Post on 13-Mar-2019
transcript
Hand Hygiene: Not Just for Health Care
Workers Anymore!
Jocelyn Srigley, MD, MSc, FRCPC
Director, PHSA IPAC
Medical Microbiologist, BC Children’s & Women’s
November 4, 2016
@JocelynSrigley
Objectives
• To understand why patient hand hygiene is important
• To review existing data on patient hand hygiene rates
• To describe patients’ hand hygiene knowledge, attitudes,
and practices
• To discuss how to improve patient hand hygiene
Transmission Can Occur Via Patients’ Hands
Indirect Contact Fecal-Oral
By Intermedichbo - Norbert Kaiser File:Intensivstation (01) 2007-03-03.jpg, CC
BY-SA 3.0, https://commons.wikimedia.org/w/index.php?curid=14641153
Bacterial Pathogens on Patients’ Hands
• 100 hand samples from patients on medical/surgical units
– One pathogen 39%
– Gram negative 34%
– C. difficile 14%
– MRSA 14%
– VRE 9%
• 357 patients admitted to 6 post-acute care facilities
– Any MDRO 24.1%
– MRSA 10.9%
– VRE 13.7%
– Resistant Gram negative bacilli 2.8%
1Istenes et al, 2013. 2Cao et al, 2016.
Patient Hand Hygiene Prevents HAIs
Author
(Year)
Study
Design Study Setting
Participating
Patients
Recipients of
Intervention
Elements of
Intervention
Results: Healthcare
Associated
Infections
Results: Hand
Hygiene Rates
Pokrywka
(2014)
Before-after 520-bed tertiary
care and
teaching hospital
All inpatients Both Education,
reminders,
provision of
product
CDI rate 10.45/
10,000 patient days
before to 6.95/
10,000 patient days
after; p=0.0009
N/A
Gagne
(2010)
Before-after 250-bed
community
hospital
All inpatients Patients Education,
provision of
product
MRSA 10.6/ 1,000
admissions before to
5.2/1,000 admissions
after
N/A
Cheng
(2007)
Before-after Inpatient
psychiatric
department
Long-stay
psychiatric
patients
HCWs Provision of
product
6 outbreaks affecting
66 patients (18.2%)
before; 4 outbreaks
affecting 23 patients
(4.4%) after; p=0.005
for total patients
involved
N/A
Thu
(2007)
Controlled
before-after
2 neurosurgical
wards
Inpatients who
had undergone a
neurosurgical
procedure
Patients Education,
provision of
product
SSI decreased from
8.3% to 3.8% on
intervention unit and
increased from 7.2%
to 9.2% on control
unit; p=0.04 for
comparison between
units
N/A
Hilburn
(2003)
Before-after Orthopedic
surgical unit
N/S Patients Education,
reminders,
provision of
product
Nosocomial infection
rate 8.2% before to
5.3% after
N/A
Peters
(1992)
Before-after
with repeated
treatment
Maternity ward Postpartum
women
Patients Provision of
product
Puerperal mastitis
2.90% before to
0.66% after; p<0.001
N/A
3Srigley et al, 2016.
Patient Hand Hygiene May Improve HCW Hand Hygiene
• Cognitive dissonance
– HCWs who emphasize the importance of hand hygiene to
patients may change their behaviour to be consistent
• Study of a patient hand hygiene protocol in an ICU
– Staff hand hygiene before room entry increased from 35% to
66%
– After room exit increased from 66% to 79%
4Fox et al, 2015.
Objectives
• To understand why patient hand hygiene is important
• To review existing data on patient hand hygiene rates
• To describe patients’ hand hygiene knowledge, attitudes,
and practices
• To discuss how to improve patient hand hygiene
Self-Reported Hand Hygiene Rates
• Emergency department patients reported hand hygiene
after 62-88% of bathroom visits and after 13-41% of
bedside urinal/bedpan uses
5Luz et al., 2011.
Direct Observation of Patients
• “Covert observation” by junior doctors
– Hand hygiene performed by patients during 73% of meals6
• 24 hours of direct observation in a hospital
– Patient/visitor compliance was 67.5% after body fluid exposures
and 50% after contact with patient surroundings7
• Study on pediatric wards
– Only found 1 child to observe, who had 100% compliance8
6Mattam et al., 2012. 7Randle et al., 2010. 8Randle et al., 2013.
Electronic Monitoring of Patients
• Hand hygiene on multi-organ transplant units measured
by a real-time locating system (RTLS) for 9 months
9Srigley et al., 2014.
