October 2010 - Infection Protection

INSIDE THE CURRENT ISSUE

October 2010

Infection Prevention

Outpatient Connection

Public handwashing takes a hike
In the latest observational study sponsored by the American Society for Microbiology and the American Cleaning Institute (formerly The Soap and Detergent Association), 85% of adults washed their hands in public restrooms, compared with 77% in 2007. The 85% total was actually the highest observed since these studies began in 1996. The results were announced at the Interscience Conference on Antimicrobial Agents and Chemotherapy, an infectious disease meeting sponsored by the American Society for Microbiology. In a separate telephone survey, 96% of adults say they always wash their hands in public restrooms, a percentage that has remained relatively constant over the years.

On behalf of ASM and ACI, Harris Interactive discreetly observed 6,028 adults in public restrooms in August 2010 to note whether or not people washed their hands. Researchers returned to six locations in four cities where two previous studies were conducted: Atlanta (Turner Field), Chicago (Museum of Science and Industry, Shedd Aquarium), New York City (Grand Central Station, Penn Station), and San Francisco (Ferry Terminal Farmers Market).

Men stepped up to the sink a bit more than they have in the past when it comes to public handwashing. More than three-quarters of the guys (77%) washed their hands publicly in 2010, compared to 66% in 2007.

The men still strike out more on handwashing in sporting venues, though. Turner Field by far fielded the worst percentage for the guys – barely two-thirds (65%) – though that’s still better than just 57% in 2007. Perhaps as a counter to the men’s poor handwashing practices, Turner Field brought out the best in women’s handwashing among all venues: 98%. Overall, the rate of women washing their hands in public restrooms improved from 88% in 2007 to 93% in 2010.

The best observed handwashing in 2010 was in Chicago and San Francisco, with 89% of adults lathering up in public restrooms. Atlanta was next (82%), followed by New York City (79%). The venue with the best overall handwashing regimen was Chicago’s Museum of Science and Industry (93%).

In a 2010 telephone survey of 1,006 American adults, Harris Interactive’s survey for ASM and ACI found the vast majority of us say we always wash our hands after using the bathroom at home (89%). More Americans now report that they always wash their hands after changing a diaper (82%), an increase from 2007 (73%). Women are better than men at this practice: 88% of the ladies say they always wash their hands after diaper duty, compared to 80% of the guys.

Those of us who say we always clean our hands before handling or eating food is staying about the same: 77% in 2010, compared to 78% in 2007. Among women, 83% say they clean their hands before touching their food; just 71% of men say they do. And only 39% of Americans say they always wash their hands after coughing or sneezing. More details from the surveys are available online at www.washup.org and www.cleaninginstitute.org/news.

Hand-hygiene compliance ... there’s the rub

by Susan Cantrell, ELS

The Kimberly-Clark Professional Electronic Cassette Skin Care System is available
with two Kleenex-brand moisturizing
instant hand sanitizers.

Look at your hands. Really. Look at your hands now. Do you think they are clean? They may look clean, but there’s a lot on our hands we can’t see. If these things were spelled out in ink, you might see diarrhea, vomiting, cold virus, flu, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), Clostridium difficile, and much more (see the World Health Organization promotional video "SAVE LIVES: Clean Your Hands," http://www.who.int/gpsc/5may/
video/en/).

Your hands can make you sick. If you’re a healthcare worker, in particular, they can make others sick, too, maybe even sick to death. Without even lifting a finger against anyone, hands can be lethal weapons. This is especially true in a healthcare setting, where we think of hands more as life savers rather than life takers.

We’ve understood the importance of hand hygiene since 1847, when Ignaz Philipp Semmelweis discovered the connection between handwashing and reduction of puerperal (childbed) fever. No one disputes its importance; yet compliance, or rather noncompliance, with hand hygiene remains a huge issue among healthcare workers (HCWs) 163 years down the healthcare road.

What’s the big deal?

