Chapter 2

REVIEW OF RELATED LITERATURE

This chapter contains various literature and studies that are related to the study

and is hereby presented.

Hand hygiene

Hand hygiene is a general term that includes handwashing (using plain soap and

water), antiseptic handwash (using antimicrobial substances and water), antiseptic hand

rub (using alcohol-based rub), and surgical hand antisepsis (using antiseptic handwash or

antiseptic hand rub preoperatively by surgical personnel to eliminate transient and reduce

resident hand flora) (CDC, 2002). When hands are visibly dirty wash hands with soap

(plain or antimicrobial) and water. If hands are not visibly soiled, an alcohol-based hand

rub may be used (CDC, 2002).

Hand hygiene, the first line of defence in medical asepsis is good hand hygiene.

Hand hygiene refers to any method approved by the Centers for Disease Control and

Prevention for decontaminating the hands. Handwashing refers to using soap and water to

clean the hands. Friction or rubbing increases the amount of soil and microorganisms

removed. When performing hand hygiene, wash from areas of clean to less clean.

(Harkreader, et al., Fundamentals of Nursing Caring and Clinical Judgment, 2nd Edition,

p. 464, Elsevier (Singapore) Pte Ltd, 2005).

Handwashing is important in every setting, including hospitals. It is considered

one of the most effective infection control measures. Any patient may be harbour micro-

organisms that are currently harmless to the patient yet potentially harmful to another

person or the same patient if they find a portal of entry. It is important that both the

nurses’ and the patients’ hands be washed at the following times to prevent the spread of

micro-organisms: before eating, after using the bedpan or toilet, and after the hands have

come in contact with anybody substances, such as sputum or drainage from a wound. In

addition, healthcare workers should wash their hands before and after giving care of any

kind to every patient.

For routine patient care, antimicrobial foam, hand gel or vigorous handwashing

under a stream of water for at least 10 seconds using liquid soap or antimicrobial liquid

soap should be performed. Antimicrobial soaps usually provided in high-risk areas, such

as the intensive care units, and are frequently supplied in dispensers at the sink. Studies

have shown that the convenience of antimicrobial foams and gels, which do not require

soap and water, may increase healthcare worker’s adherence to hand cleansing (Bischoff

et al., 2000).

It is important to recognize that handwashing with either plain or soap or

antimicrobial soap can damage the skin through the drying effect of the detergents or

chemicals. If the nurse develops dermatitis, the patient may be at higher risk because

handwashing does not decrease bacterial counts on skin with dermatitis. The nurse is also

at higher risk because the normal skin barrier has been broken. Although lotions,

moisturisers and emollients have been tried, no research has yet confirmed their

effectiveness in decreasing the problem. (Kozier, B. et al., Fundamentals of Nursing

Concepts, process and practice, pp. 207-209, Pearson Education Limited, 2008.)

Handwashing is the most important and most basic technique in preventing and

controlling transmission of infections. Handwashing is a vigorous, brief rubbing together

of all surfaces of the hands lathered in soap, followed by rinsing under a stream of water

(Larson, 1996). The purpose is to remove soil and transient organisms from the hands and

to reduce total microbial counts. (Potter and Perry, Fundamentals of Nursing, 5th Edition,

p.852)

Handwashing is the rubbing together of all surfaces and crevices of the hands

using a soap or chemical and water. Handwashing is a component of all types of isolation

precautions and is the most basic and effective infection-control measure to prevent and

control the transmission of infectious agents.

The three essential elements of Handwashing are soap or chemical, water, and

friction. Soaps that contain antimicrobial agents are frequently used in high-risk areas

such as emergency departments and nurseries. Friction is the most important element of

the trio because it physically removes soil and transient flora.

