Transcript CDC Hand Hygiene Guidelines, VA NCPS, 3M, and Six Sigma
CDC Hand Hygiene Guidelines, JCAHO, VA NCPS, NFPA, 3M Corp, and Six Sigma
Noel E. Eldridge, MS Joseph M. DeRosier, PE, CSP
VHA National Center for Patient Safety 1
CDC Guidelines Recommendations - 44 in 8 Categories
1. Indications for handwashing and hand antisepsis (14) 2. Hand-hygiene technique (4) 3. Surgical hand antisepsis (5) 4. Selection of hand-hygiene agents (5) 5. Skin care (2) 6. Other Aspects of Hand Hygiene (6) 7. Health-care worker educational and motivational programs (3) 8. Administrative measures (5)
Total Length: 1350 words in 45 page document
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JCAHO Involvement
New JCAHO Patient Safety Goal for 2004: – 7a:
“ Comply with current CDC hand-hygiene guidelines.
”
Making it a Patient Safety
“ Goal ”
for 2004 has transformed the CDC
“ Guidelines ”
into JCAHO
“ Requirements ”
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I.
II.
III.
IV.
VHA Summary of JCAHO-required CDC Recommendations (19 in 4 categories)
All Health Care Workers with Direct Patient Contact (8) Surgical Hand Hygiene (3) Facility Management: Supplies (5) Facility Management: Administrative Action (3) Total Length: 732 words (minus 45%)
http://vaww.ncps.med.va.gov/Hand_Hygiene/index.html
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New National Guidance on the Use of Alcohol Handrubs
On April 28, 2004, the NFPA announced the amendment of the 2000 and 2003 editions of the Life Safety Code (LSC) to specifically recognize and permit the use of alcohol-based hand rub solutions in patient rooms, corridors, and suites of healthcare facilities.
VHA gave the same basic OK to VAMCs in December 2003 via a memo from the USH 5
Locations
Patient care rooms Suites of rooms (ICU, Urgent Care, Radiology, etc.) Corridors that have >72” of clear width if spaced at least 48 inches apart
– Corridors may not be carpeted unless sprinkler protected – Dispensers may not project > 6” into corridor egress width – Not over, or adjacent to, ignition sources 6
Quantities
Maximum In Use – 1.2 liters (0.32 gallons) per dispenser in rooms & corridors – 2.0 liters (0.53 gallons) per dispenser in suites of rooms – 37.8 liters (10 gallons) per smoke compartment Maximum Storage per smoke compartment – 18.9 liters (5 gallons) outside of approved storage cabinets – 456 liters (120 gallons) inside approved storage cabinets Maximum Storage in the Building – 2508 liters (660 gallons) with fire sprinklers and storage to a maximum height of 5 feet 7
3M Six Sigma Process Five Steps in Six Sigma Process…
1.
Define
2.
Measure
3.
Analyze
4.
Improve
5.
Control
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Define (DMAIC)
Desire is to reduce hospital and healthcare acquired infections (bloodstream, wound, respiratory, urinary tract, etc.) No present way to measure these infections consistently across VAMCs Decided to focus on improving hand hygiene practices in ICUs, based on the provisions of the CDC Guidelines
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6 Sigma Hand Hygiene Process Map
Step 1-HCW (Health Care Worker) arrives at patient bedside Step 2-HH (Hand Hygiene) opportunity/requirement arises Step 3-HCW decides to use HH products Step 6-HCW examines patient/uses equipment Step 7-HCW decides to use HH materials again on exit Step 8-HCW uses HH materials on exit /between patients Step 4-HCW seeks supplies Step 9 - HCW exits Step 5-HCW uses HH supplies
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Measure (DMAIC)
What we’re measuring:
– Hand Hygiene compliance (via “watching’) – Quantity of alcohol handrub used per 100 patient days – Use of antimicrobial soap rather than non antimicrobial – No artificial fingernails – Staff attitudes about hand hygiene practices – Staff satisfaction with hand hygiene practices 11
Measure (DMAIC)
Foam and gel dosage not simple…
– How big is the blob or how many squirts?
Antimicrobial soap availability (122 VAMCs) in Dec 2003
– 36% antimicrobial only – 44% both – 20% non-antimicrobial only
Staff think they are doing ~90% when watchers data shows ~40-60%
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Measure (DMAIC)
How many “doses” do you get from a 15 oz. can Foam?
– 15 oz. (425g) can says use “5g (palmful)” But 5g of foam is about 80 ml…& only 85 doses – (This is ridiculous) – 7 oz. can says “palmful” – How much is a palmful???
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Measure (DMAIC):
Palmful
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This isn’t lunch
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Measure (DMAIC):
Doses…
15 oz. can yielded 204 doses in Noel’s kitchen test (2.0” diameter dose) Recalculating to a 1.75” diameter doses resulted in 300 per can (1.4g and 23 ml) For Isagel, we assumed 2 pumps per dose, tested to 1.6 ml (1.4g) and 380 doses in 21 oz.
