Artikel 1

INFECTION CONTROL: CAN NURSES IMPROVE HAND HYGIENE PRACTICES?

Jacqueline M. Smith, RN, BN, Dyan B. Lokhorst, RN, CHPCN(C), BN (November, 2009)

University of Calgary, Faculty of Nursing

 Abstract

According to the Community and Hospital Infection Control Association (2009), infection prevention and control must be made up of evidence-based knowledge, and up-to-date skills and implementation practices. In their Infection Prevention Online Course (see website below), they present a series of modules designed in such a manner that all members of the health care team (both professionals and non-professionals) can use to enhance their knowledge in a range of areas in order to “strengthen infection prevention practices even in low-resource settings” (http://meds.queensu.ca/cpd/che/online_courses/infection_control) The purpose of our paper is to help expand their educational efforts by addressing the importance of hand washing in relation to patient safety. Nurses are present in all health care settings and can play a key role in modeling and promoting evidenced- based infection control practices which will ensure the continuation of quality care for patients.

INFECTION CONTROL: CAN NURSES IMPROVE HAND HYGIENE PRACTICES?

Hospital acquired infections have generated a great deal of concern across North America and globally pose a significant threat to population health (Fauci, 2006). The World Health Organization (2009) has recently announced that the HINI influenza is nearing pandemic status. Patient safety is of primary importance to nurses who are present 24 hours a day, 7 days a week in all healthcare settings. Yet the safety of patients is being compromised every day simply by being present in a healthcare setting. According to the Center for Disease Control and Infection CDC (2002), in American hospitals alone, hospital-acquired infections account for an estimated 1.7 million infections and 99,000 associated deaths each year. The startling reality is that studies have shown that most hospital acquired pathogens are transmitted from patient to patient via the hands of healthcare workers (Larsen, 1988). Nurses have hands-on daily contact with their patients and therefore play a vital role in patient safety and infection control. The CDC explains how hand washing is the single most effective way to prevent the spread of infection.

The authors of this paper will highlight the historical roots of nursing involvement in infection control and how it has influenced their practice today. Hand washing, the

one specific aspect of infection control that needs improvement, will be explored. The authors will identify ways in which education and pro-active intervention can increase compliance among nurses and healthcare workers and thereby promote quality of care for the patient.

Background context of nursing and infection control

The relationship between nursing and infection control was first identified by Florence Nightingale in 1854, during the Crimean war, when she served in a military hospital in Scutari, Italy (Kamisky, 2004). The conditions in the hospital were deplorable. Nightingale’s observations in Scutari led her to believe that improving hygienic conditions would decrease the number of deaths. Kamisky (2004) believed that Nightingale, “championed the cause of improved hygiene, food, and living conditions for the hospitalized soldiers… she attacked the hospital conditions and called for basic public health, infection control measures, cleanliness, hygiene and education about the importance of the issue” (p.1 ).  Jean Lawrence, chairperson of the Infection Control Nurses Association (ICNA) believed that Florence Nightingale was probably the first infection control nurse without actually realizing it (Elliott, 2004). Today, nurses are key players in the fight to ensure the survival of infection control practices.

Salient tactics to promote effective infection control practices in hospitals

While not all hospital-acquired infections can be prevented, the vast majority of them can. The chain of transmission of microorganisms consists of three elements: a source of infecting microorganisms, a susceptible host, and a transmission of the microorganism (Canadian Committee on Antibiotic Resistance, 2007). The most basic strategy for prevention of infection is something that most of us learn when we are small children: hand hygiene. Despite the well established relationship between hand washing and infection, numerous studies have indicated that hand washing among all types of healthcare workers is poor (Harris, 2000). Ministry of Health and Long Term Care (2002) believes that correct hand washing is the simple most effective way to prevent the spread of communicable disease. In this section we will present 3 major strategies that can be used to promote effective infection control practices in hospital: (1) Education that promotes the “why and how to” of washing hands properly. (2) Interventionstrategies to promote clean hands in a hospital environment (3) Evaluation tools used to monitor the practice of hand washing.

Education

The relationship between knowledge and power helps to employ and implement strategies to reduce infection control and improve patient safety (WHO, 2005). Educating healthcare workers, clients and families is a vital strategy for effective infection control. There are a variety of educational strategies that can be used to help promote hand washing and infection control:

         Hand hygiene promotion posters can be placed in visible areas of the hospital reminding healthcare workers , patients and visitors to practice proper hand hygiene

         Patient admission videos can be used to teach patients and visitors the importance of practicing hand hygiene and how it is appropriate to ask or remind healthcare workers to practice hand hygiene as well

         Hospital infection control teams can be utilized to provide in-services to healthcare workers regarding the importance of hand hygiene and infection control

         Placing diagrams above sinks that outline the proper way to wash hands with soap and water and  the proper use of hand sanitizers can be helpful

         Instructional hand washing videos can be played on televisions in hospital lounges and waiting rooms

Intervention strategy

Healthcare workers and caregivers often fail to comply with hand washing protocols due to inconvenient access to hand washing utilities or shortage of time to perform this procedure. There are a variety of interventions that can be implemented to increase compliance to hand hygiene and ensure that hands and frequently handled equipment remain as clean as possible in the hospital.

