Save Lives - Clean Your Hands

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


Situations illustrating clean/aseptic


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.


Situations illustrating body fluid exposure


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)


Situations illustrating direct


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


Situation illustrating contacts with patient


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

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Save Lives - Clean Your Hands