HAND WASHING

A SOLUTION TO HOSPITAL INFECTIONS [Link] MD

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SO WHY ALL THE FUSS ABOUT HAND HYGIENE?

Most common mode of

transmission of

pathogens is via hands!

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DR. IGNAZ SEMMELWEIS POSTULATED

He postulated that the students might be carrying the infection from their dissections to birthing mothers. He ordered doctors and medical students to wash their hands with a chlorinated solution before examining women in labour. The mortality rate in his maternity wards eventually dropped to less than one per cent. [Link] MD

DR. IGNAZ SEMMELWEIS PROVED THE HYPOTHESIS MANY IGNORED

In the late 1840's, Dr. Ignaz Semmelweis was an assistant in the maternity wards of a Vienna hospital. There he observed that the mortality rate in a delivery room staffed by medical students was up to three times higher than in a second delivery room staffed by midwives. In fact, women were terrified of the room staffed by the medical students. Semmelweis observed that the students were coming straight from their lessons in the autopsy room to the delivery room.
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DOES HAND WASHING WORK?

SEMMELWEIS - 1847

Month
April May June July
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Births
312 294 268 250

Deaths
57 36 6 3

% Mortality
18.3 12.2 2.4 1.2
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HAND-BORNE MICROORGANISMS
Presence bacterial counts on hands range from 104 to 106 resident microorganisms-attached to deeper layers of the skin and are more resistant to removal; less likely to be associated with HAIs. transient microorganisms-colonize the superficial layers of skin and amenable to removable; acquired by direct contact with patients or contaminated environment surfaces; frequently associated with HAIs.
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ESTIMATED RATES OF HCAI WORLDWIDE

At any time, over 1.4 million people worldwide are suffering from infections acquired in health-care facilities In modern health-care facilities in the developed world: 510% of patients acquire one or more infections

In developing countries the risk of HCAI is 220 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25% In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%
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WHY SHOULD YOU CLEAN YOUR HANDS?

Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene Therefore hand hygiene concerns you! You must perform hand hygiene to: protect the patient against harmful germs carried on your hands or present on his/her own skin protect yourself and the health-care environment from harmful germs
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HANDS ARE THE MAJOR SOURCE OF PATHOGENS

Hands are the most common vehicle to transmit health care-associated pathogens Transmission of health care-associated pathogens from one patient to another via health-care workers hands requires

5 sequential steps

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INDICATIONS FOR HAND HYGIENE

When hands are visibly dirty, contaminated, or soiled, wash with nonantimicrobial or antimicrobial soap and water.
If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands.
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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

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 Before:

SPECIFIC INDICATIONS FOR HAND HYGIENE

Patient contact Donning gloves when inserting a CVC Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that dont require surgery

After:
Contact with a patients skin Contact with body fluids or excretions, non-intact skin, wound dressings Removing gloves

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

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EFFICACY OF HAND HYGIENE PREPARATIONS IN KILLING BACTERIA

Good
Better Best

Plain Soap

Antimicrobial soap

Alcohol-based handrub

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TIME SPENT CLEANSING HANDS:

ONE NURSE PER 8 HOUR SHIFT

Hand washing with soap and water: 56 minutes

Based on seven (60 second) handwashing episodes per hour

Alcohol-based handrub: 18 minutes

Based on seven (20 second) handrub episodes per hour

~ Alcohol-based handrubs reduce time needed for hand disinfection ~

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Voss A and Widmer AF, Infect Control Hosp Epidemiol 1997:18;205-208.

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RECOMMENDED HAND HYGIENE TECHNIQUE

Handrubs
Apply to palm of one hand, rub hands together covering all surfaces until dry Volume: based on manufacturer

Handwashing
Wet hands with water, apply soap, rub hands together for at least 15 seconds

Rinse and dry with disposable towel

Use towel to turn off faucet
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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

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SURGICAL HAND HYGIENE/ANTISEPSIS

Use either an antimicrobial soap or alcohol-based handrub
Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturer Alcohol-based handrub: follow manufacturers recommendations. Before applying, pre-wash hands and forearms with non-antimicrobial soap

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Guideline for Hand Hygiene in Health-care Settings. MMWR 2002; vol. 51, no. RR-16.

