AIM To improve staff awareness and knowledge of the importance of handwashing in reducing the risk of cross-infection.
By the end of the session, staff will: be aware of the reasons for non-compliance with handwashing understand the reasons for adequate & appropriate handwashing & drying identify resident & transient micro-organisms and their characteristics differentiate between handwashing, hand antisepsis and surgical scrub and the appropriate use of each procedure be aware of the active ingredients in handwash products demonstrate the correct use of the six-step handwashing technique identify areas of the hands incorrectly decontaminated understand the role of gloves in relation to handwashing and be aware of the risks relating to the wearing of jewellery and nail varnish OBJECTIVES
“Handwashing is an infection control practice with a clearly demonstrated efficiency, and remains the cornerstone of efforts to reduce the spread of infection” Ask yourself: What have you just done? What are you about to do? What are the risks? Which is the appropriate product and procedure to use? Infection Control Nurses Association (1997) Guidelines for Hand Hygiene
IGNAZ SEMMELWEIS 1847 Reduced puerperal fever death rate 11% 1% within 3 weeks by enforcing a strict regime of hand decontamination with chlorinated lime (bleach) after post-mortems and before delivery!
REASONS FOR NON-COMPLIANCE lack of education / knowledge / motivation perceived lack of need lack of role models insufficient time available between tasks inconvenience / lack of facilities harsh products causing poor skin conditions over reliance on gloves
TRANSIENT HAND FLORA easily acquired and transferred by direct contact loosely attached to skin surface usually removed with friction, soap and water most abundant around finger tips an important source of cross-infection
TRANSIENT MICRO-ORGANISMS Staphylococcus aureus Streptococci Gram-negative bacilli inc. Escherichia coli Pseudomonas aeruginosa Viruses Composition dependent on: prevalence in environment type of activity undertaken
RESIDENT HAND FLORA (commensals) can rapidly become highly pathogenic can cause infection when introduced via skin breaks - ‘invasiveness’ protective function survive & multiply on skin not easily removed by mechanical washing inactivated by topical antimicrobial agents
Microbial counts usually increase in warm, moist conditions under gloves beneath rings All micro-organisms found on hands are capable of colonising susceptible sites e.g. wounds, intravascular devices Multiplication of micro-organisms at susceptible sites may lead to local/systemic infection
HANDWASHING TECHNIQUES MECHANICAL removes soil and debris with abrasive action CHEMICAL use of antimicrobials to destroy or suppress both transient and resident micro-organisms chemical agents are: cidal static
TYPES OF HANDWASHING TECHNIQUES Hand antisepsisRemove or destroyAntimicrobial (hygienic)transientsoap/detergent micro-organismsor alcohol based hand-rub for at least seconds TYPEOBJECTIVEMETHOD HandwashRemoval of soil/dirtSoap or detergent (social/routine)and transient micro-for at least organismsseconds (refer to 6 stage technique) Surgical handscrubRemove or destroyAntimicrobial soap/ transient micro-detergent with brush organisms to achieve friction Reduce resident florafor at least 120 seconds OR alcohol-based hand-rub for at least 20 seconds
SIX STAGE HANDWASHING TECHNIQUE 1 palm to palm 4 fingertips 2 backs of hands 5thumbs and wrists 3 interdigital spaces 6 nails Reproduced with kind permission of the Nursing Standard
OPTIMUM HANDWASHING TECHNIQUE (social/hygienic) remove all jewellery and roll back sleeves wet hands under running water apply soap to all areas of hands rub hands together vigorously, thoroughly cleansing all surfaces* for seconds (approx 5 strokes backwards & forwards for each area) keep hands lower than elbows and do not touch equipment e.g.taps rinse hands thoroughly under running water dry hands thoroughly using paper towels * use in conjunction with 6 stage technique
SURGICAL SCRUB TECHNIQUE remove all jewellery wet hands under running water wash hands to remove soil / debris using antimicrobial agent and nail sponge / brush, clean around finger nails. Discard sponge / brush. scrub all surfaces* of hands, wrists & forearms up to elbows keep hands higher than elbows once an area has been cleaned, do not return to the cleaned area again rinse hands and arms thoroughly, keeping hands high dry all areas thoroughly with sterile cloth / towel if there is any contact with unsterile surfaces during scrubbing, restart entire procedure *use 6 stage technique
AREAS MISSED DURING HANDWASHING Reference: Taylor L. (1978)
WHICH WASH WHEN?
