Hand Hygiene and Infection Control What Happens Next

Hand Hygiene and Infection Control: What Happens Next? What Dr. Wenzel does not know and What Dr. Edmond will not tell you. Gonzalo Bearman MD, MPH Assistant Professor of Medicine, Epidemiology and Community Health Associate Hospital Epidemiologist Virginia Commonwealth University

Hand Hygiene and Infection Control: What Happens Next? What Dr. Wenzel does know and What Dr. Edmond will tell you. Gonzalo Bearman MD, MPH Assistant Professor of Medicine, Epidemiology and Community Health Associate Hospital Epidemiologist Virginia Commonwealth University

Infection Control Timeline Big Bang 10 billion and 20 billion years ago Hotel-Dieu : Paris hospital founded in the 7 th century Many years elapse 0 Circa 600 AD

Infection Control Timeline Segregation of Infectious Patients Leprosariums emerge in the Middle Ages Lazarettos for plague victims established in Venice in the 15 th century Fever hospitals established in England in the early 19 th century

History: Ignaz Semmelweis • At the Vienna Lying-in Hospital – Women who delivered on the street had less risk of developing puerperal fever – Much higher risk of puerperal fever in women delivered by physicians or medical students as opposed to those delivered by midwives • Required that hands be washed with chlorinated lime after autopsies & between exams of pregnant women – Maternal mortality decreased from 18% to 3%

History: Florence Nightingale and Louis Pasteur • Importance of unsanitary hospital conditions and post operative complications • Developed the germ theory of disease in the late 1800 s

History: Advances in Surgical Infection Control Joseph Lister introduced antiseptics in 1867 William Halstead introduced gloves in 1890 Johannes Mikulicz introduced masks in 1897

Infection Control Timeline: The Modern Era First antibiotics, sulfonamides & penicillin, developed in the late 1930 s Robert Haley, MD 1970’s SCENIC Study Hospitals with active infection control programs have a 32% lower incidence of nosocomial infections 1961: MB Edmond born R. P Wenzel MD, MSc 1980: Founded Society of Healthcare Epidemiology; applied epidemiologic techniques to infection control

So where are we now and what happens next?

Nosocomial Infections • 5 -10% of patients admitted to acute care hospitals acquire infections – 2 million patients/year – 70% are due to antibiotic-resistant organisms – ¼ of nosocomial infections occur in ICUs – 90, 000 deaths/year – Attributable annual cost: $4. 5 – $5. 7 billion • Cost is largely borne by the healthcare facility not 3 rd party payers Weinstein RA. Emerg Infect Dis 1998; 4: 416 -420. Jarvis WR. Emerg Infect Dis 2001; 7: 170 -173.

Shifting Vantage Points on Nosocomial Infections Many infections are inevitable, although some can be prevented Each infection is potentially preventable unless proven otherwise Gerberding JL. Ann Intern Med 2002; 137: 665 -670.

The medical literature is replete with studies identifying risk factors for nosocomial infections • Hand Hygiene • BSI – Catheter type, insertion, maintenance • VAP – Duration of intubation, gastric p. H, HOB elevation • UTI – Catheter use and insertion, maintenance

Sadly, we as medical professionals frequently do not practice well known nosocomial infection risk reduction practices

Pressure from legislatures, consumer groups, third party payers and regulatory agencies has resulted in mandatory public reporting of nosocomial infections This is now driving compliance with process of care measures that are associated with reductions in nosocomial infection risk

Help Consumers Union Stop Hospital Infections! Most people don't expect to go into a hospital and come out even sicker because of an infection they caught as a patient, but 1 in 20 do. And each year, about 90, 000 people die from hospital acquired infections - a leading cause of death in the U. S. The annual cost to our health care system is $5 billion. Congress is considering a bill that would let hospitals keep information about their infection rates and medical errors a secret. People should be able to find out whether their hospital is doing a good job of controlling dangerous infections. TAKE ACTION now to tell Congress to preserve state's rights to report on hospital infection rates. http: //www. consumersunion. org/pub/projectsandcampaigns. html

