1Section D 1

Welcome to Section D, Principles/Practices of Asepsis and Hand Hygiene and

Environmental Issues in Disease Transmission, the fourth of a seven part

course, created by the Statewide Program for Infection Control and

Epidemiology to meet compliance with NC Rule .0206 Infection Control in

Health Care Settings. This course was specifically designed to meet

compliance for healthcare provided in outpatient settings only.

2

There are two objectives for this lecture that will be addressed. The first

objective is to describe the principles and practices of asepsis and hand

hygiene. The second objective is that at the conclusion of this lecture you will

have a better understanding of the risk the contaminated environment plays in

disease transmission.

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3

What are some of the basic principles underlying asepsis? First,

microorganisms are capable of causing illness in humans. Second, these

illnesses can be prevented by interrupting the transmission of microorganisms

from the reservoir to the susceptible host.

Let’s begin by discussing asepsis. Asepsis is the practices that results in an

absence of pathogenic or disease producing microorganisms. Healthcare

providers have used that information since the time of Florence Nightingale

and Joseph Lister to determine when and how asepsis should be carried out to

prevent disease transmission in healthcare settings.

Medical Asepsis: refers to practices that reduce the numbers of

microorganisms and/or prevent or reduce transmission from one person

to another; also referred to as Clean Technique

Surgical Asepsis: refers to practices designed to render and maintain

objects and areas maximally free from microorganisms; also referred to

as Sterile Technique

Section D 3

4

The practice and science of infection control is the knowledge that the risk of

infection acquired by a patient is based on several factors to include: the dose

of microorganism which varies from one pathogen to another, whether a small

or large inoculums is more likely to lead to infection. This risk continues to be

multiplied if there is prolonged exposure in time, increasing the total dose.

And finally, the risk is affected by the virulence or strength of the particular

pathogen causing systemic disease from a mild case, for example a cold virus,

to Ebola, which is life threatening in humans.

The ability to withstand any microorganism and its outcome is based on the

host’s defense or underlying resistance that can be compromised by age,

nutrition, disease, or further compromised by medical treatments.

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5

Medical asepsis, also called ―clean technique,‖ refers to practices that reduce

the numbers of microorganisms or that prevent or reduce transmission from

one person to another.

Some examples of medical asepsis are hand hygiene which includes hand

washing or the use of waterless alcohol based hand rubs. Medical asepsis also

includes barrier techniques such as the use of clean gloves for the purpose of

minimizing clothing contamination, clean gloves to avoid direct contact with

infectious materials, and the ―no touch‖ dressing technique to avoid

contamination of sterile supplies or sterile gloves for dressing application.

Medical asepsis also includes routinely cleaning the environment to keep the

bio-burden low.

An important concept of asepsis is to always clean from the clean areas to the

dirty, so as not to recontaminate what is clean by dragging contamination back

onto the area that is being decontaminated. A good example of that is prepping

skin in a concentric circle out or by back and forth working out from incision.

The same principles apply to cleaning the environment.

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6

Medical asepsis then is to be utilized for all patient care activities.

This includes hand hygiene at designated times, and the routine cleaning and

disinfection of equipment that we discuss further in this lecture.

Medical asepsis also includes the care of patients with communicable diseases

And medical asepsis should be followed for all non-surgical procedures (for

example, general exams and IV medications).

Section D 6

7Section D 7

One of the important concepts of asepsis is the role the environment plays in

disease transmission in healthcare settings.

Environmental surfaces can become contaminated with microorganisms during

patient care. While environmental surfaces have not been directly involved in

bloodborne pathogen transmission to healthcare workers (HCWs) or patients,

these surfaces have been associated with an increased risk for multi-drug

resistant organisms (MDRO) pathogens.

However, environmental surfaces that include things like exam tables,

countertops, chairs, door handles do not require decontamination procedures as

stringent as those used on patient care items. You cannot sterilize the

environment. But HCWs can reduce bioburden and pathogens to make it safer

for patients.

8

It is important to realize that bloodborne pathogens have a fairly long survival

time. HIV has the least survival time averaging a one log reduction every eight

hours. What that means is the average person with HIV infection may have

1000 HIV particles per ml of blood. If a ml of blood is on a hard surface after

eight hours of exposure to the air and light, a one log reduction would mean

there be 100 infectious particles, and after another eight hours there would be

only 10 infectious particles. Thus after 24 hours most HIV infectious particles

on ―unprotected‖ surfaces will be dead.

