the 2 units of the facility where alcohol
hand-rubs w...
Study of Alcohol Handrub use at an
Acute Care Facility
• Compared one unit (orthopedic surgery) of a
hospital before and a...
Memo from Dr. Roswell and
Summary of VHA Requirements
• Memo from Dr. Roswell to VISN Directors
• Special VHA guidance, e....
VHA Summary of JCAHO-required
CDC Recommendations
(19 in 4 categories)
I.
II.
III.
IV.

All Health Care Workers with Direc...
Summary of VHA Summary (1)
I.

All Health Care Workers (HCWs)
with Direct Patient Contact
•

•
•

Decontaminate hands befo...
Summary of VHA Summary (2)
II.

Surgical Hand Hygiene
•

•

Guidance on surgical scrub with
soap and water (e.g., shorter
...
Summary of VHA Summary (3)
III. Facility Management: Supplies
•
•
•
•
•
•

Alcohol at room entrance and/or bedside
Alcohol...
Summary of VHA Summary (4)
IV. Facility Management:
Administrative Action
•
•
•

Make HH a priority and provide
financial ...
CDC Guidelines on Hand Hygiene
• If you only remember one thing,
remember this: Alcohol hand-rubs are
better than soap and...
CDC Slide on Effectiveness
Ability of Hand Hygiene
Agents to Reduce Bacteria on
Hands
Time After Disinfection
log
0 60
180...
CDC Slide on Skin Condition
Effect of Alcohol-Based Handrubs
on Skin Condition
Self-reported skin score
Dry

Healthy

Epid...
Six Sigma Pilot Project with 3M:
What we’re measuring in 3 VAMC ICUs
1.
2.
3.
4.
5.
6.

Staff compliance (observing practi...
3M-VHA Six Sigma Team Members
Dr. Robert Bonello,
Minneapolis VAMC
Kay Clutter,
Minneapolis VAMC
Linda Danko, Infectious
D...
Very Preliminary Data from
Questionnaire or Pilot Site(s)
• Staff think they’re doing 90% when they’re doing
60%.
• Nurses...
What to do now (short list)
1. Get alcohol hand-rubs close to patients
and make it convenient to use: put in
rooms or entr...
Final Thoughts
1. What doesn’t work: Telling people to use
soap and water.
2. It’s not always common sense, for
example:
•...
Recommended On-line Resources
• December 2003 VHA NCPS Topics in
Patient Safety (TIPS) Newsletter:
vaww.ncps.med.va.gov/TI...
How EAs Can Help
• Work with me to send a tailored
e-mail to your national list(s)
• Invite me to give a short
presentatio...
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Hand Hygiene Presentation for February 2004 Veterans Health Administration "Quality Management Integration Council" meeting

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This presentation made clear the VHA policy to implement the CDC hand Hygiene Guideline a year before the VHA Directive was issued. A special memo and summary had been sent to VA Network Offices and Medical Center Directors from the Under Secretary for Health (Dr. Roswell). Will post the "TIPS" issue mentioned in slides. Memo has probably been lost in the mists of time. I have a video of this presentation (because it was broadcast on the VA's internal education system) on VHS and someday may get it on YouTube...

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Hand Hygiene Presentation for February 2004 Veterans Health Administration "Quality Management Integration Council" meeting

  1. 1. 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 1
  2. 2. Presentation 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 2
  3. 3. The 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 3
  4. 4. 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 4
  5. 5. 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 5
  6. 6. 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 6
  7. 7. JCAHO Involvement • New JCAHO Patient Safety Goal for 2004: • 7a: “Comply with current CDC handhygiene guidelines.” • Making it a Patient Safety “Goal” for 2004 has transformed the CDC “Guidelines” into JCAHO “Requirements” 7
  8. 8. The 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 8
  9. 9. 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 9
  10. 10. 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 10
  11. 11. 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 11
  12. 12. VHA Summary of JCAHO-required CDC Recommendations (19 in 4 categories) I. II. III. IV. All Health Care Workers with Direct Patient Contact (8) Surgical Hand Hygiene (3) Facility Management: Supplies (5) Facility Management: Administrative Action (3) Total Length: 732 words (-45%) 12
  13. 13. 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 13
  14. 14. 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 14
  15. 15. 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 15
  16. 16. 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 16
  17. 17. CDC 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% 17
  18. 18. CDC Slide on Effectiveness Ability of Hand Hygiene Agents to Reduce Bacteria on Hands Time After Disinfection log 0 60 180 minutes 3.0 99.0 2.0 90.0 1.0 0.0 Bacterial Reduction % 99.9 0.0 Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Baseline Plain soap Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999. 18
  19. 19. CDC Slide on Skin Condition Effect of Alcohol-Based Handrubs on Skin Condition Self-reported skin score Dry Healthy Epidermal water content 6 5 4 3 2 1 0 27 25 23 21 19 17 15 Baseline Alcohol rub 2 weeks Soap and water Healthy Baseline Alcohol rub 2 weeks Dry Soap and water ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441. 19
  20. 20. Six Sigma Pilot Project with 3M: What we’re measuring in 3 VAMC ICUs 1. 2. 3. 4. 5. 6. Staff compliance (observing practices with checklist and clipboard) Volume of product used (converting to “doses” of alcohol handrub and soap) Staff Attitudes and Perception of Compliance (questionnaire) Antimicrobial soap in use (percent yes/no) No artificial nails on HCWs (percent yes/no) Staff satisfaction with HH practices (questionnaire) 20
  21. 21. 3M-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, 3M Kim Reichling, 3M Dr. Gary Roselle, Infectious Diseases Susan Woods, 3M Dr. Steven Wright, OQP 21
  22. 22. 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. 22
  23. 23. 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) 23
  24. 24. Final Thoughts 1. 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) 24
  25. 25. Recommended 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 25
  26. 26. How 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! 26

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