It was the best of times, it was the worst of times, it was the ...

It was the best of times, it was the worst of times, it was the age of wisdom, it was the epoch of belief, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, it was the era of people not washing their hands after using the bathroom, it was the era of people eating with their hands and falling violently ill after transferring bacteria to each other - in short, it was not a very sanitary period. Charles Dickens (as interpreted by the Allegany Co Health Dept) Hand Hygiene in Context CIDP Lecture – January 24, 2007 Sue Chen RN MPH CIC Infection Control Specialist CDHS Infectious Disease Branch schen3@dhs.ca.gov Talk Outline ► ► ► ► Historical review Scope and consequences of pervasive inadequacy of hand hygiene practices in health care and food service industries Whys, whens, hows, with whats Ingredients for success:  Systems approach, hand awareness, active teaching, start early! ► ► Hot topics: pandemic planning, norovirus Merciful end of lecture Disclaimer ► Concept of perfect compliance with hand hygiene recommendations, while close to religious in stature, is not the holy grail of infection prevention:  Assumption that every activity has equal potential to prevent infection (e.g. bed making = cardiac surgery); other risk factors must be considered  Conflicting information of actual impact of HH ► Other approaches such as judicious antimicrobial usage in healthcare and reduction of important transmission routes in any setting are still needed Definitions (hand hygiene), either with soap and water, or with an alcohol-based hand rub ► Antimicrobial/antiseptic – inhibits or destroys organisms on living tissues ► Detergent/disinfectant – formulations for use on inanimate surfaces  Detergents disperse and remove soil and organic material from surfaces; this enables disinfection process  Disinfectants control, prevent, or destroy microorganisms on inanimate objects or surfaces ► HH 4H: Hand Hygiene Hits Headlines Get a “C” for Handwashing”, Soap and Detergent Association‟s 2004 Clean Hands Report, St. Louis ► “Hospitals‟ Dirty Secret”, Modern Healthcare, 2006 ► “An Average of 57% Doctors Followed Handwashing Rules in a Study”, Annals of Internal Medicine, 2004 ► “Brookland Restaurant Cited For Not Having Handwashing Sink”, NewsChannel5, Ohio, 2004 ► “Pandemic Flu Mitigation”, Dept of Homeland Security ► “Americans Surveyors Leaders Administration Unions Consumers Press HCWs Mother Peers Attorney Quality Groups Payers Patients/Visitors Forward Progressions of Handwashing in Civilization Association of handwashing with religious and magical ceremonies: ► ► ► ► ► ► Ancient Greeks washed their hands “before pouring libations to a deathless god” Biblical: Pontius Pilate washed his hands of the „blood of an innocent man‟, Kosher laws: no mixing of meat and dairy Early Christians considered one bath/lifetime sufficient for purification; more was considered a heretical pagan ritual Maimonides (12th century) noted “noted need to wash hands both „before going forth to my patients‟ and „after having touched a sick person‟” Codes of hygiene part of Hindu texts; taught colonizing Europeans habit of regular bathing in 17th century Relatively recent identification of association of handwashing in medicine w/ antisepsis and hygiene Cycle of Disease Transmission/ Germ Theory Disease Germ Mode of Transmission Susceptible Host Cue for germ transmission exercise Today We Accept That Theory but There Was A Time…. 16 14 12 10 8 6 4 2 0 First Clinic Second Clinic Ignaz Semmelweis, 1815-1865 ► Two clinics, alternating admissions every 24 hours:  First Clinic: Doctors and medical students  Second Clinic: Midwives ► Maternal mortality, 1842 Hand scrub with chlorinated lime solution The Intervention: Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847. OUTCOME: Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850 Maternal Mortality (%) 18 16 14 12 10 8 6 4 2 0 1841 1842 1843 1844 1845 1946 1847 1848 1849 1850 Semmelweis’ Hand Hygiene Intervention MDs Midwives ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999. Unwashed hand (CDC slide) What is the Fomite Factor? ► Environmental Viability*      MRSA – up to 5 weeks