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Dr. Longtin will present the 10 principal factors which explain the poor compliance of health care workers to hand hygiene practices and will offer solutions to help resolve the issue. At the end of the lecture, the participant will have the background information to formulate arguments to promote good hand hygiene practices.
Citation preview
The 10 obstacles to
Yves Longtin MD Microbiologist-infectious disease specialist CHUQ-CHUL and IUCPQ Universiteacute Laval
Hand hygiene
Once upon a timehellip in 1842
Rate of maternal mortality
bull 16 in division I ndash Residents
bull 7 in division II
ndash Midwives
bull Very rare at homehellip
Ignaz Philipp Semmelweis
1818-65
A cluehellip
bull A pathologist cut his finger during an autopsyhellip
bull He died not long after of an illness similar to puerperal fever
Jakob Kolletschka (1803-1847)
Sir William Osler 1907
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Once upon a timehellip in 1842
Rate of maternal mortality
bull 16 in division I ndash Residents
bull 7 in division II
ndash Midwives
bull Very rare at homehellip
Ignaz Philipp Semmelweis
1818-65
A cluehellip
bull A pathologist cut his finger during an autopsyhellip
bull He died not long after of an illness similar to puerperal fever
Jakob Kolletschka (1803-1847)
Sir William Osler 1907
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Rate of maternal mortality
bull 16 in division I ndash Residents
bull 7 in division II
ndash Midwives
bull Very rare at homehellip
Ignaz Philipp Semmelweis
1818-65
A cluehellip
bull A pathologist cut his finger during an autopsyhellip
bull He died not long after of an illness similar to puerperal fever
Jakob Kolletschka (1803-1847)
Sir William Osler 1907
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Ignaz Philipp Semmelweis
1818-65
A cluehellip
bull A pathologist cut his finger during an autopsyhellip
bull He died not long after of an illness similar to puerperal fever
Jakob Kolletschka (1803-1847)
Sir William Osler 1907
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
A cluehellip
bull A pathologist cut his finger during an autopsyhellip
bull He died not long after of an illness similar to puerperal fever
Jakob Kolletschka (1803-1847)
Sir William Osler 1907
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Sir William Osler 1907
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Pre-dated by 15 years Pasteurrsquos 1861 work ldquoMeacutemoire sur les corpuscules organiseacutes qui existent dans latmosphegravere Examen de la doctrine des geacuteneacuterations spontaneacuteesrdquo which discussed structured bodies present in the atmosphere and the doctrine of spontaneous generation
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Robert Tom American 1915-1979 Semmelweis ndash Defender of Motherhood Oil on canvas Collection of the University of Michigan Health System 472
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Semmelweisrsquos before-and-after study
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Puerperal fever monthly mortality rates for the First Clinic at Vienna Maternity Institution 1841ndash1849 Rates drop markedly when Semmelweis implemented chlorine hand washing mid-May 1847
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Semmelweis bull Despite darrin infection rate to lt 1
ndash Idea conflicted with medical establishment of the time
ndash Doctors offended at the idea of having to wash their hands
ndash Semmelweis did not have a scientific explanation for the
mechanism
ndash Deterioration in work relationships
ndash Conflict with other scientists
ndash Depression
ndash Admission to psychiatric asylum
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Importance recognized
Pittet D et al Lancet 2000
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The 10 obstacles to
Hand hygiene
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Lack of
KNOWLEDGE 1
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene Indications
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene Indications 2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16)1-44 2002
2002 2006
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
WHO 2009
httpwhqlibdocwhointpublications20099789241597906_engpdf
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Indications
Adapted from Sax H J Hosp Infect 2007
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Many countries worldwide are committed to improving hand hygiene
Source WHO Current status March 2011
Countries committed in 2005 2006 2007 and 2008 Countries planning to commit in 2009
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
WHOrsquos indicationshellip
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The indications in Scotlandhellip
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The indications in Belgiumhellip
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The indications in Spainhellip
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The indications in Brazilhellip
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The indications in Canada
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CONCEPT OF ldquoPATIENT ZONErdquo
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CONCEPT OF ldquoPATIENT ZONErdquo
X
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Perform hand hygiene before touching a patient or hisher surroundings
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Perform hand hygiene - before touching non-intact skin or mucous membranes - before handling invasive equipment
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Perform hand hygiene after contact with body fluids excretions mucous membranes non-intact skin or bandages
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The indications in Canada
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Believing that
COMPLIANCE IS EXCELLENT
2
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Compliance measurement
Required Organizational Practice Standardized by WHO
