Hand Hygiene
اسلاید 1: بسم الله الرحمن الرحيم
اسلاید 2: پکیج آموزشی کنترل عفونت تهیه و تنظیم دکتر حسین اخوان زنجانیریاست تیم کنترل عفونت بیمارستان شهدای تجریش
اسلاید 3: Hand Hygiene
اسلاید 4: “Clean Care is Safer Care”
اسلاید 5: HCAI is a major problem for patient safety and its surveillance and prevention must be a first priority for settings and institutions committed to making health care safer.The impact of HCAI implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, massive additional financial burden, high costs for patients and their families, excess deaths.Overall estimates indicate that more than 1.4 million patients worldwide in developed and developing countries are affected at any time.
اسلاید 6: In developed countries, HCAI concerns 5–15% of hospitalized patients and can affect 9–37% of those admitted to intensive care units (ICUs ) .approximately 5 million HCAIs are estimated to occur in acute care hospitals in Europe annually, representing around 25 million extra days of hospital stay and a corresponding economic burden of €13–24 billion.In general, attributable mortality due to HCAI in Europe is estimated to be 1% (50 000 deaths per year), but HCAI contributes to death in at least 2.7% of cases (135 000 deaths per year).The estimated HCAI incidence rate in the USA was 4.5% in 2002 .approximately 99 000 deaths were attributed to HCAI. The annual economic impact of HCAI in the USA was approximately US$ 6.5 billion in 2004.
اسلاید 7: In the mid-1800s, studies by Ignaz Semmelweis in Vienna, Austria, and Oliver Wendell Holmes in Boston, USA, established that hospital-acquired diseases were transmitted via the hands of HCWs. Historical perspective on hand hygiene in health care He observed that maternal mortality rates, mostly attributable to puerperal fever, were substantially higher in one clinic compared with the other . He also noted that doctors and medical students often went directly to the delivery suite after performing autopsies and had a disagreeable odour on their hands despite handwashing with soap and water before entering the clinic.Semmelweis recommended that hands be scrubbed in a chlorinated lime solution before every patient contact and particularly after leaving the autopsy room. Following the implementation of this measure, the mortality rate fell dramatically to 3% in the clinic most affected and remained low thereafter.
اسلاید 8: Semmelweis is considered not only the father of hand hygiene, but his intervention is also a model of epidemiologically driven strategies to prevent infection.
اسلاید 9: 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.
اسلاید 10: 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.
اسلاید 11: Microorganisms survive on hands. long-sleeved white coats may become contaminated by microorganisms during patient care. Althoughevidence to formulate it as a recommendation is limited, long sleeves should be avoided.
اسلاید 12: When growing conditions are optimal (temperature, humidity, absence of hand cleansing, or friction), microorganisms can continue to grow.
اسلاید 13: Bacterial contamination increases linearly over time during patient contact.
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اسلاید 20: Relationship between hand hygiene and the acquisition of health care-associated pathogens several investigators have found that health care-associated acquisition of MRSA was reduced when the antimicrobial soap used for hygienic hand antisepsis was changed. In one of these studies, endemic MRSA in a neonatal ICU was eliminated seven months after introduction of a new hand antiseptic agent (1% triclosan) .In addition to these studies, outbreak investigations have suggested an association between infection and understaffing or overcrowding that was consistently linked with poor adherence to hand hygiene.In another study in ICU, higher staff level was indeed independently associated with a > 30% infection risk reduction and the estimate was made that, if the nurse-to patient ratio was maintained > 2.2, 26.7% of all infections could be avoided.Vicca demonstrated the relationship between understaffing and the spread of MRSA in intensive care.
اسلاید 21: Review of preparations used for hand hygiene WaterPlain (non-antimicrobial) soapAlcoholsChlorhexidineChloroxylenolHexachloropheneIodine and iodophorsTriclosanOther agents
اسلاید 22: Review of preparations used for hand hygiene WaterWhile 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.
