Hand Hygiene in Healthcare

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Importance of Hand
Hygiene Practices

Today`s Topic!
Ideal Tools for Hand Hygiene
Improving Hand Hygiene Compliance

About Myself
Name: Kelvin Lim
Age: 37
Nationality: MALAYSIAN, living in Kuala
Lumpur
Company: Saraya Hygiene Malaysia
Hobbies: Futsal, Running & Washing Car
Interests: Infection Control (Hospital)

Average HA Infection Rate

5-15% of patients admitted to acute care hospitals
Risk is higher in critical care (15-40%)
Risk is 2 to 20 fold higher in developing countries
Burdon of disease outside hospitals is mostly unknown

No hospital, country, healthcare-system in

the world can claim to have solved the
challenge of Healthcare Associated
Infection!

Dr. Ojan Assadian, 2012

Burden of HAI - Life

HAI can affect 937% of those admitted to intensive care
units (ICUs)
An estimated five million HCAI at least occur in acute care
hospitals in Europe every year
HAI contribute to 135,000 deaths per year in Europe

WHO Guidelines for Hand Hygiene in Healthcare

Burdon of Infection - Cost

The estimated HCAI incidence rate in the United States of America (USA) was 4.5% in 2002, with about 1.7 million
patients and an annual economic impact of US$ 6.5 billion in 2004.
Approx. 99,000 deaths in 2002, USA
Device-associated infections have a great economic impact; for example catheter-related bloodstream infection caused
by methicillin-resistantStaphylococcus aureus(MRSA) may cost as much as US$ 38,000 per episode in the USA.

WHO Guidelines for Hand Hygiene in Healthcare

Fundamentals of Hand
Hygiene

Contact
Influenza,
Whooping
cough, Rubella
Mumps

MRSA VRE MDRP, C.

Difficile, Scabies

Norovirus,
Varicella

Measles

Droplet

Tuberculosi
s

Airborne

Importance of Hand
Hygiene

Hand Hygiene is .the most important

way to prevent HAIs

CDC,APIC,SHEA:How-to Guide: Improving Hand Hygiene A Guide for Improving Practices among Healt

Goal and Principles of Hand

Hygiene

To Remove Soil and Infectious Microorgan

STOP Cross Contamination To
Patients
PROTECT Yourself
PREVENT Infection and PROMOTE
Treatment
Infection
Prevention

3 Types of Hand Hygiene

Daily HygienicSurgical
HH
HH
HH
Visible Soiling

Transient Flora
Resident Flora
Skin

Hygienic Hand Hygiene

Practice
WHO Guidelines for Hand Hygiene in Healthcare
2009
CDC Guidelines for Hand Hygiene in Healthcare
2002

Visible Soiling
Soap and Running Water

No Visible Soiling
Quick Drying Alcohol Hand Disinfectant

Hand Hygiene Timing

'Based on the 'My 5 moments for Hand Hygiene', URL:

Patient Zone & Care Area

Patient Zone
Patient Infection Risk
Point

Liquid Exposure
Risk Point

Care Area

5 Moments of Hand Hygiene Focuses on the

Patient Zone

Patient Zone
The Patient and the Items and
Environment Surrounding
Environment and Items Surrounding
All surfaces accessible to the patient and touching the
patients body.
Environmental Surfaces
Bed rails, table, linens, tubes, other medical devices)
Items touched and used by Medical Staff.
(Monitor, handles, buttons, doorknobs)

Patient Zone

The patient zone is not geographically

set. It is the constant area, items and
environment that surround the
patient.
If
the patient moves, so does the Zone
This means patients
in a wheelchair or
under treatment
has a Patient Zone
as well.