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Compliance in Switzerland
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene Compliance
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Institut de Cardiologie et de Pneumologie de Queacutebec
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
30 (gt2300 opportunities observed)
44
Overall compliance rate of caregivers with regard to hand hygiene (2012-2013)
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
26685029127
94215 424999
18491418144
66232
5201254
0102030405060708090
100
Avant le contact initial avec le patient ou son environnement
Avant deffectuer une proceacutedure aseptique
Apregraves une exposition agrave des liquides organiques
Apregraves le contact avec le patient ou son environnement
Ta
ux
do
bs
erv
an
ce
()
Indications pour lhygiegravene des mains
Taux dobservance de lhygiegravene des mains par indication pour lensemble des travailleurs de lIUCPQ
Anneacutee 2009-2010
Anneacutee 2010-2011
Anneacutee 2012-2013
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Indications Fait reacutefeacuterence aux 4 indications pour proceacuteder agrave lhygiegravene des mains middot Avant le contact initial avec le patient ou son environnement middot Apregraves une exposition avec des liquides organiques middot Avant deffectuer un acte aseptique middot Apregraves le contact avec le patient ou son environnement
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CHUQ 2011-2012
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
33 43 82250 153353
Compliance rate CHUQ
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
X Hospital Province of Quebec
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
23 63
0
75
32141
68
122192
09
Compliance rate X Hospital
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
23 63
0
75
32141
68
122192
09
Compliance rate CHRDL
Most room for improvement in terms of and volume of
opportunities
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Poor
M O M E N T
3
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The ideal moment to perform hand hygiene
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Not
4
B E L I E V I N G
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
FACT
bull A number of ldquobefore-and-afterrdquo-type studies
bull Not many randomized controlled trials
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
MYTH
bull A randomized controlled trial is the only way
FALSE for infection prevention
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Methodology for studies on hand hygiene
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Proven effectiveness WHO 2009
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The ldquoultimaterdquo study will probably never take place
Compliance already high or Lack of outcome indicators
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Surgery in the 19th century
Carbolic acid sprayer at the operating field J Lister (1867) Unpleasant smell for the surgeonshellip
The solution
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Culture
L A I S S E Z - FA I R E
5
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Laissez-faire culture
bull The importance of hand hygiene not taken seriously
bull Systematic errors are tolerated
bull Hand hygiene not taken seriously
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Ponce de Leon Rosales S et al Lancet Infect Dis 2005 Mar5(3)131-2
02 compliance
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
bull 29 videos released 2006-2009 ndash 206 minutes in total
ndash 66 indications in which hand hygiene mentioned or illustrated were identified
bull 1666 mentioned only bull 1416 washing with water rather than
ABHRs
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Confusing
6
ABHRs AND SOAP
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Num
ber
of g
erm
s on
han
ds
5 10 15 20 25 seconds
Duration of hand rubbing
Application of solution
-9999
ABHRs are bull more effective bull quicker
ABHRs vs Soap
-99
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Specific indications for washing with soap and water
bullVisible contamination with blood or other body fluids
bullHands visibly dirty
bullExposure to spore-forming bacteria
bullClostridium difficile bullBacillus anthracis
bullAfter using the restroom
Choice of hygiene technique
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Handwashing with ABHR after 7-10 HH opportunities
bullNot a real indication
bullA myth that persists in hospitals
bullInvented by ABHR companies bullTo avoid sticky hands and build-up of residue
bullMisinterpreted by caregivers bullGreater effectiveness of handwashing
Choice of hygiene technique
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
uarr History of atopy uarr Winter minus Gloves
ABHRs cause less irritation than soap
WITH EQUAL USE
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
All of these products contain
Glycerine
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
dermatitis Damaged skin is more difficult to disinfest Higher bacterial load
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Complications
Strategies for preventing irritation
bullUse protective creams
bullUse ABHRs rather than soap and water
bullDo not use water that is too hot bullDo not wear gloves unnecessarily
bullDry your hands completely before putting on gloves
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Competing for
A T T E N T I O N
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Doctorsrsquo schedules bull Multi-taskinghelliphellip 24 of the time
ndash Eg Patient documentation and talking to colleague
bull Interruptions and problems 112 timeshour
bull Telephone calls 7day
bull Pager ndash 1 page 69 minutes for surgeons
on duty
Chiu T et al N Z Med J 2006 Mar 31
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Not making it a
REFLEX
8
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
How to compete with a host of other priorities
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene and Remote Video Auditing
