WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

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<strong>WHO</strong> GUIDELINES ON HAND HYGIENE IN HEALTH CARE intended to complement hand hygiene and are effective as long as they are used according to the proper indications. Hand hygiene still remains the basic and most effective measure to prevent pathogen transmission and infection. In no way does glove use modify hand hygiene indications or replace hand hygiene by washing with soap and water or handrubbing with an alcohol-based handrub. Gloves represent a risk for pathogen transmission and infection if used inappropriately. 23.2 Importance of hand hygiene for safe blood and blood products Providing a safe unit of blood to a patient who requires blood transfusion is a multistep process. It includes identifying safe blood donors for blood donation, safe blood collection without harming the blood donor and the donated blood, screening of donated blood for HIV, hepatitis B and C, and syphilis, processing the blood into blood products, and issue of blood or blood product to the patient, when prescribed. Appropriate hand hygiene practice is crucial to the safety of blood and blood products at all stages in the transfusion chain during which the donated blood units are handled. The microbial contamination of blood or blood products may occur at the time of blood collection or during the processing into blood products, labelling, storage and transportation, or during administration of blood at the patient bedside. This can have fatal consequences for the recipients of the transfusion. Serious consequenses of microbial contamination can be avoided by giving particular attention to the hand hygiene of the donor care staff at the time of blood collection and by thorough cleansing of the venepuncture site on the donor arm. Furthermore, blood collection staff frequently needs to collect blood in environments that are especially challenging. Special care must be exercised in hand hygiene while collecting blood in outdoor situations where access to running water is limited. It is essential that all those who work in areas where blood is handled pay strict attention to hand hygiene. Standard operating procedures should be available to staff, detailing exactly how hands should be decontaminated in order to protect blood donors, patients, and the staff themselves, as well as the blood and blood products. Figure l.23.4 depicts the crucial steps during blood collection, processing, and transfusion with an associated risk for the contamination of blood or blood products attributable to poor hand hygiene of the staff involved in these processes. At each step, there are several critical procedures, including meticulous hand hygiene, which ultimately lead to the safety of blood and blood products. 23.3 Jewellery Several studies have shown that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings. 961-963 A study by Hoffman and colleagues 962 found that 40% of nurses harboured Gram-negative bacilli such as E. cloacae, Klebsiella spp., and Acinetobacter spp. on skin under rings and that some nurses carried the same organism under their rings for months. In one study involving more than 60 ICU nurses, multivariable analysis revealed that rings were the only significant risk factor for carriage of Gram-negative bacilli and S. aureus and that the organism bioburden recovered correlated with the number of rings worn. 964 Another study showed a stepwise increased risk of contamination with S. aureus, Gramnegative bacilli, or Candida spp. as the number of rings worn increased. 153 In a Norwegian study comparing hand flora of 121 HCWs wearing a single plain ring and 113 wearing no rings, there was no significant differences in the total bacterial load or rates of carriage of S. aureus or non-fermentative Gramnegative rods on hands, but personnel wearing rings were more likely to carry Enterobacteriaceae (P=0.006). 965 Among 60 volunteers from perioperative personnel and medical students, Wongworawat & Jones 966 found no significant difference in bacterial counts on hands with or without rings when an alcohol product was used, but there were significantly more bacteria on ringed hands when povidone-iodine was used for handwashing (P
PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE simple and practical solution allowing effective hand hygiene is for HCWs to wear their ring(s) around their neck on a chain as a pendant. 23.4 Fingernails and artificial nails Numerous studies have documented that subungual areas of the hand harbour high concentrations of bacteria, most frequently coagulase-negative staphylococci, Gram-negative rods (including Pseudomonas spp.), Corynebacteria, and yeasts. 63,534,970 Freshly applied nail polish does not increase the number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails. 971,972 Even after careful handwashing or surgical scrubs, HCWs often harbour substantial numbers of potential pathogens in the subungual spaces. 