Some studies have shown that HIV in sewage can survive longer because the

organic material is ―protected‖ from light and air that promotes the viral death.

We know less about HBV survivability. But blood contamination, even when it

cannot be seen by the human eye on a surface, can be detected by culture for

about a week. This information is important in areas with lots of blood

contamination such as dialysis units and blood drawing labs when thinking

about reuse of items such as tourniquets.

Regarding HCV, a recent study found that the virus can survive for at least 14

days, decreasing by 3 to 4 logs over that time.

Section D 8

9Section D 9

There are two categories of environmental surfaces.

Clinical contact surfaces have a high potential for direct contamination from

patient secretions especially during procedures that generate spray or splatter,

or by contact with HCWs gloved hands or from the patient’s or family’s

contaminated hands. These surfaces can become a reservoir for contamination

of instruments, patient care devices, or HCW’s bare or gloved hands.

Housekeeping surfaces such as the floor, walls, curtains, windows do not come

into contact with patients or devices used in healthcare procedures. Therefore,

they have a limited risk of disease transmission.

10Section D 10

General cleaning recommendations include the use of appropriate protective

barriers such as heavy-duty utility gloves, masks, and protective eyewear when

cleaning and disinfecting surfaces.

In general, cleaning and removal of microorganisms is as important as the

disinfection process itself. Blood or other patient materials left on surfaces can

interfere with the disinfecting process. Follow the manufacturer’s instructions

for proper storage, dilution, and use of hospital disinfectants.

Because of their toxic nature, the use of sterility or high-level disinfectants on

environmental surfaces is NOT recommended. It is critical to read the

manufacture's recommendations for correct use and verify that the written

information says that the product is an EPA approved or registered germicidal

disinfectant for healthcare.

11

There is a plethora of EPA approved germicidal cleaning agents for use in

healthcare facilities available on the market today. Some products have to be

diluted, and others are pre-diluted by the manufacturer, which are more

convenient but generally are more costly. There are several makers of

disinfectant wipes which are very convenient and improve HCW compliance

because of the ease of use. All disinfection products have an expiration date

that needs to be monitored to prevent out of date products from being used.

Also once products have been mixed, they will have a recommended time to

be used according to the manufacturer's instructions, which regulatory

agencies may be checking along with the evidence of the correct dilution.

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12

The EPA approved healthcare disinfection products are formulated and tested

for the ability to kill microorganisms. If the product can kill all

microorganisms, except for high numbers of bacterial spores, then it is

considered a high level disinfectant. Spores such as anthrax and C difficile are

the most resistant pathogens to disinfection.

An intermediate level disinfectant product can destroy mycobacterium species

including tuberculosis. This is important because the soil and water contain

mycobacterium other than TB species, such as M bovis that could contaminate

instruments if tap water rinses are used during reprocessing.

Then there are low level disinfectants; these products kill all the common

vegetative bacteria (Staph, strep, E coli, Pseudomonas and all other gram

negative and positive bacteria). But these products do not kill TB or other

strains of mycobacteria such M bovis.

Quaternary ammonium based compounds are the most common products used

in healthcare in the US for low or intermediate cleaning and disinfection

products.

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13Section D 13

Recommendations for cleaning nonclinical housekeeping surfaces, which have

the least risk for transmitting infections in healthcare settings, include the

following. On a routine basis, these environmental surfaces should be cleaned

with either soap and water, or an EPA-registered detergent/hospital

disinfectant.

Wet mops and cloths may become contaminated with microorganisms, so clean

the mop and cloths after use and allow them to dry thoroughly before re-using.

Prepare fresh cleaning and disinfecting solutions daily and follow the

manufacturer’s recommendations for use.

14

In the past decade, computers have become commonplace throughout most

healthcare settings. Because of the frequent hand contact and that the

keyboards are often in clinical areas, these surfaces may be frequently

contaminated and then serve as reservoirs for pathogens.

The question of how to disinfect keyboards was evaluated in a study done by

the researchers at the University of North Carolina Healthcare System.

