Dr. Longtin will present the 10 principal factors which explain the poor compliance of health care workers to hand hygiene practices and will offer solutions to help resolve the issue. At the end of the lecture, the participant will have the background information to formulate arguments to promote good hand hygiene practices.

1. The 10 obstacles to
Yves Longtin, MD
Microbiologist-infectious disease specialist
CHUQ-CHUL and IUCPQ
Université Laval
Hand hygiene

2. Once upon a time… in 1842

3. Rate of maternal mortality
• 16% in division I
– Residents
• 7% in division II
– Midwives
• Very rare at
home…

4. Ignaz Philipp Semmelweis,
1818-65

5. A clue…
• A pathologist cut his
finger during an
autopsy…
• He died not long
after of an illness
similar to puerperal
fever
Jakob Kolletschka (1803-1847)

6. Sir William Osler, 1907

8. Pre-dated by 15 years Pasteur’s 1861 work
“Mémoire sur les corpuscules organisés qui existent dans
l'atmosphère. Examen de la doctrine des générations
spontanées”, which discussedstructured bodies present in
the atmosphere and the doctrine of spontaneous
generation.

9. Robert Tom
American, 1915-1979
Semmelweis – Defender of Motherhood
Oil on canvas
Collection of the Universityof Michigan Health System
472

10. Semmelweis’s before-and-after
study

11. Puerperal fever monthly mortality rates for the First Clinic
at Vienna Maternity Institution 1841–1849. Rates drop
markedly when Semmelweis implemented chlorine hand
washing mid-May 1847

12. Semmelweis
• Despite ↓in infection rate to < 1%
– Idea conflicted with medical establishment of the time
– Doctors offended at the idea of having to wash their hands
– Semmelweis did not have a scientific explanation for the
mechanism
– Deterioration in work relationships
– Conflict with other scientists
– Depression
– Admission to psychiatric asylum

13. Importance recognized
Pittet D et al., Lancet, 2000

14. The 10 obstacles to
Hand hygiene

15. Lack of
KNOWLEDGE
1

16. Hand Hygiene
Indications

17. Hand Hygiene Indications
2002
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16);1-44 2002

18. Hand Hygiene Indications
Boyce JM Pittet D Morb Mort Weekly Rep 51(RR16);1-44 2002
2002 2006

19. WHO, 2009
http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf

20. Indications
Adapted from Sax H. J Hosp Infect 2007

21. Many countries worldwide are committed
to improving hand hygiene
Source: WHO. Current status, March 2011
Countries committed in 2005, 2006, 2007 and 2008
Countries planning to commit in 2009

22. WHO’s indications…

23. The indications in Scotland…

24. The indications in Belgium…

25. The indications in Spain…

26. The indications in Brazil…

27. The indications in Canada???

28. CONCEPT OF “PATIENT ZONE”

29. CONCEPT OF “PATIENT ZONE”

30. CONCEPT OF “PATIENT ZONE”

31. CONCEPT OF “PATIENT ZONE”
X

32. Perform hand hygiene before touching a patient or his/her surroundings

33. Perform hand hygiene before touching a patient or his/her surroundings

34. Perform hand hygiene
- before touching non-intact skin or mucous membranes
- before handling invasive equipment

35. Perform hand hygiene
- before touching non-intact skin or mucous membranes
- before handling invasive equipment

36. Perform hand hygiene after contact with body fluids, excretions,
mucous membranes, non-intact skin or bandages

37. Perform hand hygiene after contact with body fluids, excretions,
mucous membranes, non-intact skin or bandages

38. The indications in Canada

39. Believing that
COMPLIANCE IS
EXCELLENT
2

40. Compliance measurement
Required Organizational Practice Standardized by WHO

41. Compliance in Switzerland

42. Hand Hygiene Compliance

43. Institut de Cardiologie et de
Pneumologie de Québec

44. 30%(>2300 opportunities observed)
44
Overall compliance rate of caregivers
with regard to hand hygiene
(2012-2013)

45. 266/850
29/127
94/215 424/999
184/914
18/144
66/232
520/1254
0
10
20
30
40
50
60
70
80
90
100
Avantle contactinitial avec le
patient ou son environnement
Avantd'effectuer une procédure
aseptique
Aprèsune exposition à des liquides
organiques
Aprèsle contactavec le patient ou
son environnement
Tauxd'observance(%)
Indications pourl'hygiène des mains
Taux d'observance de l'hygiène des mains par indication
pour l'ensemble des travailleurs de l'IUCPQ
Année 2009-2010
Année 2010-2011
Année 2012-2013

46. * Indications: Fait référence aux4 indications pour procéder à l'hygiène des mains:
· Avant le contact initial avec le patient ou son environnement
· Après une exposition avec des liquides organiques
· Avant d'effectuer un acte aseptique
· Après le contact avec le patient ou son environnement

