Pennsylvania Patient Safety Advisory Hand Hygiene Practices and the Use of Alcohol-Based Sanitizers Hand hygiene, a term applied to either a thorough in unacceptably low rates of adherence to guidelines washing of hands with soap and water for at least and practice.9 A review of reports submitted through 15 seconds or the application of 3 to 5 ml of an PA-PSRS revealed violations in hand hygiene prac- alcohol-based antiseptic solution, has been reported tices, whereby healthcare workers (i.e., physicians, as the most significant method to reduce healthcare- laboratory and radiology personnel) entered patient associated infections (HAIs).1 The Centers for Disease rooms, rendered care, and left without washing their Control and Prevention (CDC) estimates that hands. This included patients in contact isolation. In approximately 90,000 patients die every year as a a 1999 study by Pittet et al., 2,834 observed opportu- result of HAI acquisition.2 In 2006, the Pennsylvania nities for handwashing revealed an average compliance Health Care Cost Containment Council reported rate of 48%. Nurses had the highest rate of compli- that more than 30,000 patients acquired HAIs in ance compared to physicians, nursing assistants, and Pennsylvania, a rate of 19.2 per 1,000 cases, and other healthcare workers.10 For the most part today, patients with hospital infections died at a rate nearly the rate of hand hygiene compliance remains at less 6 times that of uninfected patients.3 than 50% except in hospitals that have instituted extremely aggressive campaigns such as the University Background of Pittsburgh Medical Center, Shadyside Campus. In The concept of handwashing as a method of infection 2005, the hospital launched a highly visible program control dates back to 1843, when Oliver Wendell Hol- including promoting the use of alcohol hand sanitizer. mes Sr., MD, authored the “The Contagiousness of After four months, hand hygiene compliance had Puerperal Fever” in the New England Quarterly Journal of risen from 17% to 60%.11 Now, the center’s overall Medicine.4 The essay addressed Holmes’ perception that compliance rate is consistently greater than 90%. the degree of contagiousness highly suggests patient- to-patient carriage by physicians and nurses. Around System Failures and Barriers to Effective the same time, Ignaz Philipp Semmelweis, MD, a Hand Hygiene Hungarian obstetrician, discovered that “hand washing System failures encourage poor compliance by health- was an effective method to reduce the death rate due care workers. Healthcare facilities (hospitals and to childbirth fever or puerperal sepsis.”5 Semmelweis nursing homes) need to design user-friendly, easily enforced antiseptic practices among his students, and accessible, and simple but effective hand hygiene he reduced the death rate in the postpartum popula- systems. Well-designed systems in conjunction tion from 12% to 1% in two years. Both physicians with other pertinent factors, will ultimately lead to encountered significant resistance to this practice. motivation with resultant individual accountability During 2002, CDC, in collaboration with the Soci- and compliance. Several observational studies have ety for Healthcare Epidemiology, the Association of determined that noncompliance is multifaceted, and Professionals in Infection Control and Epidemiol- breaking down the barriers is critical to a successful ogy, and the Infectious Disease Society of America, program.12-14 The following barriers are most com- released its updated Guideline for Hand Hygiene in monly reported: Health-Care Settings. Included in these guidelines was ■ Lack of institutional commitment the strong recommendation for routine use of alcohol ■ Skin irritation, mainly as a result of handwashing hand sanitizers in clinical settings.6 Similar to findings of Holmes and Semmelweis, the guideline supports with soap and water hand hygiene as an evidence-based practice to reduce ■ Time constraints, particularly when handwashing HAIs as part of a multifaceted approach.7 ■ Inconvenient location and insufficient numbers HAIs have a global impact on healthcare delivery of sinks systems. The World Health Organization (WHO) ■ Frequent lack of supplies (e.g., soap, paper towels) addressed these issues in 2007 with the WHO ■ False sense of security with glove use Guidelines on Hand Hygiene in Health Care.8 The international recommendations came on the heels ■ Interference with worker-patient relation (hand of another WHO campaign, Global Patient Safety hygiene creates a brief interruption of care) Challenge 2005-2006: Clean Care is Safe Care, ■ Forgetfulness which collectively supports fundamental principles to ■ Lack of guidance improve universal health and well-being. ■ Lack of effective educational programs Hand Hygiene Compliance Issues ■ High workload and understaffing One of the most significant challenges for infection preventionists (formerly known as infection control ■ Lack of scientific information demonstrating practitioners) is the lack of overall compliance among impact of improved hand hygiene on hospital healthcare workers in all healthcare settings, resulting infection rates Page 100 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 3—September 2008 Pennsylvania Patient Safety Advisory Components of a Successful Hand Hygiene Alcohol hand sanitizer factors that increase hand Program hygiene compliance include the following: Changing behavior is complex, and facility-wide ■ Ease of use