CONTINUING EDUCATION

Closing the Hand Hygiene Gapin the Postanesthesia Care Unit:

A Body-Worn Alcohol-Based DispenserWilliam Clayton Petty, MD

Clinicians who work in the postanesthesia care unit (PACU), operating

WilliamClayton

Conflict of Inter

consultant to SPR

issues.

Address correspo

716, Cedar City, U

mac.com.

� 2013 by Ame

1089-9472/$36.

http://dx.doi.org

Journal of PeriAnesth

room (OR), and intensive care unit (ICU) have a greater opportunity

to cross-contaminate patients because of high workloads and frequent

patient contact events. Much progress has beenmade to increase hand hy-

giene compliance with the introduction of alcohol-based wall, bedside,

and pocket dispensers. The introduction of body-worn alcohol-based

dispensers to anesthesia and ICU providers has been shown to decrease

ICU hospital-acquired infections and ventilator-associated pneumonias,

and decrease contamination of the anesthesia workplace. Body-worn

alcohol-based dispensers are an improvement in ergonomics, especially

for those working in high intensity areas. The unit worn on the belt or

scrubs waist is readily accessible, can be activated with one hand, and

can be a vital tool to close the gap for hand hygiene.

Keywords: hand hygiene, infection control, health care–acquired

infection.

� 2013 by American Society of PeriAnesthesia Nurses

OBJECTIVES—On completion of this activity, the

learner will be able to: (1) identify the main route

of transmissionofmicroorganisms in ahealthcare fa-

cility, (2) discuss patient and nonpatient sources of

hand contamination, and (3) describemethods to in-

crease hand hygiene compliance.

ATAHEALTHcare collaborative in February 2012,

the author heard a former postanesthesia care unit

(PACU) nurse (now in Infection Control) stand and

say that her PACU physician director had told

PACU nurses that it would be alright to limit

hand washing to just before coming onto shift

Petty,MD,RetiredProfessorofAnesthesiology.

est: William Clayton Petty is a volunteer

IXX for hand hygiene methodologies and

ndence to William Clayton Petty, P. O. Box

T 84721; e-mail address: williamcpetty@

rican Society of PeriAnesthesia Nurses

00

/10.1016/j.jopan.2012.06.008

esia Nursing, Vol 28, No 2 (April), 2013: pp 87-97

and before going home because their patient work-

load was so intense that they really did not have

time to wash their hands between monitoring pa-

tients!

The main route of spread of infection in a healthcare facility is transmission of microorganisms

onto the hands of health care workers.1 Each

year, approximately 5% to 10% of hospitalized

patients are infected by one or more hospital-

acquired organisms. Among those, 20% are surgi-

cal site infections. Approximately 90,000 patients

die each year because of hospital-acquired infec-

tions (HAIs). Ventilator-associated pneumonias(VAPs) account for 14% of HAIs but are responsible

for 25% of the deaths. The problem with an HAI is

that the organism is usually resistant in 70% of

cases to one or more antibiotics.2 Approximately

20% of health care workers carry Staphylococcus

aureus in their nose but are nonsymptomatic.3

The human body has more than 100 trillion micro-organisms living inside and outside the body.3,4

87

88 WILLIAM CLAYTON PETTY

Sources of contamination in the hospital include

human epithelial cells shed by patients and

health care workers. Bacteria can survive on

hands for variable amounts of time. Enterococcus

and vancomycin-resistant enterococci (VREs) live60 minutes on gloved and ungloved hands;

Escherichia coli lives 6 minutes; S. aureus,

methicillin-resistant S. aureus (MRSA), and

coagulase-negative staphylococci are known to

survive as skin flora.4,5

Nonpatient Sites of Infection

Nonpatient sites that are proven sources for hand

contaminationarecomputerkeyboards, cellphones,

and fixed telephones.5-7 Contamination of computer

keyboardswas investigated by examining the degree

of contamination, the effect of cleaning with ethylalcohol, bacterial transmission between gloves/

hands by tapping of the keys, and the frequency of

health care workers performing hand hygiene.6

The computer keyboards were found to be contam-

inated with coagulase-negative staphylococci, bacil-

lus, and MRSA. Anesthesia providers performed

hand hygiene 69% of the time before lunch but

only 17% of the time before providing anesthesia.Because of contamination of keyboards, VioGuard

(VioGuard LLC, Kirkland, WA) introduced a self-

sanitizing device that disinfects the keyboard with

germicidal ultraviolet light.8 The Vanguard self-sani-

tizingcomputerkeyboard interfaceswithacomputer

via a USB connection. After use, the keyboard re-

tracts into a closed unit where it is bathed in ultravi-

olet germicidal irradiation (254 nm wavelength) for60 to 90 seconds. The ultraviolet irradiation is 99%

effective in killing harmful microorganisms.