Care Area
All areas outside the Patient Zone
In other words
Another Patient Zone
The Greater Hospital Environment

1.Before Touching a Patient

Before
Patient
Contact

1. Before Touching a Patient

Before touching a patients intact skin or
clothing.
For example, these situations
Before shaking hands with a patient or holding a child
Before care in a patients surroundings: Moving,
Bathing, Meals, Changing Clothes
Before non-invasive care, applying an oxygen mask,
physical therapy.
Physical check-up, non-invasive exam (Checking heart
rate, blood pressure, chest exam, cardiac electrogram)

2. Before a Clean Operation

Before a
clean
operation

2. Before a Clean Operation

Hand hygiene before an operation
that accesses a critical risk to
patients.
For example, these situations
Before brushing teeth, eye drops, vaginal/rectal exam,
mouth-nose-ear exam (with or without tools),
suppository/diaphragm insertion, mucous extraction
Before dressing wounds (with or without tools), treating
blisters, puncturing
Invasive procedure (nasal tubing, feeding tube, etc.)
Before preparing meals, medicine, sterile materials.

2. Before a Clean Operation

When doning gloves before a clean
operation: hand hygiene!
Prevent the transfer of pathogens from
one patient/environment to another!

3. After Body Fluid Exposure

Risk

After Body
Fluid Exposure Risk

3. After Body Fluid Exposure

Risk
Disinfect hands after a procedure with body fluid
exposure risk (and after removing gloves)

For example, in these situations

After touching mucous membranes, wounded skin
After puncture, invasive procedure (blood access, catheter,
tube, etc.)
Invasive equipment removal
After removing protective tools (Napkin, dressings, gauze,
etc.)
After cleaning up body fluids, cleaning contaminated
surfaces (bed pan)

3. After Body Fluid Exposure

Risk

When wearing gloves for an exposure

risk, quickly remove gloves and disinfect
hands after the procedure.
Protect you and your team from
pathogens.
Keep the environment clean and
contained from cross contamination!

4.After Touching a Patient

After
Touching a
Patient

4. After Touching A Patient

After patient care, disinfect hands
when leaving the patient zone.
For example, these situations.
After shaking hands, holding a child.
After patient care (bathing, feeding, moving, changing)
Non-invasive examinations
Physical check-up, non-invasive exam (Checking heart rate,
blood pressure, chest exam, cardiac electrogram)

5. After Touching a Patients

Surroundings

After touching a
patients
surroundings

5.After Touching a Patients

Surroundings
Even when not touching a patient,
disinfect hands after touching the
environment in a patient zone.
For example, these situations.
After changing bed linens, touching a bed rail, arranging a
bed side table.
After adjusting perfusion rate for a patient

5.After Touching a Patients

Surroundings
A patient has access to the surrounding
environment, prevent cross contamination
to other patients by disinfecting after
touching the environment.

Tips on Gloves
When gloves are required, always
disinfect hands before doning if a hand
hygiene moment is expected.
Disinfect hands after removing gloves
when a hand hygiene moment
occurred during care.
When a hand hygiene moment
occurred while doning gloves, remove,
toss, disinfect and re-don.
GLOVES ARE NOT A REPLACEMENT FOR HAND
HYGIENE!

Alcohol Hand
Disinfectant
The best way to prevent
healthcare associated infections

Ideal Hand Disinfectant

Alcohol based
80~85% ethanol or 70% isopropanol

Skin protecting emollients

To heal and moisturize the skin

Wide range of efficacy

EN 1500 HHD 30s, EN 12791 SHP 90s

Usability and tolerability

Low irritants (colors, fragrance), fragrance free
Assadian, O, Criteria for ABHR, 2013

Saraya Hand Disinfectants

Alsoft A

Ethanol 80v/v% CHG 0.2%

Emollients for skin health
Applicable for Saraya No-touch
dispensers.
EN1500, EN12791, etc.

Antibacterial: MRSA, Tuberculosis, etc.

