mic-lr-handhygiene-2008-02

8/9/2019 mic-lr-handhygiene-2008-02

http://slidepdf.com/reader/full/mic-lr-handhygiene-2008-02 1/12

HPS SICP: 2008 Literature Review: Hand Hygiene of 12

Standard Infection Control Precautions

Literature Review: Hand Hygiene

Date of issue: 2008Date of review: 2009




REVIEW OF LITERATURE

PRINCIPAL RESEARCH QUESTION/OBJECTIVE:

o To assess the evidence in relation to hand drying methods following hand hygiene/decontamination.

o To assess the evidence in relation to hand hygiene being a method of reducing the spread of infection.

o To assess the evidence in relation to the effect of wearing jewellery on hand hygiene.

o To assess the evidence in relation to the effect of nail hygiene on general hand hygiene.

o To assess the evidence in relation to the effectiveness/appropriate application of alcohol hand rub/gel as amethod for decontaminating hands.

o To assess the evidence in relation to hand hygiene being a method of reducing the spread of infection.

o To assess the evidence in relation to hand hygiene and its application.

i) Search strategy for identification of studies

Period of publication 1997-2007

hand hygiene hospital hand washing healthcare

handwashing occupational transmission

hand sanitizing focal infection

hand cleansing Cross Infection/

hand decontamination exp Hospitals/

Handwashing/ Occupational Diseases/

cross infection Infection/ nosocomial Focal Infection/

healthcare associated infection Infection Control/

healthcare-associated infection bacteri$

healthcare acquired infection virus$

hospital acquired infection handwashing solution

compliance hand washing solution

adherence procedure

attitudes Soaps/

perceptions Chlorhexidine/

Health Behaviour/ air dryer

Guideline Adherence/ procedure

attitude/ or "attitude of healthpersonnel"/

paper towel$

care hand towel$

care equipment ring$

environment jewellery

contaminated nail$

contact nail polish

"Delivery of Health Care"/ Nails/

exp "Equipment and Supplies,

Hospital"/

Cosmetics/

Health Facility Environment/ alcohol gel

Strategy key words

Equipment Contamination/ alcohol rub




soap alcohol solution

liquid soap alcohol

soap solution

MEDLINE X PsycINFO

Science Direct EMBASE

CINAHL X SIGLE

Cochrane Library X Web of Science

Electronic databases

(tick as appropriate)

British Nursing Index X JBI COnNECT X

References checked for relevant articles X

Review of abstracts of professional meetings/ conferences

Personal libraries consulted X

Experts consulted (give details if applicable)

Handsearching of journals (name relevant journals e.g.Journal of Hospital Infection, Infection Control andHospital Epidemiology)

Additional Resources


CDC X WHO X

Department of Health X Scottish Government X

Websites


HPA X Scottish Government Health Dept. X

How many papers found 260

How many papers included 8 (+ 3 guidance documents)

How many papers excluded 252

ii) Selection criteria for inclusion of studies

Sample All health and social care workers.

Outcome measure(s) o Bacterial count on hands following different hand drying interventions.

o Effectiveness of intervention to reduce bacterial count on hands.

o To assess the evidence in relation to the effect of wearing jewellery on handhygiene.

o Bacterial count on hands following intervention.

o Effectiveness of intervention to reduce bacterial count on hands.

o Effectiveness of hand hygiene as a measure for preventing the spread of infection.

o Bacterial count on hands following intervention.

Other inclusion criteria N/A

Language Limitations English language only




1 Results

The annual review aims to identify, review and critique any scientific studies or guidance, whichhave been published in the intervening period since the last update (2007), to determine if changesto guidance are required.

1.1 Why perform hand hygiene?

Lack of or insufficient hand hygiene continues to be highlighted as a major problem and has beenidentified as the cause of a number of outbreaks of HAI in healthcare settings. The epic2: NationalEvidence Based Guidelines for preventing healthcare associated infections in hospitals in England(Pratt et al., 2007) has included a considerable literature review specifically on this subject andconcludes that current national and international guidance consistently present supporting evidencethat effective hand hygiene practice reduces the incidence of HAI.

