A SELF STUDY GUIDE

®

HAND HYGIENE: SKIN AND HAND CARE IN THE HEALTHCARE SETTING

Registered Nurses

HAND HYGIENE:

SKIN AND HAND

CARE IN THE

HEALTHCARE

SETTING

OVERVIEWHealthcare-Associated Infections (HAIs) are infections acquired in healthcare settings and are the most frequent adverse events in healthcare. Hundreds of millions of patients are affected by HAIs worldwide each year, leading to significant mortality and financial losses for health systems. Of every 100 hospitalized patients at any given time, 7 in developed and 10 in developing countries will acquire at least one HAI.1 The endemic burden of HAI is also significant. The prevalence of HAIs in developed countries varies between 3.5% and 12%. The European Centre for Disease Prevention and Control reports an average prevalence of 7.1% in European countries. The estimated incidence rate in Canada is 11.6% and in the U.S. is 4.5%, corresponding to 2 million affected patients annually.1 It has been estimated that overall prevalence of HAIs in Australia is 9.7%, affecting as many as 150,000 patients each year.2

Transmission of healthcare-associated pathogens most often occurs via the contaminated hands of healthcare workers (HCWs). Accordingly, hand hygiene (i.e. hand washing with soap and water or use of a waterless, alcohol-based hand rub) has long been considered one of the most important infection control measures for preventing HAI. However, compliance by HCWs with recommended hand hygiene procedures has remained unacceptable, with compliance rates generally below 50% of hand hygiene opportunities.3

PROGRAM OBJECTIVESUpon completion of this educational activity, the learner should be able to:

1. Describe three functions of the skin.2. List two reasons why HCWs may not be compliant with hand hygiene guidelines.3. Describe rationale for maintaining good skin integrity.4. List three hand hygiene products used by healthcare providers.5. Describe methods to enhance skin health.

INTENDED AUDIENCE The information contained in this self-study guidebook is intended for use by healthcare professionals who are responsible for or involved in the following activities related to this topic:

• Educating HCWs• Establishing institutional or departmental policies and procedures• Decision-making responsibilities for hand-barrier products• Maintaining regulatory compliance with agencies• Managing employee health and infection prevention services

INSTRUCTIONS Ansell is a Recognized Provider of continuing education by the California Board of Registered Nursing, provider #CEP 15538 and the Australian College of Perioperative Nurses (ACORN). This course has been accredited for 2 (two) contact hours. Obtaining full credit for this offering depends on completion of the self-study materials on-line as directed below.

Approval refers to recognition of educational activities only and does not imply endorsement of any product or company displayed in any form during the educational activity

To receive contact hours for this program, please go to the “Program Tests” area and complete the post test.

You will receive your certificate via email.

AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION.Any learner who does not successfully complete the post test will be notified and given an opportunity to resubmit for certification.

For more information about our educational programs or perioperative safety solution topics, please contact Ansell Healthcare Educational Services by e-mail at edu@ansellhealthcare.com

Planning Committee Members:Luce Ouellet, BSN, RNLatisha Richardson, MSN, BSN, RNPatty Taylor, BA, RNPamela Werner, MBA, BSN, RN, CNOR

As employees of Ansell Mrs. Ouellet, Mrs. Richardson, Mrs. Taylor and Ms. Werner have declared an affiliation that could be perceived as posing a potential conflict of interest with development of this self-study module.

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TABLE OF CONTENTS

OVERVIEW ........................................................................................................................2

INTRODUCTION ...............................................................................................................4

FUNCTIONS OF SKIN .......................................................................................................5

SKIN COMPONENTS .......................................................................................................5

LAYERS OF THE SKIN ..................................................................................................... 6

SKIN PERMEABILITY ......................................................................................................8

HISTORY OF HAND HYGIENE ..........................................................................................9

CLINICAL SKIN ISSUES ..................................................................................................10

HAND CARE OPTIONS ...................................................................................................12

HAND HYGIENE COMPLIANCE ......................................................................................14

MEDICAL GLOVES ...........................................................................................................18

NEW INNOVATIONS & NEXT GENERATION ................................................................ 19

SUMMARY .......................................................................................................................20

GLOSSARY .......................................................................................................................21

BIBLIOGRAPHY ................................................................................................................22

REFERENCES ....................................................................................................................23

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HAND HYGIENE:

SKIN AND HAND

CARE IN THE

HEALTHCARE

SETTING

INTRODUCTIONIntact skin is the best barrier protection against microorganisms. The skin is the body’s largest organ, covering a surface of approximately 2 square meters. It varies in thickness from 2-3 mm. It is remarkably resilient and is an effective barrier to microorganisms. The human skin has an amazing ability to regenerate and renew itself in an orderly fashion.

