Hand Hygiene and Infection Control: What Happens Next?

1. Hand Hygiene and Infection Control: What Happens Next? What Dr. Wenzel does not know and What Dr. Edmond will not tell you. Gonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University

2. Hand Hygiene and Infection Control: What Happens Next? What Dr. Wenzel does know and What Dr. Edmond will tell you. Gonzalo Bearman MD, MPHAssistant Professor of Medicine, Epidemiology and Community HealthAssociate Hospital EpidemiologistVirginia Commonwealth University

3. Infection Control Timeline Hotel-Dieu : Paris hospital founded in the 7th century Big Bang 10 billion and 20 billion years ago Many years elapse 0 Circa 600 AD

4. Infection Control Timeline Segregation of Infectious Patients Lazarettos for plague victims established in Venice in the 15th century Leprosariums emerge in the Middle Ages Fever hospitals established in England in the early 19th century

5. History: Ignaz Semmelweis • At the Vienna Lying-in Hospital • Women who delivered on the street had less risk of developing puerperal fever • Much higher risk of puerperal fever in women delivered by physicians or medical students as opposed to those delivered by midwives • Required that hands be washed with chlorinated lime after autopsies & between exams of pregnant women • Maternal mortality decreased from 18% to 3%

6. History: Florence Nightingale and Louis Pasteur • Developed the germ theory of disease in the late 1800s • Importance of unsanitary hospital conditions and post operative complications

7. History: Advances in Surgical Infection Control

8. Infection Control Timeline: The Modern Era • Robert Haley, MD 1970’s SCENIC Study • Hospitals with active infection control programs have a 32% lower incidence of nosocomial infections R.P Wenzel MD, MSc 1980: Founded Society of Healthcare Epidemiology; applied epidemiologic techniques to infection control First antibiotics, sulfonamides & penicillin, developed in the late 1930s 1961: MB Edmond born

9. So where are we now and what happens next?

10. Nosocomial Infections • 5-10% of patients admitted to acute care hospitals acquire infections • 2 million patients/year • 70% are due to antibiotic-resistant organisms • ¼ of nosocomial infections occur in ICUs • 90,000 deaths/year • Attributable annual cost: $4.5 – $5.7 billion • Cost is largely borne by the healthcare facility not 3rd party payers Weinstein RA. Emerg Infect Dis 1998;4:416-420. Jarvis WR. Emerg Infect Dis 2001;7:170-173.

11. Shifting Vantage Points on Nosocomial Infections Many infections are inevitable, although some can be prevented Each infection is potentially preventable unless proven otherwise Gerberding JL. Ann Intern Med 2002;137:665-670.

12. The medical literature is replete with studies identifying risk factors for nosocomial infections • Hand Hygiene • BSI • Catheter type, insertion, maintenance • VAP • Duration of intubation, gastric pH, HOB elevation • UTI • Catheter use and insertion, maintenance

13. Sadly, we as medical professionals frequently do not practice well known nosocomial infection risk reduction practices

14. Pressure from legislatures, consumer groups, third party payers and regulatory agencies has resulted in mandatory public reporting of nosocomial infections This is now driving compliance with process of care measures that are associated with reductions in nosocomial infection risk

15. Help Consumers Union Stop Hospital Infections! Most people don't expect to go into a hospital and come out even sicker because of an infection they caught as a patient, but 1 in 20 do. And each year, about 90,000 people die from hospital acquired infections - a leading cause of death in the U.S. The annual cost to our health care system is $5 billion. Congress is considering a bill that would let hospitals keep information about their infection rates and medical errors a secret. People should be able to find out whether their hospital is doing a good job of controlling dangerous infections. TAKE ACTION now to tell Congress to preserve state's rights to report on hospital infection rates. http://www.consumersunion.org/pub/projectsandcampaigns.html

16. Status of Mandatory Reporting LegislationSeptember 2005 Enacted legislation Legislation introduced, under review or further study  Legislation died/defeated Source: APIC. Slide: courtesy of MB Edmond MD,MPH,MPA

17. Infection Control Process of Care Measures • Hand Hygiene • Contact Precautions • Gowns • Gloves • HOB elevation for VAP prevention • CVC insertion measures • Avoidance of femoral site • Maximal sterile barrier precautions • Proper antisepsis of skin • Prompt discontinuation of catheter use

18. 30%-40% of all Nosocomial Infections are Attributed to Cross Transmission: The Importance of Hand Hygiene

19. The inanimate environment is a reservoir of pathogens X represents a positive Enterococcus culture The pathogens are ubiquitous ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

