By Judith Green-McKenzie, M.D., MPH, FACOEM, FACP, Garson Caruso, M.D., MPH · April 2006
New strategies for improving hand hygiene practices aim to reduce transmission of pathogens to patients and personnel in health care settings.
HOSPITAL-acquired (nosocomial) infections are estimated to occur in nearly 10 percent of all acute care hospitalizations. The estimated incidence is more than 2 million cases per year, resulting in an added expenditure in excess of $4.5 billion.
Transmission of both normal and pathological microorganisms by the hands of health care workers (HCWs) is one of the main routes of infection spread. Skin microorganisms may be considered resident flora or transient flora.
Resident flora, attached to the deeper layers of the skin, are persistently found on the skin and of low pathogenicity. Transient flora, colonizing the superficial layers of the skin, are consistently present on the skin, have higher pathogenicity, and are responsible for most instances of nosocomial infection transmission. The skin functions to reduce water loss, protect against microorganisms and abrasive action, and provide a permeability barrier to the environment.
Although contaminated sources such as infected or draining wounds or wound dressings are of obvious concern, colonization of the hands of HCWs by transient flora from intact patient skin is also common. Normal skin sheds approximately a million cells containing viable microorganisms daily, allowing contamination of objects in a patient's immediate environment, including gowns, bed linen, and furniture. Thus, HCWs can acquire transient organisms from apparently innocuous patient care activities.
The role of infectious agents' transmission by the hands of HCWs was independently recognized in the mid-19th century by Semmelweis in Austria, Holmes in the United States, and Lister in Scotland. Since that time, hand washing with soap and water or other disinfectant agents has become a standard practice for infection control in health care settings.
Hand washing with an antiseptic agent (an antimicrobial substance applied to skin to reduce the number of microbial flora) has long been considered effective in reducing the incidence of health care-associated infection. Compounds currently used for both routine and pre-surgical preparation hand antisepsis in health care settings include plain (non-antimicrobial) soap, chlorhexidine, chloroxylenol, hexachlorophene, quaternary ammonium compounds, and triclosan. Optimal hand hygiene should balance protecting the skin and resident flora, and reducing or eliminating transient flora. HCW compliance with recommended hand washing practices has been found to be low, with physicians being the least compliant.
Lack of appreciation of the potential for pathogenic contamination during routine patient care activities appears to be one factor in non-compliance. Comfort factors, such as development of skin irritation manifested as irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD) due to repeated use of soaps, detergents, or antiseptic compounds, is another perceived barrier. HCWs' ability to tolerate available products (soap or other antimicrobial compounds) and acceptability of the product also may affect compliance. As frequent hand washing increases skin pH (decreases acidity), removes fatty acids (defatting), and reduces the barrier function of intact skin, reduction in normal skin antibacterial properties may result. Damaged skin harbors more pathogens, and washing damaged skin is less effective in reducing microorganism counts than washing intact skin. With continued patient care, microorganisms accumulate on the hands of HCWs over time.
Compliance may depend on convenience factors, including the degree of accessibility and the hand-washing or cleansing facilities' ease of use. In addition, HCWs who perceive time pressure as a result of workload, understaffing, and patient care demands may prioritize other patient-care activities over hand hygiene. Finally, cognitive factors such as lack of knowledge of hand hygiene guidelines or of scientific information regarding effectiveness, assumption of adequate protection from glove use, or simply forgetting contribute to non-compliance.
Alcohol-containing, waterless antiseptic agents applied to the hands are designed to reduce the number of viable microorganisms. Commonly used in Europe for many years, their use has lately become more widespread in the United States. In 1985, the Centers for Disease Control and Prevention recognized a limited role for alcohol-based hand antiseptics. Guidelines promulgated by the Association for Professionals in Infection Control (1995) expanded the role of these antiseptics, and recommendations were further expanded by CDC's Healthcare Infection Control Practices Advisory Committee (1996). More recently, CDC released a comprehensive guideline (2002) consolidating previous work recommending routine use of alcohol-based hand antiseptics in health care settings.
The effectiveness of alcohol as a germicide has been recognized for decades, and both alcohol and alcohol-based compounds have been used as antiseptics. Alcohol-based hand antiseptics available in the United States generally contain isopropanol (isopropyl alcohol), ethanol (ethyl alcohol), or a combination and are available as foams, gels, and rinses. The antimicrobial activity of the alcohols relates to their ability to denature (break down) proteins. Most effective in concentrations of 60 percent to 95 percent, alcohols are generally effective against fungi, Mycobacterium species (the causative agent of tuberculosis), some viruses (particularly those with outer envelopes containing lipids such as human influenza, herpes simplex, and human immunodeficiency viruses), and vegetative bacteria (including multi-drug resistant bacteria such as methcillin-resistant Staphylococcus aureus and vancomycin-resistant enterococcus). Neither isopropanol nor ethanol is effective against viruses without outer envelopes, bacterial spores, and protozoan oocysts. The effectiveness of alcohol-based hand hygiene preparations is affected by concentration, type, volume of alcohol used, contact time, and whether the hands are wet when these are applied.
An advantage of alcohol-based antiseptics is that their routine use has been associated with reduced nosocomial infection rates. They also require less time than traditional hand washing and irritate the hands less often. Hypersensitivity reactions, including ACD and contact urticaria, are rare with these agents. ICD incidence may be due to pre-existing skin damage from conventional hand washing and not to an irritant effect of the alcohol-containing antiseptic. Recontamination rates are reduced as the use of sinks, faucets, faucet handles, soaps and dispensers, and towels necessary for hand-washing is eliminated. In addition, microbial resistance is not considered problematic, possibly because of the mechanism of action (protein denaturation), rapid killing effect, or avoidance of subinhibitory alcohol concentrations due to rapid evaporation of the agent.
One disadvantage is that alcohol preparations are not effective against spore-forming bacteria such as Clostridium species or Bacillus anthracis, although adding 1 percent hydrogen peroxide may improve activity against the spores. Also, alcohol-based antiseptics are not recommended for use when hands are visibly soiled with dirt or debris or contaminated with organic biological materials. The drying effect of alcohol on the skin, another disadvantage, may be countered by the inclusion of emollients, humectants (moisture-retention agents), or other skin-conditioning agents. Preparations with strong fragrances may be poorly tolerated by HCWs with respiratory allergies or reactive airway conditions.
Alcohol-based antiseptics are potentially flammable, theoretically presenting both institutional and personal hazards. This institutional concern was recently addressed by the International Code Council in its adoption of rules (within the International Fire Code) allowing maximum access to alcohol-based hand antiseptics by end users, particularly in hospital corridors; this follows adoption of an amendment by the National Fire Protection Association permitting installation of dispensers in egress corridors. Finally, these preparations do not have persistent (residual) activity unless combined with other compounds, such as chlorhexidine, quaternary ammonium compounds, or triclosan.
In an effort to improve hand hygiene practices of HCWs and to reduce transmission of pathogenic microorganisms to patients and personnel in health care settings, the CDC helped develop and sponsored a guideline to promote new strategies for improving hand hygiene practices, which replace and update previous guidelines.
