Experience sharing of patient participation program on hand hygiene in Hong Kong West Cluster

Vincent CHENG

Infection Control Officer, Hong Kong West Cluster

Chief of Service, Department of Microbiology, Queen Mary Hospital

Honorary Professor, Department of Microbiology, HKU

Compliance with hand hygiene

in different hospitals

Autor Year Sector Compliance

Preston 1981 General Wards 16%

ICU 30%

Albert 1981 ICU 41%

ICU 28%

Larson 1983 Hospital-wide 45%

Donowitz 1987 Neonatal ICU 30%

Graham 1990 ICU 32%

Dubbert 1990 ICU 81%

Pettinger 1991 Surgical ICU 51%

Larson 1992 Neonatal Unit 29%

Doebbeling 1992 ICU 40%

Zimakoff 1993 ICU 40%

Meengs 1994 Emergency Room 32%

Pittet 1999 Hospital-wide 48%

Isolation of the filterable virus in pure culture (absence of other pathogens).

Consistent positive isolation / RT-PCR of SARS-CoV from SARS patients and subsequent seroconversion.

First generation diagnostic test: RT-PCR for viral genes, immunofluorescent test for specific antibodies.

Peiris JS, Lai ST, Poon LL, et al. Lancet. 2003 Apr 19;361(9366):1319-25.

Peiris JS, Chu CM, Cheng VC, et al. Lancet. 2003 May 24;361(9371):1767-72.

M/53, HK resident

Relative of Guangzhou Professor

(index case of KWH)

DOA: 25/2/03

The real challenge:

SARS, 2003

Nosocomial outbreaks of SARS in 2003

Jan 30: Guangzhou, University affiliated hospital

84 cases (81 HCWs)

Feb 26: Hanoi, two hospitals of < 60 beds

60 cases (50 HCWs)

Mar 1: Singapore, two public tertiary hospitals

121 cases (65 HCWs)

Mar 4: Hong Kong, University affiliated hospital

138 cases (69 HCWs)

Mar 7: Toronto, community hospital

128 cases (47 HCWs)

HCWs ~

60%!!!

Cheng VC, et al. Antiviral Res. 2013 Nov;100(2):407-19.

Eight healthcare workers died as a result of SARS-CoV in Hong Kong

Infection Control is a matter of life & death

Dr Tse Yuen Man, Dr Lau Tai Kwan, Dr Cheung Sik Hin, Dr Cheng Ha Yan

Ms Lau Kam Yung, Ms Tang Mei Heung, Ms Wong Kang Tai, Mr Lau Wing Kai

https://www.chp.gov.hk/en/index.html

Education in Infection Control: Infection Control Course (HKU / QMH) since 2009

Infection control is everybody’s business ! (Up to now, > 10,000 staff episodes attended the course ~ 70% from public hospitals )

Knowledge changes people’s concept & mindset, and gradually change behavior & practice

News 16 May 2011

FIRST GLOBAL PATIENT SAFETY CHALLENGE

To reduce

health care-associated infections

Hand hygiene as the cornerstone

Alcohol-based handrub at

point of care

搓手至少 20秒

Rub hands for at least

20 seconds

潔手六部曲 Hand Hygiene “Six Steps”

HKWC Infection Control Team

港島西聯網感染控制組

如有可見污垢或如廁後 需要使用梘液清洗雙手 Wash hands with soap and water

when hands are visibly soiled or

after using toilet

Reference to WHO Guidelines on Hand Hygiene in Health Care

1

手心對手心 Palm to Palm

2

手心對手背 Palm to Back

3

指隙 Finger Interlaced

4

指背 Back of Finger

6

指尖 Finger Tips

拇指 Thumb

5

Outstanding Award: Department of Paediatric Cardiology

Excellent Award: Department of Radiology

Hand hygiene compliance of Hong Kong West Cluster (2013-2017) N

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Data extracted from Annual Infection Control Report, HKWC 2017

MedSense devices including badges in beacon

(left), pump bottle sensor (center), charger (right)

Cheng VC, et al. BMC Infect Dis. 2011 May 26;11:151.

HH compliance:

88.9% with ICN observation

31.5% without ICN observation !

