Hand Hygiene

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بسم الله الرحمن الرحیم 

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پکیج آموزشی کنترل عفونت تهيه و تنظیم دکتر حسین اخوان زنجانی رياست تيم كنترل عفونت بيمارستان شهداى تجريش 

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Hand Hygiene 3 

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“Clean Careis Safer Care” 

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MCAl ls a maior preblem ‏و‎ ‎e impact o implies prolonge Overall estimates indicate that more than 1.4 million patients worldwide in developed and developing countries are affected at any time. and their families, excess deaths. 

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The estimated HCAI incidence rate in the USA was in 2002. approximately attributed to HCAI. ۲۷۱۵۵۱ 0۲ اقناصصة عط ‎the USA was approximately US$‏ ‎in 2004.‏ 

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Historic on hand hygi jective health care Semmelweis recommendedthat hands be scrubbedinachlorinatedlime solution before everypatient contact andparticularly after Ceaving the autopsy room. Following the implementation of this measure, themortality ratefell dramatically tos%intheclinicmost affectedandremained Cow thereafter. 

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iSemme(weisis considered not only the | father ofhandhygiene, but his i imterventionis alsoamodel of : epidemiologically driven strategies | toprevent infection. 

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‘Ofgantams presanton patient skin or the immedtata environment cocci, in particular at nasal, perineal, and inguinal areas (not shown), as well as axillae and upper extremities. Some environmental surfaces close to the patient are contaminated with Gram-positive cocci, presumably shed by the patient. 

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cross-transmission of microorganisms. ik this case, Gram-positive cocci from the patient’s own flora transfer to HCW’s hands. 

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Microorganisms survive onhands. Cong-sleevedwhite coats may becomecontaminated by microorganisms during patient care. A(though evidence toformulateit as arecommendation is limited, Cong sleeves show dbeavoided, 

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When growing conditions are optimal (temperature, humidity, absence of hand cleansing, or friction), microorganisms can continue togrow. 

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12 Duration of care (minutes) Bacterial contamination increases Cinearly over time during patient contact. 

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Figure .7.5b 

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7 5 Patient zone 7 3 ‏لم اا‎ ‏ت۱۵‎ ‎1 ‏كت‎ infectious risk ۱ for the patient 1 1 1 1 1 1. Critical site 1 With body fluid 1 exposure risk ۰ x ee - Health-care area 

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My 5 moments for HAND HYGIENE 

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Relationship between hand hygiene and the acquisition of health care-associated pathogens 1 {mn another ctudv in ICH ‏حطمنط‎ 2 Vicca demonstrated the relationship between understaffing and the spread of MRSA in intensive care. 

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Review of preparations used for hand hygiene Water Plain (non-antimicrobial) soap Alcohols Chlorhexidine Chloroxylenol Hexachlorophene lodine and iodophor Triclosan Other agents 4 clean hands save lives ‎6s a ea‏ اج 5 هت ع8 

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Review of preparations used for hand hygiene Water © While water is often called a “universal solvent”, it cannot directly remove hydrophobic substances such as fats and oils often present on soiled hands. © water alone is not suitable for cleaning soiled hands; soap or detergent must be applied as well as water. 

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Review of preparations used for hand hygiene Water © Tap water may contain a variety of microorganisms including human pathogens. © Pathogens identified in waterborne nosocomial infections include: Legionella spp., P. aeruginosa, Mycobacterium avium, ... 

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Review of preparations used for hand hygiene Tap water quality © Tap water, in addition to being a possible source of microbial contamination, may include substances that may interfere with the microbicidal activities of antiseptics and disinfectants. 

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Review of preparations used 622 hand hygiene Tap water quality ’ © While drinkable water may algo be ideal for handwashing, ‏اهاز‎ evidence does not suppgrt the need for potabl water for washing hands. © if the water is considered potentially unsafe for handwashing, the use of antibacterial soap alone may not be adequate. Washed hands may require further decontamination with antiseptic 

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Water temperature * water temperature does not appear to be a critical _ factor for microbial removal from hands being washed. * In contrast, in a study comparing water temperatures of 4 °C, 20 °C and 40 °C, warmer temperatures have been shown to be very significantly associated with skin irritation. * The use of very hot water for handwashing should therefore be avoided as it increases the likelihood of skin damage. 

