Hand Hygiene
Figure 1
World Health Organization's 5 Moments for Hand Hygiene in acute care settings. Reproduced with permission of the publisher from "Five Moments for Hand Hygiene". World Health Organization, 2009.
Figure 2
Patient zone defined to assist in teaching healthcare personnel about indications for hand hygiene. Reproduced with permissions of the publisher, from "WHO Guidelines on Hand Hygiene in Health Care," Figure 1.21.5a. p. 122. World Health Organization.
Table 3. Recommended Practices for Hand Hygiene in the Perioperative Setting
| Preoperative Hand Preparation Steps | Traditional Surgical Scrub | Surgical Alcohol-based Hand Rub |
|---|---|---|
| Remove all jewelry from hands and wrists. Don surgical mask. | X | X |
| Wash hands using either nonantimicrobial or antimicrobial soap to ensure that they are clean at the beginning of the day. Repeat soap-and-water hand wash anytime hands are visibly soiled. | X | X |
| Use a nail pick or brush with running water at the beginning of the day to remove debris from under the nails. | X | X |
| Ensure that hands are dry after hand wash. | X | |
| Apply alcohol product to hands according to manufacturer’s instructions: usually 2 or 3 applications of 2 mL each. | X | |
| Rub hands to dry completely before donning sterile surgical gloves. Do not wipe off the product with sterile towels. | X | |
| After initial wash, wet hands and forearms under running water and apply the antimicrobial agent to wet hands and forearms using a soft, nonabrasive sponge according to the manufacturer’s directions. In general, the time required will be 3-5 minutes. | X | |
| Visualize each finger, hand, and arm as having 4 sides. Wash all 4 sides effectively, keeping the hand elevated. Repeat the process for the opposite arm. | X | |
| Rinse hands and arms under running water in one direction from fingertips to elbows. | X | |
| Hold hands higher than elbows and away from surgical attire. | X | X |
| In the OR, dry hands and arms with a sterile towel. | X |
Basic Practices for Hand Hygiene: Recommended for All Acute Care Hospitals
Select appropriate products (II).- For routine hand hygiene, choose an alcohol-based hand rub (ABHR) with at least 62% alcohol.
- Antimicrobial or nonantimicrobial soap should be available and accessible for routine hand hygiene in all patient care areas.
- For surgical antisepsis, use an ABHR that is specially formulated for surgical use, containing alcohol for rapid action against microorganisms and another antimicrobial for persistence, or use an antimicrobial soap and water. Scrub brushes should be avoided because they damage skin.
Provide convenient access to hand hygiene equipment and products by placing them strategically and assuring that they are refilled routinely as often as required (III).
- Sinks should be located conveniently and in accordance with the local
applicable guidelines. - Dispenser location may be determined by assessing staff workflow patterns or use of a more formal framework, such as Toyota Production Systems shop floor management. Counters in product dispensers can show which dispensers are frequently used and which are rarely used.
- It is important to place hand hygiene products in the flow of work to promote adherence.
- Location of dispensers and storage of ABHR should be in compliance with fire codes.
- Various components of hand hygiene products can cause irritation, and products that are not well accepted by HCPs can negatively affect hand hygiene adherence.
- Before direct patient contact.
- Before preparing or handling medication in anticipation of patient care (eg, in medication room or at medication cart before patient encounter).
- Before inserting an invasive device.
- Before and after handling an invasive device, including before accessing intravenous devices for medication administration.
- Before moving from a contaminated body site to a clean body site on the
same patient. - After direct patient contact.
- After removing gloves.
- After contact with blood or bodily fluids.
- After contact with the patient environment.
Assess unit- or institution-specific barriers to hand hygiene with frontline HCPs for the purpose of identifying interventions that will be locally relevant (III).
Implement a multimodal strategy (or “bundle”) for improving hand hygiene adherence to directly address the organization’s most significant barriers (II).
Educate, motivate, and ensure competency of HCPs (anyone caring for the patient on the institution’s behalf) about proper hand hygiene (III).
