Hand Washing Techniques Dr.Pinaki Mukhopadhyay DCH.MD.DM (Neph,PGI,Chandigarh) Fellow of Indian college of Physician Asso.Prof & HOD,Dept of Nephrology NRS Medical College & Hospital,Kolkata

Hand Hygiene Hand Hygiene (HH) is generally poorly adhered to across the board by all levels of Health Care Worker’s 2

THE UNWASHED HAND! These are the bacteria on unwashed hands

Hand Hygiene HAIs / MRSA, ESBLs, VRE etc Majority are preventable The problem: HAIs / MRSA, ESBLs, VRE etc Majority are preventable Costly to patient Costly to health service The problem was not just a local problem but a global one but one that needed action locally. HCWs do perform HH but not always effectively they are not bad people but busy people Resistance occurs because pts require antibiotics/sicker pts Resistance is spread because HCWs don’t use HH appropriately http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16 4

Why Should I Wash My Hands? Hand Hygiene/Hand Washing is the single most effective method to reduce the risk of spreading germs. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Ignaz Philipp Semmelweis Semmelweis has been credited as being the father of HH

Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1846 (%) The First Obstetric clinic was run by the medical students and the consultants, who often went straight from the mortuary to the labour wards. The Second Obstetric clinic was run by the midwives who did not handle dead bodies. The mortality for the doctors unit was much higher than for the midwives. Semmelweis IP, 1861

Intervention Students and doctors were required to: May 1847 Students and doctors were required to: clean their hands with a chlorinated lime solution when entering the labour room in particular when moving from the autopsy to the labour room Semmelweis decided the doctors were carrying some thing on their hands and he decided this should be washed of with chlorine solution.

Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1850 Intervention May 15, 1847 As you can see there was a marked effect on the mortality in the doctors unit. This is the first and most dramatic proof that hand hygiene is effective and essential. Semmelweis IP, 1861

Evidence of Relationship Between Hand Hygiene and Healthcare-Associated Infections Substantial evidence that hand hygiene reduces the incidence of infections Historical study: Semmelweis More recent studies: rates lower when antiseptic hand washing was performed Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Why we don’t wash our hands Too busy/insufficient time Patient needs take priority Understaffing/overcrowding HCW are not bad just busy! Sinks are inconveniently located or lack of sinks Lack of soap and paper towels Poor design Poor product Hand washing agents cause irritation and dryness WHY DO PEOPLE NOT WASH THEIR HANDS??? Low risk of acquiring infection from patients More education Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.

What can we do to help change this Provide easy access to hand hygiene materials Handrub solution Conveniently located: at the patient’s bedside at the patient’s room entrance in convenient / appropriate locations in high traffic public areas Working appropriately Full of product Within use by date http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

When Should I Wash My Hands? Before starting your day, before and after lunch, and generally, when you feel it necessary, wash with soap and water. When hands are dirty, contaminated or soiled, wash with soap and water. *Especially important after coughing, sneezing or using a tissue If soap and water are not readily available, use an alcohol-based (60% or higher) hand-rub for routine scrubbing

