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Hand Hygiene Compliance- Learning from the U.S

The latest Department of Health monthly statistics show that, for the first time since mandatory surveillance began in 2001, MRSA bloodstream infections across the NHS have been sustained at under 100 reported cases per month for the last six months

MRSA numbers are also continuing to decrease, with 86 bloodstream infections reported across the NHS in November 2011. On average there is now less than one MRSA infection per primary care trust (PCT) each month. Over in the US there is a similar determination to reduce pathogens such as MRSA and Cdiff .

One particular study, carried out at North Shore Hospital, Manhasset, New York, aimed to evaluate health care workers and hand hygiene compliance with staggering results. Editor, Scott Buckler sat down with Donna Armellino, vice president of infection prevention of North Shore – the fourth-largest hospital in the New York metropolitan area one of the cornerstones of the North Shore-LIJ Health System, to discuss the study and how technology has dramatically increased hand hygiene compliance.

Could you explain more about the study and why technology has been utilised by the Hospital?

Over an initial 16-week period, the hospital staff were monitored to establish a base rate of hand hygiene compliance without any feedback to the staff. Using a very strict definition of hand hygiene (requiring health care workers to perform hand hygiene before and after patient care within 10 seconds of entering and exiting the room, regardless if gloves were used), their rates were around 10%. The next 16-week period, staff received real-time feedback on their performance via LED screens mounted on the walls of the MICU and from management. Within weeks of providing feedback, the hand hygiene rate during the second period jumped to over 80%. During a subsequent 75 week maintenance period, a sustained rate of well above 80% was achieved.

Hand hygiene issues are Global, not just in a single health system of hospitals but throughout the world. One of the biggest issues has been sustaining the high standards of hand hygiene. This study utilized a third party auditing firm and technology which removed the human element and provided consistent measurement over time. Once the high rates of hand hygiene compliance were achieved, we have been able to use the technology to sustain the strong performance for over three years.  We have had staff monitor hand hygiene, however they cannot consistently remain focused on monitoring due to their work schedule and changing priorities based on events occurring in the hospital, so technology allows a constant recording of information.

Were hand hygiene rates high at North Shore before the introduction of this technology and did the improvements North Shore achieved have an impact on hospital acquired infection rates?

Using an internal auditing method, we believed that our hand hygiene scores were 60%.  This study focused on 17 beds within a medical intensive care unit (ICU) where infections were already very low, targeting central line related bacteraemia of around 0-3 per month or pathogens such as Clostridium difficile and methicillin resistant Staphylococcus aureus (MRSA) at 3-4 per month. We looked at MRSA and Clostridium difficile and we found a temporal relation between hand hygiene. When hand hygiene increased these pathogens decreased .

How has the study impacted on staff at the hospital and their approach to hand hygiene?

When the technology was put into the ICU and the 3rd party remote video auditing servicewas started, the initial rates of hand hygiene compliance were found to be less than 10%. When we informed the staff of the rates and the measurement rules we saw a rapid increase in hand hygiene performance to over 80%.  The current rates of hand hygiene compliance are roughly 90%, which represents the strongest value of the technology - sustainability.  We have now monitored a surgical ICU which when we started was below 30% and once we started informing them of their rates, they increased their hand hygiene rates to roughly 90% and continue to perform at these high levels.  Prior to installing the technology and LED boards, the hospital had utilized a hand hygiene monitoring methodology which led us to believe that we had ~60% compliance, but this method had limitations both in terms of accuracy and sustainability.  With the implementation of technology we have gained a long-term solution. We are now monitoring hand hygiene 24/7 and creating a competitive culture where staff are determined to keep their unit’s standards high.

This study is groundbreaking since it is an innovative way to assess specific actions, delivers information, and generates results. The technology has the ability to measure and modify staff behaviour towards hand hygiene whilst also allowing assessment of how staff are ensuring the risk for infection is decreased. The Hospital staff have welcomed the technology and understand the benefit it can bring to patients and the long-term care we deliver.

Further Information

North Shore University Hospital in Manhasset, NY, one of the cornerstones of the North Shore-LIJ Health System, is the fourth-largest hospital in the New York metropolitan area with more than 800 beds. With a staff of more than 3,000 specialty and subspecialty physicians, the hospital offers the most advanced care in all medical and surgical specialties, including cardiovascular services, cancer care, a state-designated Level I trauma center and one of the region’s largest emergency departments, orthopedic services, advanced neuroscience capabilities, maternal-fetal medicine and a full array of women's health services.

Arrowsight, a web-based Software as a Service (SaaS) provider, is the leading developer of remote video auditing services and patented software. Arrowsight has helped improve practices, compliance and employee morale in safety-sensitive industries, such as healthcare, food processing, food services, and manufacturing. For more information, visitwww.arrowsight.com. 

Getting back to basics with infection prevention

Hand hygiene has for the most part been in the news for many years through the “Cleanyourhands” campaign. This initiative was launched in 2004, and it instructed acute NHS trusts to provide alcohol handrub at the point of care around patient beds and at entrances to wards to encourage participation in cleaning hands before and after giving care to every patient. The plan was to extend the campaign to primary care organisations, GP practices, community hospitals, nursing homes, care homes, ambulances, hospices, and dental surgeries.

In 2010 Cleanyourhands was closed down, moving away from a central campaign model to a program approach, designed to encourage local ownership through the individual trusts being asked to implement hand hygiene improvement and sustainability. Partners in healthcare will continue for the moment to work with the NHS to ensure current best practice and the campaign’s five moments of hand hygiene are implemented and understood. However there will no longer be the massive support there was in the past.

One of the main thrusts of the campaign was the “Right to ask” which was supposed to encourage patients and their relatives to ask staff within the NHS to wash their hands before clinical treatment. As the leading patient charity helping and supporting those affected by avoidable healthcare infections we supported this as a supplement to good hand hygiene. However in the 5 years I have been chair of MRSA Action UK, and for the 6 years that the Cleanyourhands campaign was in operation I have repeatedly heard from patients and their families stating that they have felt uncomfortable in asking staff to wash their hands, especially with the response from NHS staff when asked to do so.

Why is it then that some staff in the NHS, and I say some staff, see patients and their relatives as being “a nuisance” if they remind staff to wash their hands, this cannot be right.

I have met many who are passionate and dedicated to ensuring patients are treated in an environment that ensures they do everything possible to prevent those in their care from contracting an avoidable healthcare infection, so we should not tolerate those that don’t.

I am all for the policy of trying to change people’s culture, as the Cleanyourhands campaign’s aim was to do, however from bitter experience in my own profession as an engineer in the nuclear industry, I have found that sometimes you need to go beyond the culture change. The “carrot and the stick” comes to mind. This is not about telling someone how to do their job, far from it; it is about the fundamentals of any profession, but in this case one that cares for our loved ones, one that is still held in high esteem by the general public. This is about getting the basics right, one that if done correctly keeps patients safe. What is the point of having a clean safe environment if the staff do not follow the basics of the five moments of hand hygiene.

Whilst I understand that the staff will say that they are under pressure from targets and staff shortages, we all face pressure in our daily work and for some even targets. The difference is that while we may be able to take short cuts to fit things in to our day to day life, and the repercussions to anyone else will be minuscule, the same cannot be said about healthcare in an environment that has the potential to cause serious harm and unnecessary death to another human being from the contraction of an avoidable healthcare infection.

In life to avoid danger or mishap to others, many industries have protocols in place that ensure there is adequate defences in place to avoid harm, and in some instances are required by law to have them in place and to have the system audited to ensure people comply with them. In the medical environment, especially hospitals, protocols are put in place to prevent harm to patients, and these too are audited. However we should remember the Hawthorne effect in which workers who are being observed as part of a system, will comply with the rules of the system, but once those observing them have departed those workers fall back to the system they are comfortable with, which in many cases is non-compliance with hand hygiene when treating patients.

What is needed, I believe, to ensure not just a high level of compliance on hand-hygiene but to sustain it is a monitoring system that observes those same people 24/7 where feedback can be given in real time. In my opinion, it is time to look at the modern technology that is available to give us the sustainability to attain the high levels of compliance on hand-hygiene and to stop the softly, softly approach. The rights of patients to clean safe care should, I believe, override all other interests, be that ethical or moral and if you talk to the families of those who have been affected they believe in this whole heartedly. There is nothing ethical in allowing anyone to contract an avoidable infection when receiving care.

I think we all know that it should not be left to patients and their families to ensure that they are safe in hospital, and to have to remind hospital staff to wash their hands before touching someone, especially something so basic, not everyone has the confidence to do so. The overriding principle is that those who work in our hospitals have the first duty of care to those in their charge, and in the words of the former Chief Medical Officer Sir Liam Donaldson at the launch of year three of the Cleanyourhands campaign, he had a very clear message that if someone does not want to comply with hand hygiene, then they should not be in the healthcare profession and that they should take the greatest inspiration from people who rise above tragedy, and they must be prepared to work with them.

As the Chair of MRSA Action UK I welcomed that comment and I have questioned myself, how could anyone fail to wash his or her hands before caring for a patient when they know the harm this would cause? Therefore, MRSA Action UK is working with some healthcare professionals through the “Hand Hygiene Alliance” made up of healthcare professionals and patient representatives to seek out answers to such questions.

The Hand Hygiene Alliance was formed because it was felt by some that with the closure of Cleanyourhands there needed to be a resource to help maintain the importance of hand hygiene and keep it at the top of everyone’s agenda, not just a campaign. I believe that if we are going to reform the NHS, we need to reform the basics first. This will ensure that those within the NHS comply with the very basics and use technology to ensure that the right thing is done first time every time in keeping those in their care safe, and to set the example for others to follow, including patients, family and friends.

DIRTY DUCTS POSE SERIOUS HEALTH THREAT

The impact of poor air quality can be a major problem leading to sickness or even death - but not enough is being done to combat the problem.

The problem is partly that many people simply don’t think about air quality or its importance as an essential contributor to health and wellbeing in healthcare environments. Also, as the only legal requirement regarding ventilation hygiene is that systems are regularly inspected and the findings recorded but there is no legal obligation to clean, when budgets are under pressure as they are now it is too easy to put off what may be essential cleaning work.

In hospitals highly infectious diseases like MRSA and Clostridium difficile are not only carried through ventilation systems, but can thrive and feed on flakes of dead dry human skin which is a component of hospital dust and can build up in ventilation ducts.

Recent data from the Office for National Statistics showed that while the number of people dying due to MRSA and Clostridium difficile fell in 2008, superbug infections were still responsible for 30,000 deaths in five years. However, one expert believes that the number of patients in British hospitals dying from superbug infections has reached more than 10,000 every year.

Mark Enright, professor of molecular epidemiology at Imperial College London, said that the real number of those succumbing to MRSA and Clostridium difficile in the UK is higher than the government’s records show. “I think it is at least 10,000 a year,” he said. “A lot of people are never tested for these infections and their deaths are put down to something else.”

Dr Ghasson Shabha is facilities management MSc course leader at the School of Property, Construction and Planning at Birmingham City University. He is also MRSA project co-coordinator and is currently assessing commercial viabilities for new technologies for tackling infection control in health environments.

Dr Shabha agrees there is a real and urgent need to make regular duct cleaning an essential part of sustained hospital cleaning and maintenance programmes. He said: “MRSA has increasingly become one of the major sources of healthcare associated infection in hospitals in Britain and a main contributory factor to 100,000 cases per annum. It thrives in relatively non – humid environments and feeds on flakes of dead, dry human skin. It withstands desiccation at temperatures of 18-37 C and is thus a frequent component of hospital dust, making it more likely to spread via ventilation and air-conditioning systems. Ducts in hospitals, depending on type and function of rooms, should be cleaned on a three to six monthly basis; filters, depending on whether multi-layered or single layered, should be replaced on regular basis, ideally six monthly, as part of planned preventive maintenance programme.”

The cost of not having a thorough and regular duct cleaning and maintenance programme is very high indeed – in human terms alone, probably more than 10,000 lives lost every year - and the cost to the NHS of treating healthcare associated infections which is estimated to be around £1BN per annum.

Author: Ian Wall, sales director, Ductbusters
www.ductbusters.co.uk

Involvement in research into S.aureus bloodstream infection

Dr Martin Llewelyn is a consultant infectious diseases specialist in Brighton and is looking to undertake some research studying treatment of S. aureus blood-stream infection. He is interested in involving members of MRSA Action UK or anyone else who has been affected by S.aureus blood-stream infection in the developing the project. In particular he would like help in identifying the most important questions for the study, how to approach patients to take part in the work and how to communicate the findings to the public. If anyone is interested in becoming involved, could they contact him by email. m.j.llewelyn@bsms.ac.uk

Focus on the healthcare environment and airborne bacteria

Full implementation of measures in the Hygiene Code show that a multi-factorial approach is needed to eliminate the risk of avoidable healthcare infections:

- Hand hygiene
- Strict aseptic procedures
- Screening
- Isolation
- Information for all healthcare providers, including social care, and patients and carers

There also needs to be a stronger focus on the environment. The deep-clean was not a wasted exercise from the viewpoint of raising the profile and marking a change in behaviour in many of our healthcare settings. Although criticised as a gimmick we have seen a sea-change in many hospital trusts who are now committed to keeping the environment clean – although sadly this is not in all hospitals and care facilities.

The Health Act 2006: Code of Practice for the Prevention and Control of Healthcare Associated Infections requires healthcare providers to take this into account as part of their duty to provide the patient with “so far as is reasonably practicable, patients, staff and other persons are protected against risks of acquiring healthcare associated infections, through the provision of appropriate care, in suitable facilities, consistent with good clinical practice...”

Of concern are the number of experts who now confirm that many of the major threats from infections in both the hospital and care home environment is risk from airborne bacteria.

We believe that by being airborne this gives as much, if not more chance, of contaminating the environment where there are patients and healthcare works carrying the bacteria on their hands.

We know that those who have had MRSA or Clostridium difficile are potential carriers and we know that, particularly in the case of Clostridium difficile, once in the environment it is very difficult to remove it.

This is why every effort should be made to eliminate these bacteria from the air, after all if its airborne then it lands on surfaces, and may be responsible for many deaths from pneumonia – often the micro-organism that causes the pneumonia, for example MRSA, is not recorded on death certificates. We believe more research should be conducted to establish why it is that MRSA is often found in the throat, the sputum and in the nose.

With threats from MRSA, MSSA, Clostridium difficile and others, the duty to provide and maintain a clean and appropriate environment for healthcare becomes even more important. Yet not all healthcare facilities are making use of the technology that exists to alleviate this problem. More attention needs to be placed on the risks from airborne bacteria, Clostridium difficile spores have been found on the tops of curtain rails, therefore air handling equipment should be used routinely in cohort wards and isolation units, and may prove to be beneficial if used in the care environment, as prevention is better than cure.

The Dutch take the risk of airborne bacteria very seriously. Isolation facilities have negative pressure rooms, and those giving clinical care routinely wear masks. Guidelines in care homes are far more stringent than they are here in the UK. Masks are worn for changing bedding if a patient is colonised with MRSA or other contagions.

Used in conjunction with regular deep-cleaning there are portable devices that use biocides that can remove harmful pathogens from the air, and other technologies such as UVGI.

Policies for the environment relating to the fabric of hospital buildings, including air handling systems, is one of the many requirements of the Hygiene Code, and we believe a significant requirement to combat the problem.

More investment is needed to implement innovative solutions that exist to help healthcare providers meet their duty to protect against risks of acquiring healthcare infections.

This important element of keeping the environment clean and safe should not be overlooked when spending Infection Prevention and Control budgets. Prevention is always better than cure.

The Valued Use of Probiotics

At a time when antibiotic resistance to bacterium is as prevalent as it is today there is a need to stand back and look at prevention rather than cure. If we don't we run the risk of leaving our children and future generations a legacy that our grandparents faced when there were no antibiotics to rely on.

Antibiotics should be used efficaciously, that is as a last resort when all efforts to prevent an infection occuring have failed. Technologies, both natural and man-made are proven to work in the fight to reduce the risk of acquiring an infection in the healthcare setting, not least the human body's own defence mechanism.

It is widely reported that immune suppressed patients are more susceptable to healthcare infections, although we know from bitter experience young, fit healthy people have contracted infections which have killed and maimed. I believe that if we are to give everyone a chance of making a good recovery from any surgical procedure then we should look at the armoury we have to protect ourselves from the risks of infection. A lot of people are regularly taking probiotics in their diets as they have looked at the research, and this has been backed up recently in the BMJ, and they are safeguarding themselves for whatever eventually they may have to face in terms of staying healthy. Taking probiotics regularly can help to shore up the system to help you fight infection naturally. If you do succumb to an infection during a surgical procedure and antibiotics are given then the probiotics can help with balancing your own immune system.

Research has shown that even when probiotics are capable of establishing a colony of beneficial bacteria of the large gut it has to be regularly topped up with fresh beneficial bacteria - if it is to retain the foothold it has established. This may mean taking the probiotics at least daily and in some cases a twice daily regime is recommended.

The advantages are that once the beneficial bacteria are established from the probiotic the gut is likely to work better, nutrients will be more easily absorbed, vitamin production will be unaltered and, unwelcome gut symptoms such as irritable bowel syndrome will be lessened in many cases, ultimately resulting in the patient's immune system and defence against infections being enhanced.

Probiotics may have a special role when antibiotics have been prescribed. They reduce the chance of other infections settling in the gut after the antibiotic has upset the patient's usual gut flora. Implanting beneficial bacteria may prevent these antibiotic induced gut changes leading to serious disease. Some hospitals are now giving probiotics to patients to bolster the gut's normal flora. They've also been used to manage recurrent infection with C.Diff. The probiotics most frequently used to treat C.Diff include Lactobacillus GG, which is a concentrate that can be added to skimmed milk and Lactobacillus acidophilus, found in yogurt.

I believe that in the battle against ever prevalent healthcare infections we should be relying on our bodies natural defenses to antimicrobial resistance more and more, and making the best use of natural technology to help this process.