HAND HYGIENE INHEALTH-CARESETTING

HISTORY CONTD- 1975/ /1985- CDC Guidelines Recommended washing hands with antimicrobial soap CDC Guidelines Recommended washing hands with antimicrobial soap before & after performing invasive procedures. before & after performing invasive procedures.

1995- APIC Guidelines supported use of alcohol based hand rubs in clinical setting Healthcare infection control practices advisory committee (HICPAC) practices advisory committee (HICPAC) recommended that recommended that either Antimicrobial soap either Antimicrobial soap or or a Waterless Antiseptic Agent a Waterless Antiseptic Agent should be used in case of patients with should be used in case of patients with multidrug resistant pathogens. multidrug resistant pathogens.

Purpose Of Hand washing Removes dirt & soil from hand. Removes dirt & soil from hand. Reduces cross contamination Reduces cross contamination Reduces risk of hand acting as carrier of disease. Reduces risk of hand acting as carrier of disease. Breaks the chain of infection spread. Breaks the chain of infection spread. Prevents noscominal infections. Prevents noscominal infections. Gives psychological cleanliness feeling to the paramedical staff. Gives psychological cleanliness feeling to the paramedical staff.

Behavioural pattern of paramedical staff- Healthcare workers show resistance to frequent hand washing- Healthcare workers show resistance to frequent hand washing- Reasons behind this- Reasons behind this- Awareness of importance of hand washing is lacking. Awareness of importance of hand washing is lacking. Negligence. Negligence. Irritation faced due to contact dermatitis which results due to frequent hand washing. Irritation faced due to contact dermatitis which results due to frequent hand washing.

Gloves General excuse given to avoid hand washing is …………… General excuse given to avoid hand washing is …………… WE USE GLOVES. CDC Guidelines says that CDC Guidelines says that if hand washing is performed carefully, if hand washing is performed carefully, gloves are theoretically gloves are theoretically not necessary. not necessary. Gloves give a false sense of security.

Journal of Infectious Diseases 1938,63, Rapid multiplication of bacteria occurs under surgical gloves if hands are washed with non antimicrobial soap & growth is slow in case of preoperative scrubbing with an antiseptic. Rapid multiplication of bacteria occurs under surgical gloves if hands are washed with non antimicrobial soap & growth is slow in case of preoperative scrubbing with an antiseptic. Wearing of gloves does not provide complete protection against infections caused by hepatitis B & herpes simplex. Wearing of gloves does not provide complete protection against infections caused by hepatitis B & herpes simplex.

OTHER REASONS FOR NON COMPLIANCE Shortage of time. Shortage of time. Non availability of facility. Non availability of facility. Deleterious effects of hand washing Deleterious effects of hand washing Negligence when person is alone. Negligence when person is alone. Not convinced about the importance of Not convinced about the importance of HANDWASHING. HANDWASHING.

LETS UNDERSTAND IN DETAIL THE IMPORTANCE OF HANDWASHING. LET US START WITH THE ANATOMY FIRST

Physiology of normal skin  THE SUPERFICIAL REGION- Stratum corneum  THE VIABLE EPIDERMIS  THE DERMIS  THE HYPODERMIS

NORMAL BACTERIAL SKIN FLORA TOTAL BACTERIAL COUNT ON HANDS OF MEDICAL PERSONNEL- 3.9 X 10,000 To 4.6 X 10,000 CFUs/ sq.cm. (CFU- colony forming units) COLONIES are of 2 types.

TRANSIENT FLORA *Colonize on superficial layers of skin. *Abundant on fingertips. *Frequently associated with healthcare associated infections. *Removal by routine hand washing.

RESIDUAL FLORA * Attached to deeper layers of skin. *Less likely to be associated with noscominal infections. *Not easily removed by scrubbing. *Persistent

Transmission of pathogens on hands of Paramedical staff. Organisms from patient’s skin or in animate objects in close proximity of patient transferred to Hands of Paramedical staff. Survival of these organisms for some time on hands Inadequate Hand washing OR with inappropriate agent Contact with another patient with contaminated hands Transmission of pathogens

Facts about Transmission  Approximately 10x6 skin sqm containing viable microorganisms are shed daily from *Normal skin *Patients gown *Bed linen *Bedside furniture *Other objects in patients immediate environment.

Contamination is particularly likely caused by Contamination is particularly likely caused by staphylococci staphylococcior enterococci enterococci which are resistant to desiccation & Capable of colonizing & infecting wounds

AREAS FROM WHERE THE MICROBES SPREAD HAIR HAIR FACE FACE GROIN GROIN AXILLA AXILLA & UTMOST IMPORTANLY & UTMOST IMPORTANLY HANDS – Basically fingernails. HANDS – Basically fingernails.

