11

CDC Hand Hygiene CDC Hand Hygiene Guidelines, JCAHO, VA Guidelines, JCAHO, VA

NCPS, NFPA, 3M Corp, and NCPS, NFPA, 3M Corp, and Six SigmaSix Sigma

Noel E. Eldridge, MSNoel E. Eldridge, MS

Joseph M. DeRosier, PE, CSPJoseph M. DeRosier, PE, CSPVHA National Center for Patient SafetyVHA National Center for Patient Safety

22

CDC Guidelines Recommendations CDC Guidelines Recommendations - 44 in 8 Categories- 44 in 8 Categories

1. Indications for handwashing and hand antisepsis (14)1. Indications for handwashing and hand antisepsis (14)2. Hand-hygiene technique (4)2. Hand-hygiene technique (4)3. Surgical hand antisepsis (5)3. Surgical hand antisepsis (5)4. Selection of hand-hygiene agents (5)4. Selection of hand-hygiene agents (5)5. Skin care (2)5. Skin care (2)6. Other Aspects of Hand Hygiene (6)6. Other Aspects of Hand Hygiene (6)7. Health-care worker educational and motivational 7. Health-care worker educational and motivational

programs (3)programs (3)8. Administrative measures (5)8. Administrative measures (5)

Total Length: 1350 words in 45 page documentTotal Length: 1350 words in 45 page document

33

JCAHO Involvement

New JCAHO Patient Safety Goal for 2004: – 7a: “Comply with current CDC hand-hygiene

guidelines.”

Making it a Patient Safety “Goal” for 2004 has transformed the CDC “Guidelines” into JCAHO “Requirements”

44

VHA Summary of JCAHO-required VHA Summary of JCAHO-required CDC Recommendations CDC Recommendations

(19 in 4 categories)(19 in 4 categories)

I.I. All Health Care Workers with Direct Patient All Health Care Workers with Direct Patient Contact (8)Contact (8)

II.II. Surgical Hand Hygiene (3)Surgical Hand Hygiene (3)

III.III. Facility Management: Supplies (5)Facility Management: Supplies (5)

IV.IV. Facility Management: Administrative Action (3)Facility Management: Administrative Action (3)

Total Length: 732 words (minus 45%)Total Length: 732 words (minus 45%)

http://vaww.ncps.med.va.gov/Hand_Hygiene/index.htmlhttp://vaww.ncps.med.va.gov/Hand_Hygiene/index.html

55

New National Guidance on the Use of New National Guidance on the Use of Alcohol HandrubsAlcohol Handrubs

On April 28, 2004, the NFPA announced the On April 28, 2004, the NFPA announced the amendment of the 2000 and 2003 editions of the amendment of the 2000 and 2003 editions of the Life Safety Code (LSC) to specifically recognize Life Safety Code (LSC) to specifically recognize and permit the use of alcohol-based hand rub and permit the use of alcohol-based hand rub solutions in patient rooms, corridors, and suites solutions in patient rooms, corridors, and suites of healthcare facilities. of healthcare facilities. 

VHA gave the same basic OK to VAMCs in VHA gave the same basic OK to VAMCs in December 2003 via a memo from the USHDecember 2003 via a memo from the USH

66

LocationsLocationsPatient care roomsPatient care roomsSuites of rooms (ICU, Urgent Care, Suites of rooms (ICU, Urgent Care, Radiology, etc.)Radiology, etc.)Corridors that have >72” of clear width if Corridors that have >72” of clear width if spaced at least 48 inches apartspaced at least 48 inches apart– Corridors may not be carpeted unless Corridors may not be carpeted unless

sprinkler protectedsprinkler protected– Dispensers may not project > 6” into corridor Dispensers may not project > 6” into corridor

egress widthegress width– Not over, or adjacent to, ignition sourcesNot over, or adjacent to, ignition sources

77

QuantitiesQuantitiesMaximum In UseMaximum In Use– 1.2 liters (0.32 gallons) per dispenser in rooms & 1.2 liters (0.32 gallons) per dispenser in rooms &

corridorscorridors– 2.0 liters (0.53 gallons) per dispenser in suites of 2.0 liters (0.53 gallons) per dispenser in suites of

roomsrooms– 37.8 liters (10 gallons) per smoke compartment37.8 liters (10 gallons) per smoke compartment

