On Pathogens & PPE: Hand Hygiene in SPD

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1:12On a microscopic level, they exist to kill. They travel, they attack, they hide, they even gather together in defence maneuvers. Pathogens are the enemies of every member of the healthcare team. On Pathogens and PPE, we give you the tools you need to fight these threats and win. So sit back, tune in, and let's make these microbes tremble at the sound of your name. Hello and welcome back to the second episode of season 2 for on Pathogens and PPE. Thank you guys for coming back for a second episode and I am Jill Holtworth here with an episode all about hand hygiene and the sterile processing areas. I am joined by my co-host, Rebecca. Rebecca, thanks for joining me today. Thank you, Jill. Glad to be here. Rebecca, why don't you give everybody a little bit of your background and what you've

2:15been doing in the past few years? Sure. So I'm Rebecca Elvino. I am the system director of hospital epidemiology and infection prevention at UC Davis Health and Sacramento. I've been in infection prevention for many years over a decade now. Prior to this, I actually was a system director of sterile processing at University of California San Francisco Health in San Francisco or I oversaw the growth from 6 to 9 SP. And they continue to grow even after my departure. And prior to this life, I was an OR nurse for 15 years so that SPD-IP OR triangle might entire career envelops it. That's amazing. If anybody knows how to get all of these groups to work together, it is definitely you. So happy to have you here today. Thank you. You're host. And we have two amazing guests today. They just happened to be two of my favorite people on this earth. So I'm going to start with Ibo. And I know a lot of people know Ibo already, but Ibo, give us a little bit of your background

3:18and all of the amazing things that you do. Hello, everybody. I'm Ibo. As all of you may know, or most of you know, I've been in sterile processing for quite a while and made the transition to IP now a system IP, specifically focusing on medical device reprocessing currently and taking a huge project on standardization before that being to sterile processing all levels of sterile processing finally ending as a market director for a sterile processing prior to that surgical tech and healthcare qualities just like Mr. Baker, I've been everywhere in the healthcare system up to and including pre hospital as a paramedic. Hello. Yeah, we are. So happy that you're here with us today, Ibo. And also we have one of my long time friends, Ivan, and Ivan, why don't you tell everybody

4:20a little bit of your history and how we know each other? Hi, yes. My name is Ivan Goa. I am an infection preventionist. I've worked primarily in community healthcare centers, community hospitals. And before that, I worked in a lab. So I like to say I'm a lab rat, turned infection preventionist. I have been in IP for about 17 years and I spent about four years, four years, four years in the lab before that. And I knew Jill before she was a big deal. Jill and I were both IPs in Virginia working for Centera healthcare. So I am glad to be here. And I love Ivan's story and Ibo's story are it IPs now and much like myself for kind of that non-traditional IP, we are non-nurses, nothing against nurses, but you can be an IP basically with whatever background that you have. If you want to be an IP, you can absolutely be an IP.

5:23And that diversity in the teams is what makes our IP teams so strong. So I love all of the backgrounds that we hear about as we keep interviewing people. So let's get right down to it. This episode is all about hand hygiene and this is something that as IPs we care a lot about. But when it comes to sterile processing, there are a lot of unique challenges when we talk about washing our hands and where to do hand hygiene. So let's just talk first about traditional hand hygiene measurement methods and observation methods. And I'll start with Ivan on this one. Tell us how we typically would measure hand hygiene on a clinical floor in a hospital and why that may be simpler than measuring it in sterile processing. Hand hygiene observations in a hospital setting tend to be easier because hospital units are generally more open, they're less closed departments than a sterile processing department.

6:24And so in both of the hospitals where I worked, we pushed for hand hygiene observations coming from as many healthcare workers as possible. And so an environmental services person who is out doing their job could provide hand hygiene observations on a nurse who's walking into the room, into the room across the hall. A food services rep could provide hand hygiene observations on a physician who is working in a patient's room. And so it allows the nursing unit generally allows for more people to pass through and provide observations. I really like that you're talking about what is a tried and true method of hand hygiene observation, which is sort of a secret shopper or observer based method. In my experience, it can be a little skewed to the positive, often it can be a convenient sample that we're gathering. And you're right. Like I describe how compressed sterile processing departments can tend to be.

