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1. Dr.T.V.Rao MD Hand washing a solution to hospital infections Dr.T.V.Rao MD 1

2. Most common mode of transmission of pathogens is via hands! So Why All the Fuss About Hand Hygiene? Dr.T.V.Rao MD 2

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 3

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 4

5. Does Hand washing Work? Semmelweis - 1847 Dr.T.V.Rao MD 5

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. Dr.T.V.Rao MD 6

7. 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 7

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 Dr.T.V.Rao MD 8

9. 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 Dr.T.V.Rao MD 9

10. 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. Dr.T.V.Rao MD 10 Healthcare workers should wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use an alcohol-based handrub when hands are not visibly soiled to reduce bacterial counts. Healthcare workers should wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use an alcohol-based handrub when hands are not visibly soiled to reduce bacterial counts.

11. 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 Dr.T.V.Rao MD 11 Hand hygiene is indicated before: patient contact, donning gloves when inserting a central venous catheter (CVC), and inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don?t require surgery. Hand hygiene is also indicated after contact with a patient?s intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves. Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions. Hand hygiene is indicated before: patient contact, donning gloves when inserting a central venous catheter (CVC), and inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don?t require surgery. Hand hygiene is also indicated after contact with a patient?s intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves. Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions.

12. Efficacy of Hand Hygiene Preparations in Killing Bacteria Dr.T.V.Rao MD 12 Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best. Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best.

13. 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 Dr.T.V.Rao MD 13 The time required for nurses to leave a patient?s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis. More rapid access to hand hygiene materials could help improve adherence. Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often. The time required for nurses to leave a patient?s bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis. More rapid access to hand hygiene materials could help improve adherence. Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often.

14. 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 faucet Dr.T.V.Rao MD 14 These recommendations will improve hand hygiene practices of HCWs and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. When decontaminating hands with an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet. These recommendations will improve hand hygiene practices of HCWs and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. When decontaminating hands with an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet.

15. 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 Dr.T.V.Rao MD 15 Surgical hand hygiene (or antisepsis) can be performed by using either an antimicrobial soap OR an alcohol-based handrub with persistent activity. When an antimicrobial soap is used, the hands and forearms should be scrubbed for the length of time recommended by the product?s manufacturer, usually 2-6 minutes. Longer scrub times (e.g. 10 minutes) are usually not necessary. When an alcohol-based handrub with persistent activity is used, follow the manufacturer?s instructions on the amount of product to use. Pre-wash hands and forearms with a non-antimicrobial soap and allow them to dry completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves. Surgical hand hygiene (or antisepsis) can be performed by using either an antimicrobial soap OR an alcohol-based handrub with persistent activity. When an antimicrobial soap is used, the hands and forearms should be scrubbed for the length of time recommended by the product?s manufacturer, usually 2-6 minutes. Longer scrub times (e.g. 10 minutes) are usually not necessary. When an alcohol-based handrub with persistent activity is used, follow the manufacturer?s instructions on the amount of product to use. Pre-wash hands and forearms with a non-antimicrobial soap and allow them to dry completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.

16. 5 stages of hand transmission Dr.T.V.Rao MD 16

17. Most frequent sites of infection and their risk factors Dr.T.V.Rao MD 17 Central nervous system depressantsCentral nervous system depressants