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Hand drying * Because wet hands can more readily acquire and spread microorganisms, the proper drying of hands is an integral part of routine handwashing. * Paper towels, cloth towels, and warm air dryers are commonly used to dry washed hands. * Reusing or sharing towels should be avoided because of the risk of cross-infection. * When clean or disposable towels are used, it is important to pat the skin rather than rub it, to avoid cracking. 

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Hand hygiene products OPlain soap OAIcohol-based (hand 

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Plain (non-antimicrobial) soap ° Soaps are detergent-based products that contain esterified fatty acids and sodium or potassium hydroxide. ° They are available in various, « ۱ ۲ @ ۱ forms including bar soap\_tissu 0 leaf, and liquid prepara’ ions. nS.) CO 3 \ ۶ 

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Plain (non-antimicrobial) soap Plain soaps have minimal, if any, antimicrobial activity, though handwashing with plain soap can remove loosely adherent transient flora. Handwashing with plain soap can result ina paradoxical increase in bacterial counts on the skin. Because soaps may be associated with considerable skin irritation and dryness . plain soaps have become contaminated, which may lead to the colonization of HCWs hands with Gram- negative bacilli. Nevertheless, there is some evidence that the actual hazard of transmitting microorganisms through handwashing with previously used soap bars is negligible. 

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Some enveloped (lipophilic) viruses such as herpes simplex virus (HSV), HIV, influenza virus, RSV are susceptible to alcohols when tested in vitro. Other enveloped viruses that are somewhat less susceptible, but are killed by 60-70% alcohol, include Wey eiiite |e (HBV) and probably hepatitis C virus" 

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“ In 1994, the FDA > J 7 TFM classified ethanol 60-95% as a generally safe and effective active agent for use in antiseptic hand hygiene or HCW handwash products \ 

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Alcohols Alcohols are not good cleansing agents and their use is not recommended when ‏لاأطأوانا عه بأل عمج كلمقط‎ contaminated with proteinaceous materials. 

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Furthermore, it is worth considering that compliance is probably of higher importance, thus if a gel with lower in vitro activity is more frequently used, the overall outcome is still expected to be better. 

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Alcohols Moreover, in prospective trials, alcohol-based solutions or gels containing humectants caused significantly less skin irritation and dryness than the soaps or antimicrobial detergents tested. 

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Alcohols s handling alcohol-based preparations should respect safety standards . Because alcohols are volatile, containers should be designed so that evaporation is minimized and initial concentration is 

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Methods to reduce adverse effects of agents Oselectinglessirritating products Oavoiding certainpracticesthatincrease theriskofskinirritation Onlse of moisturizing skin careproducts 

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One strategy tor reducing exposure of HCWs to irritating soaps and detergents is to promote the use of alcohol-based handrubs containing 

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avoiding certain practices that increase the risk of skin irritation Additionally, donning gloves while hands are still wet from either washing or applying alcohol increases the risk of skin irritation. For these reasons, HCWs should be reminded not to wash their hands before or after applying alcohol and to allow their hands to dry completely before donning gloves. 

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‘Use of moisturizing skin care products owever, most hand moisturizing agents are not sterile and thus may easily become contaminated; they have been associated also with outbreaks in the neonatal ICU setting. In particular, if the lotion is poured from a large bottle into smaller bottles, the smaller containers should be washed and disinfected between uses 

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Situations requiring and not requiring alave ica GLOVES NOT INDICATED (except for CONTACT precautions) "No potatia for exposure obloed or Body thd. or santamnated environment DIREGT PATIENT EXPOSURE: aking Dion precsure: temparaksean pulse: performing SC anc MA Jejectiona: bathing ed dreosing the paint waneperting patent curing for ajou and ware asthoutaeeretone lernbuting or eolsetna patient catary rays: remewng and rplacing nen for pavent bed: paoing non-invasive Utlaon equpment and oxygen cannula: moving patent tre 

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Situations requiring and not requiring glove use STERILE GLOVES INDICATED Any surgical procedure; vaginal delivery; invasive radiological procedures; performing vascular ‏اج0۲۳عع) 0۳۵660۵۲66 ۵۳00 5کععع2‎ lines); preparing total parental nutrition and chemotherapeutic agents. 

