Infectin Preventin & Cntrl Manual 2. HAND HYGIENE Hand hygiene (HH) is a general term referring t any actin f hand cleaning. Hand hygiene relates t the remval f visible sil and remval r killing f transient micrrganisms frm the hands while maintaining the gd skin integrity resulting frm a hand care prgram. HH includes surgical hand antisepsis. Hands f HCWs are the mst cmmn vehicle fr the transmissin f micrrganisms frm patient t patient, frm patient t equipment and the envirnment, and frm equipment and the envirnment t the patient. Transmissin f rganisms by hands f HCWs between patients can result in healthcare-assciated infectins (HAIs). During the delivery f health care, the HCW s hands cntinuusly tuch surfaces and substances including inanimate bjects, patient s intact r nn-intact skin, mucus membranes, fd, waste, bdy fluids and the HCW s wn bdy. With each hand-t-surface expsure a bidirectinal exchange f micrrganisms between hands and the tuched bject ccurs and the transient handcarried flra is thus cntinuusly changing. In healthcare settings, hand hygiene is the single mst imprtant way t prevent infectins. Hand hygiene is a cre element f patient safety fr the preventin f infectins and the spread f antimicrbial resistance. There are tw methds f perfrming hand hygiene: Alchl-Based Hand Rub (ABHR): Use f alchl-based hand rub (ABHR) has been shwn t reduce healthcareassciated infectin rates ABHR is the preferred methd fr decntaminating hands. ABHR is faster and mre effective than washing hands (even with an antibacterial sap) when hands are nt visibly siled. ABHRs: Prvide fr a rapid kill f mst transient micrrganisms Are nt t be used with water Cntain emllients t reduce hand irritatin Are less time cnsuming than washing with sap and water Allw hands t dry cmpletely befre tuching the patient r their envirnment/equipment fr the ABHR t be effective and t eliminate the extremely rare risk f flammability in the presence f an xygen-enriched envirnment r static electricity Efficacy f ABHRs The efficacy f the ABHR depends n the quality f the prduct, the amunt f prduct used, the time spent rubbing, and the hand surface rubbed ABHR shuld nt be used with water, as water will dilute the alchl and reduce its effectiveness ABHR shuld nt be used after hand washing with sap and water as it will result in mre irritatin f the hands ABHRs available fr healthcare settings range in cncentratin frm 60 t 90% alchl. Cncentratins higher than 90% are less effective because prteins are nt denatured easily in the absence f water. 4.1
Infectin Preventin & Cntrl Manual Hand wipes impregnated with antimicrbials r sap may be used t remve visible sil and/r rganic material, but are nt a substitute fr alchl-based hand rub r antimicrbial sap. This is because they are nt as effective at reducing bacterial cunts n HCWs hands. Hand wipes may ONLY be cnsidered as an alternative t washing hands with plain sap and water (when hands are visibly siled) in settings where a designated hand washing sink is nt available r when the hand washing sink is nt satisfactry (e.g., cntaminated sink, sink used fr ther purpses, n running water, n sap). Fllw use f wipes in this instance (when hands are visibly siled) with an ABHR. Hands shuld be washed nce a suitable sink is available. At the present time, there is n evidence fr the efficacy f nn-alchlic, waterless antiseptic agents in the healthcare envirnment. Nn-alchlic prducts have a quaternary ammnium cmpund (QAC) as the active ingredient, which has nt been shwn t be as effective against mst micrrganisms as ABHR r sap and water. QACs are prne t cntaminatin by Gram-negative rganisms. QACs are als assciated with an increase in skin irritancy. Nn-alchl-based waterless antiseptic agents are nt recmmended fr hand hygiene in healthcare settings and shuld nt be used. Hand washing: Hand washing with sap and running water must be perfrmed when hands are visibly siled. Antimicrbial sap may be cnsidered fr use in critical care settings such as intensive care units and burn units but is nt required and nt recmmended in ther care areas. Bar saps are nt acceptable in healthcare settings except fr individual patient persnal use. In this case, the sap shuld be supplied in small pieces that are single patient use, and the bar must be stred in a sap rack t allw drainage and drying. It shuld be discarded n patient discharge. Efficacy f Saps Plain saps act n hands by emulsifying dirt and rganic substances (e.g., bld, mucus), which are then flushed away with rinsing. Antimicrbial agents in plain