Alcohol based hand rubs with no-touch dispensers should be available in every patient room, outside elevators, in waiting rooms and at staff workstations. The Hand Hygiene Resource Centre at www.handhygiene.org found that when hand sanitizers were placed next to patient’s bed that healthcare workers cleaned their hands significantly more

Automatic sinks should be placed close to the exit of each room. This will increase the likelihood of staff washing their hands between patients

There should be a policy regarding fingernails that are long, artificial or with chipped nail polish. These are reservoirs for bacteria (Gilboy & Howard, 2008)

Rings also are a haven for bacteria. Policies need to be commenced and enforced on the wearing of rings

Staff should be encouraged to wipe their frequently handled stethoscopes between patients and should be discouraged from using cloth covers on their stethoscopes

Equipment that is handled and used by healthcare workers between patients should be cleaned regularly. Gilboy and Howard described the importance of cleaning equipment in the 2008 article, Compliance with Hand Hygiene Guidelines, “cleaning practices for any medical equipment need to be followed 100% of the time” (p.197)

Evaluation

Opportunities to use surveillance activities as strategies to evaluate the effectiveness of hand washing are important and instrumental in evaluating infection control measures. The following are a few examples of evaluation tools:

         Spot checks of hand hygiene compliance can be done with a product called Glo- Germ (www.glo.germ.com) (Gilboy & Howard, 2008). This product demonstrates how well one washes their hands by using a special lamp that shows if something is left on the hands

         A 24 hour observational study of hand washing in a hospital setting during a regular shift can be used to monitor whether hand washing occurred before contact with the patient and following contact with the patient. Posting these results can provide the necessary feedback to the workers to raise their awareness

         A survey of hand washing techniques could include questions such as:  (1) How many times do you wash your hands during a shift? (2) How much time do you spend washing your hands each time they are washed? (3) Do you wash your hands with soap each time? (4) Do you wash your hands between each patient? (5) Do you wash your hands after working with a patient with a cough? (6) Do you wash your hands before changing a dressing?

Conclusion

Hospital acquired infections are a threat to population health and are not going away any time soon. Due to frequent contact between health care workers and patients, pathogens can be transmitted from one patient to another if good quality hand hygiene is not maintained. It is the responsibility of health care workers to keep the patients in their care safe by modeling effective and frequent hand washing practices. A national update from Nurse.com (2009) states that one of the actions needed by nurses to manage HINI flu is frequent hand washing.  Nurses need to have a proactive voice in the promotion of current best practices for hand washing hygiene. The Journal of Hospital infection (2001) explains how multifaceted approaches including a combination of education, written material,  intervention, reminders and continued

performance feedback , can have an important effect on hand washing compliance and rates of hospital-acquired infection. Nurses can take a leadership role in all healthcare settings to foster an organizational culture that promotes and reflects a strong obligation to patient safety through effective hand washing.

References

Canadian Committee on Antibiotic Resistance. (2007). Infection Prevention and Control Best Practices for Long-Term Care, Home and Community Care including Health Care Offices and Ambulatory Clinics.  Retrieved November 15, 2008, from http://www.ccar-ccra.com/english/pdfs/IPC-BestPractices-June2007.pdf

Centers for Disease Control and Prevention. (2002). Guideline for Hand Hygiene in Health-Care Settings.  Morbidity and Mortality Weekly Report, 57(16).

Community and Hospital Infection Control Association. (2009). Online Basic Infection Prevention & Control Course. Retrieved on May 24, 2009 from,  http://meds.queensu.ca/cpd/che/online_courses/infection_control

Domrose, C. (2009). Update: Nurse action needed to manage H1N1 flu. Retrieved May 2, 2009 from,http://include.nurse.com/apps/pbcs.dll/article?AID=/20090428/NATIONAL01/10 5040039

 Elliott, J. (2004). The multi-faceted Lady with the Lamp. Retrieved November 15, 2008,

            from http://news.bbc.co.uk/1/hi/health/3943997.stm

 Fauci, A. (2006). “Pandemic influenza threat and preparedness’ Emerging Infectious Diseases. Retrieved November 10, 2008, from http://www.ncbi.nlm.nih.gov/pubmed/16494721

Gilboy, N., & Howard. P.K. (2008). Compliance with Hand Hygiene Guidelines. Advanced Emergency Nursing Journal, 30(3), 193-200.

Hand Hygiene Resource Centre at www.handhygiene.org

Harris, AD. (2000). A survey on handwashing practices and options of healthcare workers. Journal of Hospital Infection, 45, 318-321.

Kaminsky, P. (2004). Everything is old again: an infection control update. Retrieved May 19, 2009, from:http://web.ebscohost.com.ezproxy.lib.ucalgary.ca/ehost/pdf?vid=9&hid=104&sid=aa70d1d1-e763-4f4d-9e12-e1fd76cfd74d%40sessionmgr107

Larsen, E. (1999). Skin hygiene and infection prevention. Clinical Infectious Diseases, 29, 1287-1295

Naikoba, S. (2001). Increasing handwashing in healthcare workers: the effectiveness of interventions aimed at increasing handwashing in healthcare workers -- a systematic review. Journal of Hospital Infection, 47(3), 173-180.

Ontario Ministry of Health and Long-Term Care. (2002). Hand Washing. Retrieved November 21, 2008, fromhttp://www.health.gov.on.ca/english/public/program/pubhealth/handwashing/handwashing_mn.html

World Health Organization (2009). Who guidelines on hand hygiene in health care (advanced draft): a summary. Retrieved May 2009, from www.who.int/patientsafety/events/05/HH_en.pdf

Acknowledgements

The authors wish to thank the faculty involved in the Nursing 411: Nursing Scholarship distance course at the University of Calgary, notably the Course Coordinator and Course Professor, Dr Carole-Lynne Le Navenec (cllenave@ucalgary.ca), who offered us tremendous support and encouragement.

Copyright© by The University of Arizona College of Nursing; All rights reserved.

http://www.juns.nursing.arizona.edu/articles/fall%202009/infection%20conrol.htm

Artikel 2

Handwashing: Breaking the Chain of InfectionJuly 1, 20000 Comments

Posted in Articles, Handwashing, Hand Hygiene, Hand Antisepsis, Infections, Gloves, Personal Protective Equipment (PPE), Association For Professionals In Infection Control And Epidemiology (APIC),Hygiene, Environmental Hygiene, Barrier Protection, Contact Precautions, Isolation, Standard Precautions, Guidelines & Regulations, Research & Studies, PPE & Standard Precautions

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Handwashing: Breaking the Chain of Infection

By Amy Walker Barrs

This article:

reviews APIC handwashing guidelines. discusses the role of gloves in handwashing. lists strategies for combating dry skin.