Status of Mandatory Reporting Legislation September 2005 Enacted legislation Legislation introduced, under review or further study Legislation died/defeated Source: APIC. Slide: courtesy of MB Edmond MD, MPH, MPA

Infection Control Process of Care Measures • Hand Hygiene • Contact Precautions – Gowns – Gloves • HOB elevation for VAP prevention • CVC insertion measures – – Avoidance of femoral site Maximal sterile barrier precautions Proper antisepsis of skin Prompt discontinuation of catheter use

30%-40% of all Nosocomial Infections are Attributed to Cross Transmission: The Importance of Hand Hygiene

The inanimate environment is a reservoir of pathogens X represents a positive Enterococcus culture The pathogens are ubiquitous ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

The inanimate environment is a reservoir of pathogens Recovery of MRSA, VRE, C. diff, CNS and GNR Devine et al. Journal of Hospital Infection. 2001; 43; 72 -75 Lemmen et al Journal of Hospital Infection. 2004; 56: 191 -197 Trick et al. Arch Phy Med Rehabil Vol 83, July 2002 Walther et al. Biol Review, 2004: 849 -869

Hand Hygiene Single most effective method to limit cross transmission Hand Hygiene Comment Typical Compliance Observational studies of hand hygiene report compliance rates of 5 -81% Common Insufficient time, understaffing, patient Reported Barriers overcrowding, lack of knowledge of hand To Compliance hygiene guidelines, skepticism about hand washing efficacy, inconvenient location of sinks and hand disinfectants and lack of hand hygiene promotion by the institution

HCWs' perceptions of compliance with infection control practices % of HCWs reporting compliance >80% Handwashing Contact isolation Airborne isolation 118 (36) 77 59 74 Resident physicians 99 (31) 62 61 92 Attending physicians 33 (10) 62 72 82 29 (9) 59 72 76 45 (14) 73 79 69 324 (100) 69 65 80 Position N (%) Registered nurses LPNs, patient care assistants Others Total Majority of respondents reported excellent compliance with IC practices Berhe M, Edmond MB, G Bearman in AJIC 33; 1 February 2005, 55 -57

Alcohol Based Hand Sanitizers • CDC/SHEA hand antiseptic agents of choice – Recommended by CDC based on strong experimental, clinical, epidemiologic and microbiologic data – Antimicrobial superiority • Greater microbicidal effect • Prolonged residual effect – Ease of use and application

Alcohol based hand hygiene Easy to use Quick: 5 - 15 seconds solutions Very effective antisepsis due to bactericidal properties of alcohol

Study Algorithm Incremental Increase in Alcohol Dispensers Hand Hygiene Educational Program Implemented Direct Observation of Hand Hygiene Arch Intern Med. 2000; 160: 1017 -1021.

Results Hand hygiene practice can be improved with education and greater accessibility of alcohol hand sanitizers • Improvement in Hand Hygiene Compliance Arch Intern Med. 2000; 160: 1017 -1021.

Hand Hygiene • Single most important method to limit cross transmission of nosocomial pathogens • Multiple opportunities exist for HCW hand contamination – Direct patient care – Inanimate environment • Alcohol based hand sanitizers are ubiquitous – USE THEM BEFORE AND AFTER PATIENT CARE ACTIVITIES

Hand Hygiene • HCW’s perceive that their hand hygiene practice is excellent – Observational data does not support this claim • New technologies such alcohol based hand sanitizers make the practice of hand hygiene simpler than ever – There is simply no excuse for poor hand hygiene compliance

Contact Precautions for drug resistant pathogens. Gowns and gloves must be worn upon entry into the patient’s room

Glove Use for Infection Control Variable Rationale Comment Prevent healthcare worker exposure to bloodborne pathogens Even with proper glove use, hands may become contaminated during the removal of the glove or with microtears that allow for microorganism transmission Gloves Prevent contamination of hands with drug resistant pathogens during patient care activities

Gown Use for Infection Control Variable Rationale Comment Gowns The use of gloves Several studies have and gowns is the convention for documented limiting the cross colonization of transmission of healthcare worker nosocomial apparel and pathogens, however, instruments during patient care activities the incremental benefit of gown use, without the use of in endemic settings, gowns may be minimal

What about the role of Universal Gloving For All Patient Care?