Measure hand hygiene adherence via direct observation (human observers), product volume measurement, or automated monitoring (II).
- Use a bundled approach including enhanced access to ABHR, education, reminders, feedback, and administrative support. This combination of interventions has a significant collective impact on hand hygiene adherence.
- At a minimum, use a bundled approach including education, reminders,
and feedback.
- Educate HCPs through regular sessions at hire, when job functions change, and at least annually.
- When possible use interactive means, such as fluorescing indicators, to simulate hand contamination and subsequent removal, and visual reminders, such as culture plates of hands or audience response systems, to keep the audience engaged.
- Ensure competency of HCPs by testing knowledge of the indications for hand hygiene and requiring demonstration of appropriate hand hygiene technique.
- Educate patients and families about hand hygiene on admission to healthcare facilities and when changes in circumstances warrant. Encourage patients and families to remind HCPs to clean their hands before care episodes.
- Motivate HCPs to perform hand hygiene using positive message framing for hand hygiene messaging and posters.
- Use behavioral frameworks and recognized behavioral techniques to plan and execute interventions.
- Decide on the type of measurement system on the basis of resource availability and commitment to using the data collected productively. Consider the advantages and limitations of each type of monitoring.
- Use direct observation to elucidate contextual barriers to and facilitators of hand hygiene and to provide corrective feedback to individuals.
- Use product volume measurement for large-scale benchmarking but complement with direct observation when possible.
- Use automated systems to provide real-time reminders and generate feedback for quality improvement.
Note: Be aware that such systems have been mainly used in research settings. They may be limited in their capacity to accurately measure opportunities within each patient care encounter. These systems can, however, measure a large sample of hand hygiene opportunities and can be useful for measuring trends over time and generating real-time displays for feedback.
- Provide feedback in multiple formats and on more than one occasion.
- Provide meaningful data with clear targets and an action plan in place for improving adherence.
- Meaningful data may include unit- or role-based adherence data rather than overall performance.
- Real-time displays of hand hygiene adherence may provide some incentive for improvement on a shift-by-shift basis.
Special Approaches for Hand Hygiene Practices
- During norovirus outbreaks, in addition to contact precautions requiring the use of gloves, consider preferential use of soap and water after caring for patients with known or suspected norovirus infection (III).
- During C. difficile outbreaks or in settings with hyperendemic CDI, in addition to contact precautions requiring the use of gloves, consider preferential use of soap and water after caring for patients with known or suspected CDI (III).
Clostridium difficile
- Clostridium difficile now rivals methicillin-resistant Staphylococcus aureus (MRSA) as the most common organism to cause healthcare-associated infections (HAIs) in the United States, more than doubling its incidence between 2000 and 2009.
- C. difficile infection (CDI) with onset outside the hospital may be more common than previously recognized, with ≥50% of CDIs having onset in the community. In addition, ≥75% of CDI cases have onset outside the acute care hospital.
- There have been numerous reports of an increase in CDI severity. Most reports of increases in the incidence and severity of CDI have been associated with the BI/NAP1/027 strain of C. difficile. Some studies have found that this strain produces more toxin A and B in vitro than most other strains of C. difficile, and it may produce more spores. It also produces a third toxin (binary toxin). BI/NAP1/027 is highly resistant to fluoroquinolones.
- CDI increases hospital length of stay by 2.8-5.5 days.
- In studies over the past 10 years, fluoroquinolones, previously infrequently associated with CDI, have been found to be primary precipitating antimicrobials.
- Cephalosporins, ampicillin, and clindamycin remain important predisposing antibiotics.
- Gastric acid suppression has been recognized as a risk factor for CDI in some studies.
Basic Practices for Prevention and Monitoring of CDI: Recommended for All Acute Care Hospitals
- Encourage appropriate use of antimicrobials (II).
- Use contact precautions for infected patients, single-patient room preferred (III for hand hygiene, II for gloves, III for gowns, III for single-patient room).