Many people consider handwashing to be a matter of common sense when it comes to removing dirt and germs from the hands. In fact, handwashing is more than simple common sense. According to the US Centers for Disease Control (CDC), "handwashing is the single most important procedure for preventing the spread of infection."

The Association for Professionals in Infection Control and Epidemiology (APIC) concurs, stating that "handwashing causes a significant reduction in the carriage of potential pathogens on the hands," and [in healthcare settings it] "can result in reductions in patient morbidity and mortality from nosocomial infection."

APIC Guidelines

The "APIC Guideline for Handwashing and Hand Antisepsis in Health Care Settings" was published in 1995 and supplements guides published by the Association of Operating Room Nurses (AORN), the CDC, and the Food and Drug Administration (FDA). It provides information on skin flora of hands, characteristics of selected antimicrobial agents used on hands, handwashing and surgical scrub techniques, and related aspects of hand care and protection. In addition, recommendations are made regarding healthcare personnel handwashing, personnel hand preparation for operative procedures, and other aspects of hand care and protection.1

While the purpose of this article is not to review the entire Guideline exhaustively, there are several areas that bear repeating, including recommendations on when and how to wash hands and how to choose the best soap for the job.

The decision regarding when handwashing should occur depends on:

The intensity of contact with patients. The degree of contamination that is likely to occur with that contact. The susceptibility of patients to infection. The procedure to be performed.

Healthcare workers come into frequent hand-contact with body secretions that can carry bacteria, viruses, and fungi, which may be potentially infectious. That's one of the reasons APIC recommends handwashing when there is prolonged and intense contact with any patient. APIC further recommends that handwashing be considered necessary before and after situations in which hands are likely to become contaminated, especially when hands have had contact with mucous membranes, blood and body fluids, and secretions or excretions, and after touching contaminated items such as urine-measuring devices.

According to APIC, the choice of plain or antiseptic soap, or of alcohol-based hand rinses, should depend on whether it is important to reduce and maintain minimal counts of colonizing flora (those microorganisms that are considered permanent residents of the skin and are not readily removed by mechanical friction) as well as to remove the contaminating flora mechanically (microorganisms that can be transmitted via skin-to-skin contact unless removed by mechanical friction and soap and water washing or destroyed by the application of an antiseptic handrub).

For general patient care, APIC and the CDC recommend the use of plain, non-antimicrobial soap. However, APIC goes on to note that antiseptic agents are necessary to kill or inhibit microorganisms and reduce the level of microbes still further. Moreover, APIC adds that certain antiseptic agents have the ability to bind to the stratum corneum, resulting in a persistent activity on the skin, which may be desirable to enhance continued antimicrobial activity when it is not possible to wash the hands during prolonged surgical procedures or when continued chemical activity on the skin is advantageous in other settings.

The choice of plain soap, antiseptic soap, or antiseptic handrubs should therefore be based on the degree of hand contamination and whether it is important to reduce and maintain minimal counts of resident flora as well as to remove the transient flora mechanically from the hands of healthcare personnel, according to APIC.

Handwashing Techniques

APIC offers the following handwashing techniques for healthcare workers:

Wet hands with warm running water. Apply handwashing agent (soap) and thoroughly distribute over hands. Vigorously rub hands together for 10 to 15 seconds, generating friction on all surfaces of the

hands and fingers, including thumbs, backs of fingers, backs of the hands, and beneath the fingernails.

Rinse hands thoroughly to remove residual soap then dry using paper towels dispensed from holders that require the user to remove them one at a time.

If the sink does not have foot controls or an automatic shutoff, a paper towel may be used to shut off the faucet to avoid recontaminating the hands.

While there is little evidence to recommend a specific ideal water temperature for effective handwashing, it seems logical to use warm water. Excessively hot water is harder on the skin, dries the skin, and is too uncomfortable to wash for the recommended amount of time. In addition, cold water inhibits the proper lathering of soap.

When using an alcohol-based antimicrobial cleaner, APIC recommends that a vigorous, one-minute rubbing with enough alcohol (3-5ml is generally recommended) to wet the hands completely is the most effective method for hand antisepsis. Failure to cover all surfaces of the hands because of poor technique or use of insufficient amounts of alcohol handrub solution can leave surfaces contaminated. Also, keep in mind that these alcohol handrubs are not designed to remove physical dirt, and therefore should be used with another cleaning agent in the presence of physical dirt.

The Role of Gloves

Protective gloves are routinely worn in healthcare settings as a safety barrier between skin-borne microorganisms and patients. The Occupational Safety & Health Administration (OSHA) in standards published in 1991, requires that gloves be worn whenever there is a reasonable likelihood that hands will be in contact with blood or other potentially infectious material, mucous membranes, or non-intact skin; when performing any vascular access procedure; or when handling contaminated items or surfaces.

Microbial contamination of hands and possible transmission of infection have been reported even when gloves are worn, and studies have shown that handwashing is an important complement to glove use. In fact, APIC and the CDC recommend a soap and water handwash or an antiseptic handrub after gloves are removed.

While gloves offer important protection, constant use of gloves may cause irritant dermatitis due to mechanical irritation from the glove or glove powder, or from chemical agents such as residual soap trapped between the glove and the skin. (The problem of dermatitis is discussed in more detail below.) Some healthcare workers choose powder-free gloves to decrease irritation and the risk of allergies.2 It is important to keep in mind that no glove is 100% resistant to all pathogens.

