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Current Best Practices In
Hand Hygiene
Didier Pittet, MD, MS,
Professor of Medicine
Chair, Infection Control Program
University of Geneva Hospitals , Switzerlandast v.25.9.02/DP/HHcurrentbestpractices
UPCIUniversity of Geneva Hospitals 2
UPCIUniversity of Geneva Hospitals 3
UPCIUniversity of Geneva Hospitals 4
Background
• Hand hygiene is considered the most important
measure for reducing the transmission of
nosocomial pathogens in healthcare settings
• Many studies have documented that
compliance of healthcare workers with
recommended practices is unacceptably low
UPCIUniversity of Geneva Hospitals 5
Compliance with Hand Hygiene, 1981-1999Author Year Setting CompliancePreston 1981 Open ward 16%
ICU 30%Albert 1981 ICUs 41%
ICUs 28%Larson 1983 All wards 45%Donowitz 1987 PICU 30%Graham1990 ICU 32%Dubbert 1990 ICU 81%Pettinger 1991 SICU 51%Larson 1992 NICU/others 29%Doebbeling 1992 ICUs 40%Zimakoff 1993 ICUs 40%Meengs 1994 Emergency Room 32%Pittet 1999 All wards 48%
ICUs 36%
Nurses complied more frequently than physicians in all but one studyUPCIUniversity of Geneva Hospitals 6
Hand HygieneSelf-Self-reportedreported factors for factors for poor compliancepoor compliance
• Lack of time (understaffing, overcrowding)
• Shortage of sinks / often inconveniently located
• Lack of soap, paper, ...
• Skin damage / fear that hands will be damageafter frequent hand hygiene
• Beliefs that glove use dispenses from handhygiene
• No role model from colleagues or superior(s)
• Scepticism …
• Disagreement with the recommendations
UPCIUniversity of Geneva Hospitals 7
Ignaz Philipp Semmelweis
UPCIUniversity of Geneva Hospitals 8
02
46
81
0121
4161
81 8 4 11 8 4 21 8 4 31 8 4 41 8 4 51 8 4 6
Maternal Mortality
FirstSecond
Semmelweis IP, 1861
(%)
Maternal mortality rates,First and Second Obstetrics Clinics,
GENERAL HOSPITAL OF VIENNA, 1841-1846
UPCIUniversity of Geneva Hospitals 9
Intervention
• Students and doctors were required to:
� clean their hands with a chlorinated limesolution when entering the labor room
� in particular when moving from the autopsyto the labor room
May 1847
UPCIUniversity of Geneva Hospitals 10
UPCIUniversity of Geneva Hospitals 11
Maternal mortality rates,First and Second Obstetrics Clinics,
GENERAL HOSPITAL OF VIENNA, 1841-1850
Intervention
Semmelweis IP, 1861
May 15, 1847
True or False ?
It is easy to promote handhygiene among HCWs
UPCIUniversity of Geneva Hospitals 13
Ignaz Philipp Semmelweis before and after he insistedthat students and doctors clean their handswith a chlorine solution between each patient
UPCIUniversity of Geneva Hospitals 14
Parameters associated with successfulhand hygiene promotion
Pittet, Infect Control Hosp Epidemiol 2000 / Pittet & Boyce, Lancet Infectious Diseases 2001, April,9-20
1. Education
2. Routine observation + feedback
3. Ingeneering control
Make HH possible / easy / convenient / ...
