Hand Hygiene: Not Just for Health Care Workers Anymore!

Transcription

1 Hand Hygiene: Not Just for Health Care Workers Anymore! Jocelyn Srigley, MD, MSc, FRCPC Director, PHSA IPAC Medical Microbiologist, BC Children s & Women s November 4,

2 Disclosures No conflicts of interest

3 Objectives To understand why patient hand hygiene is important To review existing data on patient hand hygiene rates To describe patients hand hygiene knowledge, attitudes, and practices To discuss how to improve patient hand hygiene

4 Transmission Can Occur Via Patients Hands Indirect Contact Fecal-Oral By Intermedichbo - Norbert Kaiser File:Intensivstation (01) jpg, CC BY-SA 3.0,

5 Bacterial Pathogens on Patients Hands 100 hand samples from patients on medical/surgical units One pathogen 39% Gram negative 34% C. difficile 14% MRSA 14% VRE 9% 357 patients admitted to 6 post-acute care facilities Any MDRO 24.1% MRSA 10.9% VRE 13.7% Resistant Gram negative bacilli 2.8% 1 Istenes et al, Cao et al, 2016.

6 Patient Hand Hygiene Prevents HAIs Author (Year) Pokrywka (2014) Gagne (2010) Study Design Before-after Before-after Study Setting Participating Patients Recipients of Intervention Elements of Intervention 520-bed tertiary care and teaching hospital All inpatients Both Education, reminders, provision of product 250-bed community hospital All inpatients Patients Education, provision of product Results: Healthcare Associated Infections CDI rate 10.45/ 10,000 patient days before to 6.95/ 10,000 patient days after; p= MRSA 10.6/ 1,000 admissions before to 5.2/1,000 admissions after N/A N/A Results: Hand Hygiene Rates Cheng (2007) Before-after Inpatient psychiatric department Long-stay psychiatric patients HCWs Provision of product 6 outbreaks affecting 66 patients (18.2%) before; 4 outbreaks affecting 23 patients (4.4%) after; p=0.005 for total patients involved N/A Thu (2007) Controlled before-after 2 neurosurgical wards Inpatients who had undergone a neurosurgical procedure Patients Education, provision of product SSI decreased from 8.3% to 3.8% on intervention unit and increased from 7.2% to 9.2% on control unit; p=0.04 for comparison between units N/A Hilburn (2003) Peters (1992) Before-after Before-after with repeated treatment Orthopedic surgical unit Maternity ward N/S Patients Education, reminders, provision of product Postpartum women Patients Provision of product Nosocomial infection rate 8.2% before to 5.3% after Puerperal mastitis 2.90% before to 0.66% after; p<0.001 N/A N/A 3 Srigley et al, 2016.

7 Patient Hand Hygiene May Improve HCW Hand Hygiene Cognitive dissonance HCWs who emphasize the importance of hand hygiene to patients may change their behaviour to be consistent Study of a patient hand hygiene protocol in an ICU Staff hand hygiene before room entry increased from 35% to 66% After room exit increased from 66% to 79% 4 Fox et al, 2015.

8 Objectives To understand why patient hand hygiene is important To review existing data on patient hand hygiene rates To describe patients hand hygiene knowledge, attitudes, and practices To discuss how to improve patient hand hygiene

9 Self-Reported Hand Hygiene Rates Emergency department patients reported hand hygiene after 62-88% of bathroom visits and after 13-41% of bedside urinal/bedpan uses 5 Luz et al., 2011.

10 Direct Observation of Patients Covert observation by junior doctors Hand hygiene performed by patients during 73% of meals 6 24 hours of direct observation in a hospital Patient/visitor compliance was 67.5% after body fluid exposures and 50% after contact with patient surroundings 7 Study on pediatric wards Only found 1 child to observe, who had 100% compliance 8 6 Mattam et al., Randle et al., Randle et al., 2013.

11 Electronic Monitoring of Patients Hand hygiene on multi-organ transplant units measured by a real-time locating system (RTLS) for 9 months 9 Srigley et al., 2014.