The guidelines strongly recommend hand washing when hands are visibly dirty, contaminated with proteinaceous material, or soiled with blood or other body fluid. However, they also strongly recommend that an alcohol-based hand rub be used (or, alternatively, that hands be washed with antimicrobial soap and water) for routine decontamination if hands are not visibly soiled, prior to direct patient contact, prior to donning sterile gloves, prior to inserting invasive devices such as catheters, after contact with body fluids, if moving from a contaminated-body site to a clean-body site, and after contact with inanimate objects. An alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures, following manufacturer's instructions and allowing hands and forearms to dry prior to donning the gloves.
The guidelines also recommend that, in selecting hand hygiene products, personnel should be provided efficacious products with low irritancy potential, especially if the product is to be used multiple times per shift, and that HCWs be provided hand lotions or creams to minimize ICD associated with antisepsis. In addition, the guidelines recommend educating HCWs regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various hand decontamination methods.
Alcohol-based hand rubs are now recommended for use in U.S. health care facilities. Availability and increased use can be facilitated by placing dispensers in convenient locations inside or outside patient rooms, and small bottled supplies can be carried by HCWs. Emollients can be added to improve acceptability. Proper and consistent use by HCWs should reduce the incidence of nosocomial infections in health care settings.
This article appeared in the April 2006 issue of Occupational Health & Safety.
Judith Green-McKenzie, M.D., MPH, FACOEM, FACP, is an assistant professor in the Division of Occupational Medicine, Department of Emergency Medicine, at the University of Pennsylvania School of Medicine.
Garson Caruso, M.D., MPH, is associate medical director at Bechtel Aberdeen Chemical Demilitarization Facility, Aberdeen Proving Ground-Edgewood Area, Md.
By Judith Green-McKenzie, M.D., MPH, FACOEM, FACP, Garson Caruso, M.D., MPH · April 2006
Express-News Medical Writer
A 10-year-old San Antonio boy died of an increasingly common, drug-resistant staph infection in Plano last week, prompting health officials to urge people to be alert for the skin infection and practice good hygiene to prevent it from spreading.
At least three other local people have died of methicillin-resistant Staphylococcus aureus, or MRSA, in the past two years, and several clusters have been reported in school athletic programs, day care centers and spas. But because doctors aren't required to report cases to health authorities, the scope of the problem is unknown.
That could change in September, as a pilot program approved by the Legislature will make Bexar County the only county in Texas where the skin infection is a reportable illness.
"MRSA is becoming a big, big problem — 10 times bigger than we initially thought," said Roger Sanchez, an epidemiologist with the Metropolitan Health District. "But because it's not reportable, we don't know the extent of the problem."
In the most recent case, the boy was visiting a sister in Plano, where he developed a rash on his stomach. His family gave him acetaminophen, thinking it might be chicken pox. He also had an abscess on his leg.
But within 72 hours, the boy become unresponsive and the family took him to a hospital where he died June 17. An autopsy determined the infection had spread to his blood and throughout his body.
Deaths from the MRSA are "fairly infrequent," Sanchez said. "But what we used to consider a common boil is no longer so. It could be an MRSA infection. And if that's the case, then it can become septic and enter the bloodstream and other organs of the body."
• Methicillin-resistant Staphylococcus aureus is a type of staph (bacteria) that is resistant to certain antibiotics, including methicillin and other more common ones such as oxacillin, penicillin and amoxicillin. Staph infections, including MRSA, occur most frequently among people in hospitals and health care facilities who have weakened immune systems.
• MRSA infections acquired by people who have not within the past year been hospitalized or had a medical procedure (dialysis, surgery, catheter, etc.) are known as community-acquired MRSA infections.
• Staph or MRSA infections in the community are usually manifested as skin infections, such as pimples and boils, and occur in otherwise healthy people.
The bacteria, which can cause skin infections that resemble a pimple or boil, are common. The Centers for Disease Control and Prevention estimates that perhaps 25 percent to 30 percent of the population carries the organism on their skin or inside their nose, usually without causing infection.
Initially, MRSA, which has been called a 'superbug,' was a problem in hospitals and nursing homes, where patients often have weakened immune systems. It still is. A national study released Monday at the Association for Professionals in Infection and Epidemiology meeting in San Jose, Calif., found as many as 1.2 million hospital patients a year are infected with MRSA — nearly 10 times as many as previously thought.
But community-acquired MRSA is a growing problem as well. The infection is easily spread from person to person, or through shared towels or other items.
"We're seeing quite a large number of (MRSA) abscesses that have to be drained on a daily basis at all of our locations," said Dr. David Gude, chief operating officer at Texas MedClinics, which operates nine clinics in San Antonio and a 10th in New Braunfels.
"Our experience is that we've been seeing over the last five years a gradually increasing amount of MRSA," Gude said. "People come in, think they have a bug bite, they have a pocket of pus that has to be opened up and drained."
The one-year pilot project in Bexar County would require medical laboratories to report MRSA infections to the health district. Health officials hope the data will tell them how common the infection is in the community, and whether it is occurring more often in certain groups or parts of the city.
"The thing to tell the public is, this bacteria is here to stay," Sanchez said. "It's not going anywhere. We have to learn to upgrade our level of hand-washing and hygiene. That's the first line of defense, hand-washing."
By Robert Preidt
(HealthDay News) -- Elderly intensive care unit patients have less risk of infection if the units have high nurse staffing levels, says a Columbia University School of Nursing study.
Hospital-acquired infections are the sixth leading cause of death in the United States.
In this study, researchers reviewed outcomes for more than 15,000 patients in 51 hospital intensive care units (ICUs) across the United States. They found lower rates of infection in ICUs with high nurse staffing levels. The average staffing level was 17 registered nurse hours per patient per day.
The study also found that higher levels of ICU nurse overtime were associated with increased rates of infections and skin ulcers. On average, ICU nurses worked overtime 5.6 percent of the time.
The findings, published in the June issue of the journal Medical Care, support the idea that improving nurses' working conditions will boost patient safety, the study authors said.
"Nurses are the hospital's safety officers. However, nursing units that are understaffed and that have overworked nurses are shown to have poor patient outcomes," first author Patricia W. Stone, assistant professor of nursing, said in a prepared statement.
By Judith Graham
Chicago Tribune staff reporter
June 25, 2007
As many as 1.2 million hospital patients are infected with dangerous, drug-resistant staph infections each year, almost 10 times more than previous estimates, based on findings from a major new study.
And 48,000 to 119,000 hospital patients a year may be dying from methicillin-resistant staphylococcus aureus (MRSA) infections, far more than previously thought, the study suggests.
The Tribune obtained the results during the weekend from the Association for Professionals in Infection Control & Epidemiology (APIC), which is releasing the report publicly on Monday. The author is Dr. William Jarvis, former acting director of the hospital infections program at the Centers for Disease Control and Prevention.
The findings come amid mounting public concern about the spread of antibiotic-resistant bacteria in health-care facilities and community settings. Medical experts consider the rise of so-called superbugs such as MRSA, a leading cause of deadly blood infections and pneumonias, one of the most alarming public health threats in the nation.