For general patient care, APIC and the CDC recommend the use of plain, non-antimicrobial soap. However, APIC goes on to note that antiseptic agents are necessary to kill or inhibit microorganisms and reduce the level of microbes still further.For general patient care, APIC and the CDC recommend the use of plain, non-antimicrobial soap. However, APIC goes on to note that antiseptic agents are necessary to kill or inhibit microorganisms and reduce the level of microbes still further.

Barriers to Proper Handwashing

According to APIC, handwashing associated with general patient care occurs in approximately half of the instances in which it is indicated and usually is of shorter duration than recommended. A recent study supports that figure, finding that average handwashing compliance was 48% in a teaching hospital.3 The study concluded that the primary problem with handwashing is laxity of practice and that high workload among healthcare workers was associated with low compliance.

Other factors influencing handwashing behavior include placement of sinks, unacceptable handwashing products, the effect of handwashing on skin condition, and awareness of the importance of handwashing in preventing infection.

The convenient placement of sinks, handwashing products, and paper towels is often suggested as a means of encouraging frequent and appropriate handwashing. Sinks with faucets that can be turned off by means other than the hands (e.g., foot pedals) and sinks that minimize splash can help personnel avoid immediate recontamination of washed hands (Table 1).4

The Dermatitis Dilemma

Dry skin and dermatitis are two conditions linked to frequent handwashing that may affect handwashing compliance among healthcare personnel. In fact, the National Institute for Occupational Safety & Health (NIOSH) states that skin injuries and diseases account for a large proportion of all occupational injuries and diseases. In 1998, dermatological diseases accounted for approximately 19% of all chronic occupational diseases in the US, according to NIOSH. And, that of workers who developed a dermatological disease in 1997, more than 28% lost three to five working days, according to the Bureau of Labor Statistics. In the service industries, which include the health service industry, nearly 18,000 cases of dermatological diseases were reported to the Bureau of Labor Statistics in 1998. Dermatitis is such an important (and until recently, overlooked) issue that NIOSH has made it a top priority in the National Occupational Research Agenda (NORA).

Dermatitis is an inflammation that occurs when an irritating substance comes into contact with the skin, causing an abnormal reaction. Areas of irritated skin may be red, swollen, tender, hot, painful or itchy. In addition, there may be some scaling as the skin heals. Skin affected for several weeks by dermatitis tends to thicken and change to a deeper color. As well as causing pain or discomfort, dermatitis in severe cases can result in long periods away from work.

The APIC Guideline notes that dermatitis in healthcare personnel may place patients at risk because handwashing will not decrease bacterial counts on dermatitic skin, and dermatitic skin contains high numbers of microorganisms. Moreover, the Guideline states that healthcare personnel with dermatitis may be at increased risk of exposure to bloodborne pathogens during skin contact with blood or body fluids because the integrity of the skin is compromised.

Dermatitis may be considered the "Catch-22" of handwashing compliance as it can be caused by the excessive handwashing that healthcare personnel must comply with on a daily basis. The problem is that many skin cleansers do not discriminate between the dirt on the skin surface and the essential oils that protect the skin.

Even given the problems associated with dermatitis, the simple act of handwashing has been an important and enduring element of most infection control programs. And now, more than ever, it is recognized that an effective handwashing program can greatly reduce the risks of cross-contamination.

Sinks that minimize splash can help personnel avoid immediate recontamination of washed hands.

Amy Walker Barrs is the executive director of the Kimberly-Clark Skin Wellness Institute (Roswell, Ga).

References

1 Larson E. APIC guideline for handwashing and hand antisepsis in health care settings. AJIC.1995;4:251-269.

2 Hutchisson B. Gloves: Practical information for healthcare workers. Infect Control Sterlization Technol.March 1999:12-16.

3 Pittet D, Mourouga P, Perneger T. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126-130.

4 Garner J, Favero S. Guideline for handwashing and hospital environmental control. US Department of Health & Human Services 1985; Section 1.

Table 1: Make It Easy to Wash up Right

A sink should be located in or just outside every patient room. More than one sink per room may be necessary if a large room is used for several patients.

If bar soap is used, it should be kept on racks that allow water to drain. Small bars of soap that can be changed frequently should be used.

If liquid soap is used, it should be stored in closed containers, and the dispenser should be replaced or cleaned and filled with fresh product when empty. Liquids should not be added to a partially full dispenser.

Paper towels should be within easy reach of the sink but beyond splash contamination. A "no-touch" dispenser lets users touch only the towels they need and reduces the possibility of hand contamination via soiled levers.

Antimicrobial-containing products that do not require water for use can be used in areas where no sinks are available or in small containers for portability.

Lotions supplied in small, non-refillable containers can be used to help prevent skin dryness and dermatitis. Lotion formulations should be checked for compatibility with antiseptic products and their effect on glove integrity.

Handwashing Protocol

Often handwashing technique leaves much to be desired. It was found, for example, that many anesthesiologists washed only the palms and the backs of their hands, whereas the main contact points are the fingers and the finger tips. Instruction was required to teach them to wash their hands from the fingers to the wrist whereupon the reduction in bacterial counts improved.1 It may be worth thinking about a technique for cleansing damaged hands. The skin on the backs of the hands is often more sensitive to damage than the palmar surface and can become readily chapped. In this condition, it may be better to wash the main contact surfaces of the hands by rubbing together only the palms and fingers including finger pads rather than avoid the handwash because of sore hands.

Chamberlain, et. al.2, based on data with inoculated as well as naturally-occurring bacteria, have questioned the value of typically recommended handwash procedures and of the "perfunctory

handwashes frequently adopted by nursing staff in busy wards." They suggest that experimental evidence should be obtained to support the recommended procedures and to identify the circumstances where they are valuable.

