using science to guide hand hygiene surveillance teleclass slides… · 2016. 9. 28. · using...

Using Science to Guide Hand Hygiene Surveillance and Improvement Prof. Eli Perencivich, University of Iowa

Broadcast live from the Infection Prevention Society conference

A Webber Training Teleclass www.webbertraining.com

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EliPerencevich,MDMSProfessorofInternalMedicine

UniversityofIowa,CarverCollegeofMedicine

PIandDirector,VAHSR&DCenterforComprehensiveAccessandDeliveryResearch&EvaluaDon

ControversiesBlog:stopinfecDons.org

[email protected]

TwiKer:@eliowa

AyliffeLecture:Usingsciencetoguidehandhygienesurveillanceandimprovement

www.webbertraining.com September 28, 2016

ConflictsofInterestStatement

! Nofinancialconflicts! SecDonEditorforGuidelines,PosiDonPapers,andInvitedReviews@ICHE

! FederalFunding! VAHSR&D(COINandCREATE)! CDCPrevenDonEpicenter! AHRQ




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Thistalkwillreviewthesciencebehindmonitoringandimprovinghandhygiene

Handhygienebasics–opportuni<es,barriersandeffec<veinterven<ons

Systemtypesandeffec9veness

Publica9onBias,Hawthorne

Handhygieneisimportant…

hKp://xkcd.com/1161/




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Handhygieneisimportant…

hKp://xkcd.com/1161/

Sneeze into your elbow!!

HandHygieneatCrossroads

! “HandHygieneCompliance:arewekiddingourselves?”1

! Targetssetat>90%,metbymostfaciliDes! 2009-2014SystemaDcReview2

! MeancompliancebeforeintervenDon–34%! AgerintervenDon–57%

! Whatshouldbethetarget?–Fairmonitoring! Achievable

! Beneficial

1. Mahida N. JHI 2016 (92) 307-8 2. Kingston L. et al. JHI 2016:309-20

FOR MORE INFO...




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VeteransHealthAdministraDon

! VHAislargestintegratedhealthsysteminUS

! 168VAMedicalCenters! 132Community-LivingCenters(NursingHomes)

! 1,053OutpaDentClinics

! Servesover9millionenrolledveterans! Centralizedmedicalrecordsandpolicies

HandHygiene2015:Complicated

! CDCGuidelineforHandHygieneinHealth-CareSenngs(2002)-56Pages

! WHOGuidelineonHandHygieneinHealthCare(2009)-270pages

! VHADIRECTIVE2011-007! EffecDve:March1,2011! Expired:February29,2016




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2012VHAHandHygieneSurvey

! VHAHandHygieneWorkgroup! 141VAhealthcaresystemsparDcipated

! AdministeredthroughtheOfficeoftheDeputyUnderSecretaryofHealthcareOperaDonManagement(DUSHOM)Office! “thestaffmemberresponsiblefortheirfacility’shandhygieneprogram”

51-ItemIntranet-BasedSurvey

! Threeareasoffocus:

1. HowhospitalsmeasuredHCWshandhygiene2. Whichinterven9onstrategiesshouldberecommendedtoimprovecompliance

3. Facilitythreshold/goalforcompliance

Reisinger HS et al. Am J Infect Control 2013 Nov;41(11):989-93

FOR MORE INFO...




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HowdidVHAmeasurecompliancein2012?%

(N=

141)


FOR MORE INFO...

Whendidtheymeasurecompliance?

N=

141





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WhichWHOMoments?

WHOFiveMomentsfrom“CleanCareisSaferCare”Pa/entSafetyChallengeandGuidelinesonHHinHealthCare(2009)


Havinga(handhygiene)moment

http://haicontroversies.blogspot.com/2011/11/im-having-hand-hygiene-moment.html




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WhichOpportuniDes?

! ComparecomplianceusingWHO“My5Moments”vs“Before&Ager”or“Before”(2009-201)

! Before&APermayprovideasurrogatemarkerofoverallhandhygienecompliance

Stewardson A. et al. J Hosp Infect Volume 77, Issue 4, April 2011, Pages 358–359

Feasibilityof“WHOMy5Moments”vsEntry/ExitintheUS?

! 3hospital(6ward,5ICU)studycomparingabilitytomonitorWHOM5MvsEntry/Exitcompliance

! QuesDon:Couldwe“see”it?

! WHOM5MinICUvsWard! M5Mobservedduring39%ofepisodesofcareinICU! Comparedto28%observedonwards,P<0.01

Chung N. et al, Am J Infect Control. 2016




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Entry/ExitcapturesmostWHOM5MOpportuni9es

ICHE 35:7 (July 2014), pp. 826-832

! 257hours

! 1605opportuni9es! Mean4.2op/hour

! 77%RN,8%MDs

42%

10%

9% 39%

Howmuchmonitoringhappens?