saps are nly present as a preservative Antimicrbial saps have residual antimicrbial activity and are nt affected by the presence f rganic material Disadvantages f antimicrbial sap include: Antimicrbial saps are harsher n hands than plain saps and frequent use may result in skin breakdwn; and Frequent use f antimicrbial sap may lead t antibitic resistance Hand hygiene with crrectly applied alchl-based hand rub kills rganisms in secnds. Hand hygiene with sap and water dne crrectly physically remves rganisms. Care Envirnments The care envirnment is the space arund a patient that may be tuched by either the patient r the healthcare wrker. Tw different envirnments: Healthcare envirnment/zne Envirnment beynd the patient s immediate area. In a single rm this is utside the rm. In a multi-bed rm this is everything utside the patient s bed area Patient envirnment/zne: the patient s area 4.2
Infectin Preventin & Cntrl Manual In a single rm this is everything in the patient s rm In a multi-bed rm this is the area inside the patient s curtain In an ambulatry setting, the patient envirnment is the area that may cme int cntact with the patient within their cubicle In an Emergency department cubicle it is the patient stretcher and the equipment in clse prximity used in the patient s care In a nursery/nenatal and intermediate care setting, the patient envirnment includes the inside f the bassinette r islette, the equipment utside the bassinette r islette used fr that infant (e.g., ventilatr, mnitr), as well as an area arund the infant (i.e., within apprximately 1 metre/ 3 feet) If the patient bathrm is used fr hand hygiene, avid cntaminatin f hands with ptentially cntaminated surfaces and bjects. Indicatins and Mments fr Hand Hygiene during Health Care Activities When shuld hand hygiene be perfrmed? A hand hygiene indicatin pints t the reasn hand hygiene is necessary at a given mment. There may be several indicatins in a single care sequence r activity. Hand hygiene shall be perfrmed befre and after any direct cntact with a patient r patient equipment, between prcedures n the same patient, and befre cntact with the next patient. While all indicatins fr hand hygiene are imprtant, there are sme essential mments in healthcare settings where the risk f transmissin is greatest and hand hygiene must be perfrmed. Essential HH indicatins can be simplified int 4 mments fr training: THE 4 MOMENTS FOR HAND HYGIENE: 1. BEFORE INITIAL PATIENT/PATIENT ENVIRONMENT CONTACT When? Clean yur hands when entering a patient care envirnment Befre entering the patient/treatment/exam rm Befre tuching patient (e.g., shaking their hand, helping the patient mve arund) Befre tuching any bject r furniture in the patient s envirnment (e.g., stretchers, wheelchairs, adjusting an IV, silencing a pump) Why? T prtect the patient and their envirnment frm harmful micrrganisms carried n yur hands. 2. BEFORE ASEPTIC/CLEAN PROCEDURES When? Clean yur hands immediately befre any aseptic prcedure Perfrming invasive prcedures Handling dressings r tuching pen wunds Preparing and administering medicatins Preparing, handling, serving r eating fd Feeding a patient Shifts and breaks Why? T prtect the patient frm harmful micrrganisms, including his/her wn micrrganisms, entering his r her bdy. 3. AFTER BODY FLUID EXPOSURE RISK 4.3
Infectin Preventin & Cntrl Manual When? Clean yur hands immediately after an expsure risk t bld and bdy fluids, nnintact skin, and/r mucus membranes (and after glve remval). Cntact with bld and bdy fluids Cntact with items knwn r cnsidered t be cntaminated Prcedures n the same patient where siling f hands is likely, t avid crsscntaminatin f bdy sites Oral care, wund care, patient tileting Remval f glves Persnal use f tilet r wiping nse/face Feeding a patient Befre and after shifts and breaks Why? T prtect yurself and the healthcare envirnment frm harmful patient micrrganisms. 