Little attention has been paid to drying as part of the handwashing protocol. Many transient bacteria will not survive drying, and drying is an important component of reducing bacterial numbers during handwashing whether cloth, paper, or warm air was used. Residual moisture on hands after washing has been found to be an important determinant of bacterial transfer.3 We also have observed this for viruses.4 The data presented by Patrick et. al demonstrate that cloth towels dry hands more quickly than warm air when both methods were applied for various periods up to 45 seconds. The longer the time spent drying hands, the fewer bacteria were transferred to representative surfaces. However, even after 45 seconds, bacterial transfer remained above preset levels. Observation of drying times routinely used for cloth towels were 3.5 and 5.2 seconds for males and females, respectively. The corresponding figures for air drying were 17 and 13.3 seconds. Paper towels, often the preferred drying mode in North America, were not included in this study. Although this work was initiated as a result of an observation of an increased touch contamination level of peritoneal dialysis equipment after handwashing, there are widespread implications for many healthcare procedures and infection.

Another study5, which looked at the transfer of bacteria from unwashed and washed hands to contact lenses, demonstrated higher transfer after washing. Bacterial transfer could only be reduced to prewash levels by the application of an alcohol wipe after washing and drying. However, because the study design was different, it is not possible to tell what proportion of the transfer was due to residual moisture.

Careful hand-drying is therefore an important factor, not only in possible transfer of microorganisms to patients but also in their acquisition by hands from patients and from contaminated objects in the patient environment. The contribution of environmental microorganisms to nosocomial infections has been controversial for many years, but we have argued that hand hygiene and sensible environment decontamination should go hand-in-hand. For example, a recent study of environmental contamination in the vicinity of patients colonized or infected with methicillin-resistant Staphylococcus aureus6suggested ready contamination of gloves and possibly hands as well as gowns and uniforms of attendant personnel.

For references, access the ICT Web site.

For a complete list of references click here

http://www.infectioncontroltoday.com/articles/2000/07/handwashing-breaking-the-chain-of-infection.aspx

Artikel 3

Hand hygieneThe control of Healthcare Associated Infections (HCAI) represents a major challenge to hospitals and healthcare providers.

Introduction

Transmission of pathogens on the hands of healthcare workers is the most common cause of cross infection (Damani 1997), occurring directly from patient contact or indirectly via contact with the environment (Epic2 Guidelines 2007).

Hand hygiene is therefore considered to be one of the most important procedures in the prevention of cross contamination and cross infection (Rationale 1).

Studies on hand hygiene compliance amongst healthcare workers suggest that the mean baseline rate ranges from 5 to 81 per cent, with an average of 40 per cent compliance (Boyce and Pittet 2002).

The Trust is committed to increasing compliance to hand washing and has reviewed hand washing agents, paper towel quality and gloves, and is actively promoting education programmes on hand hygiene (Rationale 2).

Parents and children should be taught the importance of good hand hygiene in the home environment as well as in hospital. 

Types of hand wash procedure

1. Social hand wash

Why should a social hand wash be performed? 

Social hand wash is performed to render the hands physically clean and to remove transient micro-organisms. It is an infection control practice with a clearly demonstrated efficacy and remains the cornerstone of efforts to reduce the spread of infection (Larson 1989) (Rationale 3).

When should a social hand wash be performed?

The times that hand hygiene should be performed have been summarised into the “Your 5 Moments for Hand Hygiene”, as these are considered the most fundamental times for the levels of hand hygiene to be undertaken during care delivery and daily routines (National Patient Safety Agency (NPSA) 2009).

Download: Your 5 Moments for Hand Hygiene (PDF, 185 KB) 

Examples of when to perform a social hand wash

Before:

the beginning of the shift

preparing, handling and eating food

donning gloves

any patient contact

clean/aseptic procedures

entering/leaving clinical areas

entering/leaving isolation cubicles

preparing/giving medications

using a computer keyboard in a clinical area

After: 

the end of a shift

any patient contact

bed making

contact with patient surroundings

visiting the toilet

the removal of gloves

hands become visibly soiled

handling laundry/waste

using a computer keyboard in a clinical area

the administration of medications

blood and/or body fluid exposure risk

What solution should be used for performing a social hand wash?

Liquid soap (plain or antimicrobial)

The soap comes in disposable cartridges and must not be re-used or “topped-up” (Rationale 4).

Bar soap should not be used in clinical areas (Rationale 4).  

How should a social hand wash be performed?

Social hand washing should take at least 30 seconds:

Wet hands under running warm water. Dispense one dose of soap into cupped hands. Rub hands palm to palm. Right palm over the back of the other hand with interlaced fingers and vice versa. Palm to palm with fingers interlaced. Back of fingers to opposing palms with fingers interlocked. Rotational rubbing of left thumb clasped in right palm and vice versa. Rotational rubbing, backwards and forwards with clasped fingers of right hand in left

palm and vice versa. Rinse hands with warm water. Dry thoroughly with paper towel (Rationale 5). Cloth towels must not be used

(Rationale 6). Warm air hand dryers may be used in non-clinical areas (Rationale 7).

Turn off taps using a ‘hands-free’ technique (eg elbows). Where this is not possible, the paper towel used to dry the hands can be used to turn off the tap (Rationale 8). 

Dispose of the paper towel without re-contaminating hands. Do not touch bin lid with hands (Rationale 9).

Alcohol gel/foam

This can be used on visibly clean hands as an alternative to a social hand wash. 

Alcohol gel/foam:

Will not remove dirt and organic matter and can only be used when hands are not visibly soiled.

Should not be used prior to handling medical gas cylinders because of the risk of ignition.

Is NOT effective against Clostridium difficile and Norovirus. When caring for a patient with either of these organisms, hands must be washed with soap and water.

Soap and alcohol-based handrub should not be used concomitantly (World Health Organisation (WHO) 2009).

