McKesson Medical-Surgical Webinar Wednesdays Series Hand Hygiene: In Outpatient Settings October 19, 2015

Megan J. DiGiorgio, MSN, RN, CIC Clinical Specialist, GoJo Industries, Inc.

Megan J. DiGiorgio, MSN, RN, CIC Clinical Specialist, GoJo Industries, Inc. Megan DiGiorgio has worked in infection prevention for over 10 years with the majority of her career spent at the Cleveland Clinic. Megan received her bachelors of science in nursing and masters of science in nursing from Case Western Reserve University. Megan has a background in pediatric nursing in addition to her infection prevention experience. She has published in peer-reviewed journals and has presented posters and oral abstracts at several national conferences. In addition, she is active in her local northeast Ohio Association of Professionals in Infection Control chapter, serving as president in 2012. Megan began working at GOJO in 2013 as a Clinical Specialist for Healthcare.

© 2015 McKesson Medical-Surgical

Learning Objectives • Explain the minimum standards for safe care in outpatient settings • Describe why hand hygiene is so critical in the outpatient setting

• Assess when it is appropriate to use alcohol-based hand rub and soap and water for hand hygiene • Explain why a multimodal approach is needed to improve and sustain hand hygiene compliance = Tools along the way to help you get started

Background • Healthcare is increasingly being provided in ambulatory/outpatient settings • More complex patients are being seen in the outpatient setting

• There is need for greater understanding and implementation of basic infection prevention measures • Hand hygiene is the cornerstone of every infection prevention program and is a universal indicator of safe, effective infection prevention practices

The Consequences of Inaction: Serious Outbreaks in Outpatient Settings • They serve as a reminders of the serious consequences that can result when healthcare personnel fail to follow basic principles of infection control. • 25 examples of outbreaks in outpatient settings can be found on CDC website. Setting/Year

Pathogen

Infection

Infection Control Breaches

Primary care clinic, 2009

Staph aureus

Joint infection

1) Mishandling of multi-dose vials 2) Inadequate hand hygiene 3) Incorrect cleaning and disinfection of equipment

Pain remediation clinic, 2008

Klebsiella pneumoniae, Enterobacter aerogenes

Bloodstream infection

1) Contents from single-dose vials used for ˃ 1 pt 2) Lack of hand hygiene before procedures 3) Not appropriately cleaning the injection site prior to injection

http://www.cdc.gov/hai/settings/outpatient/outbreaks-patient-notifications.html

Infection Prevention Matters

http://www.cdc.gov/HAI/settings/outpatient/outpatient-care-guidelines.html

Standard Precautions – The Foundation for all Healthcare Settings • Minimum infection prevention practices that apply to all patient care, regardless of patient diagnosis • Designed to protect healthcare workers and patients • Include: – – – – –

Hand hygiene Personal protective equipment Safe injection practices Safe handling of potentially contaminated equipment or surfaces Respiratory hygiene/cough etiquette Hospital Infection Control Practices Advisory Committee (HICPAC). Recommendations for application of standard precautions for the care of all patients in all healthcare settings. Available from: http://www.cdc.gov/hicpac/2007ip/2007ip_table4.html. Accessed August 27, 2015.

Hand Hygiene is Key for Prevention • It is the single most important measure for preventing the transmission of pathogens in healthcare settings1 • It is a universal indicator of safe and effective infection prevention and control practices

• Patients expect healthcare providers to perform hand hygiene • It is the right thing to do – First, do no harm 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.

Hand Hygiene • The term "hand hygiene" includes both handwashing with either plain soap or antimicrobial soap, or use of alcohol-based hand rubs (ABHR) that do not require the use of water

When to Clean Your Hands •

Use an ABHR: – Before direct patient contact

– After removing gloves – Before handling an invasive device for insertion – After contact with intact skin

•

Use soap and water: – When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids – Before eating – After using the restroom

– After contact with body fluids, or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled – Before moving from a contaminated body site to a clean body site – After contact with inanimate objects or medical equipment close to a patient

ABHR should be used in the majority of clinical situations, except when hands are visibly soiled or contaminated.

How to Clean Your Hands

Does hand hygiene matter in the outpatient setting? • Risk of infection in outpatient settings is commonly considered to be low • However, data are lacking and are out of date • It’s difficult to diagnose infections associated with outpatient care due to brief encounters and difficulty distinguishing them from community-acquired infections

World Health Organization. Hand hygiene in outpatient and home-based care and long-term care facilities: a guide to the application of the WHO multimodal hand hygiene improvement strategy and the “my five moments for hand hygiene” approach. Available from: http://apps.who.int/iris/bitstream/10665/78060/1/9789241503372_eng.pdf?ua=1 Accessed August 27, 2015.

