1. Hand Washing Techniques
Dr.Pinaki Mukhopadhyay
DCH.MD.DM (Neph,PGI,Chandigarh)
Fellow of Indian college of Physician
Asso.Prof & HOD,Dept of Nephrology
NRS Medical College & Hospital,Kolkata

2. Hand Hygiene
Hand Hygiene (HH) is generally poorly adhered to across the board by all levels of Health Care Worker’s 2

3. THE UNWASHED HAND!
These are the bacteria on unwashed hands

4. Hand Hygiene HAIs / MRSA, ESBLs, VRE etc Majority are preventable
The problem:
HAIs / MRSA, ESBLs, VRE etc
Majority are preventable
Costly to patient
Costly to health service
The problem was not just a local problem but a global one but one that needed action locally.
HCWs do perform HH but not always effectively they are not bad people but busy people
Resistance occurs because pts require antibiotics/sicker pts
Resistance is spread because HCWs don’t use HH appropriately
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16 4

5. Why Should I Wash My Hands?
Hand Hygiene/Hand Washing is the single most effective method to reduce the risk of spreading germs.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

6. Ignaz Philipp Semmelweis
Semmelweis has been credited as being the father of HH

7. Maternal mortality rates, First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA, 1841-1846
(%)
The First Obstetric clinic was run by the medical students and the consultants, who often went straight from the mortuary to the labour wards.
The Second Obstetric clinic was run by the midwives who did not handle dead bodies. The mortality for the doctors unit was much higher than for the midwives.
Semmelweis IP, 1861

8. Intervention Students and doctors were required to:
May 1847
Students and doctors were required to:
clean their hands with a chlorinated lime solution when entering the labour room
in particular when moving from the autopsy to the labour room
Semmelweis decided the doctors were carrying some thing on their hands and he decided this should be washed of with chlorine solution.

9. Maternal mortality rates,
First and Second Obstetrics Clinics, GENERAL HOSPITAL OF VIENNA,
Intervention
May 15, 1847
As you can see there was a marked effect on the mortality in the doctors unit. This is the first and most dramatic proof that hand hygiene is effective and essential.
Semmelweis IP, 1861

10. Evidence of Relationship Between Hand Hygiene and Healthcare-Associated Infections
Substantial evidence that hand hygiene reduces the incidence of infections
Historical study: Semmelweis
More recent studies: rates lower when antiseptic hand washing was performed
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

11. Why we don’t wash our hands
Too busy/insufficient time
Patient needs take priority
Understaffing/overcrowding
HCW are not bad just busy!
Sinks are inconveniently located or lack of sinks
Lack of soap and paper towels
Poor design
Poor product
Hand washing agents cause irritation and dryness
WHY DO PEOPLE NOT WASH THEIR HANDS???
Low risk of acquiring infection from patients
More education
Adapted from Pittet D, Infect Control Hosp Epidemiol 2000;21:

12. What can we do to help change this
Provide easy access to hand hygiene materials
Handrub solution
Conveniently located:
at the patient’s bedside
at the patient’s room entrance
in convenient / appropriate locations
in high traffic public areas
Working appropriately
Full of product
Within use by date
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

13. When Should I Wash My Hands?
Before starting your day, before and after lunch, and generally, when you feel it necessary, wash with soap and water.
When hands are dirty, contaminated or soiled, wash with soap and water.
*Especially important after coughing, sneezing or using a tissue
If soap and water are not readily available, use an alcohol-based (60% or higher) hand-rub for routine scrubbing

14. Moment 1. Before contact with a patient or patient environment
Before shaking hands
Before transferring
Clean your hands when entering or before touching the patient.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

15. Moment 1. Before contact with a patient or patient environment
Before taking temperature, blood pressure or pulse
Before making someone comfortable in bed
This will protect the patient from harmful organisms carried on your hands.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

16. Moment 1. Before contact with patient or patient environment
Patient’s room
Equipment
Wheel chair or stretcher
Clean your hands when entering or before touching any object or furniture in the patient’s environment.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

