1. 感染控制 手部衛生手護健康 (Hand Hygiene, patient safer)
陳垚生醫師 高雄榮總 感染管制室 & 內科部感染科

2. SENIC study Study on the Efficacy of Nosocomial Infection Control
Haley RW et al. Am J Epidemiol 1985;121(2):
Relative change in NI in a 5 year period ( )
14% 9%
19%
26%
18%
Without infection control
30%
20%
50%
10%
LRTI
SSI
UTI
BSI
Total 0%
-31%
-35%
-27%
-32%
-40%
-30%
-20%
-10%
With infection control

3. 預防是最重要的
保護病人，保護工作人員，提高醫療品質…

5. 維也納總醫院，一八二五年

7. 手部衛生: 非新觀念 ~ 手部衛生降低病人感染率~ Semmelweis的 手部衛生介入
手部衛生: 非新觀念
Semmelweis的
手部衛生介入
After Semmelweis insisted that students and physicians clean their hands with a chlorine solution between each patient, the maternal mortality rate in the First Clinic dropped.
Maternal mortality rate in the First Clinic dropped dramatically and remained low for years.
This is the first evidence indicating that cleansing heavily contaminated hands with an antiseptic agent between patient contacts may reduce healthcare-associated transmission of contagious diseases more effectively than handwashing with plain soap and water.
~ 手部衛生降低病人感染率~
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

8. 為何大家對「手部衛生」小題大作？
大部份致病菌都是經「手部」傳染
醫療照護相關感染
抗藥性細菌的傳播

9. 醫院內「手部衛生」的遵從度 研究年代 遵從度 醫院單位 1994 (1) 29% 一般病房及加護病房 1995 (2) 41% 一般病房
研究年代 遵從度 醫院單位
1994 (1) 29% 一般病房及加護病房
1995 (2) 41% 一般病房
1996 (3) 41% 加護病房
1998 (4) 30% 一般病房
(5) 48% 一般病房
In general, adherence of healthcare workers to recommended hand hygiene procedures has been poor.
Studies shown here are representative of the overall adherence rates which averaged about 40%.
Adherence rates do vary by occupation.
Gould D, J Hosp Infect 1994;28:15-30.
Larson E, J Hosp Infect 1995;30:
Slaughter S, Ann Intern Med 1996;3:
Watanakunakorn C, Infect Control Hosp Epidemiol 1998;19:
Pittet D, Lancet 2000:356;

10. 自述「手部衛生」遵從度低的因素 洗手液造成皮膚刺激及乾燥 洗手臺 位置不方便或數量不足 缺肥皂及擦手紙 太忙了，時間不夠 人力不足，過度擁擠
病人需優先處理
病人得到感染的機會低
摘自 Pittet D, Infect Control Hosp Epidemiol 2000;21:

11. 手部衛生適應症 手上若無可見的污染，可使用含酒精洗手劑作為常規洗手 手上若有明顯可見的污染，使用非抗菌或抗菌肥皂加上清水洗手
Healthcare workers should wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use an alcohol-based handrub when hands are not visibly soiled to reduce bacterial counts.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

12. Summary of hand transmission and indications for hand hygiene during patient care

13. 前 後 手部衛生特定適應症 接觸病患前 置放CVP，載手套前 置放導尿管、週邊血管內導管、或其它無需手術之侵入性裝置前
接觸病患皮膚或週遭物件後
接觸任何血液、體液(汗除外)、分泌物、黏膜、破損皮膚、傷口敷料後
脫卸手套後

14. 手部衛生清潔劑的選用考慮因素 清潔劑的效力 工作人員的接受度 產品的特性 對皮膚的刺激性和乾爽度 產品的可近性 使用介面
When evaluating hand hygiene products for potential use in healthcare facilities, administrators or product selection committees should consider the relative efficacy of antiseptic agents against various pathogens and the acceptability of hand hygiene products by personnel.
Product acceptance can be affected by characteristics of the product such as its smell, consistency, color and the effect of skin irritation and dryness on hands.
Easy access to hand hygiene supplies is essential for acceptance and use of products.
Dispenser systems should function adequately and deliver an appropriate volume of product. Soap should not be added to a partially empty soap dispenser because of potential bacterial contamination of the soap.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

15. 手部衛生清潔劑殺菌的效率 好 更好 最好 一般肥皂 抗菌肥皂 含酒精洗手劑
Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best.
抗菌肥皂
含酒精洗手劑

16. 手部衛生清潔劑降低手上菌的能力 0.0 1.0 2.0 3.0 60 180 分鐘 90.0 99.0 99.9 log %60
180 分鐘
90.0
99.0
99.9
log %
細 菌 減 少 度
含酒精洗手劑
(70% Isopropanol)
抗菌肥皂
(4% Chlorhexidine)
一般肥皂
清潔後的時間
基礎點
This graph shows that alcohol-based handrub is better than handwashing at killing bacteria.
Shown across the top of this graph is the amount of time after disinfection with the hand hygiene agent.
The left axis shows the percent reduction in bacterial counts.
The three lines represent alcohol-based handrub, antimicrobial soap, and plain soap.
Adapted from: Hosp Epidemiol Infect Control, 2nd Edition, 1999.

