In general, adherence of healthcare workers to recommended hand hygiene procedures has been poor. Studies shown here are representative of the overall adherence rates which averaged about 40%. Adherence rates do vary by occupation.

Healthcare workers have reported several factors that may negatively impact their adherence with recommended practices including; handwashing agents cause irritation and dryness, sinks are inconveniently located, lack of soap and paper towels, not enough time, understaffing or overcrowding, and patient needs taking priority. Lack of knowledge of guidelines/protocols, forgetfulness, and disagreement with the recommendations were also self reported factors for poor adherence with hand hygiene. Perceived barriers to hand hygiene are linked to the institution and HCWs colleagues. Therefore, both institutional and small-group dynamics need to be considered when implementing a system change to secure and improve HCWs hand hygiene practice.

In one study, hands of 131 healthcare workers (HCWs) were cultured before, and hands and gloves after, routine care. A mean of 56% of body sites and 17% of environmental sites were VRE positive. After touching the patient and environment, 75% of ungloved HCWs hands and 9% of gloved HCWs hands were contaminated with VRE. After touching only the environment, 21% of ungloved and 0 gloved HCWs hands were contaminated. The inanimate environment plays a role in facilitating transmission of organisms.

Healthcare workers should wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use an alcohol-based handrub when hands are not visibly soiled to reduce bacterial counts.

Hand hygiene is indicated before: patient contact, donning gloves when inserting a central venous catheter (CVC), and inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery. Hand hygiene is also indicated after contact with a patient’s intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves. Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions.

These recommendations will improve hand hygiene practices of HCWs and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. When decontaminating hands with an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet.

Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best.

This graph shows that alcohol-based handrub is better than handwashing at killing bacteria. Shown across the top of this graph is the amount of time after disinfection with the hand hygiene agent. The left axis shows the percent reduction in bacterial counts. The three lines represent alcohol-based handrub, antimicrobial soap, and plain soap.

The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis. More rapid access to hand hygiene materials could help improve adherence. Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often.

Alcohol-based handrubs should be stored away from high temperatures or flames, in accordance with National Fire Protection Agency recommendations. In Europe, where alcohol-based handrubs have been used extensively for many years, the reported incidence of fires related to such products has been extremely low. In the U.S., there has been a report of a flash fire that occurred as a result of an unusual series of events, which included a healthcare worker applying an alcohol gel to her hands, then immediately removing a polyester isolation gown, and touching a metal door before the alcohol had evaporated. Removing the polyester gown created a large amount of static electricity that generated an audible static spark when she touched the metal door, igniting the unevaporated alcohol on her hands. Following application of alcohol-based handrubs, hands should be rubbed together until all the alcohol has evaporated. In other words, Let It Dry!

Wearing gloves reduces the risk of healthcare workers acquiring infections from patients, prevents flora from being transmitted from healthcare workers to patients, and reduces contamination of the hands of healthcare workers by flora that can be transmitted from one patient to another. Gloves should be used when HCWs have contact with blood or other body fluids. Gloves should be removed after caring for a patient. The same pair of gloves should not be worn for the care of more than one patient. Gloves should not be washed or reused.

Nail length is important because even after careful handwashing, HCWs often harbor substantial numbers of potential pathogens in the subungual spaces. Numerous studies have documented that subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.), corynebacteria, and yeasts. Natural nail tips should be kept to ¼ inch in length. A growing body of evidence suggests that wearing artificial nails may contribute to transmission of certain healthcare-associated pathogens. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing. Therefore, artificial nails should not be worn when having direct contact with high risk patients.

No recommendation can be made regarding the routine use of nonalcohol-based handrubs for hand hygiene in healthcare settings. Whether the wearing of rings results in greater transmission of pathogens is unknown.

In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster. In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition.

It’s everybody’s business! Infection Control

Infection Kills CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection. 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.

Hand Hygiene is Key First discovered in 1840’s by Swiss obstetrician Ignaz Semmelweis, hand hygiene was slow to be accepted as a practice. It wasn’t until the 1860’s, with Pasteur’s Germ Theory, that understanding of the importance of hand hygiene became widespread. Now commonly accepted, it is STILL NOT PRACTICED consistently! Semmelweis’ Intervention: Hand scrub with chlorinated lime solution

Hand Hygiene Adherence in Hospitals 1. Gould D, J Hosp Infect 1994;28:15-30. 2. Larson E, J Hosp Infect 1995;30:88-106. 3. Slaughter S, Ann Intern Med 1996;3:360-365. 4. Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:858-860. 5. Pittet D, Lancet 2000:356;1307-1312. Year of Study Adherence Rate Hospital Area 1994 (1) 29% General and ICU 1995 (2) 41% General 1996 (3) 41% ICU 1998 (4) 30% General (5) 48% General

Self-Reported Factors for Poor Adherence with Hand Hygiene Handwashing agents cause irritation and dryness Sinks are inconveniently located/lack of sinks Lack of soap and paper towels Too busy/insufficient time Understaffing/overcrowding Patient needs take priority Low risk of acquiring infection from patients Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:381-386.