17. Before contact with patient or patient environment
Moment 1.
Before contact with patient or patient environment
Before contact with…
Home environment
Treatment area or clinic room
This is to protect the patient environment from harmful organisms carried on your hands.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

18. Moment 2. Before aseptic/clean procedure
Clean your hands before…
Handling dressings or touching open wounds
Performing invasive procedures
Clean your hands immediately before any aseptic or clean procedure to protect the patient against harmful organisms.
This prevents the patient’s own organisms from entering his or her body.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

19. Moment 3. After body fluid exposure
Clean your hands after…
Contact with blood, bodily fluids, non-intact skin or mucous membranes,
Removal of gloves
Contact with contaminated items
Clean your hands immediately after an exposure risk to body fluids (and after glove removal).
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

20. Moment 3. After body fluid exposure
Clean your hands after…
Performing invasive procedures
Using a tissue to wipe your nose or toilet use
This can help protect yourself and the health care environment from harmful patient organisms.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

21. Moment 4. After contact with a patient
Clean your hands after…
Shaking hands
Transferring
Making someone comfortable in bed
Help protect yourself and the health care environment from harmful patient organisms.
Clean your hands when leaving the environment after touching patient.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

22. Moment 4. After contact with the patient environment
Clean your hands after…
Contact with wheelchair or stretcher
Contact with room
Contact with equipment
Clean your hands when leaving after touching any object or furniture in the patient’s environment
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

23. Moment 4. After contact with the patient environment
Clean your hands after…
Contact with home environment
Contact with treatment area or clinic room
Help protect yourself and the health care environment from harmful patient organisms.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

24. How Should I Wash My Hands?
Proper Techniques for Hand Washing
Step 1
Wet hands first
with warm water
*avoid hot water

25. Proper Techniques for Hand Washing
Step 2
Apply 3-5 ml (2 - 3 pumps) of soap to hands.

26. Proper Techniques for Hand Washing Step 3
Rub hands together for at least 20 seconds, covering all surfaces of the hands and in-between fingers.

27. Proper Techniques for Hand Washing
Step 4 Rinse hands with water. .
Step 5
Dry thoroughly using paper towels, leaving
faucet on.

28. Proper Techniques for Hand Washing
Step 6 Use a new paper towel to turn off faucet.
Step 7
Discard used paper towels in trash.

29. one squirt (1-3 ml) to your hands
Easy Message
This is his HH product as discussed before. He introduced it into his HUG complex with an extensive campaign which will be described in detail when discussing the Austin experience.
SQUIRT
one squirt (1-3 ml) to your hands
ROLL
rub hands together covering all aspects of your fingers & hands until dry
RUB
apply to palm

30. Squirt Rub Roll Easy Message Basic message always the same
“Clean you hands before and after every patient touch”
Instructions always the same
Squirt
Rub
Roll
Keep your message simple and easy to remember work on the KISS theory
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

31. Soap & Water vs. Alcohol Hand Rub in Health Care Settings
Heavy workloads
Sinks not conveniently located
No soap and paper towels available
Skin irritation from frequent soap/water
Takes too long
Use soap & water for visibly dirty hands, spores such as C. difficile & anthrax
Alcohol Hand Rub
Heavy workloads
Easier to locate nearby
Requires stock maintenance
Less irritating to skin
Saves time (56 min vs. 18 min in 8 h)
Alcohol hand rub more effective at reducing bacterial counts on hands compared with soap & water
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

32. Keep natural nail tips < 1/4 inch in length
Finger Nails and Bling
Keep natural nail tips < 1/4 inch in length
No artificial nails or extenders when having direct contact with high-risk patients (e.g., ICU, OR)
Recommendations on rings unresolved
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; Vol. 51, No. RR-16.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

33. CDC Hand Hygiene Technique
Alcohol-Based Hand Rubs
Apply to palm of one hand, rub hands together covering all surfaces until dry
Volume: based on manufacturer
Hand washing
Wet hands with water, apply soap, rub hands together for at least 15 seconds (Happy Birthday song twice or the Alphabet song)
Rinse and dry with disposable towel
Use towel to turn off faucet
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; Vol. 51, No. RR-16.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