12 Patient Characteristics

13 Hand Hygiene Rates After using the bathroom 29.7% of 12,649 bathroom visits More likely among women and after 12 pm Before eating 39.1% of 6,005 meal times Ranged from 32.2% at breakfast to 45.9% at dinner 3.3% of 1,122 kitchen visits Room entry and exit 2.9% of 5,786 entries and 6.7% of 5,779 exits More likely in the afternoon and on weekdays

14 Distribution of Hand Hygiene Rates n=176 patient-room stays

15 Limitations Measured hand hygiene events, not compliance It is impossible to know what patients were doing in the bathroom or kitchen Some hand hygiene events may have been performed by untagged healthcare workers or visitors Not all patients wore RTLS tags Study conducted with a relatively small number of observations on multi-organ transplant units

16 Objectives To understand why patient hand hygiene is important To review existing data on patient hand hygiene rates To describe patients hand hygiene knowledge, attitudes, and practices To discuss how to improve patient hand hygiene

17 Mixed Methods Study Objective To assess the hand hygiene knowledge, attitudes, and practices of hospital inpatients in preparation for implementation of patient hand hygiene improvement programs Study population Inpatients at 4 adult acute care and 1 chronic care hospitals Methods Cross-sectional survey distributed on all inpatient units for 1 week Structured interviews with randomly selected patients at 3 sites

18 Results: Demographics 268 surveys completed 51.5% female Median age 66.5 years 23 patient interviews analyzed 19/23 female 17/23 age 60 and over 7 medicine, 7 surgery, 5 oncology/transplant, 4 rehab Median length of stay 5.5 days Mobility: 11 independent, 10 with assistance, 2 immobile Toileting: 12 independent, 3 bathroom with assistance, 3 commode

19 Survey Results: Compliance How often were you able to wash your hands with soap or hand sanitizer after using the bathroom or bedpan or commode? How often were you able to wash you hands with soap or hand sanitizer before eating? Always Usually Half the Time Seldom Never 66.4% 15.5% 4.2% 5.3% 7.2% 49.2% 21.2% 4.2% 10.8% 11.5%

20 Survey Results: Barriers Were you able to find soap or hand sanitizer whenever you needed it? Would you like to receive more information about hand washing while in the hospital? Yes No 84.4% 15.6% 25.4% 74.6%

21 Qualitative Results: Environmental Context and Resources Survey comments I never was given any pump bottle of hand sanitizer for my table despite asking for it why not put a bottle on each bedside table If there is concern about hand washing before meals, have something on the tray accompanying the meals Interviews Soap/ABHR usually available but sometimes dispensers were empty I take it that bottle was a sanitizer on this table right here? At first I thought it might have been moisturizer therapy.

22 Qualitative Results: Knowledge Survey comments Hand washing should be just common sense Interviews All agreed that patient hand hygiene is important and prevents infection Patients know they should perform hand hygiene after toileting, but less awareness of other moments Most patients reported not wanting any more information about hand hygiene or were indifferent I m old enough to know these things I think I know enough about it

23 Next Steps Patients don t think they need to improve their hand hygiene and they don t want information/education BUT we know patient hand hygiene is suboptimal

24 Objectives To understand why patient hand hygiene is important To review existing data on patient hand hygiene rates To describe patients hand hygiene knowledge, attitudes, and practices To discuss how to improve patient hand hygiene

25 Systematic Review of the Literature Objectives To determine the efficacy of patient hand hygiene interventions in reducing HAIs/AROs and improving patient hand hygiene compliance Searched electronic databases and grey literature to August 2014 Experimental and quasi-experimental studies were included if they evaluated a patient hand hygiene intervention conducted in an acute or chronic healthcare facility and included outcomes of interest All steps performed independently by 2 investigators 3 Srigley et al, 2016.

26 Search Results

27 Surgical Site Infections in Neurosurgery Controlled before-after study 785 patients on 2 neurosurgical units in Vietnam Intervention Inpatients on 1 unit given alcohol-based hand rub (ABHR) and education Surgical site infections decreased from 8.3% to 3.8% on intervention unit and increased from 7.2% to 9.2% on control unit (p=0.04 for comparison between units) 10 Thu et al, 2007.