acceptance is imperative. Infection control personnel ■ More readily available than sinks play a key role in assisting administration with the design of an effective program. Providing evidence ■ Less skin irritation than handwashing because of to facility administrators about new approaches can the absence of harsh chemicals as well as the addi- aid in meeting HAI reduction and prevention goals. tion of emollients How-to guides such as the toolkit and guide produced ■ Rapid evaporation by the Institute of Healthcare Improvement have assisted hospitals in achieving far higher compliance ■ Less time consuming than handwashing rates.15,16 Components of a successful system include ■ More efficacious, mainly due to increased use ver- the following: sus regular handwashing ■ Institutional commitment Risk Reduction Strategies ■ Establishment of policies and procedures for hand Approximately 165 years have passed since Holmes hygiene and Semmelweis first made the connection between ■ Active participation in promotion at the individual handwashing and infection prevention. While there and institutional/system level has always been the need for compliance, today with ■ Designated champions the prevalence of multidrug-resistant organisms, such as methicillin-resistant Staphylococcus aureus, the need ■ Ongoing staff and patient education, including tech- for risk reduction strategies is critical. nique for handwashing and alcohol sanitizer use All healthcare facilities, including acute care hospitals ■ Routine monitoring and assessments with feed- and nursing homes, must create their own action back (quality improvement tools) plans with specific risk reduction strategies that ■ Readily available sinks, paper towels, and alcohol- include but are not limited to the following: based rubs ■ Audit the current rate of hand hygiene compliance. ■ Reminders such as posters and screen savers ■ Set a target rate and time frame for improvement. ■ Personal accountability ■ Provide appropriate hand hygiene education to all ■ Sanctions for noncompliance providers of patient care. ■ Reward and recognition for good performers ■ Encourage, reward, and recognize staff input and ideas for improving hand hygiene compliance. Alcohol Hand Sanitizers and Their Role in Hand Hygiene Compliance ■ Allocate sufficient funds, and appoint unit champions. Use of alcohol hand sanitizers appears to be superior to traditional handwashing when the caregiver’s hands ■ Survey the environment, and determine placement are not visibly soiled. Sanitizers are less irritating, at point of care for the alcohol sanitizer dispensers. require less time, act faster, have rapid bactericidal ■ Encourage patient input on the overall plan to action (except for Clostridium difficile and spore-produc- improve hand hygiene compliance. ing organisms), are active against the most clinically important organisms (viruses, yeasts, fungi), and con- Ultimately, compliance with hand hygiene needs to tribute to improved compliance. A systematic review become part of a culture of patient safety. Healthcare of the efficacy of alcohol hand sanitizers revealed that advances, including alcohol hand sanitizers, have the overall compliance for hand hygiene appears to made it possible for facilities to provide the necessary be improving since the introduction of these prod- components for facilitywide compliance. Effective ucts and the strong endorsement in CDC’s 2002 systems as described above together with alignment guidelines.17-19 The review concluded that while hand of frontline team members, strong educational pro- hygiene involving alcohol hand sanitizers is increas- grams, and consistent personal accountability by all ing, relatively few well-designed studies to date reveal a staff can help achieve 100% compliance with hand reduction in the overall incidence of HAIs as a result. hygiene, which is a vital component of the nationwide However, one experimental trial/study in a hospital HAI reduction initiative.22 setting demonstrated that if staff can be convinced to In his recently published book, Results That Last: use alcohol hand sanitizers to a significant degree, the Hardwiring Behaviors That Will Take Your Company to rate of HAIs will decrease significantly, especially if it the Top, Quint Studer, a consultant whose firm imple- is part of a multifaceted approach to HAI reduction.20 ments evidence-based leadership systems, quoted a It is important to note that alcohol hand sanitizer colleague who stated that “what we permit, we pro- products within the United States usually contain mote.” If we permit low rates for compliance with 60% to 95% ethanol or isopropanol, with 60% to hand hygiene, are we promoting infections?23 Facili- 70% formulations being most commonly used.21 ties can look at this issue and commit to improving Vol. 5, No. 3—September 2008 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Page 101 Pennsylvania Patient Safety Advisory patient care by promoting hand hygiene compliance 12. Pittet D. Improving adherence to hand hygiene practice: today. a multidisciplinary approach. Emerg Infect Dis 2001 Mar- Apr;7(2):234-40. Notes 1. Reduction in central line-associated bloodstream infect- 13. Larson EL, Bryan JL, Adler LM, et al. A multifaceted ions among patients in intensive care units—Pennsylvania, approach to changing handwashing behavior. Am J Infect April 2001-March 2005. Morb Mortal Wkly Rep 2005 Oct; Control 1997 Feb;25(1):3-10. 54(40):1013-6. 