34. WHO Recommended Hand Hygiene Technique
Hand rub/hand wash
15-20 seconds
(Happy Birthday song twice)
How_and_When_Brochure.pdf

35. Alcohol-based hand rub
Apply a dime-sized amount (2-3 ml) of product into palms of dry hands
Rub product into hands
Palm to palm
Rub fingertips of each hand in opposite palm
Between and around fingers
Rub each thumb clasped in opposite hand
Rub back of each hand with opposite palm
Rub hands until dry before performing another task
DO NOT WIPE OFF
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

36. Alcohol-based hand rub
Alcohol based hand rub (ABHR) is at least 60% ethyl alcohol, or ethanol (equal to 120-proof).  To compare, a bottle of vodka is 80-proof
Ingesting small amounts of ABHR can produce the same side effects as consuming large amounts of alcohol:
Headache, dizziness, drowsiness, incoordination, nausea, slowed reaction time, slurred speech, giddiness, and unconsciousness
Consumption of ABHR can also result in:
Brain, liver, and kidney damage (from long-term use)
Toxic ethanol levels
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

37. Soap and Water
Soap and water is the recommended method when hands are visibly soiled. Plain soap is used for routine hand hygiene while anti-microbial soap is used in acute care high-risk areas.
Click link below for video on how to properly wash with soap and water.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

38. Soap and Water Wet hands under warm running water
Apply soap and distribute over hands
Rub hands together vigorously for 15 seconds to create a good lather: Palm to palm
Rub fingertips of each hand in opposite palm
Between and around fingers
Rub each thumb clasped in opposite hand
Rub back of each hand with opposite palm
Rinse hands thoroughly under warm running water
Pat hands dry with a paper towel
Turn off faucet using a paper towel
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

39. Hands are soiled and no water
On occasion, you may find yourself with soiled hands and no access to running water. When access to hand washing facilities is limited and running water is unavailable, use a moist towelette to remove visible soiling from hands followed by alcohol-based hand rub. 
Click link below for video on how to properly wash with soap and water.
Moist towelette
Followed by hand-rub

40. Hands are soiled and no water
Remove visible soiling with moist towelette
Apply a dime-sized amount of hand-rub product into palms of dry hands
Rub product into hands: Palm to palm
Rub fingertips of each hand in opposite palm
Between and around fingers
Rub each thumb clasped in opposite hand
Rub back of each hand with opposite palm
Rub hands until dry before performing another task
DO NOT WIPE OFF
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

41. “Handy” Tips
1 Artificial nails, gel nails or extenders are not to be worn by staff who have direct patient contact.
2 Contaminated surfaces or objects should not be touched after performing hand hygiene.
3 Avoid touching your face, especially your eyes and nose.
4 Fingernails should be kept short - no longer than ¼” or 0.635cm long.
5 Nail polish may be worn, but should be removed when chipped.

42. “Handy” Tips
6 Do not “top up” a partially-used hand hygiene product dispenser.
7 If re-usable dispensers are used they must be emptied, washed and dried prior to being refilled. Hand lotion bottles must not be re-used.
8 Include frequently missed areas when performing hand hygiene such as thumbs, palms, web spaces, under nails and the backs of fingers and hands.
9 Use supplied lotions that are compatible with hand hygiene products and gloves to minimize skin irritation that can occur with frequent hand hygiene.
10 Wearing hand and wrist jewelry is not recommended.
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

43. Missed Spots When Hand Washing
Between the fingers
Around the fingernails
Back of the thumb
Accessed 20 March 2017
Accessed 20 March 2017
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16

44. Remember….
Source:

45. Thank You

47. This is what happened to Semmelweis as a result of his efforts
This is what happened to Semmelweis as a result of his efforts. He colleagues at the time were not at all welcoming to his ideas and the poor chap ended dying in an asylum.
Ignaz Philipp Semmelweis before and after he insisted that students and doctors clean their hands with a chlorine solution between each patient 47

48. Resources .
able/influenza/
New York University Student Health Center
New York University Environmental Health and Safety :
September 2009 48