|Year : 2010 | Volume
| Issue : 1 | Page : 115-118
|Hand hygiene among health care workers
Ameet Mani1, AM Shubangi2, Rajiv Saini3
1 Department of Oral Implantology, Rural Dental College-Loni, Maharashtra, India
2 Department of Orthodontics, Rural Dental College-Loni, Maharashtra, India
3 Department of Periodontology, Rural Dental College-Loni, Maharashtra, India
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|Date of Submission||07-Apr-2009|
|Date of Decision||08-Aug-2009|
|Date of Acceptance||17-Sep-2009|
|Date of Web Publication||27-Apr-2010|
| Abstract|| |
Healthcare-associated infections are an important cause of morbidity and mortality among hospitalized patients worldwide. Transmission of health care associated pathogens generally occurs via the contaminated hands of health care workers. Hand hygiene has long been considered one of the most important infection control measures to prevent health care-associated infections. For generations, hand washing with soap and water has been considered a measure of personal hygiene. As early as 1822, a French pharmacist demonstrated that solutions containing chlorides of lime or soda could eradicate the foul odor associated with human corpses and that such solutions could be used as disinfectants and antiseptics. This paper provides a comprehensive review of data regarding hand washing and hand antisepsis in healthcare settings. In addition, it provides specific recommendations to uphold improved hand-hygiene practices and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. This article also makes recommendations and suggests the significance of hand health hygiene in infection control.
Keywords: Alcohol, hand hygiene, health care workers
|How to cite this article:|
Mani A, Shubangi A M, Saini R. Hand hygiene among health care workers. Indian J Dent Res 2010;21:115-8
Healthcare-associated infections are an important cause of morbidity and mortality among hospitalized patients worldwide. Transmission of healthcare-associated pathogens generally occurs via the contaminated hands of healthcare workers. 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 to prevent healthcare-associated infections. However, compliance by healthcare workers with recommended hand hygiene procedures has remained unacceptable, with compliance rates generally below 50% of hand hygiene opportunities. ,,
Many factors contribute to poor hand washing compliance among healthcare workers-ignorance about the importance of hand hygiene in reducing the spread of infection and how hands become contaminated, lack of understanding of correct hand hygiene technique, understaffing and overcrowding, poor access to hand washing facilities, irritant contact dermatitis associated with frequent exposure to soap and water, and lack of institutional commitment to good hand hygiene. 
| Hand Pathogens and Profile|| |
Larson has provided an extensive review of the physiologic and bacteriologic characteristics of the skin.  The finger nail area is associated with a major portion of the hand flora. The subungual areas (located under the fingernail) often harbor high numbers of microorganisms, which may serve as a source of continued shedding, especially under gloves.  Artificial nails  and chipped nail polish  may be associated with a further increase in the number of bacteria on fingernails. The microbial flora of the skin consists of resident (colonizing) and transient (contaminating) microorganisms. The resident microorganisms survive and multiply on the skin. Resident flora include the coagulase-negative staphylococci, members of the genus Corynebacterium (diphtheroids or coryneforms), Acinetobacter species, and occasionally members of the Enterobacteriaceae group.  Resident skin microorganisms are not usually implicated in nosocomial infections, other than minor skin infections; however, some can cause infections after invasive procedures, when the patient/client is severely immunocompromised or has an implanted device, such as a heart valve or artificial hip. The transient microbial flora represent recent contaminants of the hands acquired from colonized or infected patients/ clients or contaminated environment or equipment.
Transient microorganisms are not consistently isolated from most persons. In contrast to the resident flora, the transient microorganisms found on the hands of healthcare personnel are more frequently implicated as the source of nosocomial infections. The most common transient flora includes the gram negative coliforms and Staphylococcus aureus. Healthcare-associated pathogens can be recovered not only from infected or draining wounds, but also from frequently colonized areas of normal, intact patient skin.  Organisms are transferred to various types of surfaces in much larger numbers (i.e., >10 4 ) from wet hands than from hands that are thoroughly dried. 
| Hand Hygiene - Need and Practice|| |
The Centers for Disease Control and Prevention's (CDC's) Healthcare Infection Control Practices Advisory Committee (HICPAC) published its comprehensive Guidelines for Hand Hygiene in Healthcare Settings in 2002. One of the principal recommendations of this guideline was that waterless, alcohol-based hand rubs (liquids, gels or foams) are the preferred method for hand hygiene in most situations due to the superior efficacy of these agents in rapidly reducing bacterial counts on hands and their ease of use. Alcohol preparations also rapidly kill many fungi and viruses that cause healthcare-associated infections. The guideline recommended that healthcare facilities develop multidimensional programs to improve hand hygiene practices.  Recognizing a worldwide need to improve hand hygiene in healthcare facilities, the World Health Organization (WHO) launched its Guidelines on Hand Hygiene in Health Care (Advanced Draft) in October 2005. 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 health care leaders, to improve hand hygiene. 
| Recommendations for Hand Hygiene Protocol|| |
Hand washing with plain soap can only remove loosely adherent transient flora. Hand washing with plain soap and water for 15 seconds reduces bacterial counts on skin by 0.6-1.1 log 10  whereas washing for 30 seconds reduces count by 1.2-2.8 log10 . Hand washing with plain soap fails to remove pathogens from the hands of hospital personnel.  To help countries and healthcare facilities achieve a system change and adopt alcohol-based hand rubs as the gold standard for hand hygiene in healthcare; at present, alcohol-based hand rubs are the only known means of rapidly and effectively inactivating a wide array of potentially harmful microorganisms on hands.  The WHO recommends alcohol-based hand rubs based on the following factors: 
- Evidence-based, intrinsic advantages of fast-acting and broad-spectrum microbicidal activity with a minimal risk of generating resistance to antimicrobial agents;
- Suitability for use in resource-limited or remote areas with lack of accessibility to sinks or other facilities for hand hygiene (including clean water, towels, etc.);
- Capacity to promote improved compliance with hand hygiene by making the process faster and more convenient;
- Economic benefit by reducing annual costs for hand hygiene, representing approximately 1% of extra costs generated by HCAI;
- Minimization of risks from adverse events because of increased safety associated with better acceptability and tolerance than other products.