Maximum Storage per smoke compartmentMaximum Storage per smoke compartment– 18.9 liters (5 gallons) outside of approved storage 18.9 liters (5 gallons) outside of approved storage

cabinetscabinets– 456 liters (120 gallons) inside approved storage 456 liters (120 gallons) inside approved storage

cabinetscabinets

Maximum Storage in the BuildingMaximum Storage in the Building– 2508 liters (660 gallons) with fire sprinklers and 2508 liters (660 gallons) with fire sprinklers and

storage to a maximum height of 5 feetstorage to a maximum height of 5 feet

88

3M Six Sigma Process3M Six Sigma Process

Five Steps in Six Sigma Five Steps in Six Sigma Process…Process…

1.1. DefineDefine

2.2. MeasureMeasure

3.3. AnalyzeAnalyze

4.4. ImproveImprove

5.5. ControlControl

99

Define (Define (DDMAIC)MAIC)

Desire is to reduce hospital and healthcare Desire is to reduce hospital and healthcare acquired infections (bloodstream, wound, acquired infections (bloodstream, wound, respiratory, urinary tract, etc.)respiratory, urinary tract, etc.)

No present way to measure these No present way to measure these infections consistently across VAMCsinfections consistently across VAMCs

Decided to focus on improving hand Decided to focus on improving hand hygiene practices in ICUs, based on the hygiene practices in ICUs, based on the provisions of the CDC Guidelinesprovisions of the CDC Guidelines

1010

Step 5-HCW uses HH supplies

Step 1-HCW (Health Care Worker) arrives at patient bedside

Step 2-HH (Hand Hygiene) opportunity/requirement arises

Step 3-HCW decides to use HH products

Step 4-HCW seeks supplies

Step 9 - HCW exits

Step 6-HCW examines patient/uses equipment

Step 7-HCW decides to use HH materials again on exit

Step 8-HCW uses HH materials on exit /between patients

6 Sigma Hand Hygiene Process Map6 Sigma Hand Hygiene Process Map

1111

Measure (DMeasure (DMMAIC)AIC)

What we’re measuring:What we’re measuring:– Hand Hygiene compliance (via “watching’)Hand Hygiene compliance (via “watching’)– Quantity of alcohol handrub used per 100 Quantity of alcohol handrub used per 100

patient dayspatient days– Use of antimicrobial soap rather than non-Use of antimicrobial soap rather than non-

antimicrobialantimicrobial– No artificial fingernailsNo artificial fingernails– Staff attitudes about hand hygiene practicesStaff attitudes about hand hygiene practices– Staff satisfaction with hand hygiene practicesStaff satisfaction with hand hygiene practices

1212

Measure (DMeasure (DMMAIC)AIC)

Foam and gel dosage not simple…Foam and gel dosage not simple…– How big is the blob or how many squirts?How big is the blob or how many squirts?

Antimicrobial soap availability (122 Antimicrobial soap availability (122 VAMCs) in Dec 2003VAMCs) in Dec 2003– 36% antimicrobial only36% antimicrobial only– 44% both44% both– 20% non-antimicrobial only 20% non-antimicrobial only

Staff think they are doing ~90% when Staff think they are doing ~90% when watchers data shows ~40-60%watchers data shows ~40-60%

1313

Measure (DMeasure (DMMAIC)AIC)

How many “doses” do you get from a 15 How many “doses” do you get from a 15 oz. can Foam?oz. can Foam?– 15 oz. (425g) can says use “5g (palmful)”15 oz. (425g) can says use “5g (palmful)”

But 5g of foam is about 80 ml…& only 85 dosesBut 5g of foam is about 80 ml…& only 85 doses– (This is ridiculous)(This is ridiculous)

– 7 oz. can says “palmful”7 oz. can says “palmful”– How much is a palmful???How much is a palmful???

1414

Measure (DMeasure (DMMAIC):AIC): Palmful Palmful

1515

This isn’t lunchThis isn’t lunch

1616

Measure (DMeasure (DMMAIC):AIC): Doses… Doses…

15 oz. can yielded 204 doses in Noel’s kitchen 15 oz. can yielded 204 doses in Noel’s kitchen test (2.0” diameter dose)test (2.0” diameter dose)

Recalculating to a 1.75” diameter doses resulted Recalculating to a 1.75” diameter doses resulted in 300 per can (1.4g and 23 ml)in 300 per can (1.4g and 23 ml)

For Isagel, we assumed 2 pumps per dose, For Isagel, we assumed 2 pumps per dose, tested to 1.6 ml (1.4g) and 380 doses in 21 oz.tested to 1.6 ml (1.4g) and 380 doses in 21 oz.

