Advances in Hand Hygiene Compliance

Advances In Hand Hygiene Compliance

Hand hygiene is the most effective means of reducing hospital-associated infections (HAIs.) Infection prevention is critical to saving lives and reducing cost of care. Yet maintaining a high level of hand hygiene compliance continues to be a real challenge. Hospital visitors may not be aware of the need to use handwashing stations available in hallways, and healthcare workers (HCWs) often miss opportunities for proper hand hygiene due to a variety of reasons.

Determined to improve quality of care, hospitals are employing new and novel means to help HCWs comply with hand hygiene requirements and maintain high levels of compliance.

Targeted Solutions Tool®

In 2006 Memorial Herman Hospital System (MMHS,) consisting of 12 hospitals and over 200 alternate-site facilities and programs, set the goal of becoming a high reliability organization (HRO.) HROs maintain high levels of quality and safety over long periods with few adverse events.

Working toward this goal, Robust Process Improvement® projects proved effective in reducing HAIs, but more could be done by addressing hand hygiene compliance. MMHS implemented the Joint Commission Center for Transforming Healthcare’s Web-based Targeted Solutions Tool® (TST®.)

The TST enabled MMHS to measure compliance rates using secret observers, identify reasons for noncompliance and implement tested interventions provided by the TST. Most importantly, they were able to sustain those improvements.

MMHS found that the number one contributing cause of hand hygiene noncompliance at their hospitals was improper use of gloves, which includes not washing before or after wearing gloves. Other frequent contributing causes included frequent entry and exit of patient areas, hands being full of supplies, being distracted or forgetting, following a person during entry or exit, and ineffective or inconvenient placement of hand gel dispensers or sinks.

Interventions to increase compliance included using a code word to remind a distracted person to perform hand hygiene, relocating or adding hand gel dispensers, and providing a surface for HCWs to place supplies and medications so they could perform hand hygiene.

MHHS’s system-wide hand hygiene compliance averaged 84.4% during the “improve” phase compared to the baseline average of 58.1%. They ultimately achieved 95.6% compliance in the final 12 months of the study. All that effort paid off with fewer HAIs. Adult ICU central line-associated bloodstream infections decreased by 49%, and ventilator-associated pneumonia decreased by 45%.

To sustain these gains, MMHS continues to collect and input data on hand hygiene compliance, and each hospital’s hand hygiene team is responsible for sustaining performance.

Remote Video Auditing (RVA) with Feedback

For a more high-tech approach, a technology that has been shown to dramatically improve hand hygiene compliance in the food processing industry is now doing the same in hospitals – RVA with feedback.  The system captures and audits images and provides real-time feedback to practice areas. While it sounds ominous – cameras watching your every move – it encourages compliance in a positive way with a non-punitive approach.

NS-LIJ’s North Shore University Hospital in Manhasset, NY employed the RVA system from Arrowsight to improve hand hygiene compliance in their medical intensive care unit (MICU.) The baseline snapshot of compliance before feedback was low, around 10 percent.

Over a 16-week period, HCWs were monitored and received real-time feedback in aggregate on LED screens mounted on the walls of the MICU and from team leaders. Each shift was able to clearly see their compliance rate which naturally motivated improvement. Within weeks the hand hygiene compliance rate soared to 80 percent, then reached a sustained rate of 90 percent during the 17 month maintenance period.

Some feel this method is superior to “secret-shoppers” or observation by individuals with clipboards in hand. When we know we are being watched, we act differently.

His Eyes Are On You

Even when we aren’t being watched, just the image of a man’s intense staring eyes above a handwashing station can prompt compliance.

Employing behavioral science, researchers at a teaching hospital in Miami found that a picture of a man’s eyes increased hand hygiene by one-third at an intensive care unit. Interestingly, a picture of a woman’s eyes saw a lower compliance rate than no picture at all. This may be because of gender differences in exerting social influence, or it may have just been because the man’s eyes showed more facial musculature, which is perceived as anger or a threat. In any case, this low-tech “cue” works.

Figure 2. 

Pure Hold Hygiene Handles

PureHoldDoor knobs and handles are notorious for harboring germs, making them common sources of infection transmission. Frequent wipe-downs with a germicide are not enough to halt viruses looking for their next ride.

Enter the Pure Hold Hygiene Handle. It sprays a hand sanitizing gel on the person’s hand as they open the door. Lab testing and trials have proven that these sanitizer dispensing door handles are 98.5 percent cleaner than a standard door handle.