7:28One follow up that I wonder if you can answer for us. I've been another method for hand hygiene compliance is with electronic monitoring systems. Can you talk about those for our listeners about how that's different than the observer-based methodology? Yes, electronic observation methods generally tend to involve a badge or a carried item on the healthcare worker and a sensor on the device. And those two interact when a healthcare worker enters or exits the room or works around the patient's bed and all of those movements lead to opportunities for hand hygiene. In SPD, there are fewer interactions with those systems because a lot of people working in SPD are working at their station. And so it is a lot more difficult to then get out from your station, go wash your hands,

8:32come back, and that's efficient. And again, a lot of that is with interacting with a sensor in the dispenser and also interacting with these sensors and doorways and where you're doing the work in in SPD. That's a lot more poorly defined where those moments are. Now, Ibo, I have a question for you as someone who's worked in sterile processing areas before. If you saw someone doing the manual observations and we all know these, you see these people in a compressed area like sterile processing. So say you see that person when they're clipboard watching what you're doing. What do you think the general reaction is going to be or action? So in SPD, I was thinking from my experience, whenever we see somebody with a clipboard, we tend to assume the worst before we assume the positive.

9:33So the person that will probably happen to be, why is this person in my space and what are they doing? Most of the time will probably approach that and they'll see this is what they're doing. Then now that we know that is what is happening, we will instinctively perform hand hygiene. So that observation method is not the most practical approach in sterile processing areas. We are physically separated from the observers. So it is hard to see and when they are in our space, we actually see them coming in and see what they're doing. So we tend to adopt the best practices in that moment. But as soon as that observer or the secret shopper is out of that area, it goes back to the status quo, if hand hygiene is built in the culture, it will still continue.

10:35But if it's not already built into the culture, well, another day, let's just do what we always do. I add on to people's statements and say, like Rebecca was saying, where you have your secret shoppers in the department, that tends to skew the data. So where you have secret shoppers in SPD, you get some data, but it is not the most accurate data. And how, you know, such a great point, the clipboard. I say this so many times to IPs, don't take a clipboard anywhere that you go because no matter what you're doing with your clipboard, whether you literally just need something to write on or you are auditing, people are going to think the worst and they're going to start jumping around and acting crazy using the hand hygiene more than they need to or doing something that they don't even need to do at the moment because they're trying to overdo whatever they think you're watching. So just don't even take the clipboard so that you don't seem like the scary auditor all

11:37the time. That's what I was going to point out was even when you have a clipboard or if you don't have a clipboard, in my experience, you can tell when somebody doesn't know what to do because then they start performing hand hygiene at the wrong moments. I've had people literally even sort of pretend to hit the dispenser and then hold their hands up in the air and I'm like, I can hear the dry noise of your skin coming together, right? And they just look awkward. So if it's not your muscle memory, you can also tell that as an observer. So in a situation like that, what do you do? So in SVD areas, the five moments were not builds. The five moments were initial builds around patient interaction before touching a patient after badly fluid, exposure and so on. In star processing, we don't have patient, though we provide patient care through instrumentation. Our patients technically are the instruments.

12:39So the contamination risk we manage between dirty and clean wax zones, that is where most of our interactions happen. So to answer your question, we'll have to define a new zones for SVD when it comes to those hand hygiene's movement. And for example, one particular SVD movement will be from dirty to clean. Because you doff your PPE after the manual cleaning process, before you put the, for example, if your, if your department reprocesses flexible endoscope after the manual cleaning process, doffin of your PPE, hand hygiene glove into high level disinfection. After high level disinfection, hand hygiene glove will move it to your sterile storage or to your transportation card to your sterile storage area. If it's instrumentation, after manual cleaning and pushing the item into the washer, the