HAND DRYING wet surfaces: encourage microbial multiplication transfer micro-organisms more effectively high risk of contamination: communal hand towels roller towels warm air dryers: cycle times often inadequate can be a source of cross-infection research is scanty
USE OF GLOVES massive increase in use in recent years gloves are not a substitute for handwashing hand contamination is possible during glove removal handwashing after glove removal is essential and also before sterile glove use hypersensitivity to latex is increasing and powder- free gloves should always be used gloves must be changed: between clean and dirty tasks between patients
JEWELLERY total bacteria counts higher when rings are worn avoid rings with ridges / stones rings interfere with thorough handwashing difficulty donning gloves gloves may tear nails harbour largest number of micro-organisms - keep them short artificial nails may increase microbial load and discourage vigorous hand-washing.
CHOICE OF HANDWASHING AGENTS Dependent upon: task to be undertaken and related risks inherent characteristics type & spectrum of activity extent of hand contamination Ask yourself - is it necessary to remove / reduce: soil / dirt / debris transient micro-organisms resident flora?
HANDWASHING AGENTS alcohol chlorhexidine gluconate iodophors (e.g. povidone iodine) triclosan ACTIVE INGREDIENTS soap and water antiseptic handwashes and water alcohol hand rub / gel / wipes
IODOPHORS e.g. Povidone - iodine (Betadine, Videne) used primarily for surgical scrubbing wide range of microbial activity neutralised in presence of organic matter can cause skin irritation / hypersensitivity
CHLORHEXIDINE GLUCONATE e.g. Hibiscrub wide range of microbial activity initially slow-acting persistent chemical activity (up to 6 hrs) minimally affected by organic matter less irritating than alcohol or iodophors
TRICLOSAN e.g. Aquasept wide range of bacterial activity excellent residual activity minimally affected by organic matter commonly used in commercial products more data needed
ALCOHOLS e.g. ethyl / isopropyl / n-propyl inexpensive do not require water or facilities will not remove dirt or debris provide no residual activity provide greatest reduction in microbial counts can be drying and irritant to skin often combined with antiseptic solutions to increase residual activity
USE OF ALCOHOL RUB / GEL when facilities are limited e.g. community when access to facilities difficult / inconvenient e.g. opening dressing packs when rapid hand disinfection required between patients in high dependency units Remember alcohol is not a cleansing agent hands require washing before alcohol use if physically dirty alcohol alone has no residual activity on skin
LIQUID SOAP should be pleasant to use must contain emollients liquid soap dispensers should be wall- mounted and preferably elbow-operated disposable cartridges minimise the risk of contamination whilst refilling
ROLE OF EMOLLIENTS (hand lotion or cream) Highly effective in preventing skin from excessive drying / cracking may reduce or neutralise antiseptic agents therefore use creams with non-ionic base e.g. Diprobase multi-use pots / containers can become contaminated use regularly but do not over-use
HAVE WE ACHIEVED OUR OBJECTIVES? Are you ? aware of the reasons for non-compliance with handwashing aware of the active ingredients in handwash products aware of the risks relating to the wearing of jewellery and nail varnish Do you ? understand the reasons for adequate & appropriate handwashing & drying understand the role of gloves in relation to handwashing Can you ? identify resident & transient micro-organisms and their characteristics differentiate between handwashing, hand antisepsis and surgical scrub and the appropriate use of each procedure demonstrate the correct use of the six-step handwashing technique identify areas of the hands incorrectly decontaminated
REMEMBER WHAT HAVE YOU JUST DONE? WHAT ARE YOU ABOUT TO DO? NOW, WASH YOUR HANDS!