Handwashing should be performed after arriving from work, before leaving work,

between client contacts, after removing gloves, when hands are visibly soiled, before

eating, after excretion of body waste (urination and defecation), after contact with body

fluids, before and after performing invasive procedures, and after handling contaminated

equipment. The exact duration of time required for handwashing depends on the

circumstances. A washing time of 10 to 15 seconds is recommended to remove transient

flora from the hands. High-risk areas, such as nurseries, usually require about a minimum

2-minute handwash. Soiled hands usually require more time (CDC, 2002). (White, Lois,

Foundations of Nursing, 2nd edition, pp.527-529, Thomson Delmar Learning Inc. United

Kingdom, 2005)

Hand hygiene Techniques

1.) Using alcohol-based hand gel/ hand rub (sanitizer)

Alcohol-based hand gels (sanitizer) are available to the general public and to

healthcare institutions as a substitute for soap-and-water handwashing of physically clean

hands. However, limited research has been conducted on the effectiveness of these gels

from perspectives of their ability to kill microorganisms, effect handwashing frequency,

or impact skin condition. In this study by Earl et al. (2001), researchers designed three

phases to specifically address the question of frequency of handwashing by nurses,

physicians and ancillary personnel (Technicians and therapies) into intensive care units.

In phase I, prior to any intervention, the number of opportunities to wash hands

was compared to actual compliance with handwashing over four weeks. In phase II,

alcohol gel dispensers were installed inside and outside of patient rooms and both

opportunities and occurrences for handwashing with either soap-and-water or gel were

counted for four weeks. Phase III examined opportunities and occurrences for

handwashing between 10 and 14 weeks after installation for the dispensers.

The results were as follow: phase I, 39.6% compliance; phase II, 52.6%; phase III,

57%. The highest rates of compliance were by ancillary personnel, followed by nursing

staff and then physicians. The alcohol gel was used instead of soap about 50% to 60% of

the time. Although total amount of required time (including walking to the sinks) was not

determined, less actual time was spent in hand antisepsis with gel in phase III (7.5

seconds) than with soap-and-water in phase I (9.4 seconds).

Although the gel dispenses succeeded in increasing the percentage of compliance

with hand degerming, the researches expressed concerned that the final rate was still only

about 60% of the incidences requiring antisepsis. However the gel did take less time and

was most likely more effective than the inadequate nine-second soap use. The authors

recognized weaknesses in the study, including the common Hawthorne effect. This effect

states that the participant’s behaviour may change purely by knowing that a study is

being conducted. In this case, the health care providers may have paid more attention to

hand antisepsis than they would have had the study not been performed. In addition, at is

not possible to extrapolate these results to other institutions and types of care units.

However, this study is an important example of the need to assess, intervene and reassess

effectiveness of procedures designed to increases the safety and health of both providers

and patients. The study could easily be replicated in other settings and the results

expanded to include other variables such as cost and true time savings. (Kozier et al,

2008)

Apply product to palm of one hand and rub hands together covering all surfaces

of hands and fingers until hands are dry. Follow the manufacturer’s recommendations

regarding the volume of product to use. (Harkreader, et al, 2005)

Apply the recommended amount of product to one hand. Tub hands together,

covering hands and fingers on all sides. Continue rubbing until hands are dry. Amount of

rub required varies by product. Spreads rub to cover all aspects of hands and fingers.

Allows the rub to work. (Lois White, 2005)

2.) When washing hands with soap and water

Wet hands first with water; apply an amount of product recommended by the

manufacturer to hands, and rub hands together vigorously for at least 15 seconds,

covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly

with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because

repeated exposure to hot water may increase the risk dermatitis. (Harkreader, et al, 2005)

Materials used for hand hygiene

1.) Sink with running water and soap ( )

2.) Soap and water and alcohol gel ( )

3.) Alcohol-based hand gel

4.) Alcohol

Advantages of hand hygiene

According to Kozier et al 2008, the following are the advantages of handwasing:

1.) To reduce the number of microorganisms on the hands

2.) To reduce the risk of transmission of microorganisms to patients

3.) To reduce the risk of cross-contamination among patients

4.) To reduce the risk of transmission of infectious organisms to oneself.

Hand hygiene is easy to do and it's one of the most effective ways to prevent the

spread of many types of infection and illness in all settings—from your home and

workplace to child care facilities and hospitals. Clean hands can stop germs from

spreading from one person to another and throughout an entire community.