"We're hoping this survey is a wake-up call to health-care workers across America," said Kathy Warye, the association's executive officer.
It is the largest, most comprehensive survey of MRSA in health-care facilities to date. It's based on surveys sent last year to 10,000 infection-control practitioners, including doctors and nurses in hospitals, nursing homes and rehabilitation facilities.
Health-care professionals were asked to select one day between Oct. 1 and Nov. 10, 2005, and report all known MRSA cases in their institutions. More than 1,200 hospitals and 100 nursing homes and rehabilitation facilities responded, supplying data about patients with MRSA infections and patients colonized with the bacteria.
People colonized with MRSA typically carry it in their nose without being symptomatic. They're at risk of passing the superbug to others unknowingly by wiping their nose and then touching a table that a doctor or nurse later touches, for instance. MRSA can live on surfaces for days or even weeks.
The new survey confirms what's been observed anecdotally for years -- MRSA is rampant in health-care facilities.
It found that 34 of 1,000 patients in the survey had active MRSA infections and that 12 were colonized with the superbug, for a total MRSA prevalence rate of 46 per 1,000 patients. (In Illinois, the prevalence rate was 37 per 1,000 patients, based on responses from 74 hospitals and other acute-care facilities.)
The most widely cited previous study, published by CDC researchers in June 2005, had estimated that the MRSA infection rate at in-patient hospitals was 3.9 per 1,000 patients. Based on that rate, it estimated that 126,000 patients were infected with the superbug each year.
The new report didn't translate its findings into actual numbers, but Jarvis outlined a means of doing so to the Tribune. He said it was important for the public to see the ballpark figures.
The calculation involves 35.2 million people hospitalized in the U.S. in 2005, the latest year for which information is available. Applying the prevalence rates in the new study, the data suggest that 1.2 million hospital patients are afflicted with MRSA each year and that an additional 423,000 patients are colonized with the superbug.
This is only an estimate, subject to the accuracy of the numbers reporting by infection-control practitioners and the limitations of a "single point in time" snapshot of the data, Jarvis said. Many hospitals don't routinely test patients to see whether they're colonized with MRSA, he said. Also, the findings haven't been peer-reviewed, which is standard in scientific publications.
"Most hospital leaders are paying very close attention to infections within their institutions. ... But I think this tells us that MRSA is an even bigger problem than we thought it was," said Nancy Foster, vice president of quality and patient-safety policy at the American Hospital Association, after reviewing an advance copy of the APIC report.
Dr. John Jernigan, a medical epidemiologist at the CDC and the agency's lead expert on MRSA, said he "applauded the study" even though he hadn't examined its results or methodology. He has co-written articles on MRSA with Jarvis that appeared in leading infection-control publications.
"Everything we're finding is telling us the same thing: MRSA is an enormous problem in health-care facilities, more needs to be done to prevent it, and hospitals need to make infection control more of a priority," Jernigan said.
The CDC has said at least 5,000 patients die after being infected by MRSA at surgical sites, in their blood or in their lungs. That's a mortality rate of 4 percent, assuming a base of 126,000 patients. Using new prevalence estimates of 1.2 million MRSA patients a year, it suggests 48,000 patients a year may die of MRSA.
There is considerable uncertainty about the mortality rate associated with MRSA, however, and it may be as high as 10 percent, said Dr. Lance Peterson, director of infectious disease research at Evanston Northwestern Healthcare. Using the new estimates, that suggests as many as 119,000 hospital patients a year may be felled by the superbug.
To put that figure in context, the Institute of Medicine has estimated that nearly 100,000 patients die of 2 million infections acquired in hospitals every year. MRSA constituted only a portion of those infections and deaths. The new numbers suggest the actual number of hospital-related infections and deaths could be much larger.
An important finding in the new study suggests that hospitals may not be focusing infection-control strategies on the right locations in their institutions. Though earlier research has indicated intensive-care units, which often treat patients with compromised immune systems, are hot spots of infection, this report shows that 67 percent of patients with MRSA infections were on medical wards.
"This suggests that MRSA has become a problem throughout the institution and that [hospital staff] may need to look for it beyond the ICU," Jarvis said.
The study shows that 77 percent of patients with MRSA were identified within two days of entering a hospital, making it likely they were colonized or infected before being admitted. The vast majority of these patients picked up MRSA during an earlier stay at a hospital or nursing home, Jarvis said.
On the positive side, there is strong consensus about the steps hospitals need to take to control MRSA, said Dr. Don Goldmann, a senior vice president at the Institute for Healthcare Improvement in Boston.
All health-care workers should practice rigorous hand-washing, and all institutions should have robust programs for disinfecting medical equipment and patients' rooms, he said. When patients are known to have MRSA, hospital staff should wear gowns and gloves to prevent transmission. And patients deemed at risk of carrying MRSA should be screened to determine where bacterial hot spots are festering.
"Now that the true extent of this scandalously tragic epidemic is known, I hope that health-care leadership will finally confront it with the effective means that have always been available," said Michael Bennett, president of the Coalition for Patients' Rights in Maryland.
Copyright © 2007, Chicago Tribune
By Joe Caponi, VARBusiness
2:46 PM EDT Wed. Jun. 20, 2007
In topics ranging from hand washing to monkey prostitution, Stephen Dubner brought the study of incentives to the VARBusiness 500 last week. Dubner, co-author of the best-selling business book, "Freakonomics: A Rogue Economist Explores The Hidden Side of Everything," spoke at the VARBusiness 500 awards dinner in New York.
"Economics is the study of incentives," Dubner began, but warned that determining which incentives work can be quite challenging, and requires "asking unpopular questions" to truly change behavior. "Unless you know how the world is working now, it's hard to change it," he stated.
Much of Dubner's talk revolved around the example of the efforts of Cedars-Sinai Medical Center in Los Angeles to cut down on patient illnesses and deaths caused by bacterial infections contracted in the hospital. The hospital's research had demonstrated that the most serious conduit for infections was the doctors themselves, and the hospital embarked on a number of initiatives to remind physicans to simply wash their hands between each patient.
"The doctor's self-reported hand hygiene rate was 74%," according to Dubner, but when nurses were asked to monitor doctor's behavior, they reported a mere 9% hand hygiene rate--causing the VARBusiness audience to gasp.
"It's not that the doctors were deliberately lying, but there was definitely a perception gap," Dubner dryly noted.
A series of incentives were tested: memos; free hand sanitizer; a free-breakfast and psyching session; Starbucks gift cards; and more. Though the incentives were well received, and the doctors understood the stakes, none of the incentives managed to alter behavior over the long term.
What worked? Hospital executives cultured their own palm prints in large petri dishes. The resulting "orgy of pathogens" was photographed, and the image turned into the screen saver for the hospital's PCs. Regularly faced with the visual evidence of the dangers they faced, Dubner reported that the hospital was finally able to achieve its hygiene goals among its doctors.
The moral of the story, according to Dubner: "One: You never know where the best incentives will come from, and two: If you go to a hospital, the first thing to do is ask your doctor to wash his hands."