The hands that open them are also cleaner. At Queen Alexandra Hospital in Portsmouth, hands that used the system were 87.5 percent cleaner than those that did not. The special handles are also used in the cleanroom, pharmaceutical and food processing industries to reduce possible contamination of critical environments. Employing the door handle as the method of dispensing handwashing gel ensures that more people comply with efforts to stop viruses and HAIs.

Hand hygiene compliance, including the proper use of medical gloves, is a critical factor in reducing HAIs. Increasing and maintaining that compliance among healthcare workers is made possible by employing new and novel methods and technology.

Hand Hygiene Before Gloving – How Important?

Hand Hygiene Before Gloving - How Important?

If you work anywhere in the health care industry, you are likely aware of the importance of performing proper hand hygiene and glove use to reduce the spread of infectious organisms.

In the “Five Moments for Hand Hygiene” as outlined by the World Health Organization (WHO,) the first “moment” for performing hand hygiene is Before Patient Contact.

But is this step really necessary, especially when you are about to don a pair of gloves before touching the patient?

Recent studies on unused, non-sterile exam gloves removed from glove boxes in patient areas suggest it really is that important.

Glove Contamination in the ICU

At University Medical Center, a 412-bed tertiary care hospital in Lubbock, TX, a study compared rates and burden of non-sterile glove contamination among specialty ICUs.

A total of ninety glove pair samples were taken from occupied rooms in a 32-bed Medical ICU, a 21-bed Trauma/Surgical ICU, and a 6-bed Burn ICU.  The gloves were collected from glove boxes housed in glove box dispensers or patient carts in patient rooms where health care providers had unrestricted access to the gloves.

The results?

“We found an average contamination rate of 81.1% across all glove pairs sampled with an average bioburden of 5.83 CFU (SD = 8.04).”  These findings were consistent with previous studies, where contamination rates were 55-87% and average bioburdens ranged from 3.4-6.2 CFU per glove pair.

The study also found evidence of methicillin-resistant organism (MRO) contamination on 36.7% of glove pairs sampled.  The study noted that “because our contamination rate estimate most likely underestimates the true rate of MRO contamination due to the selective culturing process followed, actual rates of MRO contamination may be higher than those reported in this study.”

Pathogen Contamination in a Large Ward

Another study conducted in New Zealand investigated glove use on a hospital orthopaedic ward to examine whether pathogen contamination occurs prior to contact with patients.

Glove samples were removed from boxes on opening and days 3, 6 and 9 thereafter.

The results?

“Total bacterial counts ranged from 0 to 9.6 x 103 cfu/glove.  Environmental bacteria, particularly Bacillus species, were present on 31/38 (81.6%) of samples.  Half (19/38) the samples were contaminated with skin commensals; coagulase negative staphylococci were predominant.  Enterococcus faecalis , Klebsiella pneumoniae , Pseudomonas sp. or methicillin susceptible Staphylococcus aureus were recovered from 5/38 (13.2%) of samples.  Significantly more skin commensals and pathogens were recovered from samples from days 3, 6, 9 than box-opening samples.”

Clearly, both studies demonstrate that health care workers can introduce pathogenic bacteria into glove boxes, and unused, non-sterile exam gloves can become pathogen transmission vehicles in hospitals and potentially other healthcare settings.

Adhering to handwashing guidelines and performing hand hygiene before donning gloves is a critical, not to be skipped step in reducing the spread of dangerous bacteria.


Gloves, Handrubs and HAIs in the Dental Setting

staphylococcus aureus in the dental setting

Health care associated infections, or HAIs, can be acquired anywhere health care is delivered, including the dental office.  As a dental clinician or dentist, you know that proper hand hygiene and gloving is essential to your patient’s safety as well as your own.

But how prevalent are infectious agents such as bacteria, fungi and viruses in the dental setting?  And is your current hand hygiene routine enough to prevent HAIs?

Dental Staph

A recent study conducted by the Department of Public Health and Infectious Diseases at Sapienza University, in Rome, Italy, investigated staphylococci contamination on disposable gloves and clinical surfaces in the dental setting.

Environmental samples were collected from the tray and gloved dominant hand soon after dental therapy of the second or third patient at 136 general dental practitioners’ offices.  Staphylococci were detected in 41% of the trays and 57% of the gloves.  Specifically, S. aureus was found in 5% of both tray and glove samples, and MRSA was detected on 1.5% of the glove and tray samples.

The study concluded that contact surfaces and gloves in the dental setting are “frequently contaminated.”