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15

UNC tested products for their effectiveness to remove or inactivate the test

pathogens Methicillin-resistant Staphylococcus aureus (MRSA) and

Pseudomonas aeruginosa from the computer keyboards. Importantly, no

functional or cosmetic damage occurred after 300 wipes.

The disinfectants tested included: 3 quaternary ammonium compounds, 70%

isopropyl alcohol, a phenolic, and chlorine at (80ppm).

At present, based on the results of the study where all disinfection agents in

this study were found to have a 95% effectiveness, it is recommend that

keyboards be disinfected daily (for 5 sec), and when visibly soiled, and that

disinfectant wipes be used for one surface cleaning area only one time.

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16

In addition, the study found that the there was some sustained efficacy of the

disinfectants when applied to the keyboards which was evaluated by using

target pathogen Vancomycin-resistant Enterococcus (VRE). VRE was placed

on control keys and on keys that had been wiped with one of the disinfectants

listed, then challenged by reintroduction of VRE onto the keys at 6, 24, and 48

hours and re-cultured after 10 and 60 minute exposures.

The results represent the percentage differences in the number of colony

forming units on the treated versus the control keys at each of the challenges.

CaviWipes, Chlorox Disinfecting Wipes, and Sani-Cloth Plus Wipes all had

100% sustained effectiveness at 6, 24, and 48 hours, demonstrating good

residual sustained protection with these products. However, alcohol and sterile

water had minimal sustained effectiveness, which was expected.

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17

One of the expectations of CMS surveyors and OSHA inspectors is to have a

policy that includes environmental cleaning with the appropriate disinfection

products readily available, and education of HCWs as demonstrated by their

ability to describe how to decontaminate blood or other potentially infectious

materials or (body fluids) known as OPIM. The most important of these steps

is to decontaminate promptly to prevent others from being contaminated.

Appropriate PPE must be worn that will prevent skin or clothing

contamination. The product used can be either a 1:10 to 1:100 bleach to water

dilution (that means one part bleach to 9 or 99 parts of water). The

concentration depends on the size of the spill and amount of blood. The CDC

recommends that the bleach solutions be made fresh daily. However, UNC

completed a study that demonstrates a 50% reduction in effectiveness over 30

days if the solution is kept in a tightly closed and opaque container.

Alternatively, the CDC recommends use of intermediate level disinfectants

that have a tuberculocidal label claim, or a HIV and hepatitis B label claim for

killing effectiveness.

And as a reminder, although considered patient friendly, it is not recommend

to have carpets in operating or procedure rooms, labs, and instrument

processing areas because of the gross amount of contamination.

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18

Now that we have described the key points of medical asepsis, let’s review the

recommended methods to follow for sterile technique or ―surgical asepsis‖ for

maintaining a sterile field when doing invasive sterile procedures and in the

operating room.

These techniques include that scrubbed persons wear sterile gowns and gloves,

that sterile drapes are used to establish a sterile field, and that items used

within a sterile field are sterile.

Finally all items introduced onto a sterile field are opened, dispensed, and

transferred by methods that maintain sterility and integrity as described in the

Association of Operating Room Nurses (AORN) Standards.

Any equipment or medications should be prepared immediately before the

procedure to avoid contamination of the sterile field. Opened sterile packs

should not be covered especially if the idea is to preserve the setup for use

later.

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19

Sterile technique also includes environmental controls to maximize the

reduction of microorganisms during surgical procedures.

Control activities that will reduce airborne transmission include: keep patient,

supplies and reprocessing separated, segregate clean and dirty supplies, and

enforce a protocol for transporting clean, sterile, and soiled equipment and

supplies to and from the operating room. Limit those entering the operating

room to only necessary personnel.

When visible soiling or contamination with blood or OPIM of surfaces or

equipment occurs during an operation, use a disinfectant cleaner to clean the

affected area before the next case. Wet vacuum or use a clean mop and

solution on the OR floor at end of day, clean all horizontal surfaces (the

surgical lights, floors, equipment) on a daily basis, and clean patient transport

vehicles including straps after each use.

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20

Many minor office procedures are performed in examination or treatment

rooms. Consider designating one room to be reserved for any procedures

involving incisional surgery. The room should be easy to clean and contain

minimal excess equipment or carpeting.

