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Hand Hygiene:


What evidence is there that hand hygiene contributes to control of MRSA? ... Second hand was cultured to assess efficacy of washing ... – PowerPoint PPT presentation

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Title: Hand Hygiene:

Hand Hygiene An Important Element In
Controlling MRSA
John M. Boyce, MD Chief, Infectious
Diseases Section Hospital of Saint
Raphael and Clinical
Professor of Medicine Yale University School of
Medicine New Haven, CT
Transmission of Healthcare-Associated MRSA
  • Patients colonized or infected with MRSA are the
    major reservoir from which transmission occurs
  • HA-MRSA is most often transmitted from patient to
    patient via the hands of healthcare workers
    (HCWs) who have transiently contaminated their
  • Persistently colonized or infected HCWs can also
    be a source of transmission
  • Contaminated environmental surfaces may also
    serve as source of MRSA transmission

MRSA Hand Hygiene Topics
  • How do HCWs contaminate their hands with MRSA?
  • Does hand hygiene remove MRSA from hands?
  • What evidence is there that hand hygiene
    contributes to control of MRSA?
  • How can we improve hand hygiene practices?

How Do HCWs Contaminate Their Handswith MRSA?
  • Touching colonized or infected patients
  • Touching contaminated environmental surfaces in
    the immediate vicinity of affected patients
  • For HCWs who are persistently colonized with
    MRSA, touching their own nose or mucous membranes

Frequency of MRSA Colonization at Various
Patient Body Sites
Forehead 51 Nose 54 -
93 Neck 35 Axilla
13 - 28 Hands 40 Groin
30 - 39
  • 68 of positive patients were colonized at
  • more than one extranasal site
  • 95 of nasal carriers had MRSA at
  • extranasal sites
    Rohr et al.

Hill RLR et al. JAC 198822377 Sanford MD et al.
CID 1994
Rohr U et al. Int J Hyg Environ Health
Gastrointestinal Colonization with MRSA
151 (9.8) of 1543 Pts Screened Had MRSA in
Stool Culture
93/151 (62) Pts Had No Previous MRSA
58/151 (38) Pts Had Previous MRSA

75 Were In-Patients 18 Were in NH or
60/75 (80) Pts 15/75 (20) Pts
Were in Not in Isolation Isolation
for Another Organism
These 60 pts would have spent 267 days without
isolation if not detected
Boyce JM et al. J Clin Microbiol 2005435992
Environmental Contamination by Patients with
Heavy Gastrointestinal Tract Colonization
  • 10 standardized surfaces were cultured for MRSA
  • 8 cases with heavy growth of MRSA in stool
  • 6 controls with negative stool culture, but MRSA
    at one or more other body sites
  • Cases and controls had been present in their
    rooms for comparable periods of time before
    cultures were obtained (median, 3.0 vs 2.5 days,
  • MRSA was recovered from
  • 47 (59) of 80 surfaces in the rooms of cases
  • 14 (23) of 60 surfaces in the rooms of controls
  • (P

Otter J et al. SHEA annual meeting, March 2006
Frequency of environmental contamination 8 pts
with loose stools containing heavy MRSA vs6 pts
with MRSA at other body sites, but not in stool
Hand Contamination Following Contact with
Patients or Their Environment
  • HCWs who entered MRSA patient rooms were enrolled
    in a prospective study
  • After patient contact, cultures were performed
  • One gloved hand was cultured first
  • Both gloves were removed and hands were washed
  • Second hand was cultured to assess efficacy of
  • 17 of HCWs who touched the patient, patients
    clothes, or bed contaminated their gloves with

McBryde ES et al. J Hosp Infect 200458104
Hand Contamination Following Contact with
Patients or Their Environment
  • 14 of HCWs who did not wear gloves contaminated
    their hands with MRSA
  • HCWs who did not wear gloves were 5.2 times more
    likely to have MRSA on their hands AFTER
    handwashing than those who wore gloves (p 0.3)

McBryde ES et al. J Hosp Infect 200458104
Hand Contamination from Medical Items
  • All 5 nurses who changed dressings of infected
    patients had MRSA on their hands
  • All 5 personnel who handled specimen containers
    or medical equipment removed from patient rooms
    had MRSA on their hands
  • 5 (42) of the 12 nurses who had no direct
    contact with patients, but touched surfaces near
    affected patients contaminated their gloves with

Crossley K et al. J Infect Dis
1979139280 Boyce JM et al. Infect Control Hosp
Epidemiol 199718622
Hand Contamination from Environment
  • After decontaminating their hands, volunteers
  • Bedside rails for 5 seconds and
  • Bedside tables for 5 seconds
  • Hands were cultured for nosocomial pathogens
  • Hand imprints were culture-positive for
    pathogens, including MRSA
  • After touching surfaces in 53 of occupied pt
  • After touching surfaces in 24 of rooms that had
    been cleaned after a patient discharge