Hand hygiene compliance remains a significant issue and this has been the focus of the HandHygiene Campaign (http://www.washyourhandsofthem.com), which was launched in January 2007.

This campaign is aimed at the NHS in Scotland and also at the general public to raise awareness of the importance of hand hygiene. One major component of the NHS campaign is to measure handhygiene compliance across NHS boards in Scotland. This has been achieved by the use of astandardised approach involving an audit tool and protocol. The first mandatory audit took place inFebruary 2007 and the results showed that hand hygiene compliance rates were 68% acrossScotland, with compliance rates varying across boards from 50-94%. The results of the secondmandatory audit which took place in October showed an overall compliance rate of 79% with arange from 59-94%.

As the SGHD current target for compliance has now been set as 90% (This is the figurerecommended by the Institute for Healthcare Improvement (IHI) (http://www.ihi.org/ihi), as a

means to change culture in that hand hygiene is viewed as a mandatory procedure) by November2008, there has been a decision to continue the Hand Hygiene Campaign to support this and thisincludes continuation of funding of LHBCs who are responsible for implementing the campaignwithin their local health boards and for carrying out quarterly audits.(http://www.washyourhandsofthem.com)

1.2 Nail care

The literature search identified few publications within the period under review, which werespecifically concerned with nails and hand hygiene. The recently published epic2: NationalEvidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in

England (Pratt et al., 2007) recommend that before a shift of clinical work begins, all wrist and hand jewellery should be removed and that fingernails should be kept short, clean, free polish and thatfalse nails should not be worn. Artificial nails have been previously reported as causing outbreaksof HAI and another recently published paper details a further outbreak traced to a HCW wearingfalse nails, which resulted in five patients developing gram-negative bacteraemia within ahaemodialysis unit, which therefore adds further support to this recommendation. (Gordin et al.,2007)

There are no changes recommended to the Hand Hygiene policy associated with nails and nail careas a result of this annual review.




1.3 Hand hygiene and jewellery

Only one relevant study was identified (Fagernes et al., 2007) specifically on hand hygiene and jewellery. This study aimed to measure the bacterial load present on the hands of HCWs’ and toassess the effect of wearing a single plain finger ring. The result of microbiological samplingshowed no overall significant difference of total bacterial load from hands with and without a plainband ring. The model policy as present states that wearing of a plain band ring when performing

care is acceptable and there is no new evidence to the contrary. Therefore there are no changesrecommended to the Hand Hygiene policy associated with jewellery as a result of this annualreview.

1.4 When to perform hand hygiene?

Some recent studies document the use of novel methods to improve hand hygiene compliance andone notes that there was a rise in hand hygiene compliance following introduction of voice promptsin an isolation facility in the USA which demonstrates that innovative methods can be useful.(Swoboda et al., 2007)

The epic2 guidelines (Pratt et al., 2007) state that there are a number of key factors which must beconsidered when deciding when hand hygiene should be performed including the level of expectedcontact with patients or objects; the extent of contamination that may occur; the patient careactivities being performed; the susceptibility of the patient to infection. These guidelines state thatcurrent scientific evidence and expert opinion recommend that hand hygiene should be performedafter an episode of patient care and also after removal of gloves in order to be effective.