اسلاید 23: Review of preparations used for hand hygiene WaterTap water may contain a variety of microorganisms including human pathogens.Pathogens identified in waterborne nosocomial infections include: Legionella spp., P. aeruginosa, Mycobacterium avium, ...
اسلاید 24: Review of preparations used for hand hygiene Tap water qualityTap 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.
اسلاید 25: Review of preparations used for hand hygiene Tap water qualityWhile 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 handrubs.
اسلاید 26: Water temperaturewater 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.
اسلاید 27: Hand dryingBecause 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.
اسلاید 28: Hand hygiene products Plain soapAlcohol-based (hand) rub
اسلاید 29: 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.
اسلاید 30: 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.
اسلاید 31: Alcohols Most alcohol-based hand antiseptics contain either ethanol, isopropanol or n-propanol, or a combination of two of these products.The antimicrobial activity of alcohols results from their ability to denature proteins.Alcohol solutions containing 60–80% alcohol are most effective, with higher concentrations being less potentThis paradox results from the fact that proteins are not denatured easily in the absence of water.Alcohols have excellent in vitro germicidal activity against Gram-positive and Gram-negative vegetative bacteria (including multidrug-resistant pathogens such as MRSA and VRE), M.tuberculosis, and a variety of fungi.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 hepatitis B virus (HBV) and probably hepatitis C virus.
اسلاید 32: 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
اسلاید 33: AlcoholsAlcohols are rapidly germicidal when applied to the skin, but have no appreciable persistent (residual) activity. However, regrowth of bacteria on the skin occurs slowly after use of alcohol-based hand antiseptics, presumably because of the sub-lethal effect alcohols have on some of the skin bacteria.Alcohols are not good cleansing agents and their use is not recommended when hands are dirty or visibly contaminated with proteinaceous materials.
اسلاید 34: AlcoholsThe efficacy of alcohol-based hand hygiene products is affected by a number of factors including the type of alcohol used, concentration of alcohol, contact time, volume of alcohol used, and whether the hands are wet when the alcohol is applied.The ideal volume of product to apply to the hands is not known and may vary for different formulations.Alcohol-based handrubs intended for use in hospitals are available as solutions (with low viscosity), gels, and foams.Recent studies found similar results demonstrating that solutions reduced bacterial counts on the hands to a significantly greater extent than the tested gels.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.
اسلاید 35: AlcoholsFrequent use of alcohol-based formulations for hand antsepsis tends to cause drying of the skin unless humectants or other skin conditioning agents are added to the formulations. For example, the drying effect of alcohol can be reduced or eliminated by adding 1–3% glycerol or other skin conditioning agents.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.
اسلاید 36: AlcoholsA systematic review of publications between 1992 and 2002 on the effectiveness of alcohol-based solutions for hand hygiene showed that alcohol-based handrubs remove organisms more effectively, require less time, and irritate skin less often than handwashing with soap or other antiseptic agents and water. The availability of bedside alcohol-based solutions increased compliance with hand hygiene among HCWs.Alcohols are flammable, and HCWs handling alcohol-based preparations should respect safety standards . Because alcohols are volatile, containersshould be designed so that evaporation is minimized and initial concentration is preserved.
اسلاید 37: Methods to reduce adverse effects of agentsSelecting less irritating productsavoiding certain practices that increase the risk of skin irritationUse of moisturizing skin care products
اسلاید 38: Selecting less irritating productsOne strategy for reducing exposure of HCWs to irritating soaps and detergents is to promote the use of alcohol-based handrubs containing humectants.
اسلاید 39: avoiding certain practices that increase the risk of skin irritation washing hands regularly with soap and water immediately before or after using an alcohol-based product is not only unnecessary, but may lead to dermatitis.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.
