TOPICS IN PATIENT SAFETYVOL. 10, ISSUE 6NOV/DECEMBER2007

ContentsPreventing Healthcare–Associated InfectionsPages 1 and 4

“Ask Me If I’ve Washed My Hands” How Long Do You Wash Your Hands? Page 2

Where Can You Find More Information On Hand HygienePage 3

VA National Center forPatient SafetyP.O. Box 486Ann Arbor, MI 48106-0486

Phone: ................(734) 930-5890Fax: ....................(734) 930-5899E-mail: ................ NCPS@va.gov

Web sites:Internet ....www.patientsafety.govIntranet...vaww.ncps.med.va.gov

VHA Chief Patient Safety OfficerJames P. Bagian, MD, PE

Editor Joe Murphy, APRGraphics Deb Royal Copy Editing Amy Carmack Deb Royal

TIPS is published bimonthly by the VA National Center for Patient Safety. As the official patient safety newsletter of the Department of Veterans Affairs, it is meant to be a source of patient safety information for all VA employees. Opinions of contributors are not necessarily those of the VA. Suggestions and articles are always welcome.

Thanks to all contributors and those NCPS program managers and analysts who offered their time and effort to review and comment on these TIPS articles prior to publication.

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Preventing Health Care–Associated Infections: Empowering Patients and Engaging StaffBy LaToya Miller, MPH, MRSA program manager, VA Pittsburgh Healthcare System

Please use hand sanitizers when entering and exitingthis patient care area.

THANK YOU or doing your part to prevent the spread of infection!

This area is a designated

VHAhaslaunchedanationwidepreventioninitiativeaimedateliminatingMRSA(Methicil-lin-resistant Staphylococcus aureus) infections. “The‘ZEROinginonMRSAInitiative’isamajorparadigmshiftinhealthcarefortheU.S.,”saidProjectDirectorRajivJain,MD,FACP.“Untilafewyearsago,fewhospitalsintheUnitedStatesscreenedpatientstoidentifythosewhosilentlycarryMRSA,agermthathaslearnedtoresistcommonly-usedantibioticsandcaninhabittheskinandmucousmembranesof peoplewhohavenosymptoms.” MRSAcanspreadtootherpatientsviahospitalequip-ment,likewheelchairsandbedrails.Butthebiggestculpritisunsuspectinghealthcareworkerswhosehandshavecasuallytouchedapa-tientorequipment. Althoughimplementationof MRSA-controlprogramsoverthelast25yearshasprovensuccessfulinEurope,conventionalwisdomintheUnitedStatesregardedMRSAasuncontrollable:toomanypeoplehaditandnothingcouldbedonetocontainit.Baseduponpreliminarydatafrompilotfacilitiesthatbeganimplementingthe“ZEROinginonMRSAInitiative”inAu-gust2006,thereisagrowingfeelingthatsome-thingcan bedone. InJanuary2007,VHADirective2007-002wassigned,mandatingthatallVAmedicalfacilitiesbeginthe“ZEROinginonMRSAInitiative”inatleastoneacutecareunit.Imple-mentationthroughoutacutecarewascom-pletedbySeptember30of thisyear.Toviewthedirective,clickon:www1.va.gov/vhapublica-tions/ViewPublication.asp?pub_ID=1525.

Theinitiativewasdevelopedtoreducehospi-tal-acquiredinfectionsthroughamulti-prongedapproachtotheproblem.Wehopeitwillalsoserveasamodelforotherhospitalsthatwanttotakeaproactiveapproach.Theinitiativeisfocusedonfouressentialcomponentsthathavebeencollectivelycoinedthe“VHAMRSABundle.”Theyare:

• ActiveSurveillance• AggressiveHandHygiene• ContactPrecautions• CulturalTransformation

ActiveSurveillanceallowsfor the identification of MRSA carriersthroughasimpleswabof thenose.Everyveteranwhoisadmitted,discharged,oreventransferredbetweenunitshasaswabtestper-formed.ActiveSurveillanceisimportantbecauseitcaniden-tifyapreviouslyunrecognizedreservoirof asymptomaticcar-riersof MRSA.Italsoallows

healthcareworkerstotakeappropriateactionstopreventtransmission. “Assuringthathealthcareworkersappreci-atethedangerthatthe‘silentcarriers’presenttothesafetyof otherpatientsiscrucialtoasuccessfulMRSApreventionprogram,”saidKathleenRisa,MSN,CIC,educationcoordina-tor for the MRSA Program Office. WhileVAhospitalshavehandhygienepro-grams,theinitiative’sAggressiveHandHygieneelementcallsforarevitalizationof thoseprogramswithinnovativeapproachestomoni-torstaff compliance–andincorporatepatientsandvisitors. AtseveralVAmedicalcenters,patientsnowactivelyparticipate,remindingprovidersto

