VOL: 98, ISSUE: 46, PAGE NO: 48
Dinah Gould, PHD, BSc, RGN is professor of nursing, South Bank University, LondonHand decontamination is the most effective, and certainly the most cost-effective, method of preventing health-related infection (HRI). However, research has shown that health professionals, including nurses, do not decontaminate hands as often as they should. It has become apparent that hand decontamination does not always follow those activities which will probably result in the most heavy soiling, and the technique used to decontaminate hands is often poor (Larson and Kretzer, 1995).
Hand decontamination is the most effective, and certainly the most cost-effective, method of preventing health-related infection (HRI). However, research has shown that health professionals, including nurses, do not decontaminate hands as often as they should. It has become apparent that hand decontamination does not always follow those activities which will probably result in the most heavy soiling, and the technique used to decontaminate hands is often poor (Larson and Kretzer, 1995).
Promoting safe practice
To ensure that hand hygiene is performed effectively, health professionals need to develop the correct knowledge and attitudes to enable them to practise optimally. Individuals are generally surprised that such a deceptively simple activity has been the topic of so much research and is actually very complex.
However, knowledge alone is not effective in promoting hand hygiene. It appears that a shift in attitude must occur before any lasting change can be made. Campaigns to boost compliance with existing protocols only result in sustained improvements in practice if accompanied by continual audit with feedback of performance and an intensive drive to maintain standards (Naikoba and Hayward, 2001).
The first step in promoting effective hand hygiene is making sure that everybody in direct patient contact accepts that hand hygiene must become a priority. A useful starting point is to consider existing terminology. 'Hand washing', a term widely used to describe something that is performed socially as well as clinically, is not an adequate description of the hand cleansing recommended to prevent HRI in modern health care. The term 'decontamination', which refers to either the mechanical removal of micro-organisms and their debris or the destruction of micro-organisms, is more accurate and is now preferred. Whether or not the micro-organisms responsible for cross-infection are removed or destroyed depends on whether soap or a skin antiseptic is used.
The aim of hand hygiene
The aim of routine hand hygiene in the hospital ward or primary care setting is to break the chain of infection by removing transient micro-organisms from the hands before they can be transferred to a susceptible patient. As a general rule, hand decontamination is necessary whenever the health professional moves from one patient to another to engage in any activity that will result in more than superficial contact. Taking a pulse and serving a meal are often quoted as examples of such minimal patient contact.
What products are available?
A number of hand decontaminants are currently available - non-medicated soaps, aqueous antiseptic solutions, alcohol handrubs, gels and wipes. All health professionals need to know which are available in their own clinical areas and the protocol for using each.
Soaps have a useful detergent effect. They remove transient micro-organisms physically but have no impact on the resident microbial population. Unlike antiseptics, they do not kill micro-organisms or inhibit their growth, so their effectiveness is limited. However, they are still considered adequate when performing hand hygiene in many routine patient care situations. For example, many infection control teams recommend a soap and water hand wash before and after performing non-invasive activities in lower risk patients, such as recording vital signs or helping the patient with a bath. A major advantage of ordinary, non-medicated soap is that it is inexpensive.
Antiseptics produce a greater reduction in the number of transient and resident organisms on the skin, either by killing them or by inhibiting growth. Some have a natural detergent effect or are marketed in a formulation that includes a detergent. These are suitable for use on hands which are physically soiled. Familiar antiseptics include chlorhexidine gluconate, triclosan or povidone iodine as the active agent.
Chlorhexidine has quite a broad spectrum of activity but is more effective against Gram-positive than Gram-negative bacteria. One of the main advantages is its 'residual activity'. Chlorhexidine binds to the stratum corneum and remains effective for some time after it has been applied. It does not act as rapidly as alcohol, but after it has been used for several days bacterial counts on the hands fall to below their original level.
Povidone iodine is frequently used in operating departments because it destroys spores more effectively than many other antiseptics and is sometimes recommended in view of evidence that it removes MRSA from the fingertips more effectively than other antiseptics. Triclosan is a useful antiseptic for those who have developed hypersensitivity to products in more common use.
Ethyl alcohol, isopropanyl alcohol or n-propyl alcohol are the ingredients used in alcoholic gels, handrubs and wipes. These products sometimes incorporate other antiseptics, such as chlorhexidine or triclosan. When combined with chlorhexidine, residual action is provided. However, when used alone, alcohols do not display this property. They should always incorporate an emollient because they tend to dry the skin. Alcohols have excellent bactericidal activity against most Gram-positive and Gram-negative bacteria but have no effect on spores.
Alcohols destroy bacteria more swiftly than the aqueous solutions. However, they have no detergent effect and manufacturers do not recommend them in situations where hands will become heavily contaminated. Nevertheless, they are useful at times when physically clean hands require rapid decontamination.