Web Sites for CDC and WHO guidelines
Q. Where can I find the current Center for Disease Control and Prevention (CDC) hand hygiene and World Health Organization (WHO) guidelines?
A. View theCDC report . Download the WHO report .
Categories of recommendations
Q. Does Joint Commission require implementation of all the recommendations in the CDC or WHO hand hygiene guidelines?
A. Each of the CDC and WHO hand hygiene recommendations 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. 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 a 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 one quarter inch long if they care for patients at high risk of acquiring infections (e.g. patients in intensive care units or in transplant units). The WHO guidelines prohibit artificial nails and extenders for all healthcare workers. Will Joint Commission actually be requiring this?
A. Each organization must follow the IA, IB and IC recommendations from the guideline it chooses (CDC or WHO). Therefore, if WHO is chosen, no direct care providers should have artificial nails or extenders. If CDC is chosen, providers in high-risk areas must not wear artificial nails. Please note that many organizations following CDC guidelines have chosen to expand the ban on artificial nails to all care providers in the interest of safety. Regarding the length of natural nails, each organization may choose its own approach since the level of recommendation in both the CDC and WHO guidelines is “II”, thereby making compliance optional.
Mandatory use of alcohol-based hand products
Q. Do we have to use alcohol-based hand products?
A. Accredited organizations are required to provide health care workers with a readily accessible alcohol-based hand product. However, use of such a product 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 a healthcare worker chooses not to use it, then soap and water should be used instead.
Corridor dispensers for alcohol-based hand products
Q. What are the “conditions” that have to be met to be able to install alcohol-based hand rub (ABHR) dispensers in egress corridors?
A. Location conditions and permissible volume specifications for gel ABHR dispensers to be installed in egress corridors are as follows:
- The corridor width is 6 feet or greater and dispensers are at least 4 feet apart.
- The dispensers are not installed over or directly adjacent to an ignition source such as an electrical outlet or switch. Adjacent is defined as being at least 6 inches from the center of the dispenser to an ignition source.
- In locations with carpeted floor coverings, dispensers installed directly over carpeted surfaces are permitted only in sprinklered smoke compartments.
- Each smoke compartment may contain a maximum aggregate of 10 gallons (37.8 liters) of ABHR gel in dispensers and a maximum of 5 gallons (18.9 liters) in storage.
- The maximum individual dispenser fluid capacity is 0.3 gallons (1.2 liters) for dispensers in rooms, corridors, and areas open to corridors.
- The maximum dispenser size for individual dispensers in areas designated as suites of rooms is 0.5 gallons (2.0 liters).
The situation is a little different with respect to foam ABHR products because all of the testing upon which the NFPA and CMS decisions were based was done on the gel product, not on foam. However, industry experts and CMS have indicated that small-quantity ABHR foam dispensers may be handled the same as for ABHR gel. Therefore, pending further review, both The Joint Commission and CMS will allow any ABHR foam installation that meets the location criteria stated above for ABHR gel. Volumes of ABHR foam are based on suppliers’ recommendations and in no case exceed the permissible volumes for ABHR gel as defined above. In the event that subsequent testing demonstrates a safety concern relating specifically to foam dispensers in egress corridors, The Joint Commission reserves the right to modify its position on the acceptability of such installations. In that event, previously installed dispensers would be subject to the newer restrictions; that is, they would not be “grandfathered,” and noncompliant installations would have to be removed.
Q. Is there an expectation for individuals passing patient trays at mealtime to use alcohol-based hand rub between each room?
A. If the person passing the food tray has, or is likely to have, direct contact with the patient, the answer is yes because both the CDC and WHO guidelines state that hand hygiene is required after direct contact (category IB). Both guidelines also say that individuals should decontaminate hands after contact with inanimate objects in the immediate vicinity of the patient, but this is identified as a Category II by the CDC.recommendation. As such, while compliance with the CDC Guidelines is recommended for individuals passing meal trays who do not make direct contact with the patients, it is not required. In contrast, the WHO guidelines require hand hygiene after contact with the patient’s environment (category IB).
Choosing CDC or WHO guidelines
Q. May we “pick and choose” some recommendations from CDC and some from WHO, or must we decide to follow one of the guidelines in its entirety?
A. Scientific guidelines are designed to function as a cohesive whole. Following parts of a guideline is not as efficacious as compliance with the entire document. Therefore, accredited organizations must choose to follow all IA, IB and IC recommendations from either CDC or WHO. Of course, the Joint Commission would encourage organizations to go “above and beyond” by complying with additional recommendations from either document as long as compliance has been achieved with all level I recommendations from either CDC or WHO.