It is now well recognised that hand hygiene is the primary measure for infection prevention. When performed well, it reduces transmission of microbial pathogens both in the community and in the healthcare setting.¹

In Victoria, hand hygiene projects have been in place for several years. With the Hand Hygiene Australia initiative, hand hygiene education and auditing is becoming a national strategy to reduce hospital acquired infections.²

In addition to monitoring healthcare worker compliance with the 5 moments of hand hygiene³ (a process measure), Staphylococcus aureus bacteraemia data are also collected as an outcome measure.

Infection control strategies to raise the profile of hand hygiene and improve compliance:

• Make sure alcoholic chlorhexidine is available at the end of patient trolleys, fixed to equipment trolleys, at the entry and exits to departments, cubicles and clinical rooms.
• Quiz colleagues on the 5 moments of hand hygiene and when to apply alcoholic chlorhexidine hand-rub.

Many studies have described transmission of pathogenic organisms through contact with contaminated surfaces.⁴ Multiple-drug resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) are of concern because infection is associated with increased length of stay, increased healthcare costs and increased mortality.⁵

Adequate cleaning requires sufficient removal of pathogens to minimize patients' risk of acquiring infections from hospital environments.⁶  Specific VRE cleaning following discharge of patients colonised with VRE involves 2 steps; cleaning with detergent and water followed by disinfection with a weak hypochlorite solution (bleach). This process has been used since VRE was first identified in the 1990's.

There is evidence demonstrating that appropriate cleaning assists in preventing the transmission of VRE however this special cleaning technique is only used when it is known that a patient is carrying VRE.^7,8

Infection control strategies to keep your environment free of microbial pathogens:

• Make sure your department is visibly clean, conduct cleaning audits with your cleaning staff and promote their role in the health team.
• Credential cleaning staff in special cleaning techniques such as those used when patients, colonised with highly resistant organisms (e.g. VRE), are discharged.

Safety engineered medical devices are now well recognised as one strategy to assist in reducing the risk of percutaneous injury to healthcare workers.^9,10 Other important strategies include the placement of sharps containers, education about preventing sharps injuries and management of occupational exposures.¹¹

Many jurisdictions in the developed world now advocate the use of safety engineered devices. Safety devices cost more than non safety devices and are introduced to reduce the risk of acquisition of a bloodborne virus in healthcare workers. Some studies report that the degree of under-reporting of sharps injuries can be as much as 10-fold.¹²

Infection control strategies to keep your staff free of percutaneous injuries:

• Trial a range of safety devices and choose the device most appropriate for cost, useability and accessibility.
• Educate staff about the importance of preventing percutaneous injuries and promote their health as a priority.
• Ensure there is an appropriate occupational exposure management protocol in place should an injury inadvertently occur; promote its availability and the value of reporting injuries.

The Australian Commission on Safety and Quality in Healthcare report that the most important preventive strategies to reduce and prevent hospital acquired infections include hand hygiene, the appropriate use of antibiotics and immunisation of health-care workers (HCWs).

Healthcare workers who are not immunised place patients at risk of acquiring vaccine preventable diseases, and more effort is needed to help staff and employers to reduce this risk.¹³ It is well recognised now that up to 59% of HCWs can have subclinical influenza and potentially cross infect patients. Reductions in mortality of elderly patients have been demonstrated when HCWs have been vaccinated.¹⁴

Infection control strategies to improve HCW immunisations

• Ensure a system is in place for HCWs to be vaccinated on employment.
• Devise a catch up program encouraging HCWs to have their immunisation status updated.
• Prioritise HCW immunisation by using declination forms, i.e. for influenza vaccination. Studies have shown that the use of declination forms improve influenza vaccination uptake and assist dispelling the myths by informing staff.¹⁵

1. Pittet D. hand hygiene: It’s all about when and how. Infection Control Hosp Epidemiol 2008;29:957-59
2. Russo P. Hand hygiene Australia: synopsis. Healthcare Infection 2009;14:11
3. World health Organisation. About Save Lives: Clean your hands - My 5 moments in hand hygiene, last accessed August 2009
4. Zachary K, Bayne P, Morrison V, Ford D, Silver L, Hooper D. contamination of gowns, gloves and stethoscopes with vancomycin-resistant enterococci. Infect control Hosp Epidemiol 2001;22:560-564
5. Siegel J, Rhinehart E, Jackson M, Chiarello L. Healthcare Infection Control Practices Advisory Committee. Management of multidrug resistant organisms in healthcare settings, 2006. Atlanta: Centres for Disease Control and Prevention, 2006
6. Goodman E, Platt R, Bass R, Onderdonk A, Yokee D, Huang S. Impact of environmental cleaning intervention on the presence of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci on surfaces in intensive care unit rooms. Infect Control Hosp Epidemiol 2008;29:593-599
7. Puzniak L, Gillespie K, Leet T, Kollef M, Mundy L. A cost-benefit analysis of gown use in controlling vancomycin-resistant enterococcus transmission: is it worth the price? Infect Control Hosp Epidemiol 2004;25:418-424
8. Ray A, Hoyen C, Taub T, Eckstein E, Donskey C. Nosocoamial transmission of vancomycin-resistant enterococci from surfaces. JAMA 2002 ;287 :1400-1401
9. Zanni G, Wick J. Preventing needlestick injuries. Consult Pharm 2007;22:400-2
10. Sohn S, Eagan J, Sepkowitz K, Zuccotti G. Effect of implementing safety-engineered devices on percutaneous injury epidemiology. Infect Control Hosp epidemiol 2004;25:532-42
11. Tuma S, Sepkowitz K. Efficacy of safety-engineered device implementation in the prevention of percutaneous injuries: a review of published studies. Clin Infect Dis 2006;42:1159-70
12. Elder A, Paterson C. Sharps injuries in UK health care: a review of injury rates, viral transmission and potential efficacy of safety devices. Occup Med (Lond) 2006;56:566-74 Epub
13. Cruickshank M, Ferguson J, editors. Reducing harm to patients from health care associated infection: The role of surveillance. Australian Commission on Safety and Quality in Healthcare, 2008. Last accessed August 2009
14. Elder A, O'Donnell B, McCruden E, Symington I, Carmen W. Incidence and recall of influenza in a cohort of Glasgow healthcare workers during the 1993-4 epidemic: results of serum testing and questionnaire. BMJ 1996;313:1241-2
15. Ribner B, Hall C, Steinberg J, Bornstein W, Chakkalakal R, Emamifar A, Eichel I, Lee P, Castellano P, Grossman G. Use of a mandatory declination form in a program for influenza vaccination of healthcare workers. Infect Control Hosp Epidemiol 2008;29:302-308

CICP, MPubHlth (Melb)
Sterilisation and Infection Control Co-Director, Southern Health
Phone: 03 3 9594 2964