13:42disinfector, getting out of the decontam area, doff, hand hygiene, that's the movement. In the clean area, when another movement will be before you take out your instruments out of the washer, if you have to touch it to inspect if it's actually clean, that could be another movement for hand hygiene. Some of us wear gloves in our clean wear carriers, most of us do not. So before assembling, that could be another movement for hand hygiene to occur. There are so many things that you said just now that I feel like we could just dive into with the one thing that I want to talk a little bit more about is how we set up our donning and doffing. And I'll ask, I've been to comment a little bit more on this because this is something that is IPs we have been preaching for years, but to have the right supplies where you don and doff and to have the right workflows set up is something I don't see a lot in

14:43the sterile processing space. We're telling you to use hand hygiene before you put on your gloves and do all of this as soon as you doff, but then you don't see these areas set up for success. So I've been in your experience, what are we seeing, how do we fix this, what do we want to see? It seems like a no brainer, but it's not. Yes, it is, it is a little bit difficult. When I think about the last facility where I worked, there was in the decontamination area, the PPE was on one side of a long rectangular room and the workstation was on the other side of that room. And so the expectation for someone to doff PPE required a proper interruption of their workflow. They have to stop what they're doing. They have to doff their PPE, walk all the way across the room and get their new PPE.

15:44Thankfully we had hand sanitizer dispenses right next to the PPE station, but from an efficiency standpoint, these employees had to go quite out of their way to get access to those supplies. So ideally we want those supplies nearer to where the work is happening. However, decontamin poses a problem because of all of the water. And so where are you going to store that PPE in a manner in which it stays clean, that becomes a little bit problematic too. Can you talk about a little bit hand washing sinks? I think sometimes there can be some incorrect assumptions of, well, a three-base sink that we're decontaminating in. It's a sink. Why can't I wash my hands there? Right? Can you talk about that a little bit and why it's so important to have that different dedicated sink? Absolutely.

16:44A sink is not a sink, all right? I think that's what a lot of healthcare workers think. A sink is a sink is a sink if it has soap, I can wash my hands. One of the things that has come out of research in CRE outbreaks, carbon-benemase resistant or CRO, carbon-benemade resistant organisms, outbreaks is that when our water hits the sink, it splashes back on us. So if you think about that water grabbing a few microbes as it splashes back, when you are washing your hands in a sink that has been used to decontaminate an endoscope, you risk that water splashing back with whatever you have removed from the endoscope. That is why it is important to have a strict hand washing sink in areas like SPD. That way, that sink is not being contaminated by the things that are coming out of scopes

17:48and surgical instruments and the like. And I think some of our standards, STN-91 and ST-79, if I'm a mistake, can actually stage that we should have separate sink for hand hygiene and for instrument repressive. And your surveyors will look for that as well. They will look around to see where your sinks are and they will say, where do you wash your hands? And you better not say, it's that sink that you use for your instruments or your scopes or that will be an immediate citation. So it is such a good point to point out the why Ivan. We love talking about the why's because you can't just tell people, you cannot do this, you cannot do that. But to really explain to them, this is why you can't because you might be washing your hands with CRE backsplash. That actually might resonate with people. And so really telling people the why behind some of these things is really important. So thank you for explaining that. So let's talk a little bit more about the guidance.

18:53You have kind of alluded to it a little bit, Evo, with we have the five moments for hand hygiene from the WHO when we're talking about patient care. The guidance is a little bit more lacking when it comes to still processing departments. What do you think that is and what do we really feel like we need moving forward? I'm going to invite my friend Gerald into this for this one. So in our world, it's the world contamination risks are stated earlier happens between instruments and work surfaces and zone, not specifically patients. So current guidance doesn't just map to our workflow. And I think the other issue is visibility. SPD is often behind the scenes. So it hasn't been stated as deeply from a behavioral and compliance perspective as other units in our health care facilities have been.