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5 STAGES OF HAND TRANSMISSION

one two three four five

Germs present on patient skin and immediate environment surfaces

Germ transfer onto health-care workers hands

Germs survive on hands for several minutes

Suboptimal or omitted hand cleansing results in hands remaining contaminated

Contaminated hands transmit germs via direct contact with patient or patients immediate environment

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MOST FREQUENT SITES OF INFECTION AND THEIR RISK FACTORS

URINARY TRACT INFECTIONS

Urinary catheter Urinary invasive procedures

Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes

34%

13%

LOWER RESPIRATORY TRACT INFECTIONS

Mechanical ventilation Aspiration Nasogastric tube

Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency

SURGICAL SITE INFECTIONS

Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care
Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision

Most common sites of health careLACK OF associated infection HAND and the risk factors underlying the HYGIENE occurrence of infections

BLOOD INFECTIONS

Vascular catheter Neonatal age Critical care

Severe underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision

17%

14%

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INDICATIONS FOR HAND WASHING AND HAND ANTISEPSIS

Hands are visibly dirty or soiled, wash with nonantimicrobial soap and water or antimicrobial soap and water. Category IA

If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations. IA. Alternatively, wash hands with antimicrobial soap and water. IB
Before having direct contact with patients. IB
Before donning sterile gloves when inserting a central intravascular catheter. IB
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INDICATIONS FOR HAND WASHING AND HAND ANTISEPSIS

Decontaminate hands not visibly soiled with handrub/antimicrobial (continued)
Before inserting urinary catheter, peripheral vascular catheter, or other invasive device. IB After contact with a patients intact skin. IB After contact with body fluids, mucous membrane, nonintact skin or wound dressings, as long as hands are not soiled. IA If moving from a contaminated body site to clean site. II After contact with inanimate objects in vicinity of patient. II After removing gloves.
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TIME CONSTRAINT = MAJOR OBSTACLE FOR HAND HYGIENE

Adequate hand washing with water and soap requires 4060 seconds Average time usually adopted by health-care workers: <10 seconds Alcohol-based hand rubbing: 2030 seconds

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ROUTINE HAND WASH

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Repeat procedures until hands are clean

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THE MY 5 MOMENTS FOR HAND HYGIENE APPROACH

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THE IMPACT OF HCAI

HCAI can cause:

more serious illness

prolongation of stay in a health-care facility

long-term disability
excess deaths high additional financial burden high personal costs on patients and their families [Link] MD

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MOST FREQUENT SITES OF INFECTION AND THEIR RISK FACTORS

URINARY TRACT INFECTIONS

Urinary catheter Urinary invasive procedures

Advanced age Severe underlying disease Urolitiasis Pregnancy Diabetes

34%

13%

LOWER RESPIRATORY TRACT INFECTIONS

Mechanical ventilation Aspiration Nasogastric tube

Central nervous system depressants Antibiotics and anti-acids Prolonged health-care facilities stay Malnutrition Advanced age Surgery Immunodeficiency

SURGICAL SITE INFECTIONS

Inadequate antibiotic prophylaxis Incorrect surgical skin preparation Inappropriate wound care
Surgical intervention duration Type of wound Poor surgical asepsis Diabetes Nutritional state Immunodeficiency Lack of training and supervision

Most common sites of health careLACK OF associated infection HAND and the risk factors underlying the HYGIENE occurrence of infections

BLOOD INFECTIONS

Vascular catheter Neonatal age Critical care

Severe underlying disease Neutropenia Immunodeficiency New invasive technologies Lack of training and supervision

17%

14%

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WHY HAND WASHING REDUCES DIARRHEAL DISEASES

Diarrhoeal diseases kill more than 1.5 million children under five each year but the simple act of hand washing can reduce these diseas es by >45%.

MANY COUNTRIES WORLDWIDE ARE COMMITTED TO IMPROVE HAND HYGIENE

You are part of a global movement!

Countries committed in 2005, 2006, 2007 and 2008 Countries Current status, March 2009 planning to commit in 2009

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CREATE AWARENESS AT SEVERAL PLACES

Hand washing is likely to be especially important where people congregate (schools, offices), where ill or vulnerable people are concentrated (hospitals, nursing homes), where food is prepared and shared and in homes, especially where there are young children and vulnerable adults.

