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

HAND HYGIENE … THE EASY WAY!

Maria Rhona M. G. Bergantin, MDMaria Rhona M. G. Bergantin, MD

Hospital Gang

ESCHERICHIA COLIgenerally lives a blameless life in the gut

but assumes a life of crime once he is allowed to roam in the hospital

PSEUDOMONAS Normally lives in soil and in water

storage tank. but, once he gets into the hospital, is notoriously difficult to remove

KLEBSIELLA. Lesser known resident of the intestine,

fond of hitchhiking on the hands of doctors and nurses. Known to take over entire wards.

STREPTOCOCCUS Still a common cause of throat infection

but also involved in more seriousoffenses against the rest of the person

PROTEUSA motile young bacterium, anxious to swim into the wrong places. Generally follows up the dirty

work of other bacteria

STAPHYLOCOCCUS AUREUSAlias Goldie the Grape, found

in the nose and on the hands of hospital staff but survives

for days in dusty places

Normal Bacterial Skin FloraNormal 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

• 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

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

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

RESIDENT ORGANISMS• normal flora of the skin• coagulase negative staphylococci• Staphylococcus epidermidis• Corynebacterium or Diphtheroids• Propionibacterium species

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

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

TRANSIENT ORGANISMS• gram negative bacilli (E. coli,

Klebsiella and Pseudomonas)• Salmonella sp.• Staphylococcus aureus• Viruses (Rotavirus)

TRANSIENT ORGANISMS• gram negative bacilli (E. coli,

Klebsiella and Pseudomonas)• Salmonella sp.• Staphylococcus aureus• Viruses (Rotavirus)

HEALTH CARE WORKER’S HANDS

Probably the MOST common means by which spread of

infection by direct contact can occur

Probably the MOST common means by which spread of

infection by direct contact can occur

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 Infects- newly operated

- the child, the chronically ill- the old patient

- ALL sick people- ALL hospital personnel

The Hand contaminates- the physicians’ instruments

- clean laundry- toiletries

- sanitary equipments- dishes and silver etc.

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

HANDWASHINGHANDWASHING

• Considered to be one of the MOST important procedures in the prevention of hospital-acquired infection

The Hands are moistened and 3-5 ml formulation is applied to cupped hands. The hands are then rubbed together 5 times as follows :

Defined Technique for Hand WashingDefined Technique for Hand Washing

1. PALM to PALM 2. Right Palm over 3. PALM to PALM dorsum and vice versa fingers interlaced

4. Back of fingers 5. Rotational rubbing of 6. 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

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 carePitter D, 2000

• 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 carePitter D, 2000

• 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

• 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

• 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

• 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

• 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

• 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

Indications for hand washing and hand antisepsis

• Decontaminate hands before having direct contact with patients

• Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter

• Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure

• Decontaminate hand AFTER contact with patient’s intact skin

• Decontaminate hands AFTER contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings if hands are not visibly soiled

• Decontaminate hands if moving from a contaminated body- site to a clean-body site during patient care

• Decontaminate hands AFTER contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient

• Decontaminate hands AFTER removing gloves

• Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water

• 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

Hand hygiene techniqueHand 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

Hand hygiene techniqueHand hygiene technique

• Multiple-use cloth towels of the hanging or roll-type are not recommended for use in the health care setting

Other aspects of hand hygieneOther aspects of hand hygiene

• Do not wear artificial finger nails or extenders when having direct contact with patients at high risk

• Keep natural nails tips less than ¼ inch long

• No recommendation can be made regarding wearing rings in health-care settings. Unresolved issue

HYGIENIC HAND DISINFECTIONHYGIENIC HAND DISINFECTIONIT SHOULD BE

USED during outbreaks

of infection where contact with blood and body fluids or in situations where microbial contamination is likely to occur

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

USED In high risk areas,

e.g. patients in isolation, intensive care and special care baby unit

Before performing an invasive procedure

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

USEDBefore and after

touching wounds, urethral or iv catheters

before wearing and after removing gowns

IT SHOULD BE USED

Before and after touching wounds, urethral or iv catheters

before wearing and after removing gowns

HYGIENIC HAND RUBHYGIENIC 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

• 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

ALCHOLIC HAND RUBS DO NOT CLEANSE, therefore hands

should be cleaned with soap and water in the presence of visible

contamination…

ALCHOLIC HAND RUBS DO NOT CLEANSE, therefore hands

should be cleaned with soap and water in the presence of visible

contamination…

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

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

Results of culture pre and post-application of hand rub

before after

SURGICAL HAND DISINFECTION/ SURGICAL

HANDWASHING / SURGICAL SCRUB

SURGICAL HAND DISINFECTION/ SURGICAL

HANDWASHING / SURGICAL SCRUB

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

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

SURGICAL SCRUB

• ensure that fingernails are kept

SHORT and CLEAN all the time

• Wrist watches and jewelries should be

removed before surgical hand disinfection

• ensure that fingernails are kept

SHORT and CLEAN all the time

• Wrist watches and jewelries should be

removed before surgical hand disinfection

SURGICAL SCRUB

SURGICAL SCRUBPROCEDURETurn the taps

ON using the elbows and adjust the flow of water and temperature of the water

PROCEDURETurn the taps

ON using the elbows and adjust the flow of water and temperature of the water

SURGICAL SCRUB

SURGICAL SCRUBPROCEDUREWet hands and

forearmsApply antiseptic

detergent preparation from an elbow-operated pump dispenser (e.g. Chlorhexidine Povidone Iodine)

PROCEDUREWet hands and

forearmsApply antiseptic

detergent preparation from an elbow-operated pump dispenser (e.g. Chlorhexidine Povidone Iodine)

SURGICAL SCRUB

SURGICAL SCRUBPROCEDURELather hands,

wrists and forearms for ONE MINUTE

Keep them above elbow level then rinse thoroughly under running water

PROCEDURELather hands,

wrists and forearms for ONE MINUTE

Keep them above elbow level then rinse thoroughly under running water

SURGICAL SCRUB

SURGICAL SCRUBPROCEDUREClean 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

PROCEDUREClean 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

SURGICAL SCRUB

SURGICAL SCRUBPROCEDUREThe Hand Washing

procedure is then repeated for 2 MORE MINUTES

PROCEDUREThe Hand Washing

procedure is then repeated for 2 MORE MINUTES

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

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

SURGICAL SCRUB

SURGICAL SCRUBThe 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

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

ANTIBIOTICSDO NOTRENDER HAND WASHING UNNECESSARY

ReferencesReferences

• Guidelines for Hand Hygiene in Health-care Settings (CDC,2002)

• Philippine Hospital Infection Control Society (PHICS) News, July-December 2004

• Guidelines for Hand Hygiene in Health-care Settings (CDC,2002)

• Philippine Hospital Infection Control Society (PHICS) News, July-December 2004

“Little things are indeed little,

but to be faithful in little things is a great thing”

Mother Teresa

“Little things are indeed little,

but to be faithful in little things is a great thing”

Mother Teresa

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

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