Hand Hygiene in Healthcare Settings Irenic co.(p.j.s) Dr.M.YAMOHAMMADY (PHA.D)
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What can I do to protect myself from catching influenza A(H1N1)? Updated 11 June 2009 WHO avoid touching your mouth and nose; clean hands thoroughly with soap and water, or cleanse them with an alcohol-based hand rub on a regular basis (especially if touching the mouth and nose, or surfaces that are potentially contaminated); avoid close contact with people who might be ill; reduce the time spent in crowded settings if possible; improve airflow in your living space by opening windows; practice good health habits including adequate sleep, eating nutritious food, and keeping physically active.
Many personnel don t realize when they have germs on their hands Healthcare providers can get 1000s of bacteria on their hands by doing simple tasks, like pulling patients up in bed taking a blood pressure 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 Culture plate showing growth of bacteria 24 hours after a nurse placed her hand on the plate
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 handwashing was performed Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Semmelweis hand disinfection
Ignaz Semmelweis, 1815-1865 1840 s: General Hospital of Vienna Divided into two clinics, alternating admissions every 24 hours: First Clinic: Doctors and medical students Second Clinic: Midwives Maternal mortality, 1842 16 14 12 10 8 6 4 2 0 First Clinic Second Clinic
Hand Hygiene: Not a New Concept Maternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850 Maternal Mortality (%) 18 16 14 12 10 8 6 4 2 0 Semmelweis Hand Hygiene Intervention 1841 1842 1843 1844 1845 1946 1847 1848 1849 1850 MDs Midwives ~ Hand antisepsis reduces the frequency of patient infections ~ Adapted from: Hosp Epidemiol Infect Control, 2 nd Edition, 1999.
The Intervention: Hand scrub with chlorinated lime solution Hand hygiene basin at the Lying-In Women s Hospital in Vienna, 1847.
Hand Hygiene Adherence in Hospitals Year of Study Adherence Rate Hospital Area 1994 (1) 29% General and ICU 1995 (2) 41% General 1996 (3) 41% ICU 1998 (4) 30% General 2000 (5) 48% General 1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312.
Self-Reported Factors for Poor Adherence with Hand Hygiene Handwashing agents cause irritation and dryness Sinks are inconveniently located/lack of sinks Lack of soap and paper towels Too busy/insufficient time Understaffing/overcrowding Patient needs take priority Low risk of acquiring infection from patients Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.
Definitions Hand hygiene Performing handwashing, antiseptic handwash, alcohol-based handrub, surgical hand hygiene/antisepsis Handwashing Washing hands with plain soap and water Antiseptic handwash Washing hands with water and soap or other detergents containing an antiseptic agent Alcohol-based handrub Rubbing hands with an alcohol-containing preparation Surgical hand hygiene/antisepsis Handwashing or using an alcohol-based handrub before operations by surgical personnel Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Indications for Hand Hygiene When hands are visibly dirty, contaminated, or soiled, wash with nonantimicrobial or antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Standard Precautions Hand Hygiene Indications for hand hygiene: At the beginning of work Before and after patient contact, including dry skin contact Before putting on and after removing gloves, PPE Before performing invasive procedures Before and after contact with wounds After contact with patients body substances After handling equipment, supplies, or linen contaminated with body substances Before handling sterile or clean supplies After using the restroom After touching or blowing your nose Before leaving the unit
Which hand hygiene method is best at killing bacteria? 1. Plain soap and water 2. Antimicrobial soap and water 3. Alcohol-based handrub
Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub
Microbicidal effect with surgical hand disinfection
Which of the following hand hygiene agents is LEAST drying to your skin? 1. Plain soap and water 2. Antimicrobial soap and water 3. Alcohol-based handrub
Effect of Alcohol-Based Handrubs on Skin Condition Dry Healthy Self-reported skin score 6 5 4 3 2 1 0 Baseline 2 weeks Alcohol rub Soap and water ~ Alcohol-based handrub is less damaging to the skin ~ Boyce J, Infect Control Hosp Epidemiol 2000;21(7):438-441.