Hard to compare across sites… we may Hard to compare across sites… we may recommend using yourself as a controlrecommend using yourself as a control

Good rule may be “30 seconds worth” of productGood rule may be “30 seconds worth” of product

1717

Analyze (DMAnalyze (DMAAIC) IC) Count

Perc

ent

Reasons

Count40.0 25.2 10.4 8.7 7.0 4.3 4.3

Cum % 40.0 65.2

46

75.7 84.3 91.3 95.7 100.0

29 12 10 8 5 5Percent

120

100

80

60

40

20

0

100

80

60

40

20

0

Pareto Chart of Reasons

1818

KEY PROBLEMsKEY PROBLEMs SIX SIGMA RESPONSE SIX SIGMA RESPONSE

Access to productAccess to product

Patient Empowerment Patient Empowerment and Awarenessand Awareness

Staff Awareness of Staff Awareness of Requirements and how Requirements and how they improve patient they improve patient outcomesoutcomes

Hand Hygiene CultureHand Hygiene Culture– ““The way we do things The way we do things

around here…”around here…”

Physical interventions – antimicrobial Physical interventions – antimicrobial soap; new BPS for 2 oz. pocket sized soap; new BPS for 2 oz. pocket sized rub on lanyard; product by patient rub on lanyard; product by patient beds and in halls; Lotion requirement; beds and in halls; Lotion requirement;

Posters for patients and visitors; Posters for patients and visitors; patient folder inserts, buttons for staff patient folder inserts, buttons for staff to wear (encourage asking about HH)to wear (encourage asking about HH)

Posters for staff only areas – what the Posters for staff only areas – what the requirements are; communication of requirements are; communication of watcher results and product use; watcher results and product use; provide evidence that outcomes can provide evidence that outcomes can be improvedbe improved

Posters on how to remind; how to Posters on how to remind; how to reply; system of reminders (lines on reply; system of reminders (lines on floor); directives, letters, binders, web floor); directives, letters, binders, web sites; IT’S OKAY TO ASK!sites; IT’S OKAY TO ASK!

1919

Improve (DMA(DMAIIC)C): Usage

Month

Ind

ivid

ua

l V

alu

e

Mar-04F eb-04Jan-04Dec-03Nov -03O ct-03Sep-03A ug-03Jul-03

4000

3000

2000

1000

_X=2602

UC L=3711

LC L=1493

Baseline Intervention

Month

Mo

vin

g R

an

ge

Mar-04Feb-04Jan-04Dec-03Nov-03Oct-03Sep-03Aug-03Jul-03

1500

1000

500

0

__MR=417

UCL=1362

LCL=0

Baseline Intervention

I-MR Chart of Doses Alcohol/100 patient days by Timing

2020

Control (DMAIControl (DMAICC): ): No backsliding!No backsliding!1.1. Product Use Product Use

• antimicrobial soap in antimicrobial soap in placeplace

2.2. Product Use Product Use • lotion availablelotion available

3.3. Product Use Product Use • monthly vol./100 patient monthly vol./100 patient

days of alcohol productdays of alcohol product4.4. Alcohol product dispensers Alcohol product dispensers

in ICU locations (1 per bed & in ICU locations (1 per bed & +0.5/pt. in corridor)+0.5/pt. in corridor)

5.5. Pocket-sized alcohol product Pocket-sized alcohol product available to staffavailable to staff

6.6. Artificial nails – none on Artificial nails – none on those who touch patientsthose who touch patients

7.7. HH compliance HH compliance • assessed by watcher assessed by watcher

datadata

8.8. Posters up based on survey, Posters up based on survey, FMEA, etc.FMEA, etc.• patient care areas patient care areas • visitor waiting areavisitor waiting area• staff-only areastaff-only area

9.9. VAMC HH policy updatedVAMC HH policy updated10.10. VAMC (annual) Staff VAMC (annual) Staff

Training updatedTraining updated11.11. VAMC New Employee VAMC New Employee

orientation updatedorientation updated12.12. Information for Patients and Information for Patients and

Families (in admission Families (in admission folder) folder)

13.13. National Directive updated - National Directive updated - based on CDC Guidelines based on CDC Guidelines and Dec 2003 USH and Dec 2003 USH memorandummemorandum

2121

When Should I Perform Hand

Hygiene? BEFORE

–– Touching a patientTouching a patient–– Donning sterile gloves f or any Donning sterile gloves f or any

procedureprocedure–– EatingEating

AFTER–– Touching a patientTouching a patient–– Removing glovesRemoving gloves–– Hands become visibly soiled or Hands become visibly soiled or

contaminatedcontaminated–– Using the restroomUsing the restroom

HH6S17

W hat ar e t he t op 1 0 car r ier s of inf ect ious agent s?

