Handwashing

Hand contamination of personnel in NICUKnittle M A et.al. J Ped 1975, 88, 433

No. of nurses 13

No. of cultures 151

Positive cultures 130 86.1%

E. coli 25 18.6%

Klebsiella 119 78.7%

Pseudo aeruginosa 25 16.5%

Efficacy of simple handwash

log reductionS. aureus 2.54

Pseudo. aeruginosa 2.80

Lowbury EJL et al : BJM 1964, 2, 230

Efficacy of Alcohol

• Alcohols effectively reduce bacterial counts on the hands .

• Typically, log reductions of the release of test bacteria from artificially contaminated hands

• average 3.5 log10 after a 30-secondand 4.0--5.0 log10 after a 1-minute application .

Hand-washing - ? Reduce nosocomial infection ?

1. ~ 50% reduction of incidence of diarrhea in a day care center(Black R . Am. J Epidemiol. 1981, 113, 445

2. Semmelweis’s study

Ignaz Phillips Semmelweis(1818-1865)

•The Hungarian obstetrician• In 1847 He noted that • puerperal fever was more common on a maternity ward where physicians and medical students provided care to women in labour• than it was on the ward where midwives assisted at deliveries

• Divided into two clinics, alternating admissions every 24 hours:– First Clinic: Doctors

and medical students– Second Clinic:

Midwives 02468

10121416

Mat

erna

l mor

talit

y, 1

842

First Clinic SecondClinic

On May 15,1847,Semmelweis ordered all students and physicians scrub their hands with 4% chlorinated lime solution after dissecting cadavers and before examining

Hand Hygiene: Not a New ConceptMaternal Mortality due to Postpartum Infection

General Hospital, Vienna, Austria, 1841-1850

0

2

4

6

8

10

12

14

16

18

1841 1842 1843 1844 1845 1946 1847 1848 1849 1850

Mat

erna

l Mor

talit

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)

MDs Midwives

Semmelweis’ Hand Hygiene Intervention

~ Hand antisepsis reduces the frequency of patient infections ~

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Hand-hygiene compliance trends in seven consecutive hospital-wide surveys

Among major staff categories, nurses contributed an average of 68·8% (SD 3·3) of all opportunities; nursing assistants 18·0 (2·4); doctors 8·3 (1·7); and other HCWs 4·9 (1·8)

Hand-hygiene compliance trends in seven consecutive hospital-wide surveys

Handwashing - ? when1. Before performing invasive procedure2. Before taking care of newborns and

immunocompromised patients3. Before and after touching wounds4. After contact with mucous membranes

blood, secretions or urine5. After touching contaminated apparatus6. After taking care of infected patients

colonizes with epidemiologically important organisms

7. Between contacts with patients in ICUs (CDC recommendations 1985)

Indications of hand hygiene

1) Before performing

invasive procedures.

Indications of hand hygiene

2) Before taking care of particularly susceptible patients, such as those who are severely immunocompromised and newborns.

Indications of hand hygiene

3) Before and after touching wounds, whether surgical, traumatic, or associated with an invasive device.

4) After contact with mucous membranes, blood or body fluids,and secretions or excretions.

Indications of hand hygiene

5) After touching inanimate sources such as urine-measuring devices or secretion collecting apparatuses.

Indications of hand hygiene

6) After taking care of an infected patient, for example multiple-resistant bacteria.

Indications of hand hygiene

7) Between contacts with different patients in high-risk units.

Indications of hand hygiene

Handwashing in PSU Hospital

Handwashings in PSU - ICUPrevious study results (Indaraksa P et.al., 1994)

Alcohol Percent

- before 45.2%

- after 55.7% p < 0.001

Hand washing practices among nurses in Intensive Care Unit (ICU) of Songklanagarind Hospital

Khachornsakdi Silpapojakul, MDOunjai Koranantakul, MD

Mahbub-E-Elahi Khan Chowdhury, M Sc.

Handwashing in ICU of PSU Hospital

• 9 beds observed, each for 30 minutes• 8 on respirators• 31 contacts; at every 8.7 minutes• Overall compliance = 15/31 (48.4%)• Frequencies of non compliance

– Between contacts 6/7– After suctioning 7/14

• Over all hand-washing compliance is 48.4%• Common events leading to non compliance -

between contact, after suction• Fair knowledge• Very good attitude• Very busy ICU• Low nurse to patient ratio• Had problems with sinks• Complain on side effects of alcohol

Summary of results

Year 2002

The average compliance was 24.1%(95% CI = 20.5–27.9),

Compliance with Hand Hygiene in Personnel of Songklanagarind

Hospital

Sites of study12 wards:-

• 3 Surgical wards• 3 Medical wards• 2 Orthopedic wards• 1 Respiratory Care Unit (RCU)• 2 Intensive Care Units (ICU) • 1 Traumatic ward • 1 Neurological ward

Hand hygiene compliance according to personnel.