As for the monkeys: Dubner related some research done by Keith Chen, a Yale economist. In trying to understand human behavior--rational and irrational-- regarding money, he set about seeing what behaviors humans inherit from primates. To do so, he set about teaching monkeys the use of currency.
In a Yale lab, monkeys were taught to exchange coin tokens for their choice of different foods. Soon enough, the monkeys showed brand preferences, understood the nature of trade-offs, handled price spikes and generally displayed the same reactions as humans do.
ICPs Share Their Thoughts on Key Challenges and Program Needs
By Kelly M. Pyrek
Drug-resistant methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile outbreaks … pandemic influenza threats … mandatory reporting requirements … making the business case for infection prevention and control … these are but a few of the concerns on the minds of today’s infection control practitioners (ICPs) as we enter 2007. In this article we explore some of these key challenges, and share the thoughts of ICPs across the country.
The role and responsibilities of ICPs are evolving to respond to the aforementioned infectious threats. In the past decade, the field of infection control has mirrored the myriad changes taking place in the U.S. public health and infection prevention agenda.
“The field has grown as increasing responsibilities have been added to the infection prevention and control professional’s role over the past 10 years,” says Linda Greene, RN, MPS, CIC, infection control manager for Via Health Rochester General Hospital in Rochester, N.Y. “Active involvement in emergency management, bioterrorism, increasing involvement in construction and renovation projects, and pandemic influenza planning are only some of these activities. At the same time, emergence and reemergence of infectious diseases, public attention to infections and infection rates, and integration of infection control activities into the overall hospital safety and quality program present unique challenges. As more emphasis is placed on infection prevention, there will be greater demands on the ICP’s time and expertise.”
“I actually began working as a new ICP in 1994, and one of the major changes I have noticed has been the number of guidelines and documents that have been developed or revised that address areas directly affecting infection control and prevention,” observes Susan Dolan, RN, MS, CIC, hospital epidemiologist for the Children’s Hospital in Denver. “The challenge for me has been the ability to be able to thoroughly review each document and incorporate all the necessary changes in a way that is useful and so that the processes that are put into place are well understood and consistently followed by staff. I am also intrigued by the increased number of references that are utilized in preparing these documents which helps to facilitate the process of recommending evidence-based practice. Much of this literature is based on published works of ICPs and their teams, which signifies the importance of publishing our experiences so that we can advance the field.”
Linda Spaulding, RN, C, CIC, owner of Florida- based consulting firm InCo and Associates, notes, “Infection control has gone through so many changes in the past 10 years it’s hard to decide where to start. We used to just think about how to do surveillance and be sure that each infection met the Centers for Disease Control and Prevention (CDC) criteria for an infection or the criteria the hospital decided to use. Then things began to really change when the Occupational Safety and Health Administration (OSHA) entered the infection arena in 1992 with the bloodborne pathogen standards and then the TB standards. The implementation of the OSHA standards was a real challenge for many ICPs and to some extent continues to be a challenge. The more ICPs interpreting a certain standard, the more interpretations you get — some correct and some incorrect. For some ICPs, the lack of resources and/or training has led to misinterpretation of the guideline, leading to either over-implementation and in some cases, under-implementation. Some ICPs have been given the job with no training and are expected to be experts. Facilities must understand that the better the training, the better the product.”
“The field has changed dramatically in the past 10 to 15 years,” agrees Gail Bennett, RN, MSN, CIC, executive director of Georgia-based consulting firm ICP Associates, LLC. “But the area I consider to have had the greatest impact is the evolution of the Internet. We take it for granted today but I entered infection control in 1977 when we had to struggle to get any information on infection control and the ‘authority’ was the CDC. They were very helpful to ICPs but we had to request that they send us white papers on specific subjects and they would mail them to us. If we needed research studies, we did a MedLine search in the hospital library and waited for the results to come by mail. We could not get information in just minutes as we do today. Today, almost every knowledge resource that we need relating to infection control can be accessed in minutes sitting at our desks. I am still in awe of that technology and it has dramatically changed my profession.”
Even as ICPs build their Internet skills, they are spending more time researching the evolving biological threats. “There’s threat of bioterrorism, natural disasters, pandemic influenza, increased drug-resistant organisms … the list goes on and on,” Spaulding says. The skill level and knowledge base for the ICP has increased greatly and it is difficult to keep up with everything. With decreased hospital reimbursement and budget cuts it’s difficult for ICPs to get funding for resources they absolutely need, let alone funding for conferences. If it wasn’t for the ability to access the Internet it would be difficult, if not impossible, for ICPs to do their jobs. And there are still some ICPs who do not have Internet access, so for them the job can be even more overwhelming.”
While the list of challenges faced by ICPs is long, these specialists zero in on a few areas of concern. “First, I think the advancement of technology is a challenge because it not only allows for the advancement of medicine and patient care but it also results in having patients with higher acuity as well as complex devices and procedures that pose a variety of infection control risks,” Dolan says. “Second, the emergence of drug-resistant organisms in both the healthcare setting and the community is another ongoing challenge. Lastly, balancing the day to day, actual ‘real-time’ infection control issues with the time-consuming, complex processes of planning for the potential for pandemics. The infection prevention and control profession can best be described as a system-wide approach to zero-tolerance of infections, covering all aspects of healthcare. The ICP is a preventionist, charged with educating staff and patients on the importance of issues such as proper hand hygiene, new organisms and the effects of proper cleansing and use of products. In the future, it is the hope that ICPs will implement their knowledge of surveillance technology. At present, APIC is developing a template which will provide ICPs the opportunity to calculate costs of particular healthcare-associated infections in order to make a stronger case for the implementation of surveillance technology. Once completed, the template will enable ICPs to demonstrate to their administration the need for such resources.”
Dolan continues, “Overall, it can be said that in the future, cultures and attitudes toward infection prevention and control must change. The task of reducing infections and eliminating transmission must be perceived as a system, rather than a specific program. Herein lies the challenge of getting a tops-down and bottomsup approach to implementing infection prevention into every aspect of healthcare.”
For Bennett, a significant challenge for infection control today is “working with legislative bodies to format public reporting of infections in a manner that will be useful to consumers and acceptable to healthcare systems.” She continues, “If the legislators will listen to the wisdom that has been acquired especially at CDC with the NHSN program and use that model as more states require public reporting, we can have a good system.”
“Alhough complicated and multi-factorial, I think misuse and over-use of antibiotics is a key issue,” states Beth Young, RN, BSN, CIC, infection control coordinator at Robinson Memorial Hospital in Ravenna, Ohio. “Infection control measures to prevent multi-drug resistant organisms (MDROs) and Clostridium difficile-associated diarrhea cannot be successful without addressing antibiotic use.” Greene echoes that sentiment: “The most important challenges are management and control of MDROs, increasing prevalence and virulence of diseases such as C.diff., and increasing regulatory standards including issues such as mandatory reporting.”
