Assessment Of Hand Hygiene Strategies In US Healthcare Facilities

Credit WHO Hand Hygiene Campaign

 

 

# 8332

 

One hundred and sixty-seven years ago, a Hungarian physician named Ignaz Semmelweis published a controversial medical book called Etiology, Concept and Prophylaxis of Childbed Fever.

 

Childbed, or puerperal fever, was a major cause of mortality and morbidity among postpartum women, and Semmelweis demonstrated in his Viennese hospital that its incidence could be greatly reduced by having doctors wash their hands before performing gynecological exams.

 

His theories were considered radical (Pasteur wouldn’t come up with his `germ theory’ for another 17 years), and went against all currently accepted medical science. Besides, it was outrageous to suggest that doctors might actually be causing disease and death among their patients.

 

Today, while we know the importance of good hand hygiene – both inside and outside of medical settings – each year lapses in good hand cleansing practices lead to hundreds of thousands of avoidable hospital acquired infections (HAI’s) around the world, causing uncounted misery and costing tens of thousands of lives.

 

Which is the reason that the CDC, the ECDC, and the World Health Organization (among others) have promoted enhanced hand hygiene as the first – and most basic – step in reducing HAIs.  A few of their campaigns I’ve covered in the past include:

 

Aye, There’s The Rub

Study: Exam Gloves, Dispensers & Bacterial Contamination

Fomite to Fingers To Face: A Triple Play Combination

A Movement With Five Moments

Global Clean Your Hands Day

 

Although alcohol hand sanitizers are not without their limitations – particularly when dealing with norovirus and C.diff  (see CDC C. Diff FAQ & CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus) – their speed, availability, and ease of use make them an important part of any health facility's infection control program.

Yet, despite ongoing awareness campaigns, the latest report published in the American Journal of Infection Control indicates that there are still significant lapses in the WHO hand hygiene guidelines, even in the United States.

 

Between April and December 2011  health-care facilities around the world were invited to participate in a Hand hygiene self-assessment framework on the completion of the above Framework. The first analysis of that data (Summary report of the Framework global survey) was released in May of 2012, is available on the WHO website.

 

Between July and December of 2011, 2238 US facilities participating in the WHO global campaign were invited to complete the Hand Hygiene Self-Assessment Framework online.  Disappointingly, only 168 facilities (7.5%) responded, which limits the conclusions that can be drawn.

 

First a press release from Columbia University Medical Center, then a link to the study.

 

 

One in 5 US hospitals don't put hand sanitizer everywhere needed to prevent infections

Research from WHO and Columbia University School of Nursing

(NEW YORK, NY, February 27, 2014) – Approximately one in five U.S. health facilities don't make alcohol-based hand sanitizer available at every point of care, missing a critical opportunity to prevent health care-associated infections, according to new research from Columbia University School of Nursing and the World Health Organization (WHO) published in the American Journal of Infection Control. The study, which examined compliance with WHO hand hygiene guidelines in the U.S., also found that only about half of the hospitals, ambulatory care, and long-term care facilities had set aside funds in their budgets for hand hygiene training.

A research team jointly led by Laurie Conway, RN, MS, CIC, PhD student at Columbia Nursing, and Benedetta Allegranzi, MD, lead of the WHO infection control program Clean Care is Safer Care, surveyed compliance with WHO hand hygiene guidelines at a sample of 168 facilities in 42 states and Puerto Rico. Overall, 77.5% of facilities reported that alcohol-based sanitizer was continuously available at every point of care, the study found. About one in ten facilities reported that senior leaders such as the chief executive officer, medical director, and director of nursing didn't make a clear commitment to support hand hygiene improvement, according to the study.

"When hospitals don't focus heavily on hand hygiene, that puts patients at unnecessary risk for preventable health care-associated infections," says Conway. "The tone for compliance with infection control guidelines is set at the highest levels of management, and our study also found that executives aren't always doing all that they can to send a clear message that preventing infections is a priority."

(Continue . . . )

 

 

The full AJIC report is linked below:

 

Status of the implementation of the World Health Organization multimodal hand hygiene strategy in United States of America health care facilities

• Benedetta Allegranzi, MD, Laurie Conway, RN, MS, CIC, Elaine Larson, RN, PhD, FAAN, CIC, Didier Pittet, MD, MS

Results

Of 2,238 invited facilities, 168 participated in the survey (7.5%). A detailed analysis of 129, mainly nonteaching public facilities (80.6%), showed that most had an advanced or intermediate level of hand hygiene implementation progress (48.9% and 45.0%, respectively). The total Hand Hygiene Self-Assessment Framework score was 36 points higher for facilities with staffing levels of infection preventionists > 0.75/100 beds than for those with lower ratios (P = .01) and 41 points higher for facilities participating in hand hygiene campaigns (P = .002).