4. Patient education
5. Reminders in the workplace
6. Administrative sanction / rewarding
UPCIUniversity of Geneva Hospitals 15
7. Change in HH agent (but not in winter ...!!!)
8. Promote / facilitate HCW’s skin care
9. Obtain active participation at individual and institutional level
10. Obtain / drive an institutional safety climate
11. Enhance individual and institutitional self-efficacy
12. and last but not least: Use a multimodal strategy
Parameters associated withsuccessful hand hygiene
promotion Pittet, Infect Control Hosp Epidemiol 2000 / Pittet & Boyce, Lancet Infectious Diseases
2001, April, 9-20
UPCIUniversity of Geneva Hospitals 16
Hôpitaux Universitaires de Genève
UPCIUniversity of Geneva Hospitals 17
Study Objective
To determine factors associated
with poor compliance to hand
hygiene practices in a large
university hospital
UPCIUniversity of Geneva Hospitals 18
Handwashing / Hand antisepsisObservational study - Methods
Information to HCW at HCUG : November 1994
• Observational study : December 5-18th, 1994
• Convenience sample of 48 wards
• 315 20-min observation periods (total,101 hours)
• Observation periods : morning - afternoon - night
week - week-end
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Definitions
number of actions *
Compliance = --------------------------------------------
number of observed opportunities**
* Action = - handwashing (soap + water / water)
- hand antisepsis (use of alcohol-based hand rub)** Predetermined opportunities for HW/HA
number of opportunities
Activity Index = -----------------------------------------[opp/hour] total duration of observation
UPCIUniversity of Geneva Hospitals 20
Study variables
• hospital ward / department• time of the day ( morning - afternoon - night )• time of the week ( week / week-end )• profession• activity index (opportunities per hour)
• nursing census of the ward (at time ofobservation)
• patient census• type of care provided• bed occupancy rate of the ward
UPCIUniversity of Geneva Hospitals 21
Compliance and Professional Activity
N Opportunities Compliance
Nurse (520) 1875 ( 66 %) 52 %
Student nurse (48) 131 (4.7 %) 43 %
Nurses' aide (166) 378 (13 %) 47 %
Mid-wife (14) 35 (1.3 %) 66 %
Physician (158) 281 (10 %) 30 %
Phys/Resp therapist (23) 48 (1.7 %) 28 %
Radiology Techinician (4) 12 (0.4 %) 8 %
Others (58) 74 (2.7 %) 27 %
TOTAL 2,834 (100 %) 48 %
Pittet et al, Ann Intern Med 1999, 130:126
UPCIUniversity of Geneva Hospitals 22
Non-Compliance with handhygiene, HUG 1994
250
0
25
50
75
100
50 75 100Opportunities for hand hygiene per hour of care
Com
plia
nce
with
han
d hy
gien
e (%
)
When the number of opp> 10 per h,compliance decreaseson average by 5 % ( + 2% ) per 10 opp/h of care
opp > 10 per hour of care
Pittet et al, Ann Intern Med 1999, 130:126
Time constraint is themain explanatory factor
UPCIUniversity of Geneva Hospitals 23
Compliance and HospitalDepartment
Departement Opportunities (%) Compliance
Pediatrics 133 (4.7 %) 59 %
Medicine 1114 ( 39 %) 52 %
Surgery 990 ( 35 %) 47 %
Obs / Gyn 147 (5.2 %) 48 %
ICUs 450 ( 16 %) 36 %
Pittet et al, Ann Intern Med 1999, 130:126UPCIUniversity of Geneva Hospitals 24
Opportunities for hand hygiene per patient-hour of care8 12 16 20
35
45
55
65
ICU
surgery
medicine
ob / gyn
pediatrics
Com
plia
nce
with
han
d hy
gien
e (
, %
)
Relation between opportunities for hand hygiene for nurses and compliance across hospital wards
adapted from Pittet D et al. Annals Intern Med 1999; 130:126
On avearge,22 opp / hourfor an ICU nurse
UPCIUniversity of Geneva Hospitals 25
Observed reasons for not washinghands
Time and system constraints
• High demand for hand hygiene isassociated with low compliance
• Full compliance with conventialguidelines may be unrealistic
Voss and Widmer - Inf Control Hosp Epidemiol 1997; 18:205Pittet et al, Annals Intern Med 1999; 130:126
Yes or No ?
Time constraint is a majorobstacle for hand hygiene …
Would it be possible to bypass
the time constraint ?
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Time constraint = major obstacle for hand hygiene
handwashinghand antisepsis
1 to 1.5min
alcohol-basedhand rub
15 to 20sec
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Efficacy of hand hygiene products
True or False ?
Alcohol-based handrub is moreefficacous than handwashingwith medicated soap
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-4
-3.5
-3
-2.5
-2
-1.5
-1
-0.5
0 Soap Iodophor 4% CHG 70% Alcohol
Ayliffe GAJ et al. J Hosp Infection 1988;11:226
Efficacy of hand hygiene productsLog reduction in bacterial counts after 30 sec
UPCIUniversity of Geneva Hospitals 31
Advantages of alcohol-based handantisepsis vs. handwahsing
• Faster and of greater efficacy than soap &water handwashing
• Improved accessibility· No sinks (plumbing) required· In rooms, corridors, nursing stations
• Effective against wide array of organisms,including multi-drug resistant pathogens
Pittet et al, Ann Intern Med 1999 - Boyce, ICHE 2000 - Pittet, ICHE 2000
True or False ?