The reasons for noncompliance are valid, but that doesn’t make noncompliance excusable. Conscientious compliance to hand hygiene can lead to painful, damaged skin. Dry, cracked, scaly skin is more susceptible to colonization by pathogens. Some HCWs clean their hands between 30 and 100 times per shift. That’s a lot of wear and tear on skin and a chunk of time out of a workday. Sometimes facilities are not convenient when they are needed. Sometimes staff just don’t like the product and won’t accept it, perhaps because it takes too long to dry or because it has a strong fragrance or because it feels like it leaves a coating on the hand.

In the Centers for Disease Control and Prevention’s "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"¹ it states: "In certain surveys, approximately 25% of nurses report symptoms or signs of dermatitis involving their hands, and as many as 85% give a history of having skin problems (249). Frequent and repeated use of hand-hygiene products, particularly soaps and other detergents, is a primary cause of chronic irritant contact dermatitis among HCWs (250)."

Clearly, skin irritation is a major reason for noncompliance of hand hygiene; yet, conscientious compliance to hand hygiene can lead to painful, damaged skin. What can HCWs do to break this cycle and to improve and maintain hand health, making it more likely they’ll be compliant?

enMotion automated touchless soap dispenser, Georgia-Pacific Professional

Cheryl A. Littau, PhD, senior scientist, Ecolab Research, Development, and Engineering, observed: "In recent years, greater emphasis has been put on development of new hand-hygiene products that achieve a balance between skin health and the rigorous requirements of infection prevention. User acceptance of hand-hygiene products is key to achieving better hand-hygiene compliance." The CDC guideline also emphasized the importance of soliciting input from employees regarding feel, fragrance, and skin tolerance to ensure acceptance of any product being considered.

Another factor that could make a hand-hygiene product more palatable is a reduction in the time it takes out of a busy HCW’s day to use it. The CDC’s guideline stated: "The time required for traditional handwashing may render full adherence to previous guidelines unrealistic (11,12,318)... One study conducted in an intensive-care unit demonstrated that it took nurses an average of 62 seconds to leave a patient’s bedside, walk to a sink, wash their hands, and return to patient care (318). In contrast, an estimated one fourth as much time is required when using alcohol-based hand rub placed at each patient’s bedside."

No doubt about it, alcohol-based products are less time-consuming to use. The CDC’s Hand Hygiene Guidelines Fact Sheet (www.cdc.gov/media/pressrel/
fs021025.htm) noted: "In an eight-hour shift, an estimated one hour of an ICU nurse’s time will be saved by using an alcohol-based handrub."

Alcohol rub or handwash with soap?

The CDC guideline noted: "... using alcohol-based hand rubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash, because they not only require less time (166,318) but act faster (1) and irritate hands less often (1,67,96,98,166)." Whereas alcohol-based products are recommended in most instances, handwashing with soap is absolutely necessary if the hands are visibly soiled. Detergents are hard on skin, so thoughtful care is needed when selecting soap.

Georgia-Pacific Professional offers a touchless system, said Amy White, market development manager, healthcare segment. Georgia-Pacific’s enMotion Automated Touchless Soap and Sanitizer Dispenser "can be paired with a corresponding line of gentle soaps and sanitizer formulated with aloe and other conditioners to help protect against dry skin typically associated with frequent handwashing. Each product comes in a hygienic closed system to minimize the risk of bacterial growth."

The three product types for use in the enMotion Automated Touchless Soap Dispenser are fragrance-free and dye-free enMotion Gentle Foam Soap with Moisturizers; fragrance-free and dye-free enMotion Antimicrobial Foam Soap with Moisturizers; and fragrance-free enMotion Foam Hand Sanitizer with Moisturizers. The foaming sanitizer kills germs on contact and contains aloe and moisturizers to help soothe dry skin."

Kimberly-Clark Professional also offers a touchless soap dispensing system that helps to prevent cross-contamination. Beth Karnuta, skin care category manager, described the system: "The Electronic Cassette Skin Care System with Kleenex-brand Luxury Foam Moisturizing Instant Hand Sanitizer is reliable, easy to use, and hygienic. The system helps reduce cross-contamination and the spread of germs via touchless dispensing and a sealed soap system that prevents contamination of the soap itself by bacteria, a problem associated with 25% of unsealed bulk soap systems."