Bhalla A et al. 200425164
MRSA Contamination of HCW Hands
  • Hands of HCWs involved in caring for patients
    have been cultured in a variety of other
  • Contamination of HCWs hands with MRSA has been
    documented in multiple studies

Thompson RL et al. Ann Intern Med
198297309 Cookson B et al. J Clin Microbiol
1989271471 Girou E et al. Clin Infect Dis
199827543 Lacey S et al. J Hosp Infect
200148308 Grundmann H et al. J Infect Dis
Do Hand Hygiene Practices RemoveMRSA from Hands
of HCWs?
  • 7 nurses who cared for infected patients
    decontaminated their hands with hexachlorophene/
    alcohol emulsion, and 6/7 hand cultures were
    negative after hand antisepsis
  • 8/10 employees who redressed wounds infected with
    MRSA had hand cultures that were negative before
    care, but positive after manipulating wounds
  • None had positive hand cultures after washing
    hands with soap and water

Crossley K et al. J Infect Dis
1979139280 Thompson RL et al. Ann Intern Med
Efficacy of Antiseptic Solutions inReducing MRSA
on Hands
  • Relative effectiveness of antiseptics (listed in
    order of decreasing efficacy) in reducing MRSA
    counts on artificially-contaminated hands Study
  • 10 povidone-iodine (too harsh for routine use)
  • 70 ethyl alcohol
  • Plain soap
  • 4 chlorhexidine gluconate (may be more effective
    after multiple applications)
  • Study B
  • 80 ethyl alcohol
  • 7.5 povidone-iodine

Guilhermetti M et al. Infect Control Hosp
Epidemiol 200122105 HuangY et al. Am J Infect
Control 199422224
Is Improving Hand Hygiene Compliance Likely to
Reduce Transmission of MRSA?
  • At least 4 studies have used mathematical
    modeling of MRSA transmission to estimate the
    impact of various control measures on the spread
    of MRSA
  • All 4 studies suggested that improving hand
    hygiene compliance was one of the most effective
    means of reducing MRSA transmission

Grundmann H et al. J Infect Dis
2002185481 Raboud J et al. Infect Control Hosp
Epidemiol 200526607 Bootsma MCJ et al. Proc
Natl Acad Sci 20061035620 McBryde ES et al. J
Theor Biol 2006 (Epub)
Hand Hygiene ComplianceDuring 7 Hospital-Wide
Surveys, University of Geneva Hospitals, 1994-97
Pittet D et al. Lancet 20003561307
Prevalence of Nosocomial Infections and Incidence
of MRSA, University of Geneva Hospitals, 1993-98
  • In addition to improving hand hygiene compliance,
    screening patients for MRSA colonization was
  • Result substantial reduction in incidence of new
    MRSA cases and nosocomial infections

Pittet D et al. Lancet 20003561307
Impact of Hand Hygiene Promotion onIncidence of
MRSA Acquisitions in 3 ICUs
  • 1995 1999 (Period 1)
  • Screening cultures on Adm weekly
  • Contact Precautions
  • 2000 (Period 2)
  • Alcohol-based hand rub promoted for hand
  • Result significant reduction in rate of MRSA

Lucet J-C et al. Intensive Care Med 2005311051
Impact of Hand Hygiene Promotion onIncidence of
MRSA Transmission
No. of New MRSA Cases/100 Adm Before/After
Alcohol Hand Rub Plus Performance Feedback
Alcohol Hand Rub Feedback
Alcohol Hand Gel
Gordin FM et al. Infect Control Hosp Epidemiol
200526650 MacDonald A et al. J Hosp Infect
Impact of Hand Hygiene Promotion onIncidence of
MRSA Transmission
  • Several other studies have reported decreased
    MRSA transmission after implementing multimodal
    programs that included
  • Hand hygiene promotion campaign
  • Screening high risk patients for MRSA
  • Contact precautions for colonized/infected
  • /- additional cleaning of environment

Gopal Rao G et al. J Hosp Infect
20025042 Tomic V et al. Arch Intern Med
20041642038 Johnson PDR et al. Med J Austr
2005183509 Huang SS et al. Clin Infect Dis
Essential Elements of a Hand Hygiene Promotional
  • Essential elements of programs include
  • support from high-level administrators
  • involve HCWs in the planning process
  • develop new educational/motivational materials
  • monitor compliance with HH procedures and provide
    HCWs with feedback on their performance
  • making an alcohol-based hand rub readily available

Boyce JM Pittet D MMWR 200251 (RR-16)1-45
Securing Administrative Support
  • Facilities in USA should cite JCAHOs sentinel
    event alert, issue 28, released in Jan 2003
  • the alert recommends that hospitals comply with
    the new HICPAC/SHEA/APIC/IDSA Guideline for Hand
    Hygiene in Healthcare Settings
  • Also cite other healthcare organizations that
    support promotion of hand hygiene
  • Centers for Disease Control and Prevention
  • World Health Organizations Global Patient Safety
  • Institute for Healthcare Improvement (IHI)

