HAND HYGIENE … THE EASY WAY! Maria Rhona M. G. Bergantin, MD

The Hospital Gang ESCHERICHIA COLI KLEBSIELLA. PSEUDOMONAS Normally lives in soil and in water storage tank. but, once he gets into the hospital, is notoriously difficult to remove ESCHERICHIA COLI generally lives a blameless life in the gut but assumes a life of crime once he is allowed to roam in the hospital KLEBSIELLA. Lesser known resident of the intestine, fond of hitchhiking on the hands of doctors and nurses. Known to take over entire wards. The Hospital Gang STREPTOCOCCUS Still a common cause of throat infection but also involved in more serious offenses against the rest of the person STAPHYLOCOCCUS AUREUS Alias Goldie the Grape, found in the nose and on the hands of hospital staff but survives for days in dusty places PROTEUS A motile young bacterium, anxious to swim into the wrong places. Generally follows up the dirty work of other bacteria

Normal Bacterial Skin Flora Scalp 1 x 106 CFU/cm2 Axilla 5 x 105 CFU/cm2 Abdomen 4 x 104 CFU/cm2 Forearm 1 x 104 CFU/cm2 Total bacterial count on the hands = 3.9 x 104 to 4.6 x 106

ORGANISMS PRESENT ON THE HANDS RESIDENT ORGANISMS normal flora of the skin deeply seated in the epidermis not easily removed by single hand washing rarely cause infection cause infection during implant surgery and IV sites

ORGANISMS PRESENT ON THE HANDS RESIDENT ORGANISMS normal flora of the skin coagulase negative staphylococci Staphylococcus epidermidis Corynebacterium or Diphtheroids Propionibacterium species

ORGANISMS PRESENT ON THE HANDS TRANSIENT ORGANISMS microorganisms NOT part of the normal flora represent recent contamination usually survive for a limited period of time acquired during contact with the infected/colonized patient or environment easily removed by good hand washing technique

ORGANISMS PRESENT ON THE HANDS TRANSIENT ORGANISMS gram negative bacilli (E. coli, Klebsiella and Pseudomonas) Salmonella sp. Staphylococcus aureus Viruses (Rotavirus)

HEALTH CARE WORKER’S HANDS Probably the MOST common means by which spread of infection by direct contact can occur

of Nosocomial Infection How the Hands act as a VECTOR of Nosocomial Infection

The Hand Takes Germs from : - the skin, dirty wounds, pus excretions of the sick - the body, the hands, the clothes of the physicians and hospital personnel

- the child, the chronically ill - ALL hospital personnel The Hand Infects - newly operated - the child, the chronically ill - the old patient - ALL sick people - ALL hospital personnel The Hand Takes Germs from : - the skin, dirty wounds, pus excretions of the sick - the body, the hands, the clothes of the physicians and hospital personnel

The Hand Takes Germs from : - the skin, dirty wounds, pus The Hand Infects - newly operated - the child, the chronically ill - the old patient - ALL sick people - ALL hospital personnel The Hand Takes Germs from : - the skin, dirty wounds, pus excretions of the sick - the body, the hands, the clothes of the physicians and hospital personnel The Hand contaminates - the physicians’ instruments - clean laundry - toiletries - sanitary equipments - dishes and silver etc.

The Hand Takes Germs from : - the skin, dirty wounds, pus The Hand Infects - newly operated - the child, the chronically ill - the old patient - ALL sick people - ALL hospital personnel The Hand Takes Germs from : - the skin, dirty wounds, pus excretions of the sick - the body, the hands, the clothes of the physicians and hospital personnel The Hand contaminates - the healthcare worker’s instruments - clean laundry - toiletries - sanitary equipments - dishes and silver etc. The Hand transfer Germs from: bed sheets, dirty underwear, moist towels, sinks and bathtubs, toiletries

HANDWASHING Considered to be one of the MOST important procedures in the prevention of hospital-acquired infection

Defined Technique for Hand Washing The Hands are moistened and 3-5 ml formulation is applied to cupped hands. The hands are then rubbed together 5 times as follows : 1. PALM to PALM 2. Right Palm over 3. PALM to PALM dorsum and vice versa fingers interlaced 4. Back of fingers 5. Rotational rubbing of 6. Rotational rubbing, to opposing palms, right thumb clasped in backwards and forwards fingers interlocked left palm and vice versa with clasped fingers of right hand in left palm and vice versa

Factors Influencing Adherence to Hand-Hygiene Practices Observed risk factors for poor adherence to recommended hand-hygiene practices Physician status (rather than nurses) Nursing assistant status (rather than a nurse) Male sex Working in an intensive-care unit Working during the week (versus weekends) Wearing gloves/gowns Automated sink Activities with high risk of co-transmission High number of opportunities for hand hygiene per hours of patient care Pitter D, 2000

Factors Influencing Adherence to Hand-Hygiene Practices Additional perceived barriers to appropriate hand hygiene Lack of active participation in hand-hygiene promotion at individual or institutional level Lack of role model for hand hygiene Lack of institutional priority for hand hygiene Lack of administrative sanction of noncompliers/rewarding compliers Lack of institutional safety climate Pitter D, 2000

