2. Patricia Ching-Hand Hygiene Policy for Outpatient

8/12/2019 2. Patricia Ching-Hand Hygiene Policy for Outpatient

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Definition of the outpatient setting

Risk assessment

Hand contamination

Transmission/infection risk in these settings

Infection control/hand hygiene situation in these

settings

Hand hygiene concepts adaptation

Practical examples

Review


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Definitions

Outpatient (ambulatory) care (CDC):

Care provided in facilities where patients do not

remain overnight :

hospital-based outpatient clinics

non-hospital based clinicsphysician offices, urgent care centers

ambulatory surgical centers

public health clinics

imaging centeroncology clinics

ambulatory behavioral health

substance abuse clinics


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LITERATURESEARCHESANDREVIEWSTransmission of pathogens by hands in outpatient

setting (Geneva)

Keywords: outpatient settings, "disease transmission, infectious[MeSHTerms]", hand hygiene, disease outbreak[MeSH]

Source: PubMed No language or time restriction

Summaries reviewed: 633

Full-texts reviewed: 32

Final selection: 10 articles ( + 14 German titles + 1 Danish)

Hand hygiene in primary health care (Spain)

Keywords: primary care settings, "disease transmission,infectious[MeSH Terms]", hand hygiene

Source: PubMed, EMBASE, COCHRANE Time restriction: 2004July 2011

Summaries reviewed: 818

Full-texts reviewed: 60

Final selection: 35 articles


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HAI IN OUTPATIENT CARE

Most of reported outbreaks of healthcare-associated infections in

outpatient care are related to invasive medical proceduresLiterature review 1960-1990: 53 reports with transmission in general

medical offices, clinics, and emergency departments (23); ophthalmologists'

offices and clinics (11); dental offices (13); and alternative-care settings (6)

Transmission means: common source (29), person-to-person (14),airborne or droplet (10) (Goodmann et al. JAMA 1991)

Most frequent agents: Mycobacteriumspp, HBV, measles, rubella,

adenovirus

Another narrative review paper focused on HBV, HIV, M. tuberculosis,measles, adenovirus (Herwaldt et al. ICHE 1998)

SSI following ambulatory surgery (mail/phone surveys): 0.022-16.0%

(Nafziger et al. Infect Dis Clin North America 1997)


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APEAS STUDY - SPAIN

Prevalence of adverse events in Primary Healthcare:

18.63% (95% CI: 17.7819.49) 70.2% (n=778) considered clearly preventable

adverse events

47.8% (n=530) related to medications

8.4% (n=93) were HAI: surgical and/or trauma wound infection (5.1%)

opportunistic infection due to immunosuppressant orantibiotic (1.5%)

pressure ulcer infection (0.8%)

catheterization-related urinary tract infection (0.7%)

aspiration pneumonia (0.3%)


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HEALTHCARE WORKERS' HAND

CONTAMINATION (1) Primary pediatric care, doctors hands contamination: Staph

spp 85.4%, S. aureus 56.4%, MRSA 9.1% (Cohen et al.Infection 1998)

Outpatient dermatology clinics, doctors hands

contamination: Staph spp 84.6%, S. aureus 69.2%, MRSA

7.7% (Cohen et al. Dermatology 2002)

GPs' offices: 14/150 (9%) contaminated samples (hands,

stethoscopes and tension cuff); 10/50 GPs (Girier et al. MedMal Inf 2000)

Ophthalmologists: 97.2% were culture positive for at least

one resident organism and 22.2% for at least one transient

organism (Lam et al. Investigative Ophthalmology & Visual Science

2005)


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HEALTHCARE WORKERS' HAND CONTAMINATION (2

HCV-RNA retrieved on dialysis personnel hands

positive in:

19 (23.7%) of samples from HCWs caring for HCV+

patients;8 (8%) of samples from HCWs caring for HCV-

patients (p < 0.003)

2 (3.3%) of samples from HCWs entering the dialysis

unit

(Alfurayh et al. Am J Neph rol 2000)


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PATIENTS' HAND CONTAMINATION

Cystic fibrosis patients: Pseudomonas and S.aureus,including MRSA, were cultured from

patients' hands (7%), the exam room air (8%),

and environmental surfaces (1%) (Zuckerman et al.J Cistic Fib 2009)

VRE colonized patients in haemodialysis: hands

colonized with VRE (36%); VRE contaminated

haemodialysis chairs (58%), outpatientconsultation couches (48%), HCW gowns (20%)(Grabsch et al. ICHE 2006)


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HAND TRANSMISSION IN OUTPATIENT

