outcomes…. skin condition time required hand microbiology preference
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Outcomes….
• Skin condition
• Time required
• Hand microbiology
• Preference
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Data Collection
Microbiological Assay
Diary Card
mon 4 4 3tue 3 4 2
Day # scrubs hrs.surg. hrs. glove
wedthurfri
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Data Collection: Scrub Practices
61 Random Observations
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Skin Condition
• Nine ratings during each phase for self-assessment, scaling and erythema
• Skin damage significantly reduced during HP testing period (p=0.0005)
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Time Required
• 61 observations of scrub technique (31 for HP, 30 for TSS)
• Direct contact time less for HP product (79.1 vs. 146.6 secs, p=0.000)
• Protocol deficiencies fewer for HP (6.5% vs. 50%, p=0.0001)
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Hand Microbiology
• Pre- and post-scrub cultures obtained on Day 1, 5, and 19 during both phases
• 33 isolates of GNB (83.7% Acinetobacter, Enterobacter, Klebsiella), 1 S. aureus, 11 yeast
• No MRSA or VRE
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Post-Scrub Microbial Counts
00.5
11.5
22.5
33.5
44.5
Log
CF
U
Day 1 (p=.054) Day 5 (p=.002) Day 19 (p=.02)
TSSHP
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Preferences
010203040506070
Per
cen
t
Easier(p=.000)
Faster(p=.000)
Milder(p=.000)
Gloving(p=.03)
Prefer(p=.001)
TSSHP
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Costs for ScrubbingLarson, AORN J, 2001; 73:412
• Traditional Scrub– ~$60.40/application – Mean time required:
6 mins total
• Alcohol Preparation– ~$20.50/application– Mean time required:
2 mins total
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Alc vs. Soap Zaragoza, AJIC, 1999; 27:258
• Mean reduction in counts:– plain handwashing: 49.6%– alcohol: 88.2% (p<.001)
• Staff acceptance rate “good”:– plain handwashing: 9.3%– alcohol: 72%
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Log Counts, 50 MICU Staff Larson, CCM, 2001
-0.5
-0.4-0.3
-0.2
-0.1
0
0.1
0.2
0.3
Day 1 Wk 2 Wk 4
AlcCHG
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Mean Skin Scaling Scores, 50 MICU Staff Larson, CCM, 2001
4.6
4.8
5
5.2
5.4
5.6
5.8
Day 1 (p=.35) Wk 2 (p=.01) Wk 4 (p=.0005)
ALC
CHG
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Improvement in Skin Condition Boyce, ICHE, 2000; 21:442
• After 2 wk use, with soap and water – more skin irritation (p=.001)
– more transepidermal water loss (p=.003)
• “Newer alcoholic hand gels that are tolerated better than soap may be more acceptable to staff and may lead to improved hand-hygiene practices.”
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Improvement in PracticeBischoff, Arch Intern Med 2000; 160:1017
05
101520253035404550
Bas
elin
e
Ed/
Fee
dbac
k
1:4
Rat
io
1:1
Rat
ioBefore Pt ContactAfter Pt Contact
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Improvement in PracticeMaury, Am J Resp Crit Care Med, 2000; 162:324
• Frequency of appropriate hand hygiene – Conventional handwashing
only: 42.4%
– Addition of alcohol rinse: 60.9% (p=.001)
– 3 months later: 51.3% (p=.007)
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Time and Costs Voss & Widmer, ICHE, 1997; 18:205
• 100% compliance with handwashing consumes 16 hr nursing time/day shift, whereas AHD requires 3 hr (p = .01)
• “AHD, with its rapid activity, superior efficacy, and minimal time commitment, allows 100% healthcare- worker compliance without interfering with the quality of patient care”
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Conclusions• Prolonged scrubbing
unnecessary and damaging
• Brush unnecessary and damaging
• Alcohol products warrant greater use
• Link with outcomes absent
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What About Moisturizers/Lotions?
• Prevent dehydration, damage to barrier properties, skin shedding, loss of skin lipids
• Restore water-holding capacity of keratin layer
• Increase width of corneocytes
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Moisturizers may even...
• Prevent cross-infection by improving barrier properties of skin, reducing shedding of viable bacteria, creating a mechanical or chemical barrier
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Therefore...
• Use lotions
• Recommend lotions
• But choose wisely
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Fall 2002
• Hand Hygiene Guideline For Healthcare Settings
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New emphases
• Skin health, including moisturizers
• Alcohol hand rinses
• Compliance issues
• Preoperative surgical hand preparation
• Fingernails
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Outcome/Process Measure
• Develop and implement a system for measuring improvements in compliance of healthcare workers with recommended hand hygiene practices. Examples are listed below.
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Examples of Measures– Monitor and record compliance as the number of hand
hygiene episodes performed by personnel/number of hand hygiene opportunities, by ward or by service. Provide feedback to personnel regarding their performance.
– Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used/1000 patient-days.
– Monitor the prevalence of personnel wearing artificial nails.
– When outbreaks of infection occur, assess the adequacy of healthcare worker hand hygiene.