Continued on back page

Page 2

“Ask Me If I’ve Washed My Hands” By Lori Hagen, chief of quality management, James H. Quillen VA Medical Center

TheJointCommissionsurveyorscanobservestaff toseeif theyperformproperhandhygiene.If threeincidentsof non-complianceareobserved,amedicalcenterwillreceivea“Recom-mendationforImprovement,”whichrequiresanimmediateactionplanandmonitoring.(Pleasenotethatthismethodfordealingwithnoncompli-anceisbeingreviewedbytheJointCommission.) Wewanttoprovidesafeandqual-itypatientcaretoourveterans,soourstaff arecontinuouslyremindedtofollowproperhandhygiene.Whenpa-tienttracersarebeingperformed,staff areobservedtoseeif theyareproperlycompletinghandhygiene.Torecognizecompliancetohandhygiene,staff aregivenabuttontowearthatreads:Ask Me If I’ve Washed My Hands.

When You Need to Take Action Whenhandsarevisiblydirty(soiled)orcontaminatedwithproteinaceousmaterial,washthemwithantimicrobialsoapandwaterfor15seconds.Oth-erwise,useanalcohol-basedhandrubfordecontaminatinghands. Remember,staff mustalsowashtheirhandswithsoapandwaterbeforeeating,afterusingthetoilet,orafterworkingwithapatientinfectedwithaspore-formingmicroorganism,suchasClostridium difficile,orapatientwithanorovirusintestinalinfection.

Hand Hygiene Techniques

•Whendecontaminatinghandswithanalcohol-basedhandrub,applytheproducttothepalmof onehandthenrubhandstogether.Coverall

surfaces of the hands and fingers, untildry.Aping-pongballsizeof alcohol-basedfoamisrecommended.

•Whenwashinghandswithsoapandwater, first wet hands with water andthenapplythesoap.Rubhandstogethervigorouslyforatleast15seconds,coveringallsurfacesof thehands and fingers. Rinse hands with wateranddrythoroughlywithadis-posabletowel,usingatoweltoturnoff thefaucet.Avoidusinghotwatersincerepeatedexposuretohotwatermayincreasetheriskof dermatitis.

Beamodelforcorrecthandhygiene:Onepersoncanmakeadifference!Hatsoff tothoseof ourstaff whowereobservedproperlyperforminghandhygieneandarewearingtheirbutton–Ask Me If I’ve Washed My Hands–topromoteawareness.

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How Long Do You Wash Your Hands?By Carol Walden, R.N., James H. Quillen VA Medical Center; photos by Scott Reynolds, the facility’s infection control technologist

Thesehandswerecoatedwith“Glo-Germ,”atoolforteachinghandwashingwithsoapandwater. Whenphotographedunderablacklight,theGlo-Germshowsasblue.After five seconds of washing with soapandwater,thehandsactuallyappeartobemorecontaminated.After10seconds,considerablecontaminationremainsunderthenailsandcuticles,butafter15seconds,thehandsaresubstantiallycleaner. Lesson: Whenusingsoapandwaterforhandhygiene,thehandsmustbewashedforaminimumof 15seconds.

Before After 5 seconds

After 10 seconds After 15 seconds

The above articles were adapted from MountainHomeMatters, July 2007, a publication of the James H. Quillen VA Medical Center.

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Where Can You Find More Information On Hand Hygiene?The NCPS Web Site, Of Course!By Deborah Royal, NCPS visual information specialist

Visitwww.va.gov/ncps/SafetyTopics/HandHygiene/index.htmlforawealthof handhygieneinformationandtoolscollectedand/ordevelopedbyNCPS. Herearesomeof thetopics:

Reference Documents• TheVHADirectiveonHand

HygienePractices.http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1214

• Onepagesummaryforcaregiversonkeypointsof theVHADirectiveonHandHygienePractices.http://www.va.gov/ncps/SafetyTopics/HandHygiene/1PageSummaryHandHygieneCDC.doc

• TheCDCGuidelineonHandHygieneinHealthCareSettings.http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

• Onepagesummaryof allCDCHandHygieneGuidelinerecommendationsrequiredbytheVHADirectiveandtheJointCommission.http://www.va.gov/ncps/SafetyTopics/HandHygiene/1PageSummaryHandHygieneCDC.doc

