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

2. 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

3. 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

4. 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

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

6. 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

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

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

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

10. 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

11. - 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

12. 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.

13. 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

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

16. 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 Right Palm over PALM to PALM
dorsum and vice versa fingers interlaced
4. Back of fingers 5. Rotational rubbing of 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

17. 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

18. 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

19. 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

20. 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

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

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

23. 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

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

25. 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

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

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

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

29. 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

30. 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

31. 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

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

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

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

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

36. 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

37. 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

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

39. 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

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

41. 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

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

43. SURGICAL HAND DISINFECTION/ SURGICAL HANDWASHING / SURGICAL SCRUB

44. 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

45. 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

46. 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

47. 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)

48. 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

49. 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

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

51. 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

52. 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

53. 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

54. ANTIBIOTICS DO NOT RENDER HAND WASHING UNNECESSARY

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

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