It is widely acknowledged that there is still a significant issue with lack of compliance with handhygiene. In a recently published article (Sax et al., 2007) the authors state that one reason for thismay be due to deficiencies in training and information provided to HCWs on this subject. This

paper highlights a lack of consensus of opinion within infection control experts on the relative risk attached to different healthcare activities and the authors stress the importance of identification of the key times that hand hygiene must be performed. Therefore the researchers set out to define auser centred concept of when hand hygiene should be performed in order to provide a protocol,which could integrate into healthcare activities and ensure consistent training is provided. Theauthors of this research conclude that there are fundamental points and times when hand hygiene isessential in order to prevent the spread of infection during the delivery of care. As a result of thisresearch, the authors have introduced a concept of ‘my five moments for hand hygiene’ which isdefined as; before patient contact; before an aseptic task; after body fluid exposure risk; after patientcontact and after contact with patient surroundings. The 5 moments aim to bring together theevidence for hand hygiene and the daily routines undertaken in healthcare, particularly when care is

being provided to those who are sick and vulnerable. The authors anticipate that this model will beused to provide consistency of approach in training, audit and guidance to be given to HCWs. Thisconcept has been adopted within the national Hand Hygiene Campaign(http://www.washyourhandsofthem.com) in order to provide clear direction and consistency acrossavailable guidelines and as a method of auditing current hand hygiene practice within NHSScotland(http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx ).

It is therefore recommended that information on the ‘5 moments for hand hygiene’ including flowdiagram should be included as appendix to the hand hygiene policy, for consistency with theinformation made available to NHSScotland through the Hand Hygiene Campaign.




1.5 How to perform hand hygiene?

The literature search performed for this annual review did not identify any new scientificpublications specifically concerned with the technique of hand hygiene. Therefore there are nochanges recommended to the policy on how to perform hand hygiene as a result of this annualreview.

One recent guidance document published by the DH (DH, 2007), stated that the wearing of shortsleeve shirts and not long sleeved white coats by HCWs, is considered good practice to preventspread of infection and is termed ‘bare to the elbows’. The evidence for this comes from studiesidentifying contamination on the cuffs of uniforms and is not specifically concerned with handhygiene. However, it is considered common sense and good practice to remove jackets and coats;hand and wrist jewellery and ensure that wrists and forearms are exposed before performing handhygiene.

1.6 Drying hands

There were no additional scientific papers published during the period of the review, whichspecifically covered hand drying and therefore no changes to practice were identified.

1.7 Alcohol based hand hygiene products

Current reviews and scientific publications still report that there is a reluctance to use alcohol handgels by healthcare workers due to reasons of perceived drying of the skin. One recently publishedstudy (Loffler et al., 2007) attempts to specifically address this by conducting a comprehensivestudy of the effects of alcohols commonly used in hand hygiene products in comparison to washingwith soap. The results show that alcohol hand gels caused less skin irritation than hand washing in

terms of skin physiology and sensation. However, the group tested excluded atopic individuals,which is therefore not totally representative and it should also be noted that a manufacturer of alcohol hand hygiene products funded the study leaving it open to potential bias. Despite this, it isclear from this study and previously reviewed literature that the occurrence of skin irritation has notincreased in line with use of alcohol-based hand hygiene products.

The epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections inNHS Hospitals in England was published in February 2007 (Pratt et al., 2007) and includes asubstantial section and literature review on the choice of methods available for performing handhygiene. This systematic review discusses the scientific evidence on the use of hand washing versususe of alcohol hand gels and includes a section on the potential problems associated with irritation

and drying effects of hand hygiene products. A number of studies were evaluated during thepreparation of these guidelines specifically on this subject, which showed that the use of soap andwater was associated with an increased risk of skin irritation.

The literature review within these guidelines also presents evidence that substantiates that handwashing with soap and water and not alcohol hand gels should be used when C difficile is present.Evidence is presented and critiqued within the CDC guidelines on Isolation (Siegel et al., 2007) thatalcohol hand gels should not be used when infection with spore forming organism such as C

difficile is known or suspected and furthermore states that there is insufficient data currentlyavailable to reliably inform the efficacy of alcohol hand gels against viruses such as noroviruses androtaviruses and this may be an area which may have to undergo further review in the future.

However it is clear that for routine use outside outbreak situations the use of alcohol hand gels isconvenient and effective unless there is obvious visible contamination of the hands.