4. AFTER PATIENT/PATIENT ENVIRONMENT CONTACT When? Clean yur hands when leaving the patient/patient envirnment. After tuching patient t assist with any tasks (e.g., helping a patient mbilize; giving a massage; taking pulse, bld pressure, chest auscultatin, abdminal palpatin) r After tuching any bject r furniture in the patient s envirnment (e.g., changing bed linen, perfusin speed adjustment, alarm mnitring, clearing the bedside r verbed table) Why? T prtect yurself and the healthcare envirnment frm harmful micrrganisms. Risk is imprtant in making decisins f when t clean hands. Immediately after (and immediately befre) requires hand hygiene is pssible at pint f care. Hand hygiene with pint f care alchl-based hand rub (ABHR) is the standard f care expected f all HCWs, in all healthcare settings. Busy HCWs need access t hand hygiene prducts where patient/patient envirnment cntact is taking place. Prviding ABHR at the pint f care (e.g., within arm s reach) is an imprtant system supprt t imprve hand hygiene. Pint f care refers t the place where three elements ccur tgether: The patient The healthcare wrker Care ptentially invlving cntact is taking place The pint f care (POC) cncept refers t a hand hygiene prduct (e.g., alchl-based hand rub) which is easily accessible t HCWs by being as clse as pssible, e.g., within arm s reach (as resurces permit) t where patient cntact is taking place. Pint f care prducts shuld be available at the required mment, withut leaving the patient envirnment. This enables HCWs t quickly and easily fulfill the 4 Mments fr Hand Hygiene. Pint f care can be achieved in a variety f methds. (e.g., ABHR attached t the bed, wall, equipment carried by the HCW). Fcusing n a single patient, the healthcare setting is divided int tw virtual gegraphical areas: the patient envirnment/zne and the healthcare envirnment/zne. The term patient zne refers t the space that cntains the patient, as well as the immediate surrundings and inanimate surfaces in cntact with the patient (e.g., bed rails, bedside tables, bed linens, infusin tubing, and ther medical equipment). It further cntains surfaces frequently tuched by HCWs within the vicinity f the patient (e.g., mnitrs, buttns and knbs, and ther high frequency tuch surfaces within the patient zne). The 4.4
Infectin Preventin & Cntrl Manual patient zne and thus the POC extend beynd the bedside in a hspital rm. The mdel assumes that the patient flra rapidly cntaminates the entire patient zne, but that it is being cleaned between patient admissins. The POC ccurs within the patient zne. The healthcare zne cntains all surfaces utside the patient zne f the patient, i.e., all ther patients and their patient znes and the healthcare facility envirnment. Cnceptually, the healthcare zne is cntaminated with micrrganisms that might be freign and ptentially harmful t individual patients, either because they are multi-resistant r because their transmissin might result in exgenus infectin. Tw mments fr hand hygiene may smetimes fall tgether. Typically this ccurs when ging frm ne patient t anther withut tuching any surface utside the crrespnding patient znes. Naturally, a single hand hygiene actin will cver the tw mments fr hand hygiene. Techniques Using an Alchl-Based Hand Rub (ABHR) Ensure hands are visibly clean (if siled, fllw hand washing steps) Remve hand and arm jewellery; if a watch is wrn, it must be wrn abve the wrist and fit snugly; clthing r ther items that impede frequent and effective hand hygiene shuld be remved; a simple and practical slutin allwing effective hand hygiene is fr HCWs t wear their rings arund their neck n a chain as a pendant Apply ne t tw full pumps f prduct nt ne palm; the vlume shuld be such that 15 secnds f rubbing is required fr drying Spread prduct ver all surfaces f hands, cncentrating n finger tips, between fingers, back f hands, and base f thumbs; these are the mst cmmnly missed areas; and Cntinue rubbing hands until prduct is dry; this will take a minimum f 15 secnds if sufficient prduct is used. Hands must be fully dry befre tuching the patient r the care envirnment/equipment fr the ABHR t be effective and t eliminate the extremely rare risk f flammability in the presence f an xygen-enriched envirnment. Using Sap and Water Remve hand and arm jewellery; if a watch is wrn, it must be wrn abve the wrist and fit snugly; clthing r ther items that impede frequent and effective hand hygiene shuld be remved r pushed back; a simple and practical slutin allwing effective hand hygiene is fr HCWs t wear their rings arund their neck n a chain as a pendant Wet hands with warm (nt ht r cld) water; ht r cld water is hard n the hands, and will lead t dryness Apply liquid r fam sap Vigrusly lather all surfaces f hands fr a minimum f 15 secnds; remval f transient r acquired bacteria requires a minimum f 15 secnds f mechanical actin; pay particular attentin t finger tips, between fingers, backs f hands and base f the thumbs; these are the mst cmmnly missed areas Using a rubbing mtin, thrughly rinse sap frm hands; residual sap can lead t dryness and cracking f skin Dry hands thrughly by bltting hands gently with a paper twel; rubbing vigrusly with paper twels can damage the skin 4.5