Moment 1. Before contact with a patient or patient environment Before shaking hands Before transferring Clean your hands when entering or before touching the patient. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 1. Before contact with a patient or patient environment Before taking temperature, blood pressure or pulse Before making someone comfortable in bed This will protect the patient from harmful organisms carried on your hands. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 1. Before contact with patient or patient environment Patient’s room Equipment Wheel chair or stretcher Clean your hands when entering or before touching any object or furniture in the patient’s environment. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Before contact with patient or patient environment Moment 1. Before contact with patient or patient environment Before contact with… Home environment Treatment area or clinic room This is to protect the patient environment from harmful organisms carried on your hands. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 2. Before aseptic/clean procedure Clean your hands before… Handling dressings or touching open wounds Performing invasive procedures Clean your hands immediately before any aseptic or clean procedure to protect the patient against harmful organisms. This prevents the patient’s own organisms from entering his or her body. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 3. After body fluid exposure Clean your hands after… Contact with blood, bodily fluids, non-intact skin or mucous membranes, Removal of gloves Contact with contaminated items Clean your hands immediately after an exposure risk to body fluids (and after glove removal). http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 3. After body fluid exposure Clean your hands after… Performing invasive procedures Using a tissue to wipe your nose or toilet use This can help protect yourself and the health care environment from harmful patient organisms. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 4. After contact with a patient Clean your hands after… Shaking hands Transferring Making someone comfortable in bed Help protect yourself and the health care environment from harmful patient organisms. Clean your hands when leaving the environment after touching patient. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 4. After contact with the patient environment Clean your hands after… Contact with wheelchair or stretcher Contact with room Contact with equipment Clean your hands when leaving after touching any object or furniture in the patient’s environment http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Moment 4. After contact with the patient environment Clean your hands after… Contact with home environment Contact with treatment area or clinic room Help protect yourself and the health care environment from harmful patient organisms. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

How Should I Wash My Hands? Proper Techniques for Hand Washing Step 1 Wet hands first with warm water *avoid hot water

Proper Techniques for Hand Washing Step 2 Apply 3-5 ml (2 - 3 pumps) of soap to hands.

Proper Techniques for Hand Washing Step 3 Rub hands together for at least 20 seconds, covering all surfaces of the hands and in-between fingers.

Proper Techniques for Hand Washing Step 4 Rinse hands with water. . Step 5 Dry thoroughly using paper towels, leaving faucet on.

Proper Techniques for Hand Washing Step 6 Use a new paper towel to turn off faucet. Step 7 Discard used paper towels in trash.

one squirt (1-3 ml) to your hands Easy Message This is his HH product as discussed before. He introduced it into his HUG complex with an extensive campaign which will be described in detail when discussing the Austin experience. SQUIRT one squirt (1-3 ml) to your hands ROLL rub hands together covering all aspects of your fingers & hands until dry RUB apply to palm

Squirt Rub Roll Easy Message Basic message always the same “Clean you hands before and after every patient touch” Instructions always the same Squirt Rub Roll Keep your message simple and easy to remember work on the KISS theory http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Soap & Water vs. Alcohol Hand Rub in Health Care Settings Heavy workloads Sinks not conveniently located No soap and paper towels available Skin irritation from frequent soap/water Takes too long Use soap & water for visibly dirty hands, spores such as C. difficile & anthrax Alcohol Hand Rub Heavy workloads Easier to locate nearby Requires stock maintenance Less irritating to skin Saves time (56 min vs. 18 min in 8 h) Alcohol hand rub more effective at reducing bacterial counts on hands compared with soap & water http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Keep natural nail tips < 1/4 inch in length Finger Nails and Bling Keep natural nail tips < 1/4 inch in length No artificial nails or extenders when having direct contact with high-risk patients (e.g., ICU, OR) Recommendations on rings unresolved Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; Vol. 51, No. RR-16. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

CDC Hand Hygiene Technique Alcohol-Based Hand Rubs Apply to palm of one hand, rub hands together covering all surfaces until dry Volume: based on manufacturer Hand washing Wet hands with water, apply soap, rub hands together for at least 15 seconds (Happy Birthday song twice or the Alphabet song) Rinse and dry with disposable towel Use towel to turn off faucet Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; Vol. 51, No. RR-16. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

WHO Recommended Hand Hygiene Technique Hand rub/hand wash 15-20 seconds (Happy Birthday song twice) http://www.who.int/gpsc/5may/Hand_Hygiene_Why_ How_and_When_Brochure.pdf

