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1 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.

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Presentation on theme: "1 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."— Presentation transcript:

1 1 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

2 2 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

3 3 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

4 4 VHA Summary of JCAHO-required CDC Recommendations (19 in 4 categories) I. All Health Care Workers with Direct Patient Contact (8) II. Surgical Hand Hygiene (3) III. Facility Management: Supplies (5) IV. Facility Management: Administrative Action (3) Total Length: 732 words (minus 45%)

5 5 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. 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

6 6 Locations Patient care rooms Suites of rooms (ICU, Urgent Care, Radiology, etc.) Corridors that have >72 of clear width if spaced at least 48 inches apart –Corridors may not be carpeted unless sprinkler protected –Dispensers may not project > 6 into corridor egress width –Not over, or adjacent to, ignition sources

7 7Quantities 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

8 8 3M Six Sigma Process Five Steps in Six Sigma Process… 1. Define 2. Measure 3. Analyze 4. Improve 5. Control

9 9 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

10 10 6 Sigma Hand Hygiene Process Map

11 11 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

12 12 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%

13 13 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???

14 14 Measure (DMAIC): Palmful Measure (DMAIC): Palmful

15 15 This isnt lunch

16 16 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

17 17 Analyze (DMAIC)

18 18 KEY PROBLEMsSIX SIGMA RESPONSE 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… 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!

19 19 (DMAIC) Improve (DMAIC) : Usage g

20 20 Control (DMAIC): No backsliding! 1. Product Use antimicrobial soap in placeantimicrobial soap in place 2. Product Use lotion availablelotion available 3. Product Use monthly vol./100 patient days of alcohol productmonthly vol./100 patient days of alcohol product 4. Alcohol product dispensers in ICU locations (1 per bed & +0.5/pt. in corridor) 5. Pocket-sized alcohol product available to staff 6. Artificial nails – none on those who touch patients 7. HH compliance assessed by watcher dataassessed by watcher data 8. Posters up based on survey, FMEA, etc. patient care areas visitor waiting area staff-only area 9. VAMC HH policy updated 10. VAMC (annual) Staff Training updated 11. VAMC New Employee orientation updated 12. Information for Patients and Families (in admission folder) 13. National Directive updated - based on CDC Guidelines and Dec 2003 USH memorandum

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24 24 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

25 25 Final Thoughts 1.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. 2.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)

26 26 If this cat can do this… You can tell anyone to decontaminate their hands!

27 27 Hand Hygiene Questionnaire Results - DRAFT DATA YesNo Question 1: Is your facility presently using regular (non- antimicrobial soap) for staff hand washing in patient care areas* 6856%5444% Question 2: Is your facility presently using antimicrobial soap for staff hand washing patient care areas?* 9880%2420% Question 2a: If Yes to 2, what brand and specific type (product name or number)? Gojo/Provon: 1919% Steris: 5455% Other: 2526% YesNo Question 3: Is your facility presently using an alcohol gel or foam for hand antisepsis in patient care areas? 11998%32% 3a. If Yes to 3, what brand and specific type (product name or number, and dispenser size(s))? Brand/Product Names: Ecolab: 7261% Coloplast: 2924% Other 1815%

28 28 I. All Health Care Workers With Direct Patient Contact 1)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. 2)Put gloves on before you touch non-intact skin, blood, mucous membranes, or potentially infectious materials such as soiled linens. 3)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. 4)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. 5)Healthcare workers that may have direct contact with patients at high risk for infection must not wear artificial fingernails. 6)Wash your hands with soap and water if they are visibly soiled or contaminated with body fluids. 7)Wash hands with soap and water after using a restroom. 8)Wash hands with soap and water before eating.

29 29 II. Surgical Hand Hygiene 1)Before donning sterile gloves for surgical procedures use either an antimicrobial soap or an alcohol-based hand-rub with persistent activity. 2)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. 3)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.

30 30 III. Facility Management (Supplies) 1)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). 2)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. 3)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. 4)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. 5)Store supplies of alcohol-based hand-rubs in cabinets or areas approved for flammable materials.

31 31 IV. Facility Management (Administrative Action) 1)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. 2)Solicit input from employees regarding the feel, fragrance, and skin tolerance of products, such as soap, alcohol hand-rub and gloves. 3)Monitor health care workers adherence to hand-hygiene practices and provide information regarding the workers performance.

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