IMPROVING HAND HYGIENE PRACTICES IN HEALTHCARE SETTINGS Mazen Kherallah, MD, FCCP Critical Care Medicine and Infectious Disease

IMPROVING YOUR HAND HYGIENE PRACTICES Why should we clean our hands? Barriers to frequent handwashing How do hands become contaminated? Advantages of alcohol-based hand rubs New Hand Hygiene Recommendations

To remove visible soiling from hands What is the single most important reason for healthcare workers to practice good hand hygiene? To remove visible soiling from hands To prevent transfer of bacteria from the home to the hospital To prevent transfer of bacteria from the hospital to the home To prevent infections that patients acquire in the hospital

The Iceberg Effect Infected Colonized This iceberg graphically represents colonization versus infection. Those patients that are infected with an organism represent just the “tip of the iceberg” of patients that are colonized or infected. Just because a patient is not infected, or showing signs of infection, does not mean that they do not carry organisms that could be transferred to another patient if proper hand hygiene and other infection control precautions are not taken.

Why is cleaning your hands between patients important? Many studies have shown that the bacteria that cause hospital-acquired infections are most frequently spread from one patient to another on the hands of healthcare workers The Centers for Disease Control and Prevention (CDC) and other healthcare- related organizations believe that cleaning your hands before and after having contact with patients is one of the most important measures for preventing the spread of bacteria in healthcare settings

Does handwashing really reduce the spread of bacteria in healthcare settings? Yes! A scientific study performed in a hospital nursery found that when nurses did not wash their hands between patient contacts, babies acquired Staph bacteria much more frequently than babies cared for by nurses who washed their hands with an antimicrobial soap. Several other studies also show that washing hands between patient contacts reduces the spread of bacteria in healthcare

How is our track record on handwashing in healthcare facilities? Although handwashing has been proven to reduce the spread of microorganisms in healthcare facilities, healthcare workers often do not wash their hands when recommended. In 34 studies of handwashing, workers washed their hands only 40% of the time. Average Average Compliance of Personnel in 34 Studies of Handwashing

Why is compliance with recommended handwashing so poor? Heavy workloads (too busy) Sinks are poorly located Skin irritation caused by frequent exposure to soap and water Hands don’t look dirty Handwashing takes too long

Personnel with heavy workloads have little time to wash their hands A recent study showed that the busier healthcare workers are, the less likely they are to wash their hands when recommended Nursing shortages have caused nurses to be busier than ever before Handwashing Compliance Increasing Workload

Sinks are often poorly located Sinks used for handwashing are often installed in inconvenient locations. Personnel may fail to wash their hands when indicated because it is too much trouble to get to the sinks provided.

Another reason why personnel don’t wash their hands often Frequent handwashing with soap and water often causes skin irritation and dryness. In the winter months, some personnel may even develop cracks in their skin that cause bleeding, as seen in the adjacent figure.

Many personnel don’t realize when they have germs on their hands Nurses, doctors and other healthcare workers can get 100s or 1000s of bacteria on their hands by doing simple tasks, like pulling patients up in bed taking a blood pressure or pulse touching a patient’s hand rolling patients over in bed touching the patient’s gown or bed sheets touching equipment like bedside rails, over-bed tables, IV pumps How can this happen? Culture plate showing growth of bacteria 24 hours after a nurse placed her hand on the plate

Patients often carry resistant bacteria on their skin Percent of Patients with MRSA Who Carry the Organism on Their Skin Patients with resistant bacteria like methicillin- resistant S. aureus (MRSA) or vancomycin- resistant enterococci (VRE) often carry the organism on many areas of their skin, even when they don’t have any wounds or broken skin. 13-25% 40% 30-39%

Here’s another way healthcare workers contaminate their hands Healthcare workers can contaminate their hands by touching environmental surfaces near affected patients. Frequency of Environmental Contamination of Surfaces in the Rooms of Patients with Methicillin-Resistant S. aureus (MRSA) Percent of Surfaces Contaminated