Hand Hygiene Rates
• After using the bathroom
– 29.7% of 12,649 bathroom visits
– More likely among women and after 12 pm
• Before eating
– 39.1% of 6,005 meal times
– Ranged from 32.2% at breakfast to 45.9% at dinner
– 3.3% of 1,122 kitchen visits
• Room entry and exit
– 2.9% of 5,786 entries and 6.7% of 5,779 exits
– More likely in the afternoon and on weekdays
Limitations
• Measured hand hygiene events, not compliance
– It is impossible to know what patients were doing in the
bathroom or kitchen
• Some hand hygiene events may have been performed
by untagged healthcare workers or visitors
• Not all patients wore RTLS tags
• Study conducted with a relatively small number of
observations on multi-organ transplant units
Objectives
• To understand why patient hand hygiene is important
• To review existing data on patient hand hygiene rates
• To describe patients’ hand hygiene knowledge, attitudes,
and practices
• To discuss how to improve patient hand hygiene
Mixed Methods Study
• Objective
– To assess the hand hygiene knowledge, attitudes, and practices
of hospital inpatients in preparation for implementation of patient
hand hygiene improvement programs
• Study population
– Inpatients at 4 adult acute care and 1 chronic care hospitals
• Methods
– Cross-sectional survey distributed on all inpatient units for 1
week
– Structured interviews with randomly selected patients at 3 sites
Results: Demographics
• 268 surveys completed
– 51.5% female
– Median age 66.5 years
• 23 patient interviews analyzed
– 19/23 female
– 17/23 age 60 and over
– 7 medicine, 7 surgery, 5 oncology/transplant, 4 rehab
– Median length of stay 5.5 days
– Mobility: 11 independent, 10 with assistance, 2 immobile
– Toileting: 12 independent, 3 bathroom with assistance, 3 commode
Survey Results: Compliance
Always Usually Half the
Time
Seldom Never
How often were you able to
wash your hands with soap
or hand sanitizer after using
the bathroom or bedpan or
commode?
66.4% 15.5% 4.2% 5.3% 7.2%
How often were you able to
wash you hands with soap or
hand sanitizer before eating?
49.2% 21.2% 4.2% 10.8% 11.5%
Survey Results: Barriers
Yes No
Were you able to find
soap or hand sanitizer
whenever you needed it?
84.4% 15.6%
Would you like to receive
more information about
hand washing while in
the hospital?
25.4% 74.6%
Qualitative Results:
Environmental Context and Resources
• Survey comments
– “I never was given any pump bottle of hand sanitizer for my table
despite asking for it”
– “…why not put a bottle on each bedside table”
– “If there is concern about hand washing before meals, have something
on the tray accompanying the meals”
• Interviews
– Soap/ABHR usually available but sometimes dispensers were empty
– “I take it that bottle was a sanitizer on this table right here? At first I
thought it might have been moisturizer therapy.”
Qualitative Results: Knowledge
• Survey comments
– “Hand washing should be just common sense”
• Interviews
– All agreed that patient hand hygiene is important and prevents infection
– Patients know they should perform hand hygiene after toileting, but less
awareness of other moments
– Most patients reported not wanting any more information about hand
hygiene or were indifferent
• “I’m old enough to know these things”
• “I think I know enough about it”
Next Steps
• Patients don’t think they need to improve their hand
hygiene and they don’t want information/education
• BUT we know patient hand hygiene is suboptimal
Objectives
• To understand why patient hand hygiene is important
• To review existing data on patient hand hygiene rates
• To describe patients’ hand hygiene knowledge, attitudes,
and practices
• To discuss how to improve patient hand hygiene
Systematic Review of the Literature
• Objectives
– To determine the efficacy of patient hand hygiene interventions
in reducing HAIs/AROs and improving patient hand hygiene
compliance
• Searched electronic databases and grey literature to
August 2014
• Experimental and quasi-experimental studies were
included if they evaluated a patient hand hygiene
intervention conducted in an acute or chronic healthcare
facility and included outcomes of interest
• All steps performed independently by 2 investigators
3Srigley et al, 2016.
Surgical Site Infections in Neurosurgery
• Controlled before-after study
• 785 patients on 2 neurosurgical units in Vietnam
• Intervention
– Inpatients on 1 unit given alcohol-based hand rub
(ABHR) and education
• Surgical site infections decreased from 8.3% to
3.8% on intervention unit and increased from
7.2% to 9.2% on control unit (p=0.04 for
comparison between units)
10Thu et al, 2007.