47. CHUQ
2011-2012

48. 33% 43%
82/250 153/353
Compliance rate
CHUQ

49. X Hospital
Province of Quebec

50. 23% 63%
0%
75%
32/141
6/8
122/192
0/9
Compliance rate
X Hospital

51. 23% 63%
0%
75%
32/141
6/8
122/192
0/9
Compliance rate
CHRDL
Most room for improvement
in terms of % and volume of
opportunities

52. Poor
M O M E N T
3

53. The ideal moment to perform hand hygiene

54. Not
4
B E L I E V I N G

55. FACT
• A number of “before-and-after”-type
studies
• Not many randomized controlled trials

56. MYTH!
• A randomized controlled trial is the only
way
FALSE!!!! for infection prevention

57. Methodology for studies on
hand hygiene

58. Proven effectiveness
WHO, 2009

59. The “ultimate” study will
probably never take place
Compliance already high
or
Lack of outcome indicators

60. Surgery in the 19th century
Carbolic acid sprayer
at the operating field
J. Lister (1867) Unpleasant smell for the surgeons…
The solution??

61. Culture
L A I S S E Z - FA I R E
5

62. Laissez-faire culture
• The importance of hand hygiene not
taken seriously
• Systematic errors are tolerated
• Hand hygiene not taken seriously

63. Ponce de Leon Rosales S et al. Lancet Infect Dis. 2005 Mar;5(3):131-2.
0.2% compliance

64. • 29 videos released
2006-2009
– 206 minutes in total
– 66 indications in which hand hygiene
mentioned or illustrated were identified
• 16/66 mentioned only
• 14/16 washing with water rather than
ABHRs

65. Confusing
6
ABHRs AND SOAP

66. Numberofgermsonhands
5 10 15 20 25 seconds
Duration of handrubbing
Application of solution
-99.99%
ABHRs are
• more effective
• quicker
ABHRs vs. Soap
-99%

67. Specific indications for washing with soap and water
•Visible contamination with blood
or other body fluids
•Hands visibly dirty
•Exposure to spore-forming
bacteria
•Clostridium difficile
•Bacillus anthracis
•After using the restroom
Choice of hygiene technique

68. Handwashing with ABHR after 7-10 HH
opportunities?
•Not a real indication
•A myth that persists in hospitals
•Invented by ABHR companies
•To avoid sticky hands
and build-up of residue
•Misinterpreted by caregivers
•Greater effectiveness of handwashing!
Choice of hygiene technique

69. ↑ History of atopy
↑ Winter
− Gloves
ABHRs cause
less irritation than soap
WITH EQUAL USE

70. All of these products contain
Glycerine

71. dermatitis
Damaged skin is more difficult to disinfest
Higher bacterial load

72. Complications
Strategies for preventing irritation
•Use protective creams
•Use ABHRs rather than
soap and water
•Do not use water that is too hot
•Do not wear gloves unnecessarily
•Dry your hands completely before
putting on gloves

73. 7

75. Competing for
A T T E N T I O N
7

76. Doctors’ schedules
• Multi-tasking…….. 24% of the time
– E.g. Patient documentation and talking
to colleague
• Interruptions and problems
1.12 times/hour
• Telephone calls
7/day
• Pager
– 1 page / 6.9 minutes for surgeons
on duty
Chiu T et al. N Z Med J 2006 Mar 31

77. Not making it a
REFLEX
8

78. How to
compete with
a host of
other
priorities?

79. Armenillo D et al. Clin Infect Dis 2012;54(1):1–7

80. Hand Hygiene and Remote Video
Auditing
• 17-bed ICU
– Cameras placed in front of every sink and ABHRS
dispenser
– Sensors in doorways to detect HCW movement
– Monitoring 24/7 (outsourcing of evaluation)
– 107 week before-and-after study
– Feedback to HCWs provided in real-time
• Electronic boards
• Emails
Armenillo D et al. Clin Infect Dis 2012;54(1):1–7

81. Armenillo D et al. Clin Infect Dis 2012;54(1):1–7

82. Hand Hygiene and Remote Video
Auditing
Armenillo D et al. Clin Infect Dis 2012;54(1):1–7
75-week maintenance period
298 860 HH opportunities
262 826 in compliance (87.9%)
16 prefeedback weeks
60 542 hand hygiene opportunities
3933 in compliance (6.5%)

83. Hand Hygiene and Remote Video
Auditing
• Why this study matters
– The most effective way to improve HH compliance
– The most HH observations made
– The highest compliance rate ever observed
– Very long maintenance phase
• Took a pragmatic approach to HH indications
– Not WHO recommendations
– Maybe key to success