Think about all the things you touch today and how many people have touched them before you??? Food Trolley Corner, Monitor on/off switch, Drawer Handles, Patient File, Touch Screen Monitor, Freeze Handle

Hand Hygiene Products Alcohol-based (hand)rub : An alcohol-containing preparation (liquid, gel or foam). Antimicrobial (medicated) soap : Soap (detergent) containing an antiseptic agent at a concentration Plain soap : Detergents that do not contain antimicrobial agents, or that contain very low concentrations of antimicrobial agents effective solely as preservatives. Alcohol-based (hand)rub : Such preparations may contain one or more types of alcohol with excipients, other active ingredients, and humectants. Antimicrobial (medicated) soap : which is sufficient to reduce or inhibit the growth of microorganisms. Antiseptic agent : Examples include alcohols, chlorhexidine gluconate, chlorine derivatives, iodine, chloroxylenol (PCMX), quaternary ammonium compounds, and triclosan.

Ability of Hand Hygiene Agents to Reduce Bacteria on Hands 0.0 1.0 2.0 3.0 60 180 minutes 90.0 99.0 99.9 log % Bacterial Reduction Alcohol-based handrub (70% Isopropanol) Antimicrobial soap (4% Chlorhexidine) Plain soap Time After Disinfection Baseline This graph shows that alcohol-based handrub is better than handwashing at killing bacteria. Shown across the top of this graph is the amount of time after disinfection with the hand hygiene agent. The left axis shows the percent reduction in bacterial counts. The three lines represent alcohol-based handrub, antimicrobial soap, and plain soap.

Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best. Plain Soap Antimicrobial soap Alcohol-based handrub

How can we overcome problems associated with handwashing? Since washing hands frequently with soap and water is inconvenient time-consuming often causes skin irritation and dryness We need to make it easier for you to clean your hands quickly, with a minimum efforts and skin irritation. One way to accomplish these goals is to clean your hands with an alcohol-based handrub (a gel, rinse or foam).

Using an alcohol-based handrub takes less time than handwashing

Are alcohol-based handrubs really effective? More than 20 published studies have shown that alcohol-based handrubs are more effective than either plain soap or antibacterial soaps in reducing the number of live bacteria on the hands

Promoting alcohol hand rubs improve hand hygiene habits When hospitals placed alcohol handrub dispensers near each patient’s bed, healthcare workers cleaned their hands significantly more often than they did when only sinks were available for handwashing.

Advantages of cleaning hands with alcohol-based handrubs When compared to traditional soap and water handwashing, alcohol handrubs have the following advantages: take less time to use can be made more accessible than sinks cause less skin irritation and dryness are more effective in reducing the number of bacteria on hands makes alcohol-based handrubs readily available to personnel has led to improved hand hygiene practices

New CDC guideline recommends frequent use of alcohol-based handrubs New guideline developed by the Centers for Disease Control and Prevention (CDC) and infection control organizations recommends that healthcare workers use an alcohol-based handrub (a gel, rinse or foam) to routinely clean their hands between patient contacts, as long as hands are not dirty.

When should you wash your hands with soap and water? Wash your hands with plain soap and water, or with antimicrobial soap and water if: Your hands are visibly soiled (dirty) Hands are visibly contaminated with blood or body fluids Before eating After using the restroom

Here are some tips on how to wash your hands effectively Wet hands first with water Apply 3 to 5 ml of soap to hands Rub hands together for at least 15 seconds Cover all surfaces of the hands and fingers Rinse hands with water Dry your hands with a clean or disposable towel Use paper towel to turn off water faucet

Vijay Pratap Raghuvanshi M.Phil & MHA ( Hospital & Health Administration)

When should you use an alcohol-based handrub? If hands are not visibly soiled or contaminated with blood or body fluids, use an alcohol-based handrub for routinely cleaning your hands: Before having direct contact with patients After having direct contact with a patient’s skin After having contact with body fluids, wounds or broken skin After touching equipment or furniture near the patient After removing gloves

Here are some tips on how to use an alcohol handrub Apply 1.5 to 3 ml of an alcohol gel or rinse to the palm of one hand, and rub hands together Cover all surfaces of your hands and fingers Include areas around/under fingernails Continue rubbing hands together until alcohol dries If you have applied a sufficient amount of alcohol hand rub, it should take at least 10 - 15 seconds of rubbing before your hands feel dry.