CARE SETTINGS Contaminated hands are considered either one of the possible

causes or the first suspected factor or the proven cause oftransmission

One of the possible causes:

Candidemia in pediatric patients receiving parenteral nutrition

(Cano et al. Med Mycology 2005)A case of tuberculosis otitis media (Katcher et al. J Infect

2010)

First suspected factor:C-MRSA skin infections amongHCWs in an outpatient clinic (Johnston et al. ICHE 2006)

Proven cause of transmission: nurses artificial fingernailscarrying the same germs that causedBSI in 5 patients whoreceived dialysis via tunneled catheters (Gordin et al. ICHE2007)


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HAND HYGIENE COMPLIANCE IN

DIFFERENT OUTPATIENT SETTINGS

0

1020

30

40

50

60

70

80

90

100

Whyte-Family

doctors

Cohen-Ped Cohen-

Dermatol

Arenas-

Dialysis*

Martin-

Madrazo-PC

* Before patient contact


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M. Spach etal ID week 2013
https://idsa.confex.com/data/abstract/idsa/2013/Paper_42164_abstract_38224_0.pnghttps://idsa.confex.com/data/abstract/idsa/2013/Paper_42164_abstract_38223_0.png


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SELF-EVALUATION (1)

Dentists:at the start of the practice day, 71%often/almost always/always washed with soap but

never/almost never used ABHR. 22% often/almost

always/always washed with soap and disinfected with

alcohol-based hand sanitizers

Myers et al. J Am Dent Assoc 2008


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Michiels et al. BMJ 2000

Telephone interviews

with 200 GPs askedabout HW after pt contact

126/200 (63%) HW after

each consultation (79/126

(62.7%) used water andsoap; only 21 used a

disposable towel)

43/200 (21.5%) HW

after each home visit

SELF-EVALUATION (2)


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INFECTIONCONTROLPRACTICESIN68 AMBULATORY

SURGICALCENTERSINTHEUSA

Overall, 67.6% (95%CI 55.9%-77.9%) ASCs had at least 1 lapse ininfection control

17.6% (95% CI, 9.9%-28.1%) ASCs had lapses in >3 of the 5

infection control categories

Common lapses:lapses in handling of blood glucose monitoringequipment (46.3%); using single-dose medication vials for more than

1 patient (28.1%); failing to adhere to recommended practices for

equipment reprocessing (28.4%); lapses in hand hygiene

performancebefore and after the surgical procedure (17.7%)

Schaefer et al. JAMA 2010


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Summary

Healthcare associated infection occurred in outpatient setting

and are preventable

Hand hygiene compliance is low

Outpatient services are treating immunocompromised patients

e.g. oncology clinic, haemodialysis

Invasive procedures are done in outpatients


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HAND HYGIENE POLICY

FOR OUTPATIENT

- it is really necessary!!!


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WHO 2012


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APPLICATION OF THE MY FIVE MOMENTS FOR HAND

HYGIENE APPROACH IN OUTPATIENT CARE


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A PROCEDURE-FOCUSED APPROACH AND UNDERSTANDING

HAND HYGIENE WITHIN THE WORKFLOW

Son et al. AJIC 2011


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IMPLEMENTATIONSTRATEGYANDTOOLKIT

Knowledge & evidence Action


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HH practices in TCM Clinic


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AcupunctureElectric Stimulation

Cupping

Moxibustion

Massage


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Applying WHO Hand Hygiene Practices

in TCM Clinic is under study.

Results showed that it is necessary and

applicable adopting the WHO 5 moments


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Based on the

evidence and

recommendations

from the WHO

Guidelines on Hand

Hygiene in Health

Care (2009),made up of

5 core components,

to improve hand

hygiene in health-care settings

ONESystem changeAlcohol-based handrubs at point of care

and access to safe continuous water supply, soap and towels

TWOTraining and educationProviding regular training to all health-care workers

THREEEvaluation and feedbackMonitoring hand hygiene practices, infrastructure, perceptions, &

knowledge, while providing results feedback to health-care workers

FOURReminders in the workplacePrompting and reminding health-care workers

FIVE Institutional safety climateIndividual active participation, institutional support, patient participation

WHATISTHEWHO MULTIMODALHANDHYGIENEIMPROVEMENTSTRATEGY?

A S A G S O


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TRANSLATE GUIDELINES INTO

PRACTICE.

Available at http://www.who.int/gpsc/5may/tools/en/index.html
http://www.who.int/gpsc/5may/tools/en/index.htmlhttp://www.who.int/gpsc/5may/tools/en/index.html


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