S li Cl h d Save lives: Clean your hand 5 th May 5 th May
Mar 25, 2016
S li Cl h dSave lives: Clean your hand
5th May5th May
WHO P ti t S f tWHO Patient Safety
■ WHO Patient Safety was launched in October 2004■ WHO Patient Safety was launched in October 2004 with the mandate to reduce the adverse health and social consequences of unsafe health care
■ An essential element of WHO Patient Safety is the formulation of a Global Patient Safety Challenge: a topic that covers a significant aspect of risk to patients receiving health care, relevant to every WHO Member StateWHO Member State
■ The First Global Patient Safety Challenge was launched in 2005launched in 2005
Political commitment is essential t hi i t i i f ti t lto achieve improvement in infection control
Ministerial pledges to the First Global Patient Safety ChallengeMinisterial pledges to the First Global Patient Safety Challenge
I resolve to work to reduce health care-associated infection
■ acknowledging the importance f HCAI
(HCAI) through actions such as:
of HCAI;■ hand hygiene campaigns at
national or sub-national levels;■ sharing experiences and available
surveillance data, if appropriate;■ using WHO strategies and
Ministerial signature
■ using WHO strategies and guidelines…
121 countries committed to address HCAI87% ld l ti87% world population coverage
C t t tPerspective as of 5 May 2009
Current status,August 2009
Clean Care is Safer CareClean Care is Safer Care
The First Global Patient Safety Challenge
SAVE LIVES: Clean Your HandsSAVE LIVES: Clean Your Hands5 May 2009–2020
Through an annual day focused on hand hygiene improvement in health care, this initiative promotes continual, sustainable best practice in hand hygiene at the point of care in all health-care settings around the world
D fi itiDefinition
Health care-associated infection (HCAI)Health care-associated infection (HCAI)■ Also referred to as “nosocomial” or “hospital” infection
“An infection occurring in a patient during the processAn infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of p gadmission. This includes infections acquired in the health-care facility but appearing after discharge, and l ti l i f ti h lthalso occupational infections among health-care
workers of the facility”
HCAI th ld id b dHCAI: the worldwide burden
■ Estimates are hampered by limited availability■ Estimates are hampered by limited availability of reliable data
■ The burden of disease both outside and inside health-care facilities is unknown in many countriesy
■ No health-care facility no country no health-care■ No health care facility, no country, no health care system in the world can claim to have solved the problem
E ti t d t f HCAI ld idEstimated rates of HCAI worldwide
■ HCAI affects hundreds of millions of people worldwide and■ HCAI affects hundreds of millions of people worldwide and is a major global issue for patient safety.
■ In modern health-care facilities in the developed world:■ In modern health care facilities in the developed world: 5–10% of patients acquire one or more infections
■ In developing countries the risk of HCAI is 2–20 times p ghigher than in developed countries and the proportion of patients affected by HCAI can exceed 25%
■ In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%
Th i t f HCAIThe impact of HCAI
HCAI can cause:HCAI can cause:■ more serious illness■ prolongation of stay in a health care facility■ prolongation of stay in a health-care facility■ long-term disability
d th■ excess deaths ■ high additional financial burden■ high personal costs on patients and their families
Most frequent sites of infection d th i i k f tand their risk factors
