Hand Hygiene Policy

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Choose an idea of your own which you would like to be a

policy item. How would you as a health care manager get

your idea across to policymakers?

Choose an idea of your own which you would like to be a policy

item.

Introduction

Only few weeks ago, an outbreak of conjunctivitis had affected the whole Island of

Mauritius. This resulted in large cases of absenteeism at work and schools. Long queues of

patients attending health care service points for the latter disease resulted in some health care

provider being affected too. However, some care officers who took the time to disinfect their

hands after seeing hundreds of patients suffering daily from conjunctivitis remained

unaffected by this infection. The hands have been found to play a major role in the

transmission of infection in healthcare institutions, in industrial settings such as the food

industry and also in all community and domestic settings. The necessity of hand hygiene in

controlling infection can not be neglected. This has been recognised by the number of

publications in the medical literature during the last few decades. Major articles on hand

hygiene can be found in prominent general medical journal. Hand hygiene remains the single

most important and economical means of preventing and controlling the spread of infections (

Pratt R J, Pellowe C, “001). Cross infection may occur through micro-organisms on the hands

of the health care workers being introduced directly into susceptible sites e.g. wounds and

catheters ( Reybrouck 1983, Pratt et al 2001).

More a than a century ago, Ignaz P. Semmelweis demonstrated the association between hand

hygiene and nosocomial infections, by clearly demonstrating that appropriate hand hygiene

does prevent puerperal infections and maternal deaths. After that, hand hygiene has been

considered by most healthcare professionals to be the simplest and most cost-effective means

to prevent cross-transmission of microorganisms and nosocomial infections. Nevertheless,

Assignment by Dr T.Seenauth April 18, 2015

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health service providers still show a certain reluctance to translate Semmelweis’ message in

the daily practice. In Mauritius, we lag further behind. There is till date no hand hygiene

policy available in the public health service available. Improving hand hygiene is indeed a

challenge for infection control practitioners in healthcare institutions and in the community at

large.

The World Health Organisation ( WHO) and others describe the five key moments for patient

to patient transmission of organisms via healthcare workers hands ( WHO 2006; Pittet et al,

2006):

1. Before patient contact

2. Before an aseptic technique

3. After body fluid exposure risk

4. After patient contact

5. After contact with the patient surroundings

Studies have shown that at least 30% of healthcare associated infections are preventable.

Transmission of micro-organisms by the hands of health care workers is the main route of

spread (Pittet et al, 2001)/

Most of the Area Health Centres, Community Health Centres and Mediclinic are still using

soap and towels and the dispensing taps and wash basins are not user friendly for application

of good hand washing practices. Still, all is not lost as alcohol is readily available in most of

the health institutions and automatic antiseptic hand dispensers have been applied in most

local dispensaries. What we lack is a hand hygiene policy. A hand hygiene policy will help to

educate the health care staff and population at large about the importance of proper hand

hygiene in our daily lives and health care service points.

Aims and objectives

The policy aims to promote hand hygiene as evidenced-based practice and to identify

responsibilities and equipment required to ensure compliance with hand hygiene and to

prevent the cross infection via the hands.

To describe hand hygiene technique methods at different care levels

The Policy


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• Hand hygiene shall be practiced before and after each patient contact (even if gloves are

worn). All employees are required to wash, rinse, and dry their hands or apply an alcohol

hand rub before beginning work, after using the rest room and prior to leaving work.

• Antiseptic (antimicrobial) hand washing products or alcohol hand rub shall be used for hand

hygiene.

• An alcohol hand rub, may be used for hand hygiene in place of an antimicrobial soap hand

wash. Hands that are grossly contaminated must be washed with lotion soap prior to hand

disinfection with an alcohol hand rub.

• Gloves shall be worn when exposure to blood or any other body fluids, excretions or

secretions is likely.

• For a given patient, site care shall start at the cleanest site (e.g., mouth care) and progress to

the dirtiest site (e.g., urinary catheter care). When going from a dirty site to a clean site, hands

shall be washed or an alcohol hand rub applied between sites.

