Hand Hygiene - IPAC BC Day/PHH - IPAC... · Puerperal mastitis 2.90% before to 0.66% after; p

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

Disclosures

• No conflicts of interest

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




and practices


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.

Patient Characteristics

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

Distribution of Hand Hygiene Rates

n=176 patient-room stays

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




and practices


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




and practices


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.

Search Results

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


• ~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


• 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


• 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


• ~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


• ~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


• 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

QUESTIONS?

[email protected]

@JocelynSrigley

mailto:[email protected]

References

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associated infections: prevalence of contamination with bacterial pathogens and patient attitudes toward hand

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2. Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients’ hands. JAMA Int Med

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Med 2011;58(Suppl 4):S198.

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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

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