Masks for most minor brief procedures are unnecessary. However, for long

procedures with a high risk of infection due to interruption on normal host

defenses, such as those affecting or creating non-intact skin or disrupting

mucous membranes (for example, Mohs surgery, or a spinal tap) a mask and

sterile technique should be followed. This preparation should include at least a

scrub with CHG or povidone iodine soap.

Also, sterile technique is recommended by the United States Pharmacopeia

(USP) for preparation and administration of medications and fluids

administered via vascular catheters.

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21Section D 21

The next topic to be discussed is Hand Hygiene.

22Section D 22

According to the CDC, hand hygiene is the single most important factor in

preventing the spread of pathogens in healthcare settings.

• First, because hands are the most common mode of pathogen

transmission.

• Second, hand hygiene can reduce the spread of antibiotic resistance

in healthcare settings

• Finally, hand hygiene can prevent a healthcare-associated infections.

[Additional comments: CDC estimates that each year nearly 2 million patients

in the United States acquire infections in hospitals, and about 90,000 of these

patients die as a result.]

23Section D 23

Hand hygiene is a general term that applies to either handwashing, antiseptic

handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.

• Handwashing refers to washing hands with plain soap and water.

• Antiseptic handwash refers to washing hands with water and soap or

other detergents containing an antiseptic agent, such as triclosan or

chlorhexidine.

• Using a waterless agent containing 60%–95% ethanol or isopropanol

alcohol-containing preparation is referred to as an alcohol handrub.

These agents are a new addition to the guidelines and have become

used frequently in the United States to improve compliance with

handwashing in hospitals.

• Surgical antisepsis refers to an antiseptic handwash or alcohol-based

handrub performed preoperatively by surgical personnel to eliminate

microorganisms on hands. Antiseptic preparations for surgical hand

hygiene should have persistent (long-lasting) antimicrobial activity.

* If using an alcohol-based handrub as a surgical scrub, the hands

should first be washed with soap and water.

24

In the absence of a true emergency, personnel should always perform hand

hygiene

• Before and after taking care of patients

• Before performing invasive procedures

• Before eating

• When hands are visibly soiled

• After bare handed contact with a source that is likely to be

contaminated with blood, saliva, or respiratory secretions

• Before and always after glove removal

2525

First, let’s examine what is know about the presence of hand-borne microorganisms. Bacterial counts on hands range from 104 to 106, very high numbers. Resident microorganisms are attached to deeper layers of the skin and are more resistant to removal, but these are much less likely to be associated with healthcare-associated infections (HAIs). They include non-virulent skin flora like Diphtheroids, including Corynebacterium spp, coagulase-negative staphylococcus often speciated as Staph epidermis and others.

That compares to transient microorganisms that colonize the superficial layers of skin and are more easily removed. These are acquired by direct contact with patients or contaminated environment surfaces and are frequently associated with HAIs. Typical examples in healthcare are the gram negative rods, whose reservoirs are wet areas to include Pseudomonas, Serratia, and Escherichia (E) coli, and gram positives, most significantly Staph aureus, including MRSA.

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2626

What do we know about how pathogens on the hands of HCWs can be

transmitted to patients?

Transmission from patient to patient via healthcare worker (HCW) hands

requires four elements:

The organisms must first be present on HCWs hands (via patient or

environment contact).

The organisms must be able to survive for several minutes on hands

between patient contacts.

The HCWs hand hygiene must be inadequate or the agent

inappropriate.

And the contaminated hands of HCW must come in contact with

another patient (or an inanimate object that will contact the patient)

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2727

Thirty-four studies of hand hygiene practices, mostly in hospitals, observed

doctors, nurses and respiratory therapists mostly before alcohol based hand

rubs (ABHRs) were widely available, so these observations were made for

evaluating compliance with soap and water hand washing. These studies

reported an astoundingly low 40% average of hand-washing compliance

overall. Physicians consistently performed the worst in these studies. The most

frequent reasons given by HCWs for the lack of hand-washing were

inaccessibility of hand hygiene supplies, skin irritation from the hand hygiene

agents, interference with patient care, lack of knowledge of the guidelines, and

lack of information on the importance of hand hygiene.