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Situations requiring and not PC gq alove 2 AMINATION 6101/5 INDICATED IN CLINICAL SITUATIONS Potential for touching blood, body fluids, secretions, excretions and items visibly soiled by body fluids DIRECT PATIENT EXPOSURE: contact with blood; لاس نیلی muscous membrane and with non-intact skin; potential presence of highly infectious and dangerous organism; epidemic or emergency venous line; pelvic and vaginal examination; suctioning non-closed systems of endotracheal tubes. INDIRECT PATIENT EXPOSURE: emptying emesis basins; handling/cleaning instruments; handling waste; cleaning up spills of 

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Situations requiring and not requiring glove use No potential for exposure to blood or body fluids, or contaminated environment DIRECT PATIENT EXPOSURE: taking blood pressure; temperatureand pulse; performing SC and IM injections; bathing and dressing the patient; transporting patient; caring for eyes and ears (without secretions); any vascular line manipulation in absence of blood leakage. INDIRECT PATIENT EXPOSURE: using the telephone, writing in the patient chart; giving oral medications; distributing or collecting patient dietary trays; emoving and replacing linen for patient bed; 

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Fingernails and artificial nails = en eC nate recommendations are that HCWs do not wear artificia fingernails or extenders wher having direct contact witt patients and natural nails shoul be kept short 5 

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7 @ Areas most frequently missed during hand washing @ Less frequently missed Not missed 

