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Hand Hygiene Competency

Hand Hygiene May Stop Health Care Associated Infections (HCAI)

Health care-associated infections (HCAI) are also referred to as “nosocomial” or “hospital” infections. They are defined as follows:

“An infection occurring in a patient during the process of care in a hospital or other health-care facility which was not present or incubating at the time of admission. This includes infections acquired in the health-care facility but appearing after discharge and also occupational infections among health-care workers of the facility.”

What is hand hygiene?

Hand hygiene is the action of cleaning hands. There are two ways to clean hands. Using an alcohol based hand rub, which kills organisms in seconds or, when hands are visibly soiled, using soap and running water.

Hand Rubbing Procedure: RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED Duration of the entire procedure 20-30 seconds

  1. Apply a palmful of the product in a cupped hand, covering all surfaces;
  2. Rub hands palm to palm;
  3. Right palm over left dorsum with interlaced fingers and vice versa;
  4. Palm to palm with fingers interlaced;
  5. Backs of fingers to opposing palms with fingers interlocked;
  6. Rotational rubbing of left thumb clasped in right palm and vice versa;
  7. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa;
  8. Once dry, your hands are safe.

Hand Washing Procedure: HANDS WHEN VISIBLY SOILED! OTHERWISE, USE HANDRUB

Duration of the entire procedure: 40-60 seconds

  1. Rub hands palm to palm;
  2. Apply enough soap to cover all hand surfaces;
  3. Wet hands with water;
  4. Right palm over left dorsum with interlaced fingers and vice versa;
  5. Palm to palm with fingers interlaced;
  6. Backs of fingers to opposing palms with fingers interlocked;
  7. Rotational rubbing of left thumb clasped in right palm and vice versa;
  8. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa;
  9. Rinse hands with water; Your hands are now safe.
  10. Use towel to turn off faucet; Dry hands thoroughly with a single use towel.

HCAI Burden... In the United States

    • In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections
    • In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%
    • Incidence: 5–6%; 1.7 million affected patients
    • Urinary Tract Infection: 36%; 561,667 episodes, 13,088 deaths
    • Surgical Site Infection: 20%; 274,098 episodes (1.98%)
    • Catheter Related Bloodstream Infections: 11%; 250,000 episodes, 28,000 deaths
    • Ventilator Associated Pneumonia: 11%; 5.4/1000 ventilator-days
  • Attributable mortality: 3.6%, approximately 99,000 deaths
  • Annual economic impact: about $4.5 billion


Transmission: Transmission of health care-associated pathogens from one patient to another via health-care workers' hands requires 5 sequential steps. “80% of all infectious diseases are transmitted by touch.”

  1. Germs are present on patient skin and surfaces in the patient surroundings
    1. Germs present on intact areas of patients' skin.
    2. Nearly 1 million skin cells containing viable germs are shed daily from normal skin
    3. Patient surroundings (bed linen, furniture, objects) become contaminated by patient germs
  2. By direct and indirect contact, patient germs contaminate health-care workers' hands
    1. Nurses could contaminate their hands during “clean” activities (lifting patients, taking the patient's pulse, blood pressure, or oral temperature)
    2. 15% of nurses working in an isolation unit large colonies of S. aureus on their hands
    3. In a general health-care facility, 29% nurses carried S. aureus on their hands and 17–30% carried Gram negative bacilli in large quantities.
    4. Vancomycin Resistant Enterococci (VRE's) have been known to remain on countertops for up to 7 days.
  3. Germs survive and multiply on health-care workers' hands
    1. Following contact with patients and/or contaminated environment, germs can survive on hands for differing lengths of time (2–60 minutes).
    2. In the absence of hand hygiene action, the longer the duration of care, the higher the degree of hand contamination.
  4. Defective hand cleansing results in hands remaining contaminated
    1. Insufficient amount of product and/or insufficient duration of hand hygiene action lead to poor hand decontamination
    2. Transient microorganisms are still recovered on hands following hand washing with soap and water, whereas hand rubbing with an alcohol-based solution has been proven significantly more effective
  5. Transfer of pathogens from one source to another.
    1. Manipulation of invasive devices with contaminated hands determines transmission of patient's germs to sites at risk of infection – portals of entry.
    2. Contact with areas where there is a portal of entry.