Observa9onspermonthperward/unit/clinic

Minutesperobserva9onperiod

N=121 N=134





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BarrierstoCompliance:Needmorethanfeedbacktoimprovehandhygiene

! SkindrynessandirritaDon! NoDmetowash,nursingworkload

! Inconvenientsinks,handhygienedispensers! FirecodesinUS

! Carryingsomethinginyourhandswhenentering

! Compliancenotindividuallytracked*

Recognizingthebarriers,whatintervenDonshavebeenproventoincreasecompliance?

! SystemaDcReview2000toApril2012

! 8148arDclesidenDfied,65fullyreviewed

! 45studiesincluded(RCTandQuasi-experimental)

Schweizer et al. Clin Infect Dis 2014 Jan;58(2):248-59




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WHOMulDmodalHandHygieneImprovementStrategy

! EducaDon! Accesstodispensers/pocketsizehandrub! Reminders! InsDtuDonalSafetyClimate(AdministraDveSupport)

! Feedback*! 27studies,onlyoneanalyzedalone

ThereisstrongevidenceforWHObundle

Schweizer et al. Clin Infect Dis 2014 Jan;58(2):248-59




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Howmuchhandhygieneisenough?

! NomaKerhowwemeasureit,whencanwebesaDsfiedthatweareprevenDnginfecDons?

IsthereatargetthresholdforhandhygienecomplianceassociatedwithreducedinfecDons?

Kirkland KB, et al. BMJ Qual Saf 2012;21:1019-26




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Mostofhospitalshavecompliancearound40-60%


Handhygienecompliancethreshold?





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Handhygienecompliancethreshold?


Butwhataboutautomatedsystems?

! SystemaDcreview:1Jan2000–31March2013

! 3,463arDclesidenDfied,42included! EnhanceddirectobservaDon! Videomonitoring! Electronicdispensercounters! Automatedmonitoringnetworks

Ward M et al. AJIC 2014




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EnhanceddirectobservaDonsystems

! 5studies

! iScrub–free

! Customizable,Dme-stamped

! Emailspreadsheet

! Maysimplifyaudit-feedback

! Noevidenceofbenefit

http://compepi.cs.uiowa.edu/index.php/Research/IScrub

Video-monitoringshowspotenDaltoimprovecompliance

! 4studies

! Generallyassociatedwithimprovedcompliance

! Placementimportant! 5moments

! “BigBrother”

! Costs-$50,000plus$1000/monthin17bedunit





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Third-partyremotevideomonitoringeffecDveintervenDoninMICUandSICU

! 2yearstudy

! Cameraofsinks/dispensers

! SensorforEntry/Exit

! MonitorsinIndia

! Pre-feedback10%

! Post-feedback81.6%

! At75weeks87.9%

Armellino D et al. Clin Infect Dis 2012 Armellino D et al AJIC 2013

ElectronicDispenserCounters

! 15studies

! Time-stamped

! Can’tdetermineappropriateness,lacksdenominator

! AssociatedwithimprovedaccuracyvsdirectobservaDon*

*MorganDMAJIC2012

*MarraARICHE2010




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CounterswithfeedbacknoteffecDve

! 6-monthintervenDonvscontrolstep-downunits

! IntervenDon:countsgiventoindividualnurses2x/week,placedinchart,comparedtoothernurses

MarraARICHE2008

OutcomeVariable Interven9onUnit ControlUnit p

AlcoholGel 33.6 30.2 .54

CHG 7.5 5.6 .59

Total 41.1 35.8 .56

ButwhenthePosiDveDeviancemodelapplied,handhygieneincreased

! Samestep-downunits(SDU)andcounters

! 9monthstudy–3x3-monthperiods

MarraARICHE2010

Pre-intervention PD East SDU PD Both SDU

alcohol East West East West East West

dispense/1000 pt-days

46,890 44,460 62,000* 33,570 57,930 43,980

L / 1000 pt-days

136 115 250* 126 239 205

P <0.01




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Automatedhand-hygienemonitoringnetworks

! 18studies

! DetectwhenHCWentersandhandhygieneevent,remindHCW,wearablecomponent

! Audiblereminderonwardentranceraisedhandhygienefrom8%to50%inHCWandvisitors*

! Urgent-care,13HCWstudywithmonthlyreminders:37%to49%compliancep<0.01#

*FakhryMetal.AJIC2012

#SahudAGetal.JHI2012

Alcohol-sensingbadgeswithaudio-visualreminders

! 35-bedorthopaedicsward

! 19nursesworecredit-card-sizedalcoholsensorbadge(BioVigilLLC,SantaRosa,CA,USA)fortwoweeks