When applying alcohol handrub leave to dry naturally on the skin.

Hands should be washed with soap and water after several consecutive applications of handrub (Epic2 Guidelines 2007) (Rationale 10). 

Download: A poster with the correct hand cleaning techniques  

2. Hygienic hand wash

Why should a hygienic hand wash be performed?

To remove or destroy transient micro-organisms and to substantially reduce resident micro-organisms during times when surgical procedures are performed.

When should a hygienic hand wash be performed?

Before all aseptic procedures on the ward.

What should be used for performing a hygienic hand wash?

An approved antiseptic detergent (eg 4% Chlorhexidine gluconate or 7.5% Povidone iodine).

How should a hygienic hand wash be performed?

See above instructions on ‘How should a social hand wash be performed?’

3. Surgical hand wash

Why should a surgical hand wash be performed?

To remove or destroy transient micro-organisms and to substantially reduce resident micro-organisms during times when surgical procedures are performed. It is intended to decrease the risk of wound infections should surgical gloves become damaged.

When should a surgical hand wash be performed?

Before all surgical/invasive procedures.

What should be used for performing a surgical hand wash?

An approved antiseptic detergent (eg 4% Chlorhexidine gluconate or 7.5% Povidone iodine).

How should a surgical hand wash be performed?

When performing a surgical hand wash, the level of the hands should always remain above the elbows (Rationale 11).

Always use sensor or elbow operated taps (Rationale 8). Apply antiseptic detergent to the hands and wrists and wash for at least one minute

up to the elbow.  A sterile brush may be used for the first application of the day, but continual use is

inadvisable. Using a pre-packed sterile brush, clean under the nails only of both hands. Rinse thoroughly. Apply a second application of antiseptic detergent and wash hands and two thirds of

the forearms with either Povidone iodine for at least one minute, or Chlorhexidine gluconate for at least two minutes.

Rinse thoroughly.  One sterile towel should be used to blot dry the first hand and arm and another

sterile towel for the second hand and arm (Rationale 12).

The use of gloves

The use of gloves does not replace the need for hand hygiene by either hand rubbing or hand washing (WHO 2009).

Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin/mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments. Some procedures not normally requiring gloves may require gloves when infection is present eg eye care (Epic2 2007).

Gloves can have pores that may allow micro-organisms to pass through and hands should be cleaned before and after wearing gloves (Epic2 2007).

Gloves should be single-use and changed between dirty and clean procedures and between patients (Larson 1989) (Rationale 12).

Gloved hands should not be washed or cleaned with alcohol hand rubs, gels or wipes (Walsh 1987) (Rationale 13).

Sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented and alternatives to natural rubber latex gloves must be available (Epic2 2007).

Other aspects of hand hygiene

Artificial fingernails or extenders should not be worn when having direct contact with patients (Rationale 14).

Natural nails should be kept short (tips less than 0.5cm long) (Rationale 15). The wearing of rings and wrist jewellery (including watches) during health care is

strongly discouraged. If religious or cultural influences strongly condition the health care worker’s attitude, the wearing of a simple wedding ring (band) during routine care may be acceptable, but in high-risk settings, such as the operating theatre, all rings and other jewellery should be removed (WHO 2009).

Cuts and abrasions must be covered with waterproof dressings (Rationale 16). Bare below the elbows - in order to ensure that hands can be easily decontaminated,

only clothing that does not go past the elbow should be worn. Suit jackets, long sleeves, wrist watches, bracelets and rings (other than a plain wedding band) should not be worn.

Download the poster: Bare below the elbows 'Bare below the elbows' applies to all clinical staff wearing a uniform, anyone

entering a patient's bed space or room, when having clinical patient contact and anyone entering PICU, NICU or CICU.

'Bare below the elbows' is not required for anyone visiting a ward (with the exception of PICU, NICU or CICU) that does not enter a patient's bed space or room.  

Hand care

Contact dermatitis caused by frequent exposure to soaps and cleaners is the most common form of work-related skin disease in nurses and other healthcare professionals (Health and Safety Exective (HSE) 2007).

Hand care advice:

Always wet hands thoroughly before washing (Rationale 17). Ensure water is warm (neither hot nor cold). Do not use more soap product than recommended by the manufacturer ('One squirt

is enough'). During handwashing, thoroughly rinse off residual soap. Dry hands completely by carefully patting rather than rubbing with a paper towel. Donning gloves while hands are still wet from either washing or applying alcohol gel,

increases the risk of skin irritation. Use emollient creams regularly, especially before breaks and after finishing work.

Ensure all parts of the hand are covered. Check your skin for early signs of dermatitis and report concerns to Occupational

Health (Rationale 18). Early detection can help prevent more serious dermatitis from developing.

Download: Hand Care Plan 

Download: One squirt is enough hand care poster 

Rationale

Rationale 1: Hand washing causes a significant reduction in the carriage of potential pathogens on hands.

Rationale 2: This is in line with the requirements of the NHS Controls Assurance Standards 2000 and the Clinical Negligence Scheme for Trusts Criterion 5.1.6 in 2005.

Rationale 3: Transient microorganisms are located under the surface of the skin and beneath the superficial cells of the stratum corneum. They are termed “transient” because direct contact with other people, equipment or body sites all result in the transfer of microorganisms to and from the hands.

Rationale 4: This increases the risk of contamination.

Rationale 5: These are quicker 7-9 seconds compared to 25.4 seconds with dryers (Taylor 1978). They rub away transient microorganisms and old, dead skin cells loosely attached to the surface of the hands.

Rationale 6: To avoid cross-contamination.

Rationale 7: There is conflicting evidence as to their efficacy in reducing infection (Infection Control Nurses Association 1997).

Rationale 8: To avoid re-contaminating the hands.

Rationale 9: To prevent re-contamination of hands if the lid is touched.