Cell phones are now found in all areas of patient

care. A study of hand contamination of cell phones

in the operating room (OR) found that 38 of 40 cell

phones had bacterial contamination, of which 4

cultured human pathogenic organisms.7 Becausesome PACU nurses use cell phones intermittently,

it might be prudent to limit their use to break areas

and practice hand hygiene after using the cell

phone. Fixed telephones can also be a site of mi-

croorganism contamination.5,7 Approximately 33

of 40 anesthesia providers had hand bacterial

contamination after using a telephone in the

lounge area.7 Coagulase-negative staphylococci,Micrococcus, Acinetobacter, Psuedomonas, Agro-

bacterium, and non-group D Streptococcus were

cultured from fixed telephones in 14 ORs and 2

substerile rooms.5

Anesthesia providers have been found to con-

tribute to intraoperative bacterial transmission.9

The extent of bacterial contamination of the in-

travenous stopcock and adjustable pressure-

limiting (APL) valve and the vaporizer control

dial by the anesthesia provider during an

anesthetic was studied in 164 cases. Before

any patient contact, their hands were found

to be contaminated with MRSA, VRE, and

methicillin-sensitive S. aureus in 12, 4, and 18of the 164 cases, respectively. Anesthesia pro-

viders were the cause of 17 contaminations of

the anesthesia machine and 9 contaminations

of the stopcock.

Hand Hygiene Compliance

Hand hygiene compliance has been studied in

intensive care units (ICUs), emergency rooms,

medical wards, and nurseries. In 34 studies com-

pleted between 1981 and 2000, hand hygiene

compliance by health care providers before

patient contact ranged between 4% and 81%(mean5 42.4%). After multiple interventions,

that is, more convenient sink locations, introduc-

tion of alcohol rub dispensers, lectures, feedback,

and posters, the average compliance with hand hy-

giene was 53.5% (range: 7% to 92%).10 In 14 stud-

ies (1974 to 1997), health care workers were

observed to wash their hands for 5.2 to 24 seconds

(mean 5 13.3 seconds).11 The Center for DiseaseControl (CDC) recommends a vigorous hand rub

of 15 seconds when using soap and water and

rubbing the hands together until dry when using

alcohol.10

Wall, bedside, and pocket dispensers of alcohol

hand rub have improved hand hygiene compli-

ance. We have come a long way from the fixedsink, soap, and water era. Now we need to close

the gap. One way to close the gap is to put

a body-worn alcohol dispenser on the health care

worker’s belt or pant/scrub waist for easy access.

Anesthesia, PACU, and ICU providers have high

workloads, intense environments, and multiple

time-limited patient care encounters and some-

times bypass the wall and bedside dispensers, donot use the pocket dispenser, and continue work-

ing with contaminated hands. What is needed is

HAND HYGIENE COMPLIANCE 89

a body-worn alcohol dispenser that can be acti-

vated with one hand and used while rapidly mov-

ing from one task to another.

The PACU personnel constantly interact betweenpatients. Infectious agents are easily transferred

from one patient to another, especially when

proper hand hygiene is ignored. Many procedures

have a high risk of cross-transmission, that is, extu-

bation, stopcock access, catheter care, or dressing

adjustment. A patient cross-contaminated with

a pathogenic microorganism in the PACU will not

exhibit signs and symptoms of the HAI until leav-ing the PACU. The infection control office will

eventually report the HAI to the ICU or ward.

The result is that PACU personnel may be unaware

of their role in the HAI. The National Institute of

Health is investigating a technique similar to

DNA identification to link cross-contamination of

a patient to the microbiome of the health care

worker.4

A study in 2003 focused on hand hygiene in the

PACU.12 A 3-week observational period was com-

pleted in a 12-bed PACU averaging 25 to 35 admis-

sions per day. The nurse-to-patient ratio was 1:3.

A sink was nearby the patient care areas and

wall, and bedside-mounted alcohol-based dis-

pensers were available. Period 1 was defined aswhen the patient entered the PACU. Period 2

was 30 minutes after PACU admission. Intensity

of patient care was estimated by patient care ac-

tivities per hour (82 in period 1 and 72 in period

2). Only those patients who were deemed to be at

medium or high cross-contamination risk were in-

cluded in the hand hygiene adherence data.