19:55That is why it is so important that we start defining what our movements look like. For example, that could be before moving from dirty to clean as stated earlier after removing people, which I haven't previously just hit on before handling clean instrument. We can even go as far as before handling sterilized instruments that that is a controversial topic that will get the SPD folks up in flames. So we're not going to go that far yet. But until that is formalized in standards like Amy, standards and guidelines, or even the CDC, there's always going to be this great area that we have to navigate with good practice and there I say common sense. And with that, I'm glad you pointed out that currently, you know, WHO, CDC, hand hygiene

20:57recommendations, those five moments or all those different moments, they don't exactly map to the work that steril processing does. So before this podcast, I just did like a quick search, quick lit review, went into PubMed, which is, you know, in a sort of certain state with everything going on nationally at the moment. And so I found literally no articles that look at research about hand hygiene and steril processing, even going into the CRCS T9 edition book, there's a column and a half dedicated to hand hygiene, but it doesn't get into this in-depth about in your work, when should you be doing the hand hygiene across these specific tasks or when you encounter these specific scenarios? So what is the best way to close the gap with evidence-based but common sense application to identify for the folks working in steril processing? This is when you need to perform hand hygiene to produce the safest highest quality instrumentation

22:03or devices, but also to keep yourself safe. Short answer, that's the way we come in, by way, I mean us on the podcast right now, technicians that are doing the job. At some point, we don't have to wait for others to tell us what to do. We can just take on the serum wheel and just stare to where we want to do the best practice. Some of us already know the best practices, what the best practices are. We just like the resource to push it forward. So as by combining our efforts and resources, we can actually better establish guidance and standards for us in our own industry. I love that answer and you're absolutely right. We don't need to sit here and wait on other people to do the work for us because it may never happen. So I love that, especially with people like yourself who worked in SPD for years and they

23:07make the jump over to IP and people like Rebecca who have kind of done both, but I love that. I just did a quick PubMed search too because it just struck me that I do not know that there is such a map for the lab. I do not know that there is such a map for other non-patient technical areas in a health care setting. And so one, that might be a good place to start. See if any of those other departments have set anything up, but you are right. Where guidance is lacking, we have to weed it. And you're absolutely right, Ebo. Doing things like this, like this podcast to bring awareness to the fact that yes, you still do need to wash your hands and use hand hygiene in still processing departments. But it's poorly defined. This is a great start. We're bringing awareness. We're hopefully getting folks in IP and still processing to start thinking about it.

24:12Like, okay, we're not sure we have our work flow set up. We're not sure we have things set up correctly in our department to make things successful. This is a great start. So for those that are listening, we hope this has stopped provoking for you and that you go and start walking your own workflows. And this is something that is great to partner with IP. I love walking workflows like this with people and say, okay, we take our instruments from here to the window or to the washer. Where do we have potential to contaminate our hands or to have our hands contaminate other things? So those are great things. That's like a risk assessment. You know, we always talk about risk assessments and it seems very overwhelming to people. But that is a walking risk assessment that you can do with your IPs. Now, I'm going to throw another question out there for you guys and Ibo, you can start with this one. Where do you feel like we need to make sure we have hand hygiene supplies like hand gel. You can do hand washing things too in the departments that you commonly don't see that they are.

25:19We want to make sure it's in arms reach of care. It's always where I say in the clinical units, but where do you think that we're really lacking when we're talking about supplies being available like that hand gel? That and ours, you know, Sarah, for us, as soon we went from dirty to clean. So we'll start from the dirty area to contain transition point between dolphin and get an off the door. If it's right there, built into a workflow, there is that greater chance of compliance. Also, another transition point will be from mental cleaning to disinfection. If we do in the mental disinfection, mental high level disinfection or automated high level disinfection between those transition point, we should kind of have a hand hygiene or hand washing station. It could be a hand sanitizer, then right before you enter into the department on the clean

26:21side, the door, that could be a transition point for a hand sanitizer inside the clean work area. It's all there could be some hand wash station right there. Those are some of the transition point and I'm not going to touch any sterile storage or anything because what are being in that area poses a greater risk than it offers the positive outcomes. So enhanced sanitizer station will be great over there for our clean elevators transitioning to the OR, which could have a hand sanitizer station over there. There are so many areas and avenues and places that we can have some hand hygiene stations located, especially if we are looking at building it into our daily workflow. I really like how you describe those transition points, right?

