Hand-washing is answer to infection threat
CDC warns of a post-antibiotic’ era
In the direst terms, the Centers for Disease Control and Prevention is warning the nation of the growth in antibiotic-resistant organisms. In its first-ever Threat Report, the agency listed the organisms that pose the most urgent risk to the nation’s health. Two of the three, Clostridium difficile and carbapenem-resistant Enterobacteriaceae (CRE), are found primarily in hospitals.
"Without urgent action now, more patients will be thrust back to a time before we had effective drugs," said CDC director Thomas Friedan, MD, MPH. "We talk about a pre-antibiotic era and an antibiotic era. If we’re not careful, we will soon be in a post-antibiotic era. And, in fact, for some patients and some microbes, we are already there."
Hand-washing is an important strategy for reducing hospital-acquired infections. So in this issue of HEH, we are providing two case studies of hospitals that have significantly improved hand hygiene through education, monitoring and feedback.
Employee health professionals can play an important role in raising awareness about the importance of hand hygiene when they have other interactions with employees, says Amy Delp, RN, MSN, administrator of the Center for Quality at MetroHealth Medical Center in Cleveland, OH.
"Reinforcing flu vaccination, good hand hygiene and cough etiquette emphasizes how important [precautions are] in keeping our workforce and our patients healthy," she says. "[Each encounter] is an opportunity to script a message" to reduce the risk of transmission.
Wash In, Wash Out
The message at MetroHealth is simple and ubiquitous: Wash in, Wash out. Wash when you enter a patient’s room, wash when you leave. Every employee learned how and why they should use hand sanitizer or soap and water. "It was required education for every employee in the hospital," says Delp.
For two months, employees of all levels attended one of the dozens of 20-minute sessions held to explain the basics of hand hygiene. Delp and her colleagues created the educational module with free tools from The Joint Commission and the Centers for Disease Control and Prevention. One photograph showed the fluorescence of Glo Germ, illustrating that organisms may be present on high-touch surfaces, such as door knobs, bed rails, and even ATM keypads.
MetroHealth then launched an ongoing system of hand hygiene observers, usually specially trained part-time employees. On the units, "Just-In-Time Coaches" serve as champions of hand hygiene, reminding co-workers when they see any gaps in practice.
The "Wash In, Wash Out" program began in 2011, after the hospital detected an increase in multi-drug resistant acetinobacter. At the time, hand hygiene compliance was only about 50%. In the first month of the program, compliance rose to 89% and has since hovered between 92% and 98%.
The program and other infection control initiatives led to a significant reduction in common nosocomial infections, including central line-associated bloodstream infections in the ICU, ventilator-associated pneumonia , and catheter-associated urinary tract infections.
The hospital continues to promote hand hygiene awareness by recognizing units that achieve 100% compliance.
"It is rare for us to have a nosocomial drug-resistant organism," says Delp. "As soon as one pops up, we’re monitoring it and investigating it. The program has been extremely successful."
Spread the word, not germs
Hand hygiene isn’t a campaign. It’s a part of safety culture, says Bonnie Colaianne, RN, MSN, CNL, CIC, corporate infection prevention coordinator at the University of Pittsburgh Medical Center system. The goal of a sustained program is to make hand hygiene as automatic as putting on a seat belt every time you get in a car, she says.
"Historically, hand hygiene campaigns have been a one-day event or a one-week event. We’re sustaining this over three years," she says. "It takes a long time to change culture."
UPMC began with a staff survey to learn how the staff perceived hand hygiene and what they thought would lead to improvements. The responses helped guide the program, says Colaianne. For example, some employees expressed concern about access to hand sanitizer, so UPMC added additional hand hygiene stations.
Each UPMC facility could shape its own initiatives, but they interact through a multi-disciplinary task force that includes administrators of various departments, such as housekeeping, dietary, and even volunteers. They initially held conference calls every week, then less frequently, to monitor progress.
While UPMC facilities tailor the program to their own needs, they all use "secret shoppers" people who record hand hygiene observations on the units. Infection preventionists also monitor hand hygiene.
Meanwhile, the messaging is ubiquitous, on full-size elevator-door stickers, table tents in the cafeteria, digital message boards, posters: "Spread the word, not the germs Clean your hands."
The sustained focus has paid off. UPMC’s 13 acute care facilities saw an overall increase of 25% in hand hygiene compliance, and some facilities reached 100%.
Employee Health helps promote the message, particularly among new employees," Colaianne says. "They can be a key advocate and set an example," she says.
WHO Five Moments for Hand Hygiene
In its evidence-based program, the World Health Organization developed these five "moments" for health care workers to perform hand hygiene:
1. Before touching a patient. WHEN? Clean your hands before touching a patient when approaching him/her. WHY? To protect the patient against harmful germs carried on your hands.
2. Before clean/aseptic procedures. WHEN? Clean your hands immediately before performing a clean/aseptic procedure. WHY? To protect the patient against harmful germs, including the patient’s own, from entering his/her body.
3. After body fluid exposure/risk. WHEN? Clean your hands immediately after an exposure risk to body
fluids (and after glove removal). WHY? To protect yourself and the health-care environment from
harmful patient germs.
4. After touching a patient. WHEN? Clean your hands after touching a patient and her/his immediate surroundings, when leaving the patient’s side. WHY? To protect yourself and the health-care environment from harmful patient germs.
5. After touching patient surroundings. WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving even if the patient has not been touched.
WHY? To protect yourself and the health-care environment from harmful patient germs.
[Editor’s note: Hand hygiene tools are available from the World Health Organization at www.who.int/gpsc/5may/en/ and from the Centers for Disease Control and Prevention at www.cdc.gov/handhygiene.