A Controlled Trial of Universal Gloving vs. Contact Precautions for Preventing the Transmission of Multidrug. Resistant Pathogens G. Bearman MD, MPH A. Marra, MD C. Sessler, MD W. R. Smith, MD R. P. Wenzel MD, MSc M. B. Edmond MD, MPH, MPA

Hypothesis • The effectiveness of universal gloving (use of gloves for all patient care activity) in preventing the transmission of multidrug-resistant pathogens will be greater than the effectiveness of contact precautions for the following reasons: – Compliance with universal gloving will likely be greater than compliance with contact precautions. Bearman et al.

• CDC/NNIS NI definitions applied; surveillance performed by VCUMC IC Department • Hand hygiene observations performed by trained observers • Active surveillance nasal and rectal cultures were obtained on all patients within the unit Bearman et al.

Methods • Microbiologic Data – One rectal swab culture performed for VRE and 1 nasal swab culture for MRSA performed on admission and every 4 days. • Once a patient was culture positive; then no further cultures were obtained for that organism. – Pulse field gel electrophoresis (PFGE) for genetic typing and antibiotic susceptibility testing were performed on all MRSA and VRE isolated after study was completed. Bearman et al.

Methods • Healthcare Questionnaire – Administered at the end of the study protocol • Target: MRICU Nurses and Attending Physicians – Focus: » self reported compliance with infection control practice » acceptability of universal gloving vs. standard of care. Bearman et al.

Methods Additional Data Elements: Phase I vs. Phase II Length of stay MRICU occupancy rate per month MRICU invasive devices utilization ratios Nurse to patient ratio Antibiotic usage: defined daily dose (DDD) Bearman et al.

Results: Variable Phase II P value Total patient days 1090 1377 - Total observations for IC compliance 1220 1102 - Total patients screened for VRE 192 257 0. 54 Total patients screened for MRSA 228 301 0. 60 Bearman et al.

Results: Hand Hygiene Compliance Phase I Variable Phase II N Obs % P-value Hand Hygiene before patient contact 228 18. 7 126 11. 4 <0. 001 Hand Hygiene after patient contact 704 57. 7 578 52. 5 0. 011 A statistically significant reduction in hand-hygiene was observed in phase II Bearman et al.

Results: Compliance with Contact Precautions vs. Universal Gloving Phase II N % P Compliance with gloving for patients on contact precaution 387 89. 4 N/A N/A Compliance with gowns for patients on contact precaution 335 77. 4 N/A N/A Gowns and gloves for patients on contact precaution 328 75. 7 N/A N/A Total Compliance: (Contact Precautions vs. Universal Gloving) 328 75. 7 959 87. 0 <0. 001 Variable Greater adherence during universal gloving was observed Bearman et al.

Results: VRE screening Variable Total Patients Screened for VRE Phase II P value 192 257 Patients VRE positive upon admission to ICU 3 (1. 5%) 3 (1. 1) 0. 70 Patients with VRE conversion during ICU stay 39 (20%) 35 (14%) 0. 31 8 9 0. 79 Days to acquire VRE (median) No difference was observed in the rate of VRE acquisition Bearman et al.

Results: MRSA Screening Variable Phase II P value 228 301 - Patients MRSA positive upon admission to ICU 11 (4. 8%) 6 (2. 0 %) 0. 11 MRSA conversion during ICU stay 13 (5. 7%) 15 (5. 0%) 0. 92 8 9 0. 95 Total Patients Screened for MRSA Days to acquire MRSA (median) Phase I No difference was observed in the rate of MRSA acquisition Bearman et al.

