1. SHARP Safety and Health Assessment and Research for Prevention Washington State Department of Labor and Industries Skin Moisturizer Practices in Washington Hospitals Martin Cohen, ScD, CIH Christina Marino, MD, MPH

2. Overview Background of the problem Issues with hand care in health care The survey of awareness and products Results Recommendations

3. Background NIOSH grant to develop and operate a work- related dermatoses surveillance system. The data systems used: –Washington state workers’ compensation (WC) data –Sentinel provider database.

4. Surveillance Program Track work-related dermatoses Conduct site visits Develop educational materials for prevention

5. Workers’ Compensation Data, 1990-2000 (state fund) IndustryNumber (%) Eating & Drinking estab.1465 (13.2%) Agricultural Crop Production945 (8.5%) Health Care702 (6.3%) Health care has 7.4 derm. Claims/10,000 FTE and ranked 30 th, with the state-wide average being 8.1.

6. Workers’ Compensation Data, 1990- 2000 (state fund Health Care), n=702

7. Sentinel Provider Data 17% of all cases are Health Care (HC) workers. 37% of HC cases from latex. 19% of HC cases from soap/detergent Sources irritant hand dermatitis are: –protective gloves –excessive and chronic exposure to water –cleansing agents

8. Dry itchy skin isn’t the end of it! When hands are affected with dermatitis there may be.. –poor compliance with hand washing and –increased bacterial counts Increased bacterial counts may spread pathogens between patients and staff.

9. The Skin as a Barrier Dermatitis decreases the skin’s barrier integrity –increased risk of exposure to bloodborne pathogens during skin contact with blood or bodily fluids and –increased susceptibility to latex allergies.

10. Irritant Hand Dermatitis: Nurse

12. Prevention of Hand Dermatitis Use moisturizers. Dermatologists recommend thicker and/or petroleum-based moisturizers for hand dermatitis. Two limitations to moisturizer use in health care

13. First Limitation Some moisturizers may not be compatible with chlorhexidene gluconate (CHG) hand washing agents.

14. CHG Compatibility CHG is cationic and adheres to skin cells resulting in a residual antibacterial effect. Some anionic moisturizers inactivate the residual antibacterial effect of chlorhexidine gluconate.

15. Second Limitation Petroleum-based moisturizers may degrade latex gloves.

16. Original Statement from OSHA, 1993 BBP rulemaking Significant deterioration of latex gloves was noted when exposed to petroleum-based lubricants. If latex gloves are used, employees shall not apply petroleum-based, including mineral oil- based, skin care products.

17. OSHA It should be noted that some petroleum-based hand creams can adversely affect glove integrity. * * OSHA Directive CPL 2-2, 44D: Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens (current 11/5/99 version)

18. APIC* [L]otions that contain petroleum or other oil emollients may affect the integrity of gloves. *1995 Association for Professionals in Infection Control Guideline for Hand Washing and Hand Antisepsis in Health Care Settings.

19. NIOSH* When wearing latex gloves, do not use oil-based creams or lotions (which can cause glove deterioration) unless they have been shown to reduce latex-related problems and maintain glove barrier protection. There are natural oil-based creams and lotions. *NIOSH Alert: Preventing Allergic Reactions to Natural Rubber Latex in the Workplace

20. Who says what GroupProductModifier OSHAPetroleumBased APICPetroleum, or other oil emollients Contain NIOSHOilBased

21. What is Petroleum-Based? Mfgs: a water in oil emulsion with petroleum product as the first (main) ingredient. OSHA: Huh? NIOSH: Huh? What if one oil is 25%, another oil is 25%, and water is 40% and listed first - Huh? Needs research

22. Moisturizer Use Scenario

23. The Project Find out the types of: –gloves, –moisturizers, and –hand washing agents used in WA hospitals To help prevent hand dermatitis in health care

24. The Survey Survey of infection control personnel in all 106 hospitals in Washington. Infection control personnel help to set the policy for the types of hand washing agents, gloves and moisturizers used in hospital facilities.

25. The Survey Telephone Survey Awareness and understanding of moisturizer issues: –1) avoid anionic moisturizers with chlorhexidine gluconate hand washes, and –2) avoid use petroleum-based moisturizers with latex gloves. Types of gloves, moisturizers, and hand washing agents in use in their facilities.

26. Hospitals in Washington Surveyed (n=106)

27. Results of Survey CHG and anionic moisturizer incompatibility -- 48% of Infection Control Personnel (ICP) aware of the issue. Latex gloves and petroleum-based moisturizer incompatibility -- 74% of ICP aware of the issue.

28. Results of Survey 33% used a CHG hand wash in areas other than the operating rooms. 90% had some form of latex gloves available for the staff. 54% supply moisturizers for their staff which are CHG and latex compatible.

29. Types of gloves used * Non-latex gloves on request at 5 hospitals 26 51 29

30. Available Moisturizers & Incompatibilities

31. Prevention Efforts After the survey, ICP given definitions of petroleum- and water-based moisturizers A petroleum-based moisturizer is a “a water in oil emulsion” with a petroleum product as the first (main) ingredient.

32. Prevention Efforts We developed an educational, prevention and reference document for dermatitis in health care. –Survey results –Preventing hand dermatitis –Issues with moisturizers in health care The document has a list of moisturizers with their ionic nature and whether they are are water- or petroleum-based.

33. General Recommendation Use water-based lotions at work that are compatible with CHG and latex Use heavier and/or oil-based creams when away from work.