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2828

Hand hygiene encompasses hand-washing shown here or the use of alcohol

based hand rubs. Hand hygiene when done correctly and appropriately is the

single most effective procedure that HCWs can do to prevent cross-

transmission and subsequent healthcare-associated infections. The purpose of

hand hygiene is to remove transient microbial contamination acquired by

recent contact with infected or colonized patients or environmental surfaces.

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29

It is one of the first procedures taught in nursing education programs, BUT

many HCWs do not use correct hand-washing technique. Standard hand-

washing technique begins with removing jewelry; then wetting hands under

running water while keeping the hands lower than the elbows; next applying

soap or antiseptic; and using friction to clean between fingers, palms, backs of

hands, wrists, and forearms, vigorously washing under a stream of water for at

least 15 seconds; rinsing under running water; and using paper towels to dry

hands. Ideally, use the paper towel to turn off the faucet.

Section D 29

3030

Unfortunately, observational studies of HCWs have revealed dismal

compliance with the recommended handwashing technique just described,

with the average duration of handwashing between 6.5 to 21 seconds. In 10 of

14 studies, handwashing duration was less than the recommended minimum

of 15 sec, and in 8 of 14 studies it was less than 10 sec. These are inadequate

lengths of time for effective handwashing because it does not allow for all

surfaces of the hands and fingers to be cleaned as noted in these studies. The

areas between the fingers and the areas around and under the fingernails are

the most contaminated on hands.

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3131

Alcohol based hand rubs (ABHRs) are waterless, and so can be placed in more

accessible places and carried as home health providers travel. ABHRs have

been shown to be more efficacious than soap and water and have a low

incidence of dermatitis associated with their use.

The technique HCWs should use with ABHRs is to apply to one hand and rub

hands together, covering all surfaces. Follow manufacturer’s recommendation

on volume (e.g., form golf ball versus softball size).

HCWs should be educated regarding the manufacturer’s instructions about the

specific product used in their organization for number of applications

(generally 6 to 8) between a soap and water wash to remove the build-up of the

ABHR product. HCWs should also be educated about the importance of

allowing the hands to dry completely before providing direct or indirect

contact with patients or surfaces. The time for drying is when the activity of

the ABHR is eradicating organisms. HCWs should not wipe their hands on

their clothing to facilitate drying.

31

32Section D 32

This slide lists the benefits and limitations of alcohol-based preparations.

• Alcohol handrubs have a rapid and effective antimicrobial action

when applied to the skin but must contain other ingredients, such as

chlorhexidine or triclosan, to achieve persistent (long-lasting) activity.

• When combined with emollients, or skin softeners, they can improve

skin condition.

• In hospital settings, they are often more accessible than sinks.

However,

• Alcohol is not a good cleaning agent, so these products cannot be used

if hands are visibly soiled.

• Because of their flammable nature, they must be stored away from

high temperatures or flames.

• In addition, there is some concern that hand softeners and glove

powders might build up on the hands after repeated use. Hands should

be washed occasionally with soap and water.

3333

In studies comparing the efficacy of plain soap or antimicrobial soap versus

ABHR in reducing bacterial counts on hands, the ABHRs were found to be

more effective than plain soap and water in 17 studies. ABHRs are perceived

to be easier to use by HCWs and more available since a sink is not required.

In all but two trials (15 out of 17), ABHRs reduced bacterial counts on hands

to a greater extent, than washing with soaps or detergents containing povidone-

iodine, 4% CHG, or triclosan.

33

34Section D 34

In summary, plain soap is good for reducing bacterial counts, but antimicrobial

soap is better and alcohol-based handrubs are the best for providing activity

that prevents or inhibits survival of microorganisms after the product is

applied.

3535

A brief review of official hand-washing recommendations indicates significant

changes over the past 50 years.

The U.S. Public Health Service in 1961 recommended a soap and water wash

for 1-2 min before and after patient contact. The CDC between the years 1975

and 1985 recommended a non-antimicrobial hand-washing between patient

contacts and antimicrobial before invasive procedures. Elaine Larson

completed the APIC Guidelines for Hand-washing and Antisepsis in 1988,

which were similar to the prior CDC recommendations, except they included

more discussion on the ABHRs, and were revised in 1995. CDC in 1996 stated

that either antimicrobial soap or ABHRs should be used upon leaving the room

of a patient on precautions for MDROs (MRSA/VRE) which then brings us to

the most current guidelines revisions published by the CDC in 2002.