Antifungal: C. albicans, yeast, etc.
Antiviral : HIV, Influenza, HVB, HCB, etc.
Non-Irritation: Fragrance-free, Color-free. Emollients for skin protection.
Non-irritation increases skin tolerability and hand hygiene compliance

Saraya Hand Disinfectants

Alsoft Pure Isopropanol 70%
Low irritation formula
Applicable for Saraya No-touch
dispensers.
EN1500, EN12791, etc.
Antibacterial: MRSA, Tuberculosis, etc.
Antifungal: C. albicans, yeast, etc.
Antiviral : HIV, Influenza, HVB, HCB, etc.
Non-Irritation: Fragrance-free, Color-free.
Non-irritation increases skin tolerability and hand hygiene compliance

Hand Hygiene Efficacy

(Water)

Hand Hygiene Efficacy

(Soap)

Regularly Missed Areas

L.J.Taylor,SRN,SCM:An evaluation of hand washing techniques-1,NURSING TIME 1978 ;

Hand Disinfection Method

Palms

Finger Tips

Between the fingersThumbs

Dorsal surface

Wrists

Hand Hygiene Efficacy

(AHR)

Effect of Hand
Contamination
Ever touch your head at work?
Without Noticing?

Contaminating Hands

After Disinfection

Disinfection Touching
Hair

Alcohol Hand Disinfectant

is the Best Way to Prevent
Healthcare Associated
Infections


Consensus was based on speed of
action and applicability in clinical
setting

Time After Disinfection

% log
0 60
180minutes
99.9 3.0
Bacterial Reduction

x1000

99.0 2.0

x100

90.0 1.0

x10

0.0 0.0
Baseline

EN 1500:1997
Alcohol-based handrub
(70% Isopropanol)

Antimicrobial soap
(4% Chlorhexidine)
Plain soap

Adapted from: Rotter ML. Hosp Epidemiol Infect Control, 2nd Edition, 1999.

Limitations of scrubs
Lower efficacy + longer duration of the procedure of scrubs
tested by EN 1500

Active agent

exposure (s)

Propan-1-ol/
Propan-2-ol

15
20

conc. (%)

lg
reduction
4.2

30/45

30

4.3
4.9

Propan-1-ol

20

70

4.3

Ethanol

30

75

4.8

Chlorhexidin
based detergent

60

3.1

Triclosan based
detergent

60

0.1

2.8

Decrease of HAI rate

parallel to increase
of compliance from
48 to 66% the rate
Of HAI significantly
decreased from
16.9 to 9.9%

Pittet et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307-12

Decrease of urinary tract

infections and SSI
In an 498-bed acute care of orthopedic
surgery after introduction of alcohol
based hand gel for bedside use
within 16 months the infection rates as
sum of both was decreased by 36.1%
Hilburn et al. Use of alcohol hand sanitizer as
an infection control strategy in an acute care
facility. Am J Infect Control 2003;31(2):109-16.

Prevention of HAI in very low

birth weight (VLBW) neonates
Handwashing with detergent (0.5% triclosan)
vs. hand hygiene program using
antimicrobial soap (4% chlorhexidine
gluconate) + alcohol-based hand rub:
- HAI after 72 hours of life 18.8% vs. 6.3%
- rate of central venous catheter
colonization
16.6% vs. 5.8%
Capretti et al. Impact of a standardized hand
hygiene program on the incidence of nosocomial
infection in very low birth weight infants.Am J Infect
Control 2008;36(6):430-5

Reducing spread of multiresistant bacteria

Introduction of alcohol/chlorhexidine based
rub
use increased from 5.7 to 28.6 L/1000 beddays
46 months post intervention reduction of
- total MRSA isolates 40% (p < 0.001)
- patient-episodes of MRSA bacteraemia
57% (p = 0.01)
- clinical isolates of ESBL-producing E. coli
and Klebsiella spp. 90% (p < 0.001).
Johnson et al. Efficacy of an alcohol/chlorhexidine hand
hygiene program in a hospital with high rates of nosocomial methicillin-resistant Staphylococcus aureus
(MRSA) infection. Med J Aust 2005 21;183(10):509-14

Influence on MRSA rate

Study desing
Introduction of gel rinse disinfection in 250-bed
community hospital
Comparison of the nosocomial infection rate
during one year with retrospective rate.
Result
The rate of MRSA nosocomial infections
per thousand admissions decreased by
51%
Gagne et al. Systematic patients' hand disinfection:
impact on meticillin-resistant Staphylococcus
aureus infection rates in a community hospital- J
Hosp Infect 2010; 29 2010, p S1532-2939

Reasons for non-compliance

No time for hand hygiene (ABHS: 15 -30
seconds)
Forgetting to disinfect hands
Limited access to hand hygiene products
Wearing gloves as an alternative
Skin irritation when using hand disinfectants
Dislike of provided hand disinfectants
Missing role model of superiors
Patarakul K et al. J Med Assoc Thai 2005; 88Suppl 4: S287-93.