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8 * ۳ ۴ 

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Gis 9 ‏لمح‎ 3 

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بسم الله الرحمن الرحيم پکیج آموزشی کنترل عفونت تهیه و تنظیم دکتر حسین اخوان زنجانی ریاست تیم کنترل عفونت بیمارستان شهدای تجریش Hand Hygiene “Clean Care is Safer Care” HCAI is a major problem for The impact of HCAI implies prolonged patient safety and its Overall stay, estimates indicate hospital long-term disability, surveillance and prevention that more than 1.4 million increased resistance of must be a worldwide first priorityin for patients microorganisms to antimicrobials, developed developing settings andand institutions countries affected at any massive are additional financial committed to making health time. burden, high costs for patients care safer. and their families, excess deaths. approximately 5 million HCAIs are The estimated HCAI incidence rate in In developed countries, HCAI In general, attributable mortality estimated to occur in acute care the USA was 4.5% in 2002 . concerns 5–15% of hospitalized due to HCAI in Europe is estimated hospitals in Europe annually, patients and can affect 9–37% of to be 1% (50 000 deaths per year), representing around 25 million approximately 99 000 deaths were those admitted to intensive care but HCAI contributes to death ina at extra days of hospital stay and attributed to HCAI. units 2.7% (ICUsof ) .cases least (135 000 corresponding economic burden of deaths per year). impact of HCAI in The annual economic €13–24 billion. the USA was approximately US$ 6.5 billion in 2004. Historical perspective on hand hygiene in health care Semmelweis recommended that He observed that maternal rates, hands be scrubbed in a mortality chlorinated mostly attributable to puerperal fever, were In thesolution mid-1800s, studies by Ignaz lime before every patient substantially in higher in one clinicand compared Semmelweis Vienna, Austria, Oliver contact and particularly after leaving with the Holmes other . in Boston, USA, Wendell established thealso autopsy room. He noted that doctors and medical that hospital-acquired diseases were Following the implementation of this students often went directly the delivery transmitted via the hands of to HCWs. suite after performing autopsies and had a measure, the mortality rate fell disagreeable odour on in their dramatically to 3% thehands clinicdespite most handwashing with soap and water before affected and remained low entering the clinic. thereafter. Semmelweis is considered not only the father of hand hygiene, but his intervention is also a model of epidemiologically driven strategies to prevent infection. A bedridden patient colonized with Gram-positive cocci, in particular at nasal, perineal, and inguinal areas (not shown), as well as axillae and upper extremities. Some environmental surfaces close to the patient are contaminated with Gram-positive cocci, presumably shed by the patient. Contact between the HCW and the patient results in cross-transmission of microorganisms. In this case, Gram-positive cocci from the patient’s own flora transfer to HCW’s hands. Microorganisms survive on hands. long-sleeved white coats may become contaminated by microorganisms during patient care. Although evidence to formulate it as a recommendation is limited, long sleeves should be avoided. When growing conditions are optimal (temperature, humidity, absence of hand cleansing, or friction), microorganisms can continue to grow. Bacterial contamination increases linearly over time during patient contact. Relationship between hand hygiene and the acquisition of health care-associated pathogens In another study inhave ICU,found higher several investigators thatstaff health In addition to these studies, outbreak level was indeed independently care-associated acquisition of MRSA was investigations an used Vicca demonstrated the relationship reduced whenwith thehave antimicrobial soap associated a > suggested 30% infection association between infection and for hygienic hand antisepsis was changed. between understaffing and thewas risk reduction and the estimate In one of studies, endemic MRSA in a understaffing ornurse-to overcrowding spread ofthese MRSA in intensive care.that made that, if the patient neonatal ICU was eliminated seven months was consistently linked with poor ratio was maintained > 2.2, 26.7% of after introduction of a new hand antiseptic adherence to hand hygiene. all infections could. be avoided. agent (1% triclosan) Review of preparations used for hand hygiene  Water  Plain (non-antimicrobial) soap  Alcohols  Chlorhexidine  Chloroxylenol  Hexachlorophene  Iodine and iodophors  Triclosan  Other agents Review of preparations used for hand hygiene Water While water is often called a “universal solvent”, it cannot directly remove hydrophobic substances such as fats and oils often present on soiled hands. water alone is not suitable for cleaning soiled hands; soap or detergent must be applied as well as water. Review of preparations used for hand hygiene Water Tap water may contain a variety of microorganisms including human pathogens. Pathogens identified in waterborne nosocomial infections include: Legionella spp., P. aeruginosa, Mycobacterium avium, ... Review of preparations used for hand hygiene Tap water quality Tap water, in addition to being a possible source of microbial contamination, may include substances that may interfere with the microbicidal activities of antiseptics and disinfectants. Review of preparations used for hand hygiene Tap water quality While drinkable water may also be ideal for handwashing, available evidence does not support the need for potable water for washing hands. if the water is considered potentially unsafe for handwashing, the use of antibacterial soap alone may not be adequate. Washed hands may require further