Today’s healthcare environment is demanding on the skin. The hands of healthcare workers (HCWs) are a frequent vehicle for the transmission of pathogens to the patient and to the environment. The importance of hand hygiene in our ever changing world of bloodborne pathogens (BBP), healthcare-associated infections (HAI), multiple drug-resistant organisms (MDRO), influenza and pandemic potentials (H1N1, Ebola, etc.) makes it crucial for us to be mindful of the recommended hand hygiene practices.

Vancomycin-resistant Staphylococcus aureus

Due to these heightened concerns, there has been a focus by a number of professional organizations, government agencies and regulating bodies on improving handwashing compliance among all HCWs.

Knowledge deficits may be a contributing factor in non-compliance to recommended hand hygiene protocols.Education is a vehicle to provide knowledge, awareness, and information so that HCWs; nurses, technicians, physicians and all allied healthcare providers such as dentists, hygienists, Life Science, Emergency Medical Services (EMS), and Correctional Services, can make the informed, committed decision to do the right thing, improve compliance and have an impact on bringing and keeping infections under control.

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FUNCTIONS OF SKIN Because it interfaces with the environment, skin plays a key role in protecting the body against pathogens and excessive water loss. Its other functions are insulation, temperature regulation, sensation, synthesis of vitamin D, and the protection of vitamin B folates.

Skin performs the following functions:1. Protection: an anatomical barrier from pathogens and

damage between the internal and external environment in bodily defense; Langerhans cells in the skin are part of the adaptive immune system.

Langerhans cells

2. Sensation: contains a variety of nerve endings that react to heat and cold, touch, pressure, vibration, and tissue injury.

3. Heat regulation: the skin contains a blood supply far greater than its requirements which allows precise control of energy loss by radiation, convection and conduction. Dilated blood vessels increase perfusion and heat loss, while constricted vessels greatly reduce cutaneous blood flow and conserve heat.

4. Control of evaporation: the skin provides a relatively dry and semi-impermeable barrier to fluid loss. Loss of this function contributes to the massive fluid loss in burns.

5. Aesthetics and communication: others see our skin and can assess our mood, physical state and attractiveness.

6. Storage and synthesis: acts as a storage center for lipids and water, as well as a means of synthesis of vitamin D by action of UV on certain parts of the skin.

7. Excretion: sweat contains urea, however its concentration is 1/130th that of urine, hence excretion by sweating is at most a secondary function to temperature regulation.

8. Absorption: the cells comprising the outermost 0.25-0.40 mm of the skin are “almost exclusively supplied by external oxygen” (Stücker, 2002). In addition, medicine can be administered through the skin, by ointments or by means of adhesive patch. The skin is an important site of transport in many other organisms.

9. Water resistance: The skin acts as a water resistant barrier so essential nutrients aren’t washed out of the body.

SKIN COMPONENTSSkin has mesodermal cells, pigmentation, or melanin provided by melanocytes, which absorb some of the potentially dangerous ultraviolet radiation (UV) in sunlight. Skin also contains DNA-repair enzymes that help reverse UV damage, such that people lacking the genes for these enzymes suffer high rates of skin cancer. One form predominantly produced by UV light, malignant melanoma, is particularly invasive, causing it to spread quickly, and can often be deadly. Human skin pigmentation varies among populations in a striking manner. This has led to the classification of people(s) on the basis of skin color.

The skin is the largest organ in the human body. For the average adult human, the skin has a surface area of between 1.5-2.0 square meters (16.1-21.5 sq. ft.), most of it between 2–3 mm (0.10 inch) thick. The average square inch (6.5 cm²) of skin holds 650 sweat glands, 20 blood vessels, 60,000 melanocytes, and more than 1,000 nerve endings.

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HAND HYGIENE:

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SETTING

SKIN LAYERS

Skin is composed of three primary layers:• the epidermis, which provides waterproofing and serves

as a barrier to infection;• the dermis, which serves as a location for the

appendages of skin; and• the hypodermis (subcutaneous adipose layer).

EpidermisEpidermis, coming from the Greek “epi” meaning “over” or “upon," is the outermost layer of the skin. It forms the waterproof, protective wrap over the body’s surface and is made up of stratified squamous epithelium with an underlying basal lamina. The epidermis is the thinnest at eyelids being approximately 0.05 mm and thickest at the palm or soles, approximately 1.5 mm.

The epidermis contains no blood vessels, and cells in the deepest layers are nourished almost exclusively by diffused oxygen from the surrounding air and to a far lesser degree by blood capillaries extending to the upper layers of the dermis. The main type of cells which make up the epidermis are Merkel cells, keratinocytes, with melanocytes and Langerhans cells also present.

