DR.T.V.RAO MD 1

Dr.T.V.Rao MD

HAND WASHING A SOLUTION TO HOSPITAL INFECTIONS

DR.T.V.RAO MD 2

• Most common mode of transmission of pathogens is via hands!

SO WHY ALL THE FUSS ABOUT HAND HYGIENE?

DR.T.V.RAO MD 3

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

DR. IGNAZ SEMMELWEIS POSTULATED

DR.T.V.RAO MD 4

DR. IGNAZ SEMMELWEIS PROVED THE HYPOTHESIS – MANY IGNORED

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

DR.T.V.RAO MD 5

DOES HAND WASHING WORK?SEMMELWEIS - 1847

Month Births Deaths % Mortality

April 312 57 18.3

May 294 36 12.2

June 268 6 2.4

July 250 3 1.2

DR.T.V.RAO MD 6

HAND-BORNE MICROORGANISMS

• Presence – bacterial counts on hands range from 104 to 106

• resident microorganisms-attached to deeper layers of the skin and are more resistant to removal; less likely to be associated with HAIs.

• transient microorganisms-colonize the superficial layers of skin and amenable to removable; acquired by direct contact with patients or contaminated environment surfaces; frequently associated with HAIs.

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ESTIMATED RATES OF HCAI WORLDWIDE

• At any time, over 1.4 million people worldwide are suffering from infections acquired in health-care facilities

• In modern health-care facilities in the developed world: 5–10% of patients acquire one or more infections

• In developing countries the risk of HCAI is 2–20 times higher than in developed countries and the proportion of patients affected by HCAI can exceed 25%

• In intensive care units, HCAI affects about 30% of patients and the attributable mortality may reach 44%

DR.T.V.RAO MD 8

WHY SHOULD YOU CLEAN YOUR HANDS?

• Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene

• Therefore hand hygiene concerns you!

• You must perform hand hygiene to:

• protect the patient against harmful germs carried on your hands or present on his/her own skin

• protect yourself and the health-care environment from harmful germs

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• Hands are the most common vehicle to transmit health care-associated pathogens

• Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps

HANDS ARE THE MAJOR SOURCE OF PATHOGENS

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INDICATIONS FOR HAND HYGIENE

When hands are visibly dirty, contaminated, or soiled, wash with non-antimicrobial or antimicrobial soap and water.

If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands.

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

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SPECIFIC INDICATIONS FOR HAND HYGIENE

• Before:• Patient contact

• Donning gloves when inserting a CVC

• Inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don’t require surgery

• After:• Contact with a patient’s skin

• Contact with body fluids or excretions, non-intact skin, wound dressings

• Removing gloves

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

DR.T.V.RAO MD 12

EFFICACY OF HAND HYGIENE PREPARATIONS IN KILLING BACTERIA

Good Better Best

Plain Soap Antimicrobial soap

Alcohol-based handrub

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TIME SPENT CLEANSING HANDS:ONE NURSE PER 8 HOUR

SHIFT Hand washing with soap and water: 56 minutes

• Based on seven (60 second) handwashing episodes per hour

Alcohol-based handrub: 18 minutes• Based on seven (20 second) handrub episodes per hour

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

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

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RECOMMENDED HAND HYGIENE TECHNIQUE

• Handrubs• Apply to palm of one hand, rub hands together covering

all surfaces until dry

• Volume: based on manufacturer

• Handwashing

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

• Rinse and dry with disposable towel

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

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SURGICAL HAND HYGIENE/ANTISEPSIS

• Use either an antimicrobial soap or alcohol-based handrub

• Antimicrobial soap: scrub hands and forearms for length of time recommended by manufacturer

• Alcohol-based handrub: follow manufacturer’s recommendations. Before applying, pre-wash hands and forearms with non-antimicrobial soap

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

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5 STAGES OF HAND TRANSMISSION