New Emphasis on Controlling HA-MRSA
  • 1. Hand hygiene
  • 2. Decontamination of the environment and
  • 3. Active surveillance cultures
  • 4. Contact precautions for infected and colonized
  • 5. Device bundles (Central Line Bundle and
    Ventilator Bundle)

Educational Activities
  • Periodic lectures given by local experts
  • PowerPoint presentations
  • Interactive audience-response software, if
  • Videotape presentations
  • produced locally
  • by professional organizations (e.g., APIC)
  • product manufacturer
  • Computer-assisted learning sessions placed on
    hospitals Intranet

Educational Activities
  • Give examples of clinical activities that can
    result in contamination of HCWs hands
  • Touching MRSA patients or objects in their
  • Use visual methods for illustrating contamination
    of HCWs hands
  • Hand culture plates
  • Fluorescent dyes

Hand imprint from CTICU nurse
Educational Activities
  • Discuss the advantages and disadvantages of using
    an alcohol-based hand rub (ABHR) vs washing hands
    with soap and water
  • Describe the major indications for hand hygiene
  • Give instructions about how to clean hands
  • with an ABHR
  • when washing hands with soap and water

Motivational Activities
  • Colorful posters emphasizing importance of hand
  • Posters with photographs of influential hospital
    doctors/staff members recommending hand hygiene
    and use
  • Drawings designed for children, or drawings by
    children, in pediatric hospitals

Motivational Activities
  • Use opinion leaders as role models
  • Develop computer screen savers with hand hygiene
  • Encourage patients or family members to remind
    healthcare workers to clean their hands
  • Encourage competition between wards or hospital
    services for best hand hygiene compliance
  • awards for groups with best compliance
  • coffee vouchers, theater tickets, trophies

Motivational Activities
  • Provide feedback to healthcare workers regarding
    their level of compliance
  • an essential component of a multi-modal hand
    hygiene campaign
  • Compliance rates are generally determined for
  • each ward
  • hospital clinical services
  • HCW type (nurses, physicians, others)

Monitoring Hand Hygiene Compliance
  • Currently, the most widely used method of
    determining HCW hand hygiene compliance rates is
    by observational surveys conducted by trained
  • Surveys must use consistent definitions for
  • hand hygiene opportunities
  • criteria for compliance
  • criteria for lack of compliance
  • criteria for appropriate glove use

Monitoring Hand Hygiene Compliance
  • Problems associated with observational surveys of
    hand hygiene compliance include
  • time-consuming
  • may be problems with inter-rater reliability
  • Hawthorne effect
  • lack of standardization makes comparison with
    other hospitals very problematic

Hand Hygiene (HH) Monitoring Tool
Palm-Based Data Entry
(No Transcript)
Compliance with MRSA Barrier Precautions
Author Year HCW Type Gloves
Gowns HandHygiene
Richet 1996 All
63 43 52 - 83 Afif
2002 All 65
65 35 McBryde 2004 Non-MD
MDs 27 Grundmann 2002 All

Richet H et al. Infect Control Hosp Epidemiol
199617509 Afif W et al. Am J Infect Control
200230430 McBryde ES et al. J Hosp Infect
200458104 Grundmann H et al. J Infect Dis
Measuring Volume of Hand Hygiene Product Used as
a Means of Monitoring Hand Hygiene Compliance
Linear Regression of Hand Hygiene Compliance
vs Volume of Alcohol Hand Gel Used During a
3-year Period
Percent Hand Hygiene Compliance vs Liters of
Alcohol Gel Used/1000 Patient-Days,Feb 2001 -
Dec 2003
R2 0.98
Boyce JM et al. (unpublished data)
Monitoring Hand Hygiene Compliance
  • Electronic voice prompts to remind HCWs to
    perform hand hygiene
  • Electronic counters installed in ABHR dispensers
  • Observational surveys done by ward personnel
  • Need to train personnel adequately and assure
  • Self-assessment of compliance is unreliable

Swoboda SM et al. Crit Care Med 200432358
Larson EL et al. Amer J Crit Care 200514304
  • Colonized and infected patients and their
    immediate environment are sources of MRSA hand
  • Wearing gloves reduces risk of hand
  • Performing hand hygiene appropriately should
    remove most MRSA from transiently contaminated
  • There is considerable epidemiologic evidence that
    improving hand hygiene contributes to MRSA
  • Multimodal programs are needed to improve hand

Web Resources
  • www.cdc.gov/handhygiene/
  • Centers for Disease Control and
  • www.handhygiene.org (recently updated)
  • Hand Hygiene Resource Center, Hospital of Saint
  • www.WHO.int/patientsafety/information_centre
  • World Health Organization Patient Safety Campaign
  • www.IHI.org
  • Institute for Healthcare Improvement
  • www.va.gov/patientsafety/
  • Veterans Administration hand hygiene site
  • www.hopisafe.ch
  • University of Geneva Hospitals, Geneva,
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