LOWER RESPIRATORY TRACT INFECTIONS13%URINARY TRACT INFECTIONS 34%Mechanical ventilationAspirationNasogastric tubeCentral nervous system depressantsAntibiotics and anti-acids
%Urinary catheter
Urinary invasive proceduresAdvanced age
Severe underlying diseaseUrolitiasis
%
Antibiotics and anti acidsProlonged health-care facilities stayMalnutritionAdvanced ageSurgeryImmunodeficiency
PregnancyDiabetes Most common
sites of health care-associated infection
d th i k f t
LACK OF HAND
BLOOD INFECTIONSVascular catheterNeonatal ageC iti l
SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxis
Incorrect surgical skin preparationI i t d
and the risk factors underlying the occurrence of
infections
HYGIENE
Critical careSevere underlying diseaseNeutropeniaImmunodeficiencyNew invasive technologies
Inappropriate wound careSurgical intervention duration
Type of woundPoor surgical asepsis
DiabetesNutritional state Lack of training and supervision
14%Nutritional state
ImmunodeficiencyLack of training and supervision 17%
H d t i iHand transmission
■ Hands are the most■ Hands are the most common vehicle to transmit health care-associated pathogens
■ Transmission of health care-associated pathogens from one patient to another via health care workers’via health-care workers hands requires
5 sequential steps5 sequential steps
5 t f h d t i i5 stages of hand transmissionone two three four five
Germs present on patient skin
Germ transferonto health-
care worker’s
Germs survive on hands for
Suboptimal or omitted hand
cleansing
Contaminated hands
transmitpatient skin and
immediate environment
care worker s hands
hands for several minutes
cleansing results in
hands remaining
transmitgerms via
direct contact with patient orenvironment
surfacesremaining
contaminatedwith patient or
patient’s immediate
i tenvironment
Prevention of h lth i t d i f tihealth care-associated infection
■ Validated and standardized prevention strategies have■ Validated and standardized prevention strategies have been shown to reduce HCAI
■ At least 50% of HCAI could be prevented■ At least 50% of HCAI could be prevented ■ Most solutions are simple and not resource-demanding
and can be implemented in developed, as well as in p p ,transitional and developing countries
SENIC study: Study on the Efficacy of N i l I f ti C t lNosocomial Infection Control■ >30% of HCAI are preventable■ 30% of HCAI are preventable
26%Relative change in NI in a 5 year period (1970–1975)
30
Without infection
t l
14%9%
19% 18%
10
20
With infection control
controlLRTI SSI UTI BSI Total0
-10
%
31%-27%
32%-30
-20
-31% -35%-35% -32%-40
Haley RW et al. Am J Epidemiol 1985
Si l idSimple evidence…
Hand hygiene is the single mostHand hygiene is the single most effective measure to reduce HCAIs
Maternal mortality ratesMaternal mortality ratesGeneral Hospital of Vienna Ignaz Philipp Semmelweis
Impact of hand hygiene promotion■ In the last 30 years, 20 studies demonstrated the effectiveness of to reduce HCAIs
Year Hospital setting
Increase of hand hygiene compliance Reduction of HCAI rates Follow-up Reference
1989 Ad lt ICU F 14% t 73% HCAI t f 33% t 10% 6 C l t l1989 Adult ICU From 14% to 73% (before pt contact)
HCAI rates: from 33% to 10% 6 years Conly et al
2000 Hospital-wide From 48% to 66% HCAI prevalence: from 16.9% to 9.5% 8 years Pittet et al2004 NICU From 43% to 80% HCAI incidence: from 15 1 to 10 7/1000 patient days 2 years Won et al2004 NICU From 43% to 80% HCAI incidence: from 15.1 to 10.7/1000 patient-days 2 years Won et al2005 Adult ICUs From 23.1% to 64.5% HCAI incidence: from 47.5 to 27.9/1000 patient-days 21 months Rosenthal
et al2005 Hospital-wide From 62% to 81% Significant reduction in rotavirus infections 4 years Zerr et al2005 Hospital wide From 62% to 81% Significant reduction in rotavirus infections 4 years Zerr et al2007 Neonatal unit From 42% to 55% HCAI incidence: overall from 11 to 8.2