Hard to compare across sites… we may recommend using yourself as a control Good rule may be “30 seconds worth” of product 16
Analyze (DMAIC)
Pareto Chart of Reasons
120 100 80 60 40 20 Reasons 0 To o Bu sy Count Percent Cum % 46 40.0
40.0
Fo No rg t i et n co nv lo ca tio n Da m ag es S kin Ou t o f p ro du ct Un su re o f N ee d 29 25.2
65.2
12 10.4
75.7
10 8.7
84.3
8 7.0
91.3
5 4.3
95.7
Ot he r 5 4.3
100.0
40 20 0 100 80 60 17
KEY PROBLEMs Access to product Patient Empowerment and Awareness Staff Awareness of Requirements and how they improve patient outcomes Hand Hygiene Culture – “The way we do things around here…” SIX SIGMA RESPONSE
Physical interventions – antimicrobial soap; new BPS for 2 oz. pocket sized rub on lanyard; product by patient beds and in halls; Lotion requirement; Posters for patients and visitors; patient folder inserts, buttons for staff to wear (encourage asking about HH) Posters for staff only areas be improved – what the requirements are; communication of watcher results and product use; provide evidence that outcomes can Posters on how to remind; how to reply; system of reminders (lines on floor); directives, letters, binders, web sites; IT’S OKAY TO ASK!
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Improve
(DMAIC)
:
Usage
4000
I-MR Chart of Doses Alcohol/100 patient days by Timing
B aseline I nterv ention 3000 2000 1000 Jul-03 A ug-03 S ep-03 O ct-03 N ov -03
M onth
D ec-03 1500 Baseline 1000 500 0 Jul-03 A ug-03 Sep-03 O ct-03 Nov -03
M onth
Dec-03 Interv ention Jan-04 Jan-04 F eb-04 F eb-04 M ar-04 UC L=1362 __ MR=417 Mar-04 LC L=0 U C L= 3711 _ X= 2602 LC L= 1493 19
Control (DMAIC):
No backsliding!
1.
2.
3.
4.
5.
6.
7.
Product Use
•
antimicrobial soap in place Product Use
•
lotion available Product Use
•
monthly vol./100 patient days of alcohol product Alcohol product dispensers in ICU locations (1 per bed & +0.5/pt. in corridor) Pocket-sized alcohol product available to staff Artificial nails – none on those who touch patients HH compliance
•
assessed by watcher data 8.
Posters up based on survey, FMEA, etc.
•
patient care areas
•
visitor waiting area
•
staff-only area 9.
10.
VAMC HH policy updated VAMC (annual) Staff Training updated 11.
VAMC New Employee orientation updated 12.
Information for Patients and Families (in admission folder) 13.
National Directive updated based on CDC Guidelines and Dec 2003 USH memorandum
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What are the top 10 carriers of infectious agents?
10 1 5 3 4 6 7 8 9 2
Use an alcohol handrub or antimicrobial soap to decontaminate your hands.
HH6S15
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Seeing isn’t believing… T he Juic e is Wo r th t he S que e ze . (Not for germs.) When it comes to microorganisms your eyes can’t be trusted. Neither can your sense of touch. Hands that feel and look clean after washing with regular soap and water can still have multitudes of live bacteria, fungi, and virus particles on them. Your hands may not always feel cleaner after using an alcohol hand-rub, but they will harbor very few microbes. Studies show that alcohol hand-rubs kill over 99% of most micro organisms. Use an alcohol hand-rub to decontaminate your hands before and after touching each patient.
T he e x t r a e ffo r t y o u put fo r t h t o de c o nt a m ina t e y o ur ha nds b e fo r e a nd a ft e r t o uc hing a pa t ie nt is w o r t hw hile . U s ing a n a lc o ho l ha n d - r ub r a t he r t ha n s o a p c a n r e d uc e ho s pit a l a c quir e d infe c t io ns by 3 0 % o r m o r e . 22
A Quick Test When a colleague or patients asks:
“Did you practice hand hygiene?”
, should you reply: A) “Thank you! I did.” B) “I forgot – but thanks for reminding me!” C) No verbal reply - just look at the person like they are a total moron.
D) “Who are you – the JCAHO inspector?” Correct answers are A or B. Remember,
clean hands save lives.
HH6S12
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3M-VHA Six Sigma Team Members
Dr. Robert Bonello, Minneapolis VAMC Kay Clutter, Minneapolis VAMC Linda Danko, Infectious Diseases Dr. Edward Dunn, NCPS
Noel Eldridge, NCPS
Leann Ellingson, Minneapolis VAMC Mary Ann Harris, Fayetteville (AR), VAMC Barbara Livingston, Des Moines VAMC Renee Parlier, VHACO (10NC) Cheryl Pederson, 3M Kim Reichling, 3M Dr. Gary Roselle, Infectious Diseases
Susan Woods, 3M
Dr. Steven Wright, OQP 24
Final Thoughts
1. History tells us at least one thing we know doesn’t work: Just telling people to “frequently” wash their hands with soap and water. That’s what resulted in 5% of inpatients with nosocomial infections.