“But my patient isn't infected!”

  • People who carry bacteria without evidence of infection (fever, elevated white blood 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 in the absence of an infection.

So Why All the Fuss About Hand Hygiene?

  • Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings.
  • Hand hygiene reduces the incidence of healthcare associated infections.
  • More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections.
  • Validated and standardized prevention strategies have been shown to reduce HCAI
  • At least 50% of HCAI could be prevented
  • Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries

Self-Reported Factors for Poor Adherence with Hand Hygiene

Barrier Solution

Handwashing agents cause irritation and dryness

Use of alcohol based hand rubs decrease the likelihood of drying or irritating the skin

Sinks are inconveniently located/lack of sinks

Use of alcohol based hand rubs are to be used at the point of care, no need to use a sink for routine hand hygiene, only needed when visibly soiled or when coming into contact with bodily fluids.

Lack of soap and paper towels

Only needed as stated above, use of alcohol based rubs are more effective in killing pathogens.

Too busy/insufficient time

The time saved by using hand rubs instead of handwashing can save a nurse up to 1 hour daily.

Patient needs take priority

Yes they do, but proper hand hygiene and good patient care do not need to be mutually exclusive.

Low risk of acquiring infection from patients

The risk is always there. By using proper standard precautions and hand hygiene the risk can be cut substantially. But also remember the risk we may cause to the client. They are the ones with the multiple ports of entry and compromised conditions.

Consider:

  1. Adequate handwashing with water and soap requires 40-60 seconds
    Average time usually adopted by health-care workers: <10 seconds
  2. Time Constraints for Hand Hygiene
    1. Handwashing: 40-60 seconds
    2. Alcohol-based handrubbing: 20–30 seconds
  3. For an 8 hour Shift
    1. Hand washing with soap and water: 56 minutes
      Based on seven (60 second) handwashing episodes per hour
    2. Alcohol-based handrub: 18 minutes
      Based on seven (20 second) handrub episodes per hour
  4. Alcohol Based Hand Sanitizer
    1. Is easier to use, more convenient
    2. Can be used at the point of care
    3. Is better for your skin
    4. Is more effective in reducing the number of pathogens on your hands
    5. Lasts longer
    6. Is quicker than hand washing
    7. Reduces the number of infections related to healthcare contacts.

Ability of Hand Hygiene Agents to Reduce Bacteria
Optimal Hand Hygiene Should be Performed
  • The concept embraces the need to perform hand hygiene at recommended moments exactly where care delivery takes place
  • This requires that a hand hygiene product (e.g. alcohol-based handrub, if available) be easily accessible and as close as possible (e.g. within arm's reach), where patient care or treatment is taking place. Point-of-care products should be accessible without having to leave the patient zone of Care.
  • This enables health-care workers to quickly and easily fulfil the 5 indications (moments) for hand hygiene (explained above)
  • Availability of alcohol-based hand-rubs in point-of-care is usually achieved through health-care worker-carried hand-rubs (pocket bottles), wall-mounted dispensers, containers fixed to the patient's bed or bedside table or hand-rubs affixed to the patient's bed or bedside table or to dressing or medicine trolleys that are taken into the point-of-care

THE 5 ESSENTIAL MOMENTS

There are 5 essential moments where the healthcare worker is to use hand hygiene. Following are those 5 moments, the rationale and examples of each.