decontamination with antiseptic Water temperature • water temperature does not appear to be a critical factor for microbial removal from hands being washed. • In contrast, in a study comparing water temperatures of 4 °C, 20 °C and 40 °C, warmer temperatures have been shown to be very significantly associated with skin irritation. • The use of very hot water for handwashing should therefore be avoided as it increases the likelihood of skin damage. Hand drying • Because wet hands can more readily acquire and spread microorganisms , the proper drying of hands is an integral part of routine handwashing. • Paper towels, cloth towels, and warm air dryers are commonly used to dry washed hands. • Reusing or sharing towels should be avoided because of the risk of crossinfection. • When clean or disposable towels are used, it is important to pat the skin rather than rub it, to avoid cracking. Hand hygiene products Plain soap Alcohol-based (hand) rub Plain (non-antimicrobial) soap  Soaps are detergent-based products that contain esterified fatty acids and sodium or potassium hydroxide.  They are available in various forms including bar soap, tissue, leaf, and liquid preparations. Plain (non-antimicrobial) soap • Plain soaps have minimal, if any, antimicrobial activity, though handwashing with plain soap can remove loosely adherent transient flora. • Handwashing with plain soap can result in a paradoxical increase in bacterial counts on the skin. Because soaps may be associated with considerable skin irritation and dryness . • plain soaps have become contaminated, which may lead to the colonization of HCWs hands with Gram-negative bacilli. • Nevertheless, there is some evidence that the actual hazard of transmitting microorganisms through handwashing with previously used soap bars is negligible. Alcohols Some enveloped (lipophilic) viruses Alcohols havesimplex excellent in(HSV), vitro such as herpes virus Most alcohol-based handGramThe antimicrobial activity of HIV, influenza virus, RSV are germicidal activity against Alcohol solutionsresults containing This paradox from60– antiseptics contain either susceptible to results alcohols when tested in alcohols from their positive and Gram-negative 80% alcohol are proteins most effective, the fact that are vitro . ethanol, bacteria isopropanol or nvegetative (including ability to with higher concentrations being not denatured easily in the propanol, or a combination of multidrug-resistant pathogens less potent denature proteins. Other enveloped viruses that are absence of water. two ofMRSA theseand products. such as VRE), but are somewhat less susceptible, M.tuberculosis, and a variety killed by 60–70% alcohol, include of fungi. hepatitis B virus (HBV) and probably hepatitis C virus. In 1994, the FDA TFM classified ethanol 60–95% as a generally safe and effective active agent for use in antiseptic hand hygiene or HCW handwash products Alcohols Alcohols are rapidly germicidal when applied to the have no Alcohols areskin, notbut good appreciable persistent (residual) cleansing agents and their activity. use is not recommended when However, regrowth of bacteria on the skin occurs use of alcoholhands areslowly dirtyafter or visibly based hand antiseptics, presumably contaminated with because of the sub-lethal effect proteinaceous materials. alcohols have on some of the skin bacteria. Alcohols Furthermore, it is worth considering that The efficacy of alcohol-based hand Recent studies found similar compliance is probably of hygiene products is affected by a Alcohol-based handrubs The ideal volume of product results demonstrating that higher importance, thus if number of factors including the type intended hospitals are to applyfor touse theinhands is not solutions reduced bacterial of alcohol used, concentration of a gel with lower in vitro available as solutions (with low known and may vary for counts on the hands to a alcohol, contact time, volume of activity is more frequently viscosity), gels, and foams. different formulations. significantly greater extent alcohol used, and whether the hands used, the overall than tested gelsoutcome .is applied. are wetthe when the alcohol is still expected to be better. Alcohols Moreover, inalcohol-based prospective Frequent use of formulations for hand antsepsis tends trials, alcohol-based to cause drying of the skin unless solutions or gels containing humectants or other skin conditioning humectants agents are addedcaused to the formulations. significantly less skin For example, the drying effect of irritation and dryness than alcohol can be reduced or eliminated by adding 1–3% or other skin the soaps orglycerol antimicrobial conditioning agents. detergents tested. Alcohols A systematic review of publications Alcohols are flammable, and between 1992 and alcohol-based 2002 on the HCWs handling effectiveness of alcohol-based solutions for preparations should respect hand hygiene showed that alcohol-based safety standards . handrubs remove organisms more effectively, require less time, and Because irritate skinalcohols less oftenare thanvolatile, handwashing containers with soap or other antiseptic agents and water. should be designed so that The availability of alcohol-based evaporation isbedside minimized and solutions increased compliance initial concentration is with hand hygiene among HCWs. preserved. Methods to reduce adverse effects of agents Selecting less irritating products avoiding certain practices that increase the risk of skin irritation Use of moisturizing skin care products Selecting less irritating products One strategy for reducing exposure of HCWs to irritating soaps and detergents is to promote the use of alcohol-based handrubs containing humectants. avoiding certain practices that increase the risk of skin irritation Additionally, donning gloves while hands are still wet hands from either washing or washing