27:21Because I think that our clinicians, our technicians, our clinical support partners don't think about sort of transition zones as points of opportunity for performing hand hygiene. And those transition zones do tend to map with UHO and with CDC when you're going into a space you should clean your hands. When you're done eating or you're getting ready to eat, you should clean your hands, you should not be eating in sterile processing by the way, no matter which side you're on. But there are some of those things that do map. I'm also thinking about tables, right? Could we define the table, the work station as a transition zone, or do we say if there is a contamination opportunity, I know even for me as an IP and as somebody who is a sterile processing leader, that was always sort of a challenge of how do you treat your work at the table and when should you be performing hand hygiene?

28:23So I'm going to try and mirror the WHO five moments of hand hygiene and try and translate into sterile processing walls. So before starting work, before attaching any instruments, work station, or packaging in the clean area, before any accepted task, in our sense we don't actually perform accepted tests, it could be before handling sterile packs or after dawn and before dawn and gloves, also before attaching clean instrument from the washer in your work station, that could be also that after bodily fluid exposure, after handling contaminated instrument, removing PPE from decon or after attaching use cards, that is what especially the use cards, that is an area that is often not mentioned because we think that the dirty item is in the case

29:26card, there is no risk to us or there's no hand hygiene involved since we were attaching the outside, considered clean area of the clean cut, but that is also an opportunity right there. The fourth one was after attaching patient environment, after cleaning or living decontam or in the scope repressor in area, finally after glove removal, every time gloves are removed whether it's in decontam or you wear gloves in the clean area, regardless of perceived cleanliness, perform hand hygiene, that's an opportunity for that. Hope that answered your question. Absolutely. So just as a tip, some surveyors that I have seen, they are looking for a hand gel at every work station in the assembly area because they are looking for some of those moments that you just described, even though it may not be well defined, they are looking for

30:31you to be successful in those opportunities. So if you don't have disinfectant wipes and hand gel at every work station and you might have to get creative with how you organize your work stations, then you will maybe get cited, maybe get a recommendation from these surveyors, so that's something to think about is where are your expectations in these areas for using hand hygiene because they're expecting you to have it there, so that means they're expecting you to actually use it. Now I have a loaded question, I'll start with Ivan because this is one that bothers me. Ivan's going mad. So those items that are hand washed, and they're put through the past through window, they're clean, not disinfected, and I say clean with air quotes because some of them are sort of clean, so they get hand washed, they get put through the past through, how clean do we think these are? We put them on our work stations and what do we do with our hands, with our work stations

31:36after we deal with those? Do we feel we need to clean our hands afterwards and clean our work stations because they didn't go through the wash or disinfector, they just were hand washed. Let me make sure that I'm understanding you correctly, there is a contaminated instrument that is hand washed, and then it goes from the hand washing to, does it go to packing before sterilization? Okay. All right. I think any opportunity hands should be washed, you know, any opportunity hands should be washed. One of the things that I told healthcare workers when I worked in the hospital and did education was just whenever it pops into your head, just use some hand sanitizer, so.

32:36And to eat the point, we need to build it more into the SPD culture to make it pop into their head because I'm not sure that we've built it to where it will pop into their head. In the nursing culture, I think we've built it into their head that every time you touch anything, you need to wash your hands because everything is dirty. I'm not sure that we have done that enough in sterile processing. The message has to be different in sterile processing because in a patient care space, we understand that patients are making the environment dirty. We and the patients are making the environment dirty. In sterile processing, the understanding is we are making the things clean. And so we do not need to wash our hands as often. We are the clean people and so people think that the slightest clean so everything is clean including your hands so you don't need to clean your hands. Yes. And so I think emphasis needs to be on the definition of sterility and the reality that