Factors Influencing Adherence to Hand-Hygiene Practices Self-reported factors for poor adherence with hand hygiene Hand washing agents cause irritation and dryness Sinks are inconveniently located/shortage of sinks Lack of soap and paper towels Often too busy/insufficient time Understaffing/overcrowding Patients needs take priority Hand hygiene interferes with health-care worker relationships with patients Low risk of acquiring infection from patients Wearing of gloves/beliefs that glove use obviates the need for hand hygiene Pitter D, 2000

Factors Influencing Adherence to Hand-Hygiene Practices Self-reported factors for poor adherence with hand hygiene Lack of knowledge of guidelines/protocols Not thinking about it/forgetfulness No role model from colleagues or superiors Skepticism regarding the value of hand hygiene Disagreement with the recommendations Lack of scientific information of definitive impact of improved hand hygiene on health-care associated infection rates Pitter D, 2000

Indications for hand washing and hand antisepsis Decontaminate hands before having direct contact with patients

Indications for hand washing and hand antisepsis Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter

Indications for hand washing and hand antisepsis Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure

Indications for hand washing and hand antisepsis Decontaminate hand AFTER contact with patient’s intact skin

Indications for hand washing and hand antisepsis Decontaminate hands AFTER contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled

Indications for hand washing and hand antisepsis Decontaminate hands if moving from a contaminated body- site to a clean-body site during patient care

Indications for hand washing and hand antisepsis Decontaminate hands AFTER contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient

Indications for hand washing and hand antisepsis Decontaminate hands AFTER removing gloves

Indications for hand washing and hand antisepsis Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water

Indications for hand washing and hand antisepsis Antimicrobial impregnated wipes (i.e. towelletes) may be considered as an alternative to hand washing with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not substitute for using an alcohol-based hand rub or antimicrobial soap

Hand hygiene technique Liquid bar, leaflet or powdered form of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, soap rack that facilitate drainage and small bars of soap should be used

Hand hygiene technique Multiple-use cloth towels of the hanging or roll-type are not recommended for use in the health care setting

Other aspects of hand hygiene Do not wear artificial finger nails or extenders when having direct contact with patients at high risk

Other aspects of hand hygiene Keep natural nails tips less than ¼ inch long

Other aspects of hand hygiene No recommendation can be made regarding wearing rings in health-care settings. Unresolved issue

HYGIENIC HAND DISINFECTION IT SHOULD BE USED during outbreaks of infection where contact with blood and body fluids or in situations where microbial contamination is likely to occur

HYGIENIC HAND DISINFECTION IT SHOULD BE USED In high risk areas, e.g. patients in isolation, intensive care and special care baby unit Before performing an invasive procedure

HYGIENIC HAND DISINFECTION IT SHOULD BE USED Before and after touching wounds, urethral or iv catheters before wearing and after removing gowns

HYGIENIC HAND RUB An alternative method of hand disinfection a rapid and effective alternative to hand washing e.g. ward rounds with no water and no wash basin

HYGIENIC HAND RUB ALCHOLIC HAND RUBS DO NOT CLEANSE, therefore hands should be cleaned with soap and water in the presence of visible contamination…

HYGIENIC HAND RUB PROCEDURE: Apply 3-5 ml of fast acting antiseptic (e.g. alcohol hand rub) containing glycerol as an emollient to prevent excessive drying of hands Hands are rubbed according to defined technique until dried

before after Results of culture pre and post-application of hand rub

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB Requires the removal and killing of transient microorganisms and substantial reduction and suppuration of the resident flora of the surgical team for the duration of operation in case the surgical glove is punctured or torn

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB ensure that fingernails are kept SHORT and CLEAN all the time Wrist watches and jewelries should be removed before surgical hand disinfection

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB PROCEDURE Turn the taps ON using the elbows and adjust the flow of water and temperature of the water

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB PROCEDURE Wet hands and forearms Apply antiseptic detergent preparation from an elbow-operated pump dispenser (e.g. Chlorhexidine Povidone Iodine)

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB PROCEDURE Lather hands, wrists and forearms for ONE MINUTE Keep them above elbow level then rinse thoroughly under running water

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB PROCEDURE Clean fingernails and removed ingrained dirt with a manicure stick held under running water or use a sterile nail brush to clean nails and subungal spaces

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB PROCEDURE The Hand Washing procedure is then repeated for 2 MORE MINUTES

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB The hands, wrists and forearms are then rinsed thoroughly under running water making sure that fingertips should always point upward and elbows down to avoid recontamination of clean fingers and hands by water running down from contaminated proximal areas

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB The technique of drying is VERY IMPORTANT . A separate , sterile towel is used for each arm moving from fingertips to elbow using a dabbing action

SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB The towel is DISCARDED and the procedure is repeated for the other arm When both hands, wrists and forearms are thoroughly dry, the individual is READY to gown and glove

ANTIBIOTICS DO NOT RENDER HAND WASHING UNNECESSARY

References Guidelines for Hand Hygiene in Health-care Settings (CDC,2002) Philippine Hospital Infection Control Society (PHICS) News, July-December 2004

“Little things are indeed little, but to be faithful in little things is a great thing” Mother Teresa