The epidermis can be further subdivided into the following strata (beginning with the outermost layer): corneum, lucidum (only in palms of hands and bottoms of feet), granulosum, spinosum, and basale. The corneum layer of the epidermis consists of 25 to 30 layers of dead cells. This layer regulates water loss and prevents harmful pathogens from entering the body.

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DermisThe dermis is the layer of skin beneath the epidermis that consists of connective tissue and cushions the body from stress and strain. The dermis is tightly connected to the epidermis by a basement membrane. It also harbors many nerve endings that provide the sense of touch and heat. It contains the hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels and blood vessels. The blood vessels in the dermis provide nourishment and waste removal from its own cells as well as from the Stratum basale of the epidermis.The dermis is structurally divided into two areas: a superficial area adjacent to the epidermis, called the papillary region, and a deep, thicker area known as the reticular region.

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HypodermisThe hypodermis is not part of the skin, and lies below the dermis. Its purpose is to attach the skin to underlying bone and muscle as well as supplying it with blood vessels and nerves. It consists of loose connective tissue and elastin. The main cell types are fibroblasts, macrophages and adipocytes (the hypodermis contains 50% of body fat). Fat serves as padding and insulation for the body.

HAND HYGIENE:

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SKIN PERMEABILITYHuman skin has a low permeability; that is, most foreign substances are unable to penetrate and diffuse through the skin. However, dry skin may occur reducing the barrier effectiveness of the skin. Dry skin is a result of decreased water content in the outermost layers of the stratum corneum (Rawlings). This disruption of the skin’s natural barrier function has a number of causes unique in the healthcare setting. The constant need to wear gloves, due to Standard Precautions guidelines, means hands are in a perspiration environment that softens the skin and weakens the epidermis.

Additionally, frequent handwashing with detergents or soaps and/or use of alcohol-based hand rubs can attack the skin’s lipid layer. Seasonal changes in humidity, soaps, detergents and caustic chemicals can affect the skin. Glove powders can be irritating to the skin, like sand in your shoe. And the friction of donning and removing gloves numerous times during the workday can increase skin irritation.

HISTORICAL REVIEW OF HAND HYGIENEA number of historic events and discoveries that occurred in the U.S. and Europe in the 1800s set the stage for our current knowledge in microorganisms and disease processes.

1825 – Earliest paper on hand hygiene published. It suggested that utilizing a liquid chlorine solution would benefit HCWs.1843 – Oliver Wendell Holmes (1809-1894) – His independent work on spread of puerperal fever, The Contagiousness of Puerperal Fever.1847 – Ignaz Semmelweis (1818-1865) – work utilizing chlorinated lime solutions for washing hands to decrease the incidence of puerperal fever.1865 – Louis Pasteur (1822–1895) – Germ Theory – explains that germs can cause infectious diseases.1867 – Joseph Lister (1827-1912) – Carbolic acid solution to cleanse and dress wounds.1878 – Robert Koch (1843-1910) – Utilizes steam sterilization for surgical instruments and dressings.1896 – William Halsted requests that a surgical glove be made for his assistant.

Regulatory agencies and professional organizations develop and refine hand hygiene guidelines to meet patient and staff safety needs.

1961 – U.S. Public Health Service – Recommended hand washing prior to having patient contact.1975 – CDC writes formal guidelines for handwashing.1985 – CDC revises written guidelines for handwashing.1987 – Universal Precautions/Standard Precautions1988 – APIC guidelines for hand washing and hand antisepsis.1991 – Bloodborne Pathogens (BBP) Standard1995 – APIC guidelines published with detailed discussion on alcohol-based hand rubs1995 and 1996 – HICPAC recommends antimicrobial soap or waterless antiseptic agent for cleaning hands for multiple drug-resistant organisms (MDRO).

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Ignaz Semmelweis

William Halsted

HAND HYGIENE:

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CARE IN THE

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SETTING

CLINICAL SKIN ISSUESThe healthy, intact condition of our skin is our best barrier protection, but there are a number of factors in the healthcare environment that affect the skin’s condition. The need to perform hand hygiene activities throughout the day with soaps, detergents, alcohol-based rubs and antimicrobials sets the stage for local skin reactions. One of the most frequent is irritant contact dermatitis (ICD) which is simply an irritation of the skin and should not be confused with an allergy. Symptoms can include redness, chapping, chafing, dryness, scaling, cracking and subjective symptoms such as itching and burning.

In the CDC Guideline for Hand Hygiene in the Health-Care Setting (2002) the reports of contact dermatitis are frequently reported as an explanation for non-compliance by HCWs. A HCW with an ICD is a potential threat to their patient and it is a serious occupational issue. HCW skin disorders are the number one occupational illness across all occupations and costs $1 billion annually (Cantrell 2005).

