This presentation made clear the VHA policy to implement the CDC hand Hygiene Guideline a year before the VHA Directive was issued. A special memo and summary had been sent to VA Network Offices and Medical Center Directors from the Under Secretary for Health (Dr. Roswell). Will post the "TIPS" issue mentioned in slides. Memo has probably been lost in the mists of time. I have a video of this presentation (because it was broadcast on the VA's internal education system) on VHS and someday may get it on YouTube...

1. Demystifying and
Responding to CDC’s Hand
Hygiene Guidelines and
JCAHO’s Related Patient
Safety Goal for 2004
Presentation to QMIC, 2/4/04
Noel Eldridge, MS
VHA National Center for Patient Safety
202 273-8878
1

2. Presentation Outline
• CDC Guidelines and JCAHO
Patient Safety Goals for 2004
• Summary of the Evidence
• Memo from Dr. Roswell and
Summary of Requirements for
VHA facilities
• Pilot Six Sigma Project with 3M
Corporation and Three VAMCs
2

3. The Big Picture
• Patients are getting infections that
can be avoided by following the
CDC Guidelines
• My goal today here is to provide:
• a comprehensive and comprehensible
introduction to the CDC Guidelines
• summary information on how to
address the CDC Guidelines and
JCAHO requirements
3

4. CDC Guidelines on Hand
Hygiene
• Issued October 25, 2002
• Issued by CDC and others:
“CDC Healthcare Infection Control
Practices Advisory Committee
(HICPAC) and the HICPAC/SHEA/
APIC/IDSA Hand Hygiene Task Force”
• New IOM and NQF studies also give
preventing nosocomial infections high
priority
4

5. CDC Guidelines Recommendations 44 in 8 Categories
1. Indications for handwashing and hand
antisepsis (14)
2. Hand-hygiene technique (4)
3. Surgical hand antisepsis (5)
4. Selection of hand-hygiene agents (5)
5. Skin care (2)
6. Other Aspects of Hand Hygiene (6)
7. Health-care worker educational and
motivational programs (3)
8. Administrative measures (5)
Total Length: 1350 words in 45 page document
5

6. Why the Big Deal?
• Studies cited by CDC and/or IOM:
• Nosocomial infections are the most
frequent major “complication” for
inpatients -- 5% contract a
nosocomial infection
• 88,000 deaths annually from
nosocomial infections
• 350,000 years of life lost annually –
almost 1,000 years a day!
• Most common mode of transmission
of pathogens is via hands
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7. JCAHO Involvement
• New JCAHO Patient Safety Goal
for 2004:
• 7a: “Comply with current CDC handhygiene guidelines.”
• Making it a Patient Safety “Goal”
for 2004 has transformed the CDC
“Guidelines” into JCAHO
“Requirements”
7

8. The Evidence
• 423 references in CDC Guidelines
•
•
•
•
•
•
From Laboratory Tests
From Hospitals
From Long-term Care Facilities
From Schools
On Bacteria, Viruses, Fungi
On Wild-type and Antibiotic-resistant
Strains
• From VAMCs
8

9. Study of Alcohol Handrub use at
a Long-Term Care Facility
• Compared the 2 units of the facility where alcohol
hand-rubs were used with the rest of the facility.
Key findings:
• 30% fewer infections over a 34 month
period
• 2.27 (alcohol) vs. 3.19 (soap) per 1000 pt-days
• Primary infections were urinary tract with
Foley catheter, respiratory, and wound
• 253,933 pt-days total; 81,036 in alcohol group
• Reference: Fendler et al, AJIC, June 2002
9

10. Study of Alcohol Handrub use at an
Acute Care Facility
• Compared one unit (orthopedic surgery) of a
hospital before and after introduction of alcohol
handrubs in that unit. Key Findings:
• 36% fewer infections (6 months before, 10
after).
• 8.2 vs. 5.3 infections per 1,000 patient days
• “Teachable” patients given 4 oz. alcohol gel too
• Primary infections: urinary tract and surgical site
• Cost savings studied:
• Mean cost per infection: $4,828 +/- 4,868
• Cost of 10 months of supplies for unit: $1,688
• Reference: Hilburn et al, AJIC, April 2003
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11. Memo from Dr. Roswell and
Summary of VHA Requirements
• Memo from Dr. Roswell to VISN Directors
• Special VHA guidance, e.g., alcohol hand-rub in
corridors is OK
• One-page VHA Summary of the CDC Hand
Hygiene Guidelines required by JCAHO
• One-page Cross-reference between VHA
Summary and CDC Guidelines
• See also: Dec. 2003 issue of TIPS Newsletter
• All these documents were written after clarifying
discussions with top CDC and JCAHO officials
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12. VHA Summary of JCAHO-required
CDC Recommendations
(19 in 4 categories)
I.
II.
III.
IV.
All Health Care Workers with Direct
Patient Contact (8)
Surgical Hand Hygiene (3)
Facility Management: Supplies (5)
Facility Management: Administrative
Action (3)
Total Length: 732 words (-45%)
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13. Summary of VHA Summary (1)
I.
All Health Care Workers (HCWs)
with Direct Patient Contact
•
•
•
Decontaminate hands before and
after touching a patient (regular
soap doesn’t do it)
Specific gloving recommendations
Soap and water for soiled hands
13