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3636

The current CDC HICPAC, Guideline for Hand Hygiene in Healthcare

Settings was released as prepared by Drs. John Boyce and Didier Pittet. This

guideline as well as all CDC HICPAC Guidelines can be found on the SPICE

(www.unc.edu/depts/spice/) or CDC.gov website. We will review the current

recommendations in detail.

As we review the recommendations, keep in mind, category IA and IB are

recommendations from the peer reviewed scientific literature that have been

evaluated by HICPAC to be have value in implementing. Category IC are

recommendations from governmental or regulatory authority so must be done.

Category II are not based on current science to date; these procedures may or

be of some merit and have some theoretical rational but there are no studies

available to support recommending. Unresolved issues are procedures or

practices that are unanswered as to the efficacy.

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3737

The rational for adding the IB recommendations for HCWs to do hand hygiene

before having direct contact with patients and after any patient contact, even

with intact skin, is because of studies that show HCWs contaminate hands

even by performing ―clean procedures.‖ Nurses contaminated their hands with

100-1000 CFU during such ―clean‖ activities as lifting patients, taking the

patient’s pulse, blood pressure, or oral temperature, or touching the patient’s

hand, shoulder, or groin.

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3838

What are the indications for handwashing and hand antisepsis? A category IA,

the strongest scientifically supported recommendation and one that all

healthcare organizations should adopt and implement, is that if hands are

visibly dirty or soiled, they should be washed with a nonantimicrobial soap

and water, or antimicrobial soap and water. That is because ABHRs, just like

all antiseptic and disinfectant, cannot work effectively in the presence of

organic material and dirt.

BUT, if hands are not visibly soiled, HCWs should use an alcohol-based

handrub for routinely decontaminating hands in all other clinical situations, a

IA recommendation. It is important because the CDC suggests using ABHRs

as directed as the routine choice for all hand hygiene, with the exception if

hands are visibly contaminated. However, not all healthcare facilities and

organizations could implement the use of ABHRs quickly, so the CDC

included a IB recommendation that alternatively, HCWs wash hands with

antimicrobial soap and water. (IB)

There are 11 indications for when CDC recommend hand hygiene be

completed including the IB recommendations:

1)Before having direct contact with patients. IB

2) Before donning sterile gloves when inserting a central intravascular

catheter. IB

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3939

Continuing with CDC recommended indications for hand hygiene using

ABHR if not visibly soiled:

3) Before inserting urinary catheters, peripheral vascular catheters, or

other invasive devices. IB

4) After contact with a patient’s intact skin. IB

5)After contact with body fluids, mucous membranes, non-intact skin

or wound dressings, as long as hands are not soiled. IA

6)If moving from a contaminated body site to clean a site. II

7)After contact with inanimate objects in vicinity of patient. II

8)And after removing gloves. IB

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4040

The last 3 CDC HICPAC indications for handwashing or hand antisepsis

include:

9) Use non-antimicrobial/antimicrobial soap and water before eating and

after using a restroom. IB The rational is fecal oral spread pathogens including

the non-enveloped virus (Norovirus), and spore forming Clostridium difficile

are not inactivated by alcohol, so the ABHRs are not effective against

transmission. Soap and water, even antiseptic soap, will not kill these

pathogens either, BUT used as directed, soap and water will physically remove

the pathogens

10) Antimicrobial towelettes may be an alternative to washing hands with

non-antimicrobial soap and water, but studies have demonstrated they are not

as effective as the ABHRs. IB

11) No recommendation on routine use of non-alcohol-based handrubs. There

a few non ABHRs in the US market but as yet the data does support their use

in healthcare. Unresolved issue.

40

41Section D 41

Hand lotions can prevent skin dryness associated with hand washing.

However, it’s important to consider the compatibility of lotion and antiseptic

products and the effect of petroleum or other oil emollients on the integrity

of gloves when selecting and using them.

Short nails allow thorough cleaning of nails and may reduce premature glove

tearing. Artificial nails can harbor pathogens—thus, their use should be

avoided.

During surgical procedures, hand or arm jewelry can harbor microorganisms

or increase risk of glove failure. If worn during non-surgical procedures,

hand or arm jewelry can affect glove placement, fit, or durability.