Mastitis on a Maternity Ward
• Before-after with repeated treatment
• ~2300 postpartum women on a maternity ward
in Germany
• Intervention
– Patients provided with ABHR at bedside x 10 months,
then withdrawn x 2 months and reinstated x 2 months
• Puerperal mastitis decreased from 2.90% in
controls to 0.66% in intervention patients
(p<0.0001)
11Peters et al, 1992.
MRSA in a Community Hospital
• Before-after study
• 250-bed community hospital in Quebec
• Intervention
– All inpatients given education and ABHR BID x ~1
year
• Nosocomial MRSA rates decreased from
10.6/1,000 admissions in the year before to
5.2/1,000 during intervention
12Gagne et al, 2010.
Outbreaks on a Psychiatric Unit
• Before-after study
• ~900 inpatients admitted to a psychiatric unit in Hong Kong
• Intervention – Staff gave ABHR to all patients Q4H during the day x ~1
year
• Decrease in nosocomial outbreaks during the intervention compared to the year before – From 6 outbreaks affecting 66 patients (18.2%) to 4
outbreaks affecting 23 patients (4.4%) (p=0.005 for total patients involved)
13Cheng et al, 2007.
C. difficile in a Teaching Hospital
• Before-after study
• 520-bed teaching hospital in the USA
• Intervention – Education, reminders, and alcohol wipes on meal
trays
– Staff and volunteers encouraged to clean patient hands at mealtimes
– Added to an existing CDI “bundle”
• CDI rate decreased from 10.45/10,000 patient days before to 6.95/ 10,000 after (p=0.0009)
14Pokrywka et al, 2014.
HAI Rates on a Surgical Unit
• Before-after study
• Orthopedic surgery unit in the USA
• Intervention
– Patients given ABHR and education x 10 months
– Posters reminded staff, patients, and visitors about
hand hygiene
• Nosocomial infection rate decreased from 8.2%
in the 6 months before to 5.3% during
intervention (p-value not reported)
15Hilburn et al, 2003.
Hand Hygiene at a Pediatric Hospital
• Cluster randomized-controlled trial
• Children’s hospital in the UK
• Intervention
– 6 wards randomized to interactive educational
activities using “Glo-Yo,” mobile learning technology,
or control
• Hand hygiene rates increased by 31.7% among
intervention patients compared to 13.8% in
control group (p<0.001)
16Lary et al, 2013.
Hand Hygiene at a Rehab Centre
• Before-after study
• ~100 patients on 3 units of a rehab centre in
Sweden
• Intervention
– Patients education and ABHR in bathrooms
– Staff gave out alcohol wipes at mealtimes and were
encouraged to remind/assist patients with hand hygiene
• Hand hygiene rates increased from “seldom” before
intervention to 85% before meals and 49% after
toilet use
17Hedin et al, 2012.
Hand Hygiene on Surgical Units
• Before-after study
• ~160 inpatients on 3 surgical units in the USA
• Intervention
– Staff education followed by audits to assess whether
they assisted patients with hand hygiene
• Staff assisting with patient hand hygiene at 6
moments increased from 17.3% in the 6 weeks
before intervention to 44.6% in the 6 weeks after
(p=0.0003)
18Ardizzone et al, 2012.
Hand Hygiene After Commode Use
• Before-after study
• 40 inpatients with mobility difficulties
• Intervention
– Hand wipe containers and reminder signs attached to
commodes
• Patient survey
– Patients offered wipes some of the time increased
from 69% to 100% and all of the time increased from
50% to 85%
19Whiller et al, 2000.
Summary of Interventions
• Targets
– Patients (5/10)
– Healthcare workers (HCWs) (3/10)
– Both (2/10)
• Components
– Provision of product (8/10)
– Education (7/10)
– Reminders (3/10)
– Audits (1/10)
Indications for Patient Hand Hygiene
• Before patient/patient environment contact
– Upon entering their room (or facility/clinic)
– Before contacting clean supplies
• Before aseptic procedures
– Prior to eating
– Taking meds, administering injections, wound care, etc.
• After body fluid exposure
– After toileting/diapering
– After coughing/sneezing/etc.