- Ensure cleaning and disinfection of equipment and the environment (III for equipment, III for environment).
- Implement a laboratory-based alert system to provide immediate notification to infection prevention and control (IPC) and clinical personnel about newly diagnosed CDI patients (III).
- Conduct CDI surveillance and analyze and report CDI data (III).
- Educate health care practitioners (HCPs), environmental service personnel, and hospital administration about CDI (III).
- Educate patients and their families about CDI as appropriate (III).
- Measure compliance with Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) hand hygiene and contact precaution recommendations (III).
Approaches that Should NOT be Considered a Routine Part of CDI Prevention
- Patients without signs or symptoms of CDI should NOT be tested for C. difficile (II).
- C. difficile testing should NOT be repeated at the end of successful therapy in a patient recently treated for CDI (III).
- Do NOT routinely place patients who are on antimicrobials for other indications on CDI treatment to prevent CDI (III).
Table 1. Fundamental Elements of Accountability for Healthcare-Associated Infection Prevention
- Senior management is responsible for ensuring that the healthcare system supports an infection prevention and control (IPC) program that effectively prevents healthcare-associated infections (HAIs) and the transmission of epidemiologically important pathogens.
- Senior management is accountable for ensuring that an adequate number of trained personnel are assigned to the IPC program and adequate staffing of other departments that play a key role in HAI prevention (eg, environmental services).
- Senior management is accountable for ensuring that healthcare personnel, including licensed and nonlicensed personnel, are adequately trained and competent to perform their job responsibilities.
- Direct HCPs (such as physicians, nurses, aides, and therapists) and ancillary personnel (such as environmental service and equipment processing personnel) are responsible for ensuring that appropriate IPC practices are used at all times (including hand hygiene, standard and isolation precautions, and cleaning and disinfection of equipment and the environment).
- Senior and unit leaders are responsible for holding personnel accountable for their actions.
- IPC leadership is responsible for ensuring that an active program to identify HAIs is implemented, that HAI data are analyzed and regularly provided to those who can use the information to improve the quality of care (eg, unit staff, clinicians, and hospital administrators), and that evidence-based practices are incorporated into the program.
- Senior and unit leaders are accountable for ensuring that appropriate training and educational programs to prevent HAIs are developed and provided to personnel, patients, and families.
- Personnel from the IPC program, the laboratory, and information technology departments are responsible for ensuring that systems are in place to support the surveillance program.
Catheter-Associated Urinary Tract Infections
Key Points
- Urinary tract infection (UTI) is one of the most common hospital-acquired infections; 70%-80% of these infections are attributable to an indwelling urethral catheter.
- The burden of CAUTI in pediatric patients is not well defined.
- Twelve to sixteen percent of adult hospital inpatients will have a urinary catheter at some time during admission.
- The daily risk of acquisition of bacteriuria varies from 3%-7% while an indwelling urethral catheter remains in situ.
- In one 3-year Canadian study, the incidence of urinary-to-bloodstream infections was 1.4/10,000 patient-days. All-cause 30-day mortality in these patients was 15%.
- Catheter use is associated with negative outcomes in addition to infection, including nonbacterial urethral inflammation, urethral strictures, mechanical trauma, and mobility impairment.
Basic Practices for Preventing CAUTI (recommended for all acute care hospitals)
Appropriate infrastructure for preventing CAUTI
- Provide and implement written guidelines for catheter use, insertion, and maintenance (III).
- Ensure that only trained, dedicated personnel insert urinary catheters (III).
- Ensure that supplies necessary for aseptic technique for catheter insertion are available and conveniently located (III).
- Implement a system for documenting the following in the patient record: physician order for catheter placement, indications for catheter insertion, date and time of catheter insertion, name of individual who inserted catheter, nursing documentation of placement, daily presence of a catheter and maintenance care tasks, and date and time of catheter removal. Record criteria for removal or justification for continued use (III).
