HAND HYGIENE

DR. CHIRAG KHANT

DNB(PED) FIAP(NEONATOLOGY)
JR CONSULTANT
RAINBOW CHILDREN’S HOSPITAL BANGALORE
 WHY ALL THE FUSS ABOUT HAND
HYEGIENE
• 1840’s: General Hospital of Vienna 16

Maternal mortality, 1842

• Divided into two clinics, 14

alternating admissions every 24 12

10
hours:
8

• First Clinic: Doctors and 6

medical students 4

2
• Second Clinic: Midwives 0
FIRST CLINIC SECOND CLINIC
 THE INTERVENTION:
HAND SCRUB WITH CHLORINATED LIME SOLUTION

Ignaz Semmelweis Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.
HAND HYGIENE: NOT A NEW CONCEPT
Maternal Mortality due to Postpartum Infection General
Hospital, Vienna, Austria, 1841-1850

16 Semmelweis’ Hand
Maternal Mortality (%)

Hygiene Intervention

11

9 9
8 8
7.5
7
6

3.5
2.3 2.6 2.5 2.2
2 2
1 1.4
1.3

1841 1842 1843 1844 1845 1946 1847 1848 1849 1850

MDs Midwives

Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

 SO WHY ALL FUSS ABOUT HAND HYGIENE

• In ICUs HCAI incidence-30%, attributable mortality 44%.[WHO]

• In developing countries the risk of HCAI is 2–20 times.[WHO]
• 40% of HCAI could be prevented.[WHO]
• HCAI leads to doubling of treatment cost.[reference 1]
• Most common mode of transmission of pathogen is via hands
• Hand hygiene is the single most effective infection control
measure in prevention of HAI’s with highest cost benefit ratio
13.4.[reference2]
Attributable cost of a nosocomial infection in the intensive care unit: A prospective cohort stu.Chacko B and colleague,World J Crit Care Med. 2017.
Cost Benefit Analysis of Hand Hygiene ProgramSession: Poster Abstract Session: Hand Hygiene 2012
CONCEPTS:
Infected The Iceberg
Effect
1. SKIN COLONISATION
Colonized 2. GUT COLONISATION
3. HEALTHCARE WORKER
HAND COLONISATION
4. STERILISATION SOLUTION
COLONISATION.
 SOURCES OF
NOSOCOMIAL INFECTION
 Personnel
 Fomites – Equipment
 Environment
 Invasive procedures
 The Inanimate Environment Can
Facilitate Transmission
X represents VRE culture positive sites

~ Contaminated surfaces increase cross-transmission ~

Abstract: The Risk of Hand and Glove Contamination after Contact with a
VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
INFECTION CONTROLS PRECAUTIONS :

STANDARD PRECAUTIONS:

Should be applied to all patients

TRANSMISSION BASED PRECAUTIONS:

Contact
Droplet
Air borne

Often used according to clinical syndrome and likely etiological agent.

CHAIN OF
INFECTION STAGES OF HAND TRANSMISSION
one two three four five
Germs present Germ transfer Germs survive Suboptimal or Contaminated
on patient skin onto health- on hands for omitted hand hands transmit
and immediate care worker’s several minutes cleansing germs via
environment hands results in direct contact
surfaces hands with patient or
remaining patient’s
contaminated immediate
environment
BEFORE HAND HYEGIENE

Natural nail tips should be

kept to ¼ inch in length
Artificial nails should not be worn
No watches no rings [preferable]
Mobile is most famous fomite
Keep arms bare to the elbows
FLORA ON YOUR HANDS
(A) Resident Micro-Organisms (normal flora)
usually deep seated in the epidermis,
are not readily removed
do not readily cause infections.
However, during surgery/invasive procedures, they may enter deep
tissues and establish an infection.
(B) Transient Micro-Organisms
that are not part of the normal flora and represent recent
contamination,
that usually survives for a limited period of time.
They are easily removed by a good hand washing technique.
They include most of the organisms responsible for cross
infection, e.g. Gram-negative bacilli (E.coli, Klebsiella, Salmonella
spp.), MRSA and viruses
TYPES OF HAND HYGIENE
HAND HYGIENE-WHEN?

