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Published in CenterView on June 17, 2013
Dr. Rathel “Skip” Nolan and Elham Ghonim
Dr. Rathel “Skip” Nolan and Elham Ghonim

Renewed focus on hand-washing yields improved infection rates

By Jack Mazurak

University of Mississippi Medical Center hospital employees washed their hands or used alcohol foam 95 percent of the time, a new report on an effort to improve hand hygiene found, and infection rates dropped sharply among inpatients.

According to the report, nurses did best, with an average of 98 percent compliance. Physicians came in at 88 percent.

“Hand hygiene is the single most effective method of preventing the spread of infection,” said Elham Ghonim, director of infection prevention and the report’s lead author. “Any hospital quality improvement initiative needs to start with hand hygiene. Otherwise it’s not going to be successful.

“A key to our intervention was that it received support from the vice chancellor’s office, to hospital administration, to managers on down.”

Based on data gathered before the quality improvement intervention, Ghonim estimated hand-hygiene rates were no better than 50 percent overall, a figure common nationally in the early 2000s.

During the intervention, nurse volunteers in UMMC’s four hospitals anonymously catalogued their colleagues’ hygiene habits using a smartphone app. Ultimately, they collected 26,657 observations in 25 inpatient units throughout 2011.

Repeat offenders faced a stepped scale of letters and counseling.

“Once we started sending those letters, we never saw the same faces again,” Ghonim said.

The intervention, which continues today, cut infection rates of methicillin resistant Staphylococcus aureus – MRSA – and vancomycin resistant Enterococcus – VRE.

“Everybody’s been let know that this is a patient-safety issue,” said Dr. Rathel “Skip” Nolan, professor and director of the Division of Infectious Diseases. “Not doing so is as big a breach as not giving patients their medications.”

Foam dispensers are plentiful in hospital areas
Foam dispensers are plentiful in hospital areas

MRSA infections in the neuro ICU dropped from 5 per 1,000 patient days in 2010 to 1.6 in 2011. On the third floor of Batson Children’s Hospital, VRE infection plummeted from 1.5 to 0.2. Rates increased in only three of the 25 floors and units, and then only by 0.2 or less.

The 2011 data show a correlation in decreased central-line, surgery site and catheter-associated infection rates on units and floors with high compliance in hand hygiene, said Nolan, a co-author on the report. The journal Biomedical Sciences Instrumentation published the report online in May.

Under a section of the Affordable Care Act beginning in FY 2015, Medicare will dock payments by 1 percent to the quartile of hospitals with the highest rates of hospital-acquired conditions. That could cost individual hospitals hundreds of thousands of dollars annually. Those penalties come atop earlier legislation that Centers for Medicare and Medicaid Services deny additional payments to hospitals whose patients get certain infections.

“We’re fortunate to see a majority of nurses taking ownership of hand hygiene and standing up for their patients,” said Nolan, medical director of infection prevention. “Use of best practices has led to an industry-wide shift in the past five years nationally.

“We know how to prevent infection; we just have to initiate the science in practice.”

Physicians could still use more scrubbing, he said.

According to study, hand hygiene at UMMC is up
According to study, hand hygiene at UMMC is up

“Historically, rates of compliance for physicians are lower,” Nolan said. “That’s for a number of reasons. There’s sometimes an attitude that the rules don’t apply to me. It can also be from observed behavior when they were trained.”

He called on attending physicians to practice good hand hygiene because residents and medical students will follow suit.

While Ghonim’s report uses numbers collected from 2011, the hand hygiene intervention continues with improved methods. They used an app, iScrub, developed at the University of Iowa. While a good template, Ghonim and observers ran into technical problems.

The Division of Information Systems wrote an in-house app, Uscrub, which references UMMC’s employee database to reduce errors in identifying people and job titles. It also provides managers and administrators real-time compliance numbers.

Ghonim, Nolan and the team of infection preventionists widened the intervention to include certain clinics and appropriate dress for entering patient rooms under isolation precautions. They also rely on hand-hygiene champions in
individual units.

Hand Hygiene “How Tos”

According to the Medical Center’s infection preventionists, UMMC employees should:
     •  wash their hands thoroughly with hot water and soap at the beginning of each shift;
     •  wash anytime their hands become visibly soiled; and
     •  use alcohol foam before and after each patient encounter.

Common sources for the spreading of infection include:
     •  long sleeves;
     •  laboratory coats; and
     •  neckties.