Rationale 10: Some alcohol-based handrubs become less effective following ten consecutive hand hygiene episodes (Sickbert-Bennett et al 2005).

Rationale 11: To prevent contaminated water from the arms running onto the hands.

Rationale 12: To avoid cross-contamination.

Rationale 13: This may spoil the integrity of the glove material (National Association of Theatre Nurses 1998) and organisms may adhere to the material.

Rationale 14: HCWs who wear artificial nails are more likely to harbour Gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing or the use of alcohol gel. (WHO 2009).

Rationale 15: Long sharp fingernails, either natural or artificial, can puncture gloves easily. They may also limit the HCWs performance in hand hygiene practices (WHO 2009).

Rationale 16: To prevent micro-organisms from entering or leaving the wound.

Rationale 17: To minimise irritation.

Rationale 18: To monitor possible side effects of hospital antiseptics/detergents. To provide the individual with alternative cleansing agents.

References

Reference 1: Ayliffe GAJ, Lowbury EJL, Geddes AM, Williams JD (1992) Control of Hospital Infection - A Practical Handbook 3rd Edition. London, Chapman and Hall Medical

Reference 2: Boyce JM, Pittet D (2002) Guidelines for Hand Hygiene in Health-Care Settings: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee . MMWR Recommendations and Reports 51: RR-16.

Reference 3: Damani NN (1997) Manual of Infection Control Procedures. London, Greenwich Medical Media Ltd

Reference 4: Pratt RJ; Pellowe CM; Wilson JA; Loveday HP; Harper P; Jones SRLJ; McDougall C; Wilcox MH (2007) EPIC2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S: 1-64.

Reference 5: Health and Safety Executive (2007) Preventing contact dermatitis at work. London, HSE

Reference 6: Infection Control Nurses Association (1997) Guidelines for Hand Hygiene. ICNA (e-pub) www.icna.co.uk .

Reference 7: Larson E (1995) APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23 (4): 251-69.

Reference 8: Larson E (1989) Hand washing is essential - even when you use gloves. Am J Nursing 89: 934-939.

Reference 9: Walsh B, Blakemore PH, Drabu YJ (1987) The effect of handcream on the antibacterial activity of chlorhexidine gluconate. J Hosp Infect 9 (1): 30-3.

Reference 10: World Health Organisation (2009) WHO guidelines in hand hygiene in health care. France, World Health Organisation

Reference 11: National Association of Theatre Nurses (1998) Principles of safe practice in the peri-operative environment. Harrogate, National Association of Theatre Nurses

Reference 12: National Patient Safety Agency (2009) Your 5 Moments for Hand Hygiene .www.npsa.nhs.uk/cleanyourhands . Viewed on: 02/02/2010

Reference 13: Niffeneger JP (1999) Proper Hand washing Promotes Wellness in Child Care. Journal of Pediatric Healthcare January/February: 26-31.

Reference 14: Paulssen J, Eidem T, Kristiansen R (1988) Perforations in surgeons' gloves. J Hosp Infect 11 (1): 82-5.

Reference 15: Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, Sobsey MD, Samsa GP, Rutala WA (2005)Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control 33 (2): 67-77.

Reference 16: Taylor LJ (1978) An evaluation of handwashing techniques-2. Nurs Times 74 (3): 108-10.

Reference 17: Wilson J (2006) Infection Control in Clinical Practice Third edition. London, Bailliere Tindall

http://www.gosh.nhs.uk/health-professionals/clinical-guidelines/hand-hygiene/

Artikel 4

Compliance with guidelines on effective hand hygiene.3 July, 2007

The National Audit Office (2000) estimated that if all staff followed guidelines

already in place, healthcare-assoc…

AbstractVOL: 103, ISSUE: 19, PAGE NO: 28

Linda Bissett, BN, SPQ infection control, RN, Dip Food Hygiene, is infection control nurse,

NHS Tayside primary care division, Murray Royal Hospital, Perth

The National Audit Office (2000) estimated that if all staff followed guidelines already in

place, healthcare-associated infections (HCAIs) could be reduced by 15-30%. It estimated

that 5,000 people die each year from HCAIs and that they contribute to a further 15,000

deaths. Taking these figures into account, a possible 6,500 lives could be saved each year if

staff took the time to follow standard infection control guidelines including hand hygiene

guidance.

 

 

Hands are the principal route by which HCAI occurs. A thorough handwash (not a surgical

scrub) takes approximately one minute and yet research indicates that conformity to hand

hygiene guidelines rarely exceeds 40% (Widmer, 2000). It is extremely important that all

healthcare professionals are aware that they are responsible for their own practice and can

be held accountable for any act or omission on their part that endangers the well-being of

their patients or colleagues (NMC, 2002). This includes failure to comply with the hand

hygiene guidelines adopted by their employer.

 

 

Hand-hygiene activities

 

Hand-hygiene activities can be broken down into four parts: the washing and rinsing of

hands; thorough drying; use of alcohol-based handrubs/gels; and hand care.

 

 

Washing hands

 

Handwashing using liquid soap and water removes the transient micro-organisms found on

the hands (Damani, 2003). Transient organisms are those picked up by staff when handling

people, surfaces or objects and are easily transferred to the next person or surface touched.

 

 

Washing with an antimicrobial cleanser is recommended before any aseptic technique,

before caring for an immuno-compromised patient or after caring for an infected patient

(Infection Control Nurses Association, 1997). Antimicrobial cleansers remove transient flora

and also reduce the counts of colonising resident bacteria (micro-organisms that live on the

skin and are part of the individual’s normal flora). Antimicrobial cleansers have a residual

action that provides continuous antimicrobial activity for a period.

 

 

Care should be taken to rinse hands carefully before drying.