33:39anything that we human beings touch is contaminated because we are non sterile. I read somewhere a few years ago that babies are sterile until the point they're born. So we are just born into contamination and so the moment we touch anything, we should consider it contaminated and so we need to clean our hands. I like how Ebo's thinking is focusing on matching the five moments for hand hygiene from World Health Organization. And the reason I think that is particularly important in this task is because if we follow that model, as all of us have discussed, we have walked through multiple departments in healthcare. And so if we follow that same five moments model in all of these, we have one for patient care, we have one for the technical departments, I think that will help people as they transition

34:45because they're meeting this thing that is familiar to them. And just to add to Ivan's great response, hand hygiene and wet station disinfection is really important when it comes to hand wash, clean, not sterile instrumentation. Ebo and Gerald leave by this set of rules, perform hand hygiene before and after handling those instrumentation. If it's a new department that I haven't had an opportunity to actually go to what the process is for hand wash item, believe it or not, I'm going to be wearing gloves in the prepping pack area. I normally don't advocate for gloves, but I don't know what I'm touching. I don't know the processes here. And from some of the established departments, there is some actual mid-level or low-level

35:45disinfection taking place before the item is pushed through the dry and cabinet or the pasture window. Some of our even high-tech pasture windows have UV disinfection in there, so I will have to see the processes. But if it's a process that I'm comfortable with, as it always happens in the clean area, I go no gloves on that, but make sure that hand hygiene is performed. After the instrument is assembled and packaging, wipe and disinfect the workstation with EPA-registered health hospital disinfectant that is approved for your department by your IPTM or your health system. And finally, like I even said, to aid all two instruments as used as contaminated, they must be cleaned and disinfected and replaced after every year. So this health prevent cross-contamination between partially cleaned, hopefully disinfected

36:47instruments like our hand-washed item and our washer disinfected items. And also yourself, you protecting yourself. That's really important to remember, you're also protecting yourself. You don't want to take these things home with you. All right, guys. So it is time to wrap up. This went super fast, and I can't believe it's all already time to wrap up. So as we start to close here, I want you guys to give the listeners one thing that they can go and do today to improve hand hygiene in their sterile processing departments. And Rebecca, I'll start with you and give Ivan and Ebo a second since they've been on the hot seat. Yeah, I think the first thing I would ask our listeners to look at, whether an IP or technician, you're a leader or you're just curious, is to first point out, where are your current hand-washing or hand hygiene stations? And how can you incorporate them into your workflow or do you need to go consider a tabletop

37:50hand sanitizer to bring to yourself for you to clean your hands over the course of your workday? Ivan, how about you? I like to think of some things from the perspective of self-interest, while it is inconvenient for a healthcare worker to stop a task, go don, PPE or dov, PPE, etc. It is in their best interests to do that. And so my recommendation is to remind all of us in healthcare that it is in our best interests, that hand hygiene is in our best interests. It protects us from what is in our environment, that way we go home and we do not share it with our children, we do not share it with our spouses, with our pets and whoever else. And finally, Ebo, as you all know, I'm all about processes. So if you do just one thing today, that will be start a conversation.

38:56What does that look like? Walk to your department and identify where hand hygiene actually needs to happen in our various workflows, not just where the dispensers are or where the hand wash sinks are. Ask our team members, when do you clean your hands, you'll probably get 5 or 10 different answers depending on how many people you ask, and that is your opportunity right there. From there, we can start small, pick 3 key movements that make sense for our processes in our various process and department, like before moving from 30 to clean area and make sure that we stem so everyone can see them and start building that consistency in hand hygiene. Well, that about does it for this episode. Thank you guys for being here. Thanks for our guest and my co-host, Rebecca, and thanks to everyone for listening. We'll see you for episode 3 next time.

40:07Thanks for tuning in to this exclusive podcast series on pathogens and PPA. For more information and clinical resources to help you fight dirty, make sure to follow us on social media by searching for Beyond Clean and Transmission Control.