Introduction
The natural flora of the mouth and
the bowel has bacterial concentrations up to 10^10 per ml and are significant
reservoirs of nosocomial or hospital pathogens. In hospitalised patients, the
skin may become colonised with multidrug resistant (MDR) pathogens, and
infected wounds and other lesions are also potential sources of
cross-infecting organisms.
Pathogenic organisms from colonized and infected
patients (and sometimes from the environment) transiently contaminate the
hands of staff during normal clinical activities and can then be transferred
to other patients. Hand transmission is one of the most important methods of
spread of infectious agents in health care facilities. Proper hand hygiene is
an effective method for preventing the transfer of microbes between staff and
patients.
The microbial flora of the skin
consists of resident and transient microorganisms. Resident organisms (e.g.,
coagulase negative staphylococci, diphtheroids) survive and multiply in the
superficial skin layers. The transient microbial flora of the skin consists
of recent contaminants that survive only for a limited period of time. These
microorganisms (e.g., S. aureus, E. coli,
enterococci) may be acquired by contact with the normal flora or colonised or
infected sites of the patient or from the inanimate hospital environment. If
the skin of staff members' hands is damaged, the bacterial count on the skin
becomes higher. There is also a risk for colonisation with bacteria not
normally belonging to the hand flora.
Three levels of decontamination of
hands are recognized.
Social handwashing with plain soap and water removes most transient
microorganisms from moderately soiled hands.
Hygienic handwashing or
disinfection is a
procedure where an antiseptic detergent preparation is used for washing or
hands are disinfected with alcohol (alcoholic rub). This is a more effective
method to remove and kill transient microorganisms.
The distinction between the need
for social handwashing and hygienic hand washing may not always be clear. A
thorough social hand wash may be appropriate if disinfectants are not
available.
Surgical handwashing is performed with the aim of removing and killing the
transient flora and decreasing the resident flora in order to reduce the risk
of wound contamination if surgical gloves become damaged. Agents are the same
as for the hygienic hand wash.
When to wash hands
Social handwashing
- before handling food, eating
- before feeding the patient
- after visiting the toilet.
Hygienic handwashing or alcoholic
rub
- before and after nursing the
patient
- before performing invasive
procedures
- before caring for susceptible
patients (such as the immunocompromised)
- before and after touching
wounds, urethral catheters, and other indwelling devices
- before and after wearing
gloves
- after contact with blood
secretions or else following situations in which microbial contamination
is likely to have occurred
- after contact with a patient
known to be colonised with a significant nosocomial pathogen (such as MRSA,
MDRKlebsiella)
An alcoholic hand rub, ideally
from a dispenser at the patient's bedside is the most efficient and least
time consuming procedure for hand decontamination.
Surgical handwashing
- before all surgical
procedures
Methods
Watches and rings reduce hand
washing/disinfection effectiveness and should be removed during hand hygiene.
Some suggest that they not be worn in patient care.
Social hand washing
In social hand washing, vigorous
and mechanical friction is applied to all surfaces of lathered hands using
plain soap and water for at least 10 seconds using a defined technique (Fig.
4.1). The hands are rinsed under a stream of water and dried with
paper towel. In the absence of running water, a clean bowl of water
should be used. The bowl should be cleaned and water changed between each
use. Alternatively, a drum with a drain spout could be elevated to serve as
running water. Similarly, in the absence of paper towels, a small clean cloth
could be used, but the towel should not be used for extended communal use and
should be discarded after each use into a bag designated for laundering and
reuse.
In places where there is frequent
disruption of water supply, water should be stored in large receptacles
whenever water is available. The water should be free from infectious agents.
Recommended hand
wash agents
Hygienic hand washing/disinfection
Aqueous
- 4% chlorhexidine
gluconate/detergent solution
- Povidone - iodine/detergent
solution containing 0.75% available iodine
Wet hands with clean (running)
water or, if not available, from water in a bowl. Apply cleanser (3-5 ml)
depending on the product or thoroughly lather with soap. Wash the hands
for 10-15 seconds, applying friction over all hand surfaces, rinse and dry as
described above.
Alcoholic
- 0.5% chlorhexidine or
povidone-iodine in 70% isopropanol or ethanol
- 60% isopropanol or 70%
ethanol without antiseptic
Apply not less than 3ml of the
preparation to the hands and rub to dryness (approximately 30 seconds).
Alcohol is more effective than aqueous antiseptic solutions, but a
preliminary wash may be needed for physically soiled hands. Alcohol is an
effective alternative when there is no water or towels readily available and
there is need for rapid hand disinfection. Alcohol products with emollients
added will cause less skin irritation and drying to hands (1-3% glycerol).
Surgical hand washing/disinfection
Agents for surgical hand washing
are the same as for the hygienic hand wash. The difference is the time of
scrub that is increased to 2-3 min and should include wrists and forearms. If
an alcoholic preparation is used, two applications of 5ml each rubbed to
dryness are suggested.
- Sterile disposable or
autoclavable nailbrushes may be used to clean the fingernails only, but
not to scrub the hands.
- A brush should only be used
for the first scrub of the day.
- After hand washing with soap
and water, a hand rub with an alcoholic base formulation (70%) should be
used if possible. This enhances the destruction or inhibition of
resident skin flora.
- Sterile towels should be used
to dry the hands thoroughly after washing and before alcohol is applied.
Important Points to
Note
- When bar soap is in use, it
should be kept dry to prevent contamination with microorganisms that
grow in moist conditions.
- Liquid soap dispensers should
be regularly cleaned and maintained.
- Gloves should not be regarded
as a substitute for hand hygiene. A glove is not always a complete
impermeable barrier (20-30% of surgical gloves are punctured during
surgery). However, gloves reduce very substantially the number of
microorganisms being transferred to the patient or to the HCW who is
wearing the gloves. Gloves also provide some protection against the
transmission of blood-borne viruses.
- In an epidemic situation,
hand hygiene and the use of gloves are important protective measures to
prevent the transmission of infectious agents to susceptible patients or
staff. The same glove must not be worn from one patient to another
patient, or between clean and dirty procedures on the same patient.
- An alcoholic rub or hand wash
should be performed after removing gloves and before sterile gloves are
worn.
In areas where gloves are not
readily available, latex gloves can be washed with soap and water, dried,
powdered, sterilized or high level disinfected and reused. Sterilisation is
preferable for surgical procedures.
Minimal requirements
- Watches and rings reduce hand
washing effectiveness and should be removed.
- Wash hands with soap and
water and dry thoroughly with a clean towel at the start of a clinical
shift or if hands become grossly soiled.
- Decontaminate hands with a
hand disinfectant or alcoholic rinse or rub between each patient
contact.
- Perform a surgical scrub
before each operation.
- Wear gloves as necessary to
reduce transfer of organisms to patient and to reduce transmission of
blood borne viruses.
Bibliography
- Standard principles for
preventing hospital-acquired infections. Journal of Hospital
Infection 2001;47(Suppl):S21-S37.
- Guideline
for Hand Hygiene in Healthcare Settings - 2002. MMWR 2002;51(RR-16):1-44.
|