• After patient/patient environment contact
– Upon leaving their room (or facility/clinic)
Conclusions
• Patient hand hygiene is important
• Patients do not perform adequate hand hygiene
• Interventions to improve patient hand hygiene reduce
HAIs, but quality of evidence is low
• Interventions have been multifactorial with components
similar to healthcare worker hand hygiene programs
– Access to soap/ABHR is important
– Tailor components to your setting
• Need to go beyond the basics and look at behaviour
change strategies
Acknowledgements
• Dr. Michael Gardam
• Dr. Colin Furness
• Mary Jane Salpeter
• Allison McArthur
• Dr. Dominik Mertz
• Cindy O’Neill
• Dr. Christine Lee
• Anne Bialachowski
• Salary support and study
funding:
– AMMI Canada/Astellas
Post-Residency Fellowship
– Canada Health Infoway;
the Health Technology
Exchange; Infonaut, Inc.;
GOJO Industries
– Hamilton Health Sciences
Quality and Patient Safety
Grant
References
1. Istenes N, Bingham J, Hazelett S, Fleming E, Kirk J. Patients’ potential role in the transmission of health care-
associated infections: prevalence of contamination with bacterial pathogens and patient attitudes toward hand
hygiene. Am J Infect Control 2013;41:793-8.
2. Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients’ hands. JAMA Int Med
2016;176(5):705-6.
3. Srigley JA, Furness CD, Gardam M. Interventions to improve patient hand hygiene: a systematic review. J Hosp
Infect 2016;94(1):23-9.
4. Fox C, Wavra T, Ash Drake D, et al. Use of a patient hand hygiene protocol to reduce hospital-acquired infections
and improve nurses’ hand washing. Am J Crit Care 2015;24(3):216-24.
5. Luz J, Cydulka RK, Scott S. Evaluation of patient hygiene practices during emergency department visits. Ann Emerg
Med 2011;58(Suppl 4):S198.
6. Mattam K, Al-Badawi T, King S, Guleri A. The missing link in the health-care associated infection acquisition cycle:
An innovative patient hand-hygiene audit led by doctors at a tertiary cardiac centre in northwestern England. Clin
Microbiol Infec 2012;18(Suppl s3):809.
7. Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp
Infect 2010;76(3):252-5.
8. Randle J, Firth J, Vaughan N. An observational study of hand hygiene compliance in pediatric wards. J Clin Nurs
2013;22(17-18):2586-92.
9. Srigley JA, Furness CD, Gardam M. Measurement of patient hand hygiene in multiorgan transplant units using a
novel technology: an observational study. Infect Control Hosp Epidemiol 2014;35(11):1336-41.
References
10.Thu LTA, Dibley MJ, Nho VV, Archibald Lennox, Jarvis WR, Sohn AH. Reduction in surgical site infections in
neurosurgical patients associated with a bedside hand hygiene program in Vietnam. Infect Control 2007;28:583-8.
11.Peters F, Flick-Fillies D, Ebel S. Hand disinfection as the central factor in prevention of puerperal mastitis. Clinical
study and results of a survey. Geburtshilfe Frauenheilkd 1992;52(2):117-20.
12.Gagne D, Bedard G, Maziade PJ. Systematic patients' hand disinfection: impact on meticillin-resistant
Staphylococcus aureus infection rates in a community hospital. J Hosp Infect 2010;75(4):269-72.
13.Cheng VC, Wu AK, Cheung CH, Lau SK, Woo PC, Chan KH, et al. Outbreak of human metapneumovirus infection
in psychiatric inpatients: implications for directly observed use of alcohol hand rub in prevention of nosocomial
outbreaks. J Hosp Infect 2007;67(4):336-43.
14.Pokrywka M, Feigel J, Douglas B, et al. A bundle strategy including patient hand hygiene to decrease Clostridium
difficile infections. Medsurg Nurs 2014;23(3):145-8.
15.Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in
an acute care facility. Am J Infect Control 2003;31(2):109-16.
16.Lary D, Hardie K, Randle J. Improving children’s and their visitors’ hand hygiene compliance. Antimicrob Resist
Infect Control 2013;2(Suppl 1):P166.
17.Hedin G, Blomkvist A, Janson M, Lindblom A. Occurrence of potentially pathogenic bacteria on the hands of hospital
patients before and after the introduction of patient hand disinfection. APMIS 2012;120(10):802-7.
18.Ardizzone LL, Smolowitz J, Kline N, Thom B, Larson EL. Patient hand hygiene practices in surgical patients. Am J
Infect Control 2013;41(6):487-91.
19.Whiller J, Cooper T. Clean hands: how to encourage good hygiene by patients. Nurs Times 2000;96(46):37-8.