Infectin Preventin & Cntrl Manual Turn ff taps with paper twel t avid recntaminatin f the hands. If hand air dryers are used in nn-clinical areas, hands-free taps are required DO NOT use ABHR immediately after washing hands, as skin irritatin will be increased Factrs that Reduce Effectiveness f Hand Hygiene Cnditin f the Hands The cnditin f the hands and the presence f hand adrnments can influence the effectiveness f hand hygiene. Intact skin is the bdy s first line f defence against bacteria; therefre careful attentin t hand care is an essential part f the hand hygiene prgram. The presence f dermatitis, cracks, cuts r abrasins can trap bacteria and cmprmise hand hygiene. Dermatitis als increases shedding f skin squames (cells) and, therefre, shedding f bacteria. Nails Lng nails are difficult t clean, can pierce glves and harbur mre micrrganisms than shrt nails. Keep natural nails clean and shrt. The nail shuld nt shw past the end f the finger. Nail Plish Studies have shwn chipped nail plish r nail plish wrn lnger than fur days can harbur micrrganisms that are nt remved by hand washing, even with surgical hand scrubs. Freshly applied nail plish des nt result in increased numbers f bacteria arund the nails. Fingernail plish, if wrn, must be fresh and in gd cnditin. Artificial Nails r Nail Enhancements Artificial nails and nail enhancements are nt t be wrn by direct care prviders (refer t WRHA Plicy 20.70.010, Dress Cde, and WRHA Plicy 90.00.060, Rutine Practices fr Reducing the Risk f Infectin Transmissin). Acrylic nails harbur mre micrrganisms and are mre difficult t clean than natural nails. Artificial nails and nail enhancements have been implicated in the transfer f micrrganisms and in utbreaks, particularly in nenatal nurseries and ther critical care areas. Surgical site infectins and hemdialysis-related bacteremias have been linked t artificial nails. Artificial nails and nail enhancements are als assciated with pr hand hygiene practices and result in mre tears t glves. Rings, Hand Jewellery and Bracelets Hand and arm jewellery hinder hand hygiene. Rings increase the number f micrrganisms present n hands and increase the risk f tears in glves. Arm jewellery, including watches, shuld nt interfere with, r becme wet when perfrming hand hygiene. Rings and bracelets shuld nt be wrn by direct care prviders. If watches and ther wrist jewellery are present, remve r push up abve the wrist befre perfrming hand hygiene. Other Impediments t Effective Hand Hygiene Lng sleeves shuld nt interfere with, r becme wet when perfrming hand hygiene. Hand Drying (paper twel, air dryers) Effective hand drying is imprtant fr maintaining hand health. Cnsideratins include: 4.6
Infectin Preventin & Cntrl Manual Dispsable paper hand twels prvide the lwest risk f crss-cntaminatin and shuld be used fr drying hands in clinical practice areas Clth drying twels must nt be used unless a new twel is used fr each episde Twel dispensers must be munted such that access t them is unbstructed and splashing r dripping nt adjacent wall and flr surfaces is minimized Twel dispenser design shuld be such that nly the twel is tuched during remval f twel fr use Twels hanging frm the dispenser shuld nt hang directly int a garbage can Ht-air dryers, including jet air dryers, must nt be used in clinical areas as warm air currents dry hands slwly and can be used by nly ne individual at a time. This results in lines and the temptatin t dry hands n clthing Where ht-air dryers are used in nn-clinical areas, hands-free taps are required If ht-air dryers are used in nn-clinical areas, there must be a cntingency fr pwer interruptins Ltins and Creams HCWs must use facility apprved ltins cmpatible with prducts and glves in use Hand ltin bttles shall nt be reused Barrier Creams: unlike hand ltins, which penetrate the skin via pres, barrier creams are adsrbed t the skin and are designed t frm a prtective layer that is nt remved by standard hand washing. Barrier creams may actually be harmful as they trap agents beneath them, ultimately increasing risk fr either irritant r allergic cntact dermatitis. Furthermre, inapprpriate barrier cream applicatin n HCW hands may exacerbate irritatin rather than prvide benefit. Dispensers Prducts must be dispensed in a dispsable pump/squirt cntainer that is nt tpped-up, t prevent cntaminatin D nt add sap r hand rub t a partially empty dispenser If reusable dispensers are utilized they must be emptied, washed and air-dried prir t refilling 4.7