andreas f. widmer, online author md,ms core member of who

Hand hygiene technique:why you should care!

Andreas F. Widmer, MD,MS

Infection Control Program Basel, SwitzerlandCore member of WHO Collaborating Center on Patient Safety

Geneva SwitzerlandDeputy Chief of Division of Infect Dis & Hosp Epidemiol Basel

Basel, Switzerland

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No conflict of interest to reportconcerning this talk

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Hand wash with unmedicated soap Hand wash with medicated soap(hand antisepsis)

Hand rub(waterless alcoholic compound)

Hygienic hand wash or rub

Hand hygiene

Surgical scrub with medicated soap Surgical hand rub(waterless alcoholic compound)

Surgical scrub

Classification of Hand Hygiene

Widmer AF. Clin Infect Dis 2000:31:136-143Trampuz A & Widmer AF. Mayo Clin.Proc. 2004;79 (1):109-116ESCMID

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• Transient FloraMicrobial uptake from the environment or patient contact

Elimination of transient flora- Hygienic hand disinfection (handrub) or- Hygienic handwashing

• Resident floraMicroorganisms permanently colonizing the skin

Elimination of transient flora and Reduction of resident floraEffective against regrowth- Surgical handrub or - Surgical handwashing

Classification of Hand Hygiene

Widmer AF. Clin Infect Dis 2000:31:136-143Trampuz A & Widmer AF. Mayo Clin.Proc. 2004;79 (1):109-116

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Hygienic Hand Antisepsis

Resident Flora• Coagulase-negative staphylococci• Propionibacterium spp• Corynebacterium spp• Bacilli

Transient Flora• Bacteria from patient care and/or

hospital flora

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Removal / Killling oftransient microorganismse.g. E.coli, P.aeruginosa


Hygienic hand antisepsis

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Surgical Hand Antisepsis

Surgical hand antisepsisRemoval / Killling of

transient microorganismse.g. E.coli, P.aeruginosaAND Reduction of resident microfloraSuch as CNS, Propionbact,

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3 hours afterSurgicalHand Antisepsis

Surgical Hand Antisepsis

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Opportunities for hand hygiene per patient-hour of care 8 12 16 20

35

45

55

65

ICU

surgery

medicine

ob / gyn

pediatrics

Com

plia

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with

han

d hy

gien

e (

, %

)Relation between opportunities for hand hygienefor nurses and compliance across hospital wards

adapted from Pittet D et al. Annals Intern Med 1999; 130:126

On average,22 opp / hourfor an ICU nurse

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Voss A, Widmer AF. Infect Control Hosp Epidemiol 1997;18:205-208

Handwashing Versus Alcoholic Rub

handwash

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Pittet and Boyce, Lancet Infectious Diseases 2001, April, 9-20

Average duration ofhand hygiene by HCW

(HW)

(HR)HW

HR

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WHO Update Juni 07

Chair: Didier Pittethttp://www.who.int/patientsafety/en/

Widmer AF. Surgical Hand Hygiene in:WHO Guideline for Hand Hygiene 2009Widmer AF. J Hosp Infect 2009Tschudin & Widmer. Crit Care Med 2010Tschudin & Widmer. Infect Control Hosp Epidemiol 2010Widmer AF. Amercian Soc iety for Microbiology 2011

Technique of the Alcoholic hand rubWidmer AF. ESCMID Milan, Italy 2011Widmer AF. Infect Control Hosp Epidemiol 2004Widmer AF. Infect Control Hosp Epidemiol 2007

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Videos in clinical medicine. Hand hygiene.Longtin Y, N Engl J Med. 2011 Mar 31;364(13):e24

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Weber W. Marti W. & Widmer AFInfect Control Hosp Epidemiol 2009

Widmer AF. WHO Guideline on Surgical Hand AntisepsisWidmer AF. J Hosp Infect 2009

N=32 in each group

A Clinical Cross-Over Trial on Surgical Hand Rub: 1.5 vs 3 minutes

n=32 (sample: n=64)

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G. Kampf, S. Marschall, S. Eggerstedt, and C. Ostermeyer. Efficacy of ethanol-based hand foams using clinically relevant amounts: a cross-over controlled study among healthyvolunteers. BMC.Infect.Dis. 10 (1):78, 2010.

