October 2015

Infection Prevention

Prevention Update

Multiple strains of C. difficile cause severe patient outcomes

No single genetic strain of the widespread Clostridium difficile (C. difficile) bacteria appears to be any more harmful than other strains, according to new research published in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America.

The findings contradict previous research suggesting that the emergence of the most severe C. difficile infections (CDI) could be linked with a particular strain known as Ribotype 027 (R027). C. difficile is a highly infectious diarrhea that is the most common cause of healthcare-associated infections (HAI) in the United States.

"Clinical severity markers of CDI, such as white blood cell count and albumin level, a protein in blood, are more important predictors of severe outcomes than any specific strain, especially in hospitals with no single predominant strain," said Samuel L. Aitken, PharmD, lead author of the study. Although C. difficile R027 was the most prevalent strain associated with severe onset of the disease, it was found to not be any more likely to cause severe outcomes than other C. difficile strains. However, researchers noted that continued use of non-C. difficile antibiotics was a strong predictor of severe CDI outcomes in all strains. The continued use of other antibiotics has previously been associated with prolonged diarrhea and CDI treatment failure.

CDC provides Ebola PPE guidance clarifications

The Centers for Disease Control and Prevention (CDC) has clarified its guidance regarding personal protective equipment (PPE) for healthcare personnel caring for suspected and confirmed Ebola patients in U.S. healthcare facilities.

Based on feedback from healthcare facilities that have implemented the current guidance (originally posted October 2014), the guidance clarifies the use of fluid-resistant and impermeable gowns and coveralls. Specifications are provided in the guidance to assist facilities in selecting and ordering the recommended garments.

In addition to clarifying the specifications of gowns and coveralls recommended, the PPE guidance for confirmed Ebola patients is being updated with additional explanation, including:

  • expanding the rationale why respiratory protection is recommended;

  • clarifying that the trained observer should not serve as an assistant for taking off (doffing) ppe;

  • suggesting a designated doffing assistant, especially in doffing with the Powered Air Purifying Respirator (papr) option;

  • modifying the papr doffing procedure to make the steps more clear;

  • changing the order of boot cover removal. boot covers are now removed after the gown or coverall; and

  • emphasizing the importance of frequent cleaning of the floor in the doffing area.

The updated PPE guidance can be found at


All eyes on hand hygiene

Effective, gentle products and compliance monitoring give hygiene a helping hand

by Susan Cantrell, ELS

Does your medical facility have a culture of safety that emphasizes the importance of handwashing compliance in all areas-patient care, food service, housekeeping? Does your staff take to heart the simple knowledge that clean hands can mean the difference between life and death? Too often, that is not the case. According to the Centers for Disease Control and Prevention (CDC), hand washing compliance remains, outrageously, embarrassingly, at approximately 40 percent.

To healthcare workers (HCWs), being instructed to wash your hands at every opportunity probably falls under the category of "easy-for-you-to-say." There are legitimate impediments to compliance with handwashing best practices, and each impediment requires a different intervention.

One of the organizations that provides information on hand-hygiene (HH) compliance is The Joint Commission Center for Transforming Healthcare. In their info sheet "Hand Hygiene Factors and Solutions" reasons for noncompliance are addressed and practical solutions are offered for those working with patients, as well as housekeeping and food service.1

Here is a snapshot of some of those no-cost or low-cost solutions:

  • Keep sinks and hand-rub or soap dispensers in good working condition, filled, and located in areas where they are readily available and easy to access.

  • When using shared equipment, such as mobile vital sign machines, perform hand hygiene prior to touching patients. Wear gloves when appropriate and wash hands prior to donning personal protective equipment.

  • Use hand hygiene technologies that can provide real-time monitoring of hand hygiene compliance.

  • Incorporate a hand hygiene standard into meal tray deliveries; wash hands prior to entering and exiting patient rooms.

  • Avoid having hands full of medication by keeping supplies near the patient and within arm’s reach of a hand wash station.

  • Use a phrase or code word that can be used as a reminder among peers to perform hand hygiene.

  • Ensure housekeeping staff perform hand hygiene during daily or turnover room cleaning.

  • Patient admission is a time when frequent entry and exit occurs, meaning that health care personnel need to perform hand hygiene multiple times. Staff should create a standard work process for patient admission using specific roles.

  • Implement just-in-time coaching for real-time reinforcement and feedback to health care personnel. JIT coaching does not end when the baseline data collection period ends.

  • Leadership commitment, change management principles, measurement, managing expectations, and making it simple to achieve hand hygiene success are critical.