Conclusion

Despite the low response rate, the survey results are unique and allow interesting reflections. Whereas the level of progress of most participating facilities was encouraging, this may reflect reporting bias, ie, better hospitals more likely to report. However, even in respondents, further improvement can be achieved, in particular by embedding hand hygiene in a stronger institutional safety climate and optimizing staffing levels dedicated to infection prevention. These results should encourage the launch of a coordinated national campaign and higher participation in the WHO global campaign.

(Read entire study online . . . )

 

 

This oft quoted assessment from the CDC on the burden of Hospital Acquired Infections in the United States is from 2010.

A new report from CDC updates previous estimates of healthcare-associated infections. In American hospitals alone, healthcare-associated infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. Of these infections:

• 32 percent of all healthcare-associated infection are urinary tract infections
• 22 percent are surgical site infections
• 15 percent are pneumonia (lung infections)
• 14 percent are bloodstream infections

We live in a germ laden world, and you don’t have to work in a hospital or a doctor’s office to be concerned with good hand hygiene. For more on all of this I’d invite you to visit:

 

http://www.globalhandwashingday.org/

 

And can also visit the CDC’s hand hygiene website, where you will find many resources, including information on how to complete the Hand Hygiene Self-Assessment Framework.

 

Aye, There’s The Rub

 

Photo Credit – CDC

 

# 7854

 

Over the past decade, alcohol-based hand sanitizers have become ubiquitous in modern society  – both in medical facilities, and in the pockets and purses of millions of people. Their popularity stems from the fact that they are quick and easy to use, require no water or wash basin, and in many scenarios offer pretty good protection against germs.

 

While they are not always an appropriate substitute for a good old-fashioned soap & water hand scrubbing - particularly when dealing with C. difficile (see CDC C. Diff FAQ) or Norovirus (see CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus) - I confess, I keep a bottle handy almost everywhere I go. 

 

And I use it often.

 

With Global Handwashing Day just two days away, and cold & flu season upon us,  it is good timing that a study just published in BMC Infectious Disease looks at the efficacy of using alcohol hand sanitizers, focusing in particular on how much sanitizer is really needed to do a good job. 

And as it turns out, if you follow the directions on the bottle, you may not be getting the degree of disinfection you believe.  The following figure shows a composite (across 15 subjects) of areas of the hands that escaped sanitation during one of the trials conducted using the the manufacturer’s recommended quantity of product (1.1 ml).

 

 

It turns out that while alcohol based sanitizers work well against most common pathogens, the quantity of product recommended by many manufacturers (typically 1.1 ml, or a `single pump’ from the dispenser) provides inadequate coverage (both in terms of skin area and contact time) to meet current ASTM efficacy standards.

 

A `double-pump’ (ie. > 2 ml) provided not only better skin coverage, but longer contact time, resulting in a much greater reduction of skin contamination – meeting or exceeding  ASTM and  FDA efficacy standards.

 

A link to the study, along with some excerpts, then I’ll be back with a bit more.

 

Less and less–influence of volume on hand coverage and bactericidal efficacy in hand disinfection

Günter Kampf^12*, Sigunde Ruselack³, Sven Eggerstedt³, Nicolas Nowak⁴ and Muhammad Bashir⁵

BMC Infectious Diseases 2013, 13:472 doi:10.1186/1471-2334-13-472

The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-2334/13/472

Abstract

Background

Some manufacturers recommend using 1.1 mL per application of alcohol-based handrubs for effective hand disinfection. However, whether this volume is sufficient to cover both hands, as recommended by the World Health Organization, and fulfills current efficacy standards is unknown. This study aimed to determine hand coverage for three handrubs (two gels based on 70% v/v and 85% w/w ethanol and a foam based on 70% v/v ethanol) applied at various volumes.

Methods

Products were tested at product volumes of 1.1 mL, 2 mL, 2.4 mL as well as 1 and 2 pump dispenser pushes; the foam product was tested in addition at foam volumes of 1.1 mL, 2 mL, and 2.4 mL. Products were supplemented with a fluorescent dye and 15 participants applied products using responsible application techniques without any specific steps but the aim of completely covering both hands. Coverage quality was determined under ultraviolet light by two blinded investigators. Efficacy of the three handrubs was determined according to ASTM E 1174-06 and ASTM E 2755-10. For each experiment, the hands of 12 participants were contaminated with Serratia marcescens and the products applied as recommended (1.1 mL for 70% v/v ethanol products; 2 mL for the 85% w/w ethanol product). Log₁₀-reduction was calculated.

Results

Volumes < 2 mL yielded high rates of incomplete coverage (67%–87%) whereas volumes ≥ 2 mL gave lower rates (13%–53%). Differences in coverage were significant between the five volumes tested for all handrubs (p < 0.001; two-way ANOVA) but not between the three handrubs themselves (p = 0.796). Application of 1.1 mL of 70% v/v ethanol rubs reduced contamination by 1.85 log₁₀ or 1.60 log₁₀ (ASTM E 1174-06); this failed the US FDA efficacy requirement of at least 2 log₁₀. Application of 2 mL of the 85% w/w ethanol rub reduced contamination by 2.06 log₁₀ (ASTM E 1174-06), fulfilling the US FDA efficacy requirement. Similar results were obtained according to ASTM E 2755-10.