14. Summary of VHA Summary (2)
II.
Surgical Hand Hygiene
•
•
Guidance on surgical scrub with
soap and water (e.g., shorter
scrub times are OK)
Guidance on surgical scrub with
no-rinse alcohol-based products
with additional compounds for
persistent action
14

15. Summary of VHA Summary (3)
III. Facility Management: Supplies
•
•
•
•
•
•
Alcohol at room entrance and/or bedside
Alcohol available in pocket-sized
dispensers
Alcohol in other convenient locations
(e.g., in corridors is OK within limits)
Antimicrobial soap as an alternative to
alcohol
Provide hand lotion to HCWs
Store alcohol safely – it is flammable
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16. Summary of VHA Summary (4)
IV. Facility Management:
Administrative Action
•
•
•
Make HH a priority and provide
financial and administrative
support
Solicit input from employees on
products
Monitor adherence and provide
feedback on hand hygiene
performance
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17. CDC Guidelines on Hand Hygiene
• If you only remember one thing,
remember this: Alcohol hand-rubs are
better than soap and water. Why?
1. They kill germs better (lab data) and produce
better outcomes -- fewer infections -- for patients
(hospital data)
2. They are easier to use correctly (forcing function)
3. They are easier on hands (lab and hospital data)
4. Staff only use soap 20-50% of when they should
(multiple hospital data). Some studies as low as 4
or 5%
17

18. CDC Slide on Effectiveness
Ability of Hand Hygiene
Agents to Reduce Bacteria on
Hands
Time After Disinfection
log
0 60
180 minutes
3.0
99.0
2.0
90.0
1.0
0.0
Bacterial Reduction
%
99.9
0.0
Alcohol-based handrub
(70% Isopropanol)
Antimicrobial soap
(4% Chlorhexidine)
Baseline
Plain soap
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.
18

19. CDC Slide on Skin Condition
Effect of Alcohol-Based Handrubs
on Skin Condition
Self-reported skin score
Dry
Healthy
Epidermal water content
6
5
4
3
2
1
0
27
25
23
21
19
17
15
Baseline
Alcohol rub
2 weeks
Soap and water
Healthy
Baseline
Alcohol rub
2 weeks
Dry
Soap and water
~ Alcohol-based handrub is less damaging to the skin ~
Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.
19

20. Six Sigma Pilot Project with 3M:
What we’re measuring in 3 VAMC ICUs
1.
2.
3.
4.
5.
6.
Staff compliance (observing practices with
checklist and clipboard)
Volume of product used (converting to
“doses” of alcohol handrub and soap)
Staff Attitudes and Perception of
Compliance (questionnaire)
Antimicrobial soap in use (percent yes/no)
No artificial nails on HCWs (percent yes/no)
Staff satisfaction with HH practices
(questionnaire)
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21. 3M-VHA Six Sigma Team Members
Dr. Robert Bonello,
Minneapolis VAMC
Kay Clutter,
Minneapolis VAMC
Linda Danko, Infectious
Diseases
Dr. Edward Dunn,
NCPS
Noel Eldridge, NCPS
Leann Ellingson,
Minneapolis VAMC
Mary Ann Harris, Fayetteville
(AR), VAMC
Barbara Livingston, Des
Moines VAMC
Renee Parlier, VHACO
(10NC)
Cheryl Pederson, 3M
Kim Reichling, 3M
Dr. Gary Roselle, Infectious
Diseases
Susan Woods, 3M
Dr. Steven Wright, OQP
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22. Very Preliminary Data from
Questionnaire or Pilot Site(s)
• Staff think they’re doing 90% when they’re doing
60%.
• Nurses and doctors at about 50% -- but better
than others (e.g., chaplains, technicians).
• Number of HH opportunities doesn’t affect
compliance.
• HCWs believe in connection between HH and
infections, but are skeptical about specifics.
• Almost all VAMCs providing alcohol handrubs.
• Over 40 VAMCs using only antimicrobial soap in
patient care areas.
• ICU staff are not wearing artificial nails.
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23. What to do now (short list)
1. Get alcohol hand-rubs close to patients
and make it convenient to use: put in
rooms or entrances to rooms, in hallways,
and pocket size too.
2. Get antimicrobial soap in soap dispensers.
3. Tell staff that the alcohol hand-rub should
be primary method for hand
decontamination.
4. Read the CDC Guidelines and VHA
Summary. Start with TIPS article and
memo from Dr. Roswell (see final slide)
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24. Final Thoughts
1. What doesn’t work: Telling people to use
soap and water.
2. It’s not always common sense, for
example:
•
•
•
Evidence suggests that shorter surgical
scrub times and not using a brush are same
or better
Alcohol products easier on hands than
soaps
Cleaner-feeling hands may have more
microorganisms (soap vs. alcohol handrub)
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25. Recommended On-line Resources
• December 2003 VHA NCPS Topics in
Patient Safety (TIPS) Newsletter:
vaww.ncps.med.va.gov/TIPSarchive.html
• Special VHA NCPS Website on Hand
Hygiene:
vaww.ncps.med.va.gov/Hand_Hygiene/
• CDC Website: www.cdc.gov/handhygiene/
• JCAHO Website:
www.jcaho.org/accredited+organizations
/patient+safety/npsg.htm
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26. How EAs Can Help
• Work with me to send a tailored
e-mail to your national list(s)
• Invite me to give a short
presentation on this topic on a
monthly call or staff meeting
• Other ways that I haven’t thought
of? Let me know!
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