When should adults wash their hands? The following are some of the answers:

1. Before, during, and after preparing food

2. Before eating food

3. After using the toilet

4. After changing diapers or cleaning up a child who has used the toilet

5. Before and after caring for someone who is sick

6. After blowing your nose, coughing, or sneezing

7. After touching an animal or animal waste

8. After touching garbage

9. Before and after treating a cut or wound

Basing from the aforementioned instances, numbers 5-7 are optional when it comes to

when should adult wash their hands. On the other hand, numbers 2-3 and 6-7 are

applicable for children. However, numbers 6-7 are optional

(http://www.cdc.gov/Features/Handwashing/).

QUESTIONNAIRE CHECKLIST

Part I: Profile of Respondents:

Name: _________________________________________________________________

Age: __________

Grade: ________________________

School: ________________________________________________________________

Part II: Level of knowledge on hand hygiene:

Direction: Encircle the letter of the correct answer.

12. “Germs”

a. they can make you sick

b. they are too small to see

c. hand hygiene will get rid of them

d. none of the aboves

Part III: Techniques, materials and advantages of hand hygiene:

Directions: Below are questions regarding techniques and materials used in hand

hygiene as well as the advantages one could get from it.

1. Hand hygiene Techniques :

Check all the techniques you usually use in hand hygiene?

____ alcohol-based hand gel/ hand rub (sanitizer) technique

____washing hands with soap and water technique

____Alcohol technique

2. Materials used in hand hygiene:

Check all the materials you usually use in handwashing?

____ Soap and water

____ alcohol-based hand gel (sanitizer)

____ Alcohol

3. Advantages of hand hygiene:

Do you understand that:

a) “Germs” (bacteria and viruses) can make you sick?

_____ Yes

_____ No

_____ don’t know

b) Hand hygiene can get rid of “germs”?

_____ Yes

_____ No

_____ don’t know

c) Proper hand hygiene is the most effective way to prevent the spread of many

types of infection and illness?

_____ Yes

_____ No

_____ don’t know

4. When do you usually wash your hand?

____ Before eating food

____ After using the toilet

____ After blowing your nose, coughing, or sneezing

____ After touching an animal or animal waste

5. Is there anything else you can tell about hand hygiene?

__________________________________________________________________

__________________________________________________________________

SALUDSOD PARA ITI SURVEY

Nagan: ______________________________________________________________

Tawen: __________

Grado: _____________________________

Pagadalan:________________________________________________________

Direksyon: Dagiti nakasurat iti baba ket saludsod panggep iti wagas ken kasapulan

para iti panang-buggo iti ima ken dagiti nasayaat a maited detoy.

1. Markaan iti tsek (√) dagiti wagas nga ususaren iti panangbuggo iti ima.

____ alcohol-based hand gel/ hand rub technique

____ washing hands with soap and water technique

____Alcohol technique

2. Markaan iti tsek (√) dagiti ususarem para iti panang-buggo iti imam

_____ sabon ken danom

_____alcohol-based hand gel

_____ alcohol lang

3. Maawatam kadi nga:

a.) Dagiti mikrobyo wenno bakterya ket makaited iti sakit?

_____ wen _____ diak masigurado

_____ saan

b.) Ti panang-buggo iti ima ket wagas a panang-ikkat iti bakterya?

_____ wen ______ diak sigurado

_____ diak masigurado

c. Ti nasayaat nga panang-buggo iti ima ket epektibo a wagas ti panangpasardeng iti

panagwaras iti adu a klase ti sakit ken impeksyon iti bagi tayo?

_____ wen

_____ saan

_____ diak masigurado

4. Kaano ti panang-buggom iti imam?

_____ kasangwanan ti pananga

_____ kalpasan nga agusar iti kasilya weno comfort room

_____ kalpasan iti panag-pangres, panaguyek ken panagbaeng

_____ kalpasan ti panangigem wenno panangpakan iti taraken nga aso, pusa, manok,

baboy ken daduma pay a taraken

5. Ada kadi pay mainayon mo maipanggep iti panagbuggo iti ima?

_____________________________________________________________________

_____________________________________________________________________

Why is hand hygiene important?

Hand hygiene refers to removing or killing microorganisms (germs) on the hands. When

performed correctly, hand hygiene is the single most effective way to prevent the spread

of communicable diseases and infections. In health care, hand hygiene is used to

eliminate transient microorganisms that have been picked up via contact with patients,

contaminated equipment or the environment. Hand hygiene may be performed either by

using soap and running water, or with alcohol-based hand rubs.