There have been a number of recently published studies looking at the use of alcohol hand gels as amethod to increase hand hygiene compliance. A well written systematic review by QIS (Stout et al.,2007) examined the clinical effectiveness of this as a method of increasing hand hygienecompliance and reducing infection rates. This review noted that it was difficult to establishmeasures of clinical effectiveness of alcohol based products as their use tends to form part of multifactorial intervention studies and it is therefore difficult to elucidate the impact of one individual

component. Indeed, the evidence uncovered during this review, showed no demonstrable differencebetween multi-factorial interventions with and without the use of alcohol-based products andoverall increases in hand hygiene compliance. The authors note that there are particular difficultiesassociated with assessing this particular evidence base, however point out that two recent economicevaluations have shown that even a 1% reduction in the HAI rate attributable to alcohol basedproducts would be considered cost effective.

Therefore there are no changes recommended to the policy specifically on alcohol-based handhygiene products as a result of this annual review.

1.8 Respiratory Hygiene / Cough Etiquette

The importance of swift implementation of infection control precautions was highlighted during theSARS outbreak as extensive transmission of the disease occurred to patients and staff at the triagestage of point of entry to healthcare. The importance of a strategy to deal with this has been stressedand the approach which is recommended is the introduction of respiratory hygiene / cough etiquetteas part of standard infection control precautions and additional transmission based precautions.(Siegel et al., 2007, SEHD and HPS, 2005)

The introduction of respiratory hygiene / cough etiquette is aimed at patients and their familiesparticularly with respiratory illnesses (coughing, sneezing etc) and is a fundamental component of

droplet precautions. The literature suggests that application of this precaution at the point of entryinto healthcare facilities reduces the transmission of respiratory infections via droplets. (Siegel etal., 2007) and may be useful for inclusion as part of standard infection control precautions. Toencourage compliance with respiratory hygiene / cough etiquette by HCWs, patients and visitors itis clear that education and training is required and this can be achieved by use of posters and signsdescribing these precautions. (Siegel et al., 2007)

The main components of respiratory hygiene / cough etiquette, contained within the reviewedscientific literature are; covering the mouth and nose with a disposable tissue when coughing orsneezing followed by prompt disposal of the tissue in a suitable waste receptacle. Use of surgicalmask by the patient if possible; performance of hand hygiene following contact with respiratory

secretions and separation of at least 3 feet between patients / families etc suffering from respiratoryinfections within communal areas such as waiting rooms etc if achievable. (Siegel et al., 2007,SEHD and HPS, 2005)




2 Conclusions

2.1 Why perform hand hygiene?

2.1.1 Lack of or insufficient hand hygiene continues to be highlighted as a major problem and thecause of a number of outbreaks of HAI in healthcare settings.

2.1.2 Hand hygiene compliance remains a significant issue and this has been the focus of theHand Hygiene Campaign, which was launched in January 2007.

2.1.3 This campaign was aimed at the NHS in Scotland and also at the general public to raiseawareness of the importance of hand hygiene.

2.1.4 One main component of the NHS campaign was to measure compliance with hand hygieneacross health boards in Scotland and this has been achieved using a standardised approachinvolving an audit tool.

2.1.5 The first mandatory audit took place in February 2007 and the results showed that handhygiene compliance rates were 68% across Scotland.

2.1.6 The results of the second mandatory audit, which took place in October showed an overallcompliance rate of 79%.

2.1.7 The current target for hand hygiene compliance has now been set at 90% by November2008, and there has been a decision to continue the Hand Hygiene Campaign to support this

2.1.8 This includes continuation of funding of LHBCs who are responsible for implementing the

campaign within their local health boards and for carrying out quarterly audits.

2.2 Nail care

2.2.1 The epic2 guidelines recommend that before a shift of clinical work begins, all wrist andhand jewellery should be removed and that fingernails should be kept short, clean, free fromnail polish and of false nails.