Table 1. Hand Hygiene Compliance in thePACU*

Parameters Period 1y Period 2zNumber of patients 57 130

Indications of HH 485x 606

Compliance (%) 20 13

Used soap/water (%) 21 17

Used alcohol-based hand rub (%) 79 83

PACU, postanesthesia care unit; HH, hand hygiene.

*Based on data from reference 12.yImmediately at PACU admission.zApproximately 30 min after PACU admission.xOnly patients at medium or high risk for cross-

contamination were included.

Table 1 summarizes the information obtained dur-

ing the observational periods. The risk factors

identified were (1) PACU personnel not suffi-

ciently aware of cross-contamination, (2) a high

level of fluctuation of patients, and (3) the easein the PACU to transmit microorganisms from pa-

tient to patient. Cross-contamination in the PACU

is most likely because of cross-transfer from a con-

taminated device, poor hand hygiene compliance

because of acute overcrowding and high work-

load, and/or because of high frequency patient

contact.12

Compliance with hand hygiene is inversely associ-

ated with a high workload, like that found in the

PACU.11,13 The impact of hand hygiene on HAIs in

20 hospitals between 1977 and 2008 was

significant. Improved hand hygiene practices

reduced infection and cross-transmission rates.11

One hospital-wide hand hygiene campaign resulted

in an improved level ofhandhygienecompliance for8 years.14 The campaign interventions included the

introduction of dispensers of alcohol-based hand

rub on the wall, at the bedside, and in the pockets

of health care workers, coupled with hand hygiene

observations, training, performance feedback, and

posters. The campaign resulted in a sustained in-

crease in hand hygiene compliance from 48% to

66%, a 48% decrease in HAIs, and an 87% decreasein cross-transmission of MRSA.14 Research has

linked duration of patient care to the amount of bac-

terial contamination. Anesthesia providers were

found to have a hand bacterial count of

3.216 0.66 (log10) at the induction of anesthesia

that decreased to 2.556 1.15 (log10) during main-

tenance, to 2.676 1.10 (log10) during extubation,

and to 3.576 0.74 (log10) at the end of anesthesiaadministration.15 Anesthesia providers were ob-

served to have only a 62% hand hygiene compliance

rate after moving patients into the PACU and before

leaving the PACU.16 Direct patient contact, respira-

tory tract care, and handlingof body fluid secretions

caused the highest rates of hand contamination.1 Pa-

tients who have a prolonged stay in the PACU have

a greater risk of contamination, most likely for thesame reasons.17

Alcohol-Based Dispensers

Alcohol-based dispensers have improved hand hy-

giene compliance, and alcohol is now considered

the gold standard for hand hygiene.11 The CDC,

90 WILLIAM CLAYTON PETTY

the World Health Organization (WHO), and many

professional organizations support the use of

alcohol-based hand rub because alcohol has ex-

cellent antimicrobial efficacy, is fast acting, is read-

ily available at the point of patient contact, andhas better skin tolerance than soap and wa-

ter.1,2,10,11,13,18 Alcohol has been found to have

superior germicidal activity against gram-positive

and gram-negative bacteria (including MRSA),

some fungi, Mycobacterium tuberculosis, HIV,

herpes simplex virus, hepatitis B, and vaccinia vi-

rus.10 Health care workers have been observed

to wash their hands only 23% of the time beforeputting on gloves and change gloves only 16% of

the time after a patient interaction.1 Gloves are rec-

ommended to reduce bacterial contamination,

even in high turnover areas where there is contact

with bodily secretions, ie PACU. When gloves are

used in these areas, proper hand hygiene should

be performed before donning the gloves and after

removal of the gloves. Gloves in high turnoverareas should be changed between patients.

Ergonomic placement of dispensers is paramount in

encouraging the use of alcohol-based hand rub.

WhenPACUpersonnelmustwalk from the patient’s

bedside to an alcohol dispenser on a nearby wall,

chances are less that hand hygiene will be accom-

plished.10 Pocket bottles of alcohol-based handrub improved hand hygiene compliance from

38.4% to 54.5% over 3 years when combined with

wall and bedside dispensers in the patients’

rooms.13 This marked increase in hand hygiene

was linked to a decrease in hospital-acquired and

MRSA infections. The CDC recommends that health

Table 2. Body-Worn Alcohol-BasedDispensers (BWABDs) Reduce ICU Infections*

ParametersControlPeriod

AfterBWABDy

# Patients 1,262 1,331

# VAP per 100 ventilator days 6.9 3.7

Length-of-stay days 6 6

CRBSIs 2.6 1.5

Hand hygiene compliance (%)z 53 75

ICU, intensive care unit; VAP, ventilator-associated

pneumonia; CRBSIs, catheter-related blood stream infec-

tions.