infections/1000 patient-days) and in very low birth weight neonates from 15.5 to 8.8 infections /1000
i d
27 months Pessoa-Silva et al
patient-days2007 Neurosurgery NA SSI rates: from 8.3% to 3.8% 2 years Thu et al2008 1) 6 pilot health-care
f iliti1) from 21% to 48%2) f 20% t 53%
MRSA bacteraemia: 1) f 0 05 t 0 02/100 ti t di h
1) 2 years2) 1
Grayson et alfacilities2) all public health-care facilities in Victoria (Aus)
2) from 20% to 53% 1) from 0.05 to 0.02/100 patient-discharges per month; 2) from 0.03 to 0.01/100 patient-discharges per month
2) 1 year
2008 NICU NA HCAI incidence: from 4.1 to 1.2/1000 patient-days 18 months Capretti et alp y p
Compliance with hand hygienei diff t h lth f ilitiin different health-care facilitiesAuthor Year Sector ComplianceAuthor Year Sector CompliancePreston 1981 General Wards
ICU16%30%
Albert 1981 ICU 41%Albert 1981 ICUICU
41%28%
Larson 1983 Hospital-wide 45%
Donowitz 1987 Neonatal ICU 30Donowitz 1987 Neonatal ICU 30
Graham 1990 ICU 32
Dubbert 1990 ICU 81
P tti 1991 S i l ICU 51Pettinger 1991 Surgical ICU 51
Larson 1992 Neonatal Unit 29
Doebbeling 1992 ICU 40
Zimakoff 1993 ICU 40
Meengs 1994 Emergency Room 32
Pittet 1999 Hospital-wide 48Pittet and Boyce. Lancet Infectious Diseases 2001
C li d f i l ti itCompliance and professional activity■ At the University Hospitals of Geneva, compliance with hand hygiene■ At the University Hospitals of Geneva, compliance with hand hygiene
was higher among midwives and nurses, and lower among doctors
100
708090
100
5245
66
48405060
%
3021
0102030
Nurse Nurse aide & student
Midwife Doctors Others Total0
Pittet D, et al. Ann Intern Med 1999
Hand hygiene complianceU i it H it l f G 1999University Hospitals of Geneva, 1999
■ Risk factors for poor ■ Main reasons for non-■ Risk factors for poor compliance■ Morning and weekday
■ Main reasons for non-compliance reported by health-care workers■ Morning and weekday
shift■ High risk of
■ Too busy■ Skin irritationg
contamination■ Being a physician
■ Glove use■ Don’t think about itg p y
■ Working in intensive care■ Don t think about it
Pittet D, et al. Ann Intern Med 1999
Hand rubbing is the solution to obstacles t i h d h i liHand washing with soap and water when hands are visibly
to improve hand hygiene compliance
Adoption of alcohol-
Hand washing with soap and water when hands are visibly dirty or following visible exposure to body fluids
Adoption of alcohol-based hand rub is the gold standardthe gold standard in all other clinical situationssituations
Time constraint = j b t l f h d h imajor obstacle for hand hygiene
Hand washing: 40-60 seconds
Alcohol-basedAlcohol basedhand rubbing: 20–30 seconds
Adoption of alcohol-basedAdoption of alcohol based hand rub is the gold standard in all other clinical situations
Application time of hand hygiene and d ti f b t i l t i tireduction of bacterial contamination0
Hand rubbing is:1
10 re
duct
ion)
HandwashingHandrubbing
Hand rubbing is:more effectivefaster
3
2
on (m
ean
log
1
better tolerated
4
3
al c
onta
min
atio
5Bac
teria
0 15sec 30sec 1 min 2 min 3 min 4 min
6
Pittet and Boyce. Lancet Infectious Diseases 2001
The key components of the of Hand hygieneThe key components of the of Hand hygiene promotion program in Kuwait
1. Educational program to HCWs: Why, when and how to perform hand hygiene to raise awareness, engage and educate healthcare workers at all levels.
2. Availability and proper placement of alcohol hand rubs at point of care: to enable healthcare workers to clean their h d t th i ht ti i kl d ff ti lhands at the right time, quickly and effectively.