Results: MRSA PFGE MRSA Phase II Number of Strains 21 25 Conversion: negative to positive 13 13/13 clonal (100%) Type A 1, A 2, A 3, A 4 15 15/15 clonal (100%) Type A 1, A 5 PFGE Types A 1: 13/21 (62%) A 2: 5/21 (23%) A 3: 1/21 (5%) A 4: 1/21 (5%) B: 1/21 (5%) A 1: 18/25 A 5: 2/25 C: 3/25 D: 2/25 ( 72%) (8%) (12%) (8%) ALL MRSA conversions were with clonal isolates Bearman et al.

Results: VRE PFGE VRE Phase II Number of Strains 40 35 Conversion: negative to positive 39 20/40 clonal: (50%) Type A, B 35 28/35 clonal (80%) Type A, AB PFGE Types Type A: 16/40 (34%) Type B: 4/40 (11%) Type D: 2/40 Type G: 3/40 Type H: 2/40 Type J: 2/40 Type K: 2/36 Type C, E, I, L, M, Q, R S, T: 1 each 9/40 Type A: 18/35 (51%) Type AA: 4/35 (11%) Type AB: 4/35 (11%) Type H: 2/35 (6%) Types F, G, I, J, U, V, M: 1 each 7/35 (20%) Most VRE conversions were with clonal isolates

Results: Nosocomial Infections Rates Outcome Phase II P BSI/1000 catheter days 6. 2 14. 1 P<0. 001 UTI/1000 catheter days 4. 3 7. 4 P<0. 001 0 2. 3 P<0. 001 Pneumonia A statistically significant increase in NIs was observed Bearman et al.

Results: Nosocomial Infections Phase II Infection # Organisms BSI 5 P. aeruginosa (1) E. cloacae (1) K. pneumoniae (1) Prevotella species (1) C. glabrata (1) 16 Coag. negative staph (6) Enterococcal species (3) VRE (1) MRSA(2) P. aeruginosa (1) K. pneumoniae (1) C. parapsilosis (1) C. albicans (1) UTI 6 E. coli (2) E. cloacae (1) C. albicans (3) 9 Coag. negative staph (1) Enterococcal species (1) P. aeruginosa(2) E. coli (1) C. albicans (2) C. non-albicans (2) VAP 0 NA 2 MRSA(1) P. aeruginosa (1)

Results: Nosocomial Infections with VRE or MRSA Phase I Infection Phase II VRE MRSA BSI 0 0 1 2 UTI 0 0 VAP 0 0 0 1 4 VRE and MRSA infections were identified in Phase II

MRICU Demographics Phase II P value 5. 3 6. 8 0. 07 Average length of stay 87% 92% 0. 36 MRICU occupancy rate per month 1: 1. 9 NS Nurse to patient ratio Device utilization ratio Variable Phase II P Urinary Catheter 0. 85 0. 87 0. 83 Central line 0. 74 0. 72 0. 87 Ventilator 0. 56 0. 62 0. 47 Utilization ratio=device days/patient days

Results: Antibiotic Usage Defined daily dose (DDD/1000 patients-day) Antibiotic DDD Phase II P value B-lactams 391. 6 352. 9 0. 075 B-lactam/inhibitor 210. 1 211. 5 1. 0 Aminoglycosides 68. 2 118. 2 <0. 001 Glycopeptides 190. 1 226 0. 079 Metronidazole 127. 0 118. 6 0. 582 Quinolones 385. 7 359. 0 0. 206 Total 1372. 7 1386. 2 0. 806 The DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults Example: DDD of levofloxacin is 0. 5 grams, if 200 grams were dispensed in a period with 4, 500 patient days: (200 g/0. 5 g)/4, 500 pt days X 1000= 89 DDD/1000 PD

Results: Questionnaire about IC compliance During Universal Gloving Study • 34 respondents – 30 MRICU Nurses (45 eligible) – 4 Attending Physicians (7 eligible) • Overall survey compliance 65%

Results: Questionnaire about IC compliance Questionnaire Item: Proportion of respondents indicating that universal glove use was impractical 12% Proportion of respondents reporting good compliance with infection control measures 97% Proportion of respondents reporting good compliance with Hand hygiene 97%