Directly observed hand hygiene: outbreak prevention & control for epidemiologically

important viruses and multiple-drug resistant bacteria in Hong Kong

Outbreak of human metapneumovirus infection in psychiatric inpatients: implications for directly observed use of alcohol hand rub in prevention of nosocomial outbreaks. J Hosp Infect. 2007 Dec;67(4):336-43.

Successful control of vancomycin-resistant Enterococcus faecium outbreak in a neurosurgical unit at non-endemic region. Emerg Health Threats J. 2009;2:e9.

Successful control of norovirus outbreak in an infirmary with the use of alcohol-based hand rub. J Hosp Infect. 2009 Aug;72(4):370-1.

Prevention of nosocomial transmission of swine-origin pandemic influenza virus A/H1N1 by infection control bundle. J Hosp Infect. 2010 Mar;74(3):271-7.

Prevention of nosocomial transmission of norovirus by strategic infection control measures. Infect Control Hosp Epidemiol. 2011 Mar;32(3):229-37.

Sequential introduction of single room isolation and hand hygiene campaign in the control of

methicillin-resistant Staphylococcus aureus in intensive care unit. BMC Infect Dis. 2010 Sep 7;10:263.

Proactive infection control measures to prevent nosocomial transmission of carbapenem-

resistant Enterobacteriaceae in a non-endemic area. Chin Med J (Engl). 2013 Dec;126(23):4504-9.

Proactive infection control measures to prevent nosocomial transmission of vancomycin-

resistant enterococci in Hong Kong. J Formos Med Assoc. 2014 May 2. pii: S0929-6646(14)00127-2.

Benchmark of 317 hospital outbreaks in 7 hospital networks in HK (2010-2014)

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No. of outbreaks per 1 million patient -days: 0.45 (QMH) vs 6.70 (7 acute regional hospital) 15 x ↓ (Rate ratio: 0.068 [CI: 0.002 – 0.376]; p

1107 person-episodes involving in 6144 contact-episodes in 33 working days

High-touch and mutual-touch surfaces or items in acute wards, Queen Mary Hospital Contact-episodes per hour per a 6-bedded cubicle

14 contact-episodes / h 12 contact-episodes / h 9 contact-episodes / h

6 contact-episodes / h 4 contact-episodes / h 1 contact-episodes / h

Cheng VC, et al. J Hosp Infect. 2015 Jul;90(3):220-5.

Compliance of self-initiated patient hand hygiene with

respect to different age group (overall compliance ~ 38%)

Between 14 January and 30 June 2015, a total of 582 conscious patients

were observed for 114 working days, with an average of 5 patients per day.

Observed Moment 1

(before snacks, drinks, prn drugs at the bedside)

Observed Moment 2

(after use of bedpan/urinal at the bedside)

Observed Moment 3

(after attending

toilet facilities)

Overall P value

Patient aged

≤ 34 years 12.2% (6/49) 66.7% (4/6) 90.9% (20/22)

Directly observed hand hygiene (DOHH) before taking meals & drugs 進餐吃藥前潔手 超級惡菌難入口

Before drugs Before meals

Clean hands with alcohol

(入口管制)

Entry Control

Wash hands with soap and water

AFTER TOILET

Wipe the toilet seat with tissue

sprayed with disinfectant

BEFORE TOILET

283 toilet seat disinfectors: 46 wards’ toilet

Personal hygiene in toilet 如廁衛生要遵守 預防惡菌莫留手

(出口管制)

Exit control

1 VRE

48 – 72 hours

1 million VRE per gram of

stool

Importance of “Exit & Entry Control” “出入口管制”

Nurse gives tablet of 1 gm

Augmentin to patient;

Patient - no hand hygiene !

Patient’s fingers & environment full of VRE

Cheng VC, et al. Emerging Microbes & Infections (2015) 4, e8.

Bacteremia

(14 cases)

Non-bacteremia

(106 cases)

Bacteremia

(1 case – imported)

Non-bacteremia

(34 cases)

Prevalence of multiple-drug resistant A. baumannii in HKWC

Before intervention (Jan to Dec 2013)

After intervention (Jan to Jun 2014)

p < 0.001

Control of hospital endemicity of multiple-drug-resistant

Acinetobacter baumannii ST457 with directly observed hand hygiene

Cheng VC, et al. Eur J Clin Microbiol Infect Dis. 2015 Apr;34(4):713-8.