Successful hand hygienepromotion is an impossible task
UPCIUniversity of Geneva Hospitals 33
Hôpitaux Universitaires de Genève
UPCIUniversity of Geneva Hospitals 34
Objective
• To assess the effectiveness of a
hospital-wide campaign to
promote hand hygiene with an
emphasis on bedside handrub
UPCIUniversity of Geneva Hospitals 35
Design and Intervention
• Seven observational, hospital-widesurveys conducted on a bi-annual basisfrom December 1994 to December 1997
• Hospital-wide promotion of hand hygienewith a particular emphasis on handrubbing
• Talking walls figuring the importance ofhand hygiene associated withperformance feedback
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Alcohol-basedhand rub
Before and after any patient contBefore and after glove use
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BEFORE AFTERUPCIUniversity of Geneva Hospitals 38
«�Talking walls�»
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My son,if they don’t get me,you will become multiresistant
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UPCIUniversity of Geneva Hospitals 42
UPCIUniversity of Geneva Hospitals 43
Doctor, in this hospital,it becomes impossible to cause infections as we want !
The University of GenevaHospitals
against DIRTY STAPH :war has started
UPCIUniversity of Geneva Hospitals 44
Outcome measures
• The main outcome measure was overallcompliance with hand hygiene
Confounding variables included
professional activity, hospital ward, time ofthe day/week, type and intensity of patientcare at time of observation, and the use ofstandard handwashing with unmedicatedsoap and water or hand rub
UPCIUniversity of Geneva Hospitals 45
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
UPCIUniversity of Geneva Hospitals 46
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312 UPCIUniversity of Geneva Hospitals 47
UPCIUniversity of Geneva Hospitals 48
Pittet et al. Lancet 2000 356:1307
Beliefs or Science ?
Alcohol-based handrub canbypass the time constraint
UPCIUniversity of Geneva Hospitals 50
Time constraint is high in the ICU and bugs are everywhere UPCIUniversity of Geneva Hospitals 51
Trends Trends overover time in time in compliance withcompliance with handhandhygienehygiene in in ICUsICUs, 1994-1997, 1994-1997
33 33
5
22
0
10
20
30
40
50
60
1 2 3 4 5 6 7
Hand rubHandwashing
HD: p< .0001
Overall: p< .0001
Study period (Dec 94-June 97)
Com
plia
nce
%
Hugonnet, Perneger, and Pittet - Arch Intern Med 2002, 162:1037
UPCIUniversity of Geneva Hospitals 52
Relation between workload andRelation between workload andcompliance with handwashing vs.compliance with handwashing vs.handrubbing in ICUshandrubbing in ICUs
Com
plia
nce
%
Workload (nber opportunities per hour)1500 50 100
0
50
100 Handwashing Hand rub use
0 50 100 150
0
50
100
p < .001 p = .12
Adapted from Pittet D et al, Lancet 2000; 356: 1307-1312Hugonnet S et al, Arch Internal Med 2002; 162:1037-1043
Beliefs or Science ?
Improved compliance with handhygiene decreases nosocomialinfections
UPCIUniversity of Geneva Hospitals 54
Compliance with hand hygiene,HUG 1994-1998
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
UPCIUniversity of Geneva Hospitals 55
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
Hospital-wide nosocomial infections;trends 1994-1998
UPCIUniversity of Geneva Hospitals 56
UPCIUniversity of Geneva Hospitals 57
MRSA spread is essentiallyvia the hands of healthcare workers...Thus, it can be stopped
Hand rub
UPCIUniversity of Geneva Hospitals 58
Pittet et al. Lancet 2000 356:1307
Trends in prevalence of nosocomial infectionsand MRSA cross-transmission, HUG 1993-1998
UPCIUniversity of Geneva Hospitals 59
Conclusions
• The campaign resulted in a sustained andsignificant improvement in compliance withthe rules of hand hygiene
• Promotion of alcohol-based hand rub wasresponsible for more active augmentationin compliance
• We observed a parallel decrease ofnosocomial infection rates
True or False ?