Preparation for hand washing

The efficiency of hand hygiene is improved by the following:

Short nails

Removal of rings with ridges and stones

Removal of wrist watched, bracelets and rolling up of long sleeves prior to patient

contact ( Gould, 1994)

Routine Hand washing procedure

1. Use warm water to wet hands

2. Apply antiseptic soap/ hand wash containing chlorhexidine

3. Work up a good lather

4. Apply thoroughly on all surfaces of the hands

5. Wash hands for at least 15 seconds

6. Rinse while avoiding splashing and close tap with elbows for elbow-operated taps

7. Keep hands down so that run off will go into the sink and not down the arm.


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8. Dry well with paper towels

9. Discard the paper towels in foot pedal bins

Factors which have led to improved hand hygiene compliance

1. Engineered controls- automatic taps and antiseptic dispensers

2. Improved hand hygiene products

3. Easy access to alcohol gel

4. Improved staff and patients participation

5. Written guidelines, policies and education

For staff to comply with the hand hygiene policy, there should be adequate amount of hand

wash basins placed at convenient locations. If wash basins are not available, provision should

be made for alcohol gel. The latter should be readily available to both patients and health care

service providers placed at convenient places.

Barriers to hand hygiene include:

1. Lack of knowledge and scepticism about value of hand hygiene

2. Insufficient time

3. Beliefs that by wearing gloves there is no need to carry out hand hygiene

4. Basins located inconveniently

5. Lack of water temperature control

6. Poor facilities including contamination

7. Risks associated with hand hygiene products

8. Interference with worker/patient relationship

9. Poor role model


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How would you as a health care manager get your idea across to

policymakers?

The health sector is in a turmoil these days. Acute gastro-enteritis has been the unusual guest

of many Mauritians during the New Year period and conjunctivitis has also not spared many

of us. We shall also not forget the go slow and complaints being made by the Medical Health

officers concerning the working conditions. The recent sit in before the Jeetoo Hospital by

nursing officers has only added salt to the injury. Literature has shown that some policies are

easily accepted and implemented during crisis situations. Timing is very important in getting

a policy idea passed across to policy makers. Now that timing is playing is favour of hand

hygiene as a policy as both acute gastro-enteritis and acute conjunctivitis are both contagious

infections which can proliferate from one affected person to another through our hands. To

convince policy-makers, it is important to demonstrate that the ideas are well-founded and

make sense.

Evidence-based policy making based on international studies and research undertaken in

England have suggested that infection rates could be reduced by up to 10-15 % when staff

cleaned their hands at the point of care. Health care workers have the greatest potential to

spread micro-organisms that may result in infection due to the number of times they have

contact with patients or the patient environment. Hands are therefore a very efficient vehicle

for transferring micro-organisms. Preventing infections required sustained compliance with a

number of good practice areas- including the provision of clean environment, aseptic

techniques, and the management of invasive devices. However, evidence shows that

improving hand hygiene contributes significantly to the reduction of Hospital care acquired

infections (Pratt et al, 2007). Evidence also suggests that many health care professionals,

including nursing staff, do not perform hand hygiene as often as is required or use the correct

technique.

As most policy makers are not aware of the problems encountered in the health care settings,

same should be conveyed to them. However, it is not easy to come in contact with them and


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sometimes, the conveyed information may lie on the policy makers for days before the latter

come across them. It is easier to transmit the message via people who are closer to the policy

makers. Hospital directors, not regional health directors are usually people who are in close

contact with the policy makers. The former comes to visit the health service points regularly

and such concern can be easily conveyed to the policy maker by him.

Policy makers are usually very busy people and they do not have much time to read long

reports. As such, the information should be presented in a short and easily digestible form.

The language used should also be common one as medical jargons should not be used. In the

beginning, the information required will only be about the existence and importance of the

problem. Towards the end, detailed evidence in favour of a particular policy option would be

required. Sometimes, it is difficult to get the information passed up to the policymakers. In

such circumstances, it can be helpful to get the message passed to NGOs, social workers or

union leaders. Because cross-infection concerns all the health care staffs and patients, support

from the unions would be of great help in implementing hand hygiene as a policy in health

care setups.

