PREVENTION OF WOUND INFECTION USING PROPER HAND

DISCIPLINES

Dee May RGN, DMSQueens Medical CentreNottingham, England

PREVENTION OF WOUND INFECTION USING PROPER HAND-WASHING

DISCIPLINES

Dee May RGN, DMSQueens Medical CentreNottingham, England

Approx 20% of all hospitaloccur in surgical wounds

(Meers 1981; Haley 1985)

Prospective surveillance shows an overallsurgical wound infection rate of < 5%

(Cruse and Foord 1973, 1980, 1992)

Approx 20% of all hospital-acquired infectionsoccur in surgical wounds

(Meers 1981; Haley 1985)

Prospective surveillance shows an overallsurgical wound infection rate of < 5%

(Cruse and Foord 1973, 1980,

Acute and Chronic Wounds

Acute wounds are:- less heavily colonised with micro- produced on healthyevent e.g. surgery- heal well if the wound is well vascularised- infection delays normal healing and this may lead to an acute wound becoming chronic

Acute and Chronic Wounds

less heavily colonised with micro-organismshealthy tissue by a traumatic

heal well if the wound is well vascularisedinfection delays normal healing and this may

lead to an acute wound becoming chronic

Acute and Chronic Wounds (2)

Chronic wounds are:- rarely, if ever, sterile- may be heavily colonised with microdepending on: depending on:

- length of time wound has been present- underlying patient risk factors

e.g. vascularitymetabolic impairment

e.g. diabetes

Acute and Chronic Wounds (2)

may be heavily colonised with micro-organisms

length of time wound has been presentunderlying patient risk factors

vascularitymetabolic impairment

e.g. diabetes

Post- surgical infection rates3 prospective studies by Cruse and Foord

Clean1.4

Clean-contaminated 8.9Clean-contaminated 8.9

Contaminated13.3

Dirty 38.3

All Wounds 4.8

surgical infection rates3 prospective studies by Cruse and Foord

1973 1980 1992

1.8 1.5

8.9 7.7 6.38.9 7.7 6.3

21.5 15.2

38.3 40.0 39.9

4.8 4.7 4.4

Potentially pathogenic bacteria commonly found in wounds

Staphylococcus aureusEscherichia coliProteus Enterococcus fuecalisStreptococcus pyogenesBacteroids KlebsiellaAcinetobacter anitratusPseudomonas aeruginosa

Potentially pathogenic bacteria commonly found in wounds

Staphylococcus aureusEscherichia coliProteus speciesEnterococcus fuecalisStreptococcus pyogenesBacteroids species Klebsiella speciesAcinetobacter anitratusPseudomonas aeruginosa

Wound Classification- Clean Operations

Gastro-intestinal, genitourinary and respiratory tracts intact. No inflammation encountered. Asepsis maintained maintained

- e.g. varicose vein surgery.

- Clean-contaminated Operations

Viscus opened but with minimal spillagee.g. elective cholecystectomy.

Wound Classification

intestinal, genitourinary and respiratory tracts intact. No inflammation encountered. Asepsis

e.g. varicose vein surgery.

contaminated Operations

Viscus opened but with minimal spillagee.g. elective cholecystectomy.

Wound Classification(2)

- Contaminated OperationsGross spillage from an opened viscus.Acute inflammation without pus.Traumatic wound < 4 hours old. Breach in asepsis.

e.g. appendicitise.g. appendicitis

- Dirty OperationsPus encountered or perforation.Traumatic wound > 4 hours old.

e.g. perforated diverticulum

Council 1964)

Wound Classification(2)

Gross spillage from an opened viscus.Acute inflammation without pus.Traumatic wound < 4 hours old. Breach in asepsis.

Pus encountered or perforation.Traumatic wound > 4 hours old.

(National Research

Routes of spread of microorganisms causing wound infection

- handsContact

- equipment etc.

- droplet nucleiAirborne

- skin scales

Blood-borne

Routes of spread of micro -organisms causing wound infection

hands

equipment etc.

droplet nuclei

skin scales

Prevention of Wound Infection- minimise pre-operative stay- reduce skin shaving- adequate skin preparation- high quality surgical technique- antibiotic prophylaxis - clean operating environment and air filtration - sterile equipment- protective clothing- closed vacuum drainage of wound- optimum wound dressing- aseptic technique- HAND WASHING

Prevention of Wound Infectionoperative stay

adequate skin preparationhigh quality surgical technique

clean operating environment and air filtration

closed vacuum drainage of woundoptimum wound dressing

Ignaz Semmelweis 1847Hungarian Obstetrician

Reduced puerperal fever death rate

from 11% to 1%

by introducing hand

Ignaz Semmelweis 1847Hungarian Obstetrician

Reduced puerperal fever death rate

from 11% to 1%

by introducing hand-washing

Resident Hand Flora

Characteristics:- micro-organisms protect skin- survive and multiply on skin- not easily removed by scrubbing- not easily removed by scrubbing- inactivated by topical antimicrobial agents- can cause infection when enter throughbreaks in the skin - “invasiveness”