28 Mastitis on a Maternity Ward Before-after with repeated treatment ~2300 postpartum women on a maternity ward in Germany Intervention Patients provided with ABHR at bedside x 10 months, then withdrawn x 2 months and reinstated x 2 months Puerperal mastitis decreased from 2.90% in controls to 0.66% in intervention patients (p<0.0001) 11 Peters et al, 1992.

29 MRSA in a Community Hospital Before-after study 250-bed community hospital in Quebec Intervention All inpatients given education and ABHR BID x ~1 year Nosocomial MRSA rates decreased from 10.6/1,000 admissions in the year before to 5.2/1,000 during intervention 12 Gagne et al, 2010.

30 Outbreaks on a Psychiatric Unit Before-after study ~900 inpatients admitted to a psychiatric unit in Hong Kong Intervention Staff gave ABHR to all patients Q4H during the day x ~1 year Decrease in nosocomial outbreaks during the intervention compared to the year before From 6 outbreaks affecting 66 patients (18.2%) to 4 outbreaks affecting 23 patients (4.4%) (p=0.005 for total patients involved) 13 Cheng et al, 2007.

31 C. difficile in a Teaching Hospital Before-after study 520-bed teaching hospital in the USA Intervention Education, reminders, and alcohol wipes on meal trays Staff and volunteers encouraged to clean patient hands at mealtimes Added to an existing CDI bundle CDI rate decreased from 10.45/10,000 patient days before to 6.95/ 10,000 after (p=0.0009) 14 Pokrywka et al, 2014.

32 HAI Rates on a Surgical Unit Before-after study Orthopedic surgery unit in the USA Intervention Patients given ABHR and education x 10 months Posters reminded staff, patients, and visitors about hand hygiene Nosocomial infection rate decreased from 8.2% in the 6 months before to 5.3% during intervention (p-value not reported) 15 Hilburn et al, 2003.

33 Hand Hygiene at a Pediatric Hospital Cluster randomized-controlled trial Children s hospital in the UK Intervention 6 wards randomized to interactive educational activities using Glo-Yo, mobile learning technology, or control Hand hygiene rates increased by 31.7% among intervention patients compared to 13.8% in control group (p<0.001) 16 Lary et al, 2013.

34 Hand Hygiene at a Rehab Centre Before-after study ~100 patients on 3 units of a rehab centre in Sweden Intervention Patients education and ABHR in bathrooms Staff gave out alcohol wipes at mealtimes and were encouraged to remind/assist patients with hand hygiene Hand hygiene rates increased from seldom before intervention to 85% before meals and 49% after toilet use 17 Hedin et al, 2012.

35 Hand Hygiene on Surgical Units Before-after study ~160 inpatients on 3 surgical units in the USA Intervention Staff education followed by audits to assess whether they assisted patients with hand hygiene Staff assisting with patient hand hygiene at 6 moments increased from 17.3% in the 6 weeks before intervention to 44.6% in the 6 weeks after (p=0.0003) 18 Ardizzone et al, 2012.

36 Hand Hygiene After Commode Use Before-after study 40 inpatients with mobility difficulties Intervention Hand wipe containers and reminder signs attached to commodes Patient survey Patients offered wipes some of the time increased from 69% to 100% and all of the time increased from 50% to 85% 19 Whiller et al, 2000.

37 Summary of Interventions Targets Patients (5/10) Healthcare workers (HCWs) (3/10) Both (2/10) Components Provision of product (8/10) Education (7/10) Reminders (3/10) Audits (1/10)

38 Indications for Patient Hand Hygiene Before patient/patient environment contact Upon entering their room (or facility/clinic) Before contacting clean supplies Before aseptic procedures Prior to eating Taking meds, administering injections, wound care, etc. After body fluid exposure After toileting/diapering After coughing/sneezing/etc. After patient/patient environment contact Upon leaving their room (or facility/clinic)