اسلاید 40: Use of moisturizing skin care products The effects of hand hygiene products on skin vary considerably, depending upon factors such as the weather and environmental conditions.For example, in tropical countries and during the summer months in temperate climates, the skin remains more moisturized than in cold, dry environments.The effects of products also vary by skin type. In one recent study, nurses with darker skin were rated as having significantly healthier skin and less skin irritation than nurses with light skin .Results of a prevalence survey of 282 Chinese hospital nurses suggested that hand dermatitis was less common among this group when compared with those in other parts of the world.Hand lotions and creams often containhumectants, fats, and oils that increase skin hydration and replace altered or depleted skin lipids that contribute to the barrier function of the skin.Improved skin condition resulting from the frequent and scheduled use of an oil-containing lotion led to a 50% increase in hand cleansing frequency among HCWs.However, 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 and not topped up.
اسلاید 41: Situations requiring and not requiring glove use
اسلاید 42: Situations requiring and not requiring glove useSTERILEGLOVESINDICATEDAny surgicalprocedure; vaginaldelivery; invasive radiologicalprocedures; performing vascularaccess and procedures (centrallines); preparing total parental nutritionand chemotherapeutic agents.
اسلاید 43: Situations requiring and not requiring glove useEXAMINATION GLOVES INDICATED INCLINICAL SITUATIONSPotential for touching blood, body fluids, secretions,excretions and items visibly soiled by body fluidsDIRECT PATIENT EXPOSURE: contact with blood; contact withmuscous membrane and with non-intact skin; potential presenceof highly infectious and dangerous organism; epidemic or emergencyvenous line; pelvic and vaginal examination; suctioning non-closed systems ofendotracheal tubes.INDIRECT PATIENT EXPOSURE: emptying emesis basins; handling/cleaninginstruments; handling waste; cleaning up spills of body fluids.
اسلاید 44: Situations requiring and not requiring glove useGLOVES NOT INDICATED (except for CONTACT precautions)No potential for exposure to blood or body fluids, or contaminated environmentDIRECT PATIENT EXPOSURE: taking blood pressure; temperatureand pulse; performing SC and IMinjections; 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; placing non-invasive
اسلاید 45: Jewellery Several studies have shown that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings.40% of nurses harboured Gram-negative bacilli such as E.cloacae, Klebsiella spp., and Acinetobacter spp. on skin under rings and that some nurses carried the same organism under their rings for months.A survey of knowledge and beliefs regarding nosocomial infections and jewellery showed that neonatal ICU HCWs were not aware of the relationship between bacterial hand counts and rings, and did not believe that rings increased the risk of nosocomial infections; 61% regularly wore at least one ring to work.Further studies are needed to establish if wearing rings results in a greater transmission of pathogens in health-care settings.Nevertheless, it is likely that poorly maintained (dirty) rings and jewellery might harbour microorganisms that could contaminate a body site with potential pathogens. The consensus recommendation is to strongly discourage the wearing of rings or other jewellery during health care. If religious or cultural influences strongly condition the HCW’s attitude, the wearing of a simple wedding ring (band) during routine care may be acceptable, but in high-risk settings, such as the operating theatre, all rings or other jewellery should be removed.simple and practical solution allowing effective hand hygiene is for HCWs to wear their ring(s) around their neck on a chain as a pendant.
اسلاید 46: Fingernails and artificial nails Freshly applied nail polish does not increasethe number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails.Even after careful handwashing or surgical scrubs, HCWs often harbour substantial numbers of potential pathogens in the subungual spaces.In particular, the presence of fingernail disease may reduce the efficacy of hand hygiene and result in the transmission of pathogens.HCWs who wear artificial nails are more likely to harbour Gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing or handrub with an alcohol-based gel.It is not clear if the length of natural or artificial nails is an important risk factor, since most bacterial growth occurs along the proximal 1 mm of the nail, adjacent to subungalskin.1Consensus recommendations are that HCWs do not wear artificial fingernails or extenders when having direct contact with patients and natural nails should be kept short . ( 0.5 cm long orapproximately ¼ inch long)
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