Spaulding acknowledges that keeping up to date on all possible infectious threats can be exhausting. “There are so many guidelines and regulations, from departments of health, OSHA, JCAHO, CMS … everyone wants what is good for the patient but the ICP becomes a paper pusher, developing policies and procedures and education programs and inputting core measure data — but who then has the time to talk to patients or track staff practices? Staff turnover and multigenerational and multicultural employees limit the ability of the ICP to do a good job. Many hospitals still have only one ICP, no matter the hospital size, and many hospitals also have outpatient clinics, dialysis units, transplant units, and hospices that the ICP must cover.” Spaulding continues, “Many hospitals are currently participating in grant funding which gives hospitals money for purchasing personal protective equipment, staff training, laboratory equipment, etc. for bioterrorism. Doing the paperwork for the funding and tracking the money can be very time-consuming, not to mention developing the education programs and implementing staff training in areas such as decontamination training.”
The key then, is acquiring and developing the skills sets necessary to juggle such conflicting and demanding workloads.
“The skill sets that seem necessary to meet future infection control challenges are the ability to continually develop a knowledge base about the technology that is continually being introduced into the healthcare arena and to be able to determine the real infection control risks to your patient population,” Dolan suggests. “Another important skill set is the ability to prioritize using evidence and creativity.” Spaulding emphasizes that flexibility is an important asset, and adds. “ICPs must get basic infection control practices under their belts and be able to identify when more training is needed. Learning must be ongoing. There must be the motivation to sometimes read outside of work or attend conferences on their own dime. Become very friendly with the Internet and learn where the best information sites are. Networking is very important, as ICPs need to be part of their local APIC chapters and participate in the national APIC conferences. The ICP has to be able to roll with the constant changes that are happening every day in the world of infection control.”
Bennett advises, “ICPs must possess skills in several areas, including management, communication, and organizational skills. Historically we have not felt that we have adequate resources for the job therefore organizational skills are imperative for us to get the work done. In addition, management and communication skills are required for us to get our message to the decision-makers so important changes can be made as needed.”
“ICPs will need a combination of excellent organizational, interpersonal and problem solving skills,” Greene emphasizes. “At the same time they will need to be experts in data management. They will need to be able to understand and utilize quality improvement data, research data, and administrative and financial data. They will have to develop communication and presentation skills, and apply them effectively based upon the audience.” Young comments, “For me, it’s all about using the computer to sort, analyze, trend, and display data. We need more integrated systems to save us time so that we can work on prevention and control interventions and education.”
When it comes to the needs of infection control programs these days, many ICPs are not shy about communicating their wish lists. “The biggest shortcoming in the world of infection prevention programs are staffing, lack of education opportunities for some ICPs, and lack of strong antibiotic restrictions in some hospital formularies,” Spaulding asserts. “A few years ago APIC conducted a research study looking at how many ICPs are needed related to hospital size but there is no regulatory body that encourages increased staffing. With decreased hospital reimbursement, educational opportunities will remain a problem. And as for antibiotic overuse, pharmacy directors do review hospital formularies but many physicians still order antibiotics under ‘what if’ scenarios. Strong physician advocates are still needed to get other physicians to change their antibiotic prescribing habits.
Recently, there was a commercial on TV featuring a penguin telling audience members if they come down with the flu they need an antiviral, not antibiotics. I think we will begin seeing more public education done this way because it gets more people’s attention.”
For some ICPs, it’s a matter of ongoing engagement in the field. Bennett notes, “I think we still have to work hard to achieve compliance with our policies, standards, and national recommendations. ICPs have a large task of constantly monitoring and being alert to changes in our field, updating policies and practices based on evidence, and assuring that the revised policies and practices are understood and implemented correctly.”
Being able to communicate the value of infection prevention programs to other hospital stakeholders is key to addressing these issues, many ICPs say. “Many of today’s infection control programs are lacking in resources both human and technological,” Greene states. “Infection control and prevention programs are also undervalued by many top executives. In order to address these needs, ICPs must increase their visibility and value at the executive level. Making the business case for infection control, incorporating activities into the overall organization’s strategic mission and vision, and working with key stakeholders including the community are important steps in addressing these issues.”
A significant concern being brought to the attention of hospital administration these days is staffing. “I think ICPs have spoken loud and clear for some time now that staffing is a key issue for their programs,” Dolan says. “It is mainly due to budgetary restrictions in an institution that then can result in cuts to the program or denial of additional positions and resources. I wish I had the magic answer but that would be totally unrealistic.”
“Staffing, staffing, staffing,” emphasizes Young. “I think that most infection control programs are understaffed. We could start to address this by meeting the recommendation of the 2005 Delphi Project Update on Infection Control Staffing which recommends 1.2 to 1.5 ICPs per 100 beds.”
Another challenge is reconciling potentially conflicting information from regulatory or accrediting bodies. Greene observes, “Although the Joint Commission’s agenda for change is attempting to resolve many problems, there are often discrepancies among individual surveyors’ interpretation of standards. Anecdotally, many ICPs report that surveyors put too much emphasis on issues that are not evidenced-based and fail to look at the larger, more important infection control issues. ICPs need to play a more active role in developing partnerships with all stakeholders, including accrediting and regulatory agencies. Basic infection control practices such as hand hygiene or care of invasive devices often are not consistent. These issues will require us to design processes which make it easier to do the right thing, building in such things as redundancy, standardization, decision aids, and reminders.”
Dolan agrees, remarking, “Conflicts occur when recommendations are published that are not evidence-based. Subsequently, other organizations adopt these recommendations and they can even become regulations that ICPs are required to implement. The implementation of such regulations can be time-consuming and costly, and deter from issues that need more attention. It is important to evaluate the evidence behind recommendations and determine if one can adequately justify implementation of such practices. The difficulty is that some people look at a recommendation, trust the source of the recommendation, and therefore deduce that it must be needed. We must continue to address agencies that product recommendations that are not evidence-based, work to provide them with rationale for the negative impact of their actions, and suggest strategies to better address the issue. As a new member of the APIC Mandatory Reporting Task Force (which is a subcommittee of the Public Policy Committee), I am continually learning about important strategies that the national APIC organization is actively using to address such concerns so that ICP’s can focus on what they need to be focusing on.” Dolan continues, “On a smaller scale, ICPs should become knowledgeable about issues in their institution and help to squelch those ‘sacred cows’ that have become a part of the facility’s culture. The process to change requires strategy, evidence-based information and patience to change the system.”
Looking to the future, ICPs sense that what’s old is new again. “I see more threats of bioterrorism and a possible attack in the United States; worse yet, I do think there will be a pandemic of some sort — if not from the bird flu, then by some strain of influenza,” Spaulding predicts. “However, I think many ICPs are ready to handle any infection control-related issue -- some better than others depending on how long they have been doing infection control. But I’m not sure everyone is prepared to handle the psychological component and the number of lives that will be lost. Most of the population today has never dealt with the number of deaths that can result from either a terrorist attack or a pandemic, and fear can cloud anyone’s judgment. Education and practice drills with staff can help in these situations but the general public needs education as well. Many will not understand what to do to protect themselves, some will deny that anything is happening, while others will blame the government … how does any ICP plan for that?”