VRE – 80 days Pseudomonas aeruginosa – 1 hour to 2 days Larger inoculum, other conditions improve survival ► Inverse relationship between hand hygiene and environmental contamination ► Every 60 seconds, a working adult touches as many as 30 objects ► *Depends on quantity deposited, available nutrition, temperature, surface porosity, presence of ultraviolet, pH,… “Contact Precautions: No Room for Error”, Infection Control Today, October 2006 Influenza – 5 min to 48 hrs (depends on surface) Norovirus – 1-10 days Healthcare Worker Survey stated they washed their hands according to infection control (IC) recommendations ► Interviewees opined that only 50% of their peers followed IC recommendations ► Per observation by unidentified observers, only 26% washed per recommendations ► Females 33% more likely to wash; males more likely to do so effectively Dr Robert Weinstein @ 4th Decennial International Conference on Nosocomial and Healthcare Associated Infections, March 2000 ► 85% “They‟ll wonderingly ask how hands so vile, could conquer hearts so brave.” ► 5-10% hospitalized patients develop one or more healthcare associated infections (HAI) every year ► In California, this translates to ~240,000 patients w/ HAI, and $3.1 billion in excess costs annually ► 16 days added length of stay, up to five-fold increase in mortality (PA stats) as compared to risk-stratified controls ► Other factors: quality of life costs for patients and their families, cost to industry in lost wages Thomas Moore: “Weep on, Weep on”, early 1800s Fecal-Hand-Oral Link ► “Fecal-infested ► Norovirus hands” are the #1 cause of foodborne illness infection is the most common cause of acute gastroenteritis ► Contaminated hands are the single most important cause of norovirus infection 30% of people infected with norovirus do not have symptoms ► Approximately Fodder From Food Research: hand washing by employees was observed in 73% of full-service food establishments (FDA report, 2004) ►Hands were the transmission vehicle in 89% of 81 foodborne illness outbreaks attributed to food workers (Guzewich & Ross, 1999) ►Improper Findings from “Food Worker Hand Washing Practices” were washed in only 27% of activities requiring hand washing ► Hands were washed only 23% of the time after preparing raw animal products ► Hands were washed prior to sanitizer use in only 53% of activities where sanitizer was used ► Hands were washed significantly less when gloves were worn than when not Food Worker Hand Washing Practices: An Observational Study, Green LR et. al., Journal of Food Protection, Oct 2006 ► Hands Issues of Hand Hygiene in Schools and Petting Zoos… Hand Hygiene in Pandemic Flu Planning Handwashing and Risk of Respiratory Infection Meta-analysis article screened 410 articles published prior to 2004 in all languages; 8 met eligibility criteria ► All studies reported that HH lowered risks of respiratory infection by 16% (95% CI 1121), range 6-44% ► Need for further higher quality studies, studies conducted in developing countries Handwashing and risk of respiratory infections: a quantitative systemic review, Rabie T and Curtis V, Tropical Medicine and International Health, March 2006 ► Review Objectives “After tolerating poor handwashing compliance for 150 years, it is time for hospitals and healthcare professionals to get serious about improving hand hygiene.” Boyce, JM. Ann Intern Med 1999; 130:153-155 Recent Activity Related to Hand Hygiene in Health Care ► ► ► ► 2002 HICPAC Guideline for Hand Hygiene in Healthcare Settings 2005 WHO Guidelines on Hand Hygiene in Health Care (advanced draft) JCAHO 2004-2005 Patient Safety Goals IHI How-to Guide: Improving Hand Hygiene 2006 2002 Guideline for Hand Hygiene in Healthcare Settings: Scope ► Intended for healthcare settings     acute care hospitals outpatient clinics and surgical centers rehabilitation and extended care facilities home health care settings ► Not intended for:  food processing or food service establishments CDC/HICPAC Guideline Ranking of Recommendations Category 1A - strongly recommended and strongly supported by studies Category 1B - strongly recommended and supported by some studies and strong theoretical rationale Category 1C - required by regulatory