| Hand Washing Guidelines|| |
- Hands must be washed
- Between direct contact with individual patients/ residents/clients;
- Before performing invasive procedures ,
- Before caring for patients in intensive care units and immunocompromised patients ,
- Before preparing, handling, serving or eating food, and before feeding a patient;
- When hands are visibly soiled ,
- After situations or procedures in which microbial or blood contamination of hands is likely;
- After removing gloves ,, ; and
- After personal body functions, such as using the toilet or blowing one's nose.
- Hand washing should be encouraged whenever a healthcare provider is in doubt about the necessity for doing so.
- Hand washing should be encouraged between patient/resident/client contacts, hand washing may be indicated more than once in the care of one person, for example after touching excretions or secretions and before going on to another care activity for the same person. 
- Hand washing should be encouraged following superficial contact with an object not suspected of being contaminated, such as when touching or collecting food trays, generally does not require hand washing.
- Hand washing facilities should be conveniently located throughout the healthcare setting. They should be available in or adjacent to rooms where health care procedures are performed. If a large room is used for several individuals, more than one sink may be necessary. Sinks for hand washing should be used only for hand washing and not for any other purpose, e.g., as a utility sink. There should be access to adequate supplies and proper functioning soap and towel dispensers or hand dryers, or liberal use of waterless hand wash agents. ,,
- Hand washing should be encouraged to avoid recontamination of hands. Faucets with foot, wrist, or knee operated handles should be installed wherever possible; faucets with an electric eye are also desirable. If automated faucets are not available, single-use towels should be supplied for user to turn off faucets.
- Hands should be dried thoroughly with a single-use towel or electric air dryer. ,
- Hand lotion may be used to prevent skin damage from frequent hand washing. Lotion should be supplied in disposable bags in wall containers by sinks or in small, non-refillable containers to avoid product contamination. Skin lotions for patient and/or staff use have been the reported source of outbreaks.
- Compatibility between lotion and antiseptic products and lotion's potential effect on glove integrity should be checked.
- Liquid hand wash products should be stored in closed containers and dispensed from either disposable containers or containers that are washed and dried thoroughly before refilling.
- Hand washing with plain soap is indicated in routine health care and for washing hands soiled with dirt, blood or other organic material. Plain soap and water will remove many transient organisms. ,,,
- Hand washing with an antiseptic agent is indicated for the following situations:
- Heavy microbial soiling, e.g., in the presence of infection or a high level of contamination with organic matter such as infected wounds and feces ,,
- Prior to performing invasive procedures (e.g., the placement and care of intravascular catheters, indwelling urinary catheters 
- Before contact with patients who have immune defects, damage to the integumentary system (e.g., wounds, burns), or percutaneous implanted devices 
- Before and after direct contact with patients who have antimicrobial-resistant organisms.
- Hand washing with waterless/alcohol-based agents is equivalent to soap and water, and these agents should be made available where access to water is limited. , If there is heavy microbial soiling, hands must first be washed with soap and water to remove visible soiling.  Hands must be dry before an alcohol-based agent is used because moisture from wet hands dilutes the alcohol.
- Compliance with hand washing procedures should be encouraged by involving users as much as possible in product selection, facilities design, studies, application of new technologies, education programs and feedback. 
- Patients/clients/residents in settings where patient hygiene is poor should have their hands washed. Patients/residents should be helped to wash their hands before meals, after going to the bathroom, before and after dialysis, and before leaving their room.
| Health Set Up: Indian Scenario|| |
India is the second most populous country of the world and has changing socio-political-demographic and morbidity patterns, which have been drawing global attention in recent years. Despite several growth-orientated policies adopted by the government, the widening economic, regional and gender disparities are posing challenges for the health sector. About 75% of health infrastructure, medical man power and other health resources are concentrated in urban areas where 27% of the population lives. Contagious, infectious and waterborne diseases such as diarrhea, amoebiasis, typhoid, infectious hepatitis, worm infestations, measles, malaria, tuberculosis, whooping cough, respiratory infections, pneumonia and reproductive tract infections dominate the morbidity pattern, especially in rural areas.  Hospital-acquired infections often occur because of lapses in accepted standards of practice on the part of health care personnel. Despite their best intentions, healthcare workers sometimes act as vectors of disease, disseminating new infections among their unsuspecting patients. However, attention to simple preventive strategies may significantly reduce disease transmission rates.  Elevating the place of infection control on the hospital organizational chart and changing the paradigm of surveillance to continuous monitoring and effective data feedback are central to achieving improved hand hygiene practices and quality of care. 
| Discussion and Conclusions|| |
Hand hygiene is a key practice used to reduce the risk and spread of infection. Infection control professionals should promote and conduct outstanding research and provide solutions to improve healthcare worker adherence with hand hygiene and enhance patient safety. To improve compliance with hand hygiene practices should be multimodal and multidisciplinary. In-service education, information leaflets, workshops and lecture, automated dispensers, and performance feed back on hand-hygiene adherence rates need to be associated with further improvements. In developing countries like India more emphasis should be given on such practices like hand hygiene in which infection control can be done to over power the infections and to improvise the medical standards and health conditions in a very economical way.
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Department of Periodontology, Rural Dental College-Loni, Maharashtra
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