14. Goldmann D. System failure versus personal account- 2. McKibben L, Horan T, Tokars JI, et al. Guidance on ability—the case for clean hands. N Engl J Med 2006 public reporting of healthcare-associated infections: Jul;355(2):121-3. recommendations of the Healthcare Infection Control 15. Institute for Healthcare Improvement. How-to guide: Practices Advisory Committee. Am J Infect Control 2005 improving hand hygiene [online]. [cited 2008 Aug 18]. May;33(4):217-26. Available from Internet: http://www.ihi.org/IHI/ 3. Pennsylvania Health Care Cost Containment Council. Topics/CriticalCare/IntensiveCare/Tools/ Hospital-acquired infections in Pennsylvania; calendar HowtoGuideImprovingHandHygiene.htm. year 2006 [online]. 2008 Apr [cited 2008 Jul 21]. Avail- able from Internet: http://www.phc4.org/reports/ 16. The Society for Healthcare Epidemiology of America. hai/06/docs/hai2006report.pdf. How-to guide: improving hand hygiene: a guide for improving practices among health care workers [online]. 4. Holmes OW. The contagiousness of puerperal fever. [cited 2008 Aug 19]. Available from Internet: http://www. New Eng Q J Med Surg 1:503-30, 1842-3. shea-online.org/Assets/files/IHI_Hand_Hygiene.pdf. 5. Semmelweis I. The etiology, concept and prophylaxis of childbed fever [excerpts]. In: Buck C, Llopis A, Najera 17. Picheansathian W. A systematic review on the effective- E, Terris M, ed. The challenge of epidemiology—issues and ness of alcohol-based solutions for hand hygiene. Int J selected readings. Washington: PAHO Scientific Publica- Nurs Pract 2004 Feb;10(1):3-9. tion; 1988:46-59. 18. Carr MP. Waterless hand washing: a new era in hand 6. Centers for Disease Control and Prevention (CDC). hygiene. J Pract Hyg 2004 Mar-Apr:13(2):33-6. Guideline for hand hygiene in health-care settings. 2002. 19. Zoutman D, Matlow A. Alcohol hand sanitizers: an 7. Rotter ML. Semmelweis’ sesquicentennial: a little-noted examination of the evidence of their efficacy. Can J Infect anniversary of handwashing. Curr Opin Infect Dis 1998 Control 2003 Spring:8-9. Aug;11(4):457-60. 20. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of 8. World Health Organization. WHO Guidelines on Hand hospital-wide programme to improve compliance with Hygiene in Health Care (Advanced Draft). Geneva: hand hygiene. Infection Control Programme. Lancet World Health Organization: 2006. 2000 Oct;356(9238):1307-12. 9. Boyce JM. It is time for action: improving hand hygiene 21. Malik YS, Maherchandani S, Goyal SM, et al. Compara- in hospitals. Ann Intern Med 1999 Jan 19;130(2):153-5. tive efficacy of ethanol and isopropanol against feline 10. Pittet D, Mourouga P, Perneger TV. Compliance with calicivirus, a norovirus surrogate. Am J Infect Control handwashing in a teaching hospital. Infection Control 2006 Feb;34(1):31-35. Program. Ann Intern Med 1999 Jan 19;130(2):126-30. 22. Larson E. State-of-the science—2004: time for a “No 11. Institute for Healthcare Improvement. The sounds of Excuses/No Tolerance” (NET) strategy. Am J Infect Con- two hands washing: Improving hand hygiene trol 2005 Nov;33(9):548-57. [online]. [cited 2008 Aug 18]. Available from Internet: http://www.ihi.org/IHI/Topics/CriticalCare/Intensive- 23. Studer Q. Results that last: hardwiring behaviors that Care/ImprovementStories/ will take your company to the top. Hoboken (NJ): John FSSoundofTwoHandsWashing.htm. Wiley & Sons, Inc; 2007. Page 102 REPRINTED ARTICLE - ©2008 Pennsylvania Patient Safety Authority Vol. 5, No. 3—September 2008 PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 5, No. 3—September 2008. The Advisory is a publication of the Pennsylvania Patient Safety Authority, produced by ECRI Institute and ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). Copyright 2008 by the Pennsylvania Patient Safety Authority. This publication may be reprinted and distributed without restriction, provided it is printed or distributed in its entirety and without alteration. Individual articles may be reprinted in their entirety and without alteration provided the source is clearly attributed. This publication is disseminated via e-mail. To subscribe, go to https://www.papsrs.state.pa.us/ Workflow/MailingListAddition.aspx. To see other articles or issues of the Advisory, visit our Web site at http://www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. THE PENNSYLVANIA PATIENT SAFETY AUTHORITY AND ITS CONTRACTORS The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI Institute, as contractor for the PA-PSRS program, is issuing this publication to advise medical facilities of immediate changes that can be instituted to reduce Serious Events and Incidents. For more information about the PA-PSRS program or the Patient Safety Authority, see the An Independent Agency of the Commonwealth of Pennsylvania Authority’s Web site at www.psa.state.pa.us. ECRI Institute, a nonprofit organization, dedicates itself to bringing the discipline of applied scientific research in healthcare to uncover the best approaches to improving patient care. As pioneers in this science for nearly 40 years, ECRI Institute marries experience and independence with the objectivity of evidence-based research. More than 5,000 healthcare organizations worldwide rely on ECRI Institute’s expertise in patient safety improvement, risk and quality management, and healthcare processes, devices, procedures and drug technology. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP’s efforts are built on a nonpunitive approach and systems-based solutions.