agencies Category II - suggested by clinical or epidemiological studies, or theoretical rationale Unresolved Issue Key Elements of the 2002 Hand Hygiene Guidelines hand disinfectants & handwashing – when & why ► 15 second hand hygiene activity for soap and water ► No artificial nails ► Prevention of irritant contact dermatitis ► Improving hand hygiene ► Alcohol IHI Toolkit data, tools, references, and ideas •Ensure •Education •Competency •Supplies •Proper glove use FREE !! Pertinent Food-Safety Laws The Food Code: added for prevention of food contamination by workers‟ hands ► Specific hand wash procedures required  wash for 20 seconds  hand friction for 10 to 15 seconds ► Prohibits ► Parameters bare-hand contact with ready-to-eat foods (“barrier” methods required) Note: variances may be allowed Why don‟t we wash our hands? Sinks: inconvenient, inaccessible, too few ► Lack of soap, paper towels ► Overwork/don‟t have time ► Skin irritation and dryness ► Wearing gloves ► Forgetfulness ► Understaffing ► Knowledge deficit ► Skepticism as to importance, value of HH ► No consequences for not washing ► Factors That Impact Hand Hygiene Behavior ► 80 women observed in a public restroom  Researcher either talked on cell phone w/ no eye contact; or made eye contact, washed her hands, and talked to subject as she came out of stall *  Conclusion: Women are susceptible to modeling behavior of social norms (p<0.01) Handwashing Behavior of Women in Public Restrooms, Hayes MC, Dept of Psychology, Loyola University, 2006 ► In general, women more likely to wash their hands than men, more likely to respond to a visual cue, more likely to use soap Sex differences in public restroom handwashing behavior associated with visual behavior prompts, Johnson DH et. al., Perception Motor Skills, Dec 2003 From Henry the Hand: Guideline for Hand Hygiene in Health-Care Settings Factors necessary for change include: ► Dissatisfaction with current situation ► Perception of alternatives, and ► Recognition, both at the individual and institutional level, of the ability and potential to change. The first two necessitate a system change; the latter requires education. MMWR, 2002,51(RR16);1-44 When To Wash Upon arrival at work or home ► Before and after eating, preparing or serving food (cooked or uncooked) or setting the table ► Before moving between raw meat and produce ► After use of toilet, diaper changes, or assisting a child with bathroom activities ► Before inserting or removing contact lenses ► ► ► ► ► ► ► ► After handling items or persons soiled with body fluids or wastes Before treating a cut or wound, or an ill person After coughing, sneezing, or blowing one‟s nose After playing with or caring for pets or other animals After outdoor activities Whenever hands look, feel, or smell unclean Before leaving work Hand Hygiene Prep nails short, clean and polish free ► Avoid wearing wrist watches and jewelry, especially rings with ridges or stones ► Artificial nails must not be worn ► Any cuts and abrasions should be covered with a waterproof dressing. ► Remove your wristwatch and any bracelets and roll up long sleeves before washing your hands (and wrists) and dry them thoroughly. ► Keep Essential Mechanics of Hand Hygiene ► When ► Apply using water, wet hands first so that soap will rinse off more easily  Front, back, around fingers, over thumb, across fingernails  15 seconds recommended (may sing if it is helpful) vigorous friction to all areas of hand ► Take time to rinse hands thoroughly HH Mechanics Cont‟d ► Dry hands: less abrasive towels are preferable ► Turn off faucet w/ paper towel hand lotion if needed/time permits ► Apply ► If in restroom, use paper towel to open door to leave water may increase risk of dermatitis; no recommendation for cold water* Water Temperature as a Factor in Handwashing Efficacy, Michaels B et. al., Food Service Technology, Oct 2002 ► Hot Hand Hygiene Technique Cue: Perform hand hygiene here Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub Products: w/ Water Type Regular Soap Antimicrobial Soap Triclosan, Chlorohexidine (CHG), Chloroxylenol (PCMX) ►Purpose Comments is to physically remove dirt ►Contains a surfactant that lifts dirt so it can be rinsed off ►Provides ongoing „kill‟ of bacteria on hands (against transient and residual flora) ►Cost-benefit ratio for infection prevention vs. added risk and cost ►Widespread use has led to resistance and molecular precursors for resistance (triclosan-R noted in Japan, England) Products: Waterless Type Comments ►Use enough so that hands must be rubbed for minimally 15 seconds to dry ►Products vary in alcohol content (6090%); all contain an emollient Most effective if ►Excellent microbicidal characteristics hands are not visibly ►Isopropyl is better against bacteria, ethyl soiled. against viruses (x/ norovirus) Alcohol-based Hand Rubs Antiseptic Towelettes when running water is not available and hands are visibly soiled ►Permits physical removal of dirt ►Efficacy can be parallel to soap and water ►Essential Efficacy of Alcohol-Based Hand Rubs in 1986 abstract by E Larson ► Must be effective, more convenient, faster; employee must be more likely to use it ► Multiple studies affirm that hand rubs are less drying than soap and water ► Noted Gel may be better tolerated than a rinse ► Manufacturers recommend 30-60 second contact time; CDC recommends following above recommendation. Shorter contact time deemed efficacious Waterless Hand Rub in the Classroom of infectious diseases frequent; majority are respiratory, GI ► On average, students miss 4.5 days, teachers 5.3 days/year w/ illness ► >80% teachers cite absenteeism as their main problem ► Use of waterless cleaner in addition to routine hand washing resulted in 42% drop in absenteeism Alcohol-free Instant Hand Sanitizer Reduces Elementary School Illness Absenteeism, Dyer DL et al, Family Medicine, 2000;32(9):633-8) ► Transmission Measure: What is a Palmful? Effectiveness of waterless alcohol degermer on hands 1) 2) 3) 1) Before hand hygiene 2) After contaminated hands were washed with plain soap, 3) After contaminated hands were de27 germed with waterless alcohol product (Fontana Study,2002) The Juice is Worth the Squeeze. The extra effort you put forth to decontaminate your hands before and after touching a patient is worthwhile. Using an alcohol hand-rub rather than soap can reduce hospitalacquired infections by 30% or more. Artificial Fingernails artificial fingernails or extenders when having direct contact with high-risk patents, such as those in ICUs or ORs (IA) ► Hands with artificial nails carry more bacteria even after being washed with antimicrobial handwash or alcohol rub (CID 2001;32:367-72) ► No Artificial Fingernails nails support  organisms (ICHE 2000;21:505-509) and have been linked to several outbreaks ► S. marcescens wound infections close open heart program (JID 1997;175:992-995) ► Outbreak of P. aeruginosa in NICU (ICHE 2000;21:80-85) ► Can break off into food during preparation ► Not having them may have a positive effect on disposable income ► Artificial Glove Usage everything set up prior to putting on gloves (protect the patient or clean food) ► Wear gloves for anticipated contact with patient-generated secretions/excretions, if asked to make a deli sandwich, or actual or potential contact with a contaminated environment ► Dispose of gloves after use ► Perform hand hygiene after glove removal (remember that gloves can leak when „old‟ and tired). If hands are visibly soiled, soap and running water should be used. ► Get Do‟s and Don‟ts of Glove Use Do: Wear when contact w/ body secretions is anticipated ► Put them on immediately before doing a procedure ► Remove them immediately after ► Wash your hands ► Don‟t: Re-use them ► Wash them ► Touch other objects before touching your patient or food ► Use wearing them as an excuse not to wash ► Wear them for ever and ever ► Glove Efficacy Study ► 10 x 10 types of exam gloves tested  Glove durability method  Simulated clinical method  Controls Glove durability and simulated clinical methods yielded same failure rate ► Vinyl gloves (powdered, non-powdered) had highest failure rate ► Durability also affected by presence or absence of powder and long nails or rings ► Standard in progress for manufacturers to characterize durability of their product. ► 2004 Assessment of the Durability of Medical Examination Gloves, Kerr LN et al, Journal of Occupational and Environmental