17. 含酒精洗手劑對皮膚的影響 含酒精洗手劑較不引起皮膚傷害 自評皮膚狀況 表皮層含水程度 乾 健康 健康 乾
Alcohol-based handrubs are less damaging to the skin than soap and water.
In the graph on the left the blue bar shows self-reported skin health scores for persons using soap and water, and persons using alcohol-based handrubs are depicted by the orange bar. Self-reported studies indicate participants using soap and water reported a significant increase in dryness, cracking, and irritation after 2 weeks, whereas those that used the alcohol-based handrub reported improvement in skin dryness.
Epidermal water content shows the same results as the self reported scores, after 2 weeks of use, the skin water content decreased for those that used soap and water (resulting in dryer skin) as compared with those who used an alcohol-based handrub.
含酒精洗手劑較不引起皮膚傷害
Boyce J, Infect Control Hosp Epidemiol 2000;21(7):

18. 含酒精的洗手劑 不需碰水 不需要紙巾或擦手巾 可在巡房時使用，節省時間 速效，於15秒內殺菌，可降低手上的細菌量達10000倍 比洗手快兩倍
溫和，可含保濕成分
比一般抗菌肥皂沒有刺激性

19. 一位護士在一個八小時班 花在洗手的時間 用肥皂和清水洗手：56 分鐘 用含酒精洗手劑：18 分鐘 ~ 含酒精洗手劑減少手部清潔的時間 ~
假設一小時洗七次，一次 60 秒
用含酒精洗手劑：18 分鐘
假設一小時洗七次，一次 20 秒
The time required for nurses to leave a patient’s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis.
More rapid access to hand hygiene materials could help improve adherence.
Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often.
~ 含酒精洗手劑減少手部清潔的時間 ~
Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;

20. 結論：含酒精洗手劑的優點有… 洗手時間比較短 比用肥皂洗手效果更好 比用水槽洗手更方便 可有效降低手部帶菌量 對皮膚損傷較小
In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster. In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition.

21. 「手部衛生」與 「醫療照護相關感染」關係之實證
具體證據：手部衛生可降低感染率
歷史上的研究： Semmelweis
近代的研究： 使用殺菌劑的手部衛生可降低感染率

22. 手部衛生
沒有藉口!
就如Nike所說
JUST DO IT!

23. 鼓勵醫護人員洗手的有效措施 措施 效果 (增加洗手率) 效果持續時間 單次教育課程 稍微增加 (14%) 約一周 提醒標語
(請病人提醒醫師)
中等以上
(34~46%)
一個月以上
回饋提醒
(30~50%)
六個月
自動洗手裝置 無 未知
噴霧洗手或乾洗手劑
未定或稍微 未定
Naikoba S. J Hosp Infect 2001

24. 守護健康運動組織架構圖 副院長 感染管制室 護理部 門診 一般病房 急診 組別A 組別 B 種子教官 其他(放射科、 呼吸治療、清潔、復健
組別 C
組別 D
種子教官
This is the organization chain of the hand hygiene activity
The deputy director is the leader and the executive department include the infection control unit and the nursing department
We enrolled all medical-association units, including the emergency room, out patient department, general ward, ICU ward
and para-medical association unit, such as the respiratory training technicians and radiology technician or the cleaner and caregiver in the hospital.
We asked every unit to select 2 persons to act as seed-teachers, to promote hand hygiene in their own respective units,
There are about 160 seed-teachers, who were divided into 4 groups. Each group had one ICN as a consultant.
Every group was further divided into 4 subgroups and each subgroup selected one leader to help ICN for promotion of hand-hygiene

25. 洗手衛生稽核制度 自96年9月14日開始每季定時召開全院洗手運動會議 目標訂定 洗手遵從性 洗手正確性
院內感染發生率下降，院內MRSA 、CR-AB感染率下降
評估指標
工作人員洗手遵從性
工作人員洗手正確性
院內感染率
供應洗手設備-洗手劑使用量

26. 手護健康運動預定進度甘特圖 工作項目\月次 1.設計洗手觀察表 2.建立基礎值(醫療人員洗手狀況現 況觀察及分析) 3.分析及擬定策略
96年07月
96年08月
96年09月
96年10月
96年11月
96年12月
97年01月
97年02月
97年03月
97年04月
97年05月
97年06月
工作項目\月次
第一月
第二月
第三月
第四月
第五月
第六月
第七月
第八月
第九月
第十月
第十一月
第十二月 備註
1.設計洗手觀察表
2.建立基礎值(醫療人員洗手狀況現
況觀察及分析)
3.分析及擬定策略
4.問卷設計及調查
5.教育訓練展開
6.培訓種子人員
7.海報競賽
8.監測活動與醫療單位擂台奪標
9.初步成果分析