The key components of the of Hand hygiene ti i K it tipromotion program in Kuwait, continue
3 Adoption and Implementation of 5 Moments for Hand3. Adoption and Implementation of 5 Moments for Hand Hygiene
4. Work place reminders:• 5 Moments for Hand Hygiene Poster• 5 Moments for Hand Hygiene Poster • How to Hand rub Poster• How to Hand wash Poster• How to Hand wash Poster• Hand Hygiene: Why, When and How Leaflet
The key components of the of Hand hygiene promotion program in Kuwait continuepromotion program in Kuwait, continue
5. Engaging patients in improving hand hygiene: Information on why hand hygiene is important is provided and other materials such as leaflets in HH awarenessand other materials, such as leaflets in HH awareness booth.
6. Observation Audit of hand hygiene using 5 moments approachapproach
7 Data Analysis and Feedback Summary Report7. Data Analysis and Feedback Summary Report
1. Educational program to HCWs: Why when and how to perform handWhy, when and how to perform hand hygiene.
Are your hands clean?
SAVE LIVESClean Your Hands
Wh h ld l h d ?Why should you clean your hands?
You must perform hand hygiene to:You must perform hand hygiene to:■ protect the patient against harmful germs carried on
your hands or present on his/her own skinyour hands or present on his/her own skin■ protect yourself and the health-care environment
from harmful germsg
Th ld l f h d h iHand hygiene must be performed exactly where you are delivering
The golden rules for hand hygiene
health care to patients (at the point-of-care)
During health care delivery, there are 5 moments (indications) when it is essential that you perform hand hygiene ("My 5 Moments for Handessential that you perform hand hygiene ( My 5 Moments for Hand Hygiene" approach)
To clean your hands, you should prefer handrubbing with an alcohol-y , y p gbased formulation, if available. Why? Because it makes hand hygiene possible right at the point-of-care, it is faster, more effective, and better toleratedtolerated.
You should wash your hands with soap and water when visibly soiled
You must perform hand hygiene using the appropriate technique and time duration
H t h d b
To effectively reduce the
How to handrub
To effectively reduce the growth of germs on hands, handrubbing must be performed by following all of the illustrated steps.Thi t k l 20 30This takes only 20–30 seconds!
H t h d hHow to handwash
To effectively reduce theTo effectively reduce the growth of germs on hands, handwashing must last 40–60 secs and should be performed by f ll i ll f th ill t t dfollowing all of the illustrated steps.
H d h i d lHand hygiene and glove use
GLOVES PLUSHAND HYGIENEHAND HYGIENE= CLEAN HANDS
GLOVES WITHOUTHAND HYGIENE= GERM TRANSMISSION
H d h i d lHand hygiene and glove use
■ The use of gloves does not replace the need for cleaning■ The use of gloves does not replace the need for cleaning your hands!
■ You should remove gloves to perform hand hygiene, when■ You should remove gloves to perform hand hygiene, when an indication occurs while wearing gloves
■ You should wear gloves only when indicated (see the g y (Pyramid in the Hand Hygiene Why, How and When Brochure and in the Glove Use Information Leaflet) –otherwise they become a major risk for germ transmission
2. Availability of alcohol-based hand-rubs in point of carein point-of-care
• To enable healthcare workers to clean their hands at the right time, quickly and effectively.
• Achieved through:h d b ( k t b ttl )- hand-rubs (pocket bottles)
-wall-mounted dispensers-containers fixed to the patient’s bed or bedside tablecontainers fixed to the patient s bed or bedside table -hand-rubs affixed to dressing or medicine trolleys thatare taken into the point-of-care
Examples of hand hygiene products il ibl t th i t feasily accessible at the point-of-care
3. Adoption and Implementation of 5 Moments f H d H ifor Hand Hygiene
The geographical conceptualization f th t i i i k
HEALTH-CARE AREA
of the transmission risk
HEALTH-CARE AREA
PATIENT ZONECritical site withCritical site with infectious risk for the patient
Critical site with body fluid
i kexposure risk
Definitions of patient zone d h lth (1)and health-care area (1)
■ Focusing on a single patient the health-care setting is■ Focusing on a single patient, the health care setting is divided into two virtual geographical areas, the patient zone and the health-care area.