Alcohol-based hand rub Apply a dime-sized amount (2-3 ml) of product into palms of dry hands Rub product into hands Palm to palm Rub fingertips of each hand in opposite palm Between and around fingers Rub each thumb clasped in opposite hand Rub back of each hand with opposite palm Rub hands until dry before performing another task DO NOT WIPE OFF http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Alcohol-based hand rub Alcohol based hand rub (ABHR) is at least 60% ethyl alcohol, or ethanol (equal to 120-proof).  To compare, a bottle of vodka is 80-proof Ingesting small amounts of ABHR can produce the same side effects as consuming large amounts of alcohol: Headache, dizziness, drowsiness, incoordination, nausea, slowed reaction time, slurred speech, giddiness, and unconsciousness Consumption of ABHR can also result in: Brain, liver, and kidney damage (from long-term use) Toxic ethanol levels http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Soap and Water Soap and water is the recommended method when hands are visibly soiled. Plain soap is used for routine hand hygiene while anti-microbial soap is used in acute care high-risk areas. Click link below for video on how to properly wash with soap and water. http://www.wrha.mb.ca/extranet/ipc/hand-hygiene-videos.php http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Soap and Water Wet hands under warm running water Apply soap and distribute over hands Rub hands together vigorously for 15 seconds to create a good lather: Palm to palm Rub fingertips of each hand in opposite palm Between and around fingers Rub each thumb clasped in opposite hand Rub back of each hand with opposite palm Rinse hands thoroughly under warm running water Pat hands dry with a paper towel Turn off faucet using a paper towel http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Hands are soiled and no water On occasion, you may find yourself with soiled hands and no access to running water. When access to hand washing facilities is limited and running water is unavailable, use a moist towelette to remove visible soiling from hands followed by alcohol-based hand rub.  Click link below for video on how to properly wash with soap and water. http://www.wrha.mb.ca/extranet/ipc/hand-hygiene-videos.php Moist towelette Followed by hand-rub

Hands are soiled and no water Remove visible soiling with moist towelette Apply a dime-sized amount of hand-rub product into palms of dry hands Rub product into hands: Palm to palm Rub fingertips of each hand in opposite palm Between and around fingers Rub each thumb clasped in opposite hand Rub back of each hand with opposite palm Rub hands until dry before performing another task DO NOT WIPE OFF http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

“Handy” Tips 1 Artificial nails, gel nails or extenders are not to be worn by staff who have direct patient contact. 2 Contaminated surfaces or objects should not be touched after performing hand hygiene. 3 Avoid touching your face, especially your eyes and nose. 4 Fingernails should be kept short - no longer than ¼” or 0.635cm long. 5 Nail polish may be worn, but should be removed when chipped.

“Handy” Tips 6 Do not “top up” a partially-used hand hygiene product dispenser. 7 If re-usable dispensers are used they must be emptied, washed and dried prior to being refilled. Hand lotion bottles must not be re-used. 8 Include frequently missed areas when performing hand hygiene such as thumbs, palms, web spaces, under nails and the backs of fingers and hands. 9 Use supplied lotions that are compatible with hand hygiene products and gloves to minimize skin irritation that can occur with frequent hand hygiene. 10 Wearing hand and wrist jewelry is not recommended. http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Missed Spots When Hand Washing Between the fingers Around the fingernails Back of the thumb http://www.cdc.gov/handhygiene/index.html. Accessed 20 March 2017 http://www.nyu.edu/shc/flu. Accessed 20 March 2017 Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

Remember…. Source: http://www.kingcounty.gov/healthservices/health/communicable/stopgerms/posters.aspx

Thank You

This is what happened to Semmelweis as a result of his efforts This is what happened to Semmelweis as a result of his efforts. He colleagues at the time were not at all welcoming to his ideas and the poor chap ended dying in an asylum. Ignaz Philipp Semmelweis before and after he insisted that students and doctors clean their hands with a chlorine solution between each patient 47

Resources . http://www.health.state.ny.us/diseases/communic able/influenza/ New York University Student Health Center http://www.nyu.edu/shc/ New York University Environmental Health and Safety www.nyu.edu/ehs : 212-998-1450 September 2009 48