We Know That Germs are Found on Many Surfaces Examples of Environmental Items That Have Been Shown to Harbor Microorganisms* Bed linen

Door handle

Stethoscope

Bed rail

Electronic thermometer

Suction/resuscitation equipment

Bedside table

Hydrotherapy equipment

Table, staff work table, charting area

Blood pressure cuff

Infusion equipment

Telephone (desk and mobile)

Call bell

Light switch

Television

Chair

Over-bed table

Toilet/commode

Clean gloves that have touched room surfaces only

Phlebotomy tourniquet

Tourniquet

Computer keyboard

Privacy curtains

Pillow/mattress

*Microorganisms such as MRSA, VRE, C. difficile, Acinetobacter baumannii, RSV, influenza virus, and others

Archer A & Gamage B. Ambuatory care. In: APIC Text of Infection Control and Epidemiology. 4th ed. Washington, DC; 2014: 1-13.

Germs are Also on Healthcare Workers’ (HCW) Hands • Hand of HCW in a wound care center were sampled during two sampling periods • Six of the seven HCW (85.7%) hands were contaminated at some point during the study

• 22.2% of all samples were positive for at least one of the “targeted” pathogens – 11.1% positive for Acinetobacter baumannii – 8.3% positive for Methicillin-resistant Staphylococcus aureus (MRSA) – 2.8% positive for C. difficile Reynolds N, Abell G, Salisbury D, et al. Hand contamination of healthcare workers in an ambulatory care setting. Am J Infect Control. 2013;41:S40-41.

How are Germs Transmitted? • Direct contact transmission – when microorganisms are transferred from one infected person to another without a contaminated intermediate object or person

• Indirect transmission – involves the transfer of an infectious agent through a contaminated intermediate object or person The contaminated hands of healthcare personnel are the most important contributors to indirect contact transmission.

Centers for Disease Control and Prevention. Introduction to epidemiology: chain of infection. In: Principles of Epidemiology in Public Health Practice. 3rd ed. Available from: http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section10.html

For an Infection to Develop, Each Link of the Chain of Infection Must Be Connected Disease Organism

Breaking any link can stop the transmission of infection. Hand hygiene is the simplest way to break many of the links.

Mode of Transfer

Interventions are directed at: –

Controlling or eliminating agent at source of transmission (Ex: treating a patient with an antibiotic)

–

Protecting portals of entry (Ex: a healthcare worker wearing mask or eye protection)

–

Increasing host's defenses (Ex: vaccinating a patient or healthcare worker)

If you could see the germs, you would perform hand hygiene! • Patient with MRSA colonization of anterior nares • HCW’s ungloved hand after abdominal exam, then after using alcohol-based hand rub After exam

After using ABHR

Donskey CJ, Eckstein BC. The hands give it away. N Engl J Med. 2009;360:e3.

Personal Protective Equipment (PPE) • Specialized clothing or equipment worn by an employee for protection against infectious materials • Required by Occupational Safety and Health Administration (OSHA)

• OSHA specifies circumstances for which PPE is indicated • CDC recommends when, what and how to use PPE

Personal Protective Equipment Cont’d. Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin

Gowns – Use during procedures and patient care activities when contact of clothing/exposed skin with blood/body fluids secretions, or excretions is anticipated

Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions

PPE

Safe Injection Practices

http://www.cdc.gov/injectionsafety/1anOnly.html#posters

Safe Handling of Equipment and Surfaces • Assess current products and practices – What is cleaned? By whom? When? With what? And how frequently?

• Establish policies and procedures • Select EPA-registered disinfectants for healthcare • Follow manufacturer’s recommendations • Ensure that reusable medical equipment is cleaned and reprocessed appropriately between patients • Ensure that healthcare workers are appropriately trained

Safe Handling of Equipment and Surfaces • When shared medical devices and equipment are not cleaned and decontaminated after each patient use, hand hygiene cannot be expected to compensate for failure to comply with these procedures on a regular basis

Cough Etiquette • Stemmed from SARS outbreak

• Highlighted need for prompt implementation of infection control measures at the first point of contact • Includes signage and source control measures such as tissues, ABHR, and surgical masks

http://www.cdc.gov/flu/protect/covercough.htm

IMPLEMENTING A HAND HYGIENE PROGRAM DOES NOT MEAN SIMPLY PLACING DISPENSERS ON WALLS

How do you build successful and sustained hand hygiene improvement? • The WHO Multimodal Strategy: – System change – Training and education – Evaluation and feedback

– Reminders in the workplace – Institutional safety climate

1 World

Health Organization. Hand hygiene in outpatient and home-based care and long-term care facilities: a guide to the application of the WHO multimodal hand hygiene improvement strategy and the “my five moments for hand hygiene” approach. Available from: http://apps.who.int/iris/bitstream/10665/78060/1/9789241503372_eng.pdf?ua=1 Accessed August 27, 2015.