  1. BEFORE TOUCHING A PATIENT: To protect the patient against harmful germs carried on your hands
    1. Shaking hands, stroking a child's forehead
    2. Helping a patient to move around, get washed
    3. Applying oxygen mask, giving physiotherapy
    4. Taking pulse, blood pressure, chest auscultation, abdominal palpation, recording EKG.
  2. BEFORE PERFORMING A CLEAN OR ASEPTIC PROCEDURE -To protect the patient against harmful germs, including the patient's own, from entering his/her body.
    1. Before handling an invasive device for patient care, regardless of whether or not gloves are used
    2. If moving from a contaminated body site to another body site during care of the same patient
    3. Brushing the patient's teeth, instilling eye drops
    4. Skin lesion care, wound dressing, subcutaneous injection
    5. Catheter insertion, opening a vascular access system or a draining system, secretion aspiration
    6. Preparation of food, medication, pharmaceutical products, sterile material.
  3. AFTER BODY FLUID EXPOSURE RISK - To protect yourself and the health-care environment from harmful patient germs.
    1. Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions.
    2. After contact with body fluids or excretions, mucous membrane, non-intact skin or wound dressing
    3. If moving from a contaminated body site to another body site during care of the same patient
    4. After removing sterile or non-sterile gloves
    5. Brushing the patient's teeth, instilling eye drops, secretion aspiration
    6. Skin lesion care, wound dressing, subcutaneous injection, drawing and manipulating any fluid sample, opening a draining system, endotracheal tube insertion and removal
    7. Cleaning up urines, faeces, vomit, handling waste (bandages, napkin, incontinence pads), cleaning of contaminated and visibly soiled material or areas (soiled bed linen lavatories, urinal, bedpan, medical instruments)
  4. AFTER TOUCHING A PATIENT – To protect yourself and the health-care environment from harmful patient germs.
    1. Before and after touching the patient
    2. After removing sterile or non-sterile gloves
    3. Shaking hands, stroking a child forehead
    4. Helping a patient to move around, get washed
    5. Applying oxygen mask, giving physiotherapy
    6. Taking pulse, blood pressure, chest auscultation, abdominal palpation, recording ECG
  5. AFTER TOUCHING A PATIENT'S SURROUNDINGS –To protect yourself and the health-care environment from harmful patient germs.
    1. After contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient
    2. After removing sterile gloves or non-sterile gloves
    3. Changing bed linen, with the patient out of the bed
    4. Monitoring alarm
    5. Holding a bed rail, leaning against a bed, a night table
    6. Clearing the bedside table

HAND HYGIENE AND MEDICAL GLOVE USE

  • The use of gloves does not replace the need for cleaning your hands.
  • Hand hygiene must be performed when appropriate regardless of the indications for glove use.
  • Remove gloves to perform hand hygiene, when an indication occurs while wearing gloves.
  • Discard gloves after each task and clean your hands – gloves may carry germs.
  • Wear gloves only when indicated according to Standard and Contact Precautions (see examples in the pyramid below) – otherwise they become a major risk for germ transmission.
The Glove Pyramid- Used to aid decision making on when to wear (and not wear) gloves

Gloves must be worn according to STANDARD and CONTACT PRECAUTIONS The pyramid details some clinical examples in which gloves are not indicated, and others in which clean or sterile gloves are indicated. Hand hygiene should be performed when appropriate regardless of indications for 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.

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 mucous membrane and with non-intact skin; potential presence of highly infectious and dangerous organism; epidemic or emergency situations; IV insertion and removal; drawing blood; discontinuation of venous line; pelvic and vaginal examination; suctioning of tracheal tubes.

INDIRECT PATIENT EXPOSURE: Emptying emesis basins; handling/cleaning instruments; handling waste; cleaning up spills of body fluids.

GLOVES NOT INDICATED (except for CONTACT precautions)

No potential for exposure to blood or body fluids, or contaminated environment

DIRECT PATIENT EXPOSURE: Taking blood pressure, temperature and pulse; 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 ventilation equipment and oxygen cannula; moving patient furniture.

  1. Jay Hardy. CLS, SM (ASCP) 11 Handwashing Facts
  2. CDC
  3. WHO
  4. RMIT University
  5. WebMD

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