■ Patient zone: it includes the patient and some surfaces and items that are temporarily and exclusively dedicated to him or her such as all inanimate surfaces that are touched by or in direct physical contact with the patient (e.g. bed rails bedside table bed linen chairs infusion tubingrails, bedside table, bed linen, chairs, infusion tubing, monitors, knobs and buttons, and other medical equipment).equipment).
Definitions of patient zone d h lth (2)and health-care area (2)
■ Health-care area: it contains all surfaces in the health-■ Health-care area: it contains all surfaces in the healthcare setting outside the patient zone of patient X. It includes: other patients and their patient zones and the wider health-care facility environment. The health-care area is characterized by the presence of various and
i bi l i i l di lti i t tnumerous microbial species, including multi-resistant germs.
Another way of visualizing the patient zone and the contacts occurring within it
2 3
g
2 3
115
H Sax, University Hospitals, Geneva 2006
OPTIMAL HAND HYGIENE SHOULD BE PERFORMEDOPTIMAL HAND HYGIENE SHOULD BE PERFORMED
AT THE POINT-OF-CARE
D fi iti f i t f (1)Definition of point-of-care (1)■ Point-of-care – refers to the place where three elements■ Point of care refers to the place where three elements
occur together: the patient, the health-care worker, and care or treatment involving patient contact (within the patient zone)patient zone)
■ The concept embraces the need to perform hand hygiene at recommended moments exactly where care deliveryat recommended moments exactly where care delivery takes place
■ This requires that a hand hygiene product (e.g. alcohol-based handrub, if available) be easily accessible and as close as possible (e.g. within arm’s reach), where patient care or treatment is taking place Point-of-care productscare or treatment is taking place. Point of care products should be accessible without having to leave the patient zone
D fi iti f i t f (2)Definition of point-of-care (2)■ This enables health-care workers to quickly and easily fulfil■ This enables health care workers to quickly and easily fulfil
the 5 indications (moments) for hand hygiene (explained below)
■ Availability of alcohol-based hand-rubs in point-of-care
The “My 5 Moments for Hand Hygiene” happroach
Proposes a unified vision:for trainers observersfor trainers, observers and health-care workers to facilitate educationto minimize inter-individual variationto increase adherence
Sax H et al. Journal Hospital Infection 2007
Your 5 Moments for Hand Hygiene
Clean your hands immediately beforeimmediately before accessing a critical site with infectious risk for the patient!
Clean your hands before touching a
To protect the patient against harmful germs, including the patient’s own, entering
Clean your hands as soon as a task involving exposure risk
Clean your hands when leaving the patient’s side, after touching a patient and his/her immediate Clean your hands after touching any object or furniture in the patient’sbefore touching a
patient when approaching him/her!
his/her body!to body fluids has ended (and after glove removal)!
To protect yourself and the
surroundings, To protect yourself and the health-care environment from harmful
object or furniture in the patient s immediate surroundings, when leaving without having touched the patient!
To protect the patient against harmful germs carried on your hands!
To protect yourself and the health-care environment from harmful germs!
germs!To protect yourself and the health-care environment against germ spread!
The 5 Moments apply to any setting where health care involving direct contact with patients takes place
Can you identify some examples of this indication
Situations illustrating direct contact:
during your everyday practice of health care?
Situations illustrating direct contact:
shaking hands, stroking a child’s forehead
helping a patient to move around, get washed
l i k i iapplying oxygen mask, giving physiotherapy
taking pulse, blood pressure, chest g p , p ,auscultation, abdominal palpation, recording ECG
Can you identify some examples of this indication
Situations illustrating clean/aseptic
during your everyday practice of health care?
Situations illustrating clean/aseptic procedures:
brushing the patient's teeth,brushing the patient s teeth, instilling eye drops
skin lesion care, wound dressing, subcutaneous injection
catheter insertion, opening a vascular access system or avascular access system or a draining system, secretion aspiration
preparation of food, medication, pharmaceutical products, sterile materialmaterial.
Can you identify some examples of this indication
Situations illustrating body fluid exposure
during your everyday practice of health care?