Hygiene, Sept Effects of Hand Hygiene on the Epidermis What constitutes healthy skin barrier ► Soaps and detergents described as most damaging of substances routinely applied to skin; higher concentrations result in more rapid damage ► How broken skin affects transient flora ► Hand Lotions ► Strongly recommended because:  Increased use of gloves causes more hand irritation  Cracked or dry hands shed more germs  Workers with healthy hands are more likely to wash them ► Lotion Warning:  May contain petroleum or other emollients that can weaken latex and increase permeability  Read the label: if petroleum/mineral oil is the 2nd or 3rd ingredient listed, lotion may not be latex-compatible  Many hospitals prefer to provide lotion to employees ► Differences in healing characteristics Ways We Have Tried to Promote Handwashing Semmelweis in 1846 ► Education ► Demonstration ► Convenience ► Competency ► Enlist consumer to „remind‟ practitioner ► Coercion End Result: Most studies show recidivism to baseline after the end of the intervention ► What‟s the missing link? Effective Educational Efforts Principles of Adult Learning  Provide message to all senses: visual, auditory, tactile; here olfactory and taste are optional  Maintain single concept, single theory training  Actively engage the learner  Relate (“hook”) new learning to prior experiences  Immediately reinforce lesson – just-in-time competency  Start young  Don‟t lecture  HAND AWARENESS “Hand” ► Webster‟s Definition of the terminal part of the skeletal forelimb when modified (in humans) as a grasping organ “Awareness” ► implies focus and attentiveness in observing, and making deductions from that experience Do you know where your hands have been, and where they are now? Do you observe what you do with your hands? Henry the Hand‟s Four Principles of Hand Awareness your hands when they are dirty and before eating. ► Do not cough into your hands. ► Do not sneeze into your hands. ► Above all, do not put your fingers into your eyes, nose or mouth. *Endorsed by the AMA and the AAFP (2001) *referred to as individual ideas for flu prevention by CDC, but not packaged as an integrated concept. ► Wash Dress for Success (what makes a program work) ► Have a clear hand hygiene policy ► Enlist the support and involvement of administration ► Effective education: activities, hand awareness, long term goal; if possible, start training at an early age ► Set up for systems success ► Demand individual accountability ► Routine monitoring, with praise, consequences, and publicized results A “Systems” Approach to Hand Hygiene hygiene must be genuinely valued, and modeled by the leadership and management in that setting ► Facility design & equipment  Enough sinks? Proper location?  Minimal hand contact required for use? ► Sufficient ► Hand supplies  A system for monitoring use of supplies  A system for replacing soap/paper towels Systems Approach Cont‟d ► Training: ► Hand on-going & repetitive  Use demonstration and practice wash reminders: e.g. signs, pledges ► Monitoring:  Observations – e.g. the “mystery customer”  Video cameras; sinks with ID systems ► Accountability – for both employers and employees, of high performance expectations Measuring Compliance ► ► Self Report ( least reliable) Observational Approaches    Unit based Secret shopper Consumer feedback – satisfaction surveys ► Product use Do ethics of consumer trust factor in? Relationship to Pandemic Flu Planning long does influenza survive in the environment? ► How well does waterless cleaner work against this virus? ► An aside: respiratory hygiene and cough etiquette ► How Basic Influenza TransmissionReduction Measures hygiene (cleaning hands with soap and water or an alcohol-based hand rub) ► Respiratory hygiene, e.g., “Cover your cough” ► Cleaning and disinfection of contaminated objects, surfaces ► Physical barriers (e.g., glass or plastic “windows” to protect front desk workers) ► Use of personal protective equipment (PPE) in some settings (e.g., healthcare) such as gowns, gloves, eye, and respiratory protection ► Hand Respiratory Hygiene/Cough Etiquette ► Containment of respiratory secretions is recommended for symptomatic individuals    Cover the nose/mouth when coughing