An ICD is a surface condition affecting the skin. Avoiding contact with the irritants, including glove powders, and maintaining a regular regimen of proper skin care will help keep hands healthier and free of irritation. Damaged skin more often harbors increased numbers of pathogens. Moreover, washing damaged skin is less effective at reducing numbers of bacteria than washing normal skin, and the number of organisms shed from damaged skin is often higher than from healthy skin.

Irritant contact dermatitis (ICD)

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Moisturizing is beneficial for skin health and reducing microbial dispersion from the skin. These are important concepts when discussing hand washing techniques and products for hand washing compliance and skin care.

Any of the antiseptic agents used in healthcare can cause ICD. It is most commonly reported with iodophors, but chlorhexidine, PCMX, triclosan and alcohol-based products can also cause local skin reactions. Industry addresses this issue by its continued improvement to products.

Today, chemical allergy, or allergic contact dermatitis (ACD), remains an even more important cause of disability and loss of work than latex allergy. A chemical allergy is an expansive allergic condition; combined with ICD, these conditions represent the second largest occupational disability reported to U.S. OSHA.4 In Australian workplaces, the development of occupational skin disease is the second most common work-related problem presenting to general practitioners in Australia (Hendrie & Driscoll 2003) and occupational contact dermatitis is the most common occupational skin disease (OSD) in westernized industrial countries – about 90-95% of all OSD (Lushniak 2000).

Chemical allergy

A survey of U.K. National Health Service (NHS) staff showed that 43% had signs or symptoms of ICD or allergic ACD, and 10% showed latex hypersensitivity. (Johnson G.1997) In addition, ACD brings a greater risk of bloodborne pathogen infection, because the body’s most effective barrier – intact skin – becomes compromised. The breakdown of the dermis may also allow latex proteins to enter the body, which may facilitate latex protein hypersensitivity in some individuals.5

Chemical allergies to glove products are generally associated with the chemicals used in the glove manufacturing process. A chemical allergy is due to an immunological reaction to a residual chemical leached from finished glove products into the skin of the wearer.

The chemicals used in the glove manufacturing process fall into the following broad classifications:

• Accelerators• Accelerator activators• Stabilizers• Antidegradants• Retarders• Fillers• Extenders

The chemical accelerators induce the majority of chemical allergies. The residues from these accelerators have become a major concern because of their ability to sensitize users and elicit chemical allergic reactions. Over 80% of reported glove-associated ACD is attributable to chemical accelerators.6

It is important to note that chemical allergy can occur from the use of both latex and non-latex medical gloves as both types of gloves are generally manufactured using accelerators.

These figures demonstrate that contact dermatitis—whether irritant or allergic—is a significant issue for those providing medical and technical services.

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HAND HYGIENE:

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CARE IN THE

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SETTING

HAND CARE OPTIONSThere is an abundant offering of hand care options in the medical marketplace. For ease of discussion they are split into two categories: hand hygiene products and skin care products.

Hand Hygiene Products – Products used in handwashing, antiseptic handwash, antiseptic hand rub or surgical hand antisepsis.

Skin Care Products – Products provided for hydration and improved water retention of the skin.

HAND HYGIENE PRODUCTS

The primary consideration when selecting handwashing/sanitizing products must be efficacy. Other factors include, dermal tolerance, aesthetic preferences (fragrance, foaming, color), costs, accessibility, and dispensing.

Handwashing products used by HCWs are regulated by government agencies. There are specific test protocols, procedures and log reductions that must be achieved for the products to be available in the marketplace. This is also true of surgical hand antisepsis products.

The following are some of the preparations used for hand hygiene. These will vary pending government approval.

1. Plain (non-antimicrobial) soapSoaps are detergent-based products that contain esterified fatty acids and sodium or potassium hydroxide. They are available in various forms including bar soap, tissue, leaflet, and liquid or foaming preparations. Their cleaning activity can be attributed to their detergent properties, which result in removal of dirt, soil and various organic substances from the hands. Plain soaps have minimal, if any, antimicrobial activity.

2. AlcoholThe majority of alcohol-based hand antiseptics contain either isopropanol, ethanol, n-propanol, or a combination of two of these products. Although n-propanol has been used in alcohol-based hand rubs in parts of Europe for many years, it is not listed in Tentative Final Monograph (TFM) as an approved active agent for HCW handwashes or surgical hand-scrub preparations in the U.S. A concentration of 60% or higher is generally required for efficacy. Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multi-drug resistant organisms (MDRO) (e.g., methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE), Mycobacterium tuberculosis, and various fungi). Alcohols are not appropriate for use when hands are visibly dirty or

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contaminated with proteinaceous materials. It is recommended you wash your hands when visibility dirty. When hands are not visibility dirty, alcohol hand rub is the preferred method of decontaminating hands. Alcohols are effective for preoperative cleaning of the hands of surgical personnel. Some products have combined alcohol with antimicrobial products such as CHG to increase efficacy.