System Change • A systematic approach to ensure that the healthcare facility has the necessary infrastructure (equipment and facilities) in place to allow HCW to perform hand hygiene • May need to revisit existing infrastructure periodically to ensure it is maintained

System Change – Choosing the Right Products • When selecting an ABHR product, it is important to use precise criteria: – Relative efficacy of antiseptic agents according to Food and Drug Administration Tentative Final Monograph for Antiseptic Agents – Good skin and dermal tolerance – Dry times – HCW preferences (aesthetics) – Practical considerations such as convenience, function, design

System Change – Easily Accessible Products • Permanently fixed wall-mounted dispensers – ABHR dispensers should be placed outside of the exam room, and inside the exam room – Soap dispenser should be at each sink

• Point of care: where the patient, the HCW and care or treatment involving contact with the patient or patient’s surroundings come together. • Product should be within arm’s reach of where care is provided • Bracket-mountable dispensers, tabletop dispensers, personal carriage

Training and Education • HCWs need continuous training on the importance of hand hygiene importance, when, and how to perform • Without appropriate practical training – it is unlikely that system change will lead to behavioral change

• Training should occur at hire and at least annually • Ideally, competence should be checked after training

Don’t Assume HCW Know the Basics • If they did, there wouldn’t be as many serious outbreaks in the literature as there are • Self-reported factors for poor compliance include:1 – – – – – – – –

Too busy, insufficient time Low risk of acquiring infection from patients Disagreement with the recommendations Lack of knowledge of guidelines/protocols Lack of scientific information of definitive impact on HAI rates Lack of soap and paper towels Understaffing Patient needs take priority 1 The

Joint Commission. Measuring hand hygiene adherence: overcoming the challenges. 2009. Available from: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf. Accessed May 14, 2014.

Training and Education

Training and Education – Free Resources

How do You Educate Busy Healthcare Workers? • There needs to be continued investment in in-service training to build the capability of health workers to provide quality health services competently, safely and efficiently • HCW prefer hands on, simulation-type learning. • The use of multiple techniques that allow for interaction and enable learners to process and apply information are most effective. – Repetitive interventions, computer-based and case-based learning, clinical simulations, practice, and feedback Bluestone J, Johnson P, Fullerton J, et al. Effective in-service training design and delivery: evidence from an integrative literature review. Human Resources for Health. 2013;11:51 doi:10.1186/1478-4491-11-51.

Hand Hygiene within a Sequence of Care in an Outpatient Clinic 1.

Doctor enters exam room

2.

The patient and doctor sit down and talk to each other while the doctor goes through the patient’s record

3.

The doctor asks the patient to lie down on the exam table

4.

The doctor performs hand hygiene (Moment 1 – before touching a patient)

5.

The doctor performs the physical examination by listening to the patient’s heart and chest, checks the patient’s tendon reflexes with a hammer, and measures the blood pressure

6.

At the end of the physical examination, the doctor helps the patient to get up

7.

The doctor performs hand hygiene (Moment 4 – after touching a patient)

8.

The doctor walks back to charting area outside of exam room, makes notes on a computer, and writes a prescription

9.

The doctor sits down again and they discuss the patient’s medication prescription

10.

The patient leaves the room, and the doctor walks into the next exam room where another patient is waiting

Likely frequency of this sequence per hour = 4-6 Duration of the sequence = approximately 10-15 minutes Number of hand hygiene opportunities per sequence = 2 Types of hand contact = intact skin Hand hygiene product that should be used = alcohol-based hand rub (ABHR)

Evaluation and Feedback • Evaluating and repeated monitoring of hand hygiene compliance, knowledge, and perception is vital • You can’t improve what you don’t measure • There are several ways that hand hygiene compliance can be evaluated, including via direct observation by a trained observer, patient survey, self-reported behavior, and Electronic Compliance Monitoring

Evaluation and Feedback • The Joint Commission Monograph on Measuring Hand Hygiene • http://www.jointcommission.org/assets/1/18/hh_mon ograph.pdf

Evaluation and Feedback

Evaluation and Feedback

Evaluation and Feedback

How to Calculate a Compliance Rate

Total number of acts of hand hygiene when the opportunity existed Total number of hand hygiene opportunities