FIVE
MOMENTS
FOR HAND
HYGIENE”
 Ability of Hand Hygiene
Agents to Reduce Bacteria on
HAND HYEGIENE- WITH WHAT? Hands
Time After Disinfection
% log
99.9 3.0 0 60 180 minutes

Bacterial Reduction
99.0 2.0 Alcohol-based handrub
(70% Isopropanol)

90.0 1.0
Antimicrobial soap
(4% Chlorhexidine)

0.0 0.0
Plain soap
Baseline
HAND HYEGIENE-WITH WHAT?
HAND HYEGIENE-WITH WHAT?
• Handrubbing with alcohol-based handrub is the
preferred routine method of hand hygiene if hands
are not visibly soiled.
• Handwashing with soap and water – essential when
when hands are visibly dirty or visibly soiled (following
visible exposure to body fluids)1
1 If
exposure to spore forming organisms e.g. Clostridium difficile is strongly suspected
or proven, including during outbreaks – clean hands using soap and water
WHY THESE
STEPS ONLY
To effectively reduce
germs on hands,
HANDWASHING
must last
40-60 secs
and should be
performed by
following all steps
illustrated in figure.
To effectively reduce
germs on hands,
ALCOHAL
HANDRUBBING
must last for 20-30
secs & should be
performed by
following all steps
illustrated in figure.
HAND HYGIENE AND GLOVE USE

• Glove use neither alters nor replaces the

performance of hand hygiene
• You should remove gloves to perform hand hygiene,
when an indication occurs while wearing gloves
• You should wear gloves only when indicated
 RATIONALE FOR
USING MEDICAL
GLOVES
1. To reduce contamination of
health-care workers hands with
blood and other body fluids
2. To reduce the risk of germ
dissemination to the environment
and of transmission from the
health-care worker to the patient
and vice versa, as well as from one
patient to another
THE GLOVE PYRAMID
INAPPROPRIATE USE OF GLOVES

Use of gloves when it is not indicated is a:

• Waste of resources
• Does not decrease cross-transmission of germs
• May result in missed opportunities for hand hygiene
• May actually result in germ transmission
 HAND HYEGIENE-COMPLIANCE

• Dichotomy between hand hygiene knowledge

and hand hygiene compliance
• Compliance with hand hygiene differs across
facilities and countries, but is globally <40%
• All of us have knowledge but most us
don’t have habit.
• Most HH initiative induces immediate effect
with washout period.

“KNOWLEDGE IS NOT POWER, APPLICATION OF

KNOWLEDGE [HABIT] IS POWER”

Adapted from “Seven Habits of Highly Effective People ”

by Steven Covey
FACTOR INFLUENCING HH COMPLIANCE
• Material Factor:
• Environmental obstacles:

• Behavioral factor: Changing a habit.

 MATERIAL FACTOR FOR HH COMPLIANCE:
1. The time required for nurses to leave a patient’s bedside,
go to a sink, and wash and dry their hands before attending
the next patient is a deterrent to frequent handwashing or
hand antisepsis.
• ALCOHOL BASED HANDRUB SOLUTIONS AT
BEDSISE
• SMALL HANDRUB SOLUTIONS IN NURSE POCKET
• CONVENIENT AND EASILY ASESSIBLE HAND WASH
FACILITY
2. preparation that don’t cause skin irritation.
ENVIRONMENTAL FACTOR FOR HH
COMPLIANCE
1. Time constrains-
-- Clustering of care
-- Doing nothing is sometime best
action.[neonatology]
--Think one new action like introduction of unnecessary
fluid/antibiotics opens up many chances of missed
hand hygiene.
-- Avoid duplication in notes use lean approach.
2. Unbalanced pt. staff ratio
3. Overcrowding
4. Environmental reservoir –detect them and eradicate them like sink cleaning
BEHAVIORAL FACTOR
FOR HH COMPLIANCE