2.2.2 Therefore there are no changes recommended to the Hand Hygiene policy associated withnails and nail care as a result of this annual review.

2.3 Hand hygiene and jewellery

2.3.1 Only one relevant study was identified specifically on hand hygiene and jewellery andaimed to measure the bacterial load present on the hands of HCWs’ and to assess the effectof wearing a single plain finger ring.

2.3.2 The result of microbiological sampling showed no overall significant difference of totalbacterial load from hands with and without a plain band ring.

2.3.3 The epic2 guidelines recommend that before a shift of clinical work begins, all wrist andhand jewellery should be removed and that fingernails should be kept short, clean, free fromnail polish and of false nails.




2.4 When to perform hand hygiene?

2.4.1 The epic2 guidelines state that there are a number of key factors which must be consideredwhen deciding when hand hygiene should be performed including the level of expectedcontact with patients or objects; the extent of the contamination that may occur; the patientcare activities being performed; the susceptibility of the patient to infection.

2.4.2 These guidelines state that current scientific evidence and expert opinion recommends thathand hygiene should be performed after an episode of patient care and also after removal of gloves in order to be effective.

2.4.3 In a recently published review article from WHO, the authors state that one reason for lack of compliance with hand hygiene may be due to deficiencies in training and informationprovided to HCWs specifically on this subject.

2.4.4 This paper highlights that there is a lack of consensus of opinion within infection controlexperts on the relative risk attached to different healthcare activities and the authors stress

the importance of identification of the key times that hand hygiene must be performed.

2.4.5 The researchers set out to define a user centred concept of when hand hygiene should beperformed in order to provide a consistent protocol, which could integrate into healthcareactivities and ensure consistent training is provided.

2.4.6 The concept presented is ‘my five moments for hand hygiene’ which is defined as; beforepatient contact; before an aseptic task; after body fluid exposure risk; after patient contactand after contact with patient surroundings.

2.4.7 This concept has been adopted within the national Hand Hygiene Campaign in order to

provide clear direction and consistency across available guidelines and approaches and as amethod of auditing current hand hygiene practice within NHSScotland

2.5 How to perform hand hygiene?

2.5.1 The literature search performed for this annual review did not identify any new scientificpublications specifically concerned with the technique of hand hygiene during thereforethere are no changes to the policy on how to perform hand hygiene recommended.

2.6 Drying hands

2.6.1 There were no additional scientific papers published during the period of the review, whichspecifically covered hand drying and therefore no changes to practice were identified.

2.7 Alcohol based hand hygiene products

2.7.1 Current reviews and scientific publications still report that there is a reluctance to usealcohol hand gels due to reasons of perceived drying of the skin.

2.7.2 One recently published study attempts to specifically address this by conducting acomprehensive study of the effects of alcohols commonly used in hand hygiene products incomparison to washing with detergent.




2.7.3 The results show that alcohol hand gels caused less skin irritation than hand washing interms of skin physiology and sensation.

2.7.4 The epic2 guidelines include a substantial section and literature review on the choice of methods available for performing hand hygiene.

2.7.5 This systematic review discusses the scientific evidence on the use of hand washing versus

use of alcohol hand gels and includes a section on the potential problems associated withirritation and drying effects of hand hygiene products.

2.7.6 A number of studies were evaluated during the preparation of these guidelines specificallyon this subject, which showed that the use of soap and water was associated with anincreased risk of skin irritation.

2.7.7 The literature review within these guidelines also presents evidence that substantiates thathand washing with soap and water and not alcohol hand gels should be used when C difficile is present.

2.7.8 It is clear that for routine use outside outbreak situations and in cases of known or suspectedClostridium difficile associated disease (CDAD) that the use of alcohol hand gels isconvenient and effective unless there is obvious visible contamination of the hands.

2.7.9 There are no changes recommended to the policy specifically on alcohol-based handhygiene products as a result of this annual review.