3. Antimicrobial HandwashHandwash preparations containing antimicrobial agent/s which demonstrate efficacy against various microorganisms.

• Chlorhexidine gluconate, was developed in England in the early 1950s and was introduced into the U.S. in the 1970s. Chlorhexidine gluconate has been incorporated into a number of hand-hygiene preparations. Aqueous or detergent formulations containing 0.5% or 0.75% chlorhexidine are more effective than plain soap, but they are less effective than antiseptic detergent preparations containing 4% chlorhexidine gluconate (CDC). Preparations with 2% chlorhexidine gluconate are slightly less effective than those containing 4% chlorhexidine (CDC).

• Chlorhexidine has substantial residual activity and often used as a surgical scrub. Chlorhexidine has a good safety record with minimal, if any, absorption of the compound through the skin. (CDC)

• Chloroxylenol, also known as parachlorometaxylenol (PCMX), was developed in Europe in the late 1920s and has been used in the U.S. since the 1950s. PCMX is not as rapidly active as chlorhexidine gluconate or iodophors, and its residual activity is less pronounced than that observed with chlorhexidine gluconate.

• Hexachlorophene was first used in the 1950s. Studies of hexachlorophene as a hygienic handwash and surgical scrub demonstrated only modest efficacy after a single handwash. Hexachlorophene has residual activity for several hours after use and gradually reduces bacterial counts on hands after multiple uses.

• Iodines have been recognized as an effective antiseptic since the 1800s. However, because iodine often causes irritation and discoloring of skin, iodophors have largely replaced iodine as the active ingredient in antiseptics. Iodine and iodophors have bactericidal activity against gram-positive, gram-negative, and certain spore-forming bacteria (e.g., clostridia and Bacillus spp.) and are active against mycobacteria, viruses and fungi.

• Quaternary ammonium compounds. Of this large group of compounds, alkyl benzalkonium chlorides are the most widely used as antiseptics. Other compounds that have been used as antiseptics include benzethonium chloride, cetrimide, and cetylpyridium chloride. The antimicrobial activity of these compounds was first studied in the early 1900s, and a quaternary ammonium compound for preoperative cleaning of surgeons’ hands was used as early as 1935.

• Triclosan is a colorless substance that was developed in the 1960s. It has been incorporated into soaps for use by HCWs and the public and into other consumer products. Concentrations of 0.2%–2% have antimicrobial activity.

SKIN CARE PRODUCTS

One has only to look in any grocery store to see the number of products available for skin care. These products do not necessarily work well in the healthcare facility, but they do find their way through the door. The products that should be provided by the healthcare facility should meet the needs of HCWs to help minimize ICD that may be associated with their hand hygiene practices. Additionally, skin care products in the healthcare environment must not negate the effects of antimicrobial soaps and rubs used in the facility or compromise glove barrier materials like latex. Hydrocarbon lotions that contain petroleum, mineral oil or lanolin fall into this category (Davis 2008). such products may affect the barrier property of glove films and particularly latex.

Moisturizing and hydrating ingredients found in skin care products may include the following:

• Glycerin is noted as being one of the best moisturizers. It hydrates the dermis due to its water-retaining abilities.

• Citric acid is a pH adjuster that balances acidity and alkalinity.

• Sorbitol is also used as a moisturizer.• Gluconolactone helps minimize skin flaking.• Chitosan helps to retain moisture.• Panthenol is a vitamin with moisturizing effects.

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HAND HYGIENE:

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HAND HYGIENE COMPLIANCE Transmission of pathogens most often occurs via the contaminated hands of HCWs. Hand hygiene (i.e., handwashing with soap and water or use of a waterless, alcohol-based hand rub) has been considered one of the most important infection control measures for preventing HAIs. However, compliance by healthcare workers with recommended hand hygiene procedures has remained unacceptable, with compliance rates generally below 50% of hand hygiene opportunities. (CDC, WHO, ECDC)

Alcohol-based hand rub use

Observed risk factors for poor adherence to recommended hand hygiene practices*

• Physician status (rather than a nurse) – Nursing assistant status (rather than a nurse) – Male sex

• Working in an intensive-care unit• Working during the week (versus the weekend)• Wearing gowns/gloves• Automated sink• Activities with high risk of cross-transmission• High number of opportunities for hand hygiene per hour of

patient care

Self-reported factors for poor adherence with hand hygiene*• Handwashing agents cause irritation and dryness• Sinks are inconveniently located/shortage of sinks• Lack of soap and paper towels• Often too busy/insufficient time• Understaffing/overcrowding• Patient needs take priority