154,973,974 In particular, the presence of fingernail disease may reduce the efficacy of hand hygiene and result in the transmission of pathogens. A cluster of P. aeruginosa SSIs resulted from colonization of a cardiac surgeon’s onychomycotic nail. 523 A growing body of evidence suggests that wearing artificial nails may contribute to the transmission of certain health care-associated pathogens. HCWs who wear artificial nails are more likely to harbour Gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing 154,534,974,975 or handrub with an alcohol-based gel. 154 It is not clear if the length of natural or artificial nails is an important risk factor, since most bacterial growth occurs along the proximal 1 mm of the nail, adjacent to subungal skin. 154,972,974 An outbreak of P. aeruginosa in a neonatal ICU was attributed to two nurses (one with long natural nails and one with long artificial nails) who carried the implicated strains of Pseudomonas spp. on their hands. 976 Case patients were significantly more likely than controls to have been cared for by the two nurses during the exposure period, suggesting that colonization of long or artificial nails with Pseudomonas spp. may have played a role in causing the outbreak. HCWs wearing artificial nails have also been epidemiologically implicated in several other outbreaks of infection caused by Gram-negative bacilli or yeast. 159,167,977 In a recent study, multiple logistic regression analysis showed the association of an outbreak of extended-spectrum beta-lactamase-producing K. pneumoniae in a neonatal ICU resulting from exposure to an HCW wearing artificial fingernails. 155 A cluster of five cases of S. marcescens bacteraemia in haemodialysis was associated with a nurse who used an artificial fingernail to open a vial of heparin that was mixed to make a flush solution. The strains isolated from the five patients and the nurse were indistinguishable. 856 Allergic contact dermatitis resulting in months of sick leave has been reported in an office worker with artificial nails. 978 Long, sharp fingernails, either natural or artificial, can puncture gloves easily. 123 They may also limit HCWs’ performance in hand hygiene practices. In a recent survey among neonatal ICU HCWs, 8% wore artificial fingernails at work, and knowledge among them about the relationship between Gram-negative bacterial hand contamination and long or artificial fingernails was limited. 960 Jeanes & Green 979 reviewed other forms of nail art and technology in the context of hand hygiene in health care, including: applying artificial material to the nails for extensions; nail sculpturing; protecting nails by covering them with a protective layer of artificial material; and nail jewellery, where decorations such as stones may be applied to the nails or the nails are pierced. In addition to possible limitations of care practice, there may be many potential health problems, including local infection for individuals who have undergone some form of nail technology. 979 Each health-care facility should develop policies on the wearing of jewellery, artificial fingernails or nail polish by HCWs. These policies should take into account the risks of transmission of infection to patients and HCWs, rather than cultural preferences. Consensus recommendations are that HCWs do not wear artificial fingernails or extenders when having direct contact with patients and natural nails should be kept short ( 0.5 cm long or approximately ¼ inch long). 23.5 Infrastructure required for optimal hand hygiene Compliance with hand hygiene is only possible if the healthcare setting ensures the adequate infrastructure and a reliable supply of hand hygiene products at the right time and at the right location in alignment with the concept of “My five moments for hand hygiene” (Part I, Section 21.4). 1 An important cause of poor compliance may be the lack of user-friendliness of hand hygiene equipment, as well as poor logistics leading to limited procurement and replenishment of consumables. The latter is one of the most commonly cited obstacles to hand hygiene improvement in developing countries (reports of workshops hosted by the <strong>WHO</strong> Regional Offices for Africa (AFRO) and South-East Asia (SEARO) in 2007, see http:// www.who.int/gpsc/in/). As an example, very low overall hand hygiene compliance (8%) was shown in a university hospital in Mali where, at the same time, a survey on infrastructure for hand hygiene demonstrated that no alcohol-based handrub was available. Only 14.3% of patient rooms were equipped with sinks, and soap and towels were available at only 47.4% of sinks. 980 In developed countries, Suresh & Cahill 981 described several deficiencies in the structural layout of hand hygiene resources that hinder their usage: poor visibility, difficulty of access, placement at undesirable height, and wide spatial separation of resources that are used sequentially. Other parts of these <strong>Guidelines</strong> have already described the need for clean water for handwashing and have elaborated on the advantages of handrubs over handwashing, namely, the freedom from the requirement of sinks and the possibility to clean hands at the point of care. While describing the overall infrastructure necessary, this section is particularly focused on soap and handrub dispensers. 23.5.1 General guidelines All health-care settings should have written guidelines describing the appropriate placement of sinks and soap and handrub dispensers. Furthermore, the delegated responsibility with regards to supply of hand hygiene products, replenishment of consumables, and maintenance of the dispensers should be clearly described and communicated. 133
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