Bennett says she admits to remaining concerned about pandemic influenza: “Our current healthcare and social systems have never lived through anything quite like we will experience with the pandemic. We have to give priority to preparation for the pandemic yet many people look at pandemic influenza as a possibility but not a probability. Therefore some communities are not taking it as seriously as we have to. I believe ICPs are taking the challenge seriously but we have to get the ‘leaders’ to follow our lead if we are the major voice calling for rapid action.”
Greene acknowledges the challenges such as these but takes an optimistic view of the future of infection prevention and control: “I see the next five to 10 years as being exciting times for ICPs. We will become agents for change, and noted for our expertise. Our opinions will be sought by leaders in our organization, and some ICPs will rise to important leadership positions within our organizations. We will have higher standards for entry into our profession and will standardize our initial education and training. We will see an increase in collaborative activities as we work together to keep infections to an irreducible minimum. Most ICPs will be ready to face the challenge, and those who are not will most likely leave the discipline.”
Issues such as mandatory reporting of infections may very well prove to be the watershed point in an ICP’s career, acknowledges Dolan, who adds, “A main concern is that each state seems be working independently when a national approach is what is really necessary. If one of the purposes of disclosing information to consumers is to provide them with information to help them make better choices and be more knowledgeable about their providers, then we need to be able to have state to state comparisons that are accurate and have meaning. ICPs are going to need to become knowledgeable about the legislative process and work to support reputable national recommendations for disclosure of useful information to the public.”
“I see increasing concerns about multi-drug resistant organisms and decreasing public tolerance for hospital acquired infections,” Young predicts. “With leadership and guidance from APIC, the CDC, and SHEA, I think we can rise to the challenge.”
Bennett adds, “Our profession is full of strong, knowledgeable infection control leaders who are committed to continuous improvement in infection prevention and control. We have many champions that have accepted the rigorous task of fighting for positive outcomes for our patients. The tasks can be difficult but the rewards are great in positive patient outcomes and in professional satisfaction.”
June 1, 2007
INFECTION CONTROL TODAY Magazine
By Michelle Beaver
Hand hygiene is more complex than meets the eye, but ironically the most complex aspect of this practice involves getting people to follow it in the first place. The simple question is: what prevents some healthcare workers (HCWs) from following proper hand hygiene 100 percent of the time?
According to the Association of Professionals in Infection Control and Epidemiology (APIC), HCWs cite the following reasons for poor hand hygiene:
Hand dryness and irritation that can stem from over-washing
Time constraints from working in an intensive care unit
A lack of soap and/or paper towels
The belief that gloves replace the need for washing
Sinks being far away
Representatives from national healthcare alliance VHA, Inc., studied hospitals in 13 states to discover how these catalysts could be countered and found that team coaching, education sessions and individual consultations improved basic hand hygiene practices by more than 52 percent.
Hospitals nationwide are generally allocating more time and money to infection control, VHA researches announced in late 2006. More needs to be done, however, for HCWs are still far from 100 percent compliant in hand hygiene. “Observation of basic handwashing practices revealed that nurses (86 percent) and respiratory therapists (84 percent) were more likely to follow CDC guidelines for hand hygiene after direct patient contact than physicians (60 percent),” the researchers state.
Post observation, VHA teams helped facility staffs implement better infection control practices, and saw a decrease in ventilator-associated pneumonia by more than 10 percent.
According to APIC, HCWs should wash hands with plain or antimicrobial soap before they eat or handle food, after they use a restroom, when hands are visibly dirty, contaminated with proteinaceous material, blood or body fluids.
As for alcohol handrubs, APIC researchers suggest that HCWs use these products before direct patient contact when the hands are not visibly soiled, before donning sterile gloves to insert central intravascular lines, before inserting urinary catheters, other IV catheters, or invasive devices that do not require surgical placement, after removing gloves, and after contact with objects in the patient’s environment.
Motivating staff members to be hygiene compliant doesn’t have to involve one juggernaut approach. It can instead comprise lots of small and medium measures, as the team at Highland Hospital in Rochester, N.Y., discovered. Highland officials measured the amount of gel and hand soap that was used on each unit and discovered that after an education campaign was carried out, 20 percent more gel and soap was used, says Ann Marie Pettis, RN, BSN, CIC, the infection control practitioner at Highland Hospital.
“Every six months our infection control liaison nurse committee takes on a project to raise staff awareness and hopefully compliance with hand hygiene,” Pettis says. “The most successful one to date was piggybacking on (The Joint Commission’s) 'Speak Up' campaign where they encourage patients to be their own advocates,” she says. “We developed buttons for all staff to wear for a month that said ‘ask me if I washed my hands.’ We made the distribution in to a fun time with balloons, cookies etc.”
The Joint Commission’s 'Speak Up' program encourages patients to get more involved with the healthcare they receive by asking questions and expecting quality.
“Doctors, nurses, dentists and other healthcare providers come into contact with lots of bacteria and viruses,” program literature states. “So before they treat you, ask them if they’ve cleaned their hands. Healthcare providers should wear clean gloves when they perform tasks such as taking throat cultures, pulling teeth, taking blood, touching wounds or body fluids, and examining your private parts. Don’t be afraid to gently remind them to wear gloves.”
Making alcohol dispensers more accessible by putting them in public areas such as next to entrances and elevators is a big help in the battle against bacteria, says Linda Greene, RN, MPS, CIC, infection control manager at Rochester General Hospital in Rochester, N.Y.
“One of our most successful campaigns was our "follow the leader" campaign which included actual pictures of our top leadership and chiefs practicing hand hygiene,” Greene says. “We posted these pictures on all our units. These leaders served as role models.”
The Rochester General staff found peer reviews to be advantageous wherein liaison nurses collected data and then got together to share the results.
They are also fans of the “Ask me if I’ve washed my hands,” approach.
“One of the main issues with hand hygiene campaigns is sustainability,” Greene says. Clearly, most successes that we have found depend on rotating ideas and themes.”
Motivating patients to ask their healthcare provider, “Have you washed your hands,” is indeed an effective approach, according to Carolyn Twomey, RN, vice president of clinical and technical affairs at Mölnlycke Health Care. “Having been involved in a number of forums where this very (hand hygiene) discussion has taken place, the most common threads are pay-for-performance (including the CEO level where awareness is essential and enforcement needs to be addressed) and mandating practice,” Twomey says. “Think about other scenarios where mandates made the difference as in seat belts and air bags.”
Facilities are certainly seeing success in their fight against improper hygiene, says Susanne Pear, PhD, RN, CIC, associate director for infection control practices in the scientific affairs and clinical education department of Kimberly-Clark Health Care. “We’re seeing some very excellent hand hygiene campaigns being conducted,” Pear says. “ICPs around the world are recognizing that providing hand gel isn’t enough. Without training and routine re-training, HCWs are not disinfecting their hands adequately when they do use the waterless products.”
In terms of public education campaigns, creativity is helpful, says Joe Kingsley, president of Glo Germ Co. He cites a Massachusetts program that introduced a big bar of soap, “Super Soapy,” — a mascot who visits school children and teaches them to wash hands properly. Kingsley also refers to a Canadian calendar filled with hand hygiene information and trivia that explores the topics of plaque, aseptic technique, preventing infection, etc.