• PublishedarticleonthejointprojectbetweenVAandthe3MCompanyusingtheSixSigmaprocesstoimplementtheCDCHandHygieneGuideline.http://www.blackwell-synergy.com/doi/pdf/10.1111/j.1525-1497.2006.00361.x

• TheJointCommissionFAQsontheNationalPatientSafetyGoalonhandhygiene.http://www.jointcommission.org/NR/rdonlyres/DBE1118A-8AC1-470E-8089-B40076999655/0/07_NPSG_FAQs_7.pdf

• Handhygienebibliographycreatedforthe“Infection:Don’tPassItOn”campaign.http://vaww.vhaco.va.gov/phshcg/InfectionDontPassItOn/2006-12-21_OLD-HTML-FILES/bib.htm

An Important Question Onefrequentandimportantquestionaskedisthis:Whatdatacanbeacquired,studied,andreturnedtoprovidersandotherhealthcareworkerstobetterunderstandhandhygienepractices?Theanswerissimple:Threedifferenttypes.1.Observedoverallperformanceon

handhygienepractices.2.Quantity(massingrams)of alcohol

basedhandrubusedper100or1,000patientdays.

3.Responsestoquestionnairesregardingattitudesandperceptionsabouthandhygienepractices.

Hand Hygiene Tools• InstructionsforusingThe

HandHygiene/GloveUseObservationTool.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHObservationTool.doc

• Questionnaireformeasuringlocalperceptionsandattitudesregardinghandhygieneinhealthcaresettings.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHQuestionnaire.doc

• Excelspreadsheetforcomputinggramsof alcoholproductusedper100patientdays.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHTool_GramsPer100PtDays.xls

• Excelspreadsheetforcomputinggramsof alcoholproductusedper1,000patientdays.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHTool_GramsPer1000PtDays.xls

• Checklistof interventionsdevelopedintheVA3MSixSigmaProjecttoimprovehandhygienepractices.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHInterventionsVA3M.doc

• DownloadtheIt’s OK to Askbuttonformat.http://www.va.gov/ncps/SafetyTopics/HandHygiene/ItsOKtoAskButtons.doc

• SampledatafromfourVAmedicalcenterintensivecareunits.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHSampleData.doc

• CDCeducationalmaterialstopromotefacilityhandhygiene.http://www.cdc.gov/handhygiene/materials.htm

Web Links • “Infection:Don’tPassiton”

(VHA Office of Public Health and EnvironmentalHazards)andguidetorecommendeduseof relatedposters.http://www.va.gov/ncps/SafetyTopics/HandHygiene/HHPosterExplanations.doc

• CDCHandHygienesite.http://www.cdc.gov/handhygiene/

• UnitedKingdom’sNationalPatientSafetyAgency“CleanYourHands.”http://www.npsa.nhs.uk/cleanyourhands

• HandHygieneResourceCenter(organizedbyDr.JohnBoyce,chairof theCDCcommitteethatdevelopedtheguideline).http://www.handhygiene.org/

• Universityof GenevaHospitalsHandHygiene(ledbyProfessorDidierPittet,MD,MS).http://www.hopisaffe.ch/

• SafeCareCampaign.(Anexcellentresourceforpatientsandfamiliesinterestedinpreventinghealthcare-acquiredinfections.)http://www.safecarecampaign.org/

More AdditionalinformationisavailableforVAemployeesontheNCPSIntranetsite: vaww.ncps.med.va.gov

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Preventing Health Care–Associated InfectionsContinued from page 1

washtheirhands.Atonemedicalcen-ter,aveteranisgivenaredandgreencarduponadmission.Theveteranflashes the green card to indicate that theproviderhasbeenobservedwash-inghisorherhands.Aredcardmeans“pleasestopandwashyourhands.” Notonlyisthisanadditionalmea-sureof assuranceforhandhygiene,butitalsoempowersveteranstobeactiveparticipantsintheircare.Itcanbehardforpatients–especiallyolderpatients–tospeakup;thisgivesthemaneasyandpolitewaytodoso. Atmanymedicalcenters,volunteersareeducatingfamilymembers,caregiv-ers,andvisitorsontheimportanceof handhygiene. Handsanitizersandfoamdispensershavebeenplacedstrategicallythrough-outthehospitals.Nolongeraretheyisolatedinpatientcareareas.Theycannowbeseeninthecafeteriaandrecep-tionareas,alongwithsignageencour-agingstaff,patients,andvisitorsaliketousethem. Thethirdbundleelement,ContactPrecautions,requiresstaff togownandglovewhenprovidingcarethatnecessi-tatesdirectcontactwithanMRSAcol-onizedorinfectedpatient.Nursesandlaboratorystaff collaboratetoensurethat there is a systematic and efficient processinplacetoidentifypatientsthatrequirecontactprecautions. Asaremindertostaff andvisitors,contactprecautionsignsareoftenplacedontheouterdoorof apatient’sroom.Doororwall-mountedcon-tainersstoregowns,gloves,andhandwipesforeasyaccess,andalsoserveasvisualcuesthatprecautionsmustbetaken.Disposableordedicatedpatientequipmentisalsocommonplaceandhelpsreducetheriskof transmission. Somefacilitieshaveevendesignateda“safezone”withineachpatient’sroom, identified by colored tape or tile, wheregowningandglovingarenotnecessary.Beyondthesafezoneareitemstowhichthepatienthasaccess