Vijay Pratap Raghuvanshi M.Phil & MHA ( Hospital & Health Administration)

When should you wash your hands? Although it's impossible to keep your bare hands germ-free, times exist when it's critical to wash your hands to limit the transfer of bacteria, viruses and other microbes. Always wash your hands: After using the bathroom After changing a diaper — wash the diaper-wearer's hands, too After touching animals or animal waste Before and after preparing food, especially before and immediately after handling raw meat, poultry or fish Before eating After blowing your nose After coughing or sneezing into your hands Before and after treating wounds or cuts Before and after touching a sick or injured person After handling rubbish Before inserting or removing contact lenses When using public toilets. Although it's impossible to keep your hands germ-free, times exist when it's critical to wash your hands to limit the transfer of bacteria, viruses and other microbes.

How often do you clean your hands after touching a PATIENT’S INTACT SKIN Always Often Sometimes Never How often do you clean your hands after touching a patient’s intact skin ? (for example, when measuring a pulse or blood pressure)? Always

15 minutes 30 minutes 1 hour 2.5 hours How much time would an ICU nurse save during an 8 hour shift by using an alcohol-based handrub instead of soap and water? 15 minutes 30 minutes 1 hour 2.5 hours The correct answer is 1 hour, based on 12 opportunities per hour for 8 hours with a handwashing time (including walking to the sink and back) of 60 seconds per wash, and an alcohol-based handrub time of 20 seconds per handrub. According to the HICPAC hand hygiene guideline, providing an alcohol-based handrub at the patient’s bedside will save time because healthcare workers will no longer need to walk the sink and wash their hands.

How often do you clean your hands after touching an ENVIRONMENTAL SURFACE near a patient? Always Often Sometime Never (for example, a countertop or bedrail)? The correct answer is always. Patient gowns, bed linens, bedside furniture, and other objects in the patient’s immediate environment can easily become contaminated with patient flora.

Use of artificial nails by healthcare workers poses no risk to patients. Strongly agree Agree Don’t know Disagree Strongly disagree The correct answer is disagree, or strongly disagree. Even after careful handwashing, healthcare workers often harbor substantial numbers of potential pathogens in the subungual spaces. A growing body of evidence suggests that wearing artificial nails may contribute to transmission of certain healthcare-associated pathogens. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing. Studies have shown that hospital personnel with artificial nails harbor more potential pathogens both before and after handwashing than personnel with natural nails. Artificial nails contribute to nail changes that can increase the risk of colonization and transmission of organisms from HCWs to patients. Natural nail tips should be kept to ¼ inch in length. Artificial nails(18) and chipped nail polish(19) may be associated with a further increase in the number of bacteria on fingernails.

Strongly agree Agree Don’t know Disagree Strongly disagree Glove use for all patient care contacts is a useful strategy for reducing risk of transmission of organisms. Strongly agree Agree Don’t know Disagree Strongly disagree The correct answer is strongly agree, or agree. For many years, authorities have recommended that healthcare workers wear gloves for three reasons: to reduce the risk of healthcare workers acquiring infections from patients, to prevent flora from being transmitted from healthcare workers to patients, and to reduce contamination of the hands of healthcare workers by flora that can be transmitted from one patient to another.

PREVENTION IS PRIMARY! Protect patients…protect healthcare personnel… promote quality healthcare!

Critical Care is A Promise ان الله يحب العبد اذا عمل عملا أن يتقنه

If you are admitted to our ICU we will: Wash our hands before and after we touch you Use alcohol-based hand rub Make sure that physicians and all health care workers do the same before and after touching you Will use glove use to reduce risk of transmission of organisms