Studies like this underscore the importance of proper hand hygiene and proper donning and doffing of exam gloves.  But even if you are using the manufacturer’s recommended amount of alcohol-based handrub, another recent study warns that it may not be enough.

Pump Up the Volume

The Bode Science Center in Hamburg, Germany evaluated the effectiveness of different volumes of alcohol-based handrubs.  They used the manufacturer recommended product volumes of 1.1 mL, 2 mL, and 2.4 mL, as well as 1 and 2 pump dispenser pushes for foams and gels.

They discovered that 70% ethanol (v/v) handrubs at the recommended volume of 1.1 mL per application “did not ensure complete coverage of both hands and do not achieve current ASTM efficacy standards.”  Whereas an application of 2 mL of 85% w/w ethanol rub reduces contamination sufficiently to fulfill the US FDA efficacy requirement.

Proper Gloving and Handrub Guidelines

To provide the safest environment possible for yourself and your patients, diligently follow proper gloving and hand hygiene guidelines to reduce HAIs.  This includes handwashing or handrubbing before donning gloves, and immediately after careful removal of gloves.  And when using an alcohol-based handrub, use enough to completely cover all surfaces of your hands.

Share Your Experience – How is your office’s hand hygiene compliance?  What have you done to improve it?  Post your comments below.


Proper Medical Glove Use and Hand Hygiene Reduces HAIs and Saves Lives

Proper Glove Use and Hand Hygiene Reduces HAIs and Saves Lives

[dropcap]W[/dropcap]hile medical facilities appear to have gained some ground against Hospital Acquired Infections (HAIs,) the problem is still a great and very real daily threat to human life.   Bacteria that cause HAIs, such as C. diff, MRSA, E. coli, and S. aureus result in an astounding 2 million infections a year and an estimated $6.7 billion in hospital costs.  The most sobering statistic is that these deadly infections kill 100,000 people each year – that’s more than all of the deaths from car accidents, AIDS and breast cancer in the U.S. combined.

According to the World Health Organization (WHO,) “hand hygiene is the single most important measure to protect patients, HCWs and the environment from microbial contamination.”  Unfortunately, compliance with this practice is dismally low.  According to the New England Journal of Medicine, less than 40% of Health Care Workers (HCWs) practice proper hand hygiene.

Several studies have shown that wearing medical gloves reduces hand hygiene compliance.  For instance, in one study HCWs were less likely to perform hand hygiene after removing gloves upon leaving a patients room.  In contrast, other studies have shown that glove use increased overall compliance, but these studies did not investigate glove misuse.  For these reasons the impact of wearing medical gloves on hand hygiene policies has not been determined.  One thing we know for certain, though, is that proper use of gloves combined with proper hand hygiene is critical to reducing infections.

WHO Guidelines for the appropriate and safe use of medical gloves includes the following:

Medical glove use does not obviate the need to comply with hand hygiene.  When hand hygiene is indicated, handwashing or handrubbing should be performed before donning gloves.

Careful attention should be paid to glove removal.  Gloves should be removed to perform handwashing or handrubbing to protect a body site from the flora from another body site previously touched on the same patient.  WHO states that “HCWs often fail to remove gloves between patients or between contact with various sites on a single patient, thus facilitating the spread of microorganisms.”

Perform hand hygiene after glove removal.  Hand hygiene must be performed immediately after glove removal to prevent HCW contamination and spread of microorganisms.

Clear direction about medical glove use should be provided.  HCWs should be able to clearly identify situations requiring gloves, situations that do not require gloves, and how to correctly select a glove.  This requires that medical facilities have clear glove use procedures to help HCWs reason and adjust their behavior to comply with proper hand hygiene and glove use.  This includes a clear understanding of when glove use should start and end.

Medical gloves should always be stored in their original boxes.   Tucking gloves away in pockets and carrying them about is not safe.   Gloves should remain in their original box until donned to ensure the gloves do not become contaminated.  This requires that glove boxes should always be available at point of care.

Appropriate use of medical gloves, combined with proper hand hygiene, is an evidence-based measure to protect HCWs, patients and the environment from HAIs.  HCWs that fail to remove gloves or perform proper hand hygiene between patients risk spreading deadly infections.

Fortunately, the medical community is working hard to increase compliance.  New education campaigns, surveillance programs and other tools are helping ensure more HCWs do their part to reduce the cost of HAIs  – in lives lost and the billions spent to treat them.

What do you think?  Can we do more to reduce HAIs with improved hand hygiene and glove use?

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