 

 

Drying hands

 

The ICNA (1997) recommended drying hands thoroughly using good-quality paper towels. It

stated that staff should pat their hands dry to reduce damage to the skin surface. Cloth

towels are not advised within a clinical area as they can become contaminated. If they must

be used then they are for single use only and should be laundered after each use (Damani,

2003).

 

 

Handrubs and gels

 

Alcohol handrubs are less harmful to skin than constant washing and drying (Heeg, 2001).

Rubbing the hands vigorously with an alcohol-based gel/liquid for 30 seconds is an

alternative to handwashing if contact has been of a social nature (Pratt et al, 2001). This

would include, for example, after using the telephone or returning to the ward from another

area.

 

 

Between patient contacts, alcohol-based rubs and gels can be used up to three times if

hands are not visibly dirty or contaminated (ICNA, 1997). Hands should then be thoroughly

washed. Rubs and gels can also be used as a substitute for handwashing if the facilities

available are inadequate, such as in the community. Small individual dispensers of alcohol

gel/rub are available for use in these circumstances. Alcohol-based preparations are not

cleansers; therefore any visible contaminants must be removed using soap and water or

cleansing wipes before using alcohol rubs.

 

 

Bissett (2002) stated that the need for hands to be washed before and after each patient

contact must be emphasised and the proper use of alcohol-based handgels/rubs (where

appropriate) should be encouraged to reduce the risk of spreading antimicrobial-resistant

bacteria. During handwashing any cleansing agent must be applied to all surfaces of the

hands and rubbed vigorously. This can be achieved by following the six-step technique used

for handwashing (RCN, 2000).

 

 

The same technique can be adopted for applying alcohol-based rubs to ensure that the

entire surface area of the hands is rubbed when using these products. Rinsing and drying of

the hands is not necessary after applying alcohol-based rubs/gels but the alcohol product

must be allowed to dry before any task is undertaken.

 

 

Hand care

 

Skin care is an often neglected area of hand hygiene despite the fact that bacterial counts

are known to increase on dry or damaged skin. Healthcare professionals cite the effect on

the skin of constant handwashing/disinfecting as a reason for non-compliance with hand

hygiene guidance. All staff should use a good-quality, aqueous-based handcream to protect

their skin from damage. This should be applied when it will have time to be effective (such

as at lunch breaks, at the end of shifts and before going to bed).

 

 

Reasons for non-compliance

 

Some of the reasons given for non-compliance with hand hygiene guidelines include: heavy

workload; lack of awareness of contamination levels; the lack of availability of cleansing

agents; the lack of or inappropriate placement of wash facilities; and lack of awareness of

hand hygiene policies/guidelines.

 

 

It has also been suggested that staff may be confused by the over-abundance of terms used

to describe the activities covered by the term ‘hand hygiene’. Clear and concise definitions

of terminology may improve understanding and lead to informed decisions by staff on the

product to be used for different tasks. Educating practitioners on the chain of infection and

the actions needed to break the chain may also improve understanding of how infection

spreads, which in turn may highlight the importance of compliance with guidance.

 

 

Staff responsibilities

 

Each staff member is her or his own health and safety representative and, as infection

control issues are a health and safety risk, infection control measures must be risk-assessed.

If there is a lack of facilities or a lack of materials to maintain a safe environment for both

staff and patients then this must be brought to the attention of the infection control team

and managers. If members of staff are not complying with handwashing standards then it is

the responsibility of their peers to encourage them to follow guidelines or to bring this to the

attention of a senior member of staff so that appropriate action can be taken.

 

 

Education and audit

 

To ensure adherence to guidelines and protocols, surveillance and audit of practice must be

carried out and the results fed back to ward managers and employers to facilitate improved

infection control practice.

 

 

Infection control measures, particularly hand hygiene, must be included in all induction

programmes for new staff. Hand hygiene must be part of an ongoing programme of infection

control education for all staff members. Patients, relatives and carers would also benefit

from receiving information on the issue. This could take the form of booklets, posters and

information stands.

 

 

Visitors to healthcare settings should be invited to wash their hands on entering and leaving.

Creating and displaying posters aimed at visitors asking them to wash their hands to help

reduce the risk of infection could contribute to this.

 

 

In the author’s place of work the infection control team carries out hand hygiene awareness

sessions on a regular basis. These have proved popular with both staff and visitors and have

helped to raise awareness of the need for good hand hygiene practice. The team also audits

handwashing skills and handwashing facilities in all areas on an annual basis to ensure

standards remain high and that facilities are appropriate.

 

 

Conclusion

 

Practitioners must be made aware of their responsibility to patients and colleagues alike.

Failure to wash hands before and after patient contact could lead to cross-infection,

increased hospital stays, increased antibiotic therapy and in some cases the death of a

patient. Nurses must take care to avoid any act or omission that could reasonably be

foreseen as likely to cause injury or harm. It is no longer acceptable to blame lack of time,

equipment or materials.

 

 

Next week’s NT Clinical Development article is on adopting marketing techniques to improve

hand hygiene compliance.

 

 

Learning objectives

 

- Understand nurses’ responsibilities in infection control and hand hygiene

 

 

- Be aware of the different hand hygiene activities and understand when and how to carry

them out

 

 

- Know the actions nurses should take when hand hygiene protocols are not followed

 

 

- Know some measures to take to improve awareness of hand hygiene

 

 

Guided learning

 

- Outline nurses’ responsibilities in infection control and hand hygiene

 

 

- Explain the four parts of hand hygiene activities

 

 

- Outline the actions nurses should take when faced with a lack of facilities or colleagues’

failure to comply with local guidelines

 

 

- List some measures that could improve staff and patient awareness of the importance of

hand hygiene

 

 

This article has been double-blind peer-reviewed

http://www.nursingtimes.net/nursing-practice/clinical-zones/infection-control/compliance-with-guidelines-on-effective-hand-hygiene/199210.article