18. 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 18

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. Dr.T.V.Rao MD 19

20. 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 20

21. Routine Hand Wash Dr.T.V.Rao MD 21 Note: Hand and wrist jewellery including plain weddings bands should not be worn, as these are likely to increase the presence of gram negative bacilli Nails should be short and clean and artificial nails should be discouraged as they contribute to increased bacterial counts. Wet hands thoroughly with warm running water. Keep hands lower than elbows and apply soap. Use friction to clean between fingers, palms, backs of hands and wrists. 4. Rinse hands under running water until all soap is gone. DO NOT TOUCH TAPS WITH CLEAN HANDS ? IF ELBOW OR FOOT CONTROLS ARE NOT AVAILABLE, USE PAPER TOWEL TO TURN TAPS OFF. 5. Pat hands dry with a clean, single use towel. A neutral soap should be used for routine handwashing. If liquid soap is dispensed from reusable containers, these must be cleaned when empty and dried before refilling with fresh soap ? refilling soap containers is a potential source of infection. Where possible single use soap containers or bladders should be used. HANDWASH SOLUTIONS SHOULD NEVER BE TOPPED UP Scrub brushes should not be used for routine handwashing because they can cause abrasion of the skin, and may be a source of infection. Add Notes Here:Note: Hand and wrist jewellery including plain weddings bands should not be worn, as these are likely to increase the presence of gram negative bacilli Nails should be short and clean and artificial nails should be discouraged as they contribute to increased bacterial counts. Wet hands thoroughly with warm running water. Keep hands lower than elbows and apply soap. Use friction to clean between fingers, palms, backs of hands and wrists. 4. Rinse hands under running water until all soap is gone. DO NOT TOUCH TAPS WITH CLEAN HANDS ? IF ELBOW OR FOOT CONTROLS ARE NOT AVAILABLE, USE PAPER TOWEL TO TURN TAPS OFF. 5. Pat hands dry with a clean, single use towel. A neutral soap should be used for routine handwashing. If liquid soap is dispensed from reusable containers, these must be cleaned when empty and dried before refilling with fresh soap ? refilling soap containers is a potential source of infection. Where possible single use soap containers or bladders should be used. HANDWASH SOLUTIONS SHOULD NEVER BE TOPPED UP Scrub brushes should not be used for routine handwashing because they can cause abrasion of the skin, and may be a source of infection. Add Notes Here:

22. Dr.T.V.Rao MD 22

23. The ?My 5 Moments for Hand Hygiene? approach Dr.T.V.Rao MD 23

24. 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 Dr.T.V.Rao MD 24

25. Most frequent sites of infection and their risk factors Dr.T.V.Rao MD 25 Central nervous system depressantsCentral nervous system depressants

26. 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%.

27. Many countries worldwide are committed to improve hand hygiene Dr.T.V.Rao MD 27

28. Dr.T.V.Rao MD 28

29. 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.

30. Why Don?t Staff Wash their Hands (Compliance estimated at less than 50%) Dr.T.V.Rao MD 30 Hand out article and ask participants to get into small groups and select 5 most common reasons they do not was hands from the reasons listed in the article ? table 2 and list any other reasons they might think of in their own agencies. 5 ? 10 minutes Discuss each groups list and collate list on white board Mark off those that repeat ? number list in order of most common (1) to least common (2) Ask for other reasons group have come up with ? list on board Hand out article and ask participants to get into small groups and select 5 most common reasons they do not was hands from the reasons listed in the article ? table 2 and list any other reasons they might think of in their own agencies. 5 ? 10 minutes Discuss each groups list and collate list on white board Mark off those that repeat ? number list in order of most common (1) to least common (2) Ask for other reasons group have come up with ? list on board

31. 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) Dr.T.V.Rao MD 31

32. 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 Dr.T.V.Rao MD 32

33. 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) Dr.T.V.Rao MD 33

34. Teach them earlier in life Dr.T.V.Rao MD 34

35. Make all Kids partners in Hand washing Dr.T.V.Rao MD 35

36. 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? Dr.T.V.Rao MD 36

37. 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 Dr.T.V.Rao MD 37

38. Hand Care also includes Nails Rings Hand creams Cuts & abrasions ?Chapping? Skin Problems Dr.T.V.Rao MD 38

39. New CDC Hand Hygiene Guidelines Major 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 39

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 Dr.T.V.Rao MD 40

41. Sir William Osler on Hand Washing Soap, Water and Common sense, are still the best Antiseptics. Dr.T.V.Rao MD 41

42. Inspire your children on hand hygiene Dr.T.V.Rao MD 42

43. 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

44. 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. Dr.T.V.Rao MD 44

45. Dr.T.V.Rao MD 45

46. Hand washing a Tribute to Dr. Ignaz Semmelweis Dr.T.V.Rao MD 46

47. Dr.T.V.Rao MD 47 For Articles of Interest on microbiology and infectious diseases follow me on

48. Wish to save more lives with hand washing ?? Visit the SAVE LIVES: Clean Your Hands website at: www.who.int/gpsc/5may/en/ Dr.T.V.Rao MD 48

49. 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


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