Using the Six Sigma Process to Implement the Centers for Disease Control and Prevention Guideline for Hand Hygiene in 4 Intensive Care Units

BACKGROUND: The Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Health Care Settings was issued in 2002. In 2003, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established complying with the CDC Guideline as a National Patient Safety Goal for 2004. This goal has been maintained through 2006. The CDC's emphasis on the use of alcohol-based hand rubs (ABHRs) rather than soap and water was an opportunity to improve compliance, but the Guideline contained over 40 specific recommendations to implement.
OBJECTIVE: To use the Six Sigma process to examine hand hygiene practices and increase compliance with the CDC hand hygiene recommendations required by JCAHO.
DESIGN: Six Sigma Project with pre-post design.
PARTICIPANTS: Physicians, nurses, and other staff working in 4 intensive care units at 3 hospitals.
MEASUREMENTS: Observed compliance with 10 required hand hygiene practices, mass of ABHR used per month per 100 patient-days, and staff attitudes and perceptions regarding hand hygiene reported by questionnaire.
RESULTS: Observed compliance increased from 47% to 80%, based on over 4,000 total observations. The mass of ABHR used per 100 patient-days in 3 intensive care units (ICUs) increased by 97%, 94%, and 70%; increases were sustained for 9 months. Self-reported compliance using the questionnaire did not change. Staff reported increased use of ABHR and increased satisfaction with hand hygiene practices and products.
CONCLUSIONS: The Six Sigma process was effective for organizing the knowledge, opinions, and actions of a group of professionals to implement the CDC's evidence-based hand hygiene practices in 4 ICUs. Several tools were developed for widespread use.     

New CDC program focuses on those already infected. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) is instituting a program to provide comprehensive HIV prevention services to those already infected. The goal is to prevent HIV positive people from transmitting the infection to others. Up to five long term demonstration projects will be funded with $3.9 million to start, in order to develop and assess program models that later may be expanded and adapted across the country. The program goals are to increase the proportion of people who know their serostatus, provide primary prevention services, assist people in obtaining medical care and other services, and provide training and quality assurance to people at high risk.     

CDC: better needlestick reporting required. Centers for Disease Control and Prevention

A recent study of percutaneous injuries from phlebotomy devices showed that only about half of all injuries were reported through the hospital surveillance system. In light of the success of post-exposure prophylaxis in reducing occupational HIV transmission, the Centers for Disease Control and Prevention (CDC) has recommended that health care facilities work to improve reporting. The year-long CDC study of health-care professionals revealed that on average 54 percent of needlestick injuries were reported, though reporting rates varied by occupation. Janine Jagger, director of the International Health Care Worker Safety Research and Resource Center, says some workers fail to report injuries because they do not consider a needlestick a high-risk event. Others, she notes, are concerned about the potential problems associated with contracting a bloodborne pathogen. The CDC, which recently issued recommendations for post-exposure prophylaxis, hopes that reports confirming the benefit of treatment will improve the reporting of accidents. Setting up a 24-hour hotline for employees is one way to improve reporting by making it convenient and confidential.     

How HIV affects children. Centers for Disease Control and Prevention

The 1997 World AIDS Day drew attention to how the epidemic is affecting children worldwide. Last year, 400,000 children under 15 years of age became contaminated, and if the spread of HIV is not contained, infant mortality rates will climb to 75 percent by the year 2010. AIDS typically runs a faster course in children than in adults, particularly in developing countries. Directing prevention efforts toward children is crucial to contain the further spread of AIDS. Statistics are provided for infection rates worldwide.     

Post-exposure prophylaxis revisited: new CDC guidelines. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) convened a meeting in 1997 to revisit guidelines for post-exposure prophylaxis (PEP) for occupationally acquired HIV infection. Recent data show that the health care worker's infection risk is increased with deeper injury, bloodier needles, and source patients with more advanced disease suggesting higher viral load. A CDC study shows that AZT use of any kind was associated with an 81 percent reduction in the risk of seroconversion compared with controls not given AZT. AZT is the only drug for which proof exists of clinical benefits in the prophylaxis setting. However, attempts to assess AZT's efficacy in a randomized, prospective, placebo-controlled trial have failed, making the assessment of PEP's efficacy unlikely in the future. PEP initiation, according to the CDC, is guided by two principles: relative risks of exposure and the risks of the injury balanced with risks of the drug therapy. Future treatment guidelines are likely to pay more attention to the source patient, disease stage, and/or viral load as determinants of risk. Other nucleotides and protease inhibitors could arguably be included in PEP regimens, particularly for treatment of high-risk cases. Studies show no fetal harm from AZT; there is little information on fetal toxicity of other antiretrovirals. New guidelines are due to be published in the MMWR in early 1998.     

CDC: avoid preventive therapy for sexual risk. Centers for Disease Control and Prevention

At a recent meeting, AIDS experts questioned why postexposure prophylaxis that protects health care workers against blood exposure to HIV would not protect someone who has been exposed to HIV through sexual contact. There is no scientific evidence that antiretroviral drugs can prevent sexual transmission. The Centers for Disease Control and Prevention (CDC) points out that the dynamics of transmission via blood exposure versus sexual exposure differ in ways not fully known. The CDC acknowledges that the triple combination of drugs recommended for exposed health care workers has the potential to act as a morning-after pill, and have asked for additional funding to study the role of protease inhibitors in this type of prevention and intervention of HIV. Two groups that would directly benefit from the back-up protection are discordant couples and women who have been sexually assaulted and cannot determine the HIV status of their assailant.     

CDC gives communities prevention strategies. Centers for Disease Control and Prevention

Government officials say that widespread HIV prevention efforts are needed among injection drug users. This group, along with their sexual partners and children, account for one-third of all reported AIDS cases in the United States. The Centers for Disease Control and Prevention (CDC) issued community guidelines in 1997 for stopping the spread of HIV through injection drug use. These guidelines include changing community laws to permit the purchase of clean syringes, and using substance abuse intervention programs to provide education on risks associated with drug use and sexual behavior. The CDC also stressed the need for a Federal commitment to drug treatment programs.     

CDC won't recommend non-occupational PET. Centers for Disease Control and Prevention

The Centers for Disease Control and Prevention (CDC) advises not using a morning-after pill for non-occupational HIV exposures, except those that result from sexual assault. Postexposure therapy (PET), a complicated medical intervention, requires further studies to determine its effectiveness for HIV prevention. Researchers are concerned that PET could lead to increased transmission rates if people see it as a follow up to risky behavior and become less conscientious about safe sexual practices. PET has serious side effects, and one-third of patients do not complete the treatment, which may increase the risk of developing drug resistance to HIV. Although PET appears to reduce the risk of HIV transmission via exposure to infected blood in the workplace, there is not enough data to prove its efficacy against exposure through sexual relations.