Lotions, emollients prevent and repair damage

Ecolab’s FlexMount dispenser allows flexible, convenient placement
of hand sanitizers closer to the patient.

The importance of applying hand lotion or cream at least twice per day to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing is also stressed in the CDC guideline. Humectants and certain fats and oils can improve skin hydration and replace depleted skin lipids that can ward off irritant contact dermatitis caused by hand-hygiene products, contribute to the barrier function of skin, and reduce scaling and cracking, which may reduce microbial shedding. The guideline cited a study that found "...frequent and scheduled use of an oil-containing lotion improved skin condition, and thus led to a 50% increase in handwashing frequency among HCWs (273)." What a difference a little lotion or cream can make in user comfort and compliance.

When alcohol-based hand-rub products first arrived on the scene, the common complaint was that they were hard on the skin. Studies now show hand rubbing with alcohol-based products to be less damaging to skin. That’s because great strides have been made in the skin friendliness of alcohol-based products. The CDC recommends using alcohol-based hand rubs that contain emollients: "Several recent prospective, randomized trials have demonstrated that alcohol-based hand rubs containing emollients were better tolerated by HCWs than washing hands with nonantimicrobial soaps or antimicrobial soaps (96,98,166)."

Ecolab is one company that offers an emollient-containing alcohol-based hand rub. Littau noted: "Hand sanitizers are an excellent alternative to traditional hand washing. Ecolab’s Quik-Care Waterless Antimicrobial Foaming Hand Rub is formulated with emollients and humectants to help moisturize and repair skin. In addition to hand sanitizer, regular use of lotion is important to maintain skin health. Endure Revitalizing Skin Lotion is chlorhexidine gluconate-compatible and does not compromise the antimicrobial efficacy of Ecolab’s hand-hygiene products or the barrier properties of latex and nonlatex gloves."

Karnuta, Kimberly-Clark Professional, added: "Alcohol-based hand sanitizers containing emollients may cause less skin irritation and dryness than commonly used detergents and are tolerated better by healthcare personnel than washing hands with nonantimicrobial soaps or antimicrobial soaps. The Electronic Cassette Skin Care System from Kimberly-Clark Professional is available with a complete line of skin cleansers, including two Kleenex-brand moisturizing instant hand sanitizers, a luxury foam formulation, and a gel. These moisturizing instant hand sanitizers are formulated to prevent dry skin while providing fast, broad-spectrum microbial reduction on the skin. Kleenex-brand moisturizing instant hand sanitizers provide even more hand-softening, leading to more frequent handwashing within a facility."

Taking the gloves off

Detergents and alcohol can be tough on hands, but shear forces associated with constantly donning and removing gloves can irritate the skin and compromise its integrity.

Cardinal Health has developed a line of medical gloves with an interior coating that makes them easier to don and that moisturize the skin while worn. Linda McNeilly, director, marketing and product management, explained: "Cardinal Health has developed a line of medical gloves that feature a proprietary emollient coating called Neu-Thera. The coating was designed for, and tested by, healthcare professionals. The ingredients of the Neu-Thera emollient coating include glycerin, provitamin B5, and gluconolactone. The ingredients were chosen for their ability to protect hands from moisture loss, to restore smooth texture and healthy condition of hands, to moisturize skin for deep-down relief, and to soothe dry, flaky skin. The longer and more often the glove with Neu-Thera emollient coating is worn the better for the wearer. The coating also allows for easy glove donnability in both dry and damp conditions."

