Hand Hygiene:

1
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
2
Transmission of Healthcare-Associated MRSA
(HA-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
  hands
• Persistently colonized or infected HCWs can also
  be a source of transmission
• Contaminated environmental surfaces may also
  serve as source of MRSA transmission

3
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?

4
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

5
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
200420751
6
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
Out-Patients
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
7
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
  diarrhea
• 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,
  respectively)
• 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
8
Frequency of environmental contamination 8 pts
with loose stools containing heavy MRSA vs6 pts
with MRSA at other body sites, but not in stool
9
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
  washing
• 17 of HCWs who touched the patient, patients
  clothes, or bed contaminated their gloves with
  MRSA

McBryde ES et al. J Hosp Infect 200458104
10
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
11
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
  MRSA

Crossley K et al. J Infect Dis
1979139280 Boyce JM et al. Infect Control Hosp
Epidemiol 199718622
12
Hand Contamination from Environment

• After decontaminating their hands, volunteers
  touched
• 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
  rooms
• After touching surfaces in 24 of rooms that had
  been cleaned after a patient discharge

Bhalla A et al. 200425164
13
MRSA Contamination of HCW Hands

• Hands of HCWs involved in caring for patients
  have been cultured in a variety of other
  circumstances
• 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
2002185481
14
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
198297309
15
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
  A
• 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
16
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)
17
Hand Hygiene ComplianceDuring 7 Hospital-Wide
Surveys, University of Geneva Hospitals, 1994-97
Pittet D et al. Lancet 20003561307
18
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
  performed
• Result substantial reduction in incidence of new
  MRSA cases and nosocomial infections

Pittet D et al. Lancet 20003561307
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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
  hygiene
• Result significant reduction in rate of MRSA
  acquisitions

Lucet J-C et al. Intensive Care Med 2005311051
20
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
20045656
21
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
  patients
• /- 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
200643971
22
Essential Elements of a Hand Hygiene Promotional
Campaign

• 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
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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
  Challenge
• Institute for Healthcare Improvement (IHI)

http//www.jcaho.org/aboutus/newsletters/sentine
leventalert/sea_28.htm
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New Emphasis on Controlling HA-MRSA

• 1. Hand hygiene
• 2. Decontamination of the environment and
  equipment
• 3. Active surveillance cultures
• 4. Contact precautions for infected and colonized
  patients
• 5. Device bundles (Central Line Bundle and
  Ventilator Bundle)

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Educational Activities

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

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Educational Activities

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

Hand imprint from CTICU nurse
27
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

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Motivational Activities

• Colorful posters emphasizing importance of hand
  hygiene
• 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

29
Motivational Activities

• Use opinion leaders as role models
• Develop computer screen savers with hand hygiene
  reminders
• 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

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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)

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Monitoring Hand Hygiene Compliance

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

32
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

33
Hand Hygiene (HH) Monitoring Tool
Palm-Based Data Entry
www.handhygiene.org
34
(No Transcript)
35
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
75
MDs 27 Grundmann 2002 All

59
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
2002185481
36
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)
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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
  reliability
• Self-assessment of compliance is unreliable

Swoboda SM et al. Crit Care Med 200432358
Larson EL et al. Amer J Crit Care 200514304
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Summary

• Colonized and infected patients and their
  immediate environment are sources of MRSA hand
  contamination
• Wearing gloves reduces risk of hand
  contamination
• Performing hand hygiene appropriately should
  remove most MRSA from transiently contaminated
  hands
• There is considerable epidemiologic evidence that
  improving hand hygiene contributes to MRSA
  control
• Multimodal programs are needed to improve hand
  hygiene

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Web Resources

• www.cdc.gov/handhygiene/
• Centers for Disease Control and
  Prevention
• www.handhygiene.org (recently updated)
• Hand Hygiene Resource Center, Hospital of Saint
  Raphael
• 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,
  Switzerland