- can rapidly become highly pathogenic

Resident Hand Flora

organisms protect skinsurvive and multiply on skinnot easily removed by scrubbingnot easily removed by scrubbinginactivated by topical antimicrobial agentscan cause infection when enter through

“invasiveness”can rapidly become highly pathogenic

Resident Micro

Staphylococcus epidermidismicrococcimicrococcidiphtherroidsanaerobic coccipropionibacteria

Resident Micro -organisms

Staphylococcus epidermidis

Transient hand flora

Characteristics:

- loosely attached to skin surface- loosely attached to skin surface- usually removed with friction, soap and water- acquired by direct contact- most abundant around fingertips- an important cause of cross infection

Transient hand flora

loosely attached to skin surfaceloosely attached to skin surfaceusually removed with friction, soap and wateracquired by direct contactmost abundant around fingertipsan important cause of cross infection

Transient micro

Staphylococcus aureus

Streptococci

Gram-negative bacilli including

Escherichia coliPseudomonas

Viruses

Transient micro -organisms

Staphylococcus aureus

negative bacilli including

All micro-organisms found on handsare capable of colonising and infectingwounds.Microbial counts usually increase inMicrobial counts usually increase inwarm and moist conditions:

- under gloves- beneath rings

organisms found on handsare capable of colonising and infecting

Microbial counts usually increase inMicrobial counts usually increase inwarm and moist conditions:

under glovesbeneath rings

Gram Negative Bacilli Colonising Skin under Wedding Rings

Organisms No. of Staff

Ent. cloacae 10Kleb. pneumoniae 5Kleb. pneumoniae 5Acinet. calcoaceticus 3Ps. aeruginosa 2Serratia marcescens 1Proteus mirabilis 1Prov. stuartii 1

Gram Negative Bacilli Colonising Skin under Wedding Rings

No. of Staff CFU’s per swab

10 - 24,00010 - 2,200,00010 - 2,200,000

110 - 560,0007,200 - 40,000

48,00050

14,000

Hoffmann et al 1985

Jewellery esp. rings

- Total bacterial counts are higher

- Handwashing still removes bacteria under- Handwashing still removes bacteria underrings

- Difficulty donning gloves

- Gloves may tear

Jewellery esp. rings

Total bacterial counts are higher

Handwashing still removes bacteria underHandwashing still removes bacteria under

Difficulty donning gloves

Nails, nail polish, artificial nails

Nails should be kept short.

Artificial nails may increase microbial load.

Thorough, effective handwashing difficult.

Theatre staff should not wear artificial nails.

Clear nail polish only.

Nails, nail polish, artificial nails

Nails should be kept short.

Artificial nails may increase microbial load.

Thorough, effective handwashing difficult.

Theatre staff should not wear artificial nails.

Gloves

Gloves are not a substitute for handwashing.Massive increase in use in recent years.Hand contamination remains possible.Handwashing after glove removal essential andHandwashing after glove removal essential andbefore sterile glove use.

Hypersensitivity to latex increasing.Gloves must be changed:- between clean and dirty procedures- between patients

Gloves

a substitute for handwashing.Massive increase in use in recent years.Hand contamination remains possible.

glove removal essential andglove removal essential andsterile glove use.

Hypersensitivity to latex increasing.Gloves must be changed:

between clean and dirty procedures

Gloves (2)

Glove quality very variable

Beware re-use of disposable gloves.

If absolutely necessary, latex gloves can be washed and dried, powdered and reavailability is scarce.

Gloves (2)

Glove quality very variable

use of disposable gloves.

, latex gloves can be washed and dried, powdered and re-used where their

Handwashing

Mechanical

- removes soil and debris with abrasive action

ChemicalChemical

- uses antimicrobial chemical agents to destroy or suppress growth of micro-organisms

- chemical agents are:- cidal or- static

Handwashing

removes soil and debris with abrasive action

uses antimicrobial chemical agents to destroy or organisms

Choice of Handwashing Agents

Dependent on:

- task to be undertaken- task to be undertaken

- inherent characteristics

- type and spectrum of activity

Choice of Handwashing Agents

task to be undertakentask to be undertaken

inherent characteristics

type and spectrum of activity

Handwashing Agents

Soap and Water

Antiseptic handwashes and water

Alcohol hand-rubs

Handwashing Agents

Soap and Water

Antiseptic handwashes and water

rubs

Soap and Water

“Should be used for handwashingunless otherwise indicated”unless otherwise indicated”