- Ensure that there are sufficient trained personnel and technology resources to support surveillance for catheter use and outcomes (III).
Surveillance for CAUTI
(if indicated on the basis of facility risk assessment or regulatory requirements)
- Identify the patient groups or units in which to conduct surveillance on the basis of risk assessment, considering frequency of catheter use and potential risk (eg, types of surgery, obstetrics, critical care) (III).
- Use standardized criteria, such as CDC's National Healthcare Safety Network (NHSN) definitions, to identify patients who have a CAUTI (numerator data) (III).
- Collect information on catheter-days and patient-days (denominator data) and indications for catheter insertion for all patients in the patient groups or units being monitored (III).
- Calculate CAUTI rates and/or standardized infection ratio (SIR) for target populations (III).
- Use surveillance methods for case finding that are documented to be valid and appropriate for the institution (III).
- Consider providing unit-specific feedback (III).
Education and training
- Educate healthcare personnel (HCP) involved in the insertion, care, and maintenance of urinary catheters about CAUTI prevention, including alternatives to indwelling catheters and procedures for catheter insertion, management, and removal (III).
- Assess HCP competency in catheter use, catheter care, and maintenance (III).
Appropriate technique for catheter insertion
- Insert urinary catheters only when necessary for patient care and leave in place only as long as indications remain (II).
- Consider other methods for bladder management, such as intermittent catheterization, where appropriate (II).
- Practice hand hygiene (based on CDC or WHO guidelines) immediately before insertion of the catheter and before and after any manipulation of the catheter site or apparatus (III).
- Insert catheters following aseptic technique and using sterile equipment (III).
- Use sterile gloves, drape, and sponges; a sterile or antiseptic solution for cleaning the urethral meatus; and a sterile single-use packet of lubricant jelly for insertion (III).
- Use as small a catheter as possible consistent with proper drainage, to minimize urethral trauma (III).
Management of indwelling catheters
- Properly secure indwelling catheters after insertion to prevent movement and urethral traction (III).
- Maintain a sterile, continuously closed drainage system (III).
- Replace the catheter and the collecting system using aseptic technique when breaks in aseptic technique, disconnection, or leakage occur (III).
- For examination of fresh urine, collect a small sample by aspirating urine from the needleless sampling port with a sterile syringe/cannula adaptor after cleansing the port with disinfectant (III).
- Obtain larger volumes of urine for special analyses aseptically from the drainage bag (III).
- Maintain unobstructed urine flow.
- Keep the collecting bag below the level of the bladder at all times. Do not place the bag on the floor (III).
- Keep catheter and collecting tube free from kinking (III).
- Empty the collecting bag regularly using a separate collecting container for each patient. Avoid touching the draining spigot to the collecting container (III).
- Employ routine hygiene. Cleaning the meatal area with antiseptic solutions is unnecessary (III).
Special Approaches for Preventing CAUTI
Perform a CAUTI risk assessment. These special approaches are recommended for use in locations and/or populations within the hospital with unacceptably high CAUTI rates or SIRs despite implementation of the basic CAUTI prevention strategies listed previously.
- Implement an organization-wide program to identify and remove catheters that are no longer necessary using one or more methods documented to be effective (II).
- Develop a protocol for management of postoperative urinary retention, including nurse-directed use of intermittent catheterization and use of bladder scanners (II).
- Establish a system for analyzing and reporting data on catheter use and adverse events from catheter use (III).
Approaches that Should NOT be Considered a Routine Part of CAUTI Prevention
- Do NOT routinely use antimicrobial/antiseptic-impregnated catheters (I).
- Do NOT screen for asymptomatic bacteriuria in catheterized patients (II).
- Do NOT treat asymptomatic bacteriuria in catheterized patients except before invasive urologic procedures (I).
- Avoid catheter irrigation (II).
- Do NOT use systemic antimicrobials routinely as prophylaxis (III).
- Do NOT change catheters routinely (III).