Germs present on patient skin and immediate environment surfaces

Germ transfer onto health-care worker’s hands

Germs survive on hands for several minutes

Suboptimal or omitted hand cleansing results in hands remaining contaminated

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

one two three four five

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MOST FREQUENT SITES OF INFECTION AND THEIR RISK FACTORS

LOWER RESPIRATORY TRACT INFECTIONSMechanical ventilationAspirationNasogastric tubeCentral nervous system depressantsAntibiotics and anti-acidsProlonged health-care facilities stayMalnutritionAdvanced ageSurgeryImmunodeficiency

13%

BLOOD INFECTIONSVascular catheterNeonatal ageCritical care Severe underlying diseaseNeutropeniaImmunodeficiencyNew invasive technologiesLack of training and supervision

14%

SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxis

Incorrect surgical skin preparationInappropriate wound care

Surgical intervention durationType of wound

Poor surgical asepsisDiabetes

Nutritional stateImmunodeficiency

Lack of training and supervision 17%

URINARY TRACT INFECTIONSUrinary catheter

Urinary invasive proceduresAdvanced age

Severe underlying diseaseUrolitiasis

PregnancyDiabetes

34%

Most common sites of health care-associated infection and the risk factors

underlying the occurrence of

infections

LACK OF HAND

HYGIENE

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INDICATIONS FOR HAND WASHING AND HAND ANTISEPSIS

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

• If hands are not visibly soiled, use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations. IA. Alternatively, wash hands with antimicrobial soap and water. IB• Before having direct contact with patients. IB

• Before donning sterile gloves when inserting a central intravascular catheter. IB

DR.T.V.RAO MD 19

INDICATIONS FOR HAND WASHING AND HAND ANTISEPSIS

• Decontaminate hands not visibly soiled with handrub/antimicrobial (continued)• Before inserting urinary catheter, peripheral vascular catheter, or

other invasive device. IB• After contact with a patient’s intact skin. IB• After contact with body fluids, mucous membrane, nonintact skin

or wound dressings, as long as hands are not soiled. IA• If moving from a contaminated body site to clean site. II• After contact with inanimate objects in vicinity of patient. II• After removing gloves.

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• Adequate hand washing with water and soap requires 40–60 seconds

• Average time usually adopted by health-care workers: <10 seconds

• Alcohol-based • hand rubbing: 20–30 seconds

TIME CONSTRAINT = MAJOR OBSTACLE FOR HAND HYGIENE

DR.T.V.RAO MD 21Repeat procedures until hands are clean

ROUTINE HAND WASH

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DR.T.V.RAO MD 23

THE “MY 5 MOMENTS FOR HAND HYGIENE” APPROACH

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•HCAI can cause:

• more serious illness

• prolongation of stay in a health-care facility

• long-term disability

• excess deaths

• high additional financial burden

• high personal costs on patients and their families

THE IMPACT OF HCAI

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MOST FREQUENT SITES OF INFECTION AND THEIR RISK FACTORS

LOWER RESPIRATORY TRACT INFECTIONSMechanical ventilationAspirationNasogastric tubeCentral nervous system depressantsAntibiotics and anti-acidsProlonged health-care facilities stayMalnutritionAdvanced ageSurgeryImmunodeficiency

13%

BLOOD INFECTIONSVascular catheterNeonatal ageCritical care Severe underlying diseaseNeutropeniaImmunodeficiencyNew invasive technologiesLack of training and supervision

14%

SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxis

Incorrect surgical skin preparationInappropriate wound care

Surgical intervention durationType of wound

Poor surgical asepsisDiabetes

Nutritional stateImmunodeficiency

Lack of training and supervision 17%

URINARY TRACT INFECTIONSUrinary catheter

Urinary invasive proceduresAdvanced age

Severe underlying diseaseUrolitiasis

PregnancyDiabetes

34%

Most common sites of health care-associated infection and the risk factors

underlying the occurrence of

infections

LACK OF HAND

HYGIENE

WHY HAND WASHING REDUCES DIARRHEAL DISEASES

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

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MANY COUNTRIES WORLDWIDE ARE COMMITTED TO IMPROVE HAND HYGIENE

Current status, March 2009

You are part of a global movement!