Centers for Disease Control 1985

Soap and Water

“Should be used for handwashingunless otherwise indicated”unless otherwise indicated”

Centers for Disease Control 1985

Active Ingredients in Antimicrobial Agents

- alcohols

- iodophors

- chlorhexidine gluconate

- triclosan

- chloroxylenol (pcmx)

- hexachlorophene

Active Ingredients in Antimicrobial Agents

chlorhexidine gluconate

chloroxylenol (pcmx)

hexachlorophene

Alcohols (70%

- Inexpensive- Do not require water or facilities- but will not remove dirt or debris- Provide rapid and greatest reduction in microbial

countscounts- but no residual activity- Dry and irritate skin- Irritation reduced by adding emollients- Standard scrub solution in some European countries- Volatile and flammable

Alcohols (70% -90%)

Do not require water or facilitiesbut will not remove dirt or debrisProvide rapid and greatest reduction in microbial

Irritation reduced by adding emollientsStandard scrub solution in some European countries

Iodophors

e.g. povidone-iodine

- used primarily for surgical scrubbing- wide range of microbial activity- wide range of microbial activity- rapidly neutralised in presence of organic

material e.g. blood- cause skin irritation and hypersensitivity

Iodophors

used primarily for surgical scrubbingwide range of microbial activitywide range of microbial activityrapidly neutralised in presence of organic

cause skin irritation and hypersensitivity

Chlorhexidine gluconate

- wide range of microbial activity

- initially slow acting

- but persistent chemical activity (up to 6 hours) - but persistent chemical activity (up to 6 hours)

- less irritating than alcohols or iodophors

- not significantly affected by organic material

- available in combination with alcohol as ahighly-effective hand-rub

Chlorhexidine gluconate

wide range of microbial activity

but persistent chemical activity (up to 6 hours) but persistent chemical activity (up to 6 hours)

less irritating than alcohols or iodophors

not significantly affected by organic material

available in combination with alcohol as arub

Triclosan

- wide range of bacterial activity

- excellent residual activity

- minimally affected by organic material egblood

- commonly used in commercial soaps

- more data needed

Triclosan

wide range of bacterial activity

excellent residual activity

minimally affected by organic material eg

commonly used in commercial soaps

Chloroxylenol

(Para-chloro-meta

- less active than chlorhexidine gluconate

- reasonable residual activity

- minimally affected by organic material

Chloroxylenol

meta-xylenol)

less active than chlorhexidine gluconate

reasonable residual activity

minimally affected by organic material

Hexachlorophene

- inferior microbial activity

- potentially toxic

- slow-acting

- minimally affected by organic material

- must not be used on broken skin

Hexachlorophene

inferior microbial activity

minimally affected by organic material

be used on broken skin

Emollients(Hand lotion or cream)

- highly effective in protecting skin from excessivedrying or cracking

- however, may reduce or neutralise effect ofantimicrobial agents

- container can become contaminated

- essential to consider possible interactions beforepurchase

Emollients(Hand lotion or cream)

highly effective in protecting skin from excessive

however, may reduce or neutralise effect of

container can become contaminated

essential to consider possible interactions before

Summary of Handwashing Agents

Most widely used agents are:

- chlorhexidine gluconate

- alcohol

- povidone iodine

Summary of Handwashing Agents

Most widely used agents are:

chlorhexidine gluconate

povidone iodine

Reasons for Noncompliance with Handwashing- insufficient time available between tasks

- inconvenience/lack of facilities

- perceived lack of need

- poor skin condition resulting from repeatedhandwashing or harsh products

AlsoCultural factorslack of educationlack of role models

Reasons for Noncompliance with Handwashinginsufficient time available between tasks

inconvenience/lack of facilities

poor skin condition resulting from repeatedhandwashing or harsh products

Other Considerations

Soap- bar soap

keep dry (magnet, ring, string)

- liquid soap dispensers- liquid soap dispensersideally cartridge useotherwise clean nozzles regularly

- antiseptic soap dispensersideally wall-mounted and elbow

should be sterile and disposable with ameasured dose

Other Considerations

keep dry (magnet, ring, string)

liquid soap dispensersliquid soap dispensersideally cartridge useotherwise clean nozzles regularly

antiseptic soap dispensersmounted and elbow-operated

should be sterile and disposable with ameasured dose

Further Considerations

- preferably use a separate sink for handwashing.

- elbow operated taps if possible.

- paper towels are best method of drying hands.

- nail brushes should ideally be single use.