DOING A BORING TASK

OF HAND HYEGINE
40 TIMES A DAY
REQUIRES
IMMENCE MOTIVATION
AND DEEP CORE BELIEF
 GOAL: TO ESTABLISH AND SUSTAIN HAND
HYEGIENE HABIT.
Assessing and changing Knowledge, attitude and behavior
of nursing staff by education and motivation

Easy access to sink Act of leadership

ROUTINE
Hand rub solution at
bedside
Good Feedback

POSTERS
handwash/hand HH champion of
rub/moments of month
hand hygiene CUE REWARD
Financial reward
Hand rub solution at
entry gate HABIT LOOP Punishment –
Adapted from “The Power of Habit” by Charles Duhigg fine/career
Perceived danger of
HANG HYEGIENE ALSO NEEDS BOOSTER DOSES
self infection
A CONSENSUS-BASED, TESTED
IMPROVEMENT STRATEGY NOW EXISTS
• WHO Multimodal Hand Hygiene Improvement Strategy
• Field tested in eight pilot centres and over 350 additional
health-care facilities worldwide
• Based on the recommendations of the WHO Guidelines
for Hand Hygiene in Health Care
• 5 core components; 5 indications (moments) for hand
hygiene
WHAT IS THE WHO MULTIMODAL HAND HYGIENE
IMPROVEMENT STRATEGY?
• Based on the ONE System change
Access to a safe, continuous water supply as well as
evidence and to soap and towels; readily accessible alcohol-based hand
recommendations rub at the point of care
from the WHO TWO Training / Education
Guidelines on Hand Providing regular training to all health-care workers
Hygiene in Health THREE Evaluation and feedback
Care (2009), a Monitoring hand hygiene practices, infrastructure,
number of perceptions and knowledge, while providing results
feedback to health-care workers
components make
FOUR Reminders in the workplace
up an effective Prompting and reminding health-care workers
multimodal strategy
FIVE Institutional safety climate
for hand hygiene
Creating an environment and the perceptions that
facilitate awareness-raising about patient safety issues
EDUCATION:
• Doctor touches infant two times a day
,nurse touches infant 200 times a day .
• Your infection prevention is as good as
your nursing staff.
• Educating them so that they believe in
practices and then reinforcing practices
is the key.
CHANGING CULTURE
FOSTER/SUPPORT CULTURE IN
WHICH INFECTION IS CONSIDERED
A PREVENTABLE COMPLICATION
• In NICUs with low nosocomial infection rates, the staff belief was that
infections were preventable and represented a breakdown in care
• NICUs with high rates, staff belief is that infections are inevitable and
unavoidable complications of intensive care.
• A belief among staff that nosocomial sepsis is preventable leads to a
motivation to improve.

35
TOOLKIT FOR IMPROVING HAND HYEGIENE
COMPLIANCE
• WHO Guidelines on Hand Hygiene in Health Care (2009):
• Present the evidence for hand hygiene improvement
• CDC guideline on hand hygiene
• Hand Hygiene Why, How and When Brochure
• Education Sessions and Training Films
• WHO template action plan
• Glove Use Information Leaflet
• Posters displayed throughout the facility
• Your 5 Moments for Hand Hygiene
• How to Handrub
• How to Handwash
HOW TO OBSERVE HAND HYGIENE

• Direct observation is the most accurate method

• Observer must conduct the observation without interfering with ongoing work
• Observer should be familiar with “The 5 Moments for Hand Hygiene” and the data
collection tool that is being utilized
• Identify opportunities for hand hygiene and then record if the worker being observed
performed hand hygiene at that time
SAMPLE OBSERVATION TOOL:
Name or Position Before Before clean After body After After
position of touching a aseptic fluid touching a touching
person being patient procedure exposure patient patient
observed risk surroundings
Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No

Yes No Yes No Yes No Yes No Yes No

SAMPLE OBSERVATIONAL TOOL
Name or Position Before Before After body After After
position of touching a clean fluid touching a touching
person being patient aseptic exposure patient patient
observed procedure risk surroundings
Suzie CNA Yes No Yes No Yes No Yes No Yes No

Larry RN Yes No Yes No Yes No Yes No Yes No

Betty Housekeeping Yes No Yes No Yes No Yes No Yes No

CALCULATING COMPLIANCE RATES

Total number of times hand hygiene was performed

_______________________________________
Total opportunities for hand hygiene

X100
CALCULATING COMPLIANCE RATES

Total number of times hand hygiene was performed

(4)
_______________________________________
Total opportunities for hand hygiene
(6)
4/6 = 0.667
0.667 x 100= 66.7%
STERILISATION AND DISINFECTION IN NICU

DEFINITIONS
• Cleaning—Removal of contamination from an item to the extent necessary for
further processing or for intended use.