bull 17-bed ICU ndash Cameras placed in front of every sink and ABHRS
dispenser
ndash Sensors in doorways to detect HCW movement
ndash Monitoring 247 (outsourcing of evaluation)
ndash 107 week before-and-after study
ndash Feedback to HCWs provided in real-time bull Electronic boards bull Emails
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene and Remote Video Auditing
Armenillo D et al Clin Infect Dis 201254(1)1ndash7
75-week maintenance period 298 860 HH opportunities 262 826 in compliance (879)
16 prefeedback weeks 60 542 hand hygiene opportunities 3933 in compliance (65)
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand Hygiene and Remote Video Auditing bull Why this study matters
ndash The most effective way to improve HH compliance ndash The most HH observations made ndash The highest compliance rate ever observed ndash Very long maintenance phase
bull Took a pragmatic approach to HH indications
ndash Not WHO recommendations ndash Maybe key to success
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
GLOVES
9
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Gloves
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Proper use of gloves
2 uses for procedure gloves
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Gloves Protection in case of
accidental pricking Reduce the amount of
blood at the surface of the needle by 86
But no change inside the
needlehellip
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Wear gloves when you are taking care of patients carrying multi-resistant germs
(MRSA VRE ESBLhellip)
Proper Use of Gloves
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves Defects or re-contamination
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Wearing gloves and HH
bull Wearing of gloves associated with lower HH compliance ndash OR 065 (95 CI 054-079)
Fuller C et al Infect Control Hosp Epidemiol 201132(12)1194-1199
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Wearing gloves
IS NOT a substitute for hand hygiene
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
10 A bonushellip
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Microbes
I N V I S I B L E
10
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Objective
Set an objective of systematically performing HH in front of each patient
bull Not too soon but not too late bull Even if wearing gloves bull They will see you as very good and very competent
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
There are those who notice but donrsquot day say anything Perception is a matter of details ndash think about election campaigns
Donrsquot believe they donrsquot realize you arenrsquot doing it
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The stethoscope
A vector of transmission in care settings
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Medical equipment bull Any medical equipment used for a
patient must be cleaned and disinfected before being used for a second patient ndash Sphygmomanometers ndash Thermometers ndash Stethoscopes
bull If the patient is carrying a
multi-resistant germ
ndash Dedicated device or disinfection after use
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
The problemhellip 70-90 of doctors do not
disinfect their stethoscopes after each usehellip
Wood MW et al Am J Infect Control 2007 35(4) p 263-6 Bernard L et al Infect Control Hosp Epidemiol 1999 20(9) p 626-8 Fenelon L et al The Journal of hospital infection 2009 71(4) p 376-8 Muniz J et al American journal of infection control 2012
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
ldquoIdealrdquo methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Contamination of stethoscopes
Cultures from Rodac agar contact plates 83 patients recruited and examined
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Assessment of microbial load
Mean log(CFU)25cm2
Level of Contamination of Physicianrsquos Hand and Stethoscope Following a Single Physical Examination
Gloved Hand Stethoscope
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
DIAPHRAGM ndash FINGERTIPS ASSOCIATION
Pearsonrsquos r = 081 r2= 065
β=115 95 CI 084-146 plt0001
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
FINGERTIPS AND DIAPHRAGM CONNECTION ndash MRSA
Plt0001 (Spearmanrsquos)
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Fingertips Thenar Hypothenar Diaphragm Tube
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
How to remember
Clean
Contaminated
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
RECAP
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Lack of
KNOWLEDGE 1
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Believing that
COMPLIANCE IS EXCELLENT
2
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Poor
M O M E N T
3
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Not
BELIEVING
4
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Culture
L A I S S E Z - FA I R E
5
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Confusing
6
ABHRs and SOAP
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Competing for
A T T E N T I O N
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Not making it a
REFLEX
8
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
GLOVES
9
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Microbes
I N V I S I B L E
10
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
THANK YOU FOR YOUR ATTENTION Any questions
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CONCLUSIONS
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Lack of
K N OW L E D G E
1
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
RESULTS
bull 83 patients recruited and examined ndash 33 patients to evaluate total CFU ndash 50 patients to evaluate MRSA CFU ndash 52 males ndash Average age (stdev) 642 (148) ndash Average length of hospital stay (IQR) 7 (3-9)
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Objectives
bull Review the rationale for HH bull Review the indications for HH bull Understand the factors that influence
non-compliance with HH bull Propose solutions for improving
compliance by doctors
