Performance feedback of hand hygiene, using alcohol gel as the skin decontaminant, reduces the number of inpatients newly affected by MRSA and antibiotic costs

Abstract

In March 2000 the Plastic Surgery Unit of our 600-bedded district general hospital agreed to be the pilot ward for the introduction of a new standard of hand hygiene, emphasizing the use of alcohol gel on socially clean hands between clinical contact with patients. Hand hygiene practice of healthcare workers (HCWs) was observed using Formic™ forms. The data from completed forms were scanned into an Excel™ database, and results fed back to HCWs in graphical form. The case notes of patients newly affected by methicillin-resistant Staphylococcus aureus (MRSA), likely to have been acquired as inpatients, were reviewed for one year before and after this performance feedback of hand hygiene. The cost of teicoplanin use (for MRSA infections) was also determined for the two periods. There was a significant reduction in the number of patients newly affected by MRSA (P<0.05), and in the use of teicoplanin, suggesting that performance feedback of hand hygiene reduces nosocomial MRSA infection rates and antibiotic use.

Introduction

From the story of Semmelweis,¹ it is possible to conclude that the use of a chemical handwash (Chlorina liquida) before examining women in labour, can reduce the mortality from puerperal sepsis. Indeed, in the month after its introduction, mortality fell from 12.2 to 1.2%.

As a modern equivalent to Chlorina liquida, we chose alcohol gel, which kills over 99.9% of transient organisms, including methicillin-resistant Staphylococcus aureus (MRSA).2., 3. We chose the term ‘clinical handwashing’ to denote those episodes of hand decontamination that are most likely to prevent hospital-acquired infection, within an episode of care, or between patients.⁴ A hand hygiene standard can be audited and the results fed back to staff in graphical form. It has been shown that such a system of hand hygiene performance feedback both improves healthcare workers' performance and maintains the improvement for several months.⁵ This suggests a change in the hand hygiene ‘culture’ for the clinical area, in contrast to the more transient results from educational initiatives. The aim of any hand hygiene initiative is to reduce the risk of infection in patients. We chose hospital-acquired MRSA-affected patients as a marker of the effectiveness of staff hand decontamination between patient contacts. The number of patients newly affected by MRSA, likely to have been acquired as an inpatient, was fed back to clinical staff in graphical form.