Correlation between the applied amount of 62% ethanol foam and the time required for hands to feel dry;

the red arrow indicates the intercept between a drying time of 30 s and the corresponding weight of foam.

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Question 1

• The following statement is true (choose 1)

1. The technique of hand rub should be checked by on-site checks by observers

2. The technique can be checked under UV light byadding a fluorescent dye to the alcholic hand rub

3. The technique does not matter, and monitoringbasically waste of time

4. Technique does not matter, as long as 10mL of thealcoholic hand rub is applied

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Question 1Widmer AF

• The following statement is true

1. The technique of hand rub should be checked by on-site checks by observers

2. The technique can be checked under UV light byadding a fluorescent dye to the alcholic hand rub a

3. The technique does not matter, and monitoring wasteof time

4. Technique does not matter, as long as 10mL of thealcoholic hand rub is applied

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- Improved fluorescent non-staining dye in commercial product, - no detectable inhibition with antimicrobial efficacy

Camera:- DV 3 CCD- XGA beamer

Patent™ AF WidmerNon-profit commercialized box made in Switzerland

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Question 2Widmer AF

• The following statement is true (choose 1)

1. Visual assseement of missed areas of the hand rubunder UV light is reccomended as training, but has a poor correlation with antmicrobial killing

2. Visual assessment under UV light is recommended, but requires 15 minutes per individual

3. Visual assessment is optimized by immersing the handin a fluorescent dye bath

4. Visual assseement of missed areas of the hand rubunder UV light correlates well with antmicrobial killing

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Question 2Widmer AF

• The following statement is true

1. Visual assseement of missed areas of the hand rubunder UV light is reccomended as training, but has a poor correlation with antmicrobial killing

2. Visual assessment under UV light is recommended, but requires 15 minutes per individual

3. Visual assessment is optimized by immersing the handin a fluorescent dye bath

4. Visual assseement of missed areas of the hand rubunder UV light correlates well with antimicrobialkillingESCMID

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Variable Distribution Mean log10 CFU reduction factor

p-value

Age group

< 25 0%

26-35 25.0 % 1.82 ± 0.95

36-45 38.3 % 1.89 ± 0.91

> 45 35.0 % 2.34 ± 0.95 0.244

Sex femalemale

55%45%

1.92 ± 0.892.24 ± 0.90

0.18

Job description

Infection Control Practitioner 21.7% 1.99 ± 1.15

Physician 73.3% 2.05 ± 0.85

Other / no data (n=2) 5% 1.63 ± 1.26 0.65

Skin diseasenot present present

95%5%

2.60 ±1.071.20 ± 0.93 0.28

Results of testing 60 ICPs during the SHEA-ESGNITraining course in hospital epidemiology

Widmer AF. I Infect.Control Hosp.Epidemiol. 2004;25:207

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Years of infection control experience Distribution Mean log10 CFU reduction factor

p-value

None 5.0% 1.3 ± 1.05

> 1 year 1.7% 1.54

1-5 years 11.7% 1.50 ± .0.84

5-10 years 18.3% 1.94 ± .0.90

> 10 years 63.3% 2.17 ± 0.96 0.03Country of origin

Scandinavian countries / the Netherlands 21.7 1.85 ± 1.02

France / Spain / Italy 5.0 2.67±.0.32

Switzerland/ Germany and other European countries 58.3 2.03 ±.0.92

Asia / Africa 3.3 2.79 ± .0.12

Others 11.7 1.80 ± 1.07 0.35

Participant’s type of hand hygiene at their institution

Handwashing with plain soap 36.7% 2.05 ± 0.87

Handwashing with antimicrobial soap 16.7% 1.95 ± 0.82

Any alcohol rub-in 45.0% 2.04±1.04 0.49

No data provided 1.7

Wearing a ring during test

No 35.0 2.18 ± 1.03

Noble metal 56.7 1.94 ± 0.86

Fashion jewelry 6.7 1.94 ± 1.17 0.69

Widmer AF. I Infect.Control Hosp.Epidemiol. 2004;25:207

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Correlation between optical scores and antimicrobial killing (log CFU killing)