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
10 problems relating to HH 1 Not being aware of the indications
1 Teach about the patient zone 2 Show indications
2 Not realizing how HH is not being complied with 1 Show rate of compliance
1 Also talk about the number of opportunities for enhancing understanding of how to improve overall rates 2 Manage by a metric and that metric will improve (HBR)
3 Recontamination 1 NEJM video on recontamination
4 Not believing in the effectiveness of HH 1 Show the studies 2 Explain that it is important not to w ait for RCT (Europe and North America compliance already high Africa no indicator) 3 Parachute analogy
5 Impunity and laissez-faire culture towards non-compliance 1 Surgical mask analogy Would w e allow a particular hospital to get rid of them because they ldquodonrsquot believe in themrdquo
6 Not distinguishing between ABHRs and soap 1 MORE effective than soap 2 QUICKER 3 The rule of w ashing at every X HH misunderstood
7 Contact dermatitis as a result of HH 8 People are busy and have a lot on their hands other than HH
1 Aw areness test 9 Not making it a habit
1 Seatbelt analogy 2 Paper on video cameras
10 Wearing of gloves 11 Cdifficiile and HH with soap and water
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Will we be able to eliminate nosocomial infections one day
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
What role does medical equipment play in the transmission of germs at the hospital
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of germ transmission
C) Donrsquot know
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Previous studies suggest that medical equipment
A) Is a major source of germ
transmission A) Is NOT a major source of
germ transmission
B) Donrsquot know
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
bull Multiple limitations
ndash A piece of equipmentrsquos ldquopastrdquo cannot be determined
bull Number of uses today This week
bull Microbiological status of patients (MRSA Cdifficile)
bull Exactly how equipment was used ndash Full physical examination
bull If bacteria is present so what Is this
important ndash Does the equipment need to be sterile
Prevalence studies
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Mediate Auscultation 1894
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
bull 1816 ndash Difficulty during auscultation of a young
woman
ndash Bundle of 24 sheets of paper
ndash Surprise The sounds travelled very well
ndash ldquoThe cylinderrdquo
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Only 2 Francs with a bonus stethoscope
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
bull
Immediate Auscultation
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
And where do microbes fit in with all this
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Region sampled recovery Stethoscope diaphragm 56 (2850) Any stethoscope
60 (3050) Stethoscope tube 34 (1750) Fingertips 66 (3350)
Any hand 74 (3750)
Thenar region 56 (2850) Hypothenar region 62 (3150) Dorsum 28 (1450)
N=50
P=014
Proportion of MRSA recovered from Physicianrsquos Hand and Stethoscope Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Can stethoscopes transmit germs
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
ldquoIdealrdquo Methodology
Systematic culture of hands and stethoscope following a standardized
physical examination
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
CONCLUSIONS bull Stethoscope contamination following a physical
examination is not negligible
bull Need to disinfest a stethoscope after each use ndash Not just the diaphragm
bull One option not allowing doctors to wear
stethoscopes around their necks
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Contain 60-80 ethanol isopropanol or n-propanol Addition of emollients Less irritating than soap and water with equal use Liquid gel or mousse solutions
ABHRs
Equipment
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Detergents Dislodge bacteria from the skin through the effect of rinsing with water Sometimes chlorhexidine is added
Equipment
Soap
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
bull N Engl J Med 1988 Dec 15319(24)1585-9 bull The sounds of the hospital Paging patterns in three teaching hospitals bull Katz MH Schroeder SA bull Source bull Department of Medicine University of California San Francisco bull Abstract bull To examine the influence of hospital paging systems on residency training nursing
services and patient care we asked medical interns (first-year residents) in three teaching hospitals to keep logs of pages they received during a three-day period Thirty-one logs from 26 interns were completed a total of 1206 pages were recorded on 91 days (1095 hours) Interns were paged an average of once an hour on 24 occasions interns were paged five or more times an hour The majority of pages (65 percent) occurred when interns were engaged in patient care Only 34 percent of the pages were judged both to require a response within one hour and to result in a change in patient care Twenty-four percent were clinically indicated and required a response within one hour but did not result in a change in patient care Sixteen percent of pages resulted in a change in patient care or were clinically indicated but could have been postponed for more than an hour An additional 26 percent of pages neither resulted in a change in clinical management nor were clinically indicated Reducing the number of unnecessary pages and postponing nonurgent ones could result in as much as a 42 percent decrease in disruptions of patient care and more rest for interns
Katz MH Schroeder SA N Engl J Med 19883191585-9
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Hand hygiene promotion ndash Time to use a stick
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situationhellip Advantages
bullAvailable at point of care
bullMore effective
bullQuicker
bullLess irritating
Disadvantage
bullNo activity against spore-forming bacteria (Cdifficile)
D E R M A T I T I S
7
D E R M A T I T I S
7