For the complete list of Hand Hygiene Factors and Solutions, visit

The Leapfrog Group, a voluntary program, recognizes and rewards hospitals making big leaps in health care. In 2014, 1,501 hospitals completed the Leapfrog Hospital Survey.2 The section on HH safe practices measures hospitals’ compliance to an HH program in four areas: awareness, accountability, ability, and action. Is there awareness of the need for hospital-wide education and activities to improve HH? Are clinical and administrative leaders accountable? Does the hospital conduct staff training, and does the budget provide for safe HH? Are HH policies and procedures implemented across the organization? According to Leapfrog Group’s report, 77 percent of reporting hospitals earned all possible points, meeting all 10 HH safe practices. Clearly, these are questions every hospital should be asking, Leapfrog Group members or not.

Hand-hygiene compliance monitoring systems

STANLEY Healthcare’s AeroScout solution

Holding HCWs accountable for HH does not mean pulling out the whips and chains or pointing fingers to embarrass individuals or departments but is an opportunity to increase compliance by educating staff and administration. One way to do that is to install an HH-compliance monitoring system - and industry offers a great variety to choose from.

Sagi Geva, Healthcare Solutions Manager, STANLEY Healthcare, recommends that facilities implement an unobtrusive system that won’t interfere with workflow or burden overloaded HCWs.

"What’s needed is continuous, accurate, and objective monitoring of hand washing that empowers staff members to see and improve their performance," said Geva. "STANLEY Healthcare’s AeroScout solution automatically detects whether staff members wash their hands as they enter and exit patient rooms. Each staff member wears a small badge, and each patient room is uniquely identified, as are dispensers. When a caregiver enters the room, a handwashing opportunity is identified. When the caregiver uses the dispenser, the event is recorded. Data is uploaded in real time, via the hospital’s Wi-Fi network, and displayed through visual dashboards, for managers and infection-prevention staff to monitor results in near real time and to provide immediate feedback to staff.

"More detailed analytics are also available to measure compliance by role, location, time, and individual," added Geva. "One of the key components of the solution is the visual analytics. Developing the various dashboards involves close consultation with customers, with a deep dive into what they are trying to achieve and how they will measure success.

"One 900-bed hospital in the southeast has seen its compliance rates increase by half, sustained over a period of several months. Not only is compliance up, but the detailed data provide a basis for continuous improvement. The hospital has been able to identify its high performers and use them as mentors to others in need of improvement."

CenTrak's hand-hygiene compliance system employs
a staff badge and an integrated handwashing monitor.

Adam Peck, Senior Director of Marketing, CenTrak, believes that real-time location systems (RTLS) are the answer to improving compliance. "Clinical-grade RTLS is the only solution that can offer real-time visibility, automatically capturing all compliance and noncompliance events down to the individual provider level," said Peck. "With automatic data collection and analysis, RTLS reduces or eliminates the time spent entering information and building compliance reports. Regular feedback and accountability supported by this comprehensive data have been shown to reduce the spread of infections, improve patient outcomes, and lower overall costs."

Peck says CenTrak’s RTLS system determines whether personnel have washed their hands when entering and leaving patient rooms via a CenTrak RTLS badge that they wear behind their standard hospital ID tags. Dispensers and washing stations are equipped with sensors that calculate compliance rates so that facilities can measure the number of visits to HH stations (the numerator) and the number of opportunities for which hand washing should have been completed (the denominator).

"Using this data, hospitals can audit HH protocol and provide consistent feedback. Real-time gentle and personal reminders to staff are also available to assist with increasing compliance," he said.

"CenTrak’s technology was installed as part of a program to improve HH compliance in a tertiary-care center that cares for approximately 40,000 inpatients annually. After one year, the hospital reported a 48 percent decline in HAIs and significant reductions in the average patient length of stay. CenTrak’s solution was also implemented in a 443-bed comprehensive community teaching hospital. The hospital reported a 300 percent improvement in HH compliance, and the HAI rate fell to zero in the pilot’s first quarter."

UltraClenz's Patient Safeguard System is a badge-based,
hand-hygiene--monitoring system.

UltraClenz offers the Patient Safeguard System, a wireless HH-monitoring product that works on the company’s proprietary Bentley system. Bentley runs independently of the hospital information-technology infrastructure. "The beauty of our system is that it does not disrupt the hospital’s existing network," stated Charles Johnston, Executive Vice President. "The Patient Safeguard System provides the data necessary to manage compliance. At a glance, a hospital administrator can see which individuals or departments are exceeding or falling short of the compliance goals."

The Patient Safeguard System is also bed-centric, a unique feature that Johnston says differs from systems that only track in/out. "By monitoring down to the bed level, our data is accurate down to bed interactions," Johnston explained. "The Patient Safeguard System provides data that can be used to coach and counsel staff. Simply washing one’s hands results in a decreased risk of infection or cross-contamination. If the patient Safeguard System is used effectively, it is another tool in the toolbox for the infection-control managers."