Hand hygiene promotion is costly
UPCIUniversity of Geneva Hospitals 61
Objective
• To evaluate the cost-effectiveness of thesuccessful hand hygiene promotioncampaign
• Setting: University of Geneva Hospitals,Geneva, Switzerland
www.hopisafe.ch
Pittet D et al, Lancet 2000; 356: 1307-1312
UPCIUniversity of Geneva Hospitals 62
Direct costs
• Artist work
• Color posters’ reproduction
• Creation / refreshments of «TalkingWalls»
• Food during monthly meetings of theTeam Performance
• Office supplies
UPCIUniversity of Geneva Hospitals 63
Indirect costs (Personnel time)
• Team Performance (~40 individuals)
• Preparation of the Talking Walls (painter)
• Housekeeping time (poster renewal)
• Infection control team (PCI) time• Nurse 10%
• Hospital epidemiologist 5 %
• Support team 2%
• Observation sessions and feedback
• Extra nurse for 4 months at beginning
UPCIUniversity of Geneva Hospitals 64
Outcome indicators
• Annual nosocomial infection (NI)rates assessed by repeatedprevalence surveys
• Overall consumption of handrubsolution from 1993 to 2001
• Additional use of handrub, from 1995• Adjustment for hospital
demographics, 1993-2001UPCIUniversity of Geneva Hospitals 65
0
5
10
15
20
25
30
35
Liters
1 2 3 4 5 6 7 8 9
Year
Use of alcohol-based hand rub, HUG 1993-2001
75 75 mL pocket mL pocket--sized bottlesized bottle,, introduced introduced in 1996 in 1996100100 mL bedside bottle mL bedside bottle,, used since used since 1970 1970 at at HUG HUG
1993 1994 1995 1996 1997 1998 1999 2000 2001
Baselineuse beforepromotion
Hand rubpromotion
UPCIUniversity of Geneva Hospitals 66
0
50
100
150
200
250
300
350
Swiss francs (CHF)
1 2 3 4 5 6 7 8 9
Year
Hand rub use: cost per 100 admissions
93 94 95 96 97 98 99 00 01
AnAn average average of US$ of US$ 1.221.22 per admission per admission since since 1995 1995
CostCost per admission in 2001 : US$ per admission in 2001 : US$ 1.961.96
Change rate: US$ 1 ~ CHF 1.65
UPCIUniversity of Geneva Hospitals 67
0
50000
100000
150000
200000
250000
300000
350000
400000
1 2 3 4 5 6
Hand hygiene promotion campaign, HUG 1995-2001Direct and indirect costs of intervention
1995-1997 1998 1999 2000 2001
Direct costs
Indirect costs
UPCIUniversity of Geneva Hospitals 68
1 2 3 4 5 6
S1
S30
50000
100000
150000
200000
250000
300000
350000
400000
1995-97 1998 1999 2000 2001
Total costs Direct costsIndirect costs
SwissfrancsCHF
Hand hygiene promotion campaign, HUG 1995-2001Overall costs of intervention
US$ 224’165
US$ 64’992
US$ 79’112
US$ 100’673
US$ 108’945
Total costs : US$ 577’889Average : US$ 82’555 per year
UPCIUniversity of Geneva Hospitals 69
02000000400000060000008000000
10000000120000001400000016000000
US$
1 2 3 4 5 6 7 8
Years
Cost comparison: nosocomial infections vs. hand hygiene promotion campaign, HUG 1994-2001
S?rie1
S?rie2
1994 1995 1996 1997 1998 1999 2000 2001
Costs of NI Costs of hand hygiene
UPCIUniversity of Geneva Hospitals 70
02000000400000060000008000000
10000000120000001400000016000000
US$
1 2 3 4 5 6 7 8
Years
Cost comparison: nosocomial infections vs. hand hygiene promotion campaign, HUG 1994-2001
S?rie1
S?rie2
1994 1995 1996 1997 1998 1999 2000 2001
Costs of NI Costs of hand hygiene
This slide is neither a
mistake,
nor a joke
UPCIUniversity of Geneva Hospitals 71
02000000400000060000008000000
10000000120000001400000016000000
US$
1 2 3 4 5 6 7 8
Years
Cost comparison: nosocomial infections vs. hand hygiene promotion campaign, HUG 1994-2001
S?rie1
S?rie2
1994 1995 1996 1997 1998 1999 2000 2001
Costs of NI Costs of hand hygiene
NI rates
UPCIUniversity of Geneva Hospitals 72
0
5000000
10000000
15000000
20000000
25000000
30000000
US$
1 2 3 4 5
Cost comparison: nosocomial infections vs. hand hygiene promotion campaign, HUG 1999-2001
1
2
3
4
5
Average Average infection rate, 1999-2001 : 9.7 per 100 admissionsinfection rate, 1999-2001 : 9.7 per 100 admissionsEstimates Estimates of of US$US$ 28.9 28.9 mio from nosocomial mio from nosocomial infectionsinfectionsTotal Total costs costs of of US$US$ 0.29 0.29 miomio for for hand hygiene hand hygiene promotion promotion