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1

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2

2.5

5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Points by Optical Observation

Log1

0 C

FU R

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R2=0.89

Widmer AF. ICHE 2004;25:207ESCMID O

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Does training really make a difference ?a prospective study in a single institution

• 400 bed geriatric university affiliated hospital• Contract for IC in 2000• 183 HCWs • All HCW completed a one hour training in 2001 after baseline

testing was completed• Complete data from the questionnaire, visualization test and

microbiological results of 178 (97%) HCWs were available for analyses

• No side effect was observed

AF. Widmer Infect.Control Hosp.Epidemiol. 28 (1):50-54, 2007.ESCMID O

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RESULTS – 1Univariate Analyses

Before Training After Training Odds Ratio

p value

% correct % correct2 Pumps (3ml) 54% 90% 7.5 p< 0.000Application for 30s 61.40% 85.50% 3.7 p < 0.000

Proper methodology 31% 73.60% 6.1 p< 0.001

Wearing no ring 47.10% 39.10% 1.13 P= 0.28

Reported skin diseases / allergies

12.9& 15.50% 0.8 p=0.8


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RESULTS – 2Univariate Analyses

Before Training After Training

Reduction factormean ±SD

Reduction factorMean ± SD

p value

Overall 1.47 ± 0.93 (0.11) 2.19 ± 0.86 (0.83) p< 0.0002 pumps (3mL) 1.49 ± 0.98 (0.15) 2.04 ± 0.92 (0.079) p < 0.000Application for 30s 1.56 ± 0.95 (0.08) 2.01 ± 0.95 (0.14) p< 0.014

Proper methodology 1.66 ± 1.02 (0.11) 2.01 ± 0.87 (0.08) p= 0.002

Wearing no ring 1.80 ± 1.0 (0.12) 1.97 ± 0.93 (0.91) p= 0.40

Gender 1.93 ± 0.86 (0.13) 1.90 ± 0.99 (0.08) p= 0.86

Reported skin diseases / allergies

1.89 ± 0.94 (0.07) 1.99 ± 1.04 (0.20) p= 0.10


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Impact of Education on the Microbiological effectivenes of the alcoholic hand-rub

• Setting

400 bed geriatric hospital. No infection control in 2001

•N Mean STD SEM p.-value

• LOGREDF logCFU10

before education (2001) 70 1,4749 ,93923 ,11226• After education (2002) 108 2,1927 ,86689 ,08342 p<0.001

Widmer AF. Infect.Control Hosp.Epidemiol. 25 (3):207-209, 2004.Widmer AF Infect.Control Hosp.Epidemiol. 28 (1):50-54, 2007.ESCMID

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Impact of Training on the Efficacy of the alcoholic Hand-rub (n=178)

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1.5

2

2.5

3

5 4.5 4 3.5 3 2.5 2 1.5 1 0.5 0

Points by Optical Observation

Log1

0 C

FU R

educ

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P<0.001

After training

Before training

Widmer AF. Infect.Control Hosp.Epidemiol. 25 (3):207-209, 2004.Widmer AF Infect.Control Hosp.Epidemiol. 28 (1):50-54, 2007.ESCMID

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Influence of Training in Medical School

Tschudin S. & Widmer AF. Infect Control Hosp Epidemiol 2010Tschudin S. & Widmer AF. Crit Care Med 2010