Countries committed in 2005, 2006, 2007 and 2008 Countries

planning to commit in 2009

DR.T.V.RAO MD 28

CREATE AWARENESS AT SEVERAL PLACES

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

DR.T.V.RAO MD 30

Why Don’t Staff Wash

their Hands

(Compliance estimated at less than 50%)

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WHY NOT?• Skin irritation• Inaccessible hand washing facilities• Wearing gloves• Too busy• Lack of appropriate staff• Being a physician

(“Improving Compliance with Hand Hygiene in Hospitals” Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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WHY NOT?• Working in high-risk areas • Lack of hand hygiene promotion• Lack of role model• Lack of institutional priority• Lack of sanction of non-compliers• Lack of rewarding of compliers

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SUCCESSFUL PROMOTION • Education

• Routine observation & feedback

• Engineering controls

• Location of hand basins• Possible, easy & convenient• Alcohol-based hand rubs available

• Patient education

(Improving Compliance with Hand Hygiene in Hospitals . Didier Pittet. Infection Control and Hospital Epidemiology. Vol. 21 No. 6 Page 381)

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TEACH THEM EARLIER IN LIFE

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MAKE ALL KIDS PARTNERS IN HAND WASHING

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•Based on the evidence and recommendations from the WHO Guidelines on Hand Hygiene in Health Care (2009), a number of components make up an effective multimodal strategy for hand hygiene

WHAT IS THE WHO MULTIMODAL HAND HYGIENE IMPROVEMENT STRATEGY?

ONE System changeAccess to a safe, continuous water supply as well as to soap and towels; readily accessible alcohol-based handrub at the point of care

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

THREE Evaluation and feedback Monitoring hand hygiene practices, infrastructure, perceptions and knowledge, while providing results feedback to health-care workers

FOUR Reminders in the workplacePrompting and reminding health-care workers

FIVE Institutional safety climateCreating an environment and the perceptions that facilitate awareness-raising about patient safety issues

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PREVENTION OF HEALTH CARE-ASSOCIATED INFECTION

• Validated and standardized prevention strategies have been shown to reduce HCAI

• At least 50% of HCAI could be prevented • Most solutions are simple and not resource-

demanding and can be implemented in developed, as well as in transitional and developing countries

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HAND CARE ALSO INCLUDES

• Nails• Rings• Hand creams• Cuts & abrasions• “Chapping”• Skin Problems

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NEW CDC HAND HYGIENE GUIDELINESMAJOR DIFFERENCE

• Old CDC, APIC-nonantimicrobial between most patient contacts, antimicrobial before invasive procedures or caring for high-risk patients

• New CDC-if hands are not visibly soiled, use an alcohol-based handrub for decontaminating hands in all clinical situations; alternatively, wash hands with antimicrobial soap and water

DR.T.V.RAO MD 40

OUR SUPPORT TO HAND WASHING MAKES THE DIFFERENCE

• HCAI places a serious disease burden and significant economic impact on patients and health-care systems

• Good hand hygiene – the simple task of cleaning hands at the right times and in the right way – saves lives

• There are 5 Moments for Hand Hygiene in Health Care

• Global compliance with the My 5 Moments for Hand Hygiene approach is universally sub-optimal

• <insert name of facility> has implemented an Action Plan to improve hand hygiene and reduce infection

• Your support and compliance with the initiatives is essential to save lives in our facility

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SIR WILLIAM OSLER ON HAND WASHING

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

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INSPIRE YOUR CHILDREN ON HAND HYGIENE

THE GLOBAL HAND WASHING DAY

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

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GLOBAL HAND WASHING DAY• Global Hand washing

Day is a campaign to motivate and mobilize millions around the world to wash their hands with soap. The campaign is dedicated to raising awareness of hand washing with soap as a key approach to disease prevention.

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DR.T.V.RAO MD 46

HAND WASHING A TRIBUTE TO DR. IGNAZ SEMMELWEIS

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

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WISH TO SAVE MORE LIVES WITH HAND WASHING ……

• Visit the SAVE LIVES: Clean Your Hands website at:

• www.who.int/gpsc/5may/en/

PROGRAMME CREATED BY DR.T.V.RAO MD FOR HEALTH CARE WORKERS IN THE DEVELOPING

WORLD

Email

doctortvrao@gmail.com

DR.T.V.RAO MD 49