As mentioned earlier, the health sector has burning issues nowadays and the general belief is

that not enough if being done for the staff benefit. Through the implementation of the hand

hygiene policy, minor infrastructural changes need to be done as well as availability of hand

scrubs etc will be easily accessible to the staff. This will only work in the favour of the policy

makers as any step for a better working condition of the health care staff will be beneficial for

the former only.

Cost is also something which policy makers look at. Even if implementing it will require the

introduction of elbow operated/lever mixer taps or automatic mixer taps in all area health

centre and community health centres, use of disposable tissue paper instead of towels and use

of hand gels instead of soap, the health care providers will happily manage with even alcohol

if the latter is available. Alcohol is available in all the health care spots of the island and only

dispenser are required. To start with, we can use alcohol dispenser at strategic points for both

care providers and patients. Even if only alcohol dispensers are provided, cross infection will

surely decrease.

It is also very important to encourage to participate in hand hygiene activities themselves. In

order to do so, good communication between all the stakeholders is essential. In any function

when the policymakers are present in a health care facility, they should be provided with


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alcohol dispensers to start with hand hygiene. The one who is giving the policymaker the

alcohol dispenser should explain the importance of hand hygiene to the latter. Also, the

hospital director, social worker or union leaders should also be encouraged to use alcohol

dispensers for hand hygiene purposes. At some dispensaries where I work, alcohol dispensers

are put at the disposition of patients upon their entrance to the health care spot and they are

encourage by the staff present to make use good use of them.

Today, technology plays a very important role in our lives. So is it for the policy holders also.

The video Vire Mam can only speak for itself. Use of facebook, youtube and other social

networking site can further help in the implementation of hand hygiene as a policy. These

social networking sites can be used to educate people about the importance of hand hygiene.

It can also be used to communicate between the different healthcare staff and in the same way

to the policy makers. Lobbying through debates, meetings, debates and presentation can be

done to bring forward the important of hand hygiene in our daily lives and healthcare setups.

The implementation of the policy can also be started as a pilot project in a particular health

care spot. It is very easy to motivate staff from certain health centre to start with the hand

hygiene. Initially, alcohol disperser or gels can be provided to the healthcare workers and the

patients attending the particular health institution. Patient coming back with new complaints

in the following few days can be surveyed over a period of time and the same can be

compared to the same period of time before the introduction of the pilot project. The result

can be conveyed to the policy makers.

Policy makers do not make decisions in isolation. They rely on information and advice from

many other specialists and organizations. Evidence based research and lobbying from unions

and different stake holder can surely help bearing in mind that we have just passed through an

outbreak of conjunctivitis and gastroenteritis. Also, the relationship between the

policymakers and the healthcare staff is not so good nowadays. May be, this could help in

healing the wound?


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References

1. A.E. Aiello, E.L. Larson. What is the evidence for a causal link between hygiene and

infections? Lancet Infec Dis, 2 (2002), pp. 103-110

2. V. Curtis, S. Cairncross. Effect of washing hands with soap on diarrhoea risk in the

community: a systematic review. Lancet Infect Dis, 3 (2003), pp 275-282

3. E. L. Teare . Hand washing- a modest measure with big effects BMJ, 318 (1999), p.

686

4. A. Trampuz, A.F. Widmer. Hand hygiene: a frequently missed lifesaving opportunity

during patient care. Mayo Clin Proc, 79 (2004), pp. 109-116

5. Garner, J. S., Favero, M.S. 1986. CDC guidelines for the prevention of nosocomial

infections: Guidelines for handwashing and hospital environment control, 1985.

American Journal of infection control.

6. Gwaltney, J.M., Moskalski, P.B., Hendley,J.O. 1978. Hand to hand transmission of

rhinovirus colds. Annals of Internal Medicine

7. Larson, E.1989. Handwashing: It’s essential-even when you use gloves. American

Journal Infection Control

8. Reybrouck, G.1986. Role of the hands in the spread of nosocomial infections. Journal

of hospital infection


Documents

Hand Hygiene Policy