Results: Questionnaire about IC compliance Questionnaire Item: Proportion HCWs reporting less frequent entry into a patient room because of contact precautions 48% Belief that proper glove use is more important than hand hygiene to limit the spread of nosocomial organisms 6% Belief that the use of gloves is associated with decreased risk of cross-transmission of nosocomial organisms 94% HCWs reporting no difference in skin problems (e. g. , chapping, dryness, cracking) 93%

Results: Questionnaire about IC compliance During Universal Gloving Study Overall better care is delivered when: Majority of respondents felt that better care was delivered during the Universal Gloving Phase of the study

Universal Gloving Conclusions • Observed compliance with universal gloving was significantly greater than compliance with contact precautions (gowns and gloves). • However, greater compliance with hand hygiene was observed in the standard of care phase. • No differences were detected between the two study phases for: – LOS, nurse: patient ratio, MRICU occupancy rate, invasive device utilization, and antibiotic usage

Universal Gloving Conclusions • No differences in VRE and MRSA colonization was observed between the two study phases. • In both phases, the majority of VRE and MRSA conversions were of a clonal isolate • However, an increase in nosocomial infection rates was observed during the universal gloving phase of the study • 4 VRE and MRSA nosocomial infections were observed during the universal gloving phase

Universal Gloving Conclusions • HCWs found gloving acceptable and believed that the use of universal gloving is associated with decreased risk of cross-transmission of nosocomial organisms • HCWs believed that better care was delivered under the universal gloving phase • Although universal gloving was highly accepted by the staff, its implementation should proceed with caution given the observed increase in nosocomial infection rates – The use of universal gloving may have lead to a misperception of decreased cross transmission risk – This may have lead to decreased hand hygiene compliance and a consequent increase in the rates of nosocomial infections

The importance of process of care measures in the reduction of nosocomial bloodstream infections

The risk factors interact in a dynamic fashion El Host The CVC is the greatest risk factor for Nosocomial BSI The CVC: Subclavian, Femoral and IJ sites The intensity of the Catheter Manipulation As the host cannot be altered, preventive measures are focused on risk factor modification of catheter use, duration, placement and manipulation

Prevention of Nosocomial BSIs • Limit duration of use of intravascular catheters – No advantage to changing catheters routinely • Maximal barrier precautions for insertion – Sterile gloves, gown, mask, cap, full-size drape – Moderately strong supporting evidence • Chlorhexidine prep for catheter insertion – Significantly decreases catheter colonization – Disadvantages: possibility of skin sensitivity to chlorhexidine

Eliminating catheter-related bloodstream infections in the intensive care unit – Purpose: – To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs) – Method: – Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. – Patients: – All patients with a central venous catheter in the ICU Pronovost et al. Crit Care Med. 2004 Oct; 32(10): 2014 -20.

Eliminating catheter-related bloodstream infections in the intensive care unit Interventions Staff Education Creation of a catheter insertion cart Example • All staff inserting central catheters were required to complete a web-based training program with post-test. • Central catheter insertion cart that contains all equipment and supplies • Reduced the number of steps required for compliance Pronovost et al. Crit Care Med. 2004 Oct; 32(10): 2014 -20.

Eliminating catheter-related bloodstream infections in the intensive care unit Promotion of daily catheter Removal Asked daily during rounds whether catheters or tubes could be removed Evidence based checklist CVC insertion and for BSI risk reduction Hand hygiene prior to procedure Chlorhexidine skin preparation Full-barrier precautions during CVC insertion Subclavian vein as the preferred site Maintenance of sterile field during procedure Nurse Empowerment Procedure aborted if a violation in compliance with evidence-based guidelines was observed SICU attending physician notified Pronovost et al. Crit Care Med. 2004 Oct; 32(10): 2014 -20.

Eliminating catheter-related bloodstream infections in the intensive care unit • Results: – During the first month nursing completed the checklist for 38 procedures: • Eight (24%) for new central venous access, • 30 (79%) for catheter exchanges over a wire, • Three (8%) were emergent. – Nursing intervention was required in 32% (12/38) of central venous catheter insertions Pronovost et al. Crit Care Med. 2004 Oct; 32(10): 2014 -20.