McNeilly cited a study in support of emollient-impregnated gloves: "In a trial at the Virginia Commonwealth University School of Medicine, the effectiveness of universal gloving with an emollient-impregnated glove in promoting skin health and preventing the transmission of multidrug-resistant organisms was studied. The multiphase trial showed that the rate of HCWs’ hand-hygiene compliance and hand-skin health improved, that there was a trend toward reduced hand multidrug-resistant–organism contamination, and that emollient-impregnated gloves were well received by the study subjects".²

Make it convenient

OmniFoamDispenser, STERIS Corporation

The best hand-hygiene product in the world can go unused if it’s not convenient. Easy availability can help improve adherence to compliance. In their guideline, CDC stressed the connection between convenience and hand-hygiene: "Easy access to hand-hygiene supplies, whether sink, soap, medicated detergent, or alcohol-based hand-rub solution, is essential for optimal adherence to hand-hygiene recommendations. The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis (11,318)."

Charlie Kilfoyle, senior product manager, STERIS Corporation, commented: "In fast-paced healthcare environments, requiring people to go out of their way to clean their hands inhibits hand-hygiene compliance. Making hand-hygiene products, particularly waterless sanitizers, readily available helps overcome this challenge. It also helps create awareness, since the dispensers themselves act as additional reminders."

Elizabeth Kalister, product manager, STERIS Corporation, added: "One of our newest hand-hygiene support products is a dispenser, the OmniFoam Dispenser. It was developed in response to specific customer needs for a sleek, fast-dispensing design that can be accessed from any direction."

Littau, Ecolab, noted that the World Health Organization, in 2009, "identified hand-hygiene dispenser placement at the point of patient care as an area of emphasis in their guidelines on increasing hand-hygiene compliance. Ecolab’s FlexMount dispenser is designed to affix to bedrails and IV poles, placing hand-hygiene products at the point of care, giving HCWs optimal product accessibility and allowing for convenient and efficient hand-hygiene performance. A recent study³ sought to measure whether using the FlexMount dispenser increased compliance in a hospital setting. The study first determined the current rate of sanitizer use and then measured consumption after placing the FlexMount dispenser. The study found that placing point-of-care dispensers in test units within the hospital increased product consumption by 36% and ultimately improved hand-hygiene compliance."

Ask for scientific evidence

No matter the product you choose to use, make absolutely certain you know the scientific evidence behind claims of efficacy. This is information the manufacturer should have readily available and should be happy to provide.

Kilfoyle, STERIS Corporation, noted: "It’s very important to provide highly effective products that staff can use 60 or more times a day without damaging their skin. However, it’s important to request laboratory data from the supplier that factually proves a product’s efficacy and mildness."

Monitoring compliance

Each use of hand sanitizer or soap registers immediately on the Semmelweis Hand Hygienometer.

A vitally important component of ensuring hand-hygiene compliance is monitoring.

Andrew Sahud, MD, infectious disease physician and chairman, infection prevention, Allegheny General Hospital, Pittsburgh, PA, described a device he invented for monitoring of HCWs’ handwashing practices, the Semmelweis Hand Hygienometer: "Healthcare providers wear the small pager-like device, which records signals from triggers placed in patient rooms and within soap and hand-sanitizer dispensers. The reader captures the signal indicating each room entry by a healthcare provider and registers associated dispensing events, before and after the patient encounter. The information is stored in the device and can subsequently be uploaded into a database. Cumulative data can be evaluated and compared to group compliance rates. The user ‘owns’ his or her data and can check their compliance at any time. The data is captured 24 hours a day as opposed to intermittent scheduled intervals of observation."

"The device reduces the problems associated with the Hawthorne effect and eliminates the expense of paying individuals to perform direct observation. This system captures significantly more data than direct observation in a short time period."

Sahud continued: "Our pilot study evaluated the merits of the device in capturing room entries and dispensing events as surrogate markers for hand hygiene. In subsequent studies, we hope to show that such monitoring and feedback will support higher rates of hand hygiene. Many previous studies have shown that improved hand-hygiene compliance lowers the rate of HAIs and that improving compliance requires a multimodal approach for assessing rates and providing feedback."

Importance of hand-hygiene and hand-care education

Neu-Thera emollient coating from Cardinal Health
helps to improve skin condition and encourage
hand-hygiene compliance.