! Doorsensortriggeredbyentry

! Ifalcoholdetected–green+ping

! Ifalcoholnot-detected–red+beep

! 31-daystudy

Edmondetal.JHI2010,76;354-372




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Alcoholsensorbadgeraisedcompliance

Phase 1: Direct Observation

Compliance=66%

Phase 2: Electronic monitoring

Compliance=93%

Edmondetal.JHI2010,76;354-372

P =0.01

SystemaDcReviewRecommendaDon–Holdoffonbuyingthesesystems

! Small,uncontrolled,quasi-experimentalstudies

! “LimiteddataiscurrentlyavailabletorecommendadopDonofspecificautomaDcorelectronically-assistedhandhygienesurveillancesystems…GiventherestrictedclinicalandinfecDonprevenDonbudgetsofmostfaciliDes,cost-effecDvenessanalysisofspecificsystemswillberequiredbeforethesesystemsarewidelyadopted”





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Caveatemptor-“Letthebuyerbeware”

Effect Measure (ln RR)

Stan

dard

Err

or

! Buyersvs.sellers“informaDon”

! “Publica9onBias”:invesDgatorsdon’tpublishsmalland/ornegaDvestudies

CochraneDatabaseSystRev.2007Apr18;(2):MR000005

DID THEY PUBLISH THEIR ABSTRACTS?




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CochraneDatabaseSystRev.2007Apr18;(2):MR000005

Whichabstractsarelikelytobepublished?

! “Posi9ve”results(RR=1.30;CI1.14-1.47)

! Oralvs.poster(RR=1.28;CI1.09-1.49)

! Higherqualityofabstracts(RR=1.30,CI1.00-1.71)




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Real-DmelocaDonsystem(RTLS)abstract

! Before/AgerQEDesign! 10-monthstudy

! RTLSbadges

! IRbeaconsinstalledinrooms

! Outcome:directlyobservedentry-exitcompliance

BoyceJMIDWeek2012#37759

RTLSelectronicmonitoringsystemassociatedwithlowercompliance

! 36% decline in entry compliance (p=0.191) ! 32% decline in the exit compliance (p<0.001)

! The average accuracy of the badge RTLS system was 60% ! False-negative results led to HCW frustration

! Negative study – not published

BoyceJMIDWeek2012#37759




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Reminder:MostusedirectobservaDon%

(N=

141)


FOR MORE INFO...

Butifdirect-observaDonissoterrible,shouldn’twejustbuyasystemanyway?

! HandhygieneopportuniDesaretoonumerous! Nightandweekendshigs! ToomuchDme/moneytomonitor! Doweneedtocounteveryone?

! HawthorneEffect




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Lotsofhandhygieneopportuni9esgoingon

Am J Infect Control. 2014 Jun;42(6):602-7

! 12bedsingenmedward

! Video–5moments

! 72op/pa9ent/day

! 75%RN,5%MD

! If140,000pa9entdays

! 10million/year!!!

HowmanyobservaDonsneeded?

! ProspecDvecohort,3hospitals! 7,743HCWvisits! 1,989hoursofobservaDon! 3.89/hour/room

! Samplepowercalcula9ons! 10%absolutecompliancechangemonth-to-month! 2-sidedtest,typeIerrorat5%significance,80%power

Yin J. ICHE 2014;35 (9):1163-8




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UsecharttoesDmatenumberofopportuniDesandhoursofdirectobservaDon

BaselineHH TargetHH #opportuni9es#hours

(1roomat9me)#hours

(2roomsat9me)

40 50 191 50 25

50 60 194 50 25

60 70 182 47 23.5

70 80 153 40 20

80 90 108 28 14

Yin J. ICHE 2014;35 (9):1163-8

TheHawthorneEffectisalimitaDonofdirect-observaDonsurveillance

! Improvementofhumanbehaviorwhenasubjectknowstheyarebeingobserved

1932

HawthorneWorks,CiceroIL




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LengthofObservaDonPeriods?

Chen LF ICHE 2013; 34(2): 207-10

EvidenceofHawthorneEffect

! ProspecDveCohort:March2011–May2013

! 3VAhospitals! 5ICUs! 6medical/surgicalwards

! Research-assistantobservers! Hallway,didnotannouncepresence! Monitoredforfixed1-hourintervals! OpportuniDesEntry/Exit

Yin J. ICHE 2014;35 (9):1163-8




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Hypothesis

! IftheHawthorneeffectwasconDnuousacrossallDmeperiods,expectcompliancetoremainunchangedduringenDre1-hourobservaDonperiod

! Askedwhethermeanhandhygienecomplianceratechangedsignificantlyoverthe1-hourperiod! Finnglinearregressiontothehandhygienecompliancerate

Results

! 11,444HHopportuniDes! 3,432hoursofdirectobservaDons

! EntryCompliance:41.3%! (4,546/11,018opportuniDes)