The Inanimate Environment Can Facilitate Transmission ~ Contaminated surfaces increase cross-transmission ~ Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL. X represents VRE culture positive sites

The Environment is Contaminated! In one study, hands of 131 healthcare workers (HCWs) were cultured before, and hands and gloves after, routine care. A mean of 56% of body sites and 17% of environmental sites were VRE positive. After touching the patient and environment, 75% of ungloved HCWs hands and 9% of gloved HCWs hands were contaminated with VRE. After touching only the environment, 21% of ungloved and 0 gloved HCWs hands were contaminated.

Figure 1-1. The World Health Organization’s Five Moments for Hand Hygiene Source: World Health Organization (WHO): WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft): A Summary. Geneva, Switzerland: WHO, 2006. The WHO Five Moments for Hand Hygiene

Indications for Hand Hygiene When hands are visibly dirty, contaminated, or soiled, wash with non-antimicrobial or antimicrobial soap and water. If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands. Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Specific Indications for Hand Hygiene Before: Patient contact Donning gloves when inserting a CVC Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery After: Contact with a patient’s skin Contact with body fluids or excretions, non-intact skin, wound dressings Removing gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Recommended Hand Hygiene Technique Handrubs Apply to palm of one hand, rub hands together covering all surfaces until dry Volume: based on manufacturer Handwashing Wet hands with water, apply soap, rub hands together for at least 15 seconds Rinse and dry with disposable towel Use towel to turn off faucet Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Efficacy of Hand Hygiene Preparations in Killing Bacteria Good Better Best Plain Soap Antimicrobial soap Alcohol-based handrub

Ability of Hand Hygiene Agents to Reduce Bacteria on Hands Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Time Spent Cleansing Hands: one nurse per 8 hour shift Hand washing with soap and water: 56 minutes Based on seven (60 second) handwashing episodes per hour Alcohol-based handrub: 18 minutes Based on seven (20 second) handrub episodes per hour Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208. Alcohol-based handrubs reduce time needed for hand disinfection

Alcohol and Flammability Alcohols are flammable Alcohol-based handrubs should be stored away from high temperatures or flames Europe: fire incidence low U.S.: one report of flash fire Application is key: Let It Dry! Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Gloving Wear gloves when contact with blood or other potentially infectious materials is possible Remove gloves after caring for a patient Do not wear the same pair of gloves for the care of more than one patient Do not wash gloves Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Fingernails and Artificial Nails Natural nail tips should be kept to ¼ inch in length Artificial nails should not be worn when having direct contact with high-risk patients (e.g., ICU, OR) Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Unresolved Issues Routine use of nonalcohol-based handrubs Wearing rings in healthcare settings Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

Summary Alcohol-Based Handrubs: What benefits do they provide? Require less time More effective for standard handwashing than soap More accessible than sinks Reduce bacterial counts on hands Improve skin condition

Universal Precautions Universal means just that: precautions that apply to EVERY patient EVERY time. Sometimes called “Tier One” precautions. Universal (or “standard” ) precautions apply to any situation where the HCW might reasonably come in contact with blood body fluids secretions or excretions non-intact skin mucous membranes

Universal Precautions Hand Washing Wash with soap and warm water when Hands are visibly dirty Contaminated with proteinaceous material Before eating After using the toilet If contact with spores (e.g. C. difficile) is likely to have occurred.

Universal Precautions Alcohol Hand Rubs Use an alcohol hand rub at other times: Before having direct contact with patients After contact with blood, body fluids, excretions, mucous membranes, non-intact skin, or wound dressings. After contact with intact skin (i.e. after taking a BP) If hands will be moving from contaminated body site to a clean body site After contact with inanimate objects near the patient After removing gloves

Universal Precautions Gloves & Gowns Wear gloves when: It can be reasonably anticipated that contact with blood or other potentially infectious materials could occur (mucous membranes, non-intact skin, secretions, excretions) Wear gloves and gowns and face/eye shields when: The nature of anticipated patient interaction indicates contact with blood or body fluids may occur There is a chance of splashes or sprays of body fluids or blood,

Universal Precautions Gloves Remove gloves after providing direct patient care. Do not wear the same pair of gloves in providing care for more than one patient Change gloves if the hands will move from a contaminated body site to a clean body site Always perform hand hygiene after removing gloves!

Universal Precautions Respiratory Hygiene & Cough Etiquette Patients are to cover the nose/mouth when coughing or sneezing. Use tissues to contain respiratory secretions and dispose of in nearest waste container Perform hand hygiene after contacting respiratory secretions and contaminated objects or materials Contain respiratory secretions with procedure or surgical masks Sit at least 3 feet away from others if coughing

Second Tier Precautions Will be considered in a later lecture Includes Droplet, Airborne and Contact precautions Are used for patients KNOWN or SUSPECTED to have serious illnesses transmitted by airborne droplets, large particle droplets or by direct patient contact. See Potter & Perry p. 179 for details if you’re curious now.

PREVENTION IS PRIMARY! Protect patients…protect healthcare personnel… promote quality healthcare!