The Unchatables -Time for a New Approach Clinical Excellence Commission Susan Jain RN MN PhD Candidate UNSW, Project Officer – HAI Program CEC Susan.jain@health.nsw.gov.au
Acknowledgment • Prof Mary-Louise McLaws School of Public Health UNSW • Dr Kate Clezy Director Infectious Diseases POW • Kathryn Hoban Manager Research POW • Sue McFarlane RN Immunisation POW • Aurea Ayalon RN Exposure Management POW • All the participants
“ Antibiotic resistance can breed poverty, while poverty feeds the problem of antibiotic resistance ” The World Bank estimates that 24.1 million people could fall into extreme poverty by 2050 because people living in poverty are more vulnerable to antibiotic resistant infection and treating antibiotic resistant infections will be costly and arduous.
Camouflaged’ superbugs are fooling our immune cells – and that’s very bad news
Infection Prevention Control - Our Armour? • Hand Hygiene • Management of MROs- isolation/additional precautions • Personal Protective Equipment • Antimicrobial Stewardship • Surveillance and Reporting • Cleaning of shared equipment and environmental cleaning
Personal Experience
Hand hygiene compliance when Gloves are worn • Fuller 2011- Hand hygiene compliance with glove use 41.4% • Dhar 2014 - Hand hygiene prior to donning gowns/gloves 37.2% • Loveday 2014 - Hand hygiene after glove use 48% • Bingham 2016- Hand contamination before performing an aseptic procedure (moment 2) for gloved hands reached a 40%.
Standard Precautions • Confusion over whether contact and standard precautions are one and the same may contribute to inappropriate glove use • The adoption of a wider principle of considering all patients potentially infectious may contribute to increased glove use, and shown to reduce compliance with hand hygiene.
Contact Precautions • The fear of “Contact” contribute to increased glove use, and has also has been shown to reduce compliance with hand hygiene. • Distribution of bacteria from one body site to another may occur when gloves are not changed between different care activities for a particular patient.
We contaminate our gloves before the start of the care
Research shows…misuse of gloves Wilson et al. 42% Risk of cross- Loveday et al. 37% Girou et al. contamination 64.4% Misuse Katherason et al. Fuller et al. of 74.3 % 16.7% Used in Gloves Low risk Fuller et al. Naderi et al. 40.6% Not Used in 21.1% High risk Thompson et al. 84%
In a teaching hospital What about the approximately 62,000 boxes of planet? gloves (94,00 000 gloves) are used per year. Overall approximately $300,000 to $600,000 per year – just for non- sterile glove. 94,00000 gloves disposed off/year Excess cost to manage waste and the impact on the planet
Patient perceptions of glove use “Tony Nicklinson is paralysed and ‘Carers would pet my dog but they relies on 24-hour care. Here he wouldn’t touch me without gloves‘ questions why carers wear gloves for non-clinical procedures” ‘Is this another example of being too lazy to follow basic hygiene or perhaps they are taught that wearing gloves solves all problems? So, who is the more hygienic: the carer who wears gloves but doesn’t wash her hands or my wife who doesn’t wear gloves but does wash her hands?’
The extend of the problem • The observational audits are focusing on reporting rates of hand hygiene compliance only. • Many organisations do not observe glove use as an integral component of hand hygiene compliance. • This, combined with a lack of validated audit tools, means that the impact of glove use on hand hygiene compliance is not yet fully understood
The reasons for low hand hygiene compliance “I reckon it would need to [show] how much it “I think I want some evidence of protects the nursing staff like, on the benefits, if I saw by just doing hand some sort of research, in a hygiene.” simple statistic or something, this is why it’s beneficial then it will be something great I think” “Like fast paced putting on gloves and hand hygiene together is not easy, it’s either you put on the gloves or hand hygiene “ If you’re going to put on the gloves and if you’re touching something that's contaminated, you take it off and you don't wash your hands at least you had the gloves on” “I don’t want to take you know, [or] contract [infection] and then take it home and spread it to my family you know?”
Where is the evidence?
The Fact is…. • Much of the evidence is based on observational and quasi-experimental studies of varying quality. • This is a common limitation of the infection prevention and control literature, and decisions can only be made based on the data available or most consensus.
Aim of the project • To demonstrate to HWs that hand hygiene effectively removes methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) from their ungloved hands after routine (dry contact) contact with patients who are known to be colonised with either MRSA or VRE.
Ethics approval from • SESLHD Ethics Committee • UNSW Ethics Department • NNSWLHD Ethics Committee
Methods • HWs’ un-gloved hands were cultured after hand hygiene with alcohol-based hand rub (ABHR) or soap- and-water wash after routine clinical care (dry contact) of patients known to be colonised or infected with MRSA or VRE .
Bacteri rial C Contamination o on H HCWs H Hands nds post Hand nd Hygien ene e 40 35 30 25 38 40 40 40 40 40 20 15 10 5 2 0 0 0 0 0 0 MRSA VRE MRSA VRE MRSA VRE 2pumps 3spumps Soap and Water Positive No growth
Integrating My 5 Moments into Contact Precautions Risk assess and don a fresh pair of gloves if needed Risk assess for body substance exposure and don gloves if needed Remove gloves immediately after the episode of care Remove gloves immediately after the episode of care
How important is it to wear gloves when taking care of patients under Contact Precautions? I pretty much Gloves for me and look at them as hand hygiene for my protection for patients myself . I think a lot of people feel a lot safer behind gloves I wear gloves because it’s a protection to myself. So like that little bit of a security of I would come in with walking into an the same pair of infectious room gloves, come out and knowing I’m with the same pair of safe gloves, then not think about the five moments of hand hygiene in between
More layers of skin gives better protection and less hand hygiene And you're not I feel like you're less likely to do thinking, I’ve just touched that, I the more need to clean my moments of hands, because you hygiene if you’ve can’t actually feel got gloves on that thing because you're wearing the gloves Well I just see it as, kind of the gloves as an outer layer of skin, you know, and like that skin, therefore you put another one {gloves} on without washing you walk in - there’s a little hands I’d still see that as an picture on the door and the acceptable step in between first little picture on the door says, “You put your gloves on and you put your gown on”. And {you are permitted} to enter this space as long as {you have} the little barrier
Modified approach • Conducted a 5 phase study involving 250 HWs using pre-trial focus groups (N = 12), hand microbiology (N = 40), development of a modified contact precautions poster, trial of modified poster (n = 100), post-trial focus group discussion (n = 22), and a survey of HWs post-rollout in additional locations (n = 76).
Intervention Phase Risk Assessment -a systematic process of evaluating the potential risks that may be involved in a projected activity or undertaking.
Post Trial Feedback I found this to be quite empowering for the nurses, You can still use your judgment, they’re Gloves or no increased our clinical judgment, still there if you need them, and you gloves is hand our autonomy and I think that can make that decision yourself before hygiene that was a major plus from my point you put {gloves on}, and that ability to protects you of view. It wasn’t like a make the decision of your own dictatorship as it was before with judgement, I like, {it} totally floats my the contract precautions sign boat saying you have to do this there and then, it just gave us a lot of decision making and I think that kind of made our jobs as nurses I think it prompts you to do your more satisfying hand hygiene. It makes you really think. You’re not just protected by these gloves I don't even want gloves now. I'll be turning a patient, immediately clean my hands straight away. I think it's a bit of change
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