When should hand hygiene be performed?

In health care, hand hygiene is required:

Before and after contact with any patient/resident, their body substances or items

contaminated by them

Between different procedures on the same patient/resident

Before and after performing invasive procedures

Before preparing, handling, serving or eating food or feeding a patient/resident

After assisting patients/residents with personal care (e.g. assisting patient to blow

nose, toileting or doing wound care)

Before putting on and after taking off gloves

After performing personal functions (e.g. using the toilet, blowing your nose)

When hands come into contact with secretions, excretions, blood and body fluids

(use soap and running water whenever hands are visibly soiled)

When should soap and water be used?

The mechanical action of washing, rinsing and drying removes transient bacteria present

on the hands. Hand washing with soap and running water must be performed whenever

hands are visibly soiled.

Any type of plain soap may be used. However, bar soaps are not acceptable in health care

settings except for single patient/resident personal use. If used, bar soap should be kept in

a self draining holder that is cleaned thoroughly before new bars are put out. Liquid soap

containers should be used until empty and then discarded. Soap containers must not be

topped up, as there is a risk of contamination of residual soap. Antibacterial soaps may be

used in critical care areas such as ICU, or in other areas where invasive procedures are

performed.

When should alcohol-based hand rubs be used?

Alcohol-based hand rubs/gels/rinses are the preferred method for decontaminating hands,

provided they contain more than 60% alcohol. They are widely used in health care

settings, or in situations where running water is not available. Using alcohol-based hand

rub is better than washing hands (even with an antibacterial soap) when hands are not

visibly soiled.

Won't frequent hand hygiene dry my skin?

Intact skin is the first line of defence against microorganisms, hence it is important to

maintain good skin care. To prevent chafing, wet your hands before applying soap and

use a mild lotion soap with warm water; pat rather than rub hands dry; and apply lotion

liberally and frequently. Skin lotions should be chosen that will not interfere with glove

integrity.

Most alcohol-based hand rubs contain emollients to reduce the incidence of skin

irritation. Frequent use of alcohol-based hand rub actually lessens the incidence of skin

breakdown, as it does not subject hands to the friction and abrasion involved in hand

washing and drying hands.

If an individual develops compromised skin integrity, he/she should be referred to

Occupational Health for assessment.

Hand Hygiene Procedures

How do I use soap and water?

Good hand hygiene technique is easy to learn. Follow these five simple steps to keeping

hands clean:

1. Remove hand and arm jewellery and wet your hands with warm (not hot) running

water.

2. Add soap, and then rub your hands together, making a soapy lather. Do this for at

least 15 seconds, being careful not to wash the lather away. Wash the front and

back of your hands, as well as between your fingers and under your nails.

3. Rinse your hands well under warm running water, using a rubbing motion.

4. Wipe and dry hands gently with paper towel. Rubbing vigorously with paper

towels can damage the skin.

5. Turn off tap using paper towel so that you do not recontaminate your hands.

How do I use alcohol-based hand rubs?

Alcohol-based hand rubs should only be used if no visible dirt is present on the hands.

1. Remove hand and arm jewellery.

2. Apply enough antiseptic to make about the size of a quarter onto your hands,

enough when you rub your hands together to cover all areas of your hands,

including under your nails (1-2 pumps).

3. Use a rubbing motion to evenly distribute the antiseptic product over all surfaces

of the hands, particularly between fingers, fingertips, back of hands and base of

thumbs.

4. Rub hands until your hands feel dry (minimum 15-30 seconds).

What are some mistakes I should avoid regarding hand hygiene?

DON'T leave hand jewellery on when performing hand hygiene. Jewellery is very

hard to clean and hides bacteria and viruses from the mechanical action of the

washing/rubbing.

DON'T use artificial nails, nail enhancements or long (>3-4mm) nails, as they trap

bacteria and are difficult to keep clean.

DON'T wear chipped nail polish, as bacteria may become trapped along the edges

DON'T use a single damp cloth to wash a group of patient's/resident's/children's

hands.

DON'T use a standing basin of water to rinse hands.

DON'T use a common hand towel.

DON'T use sponges or non-disposable cleaning cloths. Remember that germs

thrive on moist surfaces.