1

2 3

U se an alcohol handr ub or ant imicr obial soap t o

decont aminat e your hands.

H H 6 S 1 5

4

5 67 8 9

1 0

22

The Juice is Worth the Squeeze.

The extra effort you put forth to decontaminate your hands before and after touching a patient is worthwhile.

Using an alcohol hand- rub rather than soap can reduce hospital-

acquired infections by 30% or more.

Seeing isn’t believing…

(Not for germs.)

When it comes to microorganisms your eyes can’t be trusted. Neither can your sense of touch. Hands that feel and look clean after washing with regular soap and water can still have multitudes of live bacteria, fungi, and virus particles on them. Your hands may not always feel cleaner after using an alcohol hand-rub, but they will harbor very few microbes. Studies show that alcohol hand-rubs kill over 99% of most micro-organisms. Use an alcohol hand-rub to decontaminate your hands before and after touching each patient.

2323

A Quick Test

When a colleague or patients asks: “Did you practice hand hygiene?”, should you reply:

A) “Thank you! I did.”B) “I f orgot – but thanks f or

reminding me!”C) No verbal reply - just look at

the person like they are a total moron.

D) “Who are you – the J CAHO inspector?”

Correct answers are A or B.Remember, clean hands save lives.

HH6S12

Patients and families:

It’s okay to askhealthcare providers if they have cleaned

their hands.

HH6S18

2424

3M-VHA Six Sigma Team Members3M-VHA Six Sigma Team Members

Dr. Robert Bonello, Dr. Robert Bonello, Minneapolis VAMCMinneapolis VAMC

Kay Clutter, Minneapolis Kay Clutter, Minneapolis VAMCVAMC

Linda Danko, Infectious Linda Danko, Infectious DiseasesDiseases

Dr. Edward Dunn, NCPSDr. Edward Dunn, NCPS

Noel Eldridge, NCPSNoel Eldridge, NCPS

Leann Ellingson, Leann Ellingson, Minneapolis VAMC Minneapolis VAMC

Mary Ann Harris, Fayetteville Mary Ann Harris, Fayetteville (AR), VAMC(AR), VAMC

Barbara Livingston, Des Barbara Livingston, Des Moines VAMCMoines VAMC

Renee Parlier, VHACO (10NC)Renee Parlier, VHACO (10NC)Cheryl Pederson, 3MCheryl Pederson, 3MKim Reichling, 3MKim Reichling, 3MDr. Gary Roselle, Infectious Dr. Gary Roselle, Infectious

Diseases Diseases Susan Woods, 3MSusan Woods, 3M Dr. Steven Wright, OQPDr. Steven Wright, OQP

2525

Final ThoughtsFinal Thoughts1.1. History tells us at least one thing we know History tells us at least one thing we know

doesn’t work: Just telling people to doesn’t work: Just telling people to “frequently” wash their hands with soap and “frequently” wash their hands with soap and water. That’s what resulted in 5% of water. That’s what resulted in 5% of inpatients with nosocomial infections.inpatients with nosocomial infections.

2.2. Improvements are not always common Improvements are not always common sense, for example:sense, for example:

– Evidence suggests that shorter surgical scrub Evidence suggests that shorter surgical scrub times and not using a brush are same or bettertimes and not using a brush are same or better

– Alcohol products easier on hands than soaps Alcohol products easier on hands than soaps – Cleaner-feeling hands may have more Cleaner-feeling hands may have more

microorganisms (soap vs. alcohol handrub)microorganisms (soap vs. alcohol handrub)

2626

If this cat can do this…If this cat can do this…

You can tell anyone to decontaminate their hands!

2727

Hand Hygiene Questionnaire Results - DRAFT DATAHand Hygiene Questionnaire Results - DRAFT DATA YesYes NoNo

Question 1:Question 1: Is your facility presently using regular (non- Is your facility presently using regular (non-antimicrobial soap) for staff hand washing in patient care antimicrobial soap) for staff hand washing in patient care areas*areas*

6868 56%56% 5454 44%44%

Question 2: Question 2: Is your facility presently using antimicrobial soap Is your facility presently using antimicrobial soap for staff hand washing patient care areas?*for staff hand washing patient care areas?*

9898 80%80% 2424 20%20%

Question 2a: If Yes to 2, what brand and specific type (product Question 2a: If Yes to 2, what brand and specific type (product name or number)? name or number)?

     

  Gojo/Provon:Gojo/Provon: 1919 19%19%

Steris:Steris: 5454 55%55%

Other:Other: 2525 26%26%

   YesYes NoNo

Question 3:Question 3: Is your facility presently using an alcohol gel or Is your facility presently using an alcohol gel or foam for hand antisepsis in patient care areas? foam for hand antisepsis in patient care areas?