Urinary Catheter Reminder
Date: ___/___/______
This patient has had an indewelling urethral catheter since ___/___/______
Please indicate below EITHER (1) that the catheter should be removed OR
(2) that the catheter should be retained. If the catheter should be retained, please state ALL of the reasons that apply.
❑ Please discontinue indwelling urethral catheter; OR
❑ Please continue indwelling urethral catheter because patient requires indwelling catheterization for the following reasons (please check ALL that apply):
❑ Urinary retention
❑ Very close monitoring of urine output and patient unable to use urinal or bedpan
❑ Open wound in sacral or perineal area and patient has urinary incontinence
❑ Patient too ill or fatigued to use any other type of urinary collection strategy
❑ Patient had recent surgery
❑ Management of urinary incontinence on patient's request
❑ Other — please specify:
Surgical Site Infections
Key Points
- Surgical site infections (SSIs) occur in 2%-5% of patients undergoing inpatient surgery.
- Approximately 160,000-300,000 SSIs occur each year in the US.
- SSI is now the most common and most costly hospital-acquired infection.
- Up to 60% of SSIs have been estimated to be preventable by using evidence-based guidelines.
Basic Practices for Preventing SSI
- Administer antimicrobial prophylaxis according to evidence-based standards and guidelines (I).
- Adjust dosing on the basis of patient weight.
- Redose prophylactic antimicrobial agents for long procedures and in cases with excessive blood loss during the procedure.
- Use a combination of parenteral antimicrobial agents and oral antimicrobials to reduce the risk of SSI following colorectal procedures.
- DO NOT remove hair at the operative site unless the presence of hair will interfere with the operation. Do not use razors (I).
- Control blood glucose during the immediate postoperative period for cardiac surgery patients (I) and noncardiac surgery patients (II).
- Maintain normothermia (temperature of 35.5°C or more) during the perioperative period (I).
- Optimize tissue oxygenation by administering supplemental oxygen during and immediately following surgical procedures involving mechanical ventilation (I).
- Use alcohol-containing preoperative skin preparatory agents if no contraindication exists (I).
- Use impervious plastic wound protectors for gastrointestinal and biliary tract surgery (I).
- Use a checklist based on the WHO checklist to ensure compliance with best practices to improve surgical patient safety (I).
- Perform surveillance for SSI (II).
- Identify, collect, store, and analyze data needed for the surveillance program.
- Perform postoperative surveillance for 30 days; extend the postoperative surveillance period to 90 days for certain procedure categories.
- Surveillance should be performed on patients readmitted to the hospital.
- Increase the efficiency of surveillance through utilization of automated data (II).
- Provide ongoing feedback of SSI rates to surgical and perioperative personnel and leadership (II).
- Measure and provide feedback to providers regarding rates of compliance with process measures (III).
- Educate surgeons and perioperative personnel about SSI prevention (III).
- Educate patients and their families about SSI prevention as appropriate (III).
- Implement policies and practices aimed at reducing the risk of SSI that align with evidence-based standards (eg, CDC, Association for periOperative Registered Nurses, and professional organization guidelines) (II).
Special Approaches for Preventing SSI
- Screen for S. aureus and decolonize surgical patients with an antistaphylococcal agent in the preoperative setting for high-risk procedures, including some orthopedic and cardiothoracic procedures (II).
- Perform antiseptic wound lavage (II).
- Perform an SSI risk assessment (III).
- Observe and review OR personnel and the environment of care in the OR (III).
- Observe and review practices in the postanesthesia care unit, surgical ICU, and/or surgical ward (II).
Approaches That should Not Be Considered a Routine Part of SSI Prevention
- DO NOT routinely use vancomycin for antimicrobial prophylaxis (II).
- DO NOT routinely delay surgery to provide parenteral nutrition (I).
- DO NOT routinely use antiseptic-impregnated sutures as a strategy to prevent SSIs (II).
- DO NOT routinely use antiseptic drapes as a strategy to prevent
SSIs (I).
