Hand disinfection Topics

Hand disinfection Mongolia 2011 Walter Popp, Hospital Hygiene, University Clinics Essen, Germany 1 Topics History Hand washing vs. hand disinfection Importance of hand disinfection Compliance campaigns 2 1

Ignaz Semmelweis (1818-1865) 3 Rotter: Semmelweis sesquicentennial: a little-noted anniversary of handwashing. Curr Opin Infect Dis 11, 1998, 457-460 4 2

Distribution of phage contamination by hand giving (number = log10 of re-isolated amount of phages) Von Rheinbaben, Wolff: Handbuch der viruswirksamen Desinfektionen. Springer, 2002, S. 272 5 6 3

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9 Relationship between duration of patient care and bacterial contamination of hands of hospital staff who wore gloves (solid circles and dashed line) and those who did not wear gloves (open circles and solid line) in 417 observations conducted at the University Hospitals of Geneva, Geneva, Switzerland, in 1996. Lines represent the average trend in each group, obtained using nonparametric regression (LOWESS) Pittet et al., Arch Intern Med 159, 1999, 821-826 10 5

Relationship between duration of patient care and bacterial contamination of hands of gloveless hospital staff in 287 observations conducted at the University Hospitals of Geneva, Geneva, Switzerland, in 1996 by initial hand-cleansing method: hand washing with unmedicated soap and water or water alone (dotted line), hand antisepsis with hand antiseptic agents (dashed line), or both performed sequentially (solid line). Lines represent the average trend in each group, obtained using nonparametric regression (LOWESS). Pittet et al., Arch Intern Med 159, 1999, 821-826 11 12 6

Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 13 Observational studies: On average 5 times hand washing in a shift, partly up to 30 times, singel nurses up to 100 times. Duration of hand washing 7 24 seconds (average), often not washing the complete hand. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 14 7

Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 15 Hygienic hand disinfection reduces transient skin flora significantly more than hand washing. Soaps are worse for skin than alcoholic handrub. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 16 8

Bacteria reduction on hands % 99.9 Time after disinfection log 0 60 180 Minutes 3.0 Bacter ria reduction 99.0 90.0 2.0 1.0 Alcoholic handrub (70% Isopropanol) Antiseptic soap (4% Chlorhexidin) 0.0 0.0 Pure soap Ausgangspunkt Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999. 17 Effect of Alcohol-Based Handrubs on Skin Condition Dry Healthy Self-reported skin score 6 5 4 3 2 1 0 Baseline Alcohol rub 2 weeks Soap and water Epidermal water content 27 25 23 21 19 17 15 Baseline Alcohol rub 2 weeks Soap and water Healthy Dry ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441. 18 9

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Boyce, Pittet: Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/ID SA hand hygiene task force. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 21 Hand disinfection: Maximum of bacteria reduction: 2 lg (factor 100) Boyce, Pittet: Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/ID SA hand hygiene task force. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 22 11

Listed. European regulation EN 1500. Hand disinfectants in Germany Alcohol: Efficiant against viruses with envelopes (HIV, HBV, HCV, SARS, Influenza, Herpes). Problem: some viruses without envelopes like Norovirus oder HAV. Propanols not enough efficiant. Ethanol efficiant > 90 %, alternativ combinations of different alcohols with ethanol. 23 Boyce, Pittet: Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDS A hand hygiene task force. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 24 12

Observational studies: Compliance mean 40 %, Range 5 81 %. Boyce, Pittet: Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDS A hand hygiene task force. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 25 Risk factors for bad compliance Doctor (nurses are better). Badly qualified nurse helpers. Male. ICU. Work during working days (in comparison to weekend). Wearing gowns and gloves. Touchless wash basin. Often need to disinfect hands. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 26 13

Pittet: Hand hygiene: improved standards and practice for hospital care. Curr Opin Infect Dis 16, 2003, 327-335 27 Own reasons of staff for bad compliance Irritation and dryness of skin. Sink has no functional construction. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 28 14

Own reasons of staff for bad compliance Irritation and dryness of skin. Sink has no functional construction. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 29 Own reasons of staff for bad compliance Irritation and dryness of skin. Sink has no functional construction. No soap and single-use towels available. Not enough time. Not enough staff. Not possible because of work with patient. Infection risk is small. Not necessary because of gloves. Recommendations never heard about. I forgot. Bad role model of colleague. Reason of hand hygiene not convincing. Denial of recommendations. Not enough knowledge about evidence of hand hygiene. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 30 15

Additional barriers Not enough training. No role model. Not important in hospital. No sanctions. No high safety climate in hospital. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 31 32 16

Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 33 Strategies to improve hand hygiene: Training. Routine observation and report about results. Enough dispenser available at place of work. Inform patients. Reminders at workplace (posters ) Sanctions. Provide skin protection. Improve safety climate of hospital. Prevent overcrowding and lack of staff. Combine different strategies. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 34 17

Boyce, Pittet: Guideline for hand hygiene in healthcare settings: Recommendations of fthe healthcare infection control practices advisory committee and the HICPAC/SHEA/API C/IDSA hand hygiene task force. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 35 Elements of training: Reasons for hand hygiene. When hand hygiene? Technics of hand hygiene. Skin protection. Demands and support of hospital. Gloves: when to wear and limitations (holes, contamination during pulling off. Boyce, Pittet: Guideline for hand hygiene in healthcare settings: Recommendations of fthe healthcare infection control practices advisory committee and the HICPAC/SHEA/API C/IDSA hand hygiene task force. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 36 18

- HICPAC, SHEA, APIC, IDSA and others - Possible markers of good compliance: Observational studies (disinfections done / disinfections necessary) problem: observer are known. Amount of disinfectants used (e.g. per 1.000 patient days). Indirect indicator like wearing of artificial finger nails or rings. Measure real situation of disinfection during outbreaks. Boyce, Pittet: 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. Infect Control Hosp Epidemiol 23, 2002, suppl, S3-S40 37 Intervention study of Pittet, Genf Teaching hospital, Geneva, Switzerland. Hand hygiene campaing 1994-1997. Observational study re compliance. Outcoume parameters: NI rates, MRSA, amount of hand disinfectants used. Increase of compliance 48 % 66 % (sign.) Decrease of NI rates: 16,9 % 9,9 % (sign.). Decrease of MRSA infections: 2,16 0,93 per 10.000 patient days. Amount of hand disinfectants used: 3,5 l 15,4 l per 1.000 patient days. Pittet et al: Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 356, 2000, 1307-1312 38 19

University Clinics Geneva 163 Дrzte Pittet et al: Hand hygiene among physicians: Performance, beliefs, and perceptions. Ann Intern Med 141, 2004, 1-8 39 University Clinics Geneva 163 Дrzte Compliance Higher with women. Higher with younger staff. Low at the top of doctors hierarchy. High with internists and pediatricians, low with surgeons and anesthesists. Higher if product is near bed on at clothes. Lower with more indications to disinfect hands. Pittet et al: Hand hygiene among physicians: Performance, beliefs, and perceptions. Ann Intern Med 141, 2004, 1-8 40 20

Hand disinfection is extremely cheap in comparison to hospital infections! 41 42 21

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49 Campaign of NHS since 2004 Issues: Near-patient alcohol hand-rub Talking walls (posters ) Patient empowerment (it s ok to ask) Results until end of 2006: More usage of disinfectants, Decrease of MSSA, MRSA stable (decrease from 2007 on), Clostridium difficile increasing (but decreasing in the last years). 50 25

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