*Based on data from reference 19.ySPRIXX GJ hand sanitation unit.zMean score.

care providers who work in high-intensity areas are

provided with individual pocket-sized containers.10

Body-worn alcohol dispensers have been shown to

reduce VAPs and nosocomial infections in the ICUand cross-contamination in the anesthesia work-

place.19,20 Table 2 shows the drop in VAPs and in-

crease in hand hygiene compliance after the

introduction of body-worn alcohol-based dis-

pensers. When body-worn alcohol dispensers

were used by the anesthesia providers, there was

a reduction in the rate of contaminated stopcocks,

anesthesiamachines, and ICUHAIs.20 Table 3 showsthe reduction in stopcock infectionand thedecrease

in nosocomial infections in the ICU after the intro-

duction of a body-worn (belt or pants/scrubs waist)

alcohol-based dispenser.20 The body-worn dis-

penser also reduced the extent of bacterial contam-

ination in the anesthesia environment, as measured

by bacterial contamination of the APL valve on the

anesthesia machine. The Sprixx GJ hand sanitationbody-worn device (Sprixx, Harbor Medical, Inc,

Santa Barbara, CA) used delivers 0.75 mL of

alcohol-based solution per plunger activation.21

Sprixx dispensers can electronically monitor in-

dividual health care workers hand washing com-

pliance. Each unit is 3.5" 3 3" 3 1.123" an is

provided with either a lanyard, belt clip, scrub

clip, or pocket clip. Cartridges of 70% ethyl alcoholhold58mlandpressing theunit dispenses 0.75mlof

alcohol.

Recent advances in technology have improved

hand hygiene compliance. Various dispensers

have been developed based on wireless, infrared

technology, radio frequency identification (RFID),

and alcohol-sensing to detect hand hygiene compli-ance and, in some cases, actually remind health

care workers to sanitize their hands before patient

Table 3. Infection Reduced by Body-WornAlcohol-Based Dispenser (BWABD)*

Parameters ControlAfter Useof BWABDy

# Anesthesia providers 46 97

# Patients 58 53

Stopcock positive (%) 32.8 7.5

Nosocomial infection in ICU (%) 17.2 3.8

ICU, intensive care unit.

*Based on data from reference 20.ySPRIXX GJ hand sanitation unit.

HAND HYGIENE COMPLIANCE 91

contact.22 New dispensers include: HyGreen that

detects alcohol on hands,23 Proventix Systems

nGage product24 (Proventix, Birmingham, AL)

and Versus Technology that use RFID25 (Versus

Technology, Inc, Traverse City, MI) to measurecompliance, and Sprixx21 a belt-worn dispenser

with an electronic counter. HyGreen monitors

hand washing compliance by recording each

hand washing event using a wireless, infrared, ra-

dio frequency identification and alcohol-sensing

technology. Each time the health care worker dis-

penses alcohol from the wall-mounted unit, an in-

frared signal is sent to a badge worn by the healthcare worker. If the health care worker comes

within seven feet of the HyGreen monitor and

has not sanitized their hands, the badge will vi-

brate, reminding them to use the device. The Pro-

venix nGage system utilizes an RFID tag to

monitor hand hygiene compliance. Each work re-

ceives feedback through an active communication

display located above the dispenser.

The University of Iowa has developed iScrub Lite

1.5 for iPhone and iTouch.26 iScrub provides real-

time feedback on hand hygiene compliance, thus

eliminating cumbersome clipboards and transcrip-

tion.27 Observers can quickly capture information

about hand hygiene opportunities. A pilot study

has shown that iScrub improved hand hygienecompliance from 62% to 76% in a 34-week study.28

The Versus Technology requires the health care

worker to wear a small IR-RFID badge. Real-time

hand hygiene compliance can be monitored for

each health care worker: it 1) determines exactly

how often hand washing was done and 2) deter-

mines the time between hand washing and patient

care. In addition, the Versus Technology can ana-lyze themovement of health care workers in the fa-

cility and track potential contagion pathways.