“Today, a group of Canadian companies being organized by Doug Summerfield plan another national campaign later this year centered around drug stores and pharmacies,” Kingsley says. “And of course, 'Handwashingforlife' under the leadership of Jim Mann is growing internationally as a non-profit organization contributing to better understanding and awareness.”
While many HCWs are compliant 100 percent of the time, it only takes a few to spoil the bunch and introduce insidious materials to dozens of surfaces. Even HCWs who are compliant can stand to learn more, Twomey asserts. “I believe every HCW can and should take (hand hygiene) more seriously,” she says. “It is easy in the pressures of today's healthcare environment to push so hard to get everything accomplished and the priority of hand hygiene can sometimes take a back seat to other seemingly more important tasks.
“I find HCWs are surprised about the evidence in the literature linking poor hand hygiene or infrequent hand hygiene with transmission of infectious disease,” she adds. “I also find that there are those who believe a glove is a cure-all when the evidence is clear that the use of exam gloves is no replacement for good hand hygiene.”
There is certainly room for improvement, Kingsley says. “I think those who remember on a daily basis that 85 percent of infectious diseases are passed by the hands do take hand hygiene serious,” he says.” Unfortunately, handwashing correctly takes time and doing (this) often becomes a significant part of the day. As shown by the rising nosocomial infections resulting in thousands of deaths, the problem is getting worse, not better… There has been a significant awareness and improvement in attitude toward infection control practitioners which in time will result better hand washing practices.”
Alcohol has proved to be an ally in overall hand hygiene and reduces the number of microorganisms on the skin, but the extent to which it should be used — and how much of a product it should compose — is controversial. In the U.S. alcoholbased hand rubs usually contain 60 percent to 95 percent ethanol or isopropanol.
Applying small amounts of alcohol to the hands is not more effective than washing hands with plain soap and water, according to the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the Hand Hygiene Task Force, which is formed by members of HICPAC, the Society for Healthcare Epidemiology of America (SHEA), Infectious Diseases Society of America (IDSA) and APIC.
“The ideal volume of product to apply to the hands is not known and may vary for different formulations,” the committee and task force members write. “However, if hands feel dry after rubbing hands together for 10-15 seconds, an insufficient volume of product likely was applied. Because alcohol-impregnated towelettes contain a limited amount of alcohol, their effectiveness is comparable to that of soap and water.”
Several factors determine the success of alcohol- based products including the type used, the concentration, amount of contact time, and the condition of the hands when the product was applied.
Alcohol-based products often cause drying, but this consequence can be mitigated by emollients, humectants, and other skin conditioners including 1 percent to 3 percent glycerol.
Hand lotions and creams are advisable and can “increase skin hydration and replace altered or depleted skin lipids that contribute to the barrier function of normal skin,” committee and task force members state. “Several controlled trials have demonstrated that regular use (twice a day) of such products can help prevent and treat irritant contact dermatitis caused by hand-hygiene products. In one study, frequent and scheduled use of an oil-containing lotion improved skin condition, and thus led to a 50 percent increase in handwashing frequency among HCWs.”
Alcohol-based products have consequences besides leeching hydration. Even mild alcohol rubs can sting broken skin, and products with strong fragrances can irritate respiratory tracts. There are further concerns, Twomey says.
“I have long been concerned that the dramatic move to alcohol may prove deleterious in hindsight for two reasons,” she says. “Many forget that alcohol does not clean your hands, it only degrees your hands, and alcohol has to dry to be effective, but once it is dry it is gone. The very next thing one touches will contaminate your hands.
“So, you use the alcohol product outside your patient’s door and the next thing you touch is the door, the chart, the side rail, your stethoscope, your pager or cell phone, the handle of your patient’s water pitcher — all well documented contaminated items in the healthcare environment — and your hands are loaded with germs once again,” Twomey continues. “Everyone needs to be using a product with continued killing power so that after you leave the sink or use the product, it keeps on killing for you so when you touch those contaminated items and pick up new microbes, they are killed by the product still working on your hands.”
Twomey believes that alcohol has served too big a role as the primary “de-germer” in healthcare. “Given the numerous multi-drug resistant organisms plaguing our healthcare system — and many of those are now rampant in the community — alcohol is not enough,” she says. “It is important to know when to wash and to use products with persistence and continued kill.”
Hundreds, if not thousands of good hand hygiene products are available, but perhaps the best combination is also one of the most simple, says Kingsley. “Regular soap, warm water (and) 15 seconds or more (of washing) are still the best products for hand hygiene and fighting infections,” he says.
An important tool is a good dispensing system, according to Patty Taylor, vice president of healthcare marketing for GOJO Industries. “The PURELL® PORTAL™ Program is being used by hospitals across the country to help control the spread of infection,” Taylor says. “With regard to accessibility, this program puts fully ADA-compliant Purell dispensers throughout the hospital facility, thereby making the product readily accessible to staff, patients and visitors.
“Program support includes a full in-service program that includes training video and program outline,” she adds. “To encourage compliance, user-friendly products are needed to avoid chapped hands and/or contact dermatitis. However, these products should be broad spectrum, fast acting and non-irritating.”
Every product should address the fact that people are fallible, says Wayne Albright, president of Germ Pro Products, Inc. “The average healthcare worker has good intentions regarding hand hygiene, but busy schedules and dry, cracked hands make compliance difficult,” Albright says. “Addressing human obstacles is a must.”
Products that persistently kill germs on oft-touched areas are important in the fight against HAIs, according to Albright. “The fewer germs your hands pick up, the lower the possibility of infection transmission,” he says.
“Germ Pro’s persistent action plan (PAP) uses a combination of our persistent hand-sanitizing lotion and our persistent surface disinfectant to help prevent HAI’s by killing pathogens before they can become infections.
The hand sanitizing lotion also creates a hydrophobic layer that is not easily washed off, Germ Pro claims. “This layer helps heal the hands and protects them from the harsh effects of constant regular and alcohol washes, allowing better hand wash compliance with … handwash guidelines,” Albright says.
Blast to the Past
Rinsing hands with water is likely as old as humankind itself, but the act of cleansing hands with an antiseptic seems to have started in the 19th century. “As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odors asso-ciated with human corpses and that such solutions could be used as disinfectants and antiseptics,” the committee and task force members write. “In a paper published in 1825, this pharmacist stated that physicians and other persons attending patients with contagious dis-eases would benefit from moistening their hands with a liquid chloride solution.”
In 1846 in Vienna, an observant man named Ignaz Semmelweis noticed that many more women were dying in the maternity ward of one clinic than in another, and consequently developed some interesting theories. “He noted that physicians who went directly from the autopsy suite to the obstetrics ward had a disagreeable odor on their hands despite washing their hands with soap and water upon entering the obstetrics clinic,” the committee and task force members cite in their guidelines. “He postulated that the puerperal fever that affected so many parturient women was caused by ‘cadaverous particles’ transmitted from the autopsy suite to the obstetrics ward via the hands of students and physicians.