! ExitCompliance59.4%! (6,225/10,488opportuniDes)

Yin J. ICHE 2014;35 (9):1163-8




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Entrycomplianceshowsincreasedbiasagerobserveronward>38minutes

! Before38minutes! 40.4%

! Ager38minutes! 43.4%

! p=0.005

Yin J. ICHE 2014;35 (9):1163-8

LimiDngobserverDmeonwardtolessthan14minutesreducesbias

! Before14minutes! 56.2%

! Between14-50minutes! 60.5%

! Ager50minutes! 66.0%

! P<0.001

YinJ.ICHE2014;35(9):1163-8




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Punngitalltogether

VHAHandHygieneWorkgroup

! BradleyBender,MD–ChiefofStaff(Gainesville)

! ElizabethEckstein,RN–IP(Cleveland)

! KimFindley,RN–AssocClinResearch(COHIC)! CarolKeller–SystemsRedesignManager(WestLA)

! TroyKnighton,EdS–IDPIO(OPH)

! CarylLee,RNMSN–NaDonalCenterPaDentSafety

! MichaelMarDn–NAGE(MarDnsburg)

! RichardMarDnello,MDClinicalPublicHealth(OPH)




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VHAHandHygieneWorkgroup

! DanielMorgan,MD–HospitalEpi(BalDmore)

! EliPerencevich,MD–WorkgroupChair)(IowaCity)

! LesleyRoyal,RN–IP(Omaha)! HeatherReisinger,PhD–MedAnthro(IowaCity)

! CarolVanDeusenLukas,EdD–COLMR(Boston)

! AmyZoll,RN–ClinicalNurse(KansasCity)

! LewisRadonovich,MD–COHIC,OPH(Gainesville)

DRAFTUNDERSECRETARYFORHEALTH’SINFORMATIONLETTERESTABLISHINGASTANDARDFORHANDHYGIENESURVEILLANCEINHEALTHCARESETTINGS

! (1)MonitorHandHygiene:! “Beforepa9entinterac9on”definedashandhygieneimmediatelyonorbeforeenteringthespaceoccupiedbyapaDent.

! “APerpa9entinterac9on”definedashandhygieneimmediatelyonorbeforeexiDngthespaceoccupiedbyapaDent.

! (2)DuraDonofDirectObservaDonPeriods! “monitoringbyoneormorepersonnelinasinglelocaDonshouldpersistfornomorethan15minutesateachlocaDon”




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! (3)NumberofobservaDonsrequiredperquarter! Minimumof200beforeandaPer(i.e.,200beforeentryand200agerexit)

! Note:approximately4-5opportuniDesareobservedperhour

! Wouldrequire40-50hoursofobservaDonperquarterorabout13-17hoursofobservaDonpermonth

DRAFTUNDERSECRETARYFORHEALTH’SINFORMATIONLETTERESTABLISHINGASTANDARDFORHANDHYGIENESURVEILLANCEINHEALTHCARESETTINGS

Conclusions:KeepHandHygieneSimple!

! Automatedsystemscanmonitorbutcompliancebenefitsunproven! Norandomizedtrials! NoevidenceforlowerinfecDons! SignificantpublicaDonbias

! Don’tgiveupondirect-observa9on! Focusonentry/exitmonitoring

! Lessthan14minutes!




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Thankyou

Fistbumpsandweakhandshakesonly…

Mela et al. AJIC 42 (8): 916-7, August 2014




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QuesDonsandThankyou!

! Automatedsystemscanmonitorbutcompliancebenefitsunproven! Norandomizedtrials! NoevidenceforlowerinfecDons! SignificantpublicaDonbias

! Don’tgiveupondirect-observa9on! Focusonentry/exitmonitoring

! Lessthan14minutes!

QUESTIONS?@[email protected]

September 29 ADHERENCE ENGINEERING TO REDUCE CENTRAL LINE ASSOCIATED BLOODSTREAM INFECTIONS Prof. Frank Drews, University of Utah

October 13 UPDATE ON STRATEGIES FOR CLEANING AND DISINFECTION OF ENVIRONMENTAL SURFACES IN HEALTHCARE Prof. John Boyce, J.M. Boyce Consulting Sponsored by Sealed Air Diversey Care (www.sealedair.com)

October 19 (South Pacific Teleclass) TECHNOLOGY FOR MONITORING HAND HYGIENE IN THE 21ST CENTURY – WHY ARE WE USING IT? Prof. Mary-Louise McLaws, University of New South Wales, Australia

October 20 (FREE Teleclass) THE HISTORY OF CBIC AND WHY CERTIFICATION IS STILL IMPORTANT TODAY




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using science to guide hand hygiene surveillance teleclass slides… · 2016. 9. 28. · using...

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