27. 洗手衛生稽核制度 全面進行手部衛生監測 1.參與監測人員:所有種子教官( 166人 ) 2.監測時間:每兩週監測乙次,每次監測 20分鐘
3.每月1,15日繳交監測單至各負責之感 管人員處

28. 洗手設備及相關硬體設施之方便性及安全性

29. 洗手步驟七字訣
內外夾弓大立腕

30. 手護健康海報比賽 比賽起迄日期：9702～970331 投票時間： 97年6月16日至97年6月20日 結果： 1、參賽件數43件
2、得獎者共24位
3、總投票數：2115；
有效票：1784
第一名：2000元、獎狀
第二名：1500元、獎狀
第三名：800元、獎狀
佳 作：500元、獎狀

31. 提供護手乳
(3M Cavilon Moisturizing lotion)

32. 教育計畫 監督醫護人員保持手部衛生的狀況，並公布結果 多管齊下以促使醫護人員遵照保持手部衛生的準則 鼓勵病患及其家屬提醒醫護人員保持手部衛生
One strategy to promote improved hand hygiene behavior is to monitor healthcare worker adherence with recommended hand hygiene practices and to give feedback.
Strategies to improve adherence to hand hygiene practices should be both multimodal (i.e. use several different methods or strategies) and multidisciplinary (i.e. involve several different areas of the institution, and types of HCWs). Patients and their families can be involved in reminding HCWs to wash their hands.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

33. 促進手部衛生的管理方法 將促進手部衛生做為整個醫療機構的優先目標 在每間病房門口、或病床旁邊，擺置含酒精的洗手劑
給予每位醫療工作人員可隨身攜帶的洗手劑
Make improved hand hygiene an institutional priority and provide appropriate administrative support and financial resources.
Several administrative measures may help improve hand hygiene adherence among personnel who work in areas where high workloads and high intensity of patient care are anticipated. These include placing alcohol-based handrubs at the entrance to patients’ rooms, or at the bedside and providing healthcare workers with individual pocket-sized containers.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

34. 成效評核 以病房或主治醫師為單位，監督並紀錄手部衛生保持的情況 定期公布評核的結果 監控每1000人日數所消耗含酒精洗手劑的量
These performance indicators are recommended for measuring improvements in HCWs hand-hygiene adherence.
Monitor and record adherence to hand hygiene by ward or service.
Provide feedback to healthcare workers about their performance.
Monitor the volume of alcohol-based handrub used per 1,000 patient days.
Monitor adherence to policies on wearing artificial nails.
Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

35. 「手護健康」運動推行成效

36. 全院洗手監測成效
94人次
546人次
464人次
443人次
成立手護健康運動小組

37. 『手護健康』擂台奪標 評選基準：每月由洗手種子教官查核病房單位之洗手遵從率，評選優良單位，給予適當獎勵。 獎勵：
　第一名：一名、提貨單1,000元、獎盃一座、
錦旗一面、精美小禮物一份。
　第二名：一名、提貨單750元、獎盃一座、
　第三名：一名、提貨單500元、獎盃一座、

38. 自製廣播錄音內容 (自97年10月27日始)
院長版：大家好，我是高雄榮民總醫院的院長，現在請各位注意聽，特別是我們同仁、病患及家屬，我希望各位出入醫院勤洗手，可以保護病友、你和我。播音時間:上午九點。
黃副院長版:大家好，我是黃副院長，請各位同仁、病患及家屬重視清潔衛生，人人勤洗手，病菌必遠走，保護你和我，健康常相守。播音時間:上午11點。
黎副院長版:大家好，我是黎副院長，請各位同仁接觸病人前後記得洗手，以保護病患安全，謝謝合作。播音時間:下午2點。

39. 六標準差運用於手部衛生

40. 步驟分析五大要素 人: 醫生、護士、技術員、班長 機: 聽診器、儀器(EKG、X-ray) 料: 乾洗手劑、洗手台(水、洗手 劑、擦手紙)
料: 乾洗手劑、洗手台(水、洗手 劑、擦手紙)
法: 手部衛生五大原則
環: ICU內、ICU外(放射科為主)

41. 手部衛生五大原則 直接接觸病人前、後 接觸緊鄰病人的環境後 接觸病人血液、體液、黏膜、破損的皮膚、傷口之後 脫除手套之後
照顧同一病人，由污染部位移往乾淨部位時
2005 WHO Guidelines on Hand Hygiene in Health Care: A Summary

42. 流程分析-以病患為主

43. 流程分析-以病患為主

44. 流程分析-以病患為主

46. 思想導引
態度影響思想
思想影響行為
行為養成習慣
習慣成為性格
性格成就命運
其實洗手應該從小敎起

47. 謝謝聆聽