42Section D 42

Occupationally-related contact dermatitis can develop from frequent and

repeated use of hand hygiene products, exposure to chemicals, and glove use

and create compliance issues for HCWs with hand hygiene as well as

additional exposures for HCWs and patients to bloodborne pathogens and

microorganisms.

43

Healthcare personnel with dermatitis may pose a risk to patients they contact

because the condition creates cracks and crevices in the skin that for allow

colonization where large numbers of bacteria can lodge.

Even with hand washing of the damaged skin the bacterial counts are

appreciably reduced.

Adding to the problem that these individuals are a likely reservoir for

potentially pathogenic organisms is that personnel with dermatitis tend to

avoid hand washing due to the fear of making their condition worse and or the

discomfort from performing hand hygiene on damaged skin.

Section D 43

44

Several recommendations for HCWS to help prevent and alleviate

dermatitis are known.

These include

• To rinse and dry skin adequately after performing hand washing.

• To use the appropriate amount of antiseptic per the manufacturer’s

directions.

• To use hand lotions when appropriate and that are compatible with

the soap and ABHR products.

• To obtain alternative antiseptic agent for the HCW.

A dermatologic consult may need to be obtained to determine a plan for

HCW which could include wear gloves or glove liners and or in

combination some protective hand creams have claims of efficacy in

reducing dermatitis.

Section D 44

45Section D 45

Latex allergy is a Type I or an immediate hypersensitivity reaction to the

proteins found in natural rubber latex. These proteins can attach to the powder

in gloves which, in turn, causes more latex protein to reach the skin.

• This reaction is generally a more severe and immediate systemic

reaction than contact dermatitis. Common reactions include runny

nose, itchy eyes, hives, and burning skin sensations.

• More severe reactions are characterized by breathing difficulty and,

rarely, anaphylaxis (shock) or death.

Photo credit: Arto Lahti, MD, Department of Dermatology, University of Oulu,

Finland.

46Section D 46

Not all skin reactions are due to an allergic reaction to latex rubber. Most skin

reactions are attributed to an irritant or allergic contact dermatitis.

• Irritant contact dermatitis develops as dry, itchy, irritated areas on the

skin around the contact area. It is commonly associated with frequent

handwashing and is not an allergic reaction.

• The second type of contact dermatitis is a type IV or delayed

hypersensitivity or allergic reaction due to contact with a chemical

allergen (e.g., accelerators and other chemicals used in the

manufacture of patient-care gloves). Reactions are generally localized

to the contact area and occur slowly, over a period of 12–48 hours.

47Section D 47

Other recommendations can minimize the risk of contact dermatitis and latex

hypersensitivity:

• Educate healthcare personnel about reactions associated with

frequent hand hygiene and glove use.

• Staff that have dermatologic problems should get a diagnosis from a

qualified medical provider before making changes in gloves or hand

hygiene agents.

• Screen patients and healthcare personnel for latex allergy in your

medical histories.

• Healthcare personnel and patients with latex allergy should not have

direct contact with latex-containing materials and should be in a

latex-safe environment with all latex-containing products removed

from their vicinity.

• Have medical emergency latex-free products available at all times.

48

Like all liquids used in healthcare including disinfectants and soap products,

appropriate storage to prevent contamination is important.

Disposable containers are generally recommended for liquid hand care

products.

However, be sure if using containers that are refillable that they are closeable

and can be washed and dried between all refills.

It is especially important, not to add soap or lotions which is called ―topping

off‖ to partially empty containers. The rationale is that a small amount of

contaminate can continue to grow in the containers when topping off is done.

Eventually, depending on the amount of the inoculums and type of organisms,

the soap can become contaminated.

Section D 48

49Section D 49

In summary, it is most important that HCWs know when hand hygiene should

be performed to comply with regulatory agencies and for patient protection.

The CDC recommends that hand hygiene be performed:

• When hands are visibly dirty.

• After touching contaminated objects with bare hands.

• Before and after patient treatment; that is, before glove placement

and immediately after glove removal.

Photo credit: Centers for Disease Control and Prevention, Atlanta, GA.

50

Thank you for your time and attention. That concludes Section D. References

follow on the last slide and I encourage you to use these references, along with

the this slide presentation in the development or updating of policies.

Section D 50

51Section D 51