“Perhaps because of the known deodorizing effect of chlorine compounds, as of May 1847, he insisted that students and physicians clean their hands with a chlorine solution between each patient in the clinic,” the document continues. “The maternal mortality rate in the first clinic subsequently dropped dramatically and remained low for years.”
A few years earlier (in 1843) Oliver Wendell Holmes came to the conclusion that HCWs were spreading puerperal fever through their hands. He released advice on how proper hand hygiene could decrease the spread of fever, but the advice was not immediately heeded. Even so, the combination of theories from Semmelweis, Holmes and others eventually led to hand hygiene being highly regarded in the healthcare industry.
“In 1961, the U.S. Public Health Service produced a training film that demonstrated handwashing techniques recommended for use by HCWs,” the committee and task force members write. “At the time, recommendations directed that personnel wash their hands with soap and water for 1-2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable.”
The Guideline for Hand Hygiene in Health-Care Settings Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force state that a chain-lapse in hand hygiene occurs when a HCW picks up organisms from patient skin or from something the patient touched, then fails to wash their hands or washes inadequately and comes in contact with another patient or with something another patient will touch.
Washing is much better than not washing, but does not always suffice, as is clear in a study that the committee and task force members re-viewed.
“Several investigators have studied transmission of infectious agents by using different experimental models,” they write. “In one study, nurses were asked to touch the groins of patients heavily colonized with gram-negative bacilli for 15 seconds — as though they were taking a femoral pulse. Nurses then cleaned their hands by washing with plain soap and water or by using an alcohol hand rinse.
“After cleaning their hands, they touched a piece of urinary catheter material with their fingers, and the catheter segment was cultured,” they continue. “The study revealed that touching intact areas of moist skin of the patient transferred enough organisms to the nurses' hands to result in subsequent transmission to catheter material, despite handwashing with plain soap and water.”
APIC offers the following hand hygiene tips:
Use warm (instead of hot) water to decrease the possible risk of dermatitis.
Hands contaminated by dangerous bacterial spores should be washed with water and appropriate products — not treated with alcohol-based handrubs.
Alcohol handrubs should contain 60-95 percent isopropanol, ethanol or n-propanol and 1-3 percent glycerol or other emollients.
Alcohol-based products should be stored away from high temperatures, electrical outlets or oxygen receptacles.
It is not recommended to routinely wash hands after application of alcohol-based handrubs.
Moisturizers or barrier creams (that do not inhibit glove barriers) should be widely available.
Antimicrobial-impregnated wipes are considered equivalent to handwashing, but should not be a substitute for alcohol handrubs or antimicrobial soap.
The Nitty Gritty
Members of the Healthcare Infection Control Practices Advisory Committee and the Hand Hygiene Task Force contend that a strong understanding of hand hygiene begins with knowledge that skin is a dynamic structure in which skin flora play an important role. Normal skin, of course, is covered with bacteria and different parts of the body are colonized by varying types.
“Transient flora, which colonize the superficial layers of the skin, are more amenable to removal by routine handwashing,” guideline authors state. “They are often acquired by HCWs during direct contact with patients or contact with contaminated environmental surfaces within close proximity of the patient. Transient flora are the organisms most frequently associated with healthcare associated infections. Resident flora, which are attached to deeper layers of the skin, are more resistant to removal …”
Antiseptic agents that reduce the amount of microbial flora include alcohols, chlorhexidine, chlorine, hexachlorophene, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan.² Handwashing guidelines for HCWs in the surgical field have their own intricacies and sometimes involve scrubbing with a brush. This can lead to skin damage, however, and may be unnecessary, the committee and task force members write.
“Scrubbing with a disposable sponge or combination sponge-brush has reduced bacterial counts on the hands as effectively as scrubbing with a brush,” they claim. “However, several studies indicate that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used.”
APIC lends the following surgical hand antisepsis tips:
“Remove rings, watches (and) bracelets before beginning surgical hand scrub.
Use a nail cleaner and running water to remove debris from under fingernails.
When using antimicrobial soap, scrub for at least 2-6 minutes, or as recommended by the manufacturer.
When using an alcohol-based surgical hand scrub product with persistent activity, prewash hands and forearms with a nonantimicrobial soap, then dry hands and forearms completely.” Apply alcohol-based product as recommended, allow hands and forearms to dry completely. Finally, don sterile gloves.
HCWs in any spectrum should carefully cleanse their fingernails, as this body part can host thousands of pathogenic organisms.
APIC recommends that HCWs, “clean areas under fingernails if they are visibly dirty, and pay special attention to these areas when you wash OR use alcohol handrubs for cleaning hands. Freshly applied nail polish does not increase the number of germs present, but chipped nail polish may harbor bacteria. Persons with artificial nails are more likely to harbor higher bacterial counts than those who do not wear them. For this reason, healthcare personnel who work in high risk areas should not wear artificial nails.”
Nationwide, people need to take greater action in favor of proper hand hygiene, all the way from personal practice to changing regulations, according to Kingsley.
“A partnership with Dial Soap, Sloan Valve, Georgia Pacific Paper Company, Glo Germ Co., and Kohler Sink was planned a few years ago to package a portable handwashing station for under $100 to be placed in every occupied patient room so that all visitors and staff washed hands (upon) entering and leaving,” Kingsley says.
“It did not happen because the lawyers and risk management personnel were concerned of the liability issues — for the facilities which did not participate! In my opinion this is a 'backdoor' recognition of the importance of new technology towards hand washing products,” Kingsley adds. “The gels and wipes are also contributing to better awareness, as long as … regular soap and warm water are used to wash one’s hands.”
Kingsley believes that compliance must be spurred not merely from healthcare professionals, but from the legal community as well. “I cannot tell you the number of times I have attended meetings in which risk management personnel equate costs of compliance to money, not the pain and suffering and deaths,” he says. “Therefore, the costs for non-compliance have to be monetarily expensive.” Kingsley looks for leadership from people like Atlanta’s Victoria Nahum, who co-founded Safe Care Campaign, an organization that works with corporations, advocacies, insurance companies and caregivers to invoke greater education about hand hygiene.
“Our goal is to instigate a crucial national culture change in ideology and practices within the healthcare environment in regard to hand hygiene,” Nahum says of Safe Care Campaign. “While (legislation) is not part of our mission statement, we would be in favor of “solutions with teeth” in instances where the hand hygiene standard of care is obviously being deliberately or repeatedly ignored. Sloppy care is totally unacceptable and carries disastrous consequences for everyone.”
Safe Care Campaign members work toward a shift in healthcare ideology in hospitals, surgical centers and other facilities. Nahum has heard many excuses for not demonstrating proper hand hygiene, and says none of the excuses are good enough.
“(Excuses) make me think that (HCWs), whatever their titles, must somehow still not comprehend the enormity of the potentially tragic consequences of poor hand hygiene,” she says. “I cannot imagine that people who actually realize the profound adverse physical effects and needless deaths that sloppy care causes would actually choose to forego this fundamental step when administering care to patients who trust them.”
The problem will continue, however, until hand hygiene is at the forefront of every healthcare worker’s mind and until administrators offer better education campaigns and working conditions that are more conducive to frequent and proper handwashing.