Halyard Health offers AiRISTA
hand-hygiene-compliance monitoring

Halyard Health (formerly Kimberly-Clark Health Care) offers the AiRISTA System, an easy-to-install and Bluetooth-tracking technology that fits into existing dispensers and does not interrupt staff workflow. "Halyard Health assessed over twenty monitoring technologies and recommends AiRISTA," said Jason Burnham, Associate Director–Patient Care Solution. "The AiRISTA System, along with Halyard clinical in-servicing, can dramatically improve compliance. In one case study, the AiRISTA solution was implemented in an intensive-care unit at a 300-bed metropolitan hospital in Maryland. Prior to the AiRISTA system, direct observation was providing 30 HH observation data points per month. AiRISTA increased observations to 430 data points every 24 hours; HH improved 38 percent in the first three months."

Burnham encourages HCWs to visit Halyard Health’s website ( for resources on HH compliance, including the ‘Clean Hands Care’ program featuring visual reminders and educational materials for patients, staff, and visitors. A patient information kit, posters for handwashing technique, mirror clings, and tent cards for waiting areas are available, along with continuing education credits (at

Skin-care products that promote hand-hygiene compliance

Hand Hygiene compliance may be the No.1 goal, but getting there can be hard on hand health, which is why it can be so challenging. In fact, painful skin damage, from repeated cleansing, is a major reason for non-compliance. To make matters worse, chapped, dry skin provides multitudes of nooks where pathogens can hide. That’s why a good product - one that is gentle, yet effective and does not leave an unpleasant-feeling residue on the skin - is necessary for breaking that cycle and encouraging proper HH protocol.

PURELL Advanced Hand Sanitizer ULTRA NOURISHING Foam,
from GOJO

"As pressures to reduce HAIs increase, HCWs are being asked to perform HH more frequently," said Megan DiGiorgio, Clinical Specialist, GOJO Industries. " Good efficacy, skin health, and skin feel are three important attributes when it comes to HH products. It is challenging to design products that address all three of these needs, especially when used in high-compliance environments, like healthcare. Our new PURELL Advanced Hand Sanitizer ULTRA NOURISHING Foam helps address these needs, while delivering the proven efficacy of PURELL Advanced Hand Sanitizer. This product is formulated with a unique blend of ingredients designed to improve and nourish the skin’s natural moisture barrier and to improve skin hydration in three days. The formulation accomplishes this without depositing heavy moisturizers on the skin’s surface, which can build up and create an undesirable sticky residue. In addition, our new PROVON Ultra Mild Foam Hand Wash is our mildest soap to date and helps maintain skin health, even with frequent hand washing.

"With repeated product use under very high compliance, heavy moisturizers that are deposited on top of the skin can lead to product buildup and can make tasks like gloving difficult," continued DiGiorgio.

"PURELL ULTRA NOURISHING Foam works differently than other sanitizers, by nourishing skin cells from the inside out. Ingredients rub in quickly, so the heavy buildup does not occur. The product evaporates quickly and leaves hands feeling clean and soft."

Visit GOJO at for HH science and for the GOJO Hand Hygiene blog.

From SCA Americas, the new Tork Premium Foam soap and sanitizers

Cheryl M. Rickert, Washroom Marketing Director of Away-from-Home Professional Hygiene North America, SCA Tissue, SCA Americas, explained how their product counteracts skin damage from frequent cleansing. "SCA recently developed Tork Premium Foam soap and sanitizers to meet the growing need for a gentler solution for everyday hand washing, without sacrificing hygiene. Tork gentle foam products provide comfort to all levels of skin sensitivity, while simultaneously moisturizing skin to prevent over-drying. Select Tork Premium Skincare products also hold Green Seal, National Sanitation Foundation, and ECOLOGO certifications for environmental and social responsibility," said Rickert.

SCA Americas’ new Tork Healthy Hands website ( features free resources and materials to promote HH compliance. "The site features a variety of HH insights, statistics, and reminders, as well as a selection of visual designs," she said. "Healthcare facilities can select a design style, choose the information to be featured, and add their own logo to build-out free, customized, HH signage. The site will be refreshed regularly, enabling hospitals, doctors’ offices, and long-term–care facilities to update signage frequently. Changing HH communications on a regular basis keeps messages from wearing out with employees, helping HH protocol to stay top of mind."

According to an SCA-commissioned survey on hand washing in healthcare facilities, Rickert said 93 percent of patients and visitors agree that HH is more important in healthcare settings compared to other public places and that more than 80 percent felt that handwashing signage plays a role in how they view a facility’s safety, cleanliness, and quality of care.