• Items can’t be disinfected or sterilized unless they are properly cleaned.

• “Cleaning is the initial and most critical steps in breaking the chain of
disease transmission”
• Anything that can be disassembled must be disassembled for cleaning,
decontamination, and sterilization
 DEFINITIONS
• Disinfection—The process of destroying all possible
live organisms[excluding spores]
• Low
• Intermediate
• High Level
• Sterilization—Process of effectively killing all possible
form of microorganisms [including spore] from surface
equipment food medication or biological culture
medium.
 GOOD OLD DR. EARLE SPAULDING
• The selection of a disinfection or sterilization method depends
on the intended use of the item.
1.AUTOCLAVING

• Essential parameters: Steam (dry, saturated), time, temperature and pressure.

• Time to sterilize:
• usual cycles: 121C x 30 minutes,
• 132 C x 4 minutes.
• used for steel instruments, baby linen, dressing packs, cotton and gauze, injection and
medicine tray
• Most widely used and most reliable method of sterilization
• Can be applied only to thermo stable products
2. ETHYLENE OXIDE (ETO)
• Essential parameters:
• Gas concentration (450-1200 mg/L), temperature (37-60C), relative humidity (40-80%), vacuum, pressure and
exposure time (1-6 hours; aeration requires an additional 8-12 hours).
• Advantages of ETO are:
• Low temperature
• High efficiency – destroys resistant spores also
• Large sterilizing volume/ chamber capacity
• Non corrosive to: plastic, metal and rubber materials
• Disadvantages are:
• Excessively Long cycle
• Safety concerns - carcinogenic to humans and toxic residues on instruments
• Not recommended for flexible scope
• EtO is flammable
• Like all sterilization processes, the effectiveness of ETO
sterilization can be altered by lumen length, lumen diameter,
inorganic salts, and organic materials

• ETO is used in healthcare facilities to sterilize critical items

(and sometimes semi critical items) that are moisture or heat
sensitive and cannot be sterilized by steam sterilization.
And Now its time for the
QUESTIONS !!!
Which of the following is the main route of cross-transmission of
potentially harmful germs between patients in a health- care facility?
(Pick one answer only)

a. Health- care worker’s hands when not clean

b. Air circulating in the facility
c. Patient’s exposure to colonized surfaces (i.e., beds, chairs, tables,
floors) between patients
d. Sharing non-invasive objects (i.e., stethoscopes, blood pressure
cuffs, etc.) between patients
What is the minimal time needed for alcohol based hand rub
to kill most germs on your hands? (Pick one answer only)

a. 20 seconds
b. 3 seconds
c. 1 minute
d. 10 seconds
WHICH HAND HYGIENE METHOD
IS BEST AT KILLING BACTERIA?

1. Plain soap and water

2. Antimicrobial soap and water
3. Alcohol-based hand rub
 How much time would an ICU nurse save
during an 8 hour shift by using an alcohol-
based handrub instead of soap and water?

1. 15 minutes
2. 30 minutes
3. 1 hour
4. 2.5 hours
Which is world hand hygiene day ?

1. 5 Dec
2. 2 Nov
3. 5 May
4. 22 Jan
GLOVE GAME
• Assisting a patient with using the bedpan
• Taking Vital Signs
• Removing a dressing from a wound
• Catheter insertion
• Delivering food trays
• Emptying emesis basin
• Changing the linens for a patient with MRSA
• Changing a central line dressing
• Administering oral Medications
• Emptying a Foley catheter bag
 THANK YOU
Questions ,comments suggestions?

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