84. GLOVES
9

85. Gloves

86. Proper use of gloves
2 uses for procedure gloves

87. Gloves
Protection in case of
accidental pricking
Reduce the amount of
blood at the surface of
the needle by 86%
But no change inside the
needle…

88. Proper Use of Gloves
Blood Mucous membranes
Body fluids Damaged skin

89. Wear gloves when you are taking care of patients
carrying multi-resistant germs
(MRSA, VRE, ESBL…)
Proper Use of Gloves

90. Proper Use of Gloves
ALWAYS perform HH BEFORE and AFTER removing gloves
Defectsor re-contamination

91. Wearing gloves and HH
• Wearing of gloves associated with lower
HH compliance
– OR, 0.65 (95% CI, 0.54-0.79)
Fuller C et al. Infect Control Hosp Epidemiol 2011;32(12):1194-1199

92. Wearing gloves
IS NOT a substitute for
hand hygiene

93. 10
A bonus…

94. Microbes
I N V I S I B L E
10

95. Objective
Set an objectiveof systematicallyperforming HH in front of each
patient
• Not too soon, but not too late
• Even if wearing gloves
• Theywill see you as very good and very competent!

96.  There are those who notice but don’t day say anything
 Perception is a matter of details– think about election
campaigns.
Don’t believe they
don’t realizeyou
aren’t doing it

97. The stethoscope
A vector of
transmission
in care settings?

98. Medical equipment
• Any medical equipment used for a
patient must be cleaned and
disinfected before being used for a
second patient
– Sphygmomanometers
– Thermometers
– Stethoscopes
• If the patient is carrying a
multi-resistant germ
– Dedicated device or disinfection after
use

99. The problem…
70-90% of doctors do not
disinfect their stethoscopes
after each use…
Wood, M.W. et al. Am J Infect Control, 2007. 35(4): p. 263-6.
Bernard, L., et al., Infect Control Hosp Epidemiol, 1999. 20(9): p. 626-8.
Fenelon, L., et al. The Journal of hospital infection, 2009. 71(4): p. 376-8.
Muniz, J., et al., American journal of infection control, 2012.

100. • Multiple limitations
– A piece of equipment’s “past” cannot be
determined
• Number of uses today? This week?
• Microbiological status of patients? (MRSA?
C.difficile?)
• Exactly how equipment was used?
– Full physical examination?
• If bacteria is present, so what? Is this
important?
– Does the equipment need to be sterile?
Prevalence studies

101. “Ideal” methodology
Systematic culture of hands and
stethoscope following a standardized
physical examination

102. Contamination of stethoscopes
Cultures from Rodac agar contact plates
83 patients recruited and examined

103. Assessment of microbial load
Mean
log(CFU)/25cm2
Level of Contamination of Physician’s Hand and Stethoscope Following a Single
Physical Examination
Gloved Hand Stethoscope

104. DIAPHRAGM – FINGERTIPS ASSOCIATION
Pearson’s r =0.81; r2= 0.65
β=1.15; 95% CI 0.84-1.46; p<0.001

105. FINGERTIPS AND DIAPHRAGM CONNECTION –
MRSA
P<0.001 (Spearman’s)

106. Fingertips Thenar Hypothenar Diaphragm Tube

107. How to remember?
Clean
Contaminated

108. RECAP

110. Lack of
KNOWLEDGE
1

111. Believing that
COMPLIANCE IS
EXCELLENT
2

112. Poor
M O M E N T
3

113. Not
BELIEVING
4

114. Culture
L A I S S E Z - FA I R E
5

115. Confusing
6
ABHRs and SOAP

116. Competing for
A T T E N T I O N
7

117. Not making it a
REFLEX
8

118. GLOVES
9

119. Microbes
I N V I S I B L E
10

120. THANK YOU FOR YOUR ATTENTION!
Any questions?

121. CONCLUSIONS

122. Lack of
K N OW L ED G E
1

123. RESULTS
• 83 patients recruited and examined
– 33 patients to evaluate total CFU
– 50 patients to evaluate MRSA CFU
– 52% males
– Average age (st.dev): 64.2 (14.8)
– Average length of hospital stay (IQR): 7 (3-9)

124. Objectives
• Review the rationale for HH
• Review the indications for HH
• Understand the factors that influence
non-compliance with HH
• Propose solutions for improving
compliance by doctors