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* CDC Hand Hygiene Guidelines

• Hand hygiene interferes with healthcare worker relationships with patients

• Low risk of acquiring infections from patients• Wearing of gloves/belief that glove use obviates the

need for hand hygiene• Lack of knowledge of guidelines/protocols• Not thinking about it/forgetfulness• No role model among colleagues or superiors• Skepticism regarding the value of hand hygiene• Disagreement with the recommendations

Additional perceived barriers to appropriate hand hygiene*• Lack of active participation in hand hygiene promotion

at individual or institutional level• Lack of role model for hand hygiene• Lack of institutional priority for hand hygiene• Lack of administrative sanction of non-compliers/

rewarding compliers• Lack of institutional safety climate

Recognizing a need to improve hand hygiene in healthcare facilities, a number of organizations launched Guidelines on Hand Hygiene in Healthcare. These global consensus guidelines reinforce the need for multidimensional strategies as the most effective approach to promote hand hygiene. Key elements include staff education and motivation, adoption of an alcohol-based hand rub as the primary method for hand hygiene, use of performance indicators, and strong commitment by all stakeholders, such as front-line staff, managers and healthcare leaders, to improve hand hygiene.

2002CDC Guideline for Hand Hygiene in Health-Care Settings

2003 National Patient Safety Standards

2005

World Health Organization (WHO) launched its Guidelines on Hand Hygiene in Health Care (Advanced Draft) in October 2005

2006Institute for Healthcare Improvement – How To Guide: Improving Hand Hygiene

2008 Hand Hygiene Australia

2000-2009

European Center for Disease Prevention and Control (ECDC)

2009WHO re-launched their campaign as “Save Lives: Clean Your Hands”

2013Hand Hygiene Practices in Healthcare Settings, Public Health Agency of Canada (PHAC) 2013

Members of ECDC1. European Centre for Disease Prevention and Control, Stockholm

2. National Services Scotland, Edinburgh, United Kingdom

3. General Directorate of Health, Lisbon, Portugal

4. Health Protection Surveillance Centre, Dublin, Ireland

5. Ministry of Health, Youth and Sport, Paris, France

6. Mater Dei Hospital, Malta

7. Quality Agency, Ministry of Health and Consumer Affairs, Madrid, Spain

8. Norwegian Institute of Public Health, Oslo, Norway

9. Scientific Institute of Public Health, Brussels, Belgium

10. Ministry of Health, Nicosia, Cyprus

11. Regional Health and Social Agency, Infectious Risk Unit, Region Emilia-Romagna, Bologna, Italy

12. Institute of Hygiene and Environmental Medicine, Berlin, Germany

13. Institute of Public Health, Bucharest, Romania

14. National Centre for Nosocomial Infection, Sofia, Bulgaria

15. National Patient Safety Agency, London, United Kingdom

16. Health Directorate, Luxembourg

17. Hellenic Centre for Disease Control and Prevention, Athens, Greece

18. National Ministry of Health, Vienna, Austria

19. National Center for Epidemiology, Budapest, Hungary

20. University Medical Centre, Ljubljana, Slovenia

21. Stradins University Hospital, Riga, Latvia

22. Office for Public Health, Vaduz, Liechtenstein

23. Landspitali University Hospital, Reykjavik, Iceland

24. Jagiellonian University Medical College, Cracow, Poland

25. Central Military Hospital, Prague, Czech Republic

26. Statens Serum Institut, Copenhagen, Denmark

27. Health Protection Inspectorate of Estonia, Tallinn, Estonia

28. National Institute for Health and Welfare, Helsinki, Finland

29. The National Board of Health and Welfare, Stockholm, Sweden

30. Regional Public Health Authority, Trenčín, Slovakia

31. Institute of Hygiene, Vilnius, Lithuania

32. Radboud University Nijmegen Medical Centre and Canisius-Wilhelmina Hospital, Department of Clinical Microbiology and Infectious Diseases, Nijmegen, The Netherlands

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Studies indicate sustained improvements in hand hygiene are attainable through the application of broad, multimodal programs that include a communications campaign, education, leadership engagement, environmental modifications, team performance measurement, and feedback. According to the WHO, there is convincing evidence that good hand hygiene practices lead to a reduction of infections caused by multidrug resistant bacteria in health facilities. For example, when hand hygiene compliance in health facilities increases from <60% to 90%, there can be a 24% reduction in MRSA acquisition.