CDC Recommendations for hand washing Before & after touching wound. Before & after touching wound. After touching contaminated inanimate object. After touching contaminated inanimate object. After taking care of infected patient. After taking care of infected patient. Situations where contamination might have taken place. Situations where contamination might have taken place. Before performing invasive procedures. Before performing invasive procedures.

HANDWASING IS A MUST ON HANDWASING IS A MUST ON VISIBLY SOILED HAND VISIBLY SOILED HAND which is which is Hand showing visible dirt or Hand showing visible dirt or visible contamination visible contamination with with proteinaceous material, blood proteinaceous material, blood or other body fluids. or other body fluids.

TYPES OF HANDWASHING  PLAIN HANDWASHING- Washing hands with plain (non –antimicrobial) soap & water.  HAND ANTISEPSIS- Refers to Antiseptic hand wash or Antiseptic hand rub.

ANTISEPTIC HAND WASH Washing hands with water & soap or other detergent containing an antiseptic agent

ANTISEPTIC HAND RUB Applying an antiseptic hand rub product to all surfaces of the hands to reduce the no. of microorganism present.

SURGICAL HAND ANTISEPSIS Antiseptic hand wash or Antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient & reduce residual hand flora.

HANDWASHING AGENTS HANDWASHING AGENTS DETERGENT- DETERGENT- These are compounds which possess cleansing action. PLAIN SOAP- PLAIN SOAP- This is the type of detergent which does not contain antimicrobial agent.

ANTIMICROBIAL SOAP- ANTIMICROBIAL SOAP- This is the detergent which contains antimicrobial agent antimicrobial agent ALCOHOL BASED HAND RUBS- ALCOHOL BASED HAND RUBS- An alcohol containing preparation An alcohol containing preparation designed for application to the hands for designed for application to the hands for reducing the no. of viable reducing the no. of viable microorganisms on the hand. microorganisms on the hand.

Advantages of Alcohol based preparations- Alcohols have excellent germicidal activity against gram +ve & gram –ve bacteria including MRSA & VRE, mycobacterium tuberculosis & various fungi. Alcohols have excellent germicidal activity against gram +ve & gram –ve bacteria including MRSA & VRE, mycobacterium tuberculosis & various fungi. Lipophilic viruses like HIV, Influenza, vaccinia, herpes implex are susceptible to alcohols.Alcohols have activity against hepatitis B also. Lipophilic viruses like HIV, Influenza, vaccinia, herpes implex are susceptible to alcohols.Alcohols have activity against hepatitis B also.

American Journal of Infection Control Alcohols can prevent transfer of healthcare associated pathogens. Alcohols can prevent transfer of healthcare associated pathogens. Alcohol based products reduce no of MRSA recovered from hands of healthcare workers more effectively than hand washing by soap & water. Alcohol based products reduce no of MRSA recovered from hands of healthcare workers more effectively than hand washing by soap & water.

Choice of Antimicrobial Agent Depends on the type of hand washing to be performed. Depends on the type of hand washing to be performed. Social or Hygienic hand wash- Social or Hygienic hand wash- Any soap with antimicrobial agent is recommended. Any soap with antimicrobial agent is recommended. 10 sec hand washing time is suggested. 10 sec hand washing time is suggested.

Choice of Antimicrobial Agent- For Procedural Hand washing. For Procedural Hand washing. This is where the effect of antimicrobial This is where the effect of antimicrobial should remain at least till procedure is completed. 30 sec hand washing time is suggested.

Choice of Antimicrobial Agent Surgical Antisepsis Surgical Antisepsis This is pre & post operative hand scrubbing. 30 secs hand scrubbing 3 times 30 secs hand scrubbing 3 times I.e. total 90 secs suggested. I.e. total 90 secs suggested.

Recommendations for Surgical Hand Scrub- *Should reduce microbes on intact skin substantially. * Non irritating to skin. * Broad spectrum of activity. * Fast acting & persistent.

Evaluation of antimicrobial agent in surgical hand scrub is done at three time intervals Immediately after scrubbing. After wearing surgical gloves for 6 hrs.I.e. persistent action. After multiple application over 5 days. I.e. cumulative action.

Methods to evaluate Efficacy of Hand- Hygiene products US FDA Approved Tentative Final Monograph for Healthcare antiseptic Drug Products (TFM)- Product Should reduce no. of bacteria by 90 % on each hand within 1 min of product application on day 1. Bacterial cell count must not exceed baseline within 6 hrs on day 1.

US FDA Approved Tentative Final Monograph for Healthcare antiseptic Drug Products (TFM)- 99 % reduction in micro flora on each hand within 1 min by the end of second day.

US FDA Approved Tentative Final Monograph for Healthcare antiseptic Drug Products (TFM) % reduction of micro flora on each hand within 1 min by the end of 5 the day.