andarethereforelikelytobecontami-nated. Cultural Transformation is the final element,andisarguablythedrivingforceinsustainingtheprogramasawhole.ThroughCulturalTransforma-tion,staff areencouragedtoproposenewideasandpracticesintheirownuniquecultureandenvironment.Inthisway,theprogramisinherentlyculturallyappropriateandstaff-owned.Thisshiftalsoemphasizesthecollectiveeffortsof allstaff ininfectioncontrol. Nolongerispreventioncompart-mentalizedsolelytotheinfectioncontroldepartment.Eachstaff person–fromdirector,todietician,tohouse-keeper–hasanimportantroleinpre-ventingthetransmissionof MRSA.“Itis a significant change in the way we’ve operatedinthepast,”notedDr.Jain.“Themorepeopleweinvolve,thebetterourresult–successcomesmorequickly.” CulturalTransformationalsofocusesonmovingbeyondthetraditional,top-downleadershipapproachtodo-ingbusiness.Instead,leadershipsup-portsstaff ideasandsolutions,whileworkingtoremovebarrierstoimple-mentation. “Tappingthepowerfulenthusiasmandresourcesof allemployeesmakestheprogramsustainable,”saidMs.Risa.“Staff owntheprogramandareinvestedinthesuccessof theprogram.It’stimetothinkoutsidetheboxandourstaff areuptothetask.” VHA provided financial support for theinitiativethroughtheapprovalof a$30millionbudgetinApril,includingfundstosupportlaboratoryequip-ment,generalsupplies,andadditionalstaff positions. Onesuchpositionisthenewlycre-atedroleof MRSAPreventionCoor-dinator(MPC),developedtomanagetheprogramonaday-to-daybasis.“Wehavefoundinourpilotsites,thatadedicatedpositionisintegraltothesuccessof theprogram.Therearesim-

plyfartoomanyaspectstocoordinatewhenyouconsiderthisprogramwillultimatelycoverallof acutecare,long-termcare,andbehavioralhealth.Ididnotwanttoseethisprogramforceduponouralreadyoverburdenedinfec-tioncontrolpersonnel,”saidDr.Jain. Eachfacilityhashiredorisrecruit-ingforanMPC,whosedutiesincludecoordinatingwithinfectioncontroltotrackandreportMRSArates,andtoensurethatpatientsandstaff receiveappropriateeducationalmaterial.Tohelpfocustheirefforts,manyMPCsattendedatwo-dayMRSAPreventionCoordinatorTrainingthispastSep-tember,offeredbytheMRSAProgramOffice. InearlyNovember,aNationalMRSAPreventionForumisscheduledtobeheldinOrlando,Fla.Itwillbringtogetherbothadministrativeandclini-calrepresentationfromeachVAfacil-itytosharebestpracticesandaccom-plishmentsof theprogramthusfar. Duringtheconference,thenextphaseof implementationwillbeunveiled,whichincludesexpansionintolong-termcareandbehavioralhealth, slated to begin in early fiscal year2008.Otherhighlightsincludeapostersession,vendorfair,andkeynotespeakersfromtheCentersforDiseaseControlandPrevention,aswellasanexpertfromtheNetherlands. Asthelargestintegratedhealthcaresysteminthecountry,VHAhastrulytakentheleadinthewaragainstMRSAthroughtheestablishmentof thisnationwidepreventionstrategy.VHAwillcontinuetotakeboldstepstowardeliminatingMRSAandotherhospi-tal-acquiredinfections.Preventionof MRSAisonlypossiblewhenpreven-tionbecomeseveryone’sresponsibility! FormoreinformationontheVHAMRSAInitiative,contacttheprogramoffice at 412-688-6231. VAemployeescanalsovisitourwebsite:vaww.va.gov/pittsburgh/mrsa/mrsa_home.htm