Costs of NI Costs of hand hygiene
X 100
US$ 28.9 mio
US$ 0.29 mio
UPCIUniversity of Geneva Hospitals 73
Conclusions• The total costs of the campaign averaged
US$ 82’555 per year; US$ 1.62 per admission• in 2001; it reached US$ 2.30 per admission• while indirect costs remained stable, direct
costs increased, in particular because ofincreased use of alcohol-based handrub thatreached US$ 1.96 per admission in 2001 (85% oftotal costs)
• Costs of hand hygiene promotion includinghandrub use corresponded to ~ 1% ofcosts attributable to NI in a large teachinginstitution UPCI
University of Geneva Hospitals 74
We can do it
UPCIUniversity of Geneva Hospitals 75
You cando ittoo …
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Rubhands …it savesmoney
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Handwashing …an action of the past(except when hands are soiled)
Alcohol-basedhand rubis standard of care
Hand hygiene:
compliance
and how to get things done
True or False ?
Poor compliance should beviewed only as a problematicindividual behavior
UPCIUniversity of Geneva Hospitals 80
Hand Hygiene (HH) Pittet - Infect Control Hosp Epidemiol 2000
Factors associated withnoncompliance
Individual level• lack of education / experience• being a physician• male gender• lack of knowledge of guidelines• being a refractory noncomplier
Group level• lack of education / performance feedback• working in critical care (high workload)• downsizing / understaffing• lack of encouragement from key staffs
UPCIUniversity of Geneva Hospitals 81
Institutional level• lack of guidelines (written)
• lack of administrative leadership / sanction /rewarding / support
• lack of available / suitable HH agents
• lack of skin care promotion / agent
• lack of HH facilities
• lack of culture / tradition of compliance
Hand Hygiene (HH) Pittet - Infect Control Hosp Epidemiol 2000
Factors associated withnoncompliance
True or False ?
Parameters for successful handhygiene promotion are many
UPCIUniversity of Geneva Hospitals 83
Parameters associated withsuccessful hand hygiene promotion
1. Education yes
2. Routine observation + feedback yes
3. Ingeneering control
Make HH possible, easy, convenient yes
4. Patient education no
5. Reminders in the workplace yes
6. Administrative sanction / rewarding no
... usedin Geneva
UPCIUniversity of Geneva Hospitals 84
7. Change in HH agent
8. Promote / facilitate HCW’s skin care
9. Obtain active participation at individual and institutional level
10. Obtain / drive an institutional safetyclimate
11. Enhance individual and institutitionalself-efficacy
12. Use a multimodal strategy
no
yes
yes
?
may be
yes
... usedin Geneva
Parameters associated withsuccessful hand hygiene promotion
UPCIUniversity of Geneva Hospitals 85
Possible reasons for successful promotion
• Make hand hygiene possible in a timely fashion
• Observation and performance feedback
• Multimodal / multidisciplinary approach:– communication and education tools
– reminders and performance feedback
– active participation at individual level
– active participation at institutional level
– make hand hygiene compliance an institutional priority
– enhance the image of the institution
– enhance the sense of individual / collectivecommittment
– enhance self-efficacy and perception to health threat UPCIUniversity of Geneva Hospitals 86
Each poster was createdby the artist in wardswith the collaborationof ward nurses and physicians
Text and wording werereviewed by a team ofrepresentative HCWs atHUG(Team Performance)
Each poster carried the nameof the ward that had proposedthe message
UPCIUniversity of Geneva Hospitals 87
UPCIUniversity of Geneva Hospitals 88
UPCIUniversity of Geneva Hospitals 89
Sweet home
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