JCAHO looking for hand hygiene compliance

Staff workers may be interviewed

ICPs be advised: Surveyors for the Joint Commission on Accreditation of Healthcare Organizations are asking health care workers whether they understand the new hand hygiene guidelines and are looking for signs of compliance.

"Compliance will be surveyed through interviews with caregiver staff and direct observation," the Joint Commission stated in information posted on its web site. "Caregivers should know what is expected of them with regard to hand hygiene and should practice it consistently. It is expected that noncompliance will be quite low, so that any pattern of noncompliance, i.e., more than a sporadic miss, will be scored as noncompliance."

As part of its 2004 patient safety goal to reduce nosocomial infections, the Joint Commission is looking for compliance with the hand hygiene guidelines by the Centers for Disease Control and Prevention (CDC). The CDC has abandoned its traditional emphasis on sinks and soaps in favor of new guidelines based on the European model of using alcohol-based hand rubs. As part of those guidelines, the CDC urges clinicians to monitor health care workers’ adherence with recommended hand hygiene practices and provide personnel with information regarding their performance. The Joint Commission posted the following answers to commonly asked questions to help ICPs comply with the measures and pass JCAHO inspections:

Q. Where can I find the current CDC hand hygiene guidelines?

A. The full report is available at www.cdc.gov/handhygiene/. The report is extremely detailed and well documented. The specific recommendations referred to in the patient safety are on pages 31 to 34 of the report.

Q. Does JCAHO require implementation of all the recommendations in the CDC hand hygiene guidelines?

A. Each of the CDC hand hygiene guidelines is categorized on the basis of the strength of evidence supporting the recommendation. All "category I" recommendations (including categories IA, IB, and IC) must be implemented. Category II recommendations should be considered for implementation but are not required for accreditation purposes.

Q. What do these categories mean?

A. Category IA recommendations are strongly supported by well-designed experimental, clinical, or epidemiological studies; category IB recommendations are supported by certain experimental, clinical, or epidemiological studies and a strong theoretical rationale; category IC recommendations are required by regulation; category II recommendations are supported by suggestive clinical or epidemiological studies or theoretical rationale. The CDC also includes among its recommendations several unresolved issues for which it makes no recommendation.

Q. The CDC guidelines say that health care personnel should not wear artificial nails and should keep natural nails less than ¼ inch long if they care for patients at high risk of acquiring infections (e.g. patients in intensive care units or in transplant units). Will JCAHO actually be requiring this?

A. The artificial nails recommendation is a category IA recommendation, so it will be required for those individuals providing direct care to high-risk patients. However, the ¼ inch nail tips recommendation is category II, so should be considered for implementation but will not be required.

Q. Do we have to use alcohol-based hand cleaners?

A. Accredited organizations are required to provide health care workers with a readily accessible alcohol-based hand-rub product. However, use of an alcohol-based hand-rub cleaner by any individual health care worker is not required. The guidelines describe when this type of cleaner may be used instead of soap and water. If you choose not to use it, then soap and water should be used instead.

Q. Isn’t the alcohol-based hand sanitizing gel flammable? Should we be concerned about a fire hazard?

A. The typical alcohol gel and foam dispensers used in the health care setting are of such limited size and volume that their contribution to the hazard of acceleration of fire development or fire spread in most situations is small. In a recent survey of 800 facilities reporting a cumulative 1,430 years of hand-rub use, no fires attributable to or involving a hand-rub dispenser were reported. However, the 2000 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code prohibits the installation of alcohol-based hand sanitizing gel dispensers in egress corridors. JCAHO recommends that organizations install these dispensers just inside each patient’s room (and whichever other rooms the organization deems necessary), or just outside the room if this is not an egress corridor. Studies have shown significantly better compliance when the dispensers are located just outside the room (when permissible) rather than just inside. Do not install them in egress corridors, above heat/ignition sources, electrical outlets, or light switches. Note that local or state fire code requirements may differ from the national codes, therefore, you should determine and follow the requirements for your particular locale.

Q. Where can I get more information about the fire safety issues?

A. A number of organizations including the National Association of State Fire Marshals, the American Society of Healthcare Engineering, and the Association for Professionals in Infection Control and Epidemiology have published interim guidance documents for the placement of dispensers and control of bulk storage of alcohol-based hand cleaners. These are subject to revision as more data become available.