2.52-55.61 %20.0%10 Other*

18.9-42.4%29.7%64 Physician

26.6-41.0%33.5%176 Medical Student

25.5-59.2%41.7%36Nurse Assistant

38.9-50.9% 44.8%279 Nurse

95%C.IAdherencenPersonnel

n = opportunity for hand hygiene*Other include nursing student, and patient’s relative

Hand hygiene compliance according to wards

34.9-43.1%38.9%565TOTAL27.5-39.8%33.5%239Surgery*

30.8-46.4%38.4%159Internal Medicine

34.2-54.8%44.3%97Orthopedic

39.2-63.6%51.4%70ICU

95%C.IAdherencenWards

n = opportunity for hand hygiene*Surgery = General, Neurosurgery and Traumatic ward

Hand hygiene compliance according to before or after patient care procedure

34.9-43.1%38.9%565TOTAL41.2-53.0%65.7%289After7.5-15.2%10.9%276Before95%C.I*AdherencenSequence

n = opportunity for hand hygiene*Exact binomial statistics

Hand hygiene compliance according to patient care procedure

34.9-43.1%38.9%565TOTAL

28.1-39.533.7282Dressing

36.3-48.842.2270Airway suction

54.6-98.184.613After touching urine

95%C.I*AdherencenProcedure

n = opportunity for hand hygiene*Exact binomial statistics

Hand hygiene compliance according to patient care procedure (year 2005)

36.3-48.842.2270Airway suction

95%C.I*AdherencenProcedure

n = opportunity for hand hygiene*Exact binomial statistics

010014.285.8อัตราลางมือ(รอยละ)033047283จํานวนรวม (330 ครั้ง)

ไมลางลางไมลางลางsuctioningafterbeforePROCEDURE

สรุปผลสํารวจภาพรวมการลางมือกอน-หลัง การดดูเสมหะ (ตุลาคม 2549)

NosocomialNosocomial bacteremia:PSUbacteremia:PSU

• Incidence rate was 15.5 per 1000 admissions in 1990-1991 and case fatality rate was 37.2%.

• Jamulitrat S et al Infect Control Hosp Epi 1994;15:163-170

Nosocomial Bacteremia, PSU HospitalYear 1990 –1991 = 15.5 per 1000 admissions.(Jamulitrat S et al. Infect Control Hosp Epidemiol.1994;15:163

Year 2003-2004 = 12.7 per 1000 admissions.(Visartrapong T et al.)

NosocomialNosocomial BacteremiaBacteremiaIncidence of nosocomialbacteremia 7.6 per 1000 admissions(Gatell J.M. et al Nosocomial bacteremia in a large

Spanish Teaching Hospital. RID 1988;10:203-210)

Overall infection rate was 0.8 infections per 1000 patient-days and 2.7 infections per 1000 discharge

Source of infection and Source of infection and organisms:PSUorganisms:PSU

• Lower respiratory tract infection1 S.aureus 41.7%(MRSA 50%), 2 Acinetobacter spp. 25%,3 K.pneumoniae 12.5%4 Pseudomonas aeruginosa 12.5%

Surgical Wound Infections

PSU Hospital Surgical Site Infection Rates(infections/100 operations) and standardized infection ratio. Na-narong M et al. AJIC 2003;31:274

Operative procedures n Infection Rate SIR

Craniotomy 341 19 5.6 4.1

Laminectomy 126 3 2.4 2.0

Vascular 160 5 3.1 2.1

Appendectomy 335 11 3.3 1.3

Cholecystectomy 202 3 1.5 1.6

Herniorrhaphy 169 6 3.6 3.8

Small-bowel 152 25 16.4 2.2

Operative procedures n Infection Rate SIRGastric 101 7 6.9 1.4

Colon 102 6 5.9 1.0

Other genitourinary 161 6 3.7 6.7

Open reduction fracture 280 10 3.6 3.7

Limb amputation 107 12 11.2 3.0

Other musculoskeletal 745 18 2.4 3.6

Mastectomy 151 5 3.3 1.6

Other integumentary system323 5 1.5 1.2

Miscellaneous 699 51 7.3 2.6

Other operation 283 0 0.0 0.0

Total 4437 192 4.3 2.3

Ref.:Montha Na Narong, Somchit Thongpiyapoom, Nonglak Thaikul,,, Silom Jamulitrat, and Nongyao Kasatpibal AJIC 2003;31:274

จํานวนผูปวย ( คน )

จํานวนยา ( vial )

Cost( บาท )

จํานวนผูปวย

จํานวนยา ( vial )

Cost ( บาท )

Cefoperazone + Sulbactam 1 g 776 5,159 1,906,354 1,760 12,163 4,798,304

Fosmicin 2 g 453 1,462 427,606 681 2,315 727,488

Meronem 500 mg 27 94 87,841 107 416 392,903

Meronem 1 g 55 281 390,073 391 1,617 2,260,105

Tienem 500 mg 784 4,111 3,261,010 982 6,079 4,882,896

Vancomycin 500 mg 526 2,282 1,016,776 1,147 5,075 1,952,707

ยา

1 ตุลาคม 2546 - 31 มีนาคม 2547 ( ชวงกอนการสั่งใชโดย Computer )

1 ตุลาคม 2547 - 31 มีนาคม 2548 ( ชวงหลังการสั่งใชโดย Computer)

ตาราง สรุปจํานวนการสั่งใชยาในกลุม ID restrict drug (5 ชนดิ)

Administrative Measures to Improve

Hand Hygiene• Make improved hand hygiene an

institutional priority• Place alcohol-based handrubs at

entrance to patient room, or at bedside

CDC Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Performance Indicators

• Monitor and record adherence to hand hygiene by ward or service

• Provide feedback to healthcare workers about their performance

• Monitor the volume of alcohol-based handrub used per 1,000 patient days

CDC Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.