2. Improvements are not always common sense, for example: – Evidence suggests that shorter surgical scrub times and not using a brush are same or better – – Alcohol products easier on hands than soaps Cleaner-feeling hands may have more microorganisms (soap vs. alcohol handrub) 25
If this cat can do this…
You can tell anyone to decontaminate their hands!
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Hand Hygiene Questionnaire Results - DRAFT DATA Yes Question 1:
Is your facility presently using regular (non antimicrobial soap) for staff hand washing in patient care areas*
Question 2:
Is your facility presently using antimicrobial soap for staff hand washing patient care areas?* Question 2a: If Yes to 2, what brand and specific type (product name or number)?
Gojo/Provon: Steris: Other:
68 98 56% 80% 19 54 25
Yes
19% 55% 26% 119 98%
Question 3:
Is your facility presently using an alcohol gel or foam for hand antisepsis in patient care areas? 3a. If Yes to 3, what brand and specific type (product name or number, and dispenser size(s))?
Brand/Product Names:
Ecolab: Coloplast: Other 72 29 18 61% 24% 15% 54 24
No
44% 20% 3
No
2% 27
I. All Health Care Workers With Direct Patient Contact
1) Use an alcohol hand-rub or antimicrobial soap to routinely decontaminate your hands before and after you touch a patient.
Note: A single act of hand “washing” (with an alcohol hand-rub or an antimicrobial soap) after one patient and before the next patient suffices to decontaminate your hands if you are not recontaminating your hands in between patients (as in talking on the telephone, handling objects, etc.). A good rule of thumb is that if you apply an alcohol hand-rub as you leave one patient and are still rubbing your hands together as you arrive at the next patient then there is no need to repeat hand antisepsis.
2) Put gloves on before you touch non-intact skin, blood, mucous membranes, or potentially infectious materials such as soiled linens.
3) Use an alcohol hand-rub or antimicrobial soap before donning sterile gloves when inserting a central venous catheter, an indwelling urinary catheter, a peripheral vascular catheter, or performing other similar invasive procedures.
4) Remove gloves after caring for a patient or touching potentially infectious materials, and use an alcohol hand-rub or antimicrobial soap to decontaminate your hands after removing gloves.
5) Healthcare workers that may have direct contact with patients at high risk for infection must not wear artificial fingernails.
6) Wash your hands with soap and water if they are visibly soiled or contaminated with body fluids.
7) Wash hands with soap and water after using a restroom.
8) Wash hands with soap and water before eating.
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II. Surgical Hand Hygiene
1) Before donning sterile gloves for surgical procedures use either an antimicrobial soap or an alcohol-based hand-rub with persistent activity.
2) When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions. Usage protocols may vary by manufacturer. For example, some products recommend that health care workers dip each fingernail in the antimicrobial solution prior to applying the product to their hands and forearms.
Note: Most alcohol hand-rub products designed for non-surgical applications do not have persistent activity. “Persistent activity” is not a characteristic of alcohol, but is a characteristic of most other antimicrobial agents such as Chlorhexidine Gluconate, which are added to the alcohol based products and soaps designed for use by surgeons. Consult infection control staff if you have questions on the appropriate use of alcohol-based surgical scrub products.
3) When performing surgical hand antisepsis using an antimicrobial soap, long scrub times (e.g., 10 minutes) are not necessary. Scrub hands and forearms for the length of time recommended by the manufacturer, usually 2 to 6 minutes.
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III. Facility Management (Supplies)
1) Provide an alcohol-based hand rub at the entrance to the patient’s room and/or at the bedside, as well as other convenient locations. To provide an alternative to alcohol-based hand-rubs for decontaminating hands, provide antimicrobial soap in all patient care areas where soap is provided (i.e., at all sinks with a soap dispenser).
2) Make pocket-sized containers of alcohol hand-rub available to HCWs. Note: This does not imply a requirement for HCWs to carry pocket-sized alcohol hand-rubs.
3) Provide healthcare workers with hand lotions or creams to minimize irritant contact dermatitis.
4)
Note: Be sure to provide products designed for healthcare applications that do not reduce the effectiveness of other hand hygiene products, such as gloves and antimicrobial compounds, e.g., Chlorhexidine Gluconate (CHG). Some lotions are specifically advertised as “CHG compliant.” Providing lotion should not be seen as a frill.
Do not add soap to partially empty dispensers. “Topping off” soap dispensers can lead to bacterial contamination.
Note: This means that in patient care settings soap should be provided in disposable bladders or other products that prevent old and new soap from mixing.
5) Store supplies of alcohol-based hand-rubs in cabinets or areas approved for flammable materials.
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IV. Facility Management (Administrative Action)
1) Make improved hand-hygiene an institutional priority and provide administrative and financial support.
Note: Financial support includes providing adequate supplies of alcohol hand-rubs (wall mounted and pocket-sized), antimicrobial soaps, gloves (regular and sterile), and lotion.
2) Solicit input from employees regarding the feel, fragrance, and skin 3) tolerance of products, such as soap, alcohol hand-rub and gloves.
Monitor health care workers’ adherence to hand-hygiene practices and provide information regarding the workers’ performance.
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