Saraya Automatic
Dispenser
Sensor Activated Hand Hygiene

GUD-1000

No cross contamination
Intuitive support for increased
compliance
Disposable pump system

Proven support for increased compliance and hand hygiene usage

Battery life of 1 year.
No contamination risk for bottle or nozzle
Hand hygiene should always be at the point of care

Influence of the dispenser type on consumption of hand

rub
3 months observational study
Installation of different dispenser models
No pre-study teaching or demonstration of usage.

Assadian, O., 2005, Observational Study

Increased usage with sensor

dispensers
L / week
p < 0.01
p < 0.05
p < 0.05
p < 0.05

0.15

0.85
0.70

NS

1.80

Hand Care

The Adverse Effects of Hand

Roughness
Hand
Roughness

A breeding ground for bacteria

Dry skin will
Shed and Fall

Skin carries bacteria to

Contaminate the Area

The Skins Natural More bacteria,

more danger to
Barrier Weakens health
Lower Compliance in Hand Hygiene!

Hand Care Points

Prevent Roughness
Choose a Product That Is Gentle
Less Irritants (Fragrance, Colors)
Rethinking Hand Hygiene Methods
Rinse Well, Wash Less
Use cold water
Use soft paper towels
Always use disinfectant when hands are not
visibly dirty!

Emollient Hand Lotion if Necessary

No Effect on Sebum

g/cm2

Time interval after one hand

disinfection

Alcohols no affect content of sebum (g/cm2)

after one single hand rub for 1 minute

Soaps decrease sebum content (g/cm2) after one

single hand scrub of 30 s > 1 hour

g/cm
2

Time interval after one hand

Absorption of Alcohols
Investigation after excessive hygienic and surgical hand disinfection
alcohol-based hand sanitizer rubs or gel under identical test conditions
with the same test persons to determine the application security

Reasons of the high chosen expositions

no knowledge about the expected resorption rate
detection limit of the concentration for the
chemical analysis
the highest measured blood level of ethanol was
0.03 , for propanols 0.02
Kramer A, Below H, Bieber N, Kampf G, Toma CD, Hbner NO,
Assadian O. BMC Inf Dis. 2007; 7: 117.
Below H, Partecke I, Huebner NO, Bieber N, Nicolai T, Usche A,
Assadian O, Below E, Kampf G, Parzefall W, Heidecke CD, Zuba D,
Bessonneau V, Kohlmann T, Kramer A. Dermal and pulmonary
absorption of propan-1-ol and propan-2-ol from hand rubs.
Am J Infect Control 2012; 40(3): 250-7.

Risk Assessment
Apple juice contain up to 2 g ethanol/l 1
0.5 l
apple juice resulted in an ethanol level for
Male (75 kg)
0.17
Female (60 kg)
0.25
~ 10-fold higher than after an excessive
surgical hand disinfection

Windirsch B, Brinkmann B, Taschan H. Alkoholgehalte

ausgewhlter Lebensmittel. Lebensmittelchemie 2005; 59: 149150

Conclusion
Absorption of all 3 alcohols < 0.03 (under real
conditions ~ 0,003 )

no systemic risk
however the exposure duration should be limited to the
time period which is necessary for the disinfection
effect, because:
- skin tolerability
- compliance
- systemic tolerance

prefer 1,5 min preparations

For skin antisepsis of newborns, use ethanol- instead
propanol- based preparations, for immature premature
infants use non-absorbable antiseptics

"Instead of trying to kill

bacteria in a wound, wouldn't
it be easier if they never had
entered the wound in the first
place?"
Louis
Pasteur

Thank you for listening.

Hand hygiene is essential to patient safety in
in hospitals no matter the situation or symptom.