- handwash dispensers should be wallelbow-operated pump

Further Considerations

preferably use a separate sink for handwashing.

elbow operated taps if possible.

paper towels are best method of drying hands.

nail brushes should ideally be single use.

handwash dispensers should be wall-mounted with

Limited/Restricted Resources In absence of running water:

- clean bowl of water change water after each use

- drum with a spout- drum with a spoutelevate to serve as running water

- store water in large clean receptacles whenever a

water supply is available

- ensure water is pathogen-consider chlorination/filtration/boiling

Limited/Restricted Resources In absence of running water:

change water after each use

elevate to serve as running water

store water in large clean receptacles

water supply is available

-free e.g. choleraconsider chlorination/filtration/boiling

Limited Resources

In absence of paper towels:

- clean cloth (12” x 12”)single person use and use once only launder after use

- air dryerspreferably non-touch

Limited Resources

In absence of paper towels:

clean cloth (12” x 12”)single person use and use once only

touch

“Hand-washing using an appropriatetechnique covering all surfaces ... atthe right time is more important thanthe agent used or the length of timethe agent used or the length of timeof handwashing”

washing using an appropriatetechnique covering all surfaces ... atthe right time is more important thanthe agent used or the length of timethe agent used or the length of time

Ayliffe 1992

Optimum Handwashing Technique(social and hygienic wash)

Remove jewellery if possible. Roll back sleeves.

Wet hands under running water.

Apply soap to all areas of hands.

Rub hands together vigorously and cleanse all areas of

hands and wrists.

Keep hands lower than elbows and do not touch equipment.

Rinse hands thoroughly under running water.

Dry hands thoroughly.

Optimum Handwashing Technique(social and hygienic wash)

Remove jewellery if possible. Roll back sleeves.

Rub hands together vigorously and cleanse all areas of

Keep hands lower than elbows and do not touch equipment.

Rinse hands thoroughly under running water.

Surgical Scrub Technique

Remove all jewellery.

Wet hands under running water.

Wash hands to remove soil and debris.Wash hands to remove soil and debris.

Using antimicrobial agent and nail sponge/brush, clean undernails. Discard sponge/brush.

Scrub all surfaces of hands, wrists and forearms up to elbows.

Keep hands higher than elbows.

Surgical Scrub Technique

Wash hands to remove soil and debris.Wash hands to remove soil and debris.

Using antimicrobial agent and nail sponge/brush, clean under

Scrub all surfaces of hands, wrists and forearms up to elbows.

Surgical Scrub Technique (2)

If there is any contact with unclean surfaces during scrubbing,restart procedure with a fresh sponge/brush.

Once an area has been cleaned, do area again.area again.

Rinse hands and arms thoroughly. Avoid wetting clothes.

Dry all areas with sterile cloth or towels.

Surgical Scrub Technique (2)

If there is any contact with unclean surfaces during scrubbing,restart procedure with a fresh sponge/brush.

Once an area has been cleaned, do not return to the cleaned

Rinse hands and arms thoroughly. Avoid wetting clothes.

cloth or towels.

Hand DryingWet surfaces

- encourage multiplication of microtransfer micro-organisms more effectively than dry

High risk of contamination:communal hand towelscommunal hand towelsroller towels

Warm air dryers:cycle time often inadequatecan be a source of crossresearch is scanty

Hand Drying

encourage multiplication of micro-organismsorganisms more effectively than dry

cycle time often inadequatecan be a source of cross-infection

TYPES OF HAND CARE

Type Objective

Handwash Remove soil and transientmicro-organisms

Hand antisepsis Remove or destroy transientmicro-organismsmicro-organisms

Surgical hand Remove or destroy transientscrub micro-organisms and reduce

resident flora

APIC Guidelines 1995

TYPES OF HAND CARE

Method

Remove soil and transient Soap or detergent forat least 10-15 seconds

Remove or destroy transient Antimicrobial soap/detergent/alcohol-baseddetergent/alcohol-basedhand rub for at least 10-15seconds

Remove or destroy transient Antimicrobial soap/detergentorganisms and reduce with brush to achieve friction

for at least 2 minutes OR alcohol-based preparation forat least 20 seconds

How do I know which procedure to use?

Handwash Antisepsis

* before and after routine * before performing invasive procedurespatient contact * before care of susceptible patients

* before and after contact with wounds* before handling food or invasive devices (e.g. IV cannula)

* after situations where contamination of* after using toilet hands with blood or body fluids is likely* after using toilet hands with blood or body fluids is likely

to occur* whenever hands are * after caring for patients with a known

soiled infection or colonised with microorganisms of significance (e.g. resistantstrains)

* between contact with different patientsin high-dependency units

How do I know which procedure to use?

Surgical Scrub

* before performing invasive procedures * prior to any surgical* before care of susceptible patients (operative)* before and after contact with wounds procedure

or invasive devices (e.g. IV cannula)* after situations where contamination of

hands with blood or body fluids is likelyhands with blood or body fluids is likely

* after caring for patients with a knowninfection or colonised with micro-organisms of significance (e.g. resistant

* between contact with different patientsdependency units