Table 2. Selected Risk Factors for and Recommendations to Prevent Surgical Site Infections (SSIs)
Intrinsic, patient related (preoperative)
Unmodifiable
| Risk Factor | Recommendation | Quality of Evidence |
|---|---|---|
| Age | No formal recommendation. Relationship to increased risk of SSI may be secondary to comorbidities or immunosenescence. | NA |
| History of radiation | No formal recommendation. Prior irradiation at the surgical site increases the risk of SSI, likely due to tissue damage and wound ischemia. | NA |
| History of SSTIs | No formal recommendation. History of a prior skin infection may be a marker for inherent differences in host immune function. | NA |
Modifiable
| Risk Factor | Recommendation | Quality of Evidence |
|---|---|---|
| Glucose control | Control serum blood glucose levels for all surgical patients, including patients without diabetes. For patients with diabetes mellitus, reduce glycosolated hemoglobin A1c levels to <7% before surgery, if possible. | I |
| Obesity | Increase dosing of prophylactic antimicrobial agent for morbidly obese patients. | I |
| Smoking cessation | Encourage smoking cessation within 30 days of procedure. | I |
| Immunosuppressive medications | Avoid immune-suppressive medications in perioperative period, if possible. | III |
| Hypoalbuminemia | No formal recommendation. Although a noted risk factor, DO NOT delay surgery for use of total parenteral nutrition. | NA |
Extrinsic, procedure related (perioperative)
Preparation of patient
| Risk Factor | Recommendation | Quality of Evidence |
|---|---|---|
| Hair removal | DO NOT remove unless hair will interfere with the operation. If hair removal is necessary, remove outside the OR by clipping. DO NOT use razors. | II |
| Preoperative infections | Identify and treat infections (eg, urinary tract infection) remote to the surgical site prior to elective surgery. DO NOT routinely treat colonization or contamination. | II |
Extrinsic, procedure related (perioperative)
Operative characteristics
| Risk Factor | Recommendation | Quality of Evidence |
|---|---|---|
| Surgical scrub (surgical team members’ hands and forearms) | Use appropriate antiseptic agent to perform preoperative surgical scrub. For most products, scrub the hands and forearms for 2-5 minutes. | II |
| Skin preparation | Wash and clean skin around incision site. Use a dual agent skin preparation containing alcohol, unless contraindications exist. | I |
| Antimicrobial prophylaxis | Administer only when indicated. | I |
| Timing | Administer within 1 hour of incision to maximize tissue concentration.a | I |
| Choice of prophylactic agent | Select appropriate agents on the basis of surgical procedure, most common pathogens causing SSIs for a specific procedure, and published recommendations. | I |
| Duration of prophylaxis | Stop agent within 24 hours after the procedure for all procedures. | II |
| Blood transfusion | Blood transfusions increase the risk of SSI by decreasing macrophage function. Reduce blood loss and need for blood transfusion to the greatest extent possible. | II |
| Surgeon skill/technique | Handle tissue carefully and eradicate dead space. | III |
| Appropriate gloving | All members of the operative team should double-glove and change gloves when perforation is noted. | III |
| Asepsis | Adhere to standard principles of OR asepsis. | III |
| Operative time | No formal recommendation in most recent guidelines. Minimize as much as possible without sacrificing surgical technique and aseptic practice. | I |
Operating room characteristics
| Risk Factor | Recommendation | Quality of Evidence |
|---|---|---|
| Ventilation | Follow American Institute of Architects’ recommendations for proper air handling in the OR. | III |
| Traffic | Minimize OR traffic. | III |
| Environmental surfaces | Use an EPA-approved hospital disinfectant to clean visibly soiled or contaminated surfaces and equipment. | III |
| Sterilization of surgical equipment | Sterilize all surgical equipment according to published guidelines. Minimize the use of immediate-use steam sterilization. | II |
a Vancomycin and fluoroquinolones can be given 2 hours prior to incision.