Hand Hygiene in Health Care

What is the role of hands in health care?

1) Clinical Examination 2) Assurance 3) Healing and ..

Carry and transmit potentially harmful microorganisms!

Unwashed Hand
Culture plate showing growth of bacteria 24 hours after a nurse placed her unwashed hand on the plate.

Most common mode of transmission of pathogens in a health care setting is

via hands!

Nurses could contaminate their hands with 100 - 1,000 CFU of Klebsiella spp. during cleaning activities Lifting patients Taking the patient's pulse Blood pressure, or Oral temperature

The Evidence

Hand hygiene reduces the incidence of infections

The Pioneer of hand hygiene

Ignaz Philipp Semmelweis: Vienna, Austria General Hospital, 1841-1850 Fighting puerpral fever

Maternal mortality rates, first & second obstetrics clinics, General Hospital of Vienna
8 10 12 14 16 18

Intervention
May 15, 1847

Maternal mortality

First

Second
4 0 1841 2 6

1842

1843

1844

1845

1846

1847

1848

1849

1850

Semmelweis IP, 1861

Improved adherence to hand hygiene

Hand washing or Alcohol-based hand rubs

Terminate outbreaks in health care facilities Reduce transmission of antimicrobial resistant organisms
(e.g. methicillin resistant staphylococcus aureus)

And reduce overall infection rates

How do organisms get onto the hands?

Resident flora (normally present) Transient flora (acquired during health care delivery)

How do organisms on hands get to the patients?

Hand transmission
5 step process

Organisms present on patients skin / external devices / environmenta l surfaces

Transferre d to HCW hands during direct / indirect contact

Survive and persist on hands from few minutes hours

Hands are not decontaminated / inadequately decontaminated

Contaminate d hands further spread the organisms to other patients / environment

What happens when organisms are transmitted / transferred to susceptible patients?

Transmission between two patients via health care workers results in health care associated infections (HAIs).

Adapted from the Swiss Hand Hygiene Campaign

Getting acquainted with certain terms

Hand hygiene Performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis Handwashing Washing hands with plain soap and water Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub Rubbing hands with an alcohol-containing preparation Surgical hand hygiene/antisepsis Handwashing or using an alcohol-based handrub before operations by surgical personnel
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Hand hygiene refers to

Removing / killing microorganisms on

hands
Maintaining good skin integrity

What does hand hygiene achieve ?

Prevents the transfer of microorganisms from HCW hands to patients and self! It protects both the patients and the HCW.

Hand hygiene with alcohol-based hand rub correctly applied kills organisms in seconds.
Hand hygiene with soap and water done correctly removes organisms.

Hand hygiene When ?

I. Before patient contact some examples

Shaking hands, stroking an arm

Helping patient move around, get washed, giving a massage Taking pulse, blood pressure, chest auscultation, abdominal palpation
Before adjusting an IV line

II. Before aseptic procedure some examples

Oral/ dental care, giving eye drops, secretion aspiration Skin lesion care, wound dressing, subcutaneous injection Catheter insertion, opening a vascular access system or a draining system Preparation of medication, dressing sets

III. After body fluid exposure risk some examples

Oral/dental care, giving eye drops, secretion aspiration
Skin lesion care, wound dressing, subcutaneous injection Drawing and manipulating any fluid sample, opening a draining system, endotracheal tube insertion and removal Clearing up urine, faeces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning of contaminated and visibly soiled material or areas (bathroom, medical instruments)

IV. After patient contact some examples

- Shaking hands, stroking an arm - Helping a patient to move around, get washed, giving a massage - Taking pulse, blood pressure, chest auscultation, abdominal palpation - Changing bed linen - Perfusion speed adjustment - Monitoring alarm - Holding a bed rail - Clearing the bedside table

Hand hygiene How?

Hand washing The process

1 2 3 4 5 6 7 8 Turn on taps or pour water (never dip hands in a mug of water) Wet hands with warm water Apply liquid soap Vigorously lather and rub hands together for 15 seconds Thoroughly rinse soap from hands Dry hands thoroughly Turn off taps with paper towels Discard paper towels

Always dry hands with a clean towel after washing.

Wet hands invite bacteria and transfer more of them !

6 Steps of effective hand washing

Step 1
Wash palms and fingers

Step 2
Wash back of hands

Step 3
Wash fingers and knuckles

Step 4
Wash thumbs

Step 5
Wash finger tips

Step 6
Wash wrists

Areas frequently missed during hand washing

What is surgical hand scrub?

1) The hands are washed up to the elbow

2) A nail file is used to clean under the nails

3) A long acting antiseptic is used such as chlorhexidine or iodophor, sometimes with alcohol) 4) Hands are rubbed for 2-6 minutes and then washed under running water 5) Hands are dried on a sterile towel

The difference
Hand wash
When visibly soiled or dirty

Hand rub
No visible soil / dirt

Surgical Scrub
Done before all surgeries and other invasive procedures needing strict asepsis With antiseptic soap and water Scrub vigorously with upto elbows. Also, clean under the nail bed. 2-5 minutes Use sterile towel for drying

With soap and water upto wrist

with alcoholic hand rub upto wrist

Rub for 15 seconds

Rub until dry

Dry with a clean single No water or towel use towel / paper napkin needed.

Hand Hygiene with what?

1. Liquid soap 2. Anti-bacterial soap 3. Alcoholic hand rub

Efficacy of Hand Hygiene Preparations in Killing Bacteria

Good Better

Best

Plain Soap

Antimicrobial soap

Alcohol-based hand rub

When hands are visibly soiled Liquid soap (plain) and Water Anti-bacterial soap in high risk areas

When hands are not visibly soiled Hand rub (alcoholic)

Hand wash for how long?

Soap and water 15 secs Alcoholic hand rub till it dries

What are alcoholic hand rubs?

Contain variety of alcohols Concentrations ranging from 60 90% Kill more effectively and more quickly Cause less dryness and irritation of skin (Contain emollients to reduce skin drying and irritation)

Require less time

Should not be followed by water rinse

Hand washing - Prerequisites

Keep nails short and clean

Do not wear artificial nails

Remove rings and bracelets Remove chipped nail polish Make sure that sleeves are rolled up and do not get wet

Benefits of hand hygiene in health care

Increase in hand hygiene adherence of only 20 percent results in a 40 percent reduction in the rate of health care associated infections.
(McGeer, A. Hand Hygiene by Habit. Infection prevention: practical tips for physicians to improve hand hygiene. Ontario Medical Review, November 2007, 74 (10).)

Improvement in patient outcomes and decreased costs associated with HAIs

Gloves are not a replacement for hand hygiene !

Hand hygiene is the single most important means of preventing infection.

hand hygiene saves lives