ICPIC 2013: The effect of improved hand hygiene compliance on nosocomial transmission of Staphylococcus aureus

The effect of improved hand hygiene compliance on nosocomial transmission of Staphylococcus aureus

Veronica Weterings1

J. van Esser1

R. van Etten1

J. Kluytmans1,2

ICPIC13-ABS-1497

1Amphia hospital Breda, Netherlands2VU university medical center Amsterdam,

Netherlands

I MINDInnovation in Microbiology and Infection control by New Design (I MIND)

I MIND

Aim to investigate the effect of improved hand hygiene compliance on nosocomial transmission between patients

I MIND

• September 2011 – December 2012• 32-bed oncology unit

• Nursing team• 35 nurses• 6 student nurses• 1 head nurse

Study design

I MIND: Intervention study

[0] Pre intervention

Sept. ‘11 Dec. ‘11 Jan. ‘12 Apr. ‘12 Aug. ‘12 Dec. ‘12



[I] Increase numberof handalcohol

dispensers


Intervention [I]

Bathroom

Patient roomEntrance Lock room

Room for protective isolation




dispensers

[II] Education





dispensers

[II] Education

Sept. ‘11 Dec. ‘11 Jan. ‘12 Apr. ‘12

[III] New dispensers

Aug. ‘12 Dec. ‘12

Intervention [III]

Badge

Data Collection Point (DCP)

Saves all hand hygiene moments• Dispenser no.• Liquid (soap/hand alcohol)• Time stamp

(Incl. badge no.)

Intervention [III]




dispensers

[II] Education

Sept. ‘11 Dec. ‘11 Jan. ‘12 Apr. ‘12

[III] New dispensers

[IV] Individual feedback

Aug. ‘12 Dec. ‘12

Intervention [IV]

Process and outcome measures


• According to the WHO method• Assesed by trained Infection Prevention staff• Direct overt observation • Twice per week; one hour (8:00 - 9:00 a.m.)

Hand hygiene compliance

Process and outcome measures


Nosocomial transmission of S. aureus

• All hospitalised patients cultured weekly• Nose swab• Nasal carriage of S. aureus

• Strains were typed using AFLP

Results

Hand Hygiene compliance


Sessies

HHC%

Pre intervention[212/426; CI 44.9- 54.6]

49.8%


Sessies

HHC%

Pre intervention[212/426; CI 44.9- 54.6]

49.8%


Sessies

HHC%

49.8%

Increase dispensers[98/249; CI 33.2-45.7]

39.4%


Sessies

HHC%

49.8% 39.4%

Education[92/302; CI 25.3-36.0]

31.5%


Sessies

HHC%

49.8% 39.4%

New dispensers[196/436; CI 40.2-49.8]

31.5% 45.0%


Sessies

HHC%

49.8% 39.4%

Feedback[197/386; CI 45.9-56.1]

31.5% 45.0% 51.0%

Nosocomial transmission S. aureus


Sessies

HHC%

49.8% 39.4% 31.5% 45.0% 51.0%

p<0,001


Intervention period Education Feedback

Total patient populationon days of culture

266 298

S. aureus carriage




266 298

Nasal swabs 246 (92.5%) 263 (88.2%)

Unique patients 141 (57.3%) 160 (60.8%)

S. aureus carriage




266 298

Nasal swabs 246 (92.5%) 263 (88.2%)

Unique patients 141 (57.3%) 160 (60.8%) #

S. aureus isolates• Unique patients• % carriage unique pat.

6342

29.8%

5345

28.1% #

S. aureus carriage

# Not significant



S. aureus isolates• Unique patients

6342

5345

Amplification Fragment Length Polymorphism (AFLP)




6342

5345

Isolates typed 62 (1 missing) 52 (1 missing)





6341

5345


Unrelated isolates 7 20





6341

5345



AFLP Clusters 13 9





6341

5345



AFLP Clusters- min, max - median

132-14 isolates

3 isolates

92-7 isolates3 isolates


AFLP cluster ≠ nosocomial transmission!

For example:

AFLP Cluster Total isolates Unique patients Transmission?

A 2 1 No

B 11 6 Yes


For example:

AFLP Cluster Total isolates Unique patients Transmission?

A 2 1 No

B 11 6 Yes


Transmission index (TI)

Transmission Index (TI)

Primary cases + unrelated isolates

TI:Secundary cases

Transmission Index is the ratio between primary cases and secundary cases

Calculate primary and secundairy cases

For example:

AFLP Cluster

Total isolates Unique patients Primarycase

SecundaryCase(s)

A 2 1 1 0

B 11 6 1 5



Primary cases + unrelatedisolates

20 29




20 29

Secundairy cases 22 17




20 29


Transmission index 1,1 (22/20) 0,6 (17/29)




20 29


Transmission index 1,1 (22/20) 0,6 (17/29)

An improvement of HHC from 31.5% to 52.9% (RR: 1.48; CI 1.18-1.87)

was associated with a 41% reduction of the TI

Conclusion

Conclusion

Improvement of hand hygiene compliance - using automatic dispensers - reduces the transmission of S. aureus in the hospital.

Acknowledgment

• Collegues from the Laboratory for microbiology and Infection control, in particular:

– Esther Weterings

– Marie Louise van Leest

• Health care workers of the oncology department

• Marjolein Kluytmans (Amphia Academy Infectious Disease Foundation)

• Dr. Robert Roosendaal; Medical Microbiology and Infection Control, VU university medical center Amsterdam

You cannot change what you

don’t acknowledge.

Dr. Phil



Duration 10 weeks 14 weeks

Total patient population on days of culture 266 314

Unit occupancy rate 83,1% 70,1%

Total days hopitalized, on DOC

9,3 10,5

Mean age 65 66

Female 51,8% 68,8%*

General information

* Sign diff

Hand hygiene

Interventionperiod

Total weeks HH sessies

0 12 24

I 8 16

II 10 16

III 16 29

IV 20 26

General information

I MIND

• 32-bed oncology unit

1

4

1 1 1

4

44

1111

22

22

Hand Hygiene Management System

Hand Hygiene Management System

Healthcare

ICPIC 2013: The effect of improved hand hygiene compliance on nosocomial transmission of Staphylococcus aureus