Regarding hand-hygiene education, Kilfoyle said: "It’s very important. Hospital leadership should view hand-hygiene education as an investment in the health and safety of the staff, patients, and visitors, and treat it as they would any other significant investment: properly fund it, measure the impact against pre-determined criteria, and make changes or additional investment as appropriate."

Kalister added: "We recently conducted a survey of primarily infection preventionists, asking ‘If you could have supplier-supported education related to hand hygiene, what type would you prefer?’ The majority of respondents chose in-services. STERIS professionals are available to come in and do in-services with staff, and we also have accredited courses available that provide CEU hours." Go to http://www.steris.com/support/education/index.cfm.

Kilfoyle continued: "STERIS offers a full array of hand-hygiene compliance tools, including awareness and education materials and product-placement audits. STERIS was also the first to introduce a web-based hand-hygiene–measurement program that offers easily accessible and impactful user data."

STERIS recently renamed and expanded its hand hygiene compliance offering. The new ComplyTrack Hand Hygiene Compliance Platform includes two programs – the AccuTrack Hand Hygiene Compliance Program (formerly Partners in Your Care) that tracks and provides detailed reports on hand hygiene product consumption, and a new, more automated program that tracks a second type of hand hygiene data. The new FasTrack Hand Hygiene Compliance Program is a user-friendly, automated tool that tracks and provides reports on hand hygiene product purchasing. With a one-step command from the user, this program collects purchase-based data and generates monthly reports automatically. Trends for both hand sanitizers and handwashing products can be displayed in graph format, and the product mix by percentage can also be illustrated. Infection preventionists can use the information to get trend data on their hospitals hand hygiene performance and can export the data for their own customized use.

Stephanne Hale, senior clinical manager, Novation, believes the education connection is paramount. "The connection here is of critical importance and should be addressed in tandem. Because hospital-acquired infections (HAIs) are a significant cause of mortality and morbidity, resulting in more than 100,000 deaths annually and costing in excess of $25 billion in direct healthcare costs, hand hygiene is not an option. However, compliance seems to remain low; in fact, some studies report compliance as low as 40%. Because hand hygiene is imperative to decreasing the spread of HAIs and skin irritation can be a barrier to hand hygiene, a multifaceted approach to educating the healthcare professional is warranted to inform HCWs of the negative impact of hand-hygiene noncompliance, to advocate for proper hand-hygiene practices, and to educate HCWs on hand health and the products that are available on the market today. Novation has educational tools and resources available for members to assist not only with hand-hygiene practices but those that assist in the prevention of HAIs. The Hand Hygiene Clinical Resource Guide, HAI Encounter, and CMS Solutions set are a few and are located on the Marketplace website."

Hand-hygiene resources

Visit the WHO website for more information on the "Save Lives: Clean Your Hands" campaign. Be sure to see their hand-hygiene videos. Go to http://www.who.int/gpsc/5may/video/en. WHO also has other tools and educational resources on hand hygiene on their website.

Speaking of videos, a number of healthcare facilities have made their own hand-hygiene videos. Some manage to get a serious message across in an entertaining, sometimes memorable, way. Here is a smattering of what’s available:

• Don’t miss the avant-garde dance video from University of Geneva, Switzerland: http://www.youtube.com/watch?v=0at_jtzJCDM

• Healthcare team members at Wesley Woods Geriatric Hospital sing about hand hygiene: http://www.youtube.com/watch?
v=hHKGZwAINHg&feature=relatedEmory

• See Massachusetts General Hospital staff do the Cal Stat rap: http://www.youtube.com/watch?
v=wjg5LxRRQfA&feature=related

• Erie St. Clair Regional Infection Control Net-work also raps on handwashing: http://www.youtube.com/watch?
v=RRQpcUMMj9M&feature=related

• Watch staff at Trinity Regional Health System do the Hygiene Shuffle: http://www.youtube.com/watch?
v=VbTx5dEHJMA