119119 98%98% 33 2%2%

3a. If Yes to 3, what brand and specific type (product name or 3a. If Yes to 3, what brand and specific type (product name or number, and dispenser size(s))? number, and dispenser size(s))?   

Brand/Product Names:Brand/Product Names:

Ecolab:Ecolab:7272 61%61%   

Coloplast:Coloplast:2929 24%24%   

OtherOther 1818 15%15%      

2828

I. All Health Care Workers With Direct Patient Contact1) Use an alcohol hand-rub or antimicrobial soap to routinely decontaminate

your hands before and after you touch a patient.Note: A single act of hand “washing” (with an alcohol hand-rub or an antimicrobial soap) after one patient and before the next patient suffices to decontaminate your hands if you are not recontaminating your hands in-between patients (as in talking on the telephone, handling objects, etc.). A good rule of thumb is that if you apply an alcohol hand-rub as you leave one patient and are still rubbing your hands together as you arrive at the next patient then there is no need to repeat hand antisepsis.

2) Put gloves on before you touch non-intact skin, blood, mucous membranes, or potentially infectious materials such as soiled linens.

3) Use an alcohol hand-rub or antimicrobial soap before donning sterile gloves when inserting a central venous catheter, an indwelling urinary catheter, a peripheral vascular catheter, or performing other similar invasive procedures.

4) Remove gloves after caring for a patient or touching potentially infectious materials, and use an alcohol hand-rub or antimicrobial soap to decontaminate your hands after removing gloves.

5) Healthcare workers that may have direct contact with patients at high risk for infection must not wear artificial fingernails.

6) Wash your hands with soap and water if they are visibly soiled or contaminated with body fluids.

7) Wash hands with soap and water after using a restroom.8) Wash hands with soap and water before eating.

2929

II. Surgical Hand Hygiene1) Before donning sterile gloves for surgical procedures use either an

antimicrobial soap or an alcohol-based hand-rub with persistent activity.2) When using an alcohol-based surgical hand-scrub product with persistent

activity, follow the manufacturer’s instructions. Usage protocols may vary by manufacturer. For example, some products recommend that health care workers dip each fingernail in the antimicrobial solution prior to applying the product to their hands and forearms.Note: Most alcohol hand-rub products designed for non-surgical applications do not have persistent activity. “Persistent activity” is not a characteristic of alcohol, but is a characteristic of most other antimicrobial agents such as Chlorhexidine Gluconate, which are added to the alcohol-based products and soaps designed for use by surgeons. Consult infection control staff if you have questions on the appropriate use of alcohol-based surgical scrub products.

3) When performing surgical hand antisepsis using an antimicrobial soap, long scrub times (e.g., 10 minutes) are not necessary. Scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 to 6 minutes.

3030

III. Facility Management (Supplies)1) Provide an alcohol-based hand-rub at the entrance to the patient’s room and/or

at the bedside, as well as other convenient locations. To provide an alternative to alcohol-based hand-rubs for decontaminating hands, provide antimicrobial soap in all patient care areas where soap is provided (i.e., at all sinks with a soap dispenser).

2) Make pocket-sized containers of alcohol hand-rub available to HCWs. Note: This does not imply a requirement for HCWs to carry pocket-sized alcohol hand-rubs.

3) Provide healthcare workers with hand lotions or creams to minimize irritant contact dermatitis.Note: Be sure to provide products designed for healthcare applications that do not reduce the effectiveness of other hand hygiene products, such as gloves and antimicrobial compounds, e.g., Chlorhexidine Gluconate (CHG). Some lotions are specifically advertised as “CHG compliant.” Providing lotion should not be seen as a frill.

4) Do not add soap to partially empty dispensers. “Topping off” soap dispensers can lead to bacterial contamination.Note: This means that in patient care settings soap should be provided in disposable bladders or other products that prevent old and new soap from mixing.

5) Store supplies of alcohol-based hand-rubs in cabinets or areas approved for flammable materials.

3131

IV. Facility Management (Administrative Action)1) Make improved hand-hygiene an institutional priority and provide

administrative and financial support. Note: Financial support includes providing adequate supplies of alcohol hand-rubs (wall mounted and pocket-sized), antimicrobial soaps, gloves (regular and sterile), and lotion.

2) Solicit input from employees regarding the feel, fragrance, and skin tolerance of products, such as soap, alcohol hand-rub and gloves.

3) Monitor health care workers’ adherence to hand-hygiene practices and provide information regarding the workers’ performance.