Because of a rapid rise in HAIs, the University of

Pittsburgh Medical Center has threatened to fine

the health care workers who do not wash their

hands. Staff physicians will be fined $1000, resi-

dents and fellows $250, and other health careworkers will be sent home for 1 day without pay.29

The Royal College of Nursing (London) considers

the PACU to be a unique environment in most

hospitals.30 The PACU is essentially a critical con-

trol point, and the staff should practice standard

precautions at all times because it is impossible

to identify patients who are infected or carriers

of potential infections. The College states, ‘‘Effec-

tive hand hygiene should be an integral part of

clinical culture.’’30 Sometimes PACU personnel

do not have time to practice hand hygiene be-tween patients, especially if they rely solely on

soap and water. The time required for a nurse to

walk to a sink, wash and dry hands, and walk

back to the patient can take 2 to 3 minutes, mak-

ing it unreasonable when the PACU is full. The

fast action of alcohol-based hand rub has short-

ened the time for disinfection of hands. Having

alcohol-based hand rub dispensers mounted onthe wall by each bed, mounted on the end of

the bed, and a bottle of the hand rub in the pocket

of the ICU nurse has been shown to increase hand

hygiene compliance.13 Because it takes an inordi-

nate amount of time to take the bottle of hand rub

out of the pocket, flip the cap open, rub the alco-

hol on the hands, and put the bottle back in the

pocket, an alcohol-based hand rub dispensermounted on the belt or at the waist of the scrub

pants, accessed by one hand, makes hand hygiene

compliance easier and more effective.

As we evaluate the goals for hand hygiene compli-

ance, we must keep looking at the reality of the

environment in the PACU. No PACU can sustain

a 100% compliance because of a complex rangeof factors influencing health care workers’ behav-

ior related to hand hygiene performance.11 Setting

the goal too high may backfire because of frustra-

tion and eventual failure. Staff members in the

PACU, both nurses and physicians, must view

themselves as links in the infection control chain.

The ‘‘My 5 Moments of Hand Hygiene’’ of the

WHO still apply in all our health care work: handhygiene (1) before touching the patient, (2) before

cleaning/aseptic procedures, (3) after body fluid

exposure/risk, (4) after touching a patient, and

(5) after touching patient’s surroundings.18,31

With the rise of mutated pathogenic microorgan-

isms in the United States and abroad, it is impera-

tive that we practice the highest quality of handhygiene possible.32 An editorial discussing the

role of anesthesia providers cross-contaminating

patients in the OR stated: ‘‘We should not miss

the opportunity as a profession to advocate for

increased hand hygiene in the OR and support on-

going practitioner education in reducing Health-

care Associated Infections. With these efforts, we

92 WILLIAM CLAYTON PETTY

can change clinical practice and reduce prevent-

able complications in surgical patients.’’33

Summary

Hand hygiene has been shown to be the best

means of stopping cross-contamination of patho-

genic microorganisms. Wall, bedside, and pocket

alcohol-based dispensers are important instru-

ments to improve hand hygiene in health care facil-

ities. Now we can close the final gap and provide

health care workers with a body-worn alcohol-

based hand rub dispenser that will improve handhygiene compliance, especially for anesthesia,

PACU, and ICU health care providers who work

in an intense patient care environment.

References

1. Pittet D, Dharan S, Touveneau S, Sauvan V, Perneger TV.

Bacterial contamination of the hands of hospital staff during

routine patient care. Arch Intern Med. 1999;159:821-826.

2. American Society of Anesthesiologists: Recommendations

for infection control for the practice of anesthesiology (3rd ed).

ASA Committee on Occupational Health Task Force on Infec-

tion Control. 1–86. American Society of Anesthesiologists;

Park Ridge, IL. Available at: www.asahq.org. (Search: hand hy-

giene) Accessed February 17, 2012.

3. Roy R, Brull SJ, Eichhorn JH. Surgical site infections and

the anesthesia professionals’ microbiome: We’ve all been

slimed! Now what are we going to do about it? Anesth Analg.

2011;112:4-7.

4. Peterson J, Garges S, GiovanniM, et al. TheNIHHumanMi-

crobiome Project. Genome Res. 2009;19:2317-2323.

5. Nelson J, Bivens A, Shinn A,Wanzer L, Kasper C. Microbial

flora on operating room telephones. AORN J. 2006;83:607-628.

6. Fukada T, Iwakiri H, Ozaki M. Anaesthetists’ role in com-

puter keyboard contamination in an operating room. J Hosp In-

fect. 2008;70:148-153.

7. Jeske HC, Tiefenthaler W, Hohlrieder M, Hinterberger G,

Benzer A. Bacterial contamination of anaesthetists’ hands by

personal mobile phone and fixed phone use in the operating

theatre. Anaesthesia. 2007;62:904-906.