Eliminating catheter-related bloodstream infections in the intensive care unit BSI Rate 1 st quarter 1998 Study ICU BSI Rate 4 th quarter 2002 January 2003 April 2004 11. 3/1, 000 catheter days 0/1, 000 catheter 0. 54/1, 000 days catheter days No cr. BSI over 9 months Control ICU 5. 7/1, 000 catheter days 1. 6/1, 000 catheter days Multifaceted, comprehensive program requiring CVC insertion education, with safety checks for proper hand hygiene, aseptic insertion procedure and operator responsibility can result in reduction of nosocomial BSI in an ICU setting. Pronovost et al. Crit Care Med. 2004 Oct; 32(10): 2014 -20.

Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1, 2, Gonzalo Bearman MD, MPH 1, 2 Divisions of Infectious Diseases 1 and Quality Health Care 2 Department of Internal Medicine Virginia Commonwealth University School of Medicine Richmond, VA, USA

Measurement and feedback of infection control process measures in the intensive care unit: impact on compliance MRICU STICU Process Measure Baseline Q 2 -2004 Q 3 (2004) Q 4 (2004) Q 1 (2005) P value* Baseline Q 2 -2004 Q 3 (2004 Q 4 (2004) Q 1 (2005) P value* HH % Opp 14/44 (32%) 31/91 (37%) 33/91 (36%) 50/108 (46%) 0. 101 19/38 (50%) 42/80 (53%) 40/80 (50%) 49/100 (49%) 0. 916 HOB % Opp 28/51 (55%) 320/333 (96%) 450/454 (99%) 551/556 (99%) <0. 001 20/43 (47%) 229/3 07 (75%) 389/488 (79%) 275/361 (76%) <0. 001 Fem. CVC % of Days 195/1093 (18%) 130/769 (16%) 80/879 (9. 1%) 51/951 (5. 4%) <0. 001 93/1109 (8. 4%) 49/97 0 (5. 1% ) 14/1077 (1. 3%) 26/920 (2. 8%) 0. 01 Mezgebe Berhe MD 1, Mike Edmond MD, MHA, MPH 1, 2, Gonzalo Bearman MD, MPH 1, 2

Head of Bed Elevation in VCU Medical ICU: Effect of Feedback % Compliance with HOB elevation Pneumonia cases/1, 000 ventilator-days Baseline; no feedback Performance feedback quarterly Slide: courtesy of MB Edmond MD, MPH, MPA

Ask Yourself: • If other professions can impose much tighter regulations to minimize risks, should we do the same? • Are 3 -5 infections/ 1000 patient days acceptable? • Are we doing all that is possible to minimize risk? United States & Canada: accident rates as of 12. 31. 2004 Airline Rate Events No. Flights Air Canada 0. 63 3 4. 75 Million Alaska Airlines 0. 74 3 4. 05 Million Aloha Airlines 0. 49 1 1. 34 Million American Airlines/Eagle 0. 59 10 17. 0 Million Continental Airlines/Express 0. 63 5 8. 00 Million Delta Air Lines 0. 30 6 20. 0 Million http: //www. airdisaster. com/statistics/

Conclusion • Risk reduction strategies for the prevention of nosocomial infections are well defined in the literature – Lack of adherence to IC measures is recognized as important in the pathogenesis of NIs – Sadly, HCWs overestimate their degree of compliance with infection control measures • Pressure from legislatures, consumer’s groups, hospital administration, third party payers and regulatory agencies will result in the mandatory public reporting of nosocomial infections. – Drive increase compliance with process of care measures that are associated with reductions in nosocomial infection risk

Conclusion • System level changes involving the measurement and feedback of adherence to IC measures are needed to implement risk reduction strategies consistently – BSI: enforcement of comprehensive catheter use/care policies – VAP: HOB elevation – Hand hygiene- alcohol based sanitizers

“ I suppose that I shall have to die beyond my means” Oscar Wilde, upon being told the cost of an operation