Situations illustrating body fluid exposure risk:
brushing the patient's teeth, instilling eye drops secretion aspirationeye drops, secretion aspiration
skin lesion care, wound dressing, subcutaneous injection
drawing and manipulating any fluid sample, opening a draining system, endotracheal tube insertion and removal
clearing up urines, faeces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning of contaminated and visibly soiled material or areas (soiled bedvisibly soiled material or areas (soiled bed linen lavatories, urinal, bedpan, medical instruments)
Can you identify some examples of this indication
Situations illustrating direct
during your everyday practice of health care?
Situations illustrating direct contact :shaking hands, stroking
hild f h da child forehead
helping a patient to move around, get washed
applying oxygen mask, giving physiotherapy
taking pulse, blood pressure, g p , p ,chest auscultation,
abdominal palpation, recording ECG g
Can you identify some examples of this indication
Situation illustrating contacts with patient
during your everyday practice of health care?
Situation illustrating contacts with patient surroundings:
changing bed linen, with the patient out of the bedout of the bed
perfusion speed adjustment
monitoring alarm
holding a bed rail, leaning against a bed, a night table
clearing the bedside tableclearing the bedside table
Key points on h d h i d l (1)hand hygiene and glove use (1)
■ Indications for glove use do■ Indications for glove use do not modify any indication for hand hygiene
≠■ Glove use does not replace any hand ≠hygiene action
Key points on h d h i d l (2)hand hygiene and glove use (2)
When indications for gloves use and hand hygiene applyWhen indications for gloves use and hand hygiene apply concomitantly■ Regarding the "before” indications, hand hygiene should■ Regarding the before indications, hand hygiene should
immediately precede glove donning, when glove use is indicated
1 22
Key points on hand hygiene and glove use (3)hand hygiene and glove use (3)When indications for gloves use and hand hygiene apply concomitantlyconcomitantly■ Regarding the indications "after", hand hygiene should
immediately follow glove removal when the indicationimmediately follow glove removal, when the indication follows a contact that has required gloves
1
2
4. Work place preminders
PostersH t h H t bHow to wash How to rub
5. Engaging Patients through HH awareness boothawareness booth.
P ti t l fl tPatient leaflet
6. Observation of hand hygiene Wh ?Why? ■ The purpose of observing hand hygiene is to determine the
d f li ith h d h i ti b h lthdegree of compliance with hand hygiene practices by health-care workers
■ The results of the observation will help to identify the most appropriate interventions for hand hygiene promotion, pp p yg peducation and training
■ The results of observation (compliance rates) will be reported to health-care workers to :• explain the current compliance of hand hygiene in the health-care setting• explain the current compliance of hand hygiene in the health-care setting • highlight the aspects that need improvement, • compare baseline with follow-up data to show possible improvements
Setting g•The observation will be carried out in all hospital ICUs (adult, paediatric and neonatal)and neonatal).
•Observation period is from May 1st to May 31st 2011 which isObservation period is from May 1 to May 31 2011 which is corresponding to 23 working days with daily session.
•The daily session will be of 30 minutes duration alternating between early morning, midday and late morning.
•Direct observation of hand hygeine actions required during health care practices at the point-of-care
■ Compliance should be detected according to the "My 5 Moments for Hand Hygiene" approach recommended by WHO
S ttiSetting•The observer will observe up to three health-care workersThe observer will observe up to three health care workers simultaneously, if the density of hand hygiene opportunities permits.
•The observer will not interfere with health-care activities being carried out during the session.
•Observation will not be performed in extreme situations (emergency medical treatment, signs of uncontrolled stress as they do not reflect a “standard” care situation.
Ob ti FObservation Form
■ Detailed instructions are■ Detailed instructions are available on the back of the form, to be consulted during observation
It is now possible toIt is now possible to improve hand hygiene in your facility!
It’s your duty, to protect patients and yourself!patients and yourself!
You can make a change!
Easy infection control for everyone… simple measures save lives!measures save lives!
Thank youThank you