2.8 Respiratory Hygiene/Cough Etiquette

2.8.1 Review of studies on the SARS outbreak showed the importance of swift implementation of

infection control precautions as transmission to patients and staff often occurred at the triagestage of point of entry to healthcare.

2.8.2 A strategy to deal with this has been recommended which is the introduction of respiratoryhygiene / cough etiquette as part of standard infection control precautions and transmissionbased precautions

2.8.3 Respiratory hygiene / cough etiquette is aimed at patients with undiagnosed respiratoryillnesses (cough, sneezing etc) and is a fundamental component of droplet precautions.

2.8.4 Review of scientific literature shows that application of this precaution reduces the

transmission of respiratory infections via droplets.

2.8.5 Education and training of HCWs, patients and visitors specifically on rationale andtechnique of respiratory hygiene / cough etiquette is required to promote compliance

2.8.6 This can be achieved by the use of posters, leaflets and signs, in languages appropriate to thetarget audience

2.8.7 Respiratory hygiene / cough etiquette consists of covering the mouth and nose withdisposable tissue when coughing or sneezing followed by prompt disposal in suitable wastereceptacle; use of surgical masks by patient if possible; performance of hand hygiene

following contact with respiratory secretions; separation of at least 3 feet between patientssuffering from respiratory infections within communal areas such as waiting rooms




2.8.8 The wearing of masks by certain patient groups may not be practical within healthcaresettings such as paediatrics

3 Recommendations

The only change to the policy recommended as a result of this annual review is that information onthe ‘5 moments for hand hygiene’ including flow diagram should be included as appendix to thehand hygiene policy, for consistency with the information made available to NHSScotland throughthe Hand Hygiene Campaign.

4 Practical Application

No change to practice is recommended.

5 Resource Implications

As per current policies, all resources required for hand hygiene should already be in place.

6 Key References

Department of Health (2007) Uniforms and Workwear - An evidence base for developing localpolicy, DH, London.

Fagernes, M., Lingaas, E. and Bjark, P. (2007) Impact of a single plain finger ring on the bacterialload on the hands of healthcare workers, Infection Control & Hospital Epidemiology, 28, 1191-5.

Gordin, F. M., Schultz, M. E., Huber, R., Zubairi, S., Stock, F. and Kariyil, J. (2007) A cluster of hemodialysis-related bacteremia linked to artificial fingernails, Infection Control and Hospital

Epidemiology, 28, 743-4.

Loffler, H., Kampf, G., Schmermund, D. and Maibach, H. I. (2007) How irritant is alcohol?, British

Journal of Dermatology, 157, 74-81.

Pratt, R. J., Pellowe, C. M., Wilson, J. A., Loveday, H. P., Harper, P. J., Jones, S. R., McDougall, C.and Wilcox, M. H. (2007) epic2: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England, Journal of Hospital Infection, 65, S1-64.

Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J. and Pittet, D. (2007) 'My five moments forhand hygiene': a user-centred design approach to understand, train, monitor and report handhygiene, Journal of Hospital Infection, 67, 9-21.

Scottish Executive Health Department and Health Protection Scotland (2005) Pandemic Influenza -Infection Control Guidelines for use in hospitals and primary care settings, SEHD and HPS,Scotland.

Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L. and The Healthcare Infection Control PracticesAdvisory Committee (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, June 2007.

Stout, A., Ritchie, K. and Macpherson, K. (2007) Clinical effectiveness of alcohol-based productsin increasing hand hygiene compliance and reducing infection rates: a systematic review, Journal of

Hospital Infection, 66, 308-12.




Swoboda, S. M., Earsing, K., Strauss, K., Lane, S. and Lipsett, P. A. (2007) Isolation status andvoice prompts improve hand hygiene, American Journal of Infection Control, 35, 470-6.

mic-lr-handhygiene-2008-02

Documents

Transcript of mic-lr-handhygiene-2008-02