• See staff at Southwest Washington Medical Center Southwest Washington Medical Center rock to Hand Hygiene One Way or Another: http://www.youtube.com/watch?
v=MkjynYbK7s4

• This video features hand-hygiene signage with an attitude, developed in partnership by Tufts Medical Center and Jennings Company’s "Speak Up. Wash Up" campaign: http://www.youtube.com/watch?
v=tUZF6fVN4vY

• "INFECTION. Don’t be the one to pass it on" is a bluesy video from the infection control team at UCLH: http://www.youtube.com/watch?
v=HYeiNPIxqKw

• Global Handwashing Day is October 15. View their video at http://www.global
handwashingday.org/GHD_Video.asp

"Hand-hygiene education for HCWs, patients, and visitors plays a critical role in the prevention of infection," said Littau. "Ecolab offers a multifaceted educational approach to increase hand-hygiene awareness. In-service programs train hospital staff on proper handwashing, and public awareness kits, wall cards, and educational signage keep hand hygiene front-of-mind for patients, visitors, and staff. Ecolab’s ‘It’s Ok to Ask’ campaign encourages patients to be active in their own care and sends the message that proper hand hygiene is everyone’s responsibility."

Mark Semmelmayer, communications manager, described Kimberly-Clark Health Care’s educational offerings: "One thousand four hundred-eighty healthcare facilities have experienced Kimberly-Clark’s cross-country ‘Not on My Watch’ bus tour since 2008. We’ve learned about the importance of education in staff empowerment and patient safety: Education makes staff feel empowered. According to a survey of the HAI Education Bus (a mobile classroom that brings accredited CE and CME education on HAI to your door) participants, 99% agreed that event-driven education made them feel more empowered to prevent HAIs; 97% felt that education would help them perform their job better. In-facility events and communication help awareness and effort. Ninety-four percent of hospital staff felt that organized educational events reinforced their hospital’s leadership position in patient-staff protection. As a result, the staff felt better about their hospital. C-suite commitment to patient safety is critical. The support of hospital executives sends a powerful message to the staff and helps further create a culture focused on education."

Karnuta added: "Kimberly-Clark Professional has a wealth of resources and links to organizations on its website about hand hygiene and hand-hygiene compliance. Visit www.kcprofessional.com."

"Hand hygiene is the simplest and the most cost-effective way to reduce HAIs," pointed out McNeilly, Cardinal Health. "Improved adherence to hand-hygiene practices and multidisciplinary approaches to skin wellness may have a significant impact on patient outcomes and occupational health. Maintenance of intact, healthy skin reduces the risk of transmission of pathogenic organisms and the risk of occupational-related skin disease. Understanding the key components of an effective hand-care plan and implementing a therapeutic regime are fundamental components of any patient and employee safety program. Cardinal Health offers a wide range of programs, articles, and education to support these programs."

"In May, Novation participated in WHO’s ‘Save Lives: Clean Your Hands’ campaign," said Hale. "The initial launch was in May 2009 and was supported by more than 5,000 hospitals and other healthcare organizations. This year, the goal was to double the commitment to 10,000 participants. The campaign’s goal was to promote improved hand hygiene to reduce HAIs and to demonstrate healthcare organizations’ commitment to improving hand-hygiene practices. Although Novation is not a direct patient-care organization, we are the nation’s largest group purchasing organization. Our goal was to support our members’ efforts in improving hand-hygiene practices as well as their infection control and prevention initiatives."

References

1. Centers for Disease Control and Prevention. 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. MMWR 2002;51(RR-16):[inclusive page numbers].

2. Bearman G, Rosato AE, Duane TM, Elam K, Sanogo K, Haner C, et al. Trial of universal gloving with emollient-impregnated gloves to promote skin health and prevent the transmission of multidrug-resistant organisms in a surgical intensive care unit." Infect Control Hosp Epidemiol 2010;31:491-497. Abstract.

3. Ventrucci C, White B. Study conducted November 4, 2009, through February 11, 2009, at Regions Hospital in St. Paul, MN. Presented at the 2010 APIC Annual Conference.