hand hygiene for health workers

see also:

• aseptic non-touch technique (ANTT)
• prevention of infection in healthcare - standard precautions
• clinically important bacteria
• NHHI staff Hand hygiene mandatory competency module for Australian healthcare workers

• Micro-organisms are transmitted from one patient to another via a healthcare worker's hands (HCW) in 5 sequential steps¹⁾:
  • organisms on patient's skin or shed onto surrounding objects (fomites)
  • organisms transferred to HCW's hands
  • organisms capable of surviving at least several minutes on HCW's hands
  • organisms not cleared from HCW's hands - inadequate or inappropriate washing
  • organisms transmitted to another patient via HCW's hands or objects they touch
• 5 moments of hand hygiene targets:²⁾
  • cross-colonisation of patients
  • endogenous and exogenous infection in patients
  • infection in HCWs
  • cross-colonisation of the healthcare environment including HCWs.

1. Before touching a patient
2. Before a procedure
3. After a procedure or body fluid exposure risk
4. After touching a patient
5. After touching a patient's surroundings

• in addition to washing before entering hospital and on leaving hospital, before eating or handling food/drinks, after toilet, using computers, using gloves/PPE, wiping nose or touching mouth or smoking

• the patient and the patient's immediate surroundings
• hand hygiene should be performed:
  • BEFORE entering the patient zone (ie. AFTER touching doors or curtains), and,
  • AFTER exiting the patient zone (ie. BEFORE touching doors or curtains)
• any equipment brought into the patient zone should be cleaned before and after each patient use eg. stethoscope, BP cuff, tourniquet, chairs, etc.
• after handling a contaminated site and before handing a clean body site such as IV cannula

• everything outside the patient zone including curtains or doors between separate patient zones
• patient bed curtains are outside the patient zone and assumed to be contaminated
  • Perform Hand hygiene BEFORE entering the healthcare zone
  • Perform Hand hygiene AFTER exiting the healthcare zone

• alcohol based hand rub is sufficient - rub hands until completely dry
  • more effective at killing bugs than soap and water
  • faster than handwashing (20-30secs for proper alcohol hand rub)
  • are self-drying
  • may cause less skin irritation and dryness
  • more readily accessible and portable
  • BUT LESS EFFECTIVE against gastro bugs such as Norovirus, C Diff, non-enveloped viruses - use soap and water for these

• soap and water wash then thorough drying

• gloves should be worn when there is risk of contamination of your hands with blood or body fluids
• colonising bacteria can be found on 30% of hands of HCW's despite use of gloves
• thus hand hygiene BEFORE AND AFTER wearing gloves ³⁾
• gloves must be changed:
  • between episodes of care with different patients
  • during single patient care of different body sites
  • if required to use keyboards, etc which are moved from room to room
• use STERILE gloves if surgical aseptic non-touch technique (ANTT) required

• WHO Consensus recommendations are that HCWs do not wear artificial nails or extenders when having direct contact with patients and natural nails should be kept short (<0.4cm long) ⁴⁾
• Artificial, painted and chipped nails should not be worn in clinical areas as they can harbour microorganisms and are linked with outbreaks of infections ⁵⁾
• WHO recommendations strongly discourage the wearing of hand and wrist jewellery:⁶⁾
  • inhibits correct hand hygiene
  • skin underneath rings are more likely to be heavily colonised
  • jewelry increases numbers and species of organisms on hands
• Bare below the elbows
  • also means avoiding long sleeves and smart watches

• 3 main types of contact dermatitis:
  • irritant contact dermatitis (ICD)
    • usually caused by either:
      • repeated exposure to irritants (soap, antiseptics, hot water)
      • drying with paper towels
      • sweating from prolonged use of gloves
      • glove powder
      • low humidity
    • most often starts as dryness in webspaces and needs to be addressed early to prevent infection and transmission of infections
    • resolution may take months
    • prevention:
      • alcohol based hand washing reduces risk compared to soap (or antiseptics) and water wash (especially hot water) and dry paper towels
  • allergic contact dermatitis (ACD)
    • delayed onset hours or days after contact
    • may complicate ICD
    • common causes:
      • rubber glove ingredients such as thiurams and carbamates
      • preservatives such as methylisothiazolinone (MI), formaldehyde and formaldehyde releasing preservatives used in products such as skin cleansers
      • hand cleansing ingredients such as coconut diethanolamide
      • fragrances
      • colophony (rosin) is the usual cause of sticking plaster allergies in patients
      • rarely, chlorhexidine
    • patch testing by dermatologists may be useful
  • contact urticaria
    • immediate onset allergy within minutes
    • common causes:
      • latex especially powdered latex gloves which provides increased exposure to the latex
    • may be diagnosed by IgE blood test or by prick testing
    • treatment is avoidance of all latex products:
      • use nitrile gloves or PVC gloves
• general preventative measures:
  • apply a fragrant free skin moisturising cream to help to restore the skin barrier
  • alcohol based hand washing reduces risk compared to soap (or antiseptics) and water wash (especially hot water) and dry paper towels
  • use of a non-fragranced soap substitute at home, avoid liquid soaps which generally have perfumes or MI
  • appropriate glove use, including at home gardening or washing dishes
  • avoid allergens
• early recognition and referral
  • report skin issues to management
  • follow skin care measures at work and at home
  • see GP for possible topical corticosteroid Rx
  • if not settling, see a dermatologist for testing
• see also http://www.occderm.asn.au/