39 Conclusions Patient hand hygiene is important Patients do not perform adequate hand hygiene Interventions to improve patient hand hygiene reduce HAIs, but quality of evidence is low Interventions have been multifactorial with components similar to healthcare worker hand hygiene programs Access to soap/abhr is important Tailor components to your setting Need to go beyond the basics and look at behaviour change strategies

40 Acknowledgements Dr. Michael Gardam Dr. Colin Furness Mary Jane Salpeter Allison McArthur Dr. Dominik Mertz Cindy O Neill Dr. Christine Lee Anne Bialachowski Salary support and study funding: AMMI Canada/Astellas Post-Residency Fellowship Canada Health Infoway; the Health Technology Exchange; Infonaut, Inc.; GOJO Industries Hamilton Health Sciences Quality and Patient Safety Grant

41 @JocelynSrigley QUESTIONS?

42 References 1. Istenes N, Bingham J, Hazelett S, Fleming E, Kirk J. Patients potential role in the transmission of health careassociated infections: prevalence of contamination with bacterial pathogens and patient attitudes toward hand hygiene. Am J Infect Control 2013;41: Cao J, Min L, Lansing B, Foxman B, Mody L. Multidrug-resistant organisms on patients hands. JAMA Int Med 2016;176(5): Srigley JA, Furness CD, Gardam M. Interventions to improve patient hand hygiene: a systematic review. J Hosp Infect 2016;94(1): Fox C, Wavra T, Ash Drake D, et al. Use of a patient hand hygiene protocol to reduce hospital-acquired infections and improve nurses hand washing. Am J Crit Care 2015;24(3): Luz J, Cydulka RK, Scott S. Evaluation of patient hygiene practices during emergency department visits. Ann Emerg Med 2011;58(Suppl 4):S Mattam K, Al-Badawi T, King S, Guleri A. The missing link in the health-care associated infection acquisition cycle: An innovative patient hand-hygiene audit led by doctors at a tertiary cardiac centre in northwestern England. Clin Microbiol Infec 2012;18(Suppl s3): Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp Infect 2010;76(3): Randle J, Firth J, Vaughan N. An observational study of hand hygiene compliance in pediatric wards. J Clin Nurs 2013;22(17-18): Srigley JA, Furness CD, Gardam M. Measurement of patient hand hygiene in multiorgan transplant units using a novel technology: an observational study. Infect Control Hosp Epidemiol 2014;35(11):

43 References 10.Thu LTA, Dibley MJ, Nho VV, Archibald Lennox, Jarvis WR, Sohn AH. Reduction in surgical site infections in neurosurgical patients associated with a bedside hand hygiene program in Vietnam. Infect Control 2007;28: Peters F, Flick-Fillies D, Ebel S. Hand disinfection as the central factor in prevention of puerperal mastitis. Clinical study and results of a survey. Geburtshilfe Frauenheilkd 1992;52(2): Gagne D, Bedard G, Maziade PJ. Systematic patients' hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital. J Hosp Infect 2010;75(4): Cheng VC, Wu AK, Cheung CH, Lau SK, Woo PC, Chan KH, et al. Outbreak of human metapneumovirus infection in psychiatric inpatients: implications for directly observed use of alcohol hand rub in prevention of nosocomial outbreaks. J Hosp Infect 2007;67(4): Pokrywka M, Feigel J, Douglas B, et al. A bundle strategy including patient hand hygiene to decrease Clostridium difficile infections. Medsurg Nurs 2014;23(3): Hilburn J, Hammond BS, Fendler EJ, Groziak PA. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control 2003;31(2): Lary D, Hardie K, Randle J. Improving children s and their visitors hand hygiene compliance. Antimicrob Resist Infect Control 2013;2(Suppl 1):P Hedin G, Blomkvist A, Janson M, Lindblom A. Occurrence of potentially pathogenic bacteria on the hands of hospital patients before and after the introduction of patient hand disinfection. APMIS 2012;120(10): Ardizzone LL, Smolowitz J, Kline N, Thom B, Larson EL. Patient hand hygiene practices in surgical patients. Am J Infect Control 2013;41(6): Whiller J, Cooper T. Clean hands: how to encourage good hygiene by patients. Nurs Times 2000;96(46):37-8.