regularly with applying alcohol increases the risk of skin soap and water immediately irritation. before or after using an alcoholbased is not onlybe For theseproduct reasons, HCWs should reminded not to wash hands unnecessary, buttheir may leadbefore to or after applying alcohol and to allow their dermatitis. hands to dry completely before donning gloves. Use of moisturizing skin care products However, most hand moisturizing agents are of nota sterile and thus may Results prevalence The effects of products also vary Hand lotions and creams often For example, in tropical The effects of hand hygiene Improved skin condition resulting easily become contaminated; they have survey of 282 Chinese by skin type. In one recent contain been countries associated and also during with the outbreaks in products on skin vary from the frequent and scheduled hospital nurses suggested study, nurses with darker skin humectants, fats, and oils that the neonatal ICU setting. summer months in temperate considerably, depending upon use of an oil-containing increase skin dermatitis hydration andwas replace that hand less were rated as having climates, the skin remains more factors such as the weather and lotion led to a 50% increase in In particular, if the lotion is poured altered or depleted skin lipids that common among this group significantly healthier skin and moisturized than in cold, dry environmental conditions. from a cleansing largetobottle into smaller bottles, hand frequency among contribute the barrier function of when compared with those in less skin irritation than nurses the smaller containers should be environments. HCWs. the skin. other parts of. the world. washed and disinfected between uses with light skin and not topped up. Situations requiring and not requiring glove use Situations requiring and not requiring glove use STERILE GLOVES INDICATED Any surgical procedure; vaginal delivery; invasive radiological procedures; performing vascular access and procedures (central lines); preparing total parental nutrition and chemotherapeutic agents. Situations requiring and not requiring glove use EXAMINATION GLOVES INDICATED IN CLINICAL SITUATIONS Potential for touching blood, body fluids, secretions, excretions and items visibly soiled by body fluids DIRECT PATIENT EXPOSURE: contact with blood; contact with muscous membrane and with non-intact skin; potential presence of highly infectious and dangerous organism; epidemic or emergency venous line; pelvic and vaginal examination; suctioning non-closed systems of endotracheal tubes. INDIRECT PATIENT EXPOSURE: emptying emesis basins; handling/cleaning instruments; handling waste; cleaning up spills of body fluids. Situations requiring and not requiring GLOVES NOT INDICATED (except for CONTACT glove use precautions) No potential for exposure to blood or body fluids, or contaminated environment DIRECT PATIENT EXPOSURE: taking blood pressure; temperatureand pulse; performing SC and IM injections; bathing and dressing the patient; transporting patient; caring for eyes and ears (without secretions); any vascular line manipulation in absence of blood leakage. INDIRECT PATIENT EXPOSURE: using the telephone, writing in the patient chart; giving oral medications; distributing or collecting patient dietary trays; removing and replacing linen for patient bed; Jewellery The consensus recommendation is to strongly discourage theand wearing of if 40% of nurses A Further survey studies of knowledge are harboured needed to establish beliefs rings or rings other jewellery during regarding wearing nosocomial results in ainfections greater and Gram-negative bacilli such health as care. jewellery transmission showed of pathogens that neonatal in health-care ICU Several studies have shown E.cloacae, Klebsiella spp., and simple and practical solution HCWs settings. were not aware of the that skin underneath rings is Acinetobacter spp. on skin allowing effective hand If religious orbetween cultural bacterial influences relationship hand more heavily colonized than under rings and that some strongly condition the HCW’s hygiene for HCWs topoorly wear counts Nevertheless, andisrings, it is likely andthat did not comparable areas oftheir skin on nurses carried the same attitude, the wearing of ajewellery simple believe maintained that (dirty) rings rings increased and the risk their ring(s) around neck fingers without rings. organism under their rings wedding ring (band) during routine of might nosocomial harbour microorganisms infections; 61% that for could on a chain as a pendant. care may be but in highmonths. regularly contaminate wore aacceptable, body at least site with one potential ring to risk settings, such as the operating work. pathogens. theatre, all rings or other jewellery should be removed. Fingernails and artificial nails Consensus recommendations are It is not clear if the length of that HCWs do the not wear artificial Freshly applied nail polish does not HCWs who wear artificial nails are In particular, presence of natural or artificial nails is an Even after careful handwashing or increase fingernails or extenders when more likely to harbour Gram-negative fingernailrisk disease may reduce important factor, since most surgical scrubs, HCWs often harbour the number of bacteria recovered having direct contact withthanand pathogens on their fingertips the efficacy of hand hygiene bacterial growth occurs along the substantial numbers of potential from periungual skin, but chipped patients and natural nails should those who have natural nails, both result in the transmission of pathogens the 1 subungual spaces. nail polishinmay support growth proximal mm ofthe the nail, be kept short . before and after handwashing or pathogens. of larger numbers of organisms on adjacent to subungal (fingernails. 0.5 cmwith long orapproximately ¼ handrub an alcohol-based gel. skin.1 inch long)