It is important to understand when hand hygiene should be practiced. A 2011 study published in Infection Control and Hospital Epidemiology observed that the rate of HCWs practicing hand hygiene when exam gloves were worn was worse than when exam gloves were not worn. The chances of hands being cleaned before or after patient contact appear to be substantially lower if gloves were being worn 7.

These findings reinforce the need to continue educating on the importance of hand hygiene and when it should be practiced:

• BEFORE touching a patient• BEFORE clean/aseptic procedures• AFTER a body fluid exposure risk• AFTER touching a patient• AFTER touching a patient’s surroundings6,7

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WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members of the Infection Control Programme, for their active participation in developing this material.

October 2006, version 1.

1 BEFORE PATIENT CONTACT

WHEN? Clean your hands before touching a patient when approaching him or her

WHY? To protect the patient against harmful germs carried on your hands

2 BEFORE AN ASEPTIC TASK

WHEN? Clean your hands immediately before any aseptic task

WHY? To protect the patient against harmful germs, including the patient’s own germs, entering his or her body

3 AFTER BODY FLUID EXPOSURE RISK

WHEN? Clean your hands immediately after an exposure risk to body fl uids (and after glove removal)

WHY? To protect yourself and the health-care environment from harmful patient germs

4 AFTER PATIENT CONTACT

WHEN? Clean your hands after touching a patient and his or her immediate surroundings when leaving

WHY? To protect yourself and the health-care environment from harmful patient germs

5 AFTER CONTACT WITH PATIENT SURROUNDINGS

WHEN? Clean your hands after touching any object or furniture in the patient’s immediate surroundings, when leaving - even without touching the patient

WHY? To protect yourself and the health-care environment from harmful patient germs

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MEDICAL GLOVESMedical gloves are an important personal protective device and should be worn during all patient care activities that may involve exposure to blood and other bodily fluids, including contact with mucus membranes and non-intact skin.

Medical gloves serve many purposes, including to help reduce the risk of:

• Contamination of HCWs hands with blood and other body fluids

• Pathogen dissemination to the environment • Transmission from the HCW to the patient and vice

versa, as well as from one patient to another

Gloves should always be changed or removed:• AFTER contact with blood or body fluids• BEFORE seeing a new patient• BETWEEN clean and contaminated sites on the

same patient

Do not wash and reuse gloves since this practice has been associated with transmission of pathogens.8

Unfortunately, glove misuse is regularly present in healthcare facilities, and medical staff often fail to follow gloving best practices, thus facilitating the spread of microorganisms. Studies have demonstrated that HCWs acquire microorganisms on gloved hands when touching contaminated surfaces, which could result in transmission to patients. Bacterial contamination of unused disposable gloves from recently open boxes has also been demonstrated. The unwashed contaminated hand of the HCW reaching into glove boxes has been identified as the source.9

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A research article published in Antimicrobial Resistance and Infection Control 2013, demonstrated that an antibacterial examination glove coated on its outside surface with polyhexanide (PHMB), was able to reduce cross-contamination by > 4 log10, compared to a control non-coated examination glove. The results are encouraging and bolster further clinical investigation on the impact of an antibacterial examination glove.10

Petrie Dish

Bacterial Growth No Bacterial Growth

Additionally, surgical gloves coated on the internal surface with a topical antimicrobial known as chlorhexidine gluconate (CHG) demonstrated the ability to reduce the microbial growth on the hands of the wearer. (Reitzel 2009)

The science of this antimicrobial technology is both theoretically and practically sound and has the potential to prevent microbial transmission in conjunction with good hand hygiene.

NEW INNOVATIONS & NEXT GENERATION

MEDICAL GLOVES WITH ENHANCED SKIN CARE PROPERTIES.

The newest innovations for HCWs have come in the form of protective hand-healthy coatings applied to the inside of surgical and examination gloves. These coatings offer specific benefits to retain moisture and rehydrate skin, despite the negative effects of continual glove-wearing and frequent contact with anti-bacterial handwashing products. Glycerin is found in numerous skin care lotions and has made the transition into a coating for gloves in healthcare. Glycerin is a skin-friendly humectant moisturizer that penetrates into the stratum corneum, where it attracts and retains water. Dimethicone used for decades to protect the skin of babies from diaper rash, is also being incorporated as a coating inside examination gloves. Dimethicone, forms a protective barrier that blocks attack from foreign substances and prevents the skin from drying out has also been utilized in glove coatings.

There is a “Dry Skin Model” (Dermatology Foundation) that describes the path to dry skin and further describes that if there are interventions along this path then this cycle can be broken. Prudent use of proper skin care products and gloves enhanced with skin care ingredients may be of significant help, especially to those HCWs who have skin prone to drying.