8. Vioguard. Self-sanitizing keyboard. Vioguard LLC; Kirk-

land, WA. Available at: www.vioguard.com. Accessed February

23, 2012.

9. Loftus RW, Muffly MK, Brown JR, et al. Hand contamina-

tion of anesthesia providers is an important risk factor for intra-

operative bacterial transmission. Anesth Analg. 2011;112:

98-105.

10. Boyce JM, Pittet D. Guidelines for hand hygiene in health-

care settings: Recommendations of the Healthcare Infection

Control Practices Advisory Committee and the HICPAC/SHEA/

APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epi-

demiol. 2002;23(suppl):S3-S40.

11. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-

associated infectionprevention. JHosp Infect. 2009;73:305-315.

12. Pittet D, Stephan F, Hugonnet S, Akakpo C, Souweine B,

Clergue F. Hand-cleansing during postanesthesia care. Anesthe-

siology. 2003;99:530-535.

13. Hugonnet S, Perneger TV, Pittet D. Alcohol-based hand-

rub improves compliance with hand hygiene in intensive care

units. Arch Intern Med. 2002;162:1037-1043.

14. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of

a hospital-wide programme to improve compliance with hand

hygiene. Lancet. 2000;356:1307-1312.

15. Fukada T, Tachibana C, Tsukazaki Y, Satoh K, Furuya Y,

Ohe Y. Bacterial contamination of anesthesiologists hands and

the efficacy of handwashing. Masui. 1996;45:1026-1030 [Arti-

cle in Japanese].

16. Khan MU, Siddiqui KM. Hand washing and gloving

practices among anaesthetists. J Pak Med Assoc. 2008;58:

27-28.

17. Rogues AM, Forestier JF, Valentin ML, et al. Is length of

stay in the recovery room a risk factor for cross infections?

[Le sejoar en salie de survellance postinterventionnelle peut-ll

entre a l’orgine de transmissions croisees?] Ann Fr Anesth Re-

anim. 2002;21:643-647. In French.

18. WHO Guidelines on Hand Hygiene in Health Care: First

global patient safety challenge. Clean care is safer care. World

Health Organization; Geneva, Switzerland. 2009. Available at:

www.who.int.gpsc/5may/tools/9789241597906/en. Accessed

January 31, 2012.

19. Koff MD, Corwin HL, Beach ML, Surgenor SD, Loftus RW.

Reduction in ventilator associated pneumonia in a mixed inten-

sive care unit after initiation of a novel hand hygiene program.

J Crit Care. 2011;26:489-495.

20. Koff MD, Loftus RW, Burchman CC, et al. Reduction in in-

traoperative bacterial contamination of peripheral intravenous

tubing through the use of a novel device. Anesthesiology.

2009;110:978-985.

21. SPRIXX Personal Alcohol Sanitizer Gel Dispenser. Harbor

Medical, Inc. dbaSprixx; Santa Barbara, CA. Available at:

www.sprixx.com. Accessed February 15, 2012.

22. O’Reilly KB. Hospitals’ high-tech tools track who’s wash-

ing their hands. Am Med News. 25 April 2011. Available at:

www.ama-assn.org/amednews/2011/04/25/prsa0425.html. Ac-

cessed February 24, 2012.

23. Xhale Inc. HyGreen Hand Hygiene Recording and Re-

minding System. HyGreen, Inc; Gainesville, FL. Available at:

www.hygreeninc.com. Accessed February 24, 2012.

24. Proventix Systems’ nGage System. Proventix; Birming-

ham, AL. Available at: http://proventix.com/ngage.html. Ac-

cessed February 25, 2012.

25. Versus Technology Inc. Versus Technology, Inc; Traverse

City, MI. Available at: www.versustech.com/hand_hygiene

.html. Accessed February 25, 2012.

26. PolgreenP,HldayC, SegreA.Handwashing.UIHealthCare

News. 2010. Available at: www.uihealthcare.com/news/news/

2010/05/17handwashing.html. Accessed February 24, 2012.

27. iScrub Lite University of Iowa. UI Hospitals and Clinics;

Iowa City, IA. Available at: http://itunes.apple.com/us/app/

iscrublite/id329764570?mt58. Accessed February 24, 2012.

HAND HYGIENE COMPLIANCE 93

28. Hlady CS, Curtis DE, Fries J, Yang M, Segre AM, Polgreen

PM. iScrub: A pilot interventionwith feedback from a companion

website. Presented at the 2011 SHEA Annual Scientific Meeting,

Dallas, TX, April 2, 2011. Dallas, TX. Available at: http://shea

.confex.com/shea/2011/webprogram/Paper5059.html. Accessed

February 22, 2012.

