CDC Hand Hygiene Guidelines, JCAHO, VA NCPS, NFPA, 3M Corp, and Six Sigma

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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

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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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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.htm
  l

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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

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Locations

• Patient care rooms
• Suites of rooms (ICU, Urgent Care, Radiology,
  etc.)
• Corridors that have gt72 of clear width if spaced
  at least 48 inches apart
• Corridors may not be carpeted unless sprinkler
  protected
• Dispensers may not project gt 6 into corridor
  egress width
• Not over, or adjacent to, ignition sources

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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

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3M Six Sigma Process

• Five Steps in Six Sigma Process
• Define
• Measure
• Analyze
• Improve
• 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
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Measure (DMAIC)

• What were 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

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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 isnt lunch
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Measure (DMAIC) Doses

• 15 oz. can yielded 204 doses in Noels 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

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Analyze (DMAIC)

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KEY PROBLEMs 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 what the
  requirements are communication of watcher
  results and product use provide evidence that
  outcomes can be improved
• Posters on how to remind how to reply system of
  reminders (lines on floor) directives, letters,
  binders, web sites ITS OKAY TO ASK!

• 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

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Improve (DMAIC) Usage
g


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Control (DMAIC) No backsliding!

• 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

• Posters up based on survey, FMEA, etc.
• patient care areas
• visitor waiting area
• staff-only area
• VAMC HH policy updated
• VAMC (annual) Staff Training updated
• VAMC New Employee orientation updated
• Information for Patients and Families (in
  admission folder)
• National Directive updated - based on CDC
  Guidelines and Dec 2003 USH memorandum

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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
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Final Thoughts

• History tells us at least one thing we know
  doesnt work Just telling people to
  frequently wash their hands with soap and
  water. Thats what resulted in 5 of inpatients
  with nosocomial infections.
• 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)

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If this cat can do this
You can tell anyone to decontaminate their hands!
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• I. All Health Care Workers With Direct Patient
  Contact
• 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.
• Put gloves on before you touch non-intact skin,
  blood, mucous membranes, or potentially
  infectious materials such as soiled linens.
• 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.
• 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.
• Healthcare workers that may have direct contact
  with patients at high risk for infection must not
  wear artificial fingernails.
• Wash your hands with soap and water if they are
  visibly soiled or contaminated with body fluids.
• Wash hands with soap and water after using a
  restroom.
• Wash hands with soap and water before eating.

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• II. Surgical Hand Hygiene
• Before donning sterile gloves for surgical
  procedures use either an antimicrobial soap or an
  alcohol-based hand-rub with persistent activity.
• When using an alcohol-based surgical hand-scrub
  product with persistent activity, follow the
  manufacturers 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.
• 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)
• Provide an alcohol-based hand-rub at the entrance
  to the patients 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).
• 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.
• Provide healthcare workers with hand lotions or
  creams to minimize irritant contact
  dermatitis.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.
• Store supplies of alcohol-based hand-rubs in
  cabinets or areas approved for flammable
  materials.

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• IV. Facility Management (Administrative Action)
• 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.
• Solicit input from employees regarding the feel,
  fragrance, and skin 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.