ANTIMICROBIAL MEDICAL GLOVES

New innovations are being explored to make medical gloves safer, reducing the risk of surface contamination and ease of use for HCWs. A new breed of examination gloves is being equipped with antibacterial coating on its external surface that reduces the risk of bacterial cross-contamination following glove contact with patients and surfaces by HCWs.

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HAND HYGIENE:

SKIN AND HAND

CARE IN THE

HEALTHCARE

SETTING

SUMMARY

As the body’s largest organ, the skin serves as a waterproof covering that prevents excessive loss or gain of bodily moisture, provides a barrier against invasion by outside organisms that helps keep out disease causing pathogens (bacteria, viruses, fungi). The skin protects underlying tissues and organs from abrasion and other injury, and its pigments shield the body from the dangerous ultraviolet rays in sunlight.

HCWs have a high prevalence of skin irritation because of the need for frequent hand washing during patient care. Hand problems associated with the hand hygiene of HCWs is due to a combination of damaging factors: (1) the removal of barrier lipids by detergent cleaning and alcohol antisepsis followed by a loss of moisturizers and stratum corneum water and (2) the over hydration of the stratum corneum by sweat trapped within gloves. Together they facilitate the invasion of irritants and allergens which elicit inflammatory responses in the dermis.

Ways to minimize adverse effects of hand hygiene include selecting less irritating products, using skin moisturizers, and modifying certain hand hygiene practices such as unnecessary washing. Institutions need to consider several factors when selecting hand hygiene products: dermal tolerance and aesthetic preferences of users as well as practical considerations such as convenience, storage, and costs. (E. Larson)

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GLOSSARY

ACCELERATORS A substance that increases the rate of a chemical reaction

ADIPOCYTESAlso known as lipocytes and fat cells, are the cells that primarily compose adipose tissue, specialized in storing energy as fat

ANTI-DEGRADANT, OR DETERIORATION INHIBITOR Is an ingredient in rubber compounds

EPITHELIUM Is one of the four basic types of animal tissue, along with connective tissue, muscle tissue and nervous tissue. Epithelial tissues line the cavities and surfaces of structures throughout the body. Many glands are made up of epithelial cells. Functions of epithelial cells include secretion, selective absorption, protection, trans-cellular transport and detection of sensation.

ENZYMES Enzymes are macromolecular biological catalysts which are responsible for thousands of metabolic processes that sustain life. They are highly selective catalysts, greatly accelerating both the rate and specificity of metabolic reactions, from the digestion of food to the synthesis of DNA. Most enzymes are proteins, although some catalytic RNA molecules have been identified. Enzymes adopt a specific three-dimensional structure, and may employ organic (e.g. biotin) and inorganic (e.g. magnesium ion) cofactors to assist in catalysis.

FIBROBLAST A type of cell that synthesizes the extracellular matrix and collagen and plays a critical role in wound healing.

LANGERHANS CELL Langerhans cells are dendritic cells (antigen-presenting immune cells) of the skin and mucosa. They are present in all layers of the epidermis, but are most prominent in the stratum spinosum.They are named after Paul Langerhans, a German physician and anatomist, who discovered the cells at the age of 21 while he was a medical student.

KERATINOCYTE The predominant cell type in the epidermis, the outermost layer of the skin, constituting 90% of the cells found there

PIGMENT In biology, a pigment is any colored material found in plant or animal cells. Many biological structures, such as skin, eyes, fur and hair contain pigments (such as melanin).

MACROPHAGES Are a type of white blood cell that engulf and digest cellular debris, foreign substances, microbes, and cancer cells in a process called phagocytosis.

MELANOCYTES Melanin-producing cells located in the bottom layer (the stratum basale) of the skin’s epidermis, the middle layer of the eye (the uvea), the inner ear, meninges, bones, and heart.

MERKEL OR MERKEL-RANVIER CELLS Oval receptor cells found in the skin of vertebrates that have synaptic contacts with somato-sensory afferents. They are associated with the sense of light touch discrimination of shapes and textures. They can turn malignant and form the skin tumor known as Merkel cell carcinoma.

POLYHEXANIDE (polyhexamethylene biguanide, PHMB) A polymer used as a disinfectant and antiseptic. Some products containing PHMB are used for inter-operative irrigation, pre- and post-surgery skin and mucous membrane disinfection, post-operative dressings, surgical and non-surgical wound dressings, surgical bath/hydrotherapy, chronic wounds like diabetic foot ulcer and burn wound management, routine antisepsis during minor incisions, catheterization, first aid, surface disinfection, and linen disinfection.

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HAND HYGIENE:

SKIN AND HAND

CARE IN THE

HEALTHCARE

SETTING

BIBLIOGRAPHY

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REFERENCES

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* Some of the authors listed above are employees of Ansell.

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