16 cases per 100,000

patient-days 8 cases per 100,000

patient-days

The observed incidence and the predicted incidence of VRE based on the segmented Poisson regression before and after the territory-wide implementation

of the directly observed hand hygiene-based infection control measures

Cheng VC et al. Am J Infect Control. 2016 Oct 1;44(10):1168-1171.

Cheng VC, et al. Infect Control Hosp Epidemiol. 2018 May;39(5):571-577.

Patient empowerment in hand hygiene: a pilot program in two extended care hospitals

Tung Wah Hospital / Grantham Hospital

Patient (TWH) Patient (GH) Subtotal Staff (TWH) Staff (GH) Subtotal

130 72

202

139 52

191

128 39

167

78 36

114

Baseline (May-Jun 16)

Intervention (Jul-Aug 16)

258 111 369

217 88

305

Entire period

Patient empowerment in hand hygiene in Chinese healthcare settings: Baseline period (May – June 2016)

Cheng VC, Wong Shuk-Ching, et al. Am J Infect Control. 2017 May 1;45(5):562-565.

Patient empowerment in hand hygiene in Chinese healthcare settings: Intervention period (July – August 2016)

Cheng VC, Wong Shuk-Ching, et al. Am J Infect Control. 2017 May 1;45(5):562-565.

Intervention wards a Control wards b Baseline period

without patient empowerment (A)

Intervention period with patient empowerment (B)

P value (A) vs (B)

Baseline period without patient empowerment (C)

Intervention period without patient empowerment (D)

P value (C) vs (D)

Total number of patients 546 502 NA 324 270 NA

Number of patients per ward (mean ± SD)

137 ± 31 126 ± 33 0.816 108 ± 44 90 ± 33 0.602

Presence of Tracheostomy 3 (0.5%) 0 0.096 2 (0.6%) 2 (0.7%) 0.855 Urinary catheter 58 (10.6%) 46 (9.2%) 0.430 22 (6.8%) 19 (7.0%) 0.906 Wound or drain 17 (1.3%) 25 (5.0%) 0.124 10 (3.1%) 6 (2.2%) 0.517 Colonization or infection with d

MRSA 9 (1.6%) 4 (0.8%) 0.213 6 (1.9%) 4 (1.5%) 0.727 CRAB 13 (0.5%) 9 (1.8%) 0.507 2 (0.6%) 6 (2.2%) 0.091 CRE 4 (0.7%) 7 (1.4%) 0.294 1 (0.3%) 3 (1.1%) 0.234 VRE 0 0 0 0 HH compliance (%) (Actions/opportunities)

87.2% (211 / 242)

87.9% (218 / 248)

0.891 87.1% (230 / 264)

83.5% (198 / 237)

0.310

Monthly volume of alcohol consumption (ml) per ward (mean ± S.D.)

22812.3 ± 11107.2

30153.3 ± 15775.6

0.300 24802.5 ± 13785.5

26020 ± 11058.2

0.869

Monthly total patient-day per ward (mean ± S.D.)

819.5 ± 313.1 798.1 ± 405.6 0.908 983.7 ± 245.6 896.3 ± 346.2 0.625

Monthly volume of alcohol handrub consumption (ml) per patient-day per ward (mean ± S.D.)

28.2 ± 7.7 37.6 ± 9.0 0.042 26.2 ±12.5 30.0 ± 6.0 0.518

Epidemiologic characteristics of patients and alcohol handrub consumption during baseline and intervention periods in the two extended care hospitals

Cheng VC, Wong Shuk-Ching, et al. Am J Infect Control. 2017 May 1;45(5):562-565.

Liver transplantation & Renal dialysis centers in QMH (2017 3Q)

Promotion & Implementation of Patient Empowerment in Hand Hygiene

Welcome Professor Yves LONGTIN & Ms. Rachel THOMSON to QMH

Infection Control Team, Queen Mary Hospital