29. Smith P. UPMC threatens to fine employees: As infec-

tions rise, workers could be fined for not washing hands.

Pennsylvania: Pittsburgh Post-Gazette, Pittsburg, PA; 2011. Lex-

isNexis Academic search February 24, 2012.

30. Preventing Infection in Post-Anaesthesia Care Units. Royal

College of Nursing; London, England. Available at: www.rcn.org

.uk/_data/assets/pdf_file/0008/159758/003224.pdf. Accessed

February 24, 2012.

31. Petty WC. PACU—Why hand washing is vital! J Peria-

nesth Nurs. 2009;24:250-253.

32. Laurance J. Experts Fear Diseases ‘Impossible to Treat.’

London, UK: The Independent; 2012.

33. HopfHW,RollinsMD.Reducingperioperative infection is as

simple aswashing your hands.Anesthesiology. 2009;110:959-960.

94 WILLIAM CLAYTON PETTY

Closing the Hand Hygiene Gap in the Postanesthesia Care Unit: A Body-WornAlcohol-Based Dispenser

.83 Contact Hours

Purpose of the Journal of PeriAnesthesia Nursing: To facilitate communication about and deliver

education specific to the body of knowledge unique to the practice of perianesthesia nursing.

Purpose/Goal: The purpose of this educational activity is to review the hand hygiene gap in the PACU byusing a body-worn alcohol-based dispenser.

Target Audience: All perianesthesia nurses.

Article Objectives: (1) Identify the main route of transmission of microorganisms in a health care facility.

(2) Discuss patient and nonpatient sources of hand contamination. (3) Describe methods to increase hand

hygiene compliance.

Accreditation

American Society of PeriAnesthesia Nurses is accredited as a provider of continuing nursing education by

the American Nurses Credentialing Center’s Commission on Accreditation.

Accreditation does not imply that ASPAN or ANCC-COA approves or endorses any product included in theactivity. Additional provider numbers: Alabama #ABNP0074, California #CEP5197, Florida 50-114.

Registered nurse participants can receive .83 contact hours for this activity.

Non-endorsement of Products: Accreditation refers to recognition of continuing nursing education

activities only and does not imply ASPAN or ANCC Commission on Accreditation approval or endorsement

of any commercial product.

Disclosure: All planners and authors of continuing nursing education activities are required to disclose (1)

any significant financial relationships with the manufacturer(s) of any commercial products, goods or ser-

vices and (2) any unlabeled/unapproved uses of drugs or devices discussed in the educational activity. Anyconflicts of interest must be resolved prior to the development of the educational activity. Such disclosures

are included below.

Planner and Author Disclosure: The members of the planning committee for this continuing nursing

education activity do not have any financial arrangements, interests or affiliations related to the subject mat-

ter of this continuing education activity to disclose.

The author for this continuing nursing education activity does not have any financial arrangements, inter-

ests or affiliations related to the subject matter of this continuing nursing education activity to disclose.

Off Label Use of a Commercial Product: The author will not be discussing any off-label use of equip-ment, products, etc. in this continuing nursing education activity.

Verification of Participation: Verification of your participation in this educational activity is done by hav-

ing you complete the registration form and submit the form along with the post test and evaluation form to

the ASPAN national office.

Requirements for Successful Completion: To receive contact hours for this continuing nursing educa-

tion activity you must submit the posttest and evaluation form to the ASPAN national office and achieve

a minimum grade of 80% on the posttest.

Commercial Support: No commercial support has been received for this educational activity.

HAND HYGIENE COMPLIANCE 95

Directions: The multiple-choice examination

below is designed to test your understanding of

Closing the Hand Hygiene Gap in the Post-anesthesia Care Unit: A Body-Worn Alcohol-Based Dispenser according to the objectiveslisted. To earn contact hours from the American

Society of PeriAnesthesia Nurses (ASPAN) Con-

tinuing Education Provider Program: (1) read the

article, (2) complete the posttest by indicating

the answers in the test grid provided, and (3)

tear out the page (or photocopy) and submit post-

marked before April 31, 2015, with check payable

to ASPAN (ASPAN member, $12.00 per test; non-

member, $15.00 per test) and return to ASPAN,90 Frontage Road, Cherry Hill, NJ 08034–1424.

Notification of contact hours awarded will be

sent to you in 4 to 6 weeks.