or sneezing; Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use; and Perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol-based hand rub, or antiseptic handwash) after having contact with respiratory secretions and contaminated objects/materials. ► Healthcare facilities should ensure that individuals have supplies to comply with secretion containment   Provide tissues and no-touch receptacles for used tissue disposal; and Provide conveniently located dispensers of alcohol-based hand rub; where sinks are available, ensure that supplies for hand washing (i.e., soap, disposable towels) are consistently available. Cue for Cough Video Specific HH Issues ► Non-enveloped ► Vomiting viruses (read „norovirus‟)  The alcohol-based hand rub issue and diarrhea contaminate the environment; unless properly decontaminated, this sets up a chain (think downward spiral) of hand/environmental viral sharing ► The antimicrobial towelette question Should Alcohol Hand Hygiene Products Be Used During a Norovirus Outbreak? ► ► Using MS2, “Effective hand hygiene for high levels of viral contamination with a non-enveloped virus was best achieved by physical removal with a non-antimicrobial soap or tap water alone.” (AJIC. 2005:33(2):67-77) Alcohol may be used if:  It is the best way to achieve high rates of HH compliance in settings where hand washing is not feasible  Hands or gloves are not visibly soiled  Accumulated cell debris is periodically washed off Few tests of alcohol-based hand products published using FCV in vivo; results mixed ► Need for hand washing for physical removal of virus during outbreak should be stressed! Ideally: WASH, then use HAND RUB ► References ► HAI Recommendations for Reducing Morbidity and Mortality Related to Healthcare –Associated Infections in California. 12/05. www.cacc.net or http://www.dhs.ca.gov/ps/dcdc/dcdcindex.htm Advisory Workgroup Final Report to DHS, ► http://www.cdc.gov/handhygiene/ This website has the 2002 Hand Hygiene Guidelines, powerpoints, & more. Your tax dollars at work! CDC guidelines… http://www.cdc.gov/ncidod/dhqp/guidelines.html ► Other More References ► CDC Hand Hygiene After Disasters: http://www.bt.cdc.gov/disasters/handhygiene.asp for Health Improvement: http://www.ihi.org/IHI/Topics/CriticalCare/Intensive Care/Tools/HowtoGuideImprovingHandHygiene.htm Need to be registered (free) to access tool but it is also available at the APIC website www.APIC.net ► Institute More References ► JCAHO: Type “hand hygiene” into search to pull up multiple references http://www.jointcommission.org/ ► WHO Guidelines: www.who.int/patientsafety/events/05/HH_ en.pdf The CA Uniform Retail Food Facilities Law* (CURFFL) hand contact w/ foods allowed ► Proper hand washing is required ► Addresses employee illness issues ► Bare SB 144 Cal Code: ► Legislation foods that also allows bare hand contact w/ * Part of California Health and Safety Code Summation and importance of HH efforts is to stop the seeding of illness via hand carriage ► Dearth of adequate and timely hand hygiene is a significant public health/patient safety issue that crosses disciplines you ask people to use inconvenient preventive measures when they think it is unnecessary, they won‟t do it.” Allison McGeer, Toronto, SARS ► It may take a village to get us to wash our hands ► “If ► Theory  Healthcare and food service industries have collected data on the impact Parting Shots What should you do when someone tries to shake hands with you? ► ► ► ► Raise your leg and say, “Do you mind if we shake feet instead? It‟s the latest on MTV.” Reach into your pocket for a plastic glove. If the person looks offended say “I haven‟t washed it (my hand) since the day Elvis kissed it.” Try to determine the risks: “Wow, your hands look clean. How many times a day do you wash them?” Be direct: “Sorry I can‟t shake your hand. Just trying to save a tree.” Plagiarized from the Humor of Melvin Durai; www.melvindurai.com Your Picture Here? Acknowledgements Frick REHS, MPH ► Kathy Harriman RN, PhD, CIC ► Mary Mendelsohn RN, BSN, CIC ► Jon Rosenberg MD, CDHS Infectious Disease Branch ► Dr. Will Sawyer, proud father of “Henry the Hand”, a website, and 3 other children ► Google ► Roberta Questions? Thank you