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Question 3Widmer AF

• The following statement (s) is /are true (one or moreanswers is/are correct

1. Training of hand hygiene technique requiresapproximately 12 hours over 3 months

2. Training of hand hygiene technique requires 1 hours/ individual

3. Once implemented, Health care workers continue toimprove without standardized training sessions

4. Training sessions can be avoided by using selectedcommercially available hand alcoholsESCMID

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Question 3Widmer AF

The following statement (s) is /are true (one or moreanswers is/are correct

1. Training of hand hygiene technique requiresapproximately 12 hours over 3 months

2. Training of hand hygiene technique requires 1 hours/ individual

3. Once implemented, Health care workers continue toimprove without standardized training sessions

4. Training sessions can be avoided by using selectedcommercially available hand alcoholsESCMID

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NFT

Compliance Hand hygiene University of Basel Hospitals Feb - March 2011 (n=1151) [ >5000 2009-2011]

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Pilot study on Hand Hygiene Technique

• Trained observer• Observation Mo to Sat

– No sundays– No night shifts

– Observation in all wards including• ICUs • ER, • Transplant units

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Age and profession

69.4

16.614.0

NursesPhysiciansOthers

Widmer AF. ESCMID Milan 2011

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Nurses MDs Other total

WHO Technique (all 6 steps)

Compliant (n=) 101 15 30 146

% Compliance 12.4% 7.7% 18.2% 12.4%

Total observation 815 195 165 1175

Compliance with the WHO Protocol forthe alcoholic hand rub

Pilot study at the University of Basel

Widmer AF. ESCMID Milan 2011

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The WHO technique in vivo-test with different application times

Superimposed untreated skin areas of 15 volunteers who performed each of the six rub-in steps for hygienic hand disinfection once; median duration: 17 seconds.

Black areas: not in contact with rub (%)

Kampf G. BMC Infect Dis. 2008; 8: 149.

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The WHO technique in vivo-test 17, 40, 70 seconds.

Superimposed untreated skin areas of 15 volunteers who performed each of the six rub-in steps for hygienic hand disinfection once;

Black areas: not in contact with rub (%)Kampf G. BMC Infect Dis. 2008; 8: 149.

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Duration and quality of coverage of the WHO Hand hygiene techniques

Type ofhand rub

Repetitions of six

steps (n)

Duration (median)

Duration (mean)

Location of untreated skin areas

Areas (%) of hand not in contact with alcoholic hand rub

Whole hand

Palmar side

Dorsal side 0% < 5% 5% – 15% > 15%

PBHR* 1 17 s 16.7 s 100% 20% 100% 0% 7% 40% 53%

PBHR 2 23 s 24.7 s 93% 53% 87% 13% 40% 20% 27%

PBHR 3 25 s 25.7 s 93% 20% 93% 7% 67% 27% 0%

PBHR 4 35 s 34.9 s 87% 33% 80% 20% 53% 7% 20%

PBHR 5 40 s 37.3 s 67% 13% 67% 33% 53% 13% 0%

Reference alcohol 5 (twice) 70 s 74.8 s 53% 7% 53% 47% 47% 7% 0%

Kampf G. BMC Infect Dis. 2008; 8: 149.

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CONCLUSIONS

• Compliance with hand hygiene remains a keyissue of any infection control

• Technique of hand hygiene is poor at USB despite high compliance (>70% overall)

• Teaching of medical students and nurses in training over the last 5 years imiproved, but didnot yet result in acceptable techniques to applyhand rub.

• Hand Hygiene technique should become a n equal priority as did compliance/adherence in the pastESCMID

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Hand of Fame: Individuals with excellent techniquesThe Basel Hollywood for Infection Control

2011WHO Handhygiene Day

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Society for Heatlhcare Epidemiology of AmericaEuropean Study group on Nosocomial InfectionsSwiss Society for Hospital Epidemiology

Course in Hospital Epidemiology and InfectionControl

3.-6. Sept 2011 Brunnen / SwitzerlandChair: Widmer AF

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andreas f. widmer, online author md,ms core member of who

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