ALCHOHOL BASED HAND RUB THE USE OF ALCHOHOL BASED HAND RUBS HAS NOW BECOME THE GOLD STANDARD FOR ROUTIN HAND DECONTAMINATION. INFECTION PREVENTION AND CONTROL ;Debbie Wston ; WILLY;2007.
Time Spent Cleansing Hands: one nurse per 8 hour shift Hand washing with soap and water: 56 minutes Based on seven (60 second) handwashing episodes per hour Alcohol-based handrub: 18 minutes Based on seven (20 second) handrub episodes per hour ~ Alcohol-based handrubs reduce time needed for hand disinfection ~ Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.
Standard Precautions Hand Hygiene Alcohol based hand rub Dispense into hand Rub vigorously including backs of hands, between fingers, into nail beds and up wrists Allow to air dry DO NOT WIPE OR WASH OFF! Total time = 30 seconds
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Hand disinfection Samples taken from hands a) contaminate d hands b) after washing hands c) after hand disinfection Quelle: Händehygiene in der Medizin, 1996
Surgical Hand Hygiene/Antisepsis Use either an antimicrobial soap or alcoholbased handrub Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturer Alcohol-based handrub: follow manufacturer s recommendations. Before applying, pre-wash hands and forearms with non-antimicrobial soap Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Fingernails and Artificial Nails Natural nail tips should be kept to ¼ inch in length Artificial nails should not be worn when having direct contact with high-risk patients (e.g., ICU, OR) Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
% Recovery of gram negative bacteria 40 30 20 10 0 Can a Fashion Statement Harm the Patient? 5 NATURAL 35 ARTIFICIAL p<0.05 Edel et. al, Nursing Research 1998: 47;54-59 Natural (n=31) Artificial (n=27) Polished (n=31) 10 POLISHED Avoid wearing artificial nails, keep natural nails <1/4 inch if caring for high risk patients (ICU, OR)
Unresolved Issues Routine use of nonalcohol-based handrubs Wearing rings in healthcare settings Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Limited use of alcohol-based hand gels Using hand gel should be considered a retrograde step for hand hygiene No gel met the EN 1500 requirement within the 30 s in the study done at University of Geneva Hospital The lancet.april,2002;vol 359:1489-90 WHO guideline on hand hygiene
Gloving Wear gloves when contact with blood or other potentially infectious materials is possible Remove gloves after caring for a patient Do not wear the same pair of gloves for the care of more than one patient Do not wash gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Hand disinfection
Hand disinfection Gloves Brand-new vinyl glove, not sterile, top of the index finger Photo: K.-P. Wefers, Zentrum für Zahn-, Mund- und Kieferheilkunde der Universität Gießen
Colonized or Infected: What is the Difference? People who carry bacteria without evidence of infection (fever, increased white blood cell count) are colonized If an infection develops, it is usually from bacteria that colonize patients Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers ~ Bacteria can be transmitted even if the patient is just colonized ~ Isolation IS still required!
The Inanimate Environment Can Facilitate Transmission X represents VRE culture positive sites ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.
Performance Indicators Monitor & record adherence to hand hygiene by ward or service; Big brother is watching you! Provide feedback to healthcare workers about their performance Monitor the volume of alcohol-based handrub used per 1,000 patient days Monitor adherence to policies on wearing artificial nails Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
Skin Care Provide healthcare workers with hand lotions or creams Get information from manufacturers regarding effects that hand lotions, creams, or alcohol-based handrubs may have on the effectiveness of antimicrobial soaps Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.
How often should you clean your hands after touching an ENVIRONMENTAL SURFACE near a patient (for example, a countertop or bedrail)? 1. Always 2. Often 3. Sometimes 4. Never