1 The

Joint Commission. Measuring hand hygiene adherence: overcoming the challenges. 2009. Available from: http://www.jointcommission.org/assets/1/18/hh_monograph.pdf. Accessed May 14, 2014.

x 100

Evaluation and Feedback • How many observations should I conduct in a month? – Accrediting bodies generally do not stipulate the number of observations you need to collect in a month – Use your judgment to determine a reasonable amount

• What should my hand hygiene compliance goal be? – It is less important that you meet your goal than whether you can demonstrate that you have obtained a baseline and have set incremental goals for improvement

• What do I do with the hand hygiene data? – Share it with employees regularly (staff meetings, posters, etc.) – Track and trend over time

Reminders in the Workplace • Tools used to remind and prompt HCW about the importance of hand hygiene • Reminders can also inform patients of the standard of care they should expect

Reminders in the Workplace • Eventually, everything will start to look like wallpaper • It’s a good idea to periodically change posters and other reminders

Institutional Safety Climate • Creating an environment and the perceptions that facilitate raising awareness around patient safety issues with hand hygiene as a high priority at all levels Top down Bottom up

Institutional Safety Climate • “Cultures isn’t just one aspect of the game – it is the game.” -- Lou Gerstner, Former CEO of IBM • Culture change is an ongoing journey that requires leaders to understand the current state of the organization, establish a clear vision, align behaviors and instill accountability.

Culture eats strategy for breakfast.

It is Time for Personal Accountability • Hand hygiene and use of alcohol-based handrub must become a ritual, automatic behavior

• We must change the rules so that healthcare workers expect to be observed and given direct, immediate feedback until the behavior of role models becomes everyone’s ritual

Weinstein RA. Hand hygiene – of reason and ritual. Annals of Internal Medicine 2004;141:65-66.

Learning Objectives  Explain the minimum standards for safe care in outpatient settings  Describe why hand hygiene is so critical in the outpatient setting

 Assess when it is appropriate to use alcohol-based hand rub and soap and water for hand hygiene  Explain why a multimodal approach is needed to improve and sustain hand hygiene compliance

Thank you!

©2015 GOJO Industries, Inc. All rights reserved.

Thank You! Megan J. DiGiorgio, MSN, RN, CIC Clinical Specialist, GoJo Industries, Inc.

Unless otherwise noted, the recommendations in this document were obtained from the presenter and http://www.cdc.gov/flu/protect/covercough.htm; http://www.jointcommission.org/assets/1/18/hh_monograph.pdf., http://apps.who.int/iris/bitstream/10665/78060/1/9789241503372_eng.pdf?ua=1, http://www.cdc.gov/injectionsafety/1anOnly.html#posters, http://www.cdc.gov/ophss/csels/dsepd/ss1978/lesson1/section10.html, http://apps.who.int/iris/bitstream/10665/78060/1/9789241503372_eng.pdf?ua=1, http://www.cdc.gov/hicpac/2007ip/2007ip_table4.html. Be advised that information contained herein is intended to serve as a useful reference for informational purposes only and is not complete information. McKesson cannot be held responsible for the continued currency of or for any errors or omissions in the information. This webinar has been provided to participants on a complimentary basis. McKesson makes no representations or warranties about, and disclaims all responsibility for, the accuracy or suitability of any information in the webinar and related materials; all such content is provided on an “as is” basis. MCKESSON FURTHER DISCLAIMS ALL WARRANTIES REGARDING THE CONTENTS OF THESE MATERIALS AND ANY PRODUCTS OR SERVICES DISCUSSED THEREIN, INCLUDING WITHOUT LIMITATION ALL WARRANTIES OF TITLE, NON-INFRINGEMENT, MERCHANTABILITY, AND FITNESS FOR A PARTICULAR PURPOSE. The content of webinar and related materials should not be construed as legal advice and is intended solely for the use of a competent healthcare professional. Eligibility Requirements For Participating in a McKesson Webinar: This webinar is not open to the general public. Your participation in this webinar cannot be transferred or assigned to anyone for any reason. You do not have to be a current customer of, purchase products from, or be affiliated with, McKesson, in order to participate in the webinars. McKesson, in its sole discretion, may terminate this promotion at any time. Due to certain regulatory restrictions, this promotion cannot be offered to health care providers licensed in Vermont and/or to government employees.

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Please join tomorrow, Infection Prevention Week Series! Hard and Soft Surfaces in Healthcare Settings Sarah C. Bell-West, PhD October 20, 2015 at 2:30pm ET