Posttest Questions

1

1. The main route of the spread of hospital-

acquired infections (HAIs) is the cable

system from cardiac monitors.

A. TrueB. False

2. Computer keyboards are frequently contam-

inated by

A. MRSA

B. Pseudomonas aeruginosa

C. Haemophilus influenzae

D. Legionella pneumophila

3. The approximate percent of HAIs that are

usually resistant to one or more antibiotics is

A. 14%

B. 17%

C. 25%

D. 70%

4. Approximately 20% of health care workers

carry Staphylococcus aureus in their nose

but are nonsymptomatic.

A. True

B. False

5. All of the following increase the likelihood of

spreading infections in the PACU except:A. Poor hand hygiene

B. A sink-to-patient ratio of 1:5

C. High frequency patient contact

D. Cross-transfer from contaminated devices

6. Patient-related activities that increase hand

contamination of the health care provider in-

clude all of the following except:A. Direct patient contactB. Providing oral nourishment

C. Pulmonary toilet activities

D. Emptying drains

7. A patient with an HAI will begin to demon-

strate early symptoms of the infection while

still in PACU.

A. TrueB. False

8. The gold standard for hand hygiene is

A. Soap

B. Detergent and water

C. Alcohol-based hand rub

D. Petroleum-based sanitizer

9. Hand hygiene compliance is improved by

the following measure:

A. Maintaining strict adherence to a 1:1

nurse-patient ratio

B. Scheduling regular hand hygiene breaks

C. Delegating patient care tasks to the assis-

tive personnel

D. Ergonomic placement of hand rub dis-pensers

0. Body-worn alcohol dispensers were ineffec-

tive in reducing HAIs.

A. True

B. False

CLOSING THE HAND HYGIENE GAP IN THE POSTANESTHESIA CARE UNIT:A BODY-WORN ALCOHOL-BASED DISPENSER

ANSWERS

W010415 Please circle the correct answer

1. A. 2. A. 3. A. 4. A. 5. A.

B. B. B. B. B.

C. C. C.

D. D. D.

6. A. 7. A. 8. A. 9. A. 10. A.

B. B. B. B. B.

C. C. C.

D. D. D.

________________________________________________________________________________________

Please Print

Name__________________________________Nursing License No./State____________________________

Address__________________________________________________________________________________

City_______________________________State_______________________Zip_________________________

ASPAN Member #__________________________________________________________________________

EVALUATION: Closing the Hand Hygiene Gap in the Postanesthesia Care Unit: A Body-Worn Alcohol-Based

Dispenser

(SD, strongly disagree; D, disagree; ?, uncertain; A, agree; SA, strongly agree) SD D ? A SA

1. To what degree did the content meet the objectives? 1 2 3 4 5

a. Objective # 1 was met 1 2 3 4 5

b. Objective # 2 was met 1 2 3 4 5

c. Objective # 3 was met 1 2 3 4 5

2. The program content was pertinent, comprehensive, and useful to me. 1 2 3 4 5

3. The program content was relevant to my nursing practice. 1 2 3 4 5

4. Self-study/home study was an appropriate format for the content. 1 2 3 4 5

5. This educational activity was free from commercial bias. 1 2 3 4 5

6. The planner and author disclosure information was included in this educational

activity.

1 2 3 4 5

7. Identify the amount of time required to read the article and take the test:

Under 30 min 30-60 min 61-90 min 91-120 min over 120 min

Test answers must be submitted before April 30, 2015 to receive contact hours.

96 WILLIAM CLAYTON PETTY

1

HAND HYGIENE COMPLIANCE 97

1) After completion of this CE offering, I am

able to identify the main route of transmis-

sion of microorganisms in a healthcare facil-

ity.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

2) After completion of this CE offering, I am

able to discuss patient and non-patient sour-

ces of hand contamination.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

3) After completion of this CE offering, I am

able to describe methods to increase hand

hygiene compliance.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

4) The program content was pertinent, com-

prehensive, and useful to me.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

5) The program content was relevant to my

nursing practice.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

6) Self-study/home-study was an appropriate

format for the content.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

7) This educational activity was free from com-

mercial bias.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

8) The planner and author disclosure informa-

tion was included in this educational activ-

ity.

5: strongly agree4: agree3: uncertain2: disagree1: strongly disagree——————————————————

9) Identify the amount of time required to read

the article and take the test. over 120 min-

utes

91-120 minutes61-90 minutes30-60 minutes under 30 minutes——————————————————

0) Will the information you learned from this

educational activity change your practice?

YesNo

Explain: