This slide set is almost 10 years old, but it hits some good points. Especially about us knowing what doesn't work to reduce healthcare associated infections, and needing to do things differently. I have a video of this presentation on a VHS tape somewhere and need to figure out how to get it on YouTube like one I did at the conclusion of the Six Sigma Project referred to in these slides. http://www.youtube.com/watch?v=Zb_fVETGzwg Some formatting is a little off in the translation to the current version of PowerPoint, but I didn't want to start editing and be tempted to change anything.

1. Demystifying and Responding to
CDC’s Hand Hygiene Guidelines
and JCAHO’s related Patient
Safety Goal for 2004
Presentation to QMIC, 2/4/04
Noel Eldridge, MS
VHA National Center for Patient Safety
202 273-8878

2. Presentation Outline
• CDC Guidelines and JCAHO Patient Safety
Goals for 2004
• Summary of the Evidence
• Letter from Dr. Roswell and Summary for
VHA facilities
• Six Sigma Project with 3M Corporation
• Wrap-up

3. CDC Guidelines on Hand Hygiene
• Issued October 25, 2002
• Issued by CDC and others:
– “CDC Healthcare Infection Control Practices
Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force”
• Since the CDC Guidelines were issued, new
IOM and NQF studies also give preventing
nosocomial infections high priority

4. Recommendations (44) from
CDC Guidelines
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

5. JCAHO Involvement
• JCAHO issued 6 Patient Safety Goals for
2003
• JCAHO added a new one (#7) for 2004:
– 7a: “Comply with current CDC hand-hygiene
guidelines.” and
– 7b: “Manage as sentinel events all identified
cases of unanticipated death or major
permanent loss of function associated with a
health care-acquired infection.”

6. “Comply with current CDC
hand-hygiene guidelines”
Category IA. Strongly recommended for implementation and strongly
supported by well-designed experimental, clinical, or epidemiologic studies.
Category IB. Strongly recommended for implementation and supported by
certain experimental, clinical, or epidemiologic studies and a strong
theoretical rationale.
Category IC. Required for implementation, as mandated by federal or state
regulation or standard.
Category II. Suggested for implementation and supported by suggestive
clinical or epidemiologic studies or a theoretical rationale.
No recommendation. Unresolved issue. Practices for which insufficient
evidence or no consensus regarding efficacy exist.

7. JCAHO Patient Safety Goals
• Resources:
– December 2003 Topics in Patient Safety (TIPS)
Newsletter: www.patientsafety.gov/tips.html
– December 2002 TIPS Newsletter
– JCAHO Website:
www.jcaho.org/accredited+organizations/patient+safety/npsg.htm
– VHA NCPS Website: INSERT INTRANET URL

8. The Evidence
• 423 references in CDC Guidelines
– From Laboratory Tests
– From Hospitals
– From Long-term Care Facilities
– From Schools
– On Bacteria, Viruses, Fungi
– On Wild-type and Antibiotic-resistant Strains
• From VAMCs

9. Study of Alcohol Handrub use at
a Long-Term Care Facility
• Compared the 2 units of the facility where
alcohol hand-rubs were used with the rest of
the facility. Key findings:
– 30% fewer infections over a 34 month period
• 2.27 (alcohol) vs. 3.19 (soap) per 1000 pt-days
• Primary infections were urinary tract with Foley
catheter, respiratory, and wound
• 253,933 pt-days total; 81,036 in alcohol group
– Reference: Fendler et al, AJIC, June 2002

10. Study of Alcohol Handrub use at
an Acute Care Facility
• Compared one unit (orthopedic surgery) of a
hospital before and after introduction of alcohol
handrubs in that unit.
– 36% fewer infections (6 months before, 10 after).
• 8.2 vs. 5.3 infections per 1,000 patient days
• “Teachable” patients given 4 oz. alcohol gel too
• Primary infections: urinary tract and surgical site
• Cost savings studied:
– Mean cost per infection: $4,828 +/- 4,868
– Cost of 10 months of supplies for unit: $1,688
– Reference: Hilburn et al, AJIC, April 2003

11. VHA Summary
• Issued by Dr. Roswell in a memo to VISN
Directors dated 12/15/03
• Also issued in December 2003 issue of
TIPS Newsletter
• Memo and web site contain cross-reference
to CDC Guidelines

12. VHA Summary of
JCAHO-required CDC
Recommendations (19)
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 (-45%)

13. Summary of VHA Summary (1)
I. All Health Care Workers with Direct Patient
Contact
• Decontaminate hands before and after
touching a patient (regular soap doesn’t do it)
• Specific gloving recommendations
• No artificial nails for HCWs contacting high
risk patients
• Soap and water for soiled hands

14. Summary of VHA Summary (2)
II. Surgical Hand Hygiene
• Guidance on surgical scrub with soap and water
(e.g., shorter scrub times)
• Guidance on surgical scrub with no-rinse alcohol-
based products with ingredients for persistent
action

15. Summary of VHA Summary (3)
III. Facility Management: Supplies
• Alcohol at room entrance and/or bedside
• Alcohol available in pocket-sized dispensers
• Alcohol in other convenient locations (e.g., in
corridors is OK within limits)
• Antimicrobial soap as an alternative to alcohol
• Provide hand lotion to HCWs
• Store alcohol safely -- it’s flammable

16. Summary of VHA Summary (4)
IV. Facility Management: Administrative
Action
• Make HH a priority and provide financial and
administrative support
• Solicit input from employees
• Monitor adherence and provide feedback on
performance

17. Cross-reference

18. CDC Guidelines on Hand Hygiene
• If you only remember one thing, remember
this: Alcohol hand-rubs are better than soap
and water. Why?
1. They kill germs better (lab data) and produce
better outcome for patients (hospital data)
2. They are easier to use correctly (forcing function)
3. They are easier on hands (lab and hospital data)
4. People only use soap 20-50% of when they should
(multiple hospital data)

19. Six Sigma Project with 3M
Corporation
• DMAIC
– Define: project charter
– Measure: process map, cause and effect matrix,
– Analyze: failure modes and effects analysis,
multi-variable studies
– Improve: pilot studies
– Control: control plan, hand-off training, final
capability, owner sign-off, final project report

20. What we’re measuring
(in 3 VAMC ICUs)
• Staff compliance (observing staff with checklist
and clipboard)
• Volume of product used (to be converted to
“doses” of alcohol handrub and soap)
• Staff Attitudes and Perception of Compliance
(questionnaire)
• Antimicrobial soap in use (percent yes/no)
• Staff artificial nails (percent yes/no)
• Staff satisfaction with HH practice (questionnaire)

21. 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, VISN 23
Cheryl Pederson, 3M
Kim Reichling, 3M
Dr. Gary Roselle, Infectious
Diseases
Susan Woods, 3M
Dr. Steven Wright, OQP

22. Preliminary Data
• Staff think they’re doing 90% when they’re doing
60%
• Nurses and doctors are better than others (e.g.,
chaplains, technicians)
• Number of HH opportunities doesn’t affect
compliance
• HCWs believe in connection between HH and
infections, but are simultaneously skeptical about
some specifics

23. Some Tentative Opportunities for
Improvement
• Improve availability of and access to appropriate
supplies (make it easier to do it right)
• Involving patients and visitors
• Providing scientific evidence to educated skeptics
(learning and unlearning)
• Educating “others” of benefits of hand hygiene
• HCWs reminding each other (culture change)
• Feeding back real VAMC facility data on
compliance/performance

24. What to do now
• Get alcohol hand-rubs close to patients to make it
convenient to use: in rooms or entrances to rooms,
in hallways, and pocket size too.
• Get antimicrobial soap in soap dispensers
• Tell staff that the alcohol hand-rub should be
primary method for hand decontamination
• Don’t assume you know what the CDC Guidelines
say, if you haven’t read them you don’t. It’s not
always “common sense”.
– Start with 1-page VHA summary

25. Final Thought
• We know what doesn’t work: status quo of
telling people to use soap and water and
doing nothing when they don’t do it.