3M Avagard (Chlorhexidine Gluconate 1 percent Solution and Ethyl Alcohol 61 percent w/w) Surgical and Healthcare Personnel Hand Antiseptic with Moisturizers

Keeping in mind how tough repeated hand cleansing can be on skin is what prompted 3M to develop its Avagard (chlorhexidine gluconate 1 percent solution and ethyl alcohol 61 percent w/w) Surgical and Healthcare Personnel Hand Antiseptic with Moisturizers. "We understand the demands placed on the healthcare provider’s hands from repeated hand cleansing throughout the day," said Kimberly S. Prinsen, R.N., MSN, Technical Service Specialist, 3M Infection Prevention Division. "When a healthcare provider cleanses their hands up to 90 times a shift, it is important to have a product that not only cleanses but protects and enhances hand health.

"There are multiple ways that 3M Avagard Surgical and Healthcare Personnel Hand Antiseptic with Moisturizers promotes compliance," Prinsen continued. "First, when the pump is activated, a pre-measured dose is dispensed into the hand of the healthcare provider." Prinsen explained that the right amount of product ensures efficacy and promotes skin health, because too much of any product can cause skin irritation. "Second, there is no time requirement as to how long 3M Avagard Surgical Hand Antiseptic must be applied to the hands, unlike other HH products. Simply rub it into your hands and allow it to dry. It is quick and easy to use. In addition, the proven persistent property of the active ingredient, chlorhexidine gluconate, has a cumulative effect with repeated use. This means greater protection for both the healthcare providers and the patients for whom they are caring."

Prinsen says 3M’s sales team, technical-service specialists, and clinical specialists provide in-facility education and training for staff and that application and competency tools, webinars, and continuing education opportunities can be accessed online at 3M’s Healthcare Academy (

Henry Schein hand-hygiene-compliance solutions

Denise Sternbach, Product Category Manager, Henry Schein Medical, says hand sanitizers, such as the Maxiclens Instant Hand Sanitizer, are a popular choice among HCWs because they are convenient and can be used anywhere, anytime. They’re also effective. "The Henry Schein Brand Maxiclens Hand Sanitizer kills 99.9 percent of germs in 15 seconds, without the use of soap and water," said Sternbach. "Because soap and water are not always readily available, hand sanitizers are a popular alternative routinely used by millions of HCWs. The Maxiclens Instant Hand Sanitizer is convenient, but users should keep in mind that it is only effective for infection prevention when used properly and in sufficient quantity. The Henry Schein Brand Maxiclens Hand Soap contains 0.6 percent chloroxylenol and has a touchless dispensing system to provide added protection against the inadvertent transmission of germs."

To promote moisture and ward off dryness, the Maxiclens Hand Hygiene System contains aloe vera. Sternbach says the products also aid in reducing the risk of cross-contamination, while helping healthcare providers meet Association for Professionals in Infection Control and Epidemiology, Occupational Safety and Health Administration, and CDC handwashing guidelines and recommendations. Further details about the Henry Schein Maxiclens Hand Hygiene System can be found online at

PDI Sani-Hands Instant Hand Sanitizing Wipes

PDI offers a hand sanitizer product in a convenient wipe, which Hudson Garrett, Jr., Ph.D., MSN, MPH, FNP, VA-BC, says was developed specifically for repeated use in healthcare environments and to counteract the drying effect of alcohol. "Sani-Hands Instant Hand Sanitizing Wipes have added emollients to moisturize the user’s skin and can be used repeatedly by the healthcare provider with minimal risk for irritation. The formulation contains soothing aloe and vitamin E, and is clinically proven to moisturize skin after repeated use," Garrett said, asserting that the product removes dirt and soil better than gels and foams. "Because the wipe physically removes soil from the hands via mechanical friction, there is no build-up on the user’s hands, as is common with many alcohol-based gels and foams." 

Citing a recently published study, Garrett says Sani-Hands wipes demonstrated sustained improvements in overall Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores by engaging the patients in efforts to prevent HAIs through HH.3 "Sani-Hands Instant Hand Sanitizing Wipes have been proven in multiple clinical studies to reduce rates of HAIs and HCAHPS scores," he said, adding that comprehensive educational resources for professionals and patients, product info, and compliance tools can be found online at In addition to on-going clinical support, Garrett said, "Our Sani-Hands Bedside Pack includes educational icons on the packaging to reinforce key moments for HH. We also have wall charts, in-service videos, and patient-education videos. Continuing-education programs are available on infection-prevention and are available through the PDI Clinical Affairs Team."


1. The Joint Commission Center for Transforming Healthcare. Hand hygiene factors and solutions.
%20factors%20and%20solutions.pdf. Last accessed September 3, 2015.

2. The Leapfrog Group. The Leapfrog hospital survey: hand hygiene safe practices. Last accessed September 3, 2015.

3. Walrath B. Patient hand hygiene project improves quality measures in an orthopedic surgical post-operative unit. Am J Infect Control. 2015;43:S18-S73.