Why Dont Staff Wash their Hands

(Compliance estimated at less than 50%)
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WHY NOT?
Skin irritation Inaccessible hand washing facilities Wearing gloves Too busy Lack of appropriate staff Being a physician
(Improving Compliance with Hand Hygiene in Hospitals Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)
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WHY NOT?
Working in high-risk areas Lack of hand hygiene promotion Lack of role model Lack of institutional priority Lack of sanction of non-compliers Lack of rewarding of compliers
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SUCCESSFUL PROMOTION
Education

Routine observation & feedback

Engineering controls

Location of hand basins Possible, easy & convenient Alcohol-based hand rubs available
Patient education
(Improving Compliance with Hand Hygiene in Hospitals. Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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TEACH THEM EARLIER IN LIFE

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MAKE ALL KIDS PARTNERS IN HAND WASHING

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WHAT IS THE WHO MULTIMODAL HAND HYGIENE IMPROVEMENT STRATEGY?

Based on the evidence and recommendations from the WHO Guidelines on Hand Hygiene in Health Care (2009), a number of components make up an effective multimodal strategy for hand hygiene
ONE System change Access to a safe, continuous water supply as well as to soap and towels; readily accessible alcohol-based handrub at the point of care

TWO Training / Education Providing regular training to all health-care workers

THREE Evaluation and feedback

Monitoring hand hygiene practices, infrastructure, perceptions and knowledge, while providing results feedback to health-care workers
FOUR Reminders in the workplace

Prompting and reminding health-care workers

FIVE Institutional safety climate

Creating an environment and the perceptions that facilitate awareness-raising about patient safety issues

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PREVENTION OF HEALTH CARE-ASSOCIATED INFECTION

Validated and standardized prevention strategies have been shown to reduce HCAI At least 50% of HCAI could be prevented Most solutions are simple and not resource-demanding and can be implemented in developed, as well as in transitional and developing countries
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HAND CARE ALSO INCLUDES

Nails Rings Hand creams Cuts & abrasions Chapping Skin Problems
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NEW CDC HAND HYGIENE GUIDELINES

MAJOR DIFFERENCE

Old CDC, APIC-nonantimicrobial between most patient contacts, antimicrobial before invasive procedures or caring for high-risk patients New CDC-if hands are not visibly soiled, use an alcohol-based handrub for decontaminating hands in all clinical situations; alternatively, wash hands with antimicrobial soap and wat er
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OUR SUPPORT TO HAND WASHING MAKES THE DIFFERENCE

HCAI places a serious disease burden and significant economic impact on patients and health-care systems Good hand hygiene the simple task of cleaning hands at the right times and in the right way saves lives There are 5 Moments for Hand Hygiene in Health Care

Global compliance with the My 5 Moments for Hand Hygiene approach is universally sub-optimal
<insert name of facility> has implemented an Action Plan to improve hand hygiene and reduce infection Your support and compliance with the initiatives is essential to save lives in our facility
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SIR WILLIAM OSLER ON HAND WASHING

Soap, Water and Common sense, are still the best Antiseptics.

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INSPIRE YOUR CHILDREN ON HAND HYGIENE

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THE GLOBAL HAND WASHING DAY

The Global Hand washing Day took place for the first time on October 15, 2008, the date appointed by UN General Assembly in accordance with year 2008 as the International Year of Sanitation

GLOBAL HAND WASHING DAY

Global Hand washing Day is a campaign to motivate and mobilize millions around the world to wash their hands with soap. The campaign is dedicated to raising awareness of hand washing with soap as a key approach to disease prevention.
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HAND WASHING A TRIBUTE TO DR. IGNAZ SEMMELWEIS

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FOR ARTICLES OF INTEREST ON MICROBIOLOGY AND INFECTIOUS DISEASES FOLLOW ME ON

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WISH TO SAVE MORE LIVES WITH HAND WASHING

Visit the SAVE LIVES: Clean Your Hands website at: [Link]/gpsc/5may/en/

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PROGRAMME CREATED BY [Link] MD FOR HEALTH CARE WORKERS IN THE DEVELOPING WORLD
Email

doctortvrao@[Link]

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