125. 10 problems relating to HH
1. Not being aware of the indications
1. Teach about the patient zone
2. Show indications
2. Not realizing how HH is not being complied with
1. Show rate of compliance
1. Also talk about the number of opportunitiesfor enhancingunderstandingof how to improveoverall rates
2. Manage by a metric and that metric will improve (HBR)
3. Recontamination
1. NEJM video on recontamination
4. Not believing in the effectiveness of HH
1. Show the studies
2. Explain that it is important not to w ait for RCT (Europe and North America: compliance already high; Africa: no indicator)
3. Parachute analogy
5. Impunity and laissez-faire culture towards non-compliance
1. Surgical mask analogy: Would w e allow a particular hospital to get rid of them because they “don’t believe in them”?
6. Not distinguishing betweenABHRs and soap
1. MORE effective than soap!
2. QUICKER
3. The rule of w ashing at every X HH: misunderstood!
7. Contact dermatitis as a result of HH
8. People are busy and have a lot on their hands other than HH
1. Aw areness test
9. Not making it a habit
1. Seatbelt analogy
2. Paper on video cameras
10. Wearing of gloves
11. C.difficiile and HH with soap and water

126. Will we be able to eliminate nosocomial
infections one day?

128. What role does medical
equipment play in the
transmission of germs at the
hospital?

129. Previous studies suggest that
medical equipment
A) Is a major source of germ
transmission
B) Is NOT a major source of
germ transmission
C) Don’t know

130. Previous studies suggest that
medical equipment
A) Is a major source of germ
transmission
A) Is NOT a major source of
germ transmission
B) Don’t know

131. • Multiple limitations
– A piece of equipment’s “past” cannot be
determined
• Number of uses today? This week?
• Microbiological status of patients? (MRSA?
C.difficile?)
• Exactly how equipment was used?
– Full physical examination?
• If bacteria is present, so what? Is this
important?
– Does the equipment need to be sterile?
Prevalence studies

132. Mediate Auscultation 1894

134. • 1816
– Difficulty during auscultation of a young
woman
– Bundle of 24 sheets of paper
– Surprise! The sounds travelled very well
– “The cylinder”

135. Only 2 Francs, with a bonus stethoscope

136. •
Immediate Auscultation

137. And where do microbes fit in with all this????

138. Region sampled % recovery
Stethoscope diaphragm 56% (28/50) Any stethoscope
60% (30/50)Stethoscope tube 34% (17/50)
Fingertips 66% (33/50)
Any hand
74% (37/50)
Thenar region 56% (28/50)
Hypothenar region 62% (31/50)
Dorsum 28% (14/50)
N=50
P=0.14
Proportion of MRSA recovered from Physician’s Hand and Stethoscope
Following Physical Examination of an MRSA-Colonized Patient
PRESENCE OF MRSA

139. Can stethoscopes
transmit germs?

140. “Ideal” Methodology
Systematic culture of hands and
stethoscope following a standardized
physical examination

141. CONCLUSIONS
• Stethoscope contamination following a physical
examination is not negligible
• Need to disinfest a stethoscope after each use?
– Not just the diaphragm!
• One option: not allowing doctors to wear
stethoscopes around their necks?

143. Contain 60-80% ethanol, isopropanol
or n-propanol
Addition of emollients
Less irritating than soap and water with
equal use!
Liquid, gel or mousse solutions
ABHRs
Equipment

144. Detergents
Dislodge bacteria from the skin
through the effect of rinsing
with water
Sometimes chlorhexidine is added
Equipment
Soap

145. • N Engl J Med. 1988 Dec 15;319(24):1585-9.
• The soundsof the hospital.Paging patterns in three teaching hospitals.
• Katz MH, SchroederSA.
• Source
• Department of Medicine, University of California, San Francisco.
• Abstract
• To examine the influence of hospital paging systems on residency training, nursing
services,and patient care, we asked medical interns (first-year residents)in three
teaching hospitals to keep logs of pages they received during a three-day period.Thirty-
one logs from 26 interns were completed;a total of 1206 pages were recorded on 91
days (1095 hours). Interns were paged an average of once an hour; on 24 occasions,
interns were paged five or more times an hour. The majority of pages (65 percent)
occurred when interns were engaged in patient care. Only 34 percent of the pages were
judged both to require a response within one hour and to result in a change in patient
care. Twenty-four percent were clinically indicated and required a response within one
hour but did not result in a change in patient care. Sixteen percent of pages resulted in a
change in patient care or were clinically indicated but could have been postponed for
more than an hour. An additional 26 percent of pages neither resulted in a change in
clinical management nor were clinically indicated. Reducing the number of unnecessary
pages and postponing nonurgent ones could result in as much as a 42 percent decrease
in disruptions of patient care and more rest for interns.
Katz MH, Schroeder SA. N Engl J Med. 1988;319:1585-9.

146. Hand hygiene promotion –
Time to use a stick?

148. Choice of hygiene technique
Hand hygiene with ABHRs is preferable in almost every situation…
Advantages
•Available at point of care
•More effective
•Quicker
•Less irritating
Disadvantage
•No activity against spore-forming
bacteria (C.difficile)

149. D E R M A T I T I S
7