Conclusions

Our data indicated that handrubs based on 70% ethanol (v/v) with a recommended volume of 1.1 mL per application do not ensure complete coverage of both hands and do not achieve current ASTM efficacy standards.

 

Actually, the entire (open access) study is worth reading, but for those not particularly interested in methods and materials, the Discussion at the end wraps things up nicely.  

 

As a former paramedic - I was, and still am - fanatical about hand hygiene. So we’ve looked at the topic of hand washing, and Hospital Acquired Infections (HAIs) often.

Last June, in The Great Unwashed, we looked at a Michigan State University study that found only about 5% of people who were observed in public restrooms washed their hands effectively.   While in Before You Ask To Borrow Someone’s Cell Phone . . . we looked at the degree of fecal (and other) contamination on fomites (inanimate objects like cell phones, keyboards, credit cards, money . . . )

 

We live in a germy world, and you don’t have to work in a hospital or a doctor’s office to be concerned with good hand hygiene.

 

For more on all of this I’d invite you to visit:

 

http://www.globalhandwashingday.org/

 

And the CDC’s hand hygiene website, where you will find many resources, including a link to a new iPad/iPhone application called iScrub.

 

 

 

 

CMAJ: Hand Sanitizers May Be `Suboptimal’ For Preventing Norovirus

 

 

Photo Credit – CDC

 

# 5747

 

While dispensers of alcohol-based hand sanitizers have become ubiquitous in many health care facilities over the past few years, there remain serious questions over just how effective they may be in killing some particularly hearty pathogens.

 

In recent years it has become apparent that alcohol based hand cleansers are not effective at killing the spores of the Clostridium difficile bacteria, and so the CDC offers this advice:

 

How can Clostridium difficile infection be prevented in hospitals and other healthcare settings?

• Use gloves when entering patients’ rooms and during patient care.
• Perform Hand Hygiene after removing gloves.
• Because alcohol does not kill Clostridium difficile  spores, use of soap and water is more efficacious than alcohol-based hand rubs. However, early experimental data suggest that, even using soap and water, the removal of C. diffile spores is more challenging than the removal or inactivation of other common pathogens.
• Preventing contamination of the hands via glove use remains the cornerstone for preventing Clostridium difficile transmission via the hands of healthcare workers; any theoretical benefit from instituting soap and water must be balanced against the potential for decreased compliance resulting from a more complex hand hygiene message.

 

And more recently, we’ve seen increased evidence that these handy hand sanitizers may be `suboptimal’ at killing some nonenveloped viruses (including norovirus), as well.

 

In March of this year, the CDC’s MMWR published a lengthy report that called into question the efficacy of alcohol based products against norovirus:

 

Updated Norovirus Outbreak Management and Disease Prevention Guidelines

(Excerpt)

Overall, studies suggest that proper hand washing with soap and running water for at least 20 seconds is the most effective way to reduce norovirus contamination on the hands, whereas hand sanitizers might serve as an effective adjunct in between proper handwashings but should not be considered a substitute for soap and water handwashing.

 

Today, the CMAJ has an early release news item that summarizes the findings of a couple of recent studies that showed that health care facilities that relied more heavily on alcohol-based sanitizers were more apt to experience outbreaks of norovirus.

 

 

Hand sanitizers may increase norovirus risk

August 10, 2011

 

Alcohol-based hand sanitizers may not be the panacea for hand hygiene they were once supposed, as mounting research indicates they may not be effective substitutes for soap and water, and in some cases may actually increase the risk for outbreaks of highly contagious viruses in health care settings.

 

Public health experts, however, say more rigorous investigations will be necessary to trump the convenience of using hand sanitizers, among other benefits, or substantially alter existing recommendations that strongly encourage their use by health care professionals.

(Continue . . . )

 

You can read the abstract to one of these studies in the May 2011 edition of the  AJIC.

 

Use of alcohol-based hand sanitizers as a risk factor for norovirus outbreaks in long-term care facilities in northern New England: December 2006 to March 2007

 

David D. Blaney, MD, MPH , Elizabeth R. Daly, MPH , Kathryn B. Kirkland, MD ,Jon Eric Tongren, PhD, MSPH , Patsy Tassler Kelso, PhD , Elizabeth A. Talbot, MD

 

Lead author Dr. David Blaney of CDC’s  Epidemic Intelligence Service is quoted in the CMAJ article as saying that alcohol-based hand sanitizers might be, “suboptimal in controlling the spread of noroviruses.”

 

For now, the efficacy of alcohol based hand sanitizers against norovirus remains controversial at best. More, and better studies will be needed before any firm conclusions can be drawn.

 

None of this is to suggest that hand sanitizers are without value.

 

They are fast and easy - which promotes their frequent use - and when used properly they appear effective against a wide variety of bacteria and enveloped viruses, including colds and influenzas.

 

 

But when dealing with a norovirus outbreak, for now the best policy appears to be washing your hands thoroughly with soap and water.