20. The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, C.diff, CNS and GNR Devine et al. Journal of Hospital Infection. 2001;43;72-75 Lemmen et al Journal of Hospital Infection. 2004; 56:191-197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004:849-869

21. Hand Hygiene Single most effective method to limit cross transmission

22. HCWs' perceptions of compliance with infection control practices Majority of respondents reported excellent compliance with IC practices Berhe M, Edmond MB, G Bearman in AJIC 33;1 February 2005, 55-57

23. Alcohol Based Hand Sanitizers • CDC/SHEA hand antiseptic agents of choice • Recommended by CDC basedon strong experimental,clinical, epidemiologic and microbiologic data • Antimicrobial superiority • Greater microbicidal effect • Prolonged residual effect • Ease of use and application

24. Alcohol based hand hygiene solutions Easy to use Quick: 5- 15 seconds Very effective antisepsis due to bactericidal properties of alcohol

25. Study Algorithm Incremental Increase in Alcohol Dispensers Hand Hygiene Educational Program Implemented Direct Observation of Hand Hygiene Arch Intern Med. 2000;160:1017-1021.

26. Results Hand hygiene practice can be improved with education and greater accessibility of alcohol hand sanitizers • Improvement in Hand Hygiene Compliance Arch Intern Med. 2000;160:1017-1021.

27. Hand Hygiene • Single most important method to limit cross transmission of nosocomial pathogens • Multiple opportunities exist for HCW hand contamination • Direct patient care • Inanimate environment • Alcohol based hand sanitizers are ubiquitous • USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

28. Hand Hygiene • HCW’s perceive that their hand hygiene practice is excellent • Observational data does not support this claim • New technologies such alcohol based hand sanitizers make the practice of hand hygiene simpler than ever • There is simply no excuse for poor hand hygiene compliance

29. Contact Precautions for drug resistant pathogens. Gowns and gloves must be worn upon entry into the patient’s room

30. Glove Use for Infection Control

31. Gown Use for Infection Control

32. What about the role of Universal Gloving For All Patient Care?

33. A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug-Resistant Pathogens G. Bearman MD,MPH A. Marra, MD C. Sessler, MD W.R. Smith, MD R.P. Wenzel MD, MSc M.B. Edmond MD,MPH,MPA

34. Hypothesis • The effectiveness of universal gloving (use of gloves for all patient care activity) in preventing the transmission of multidrug-resistant pathogens will be greater than the effectiveness of contact precautions for the following reasons: • Compliance with universal gloving will likely be greater than compliance with contact precautions. Bearman et al.

35. CDC/NNIS NI definitions applied; surveillance performed by VCUMC IC Department • Hand hygiene observations performed by trained observers • Active surveillance nasal and rectal cultures were obtained on all patients within the unit Bearman et al.

36. Methods • Microbiologic Data • One rectal swab culture performed for VRE and 1 nasal swab culture for MRSA performed on admission and every 4 days. • Once a patient was culture positive; then no further cultures were obtained for that organism. • Pulse field gel electrophoresis (PFGE) for genetic typing and antibiotic susceptibility testing were performed on all MRSA and VRE isolated after study was completed. Bearman et al.

37. Methods • Healthcare Questionnaire • Administered at the end of the study protocol • Target: MRICU Nurses and Attending Physicians • Focus: • self reported compliance with infection control practice • acceptability of universal gloving vs. standard of care. Bearman et al.

38. MethodsAdditional Data Elements: Bearman et al.

39. Results: Bearman et al.

40. Results: Hand Hygiene Compliance A statistically significant reduction in hand-hygiene was observed in phase II Bearman et al.

41. Results:Compliance with Contact Precautions vs. Universal Gloving Greater adherence during universal gloving was observed Bearman et al.

42. Results: VRE screening No difference was observed in the rate of VRE acquisition Bearman et al.

43. Results: MRSA Screening No difference was observed in the rate of MRSA acquisition Bearman et al.

44. Results: MRSA PFGE ALL MRSA conversions were with clonal isolates Bearman et al.

45. Results: VRE PFGE Most VRE conversions were with clonal isolates

46. Results:Nosocomial Infections Rates A statistically significant increase in NIs was observed Bearman et al.

47. Results: Nosocomial Infections

48. Results: Nosocomial Infections with VRE or MRSA 4 VRE and MRSA infections were identified in Phase II

49. MRICU Demographics Utilization ratio=device days/patient days

50. Results: Antibiotic UsageDefined daily dose (DDD/1000 patients-day) The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults Example:DDD of levofloxacin is 0.5grams, if 200 grams were dispensed in a period with 4,500 patient days:(200g/0.5g)/4,500 pt days X 1000= 89 DDD/1000 PD