Saraya Hand Hygiene and Tb Patient Safety Mar 6 2014

２０１３年度版

Hand Hygiene in Healthcare Hand Hygiene in Healthcare Settings Settings

“Importance of Hand Hygiene Practices”


Ideal Tools for Hand HygieneImproving Hand Hygiene Compliance　

Today`s Topic!Today`s Topic!


Name: Kelvin LimAge: 37Nationality: MALAYSIAN, living in Kuala

Lumpur Company: Saraya Hygiene MalaysiaHobbies: Futsal, Running & Washing CarInterests: Infection Control (Hospital) 　

About MyselfAbout Myself


5-15% of patients admitted to acute care hospitals Risk is higher in critical care (15-40%) Risk is 2 to 20 fold higher in developing countries Burdon of disease outside hospitals is mostly unknown　

Average HA Infection RateAverage HA Infection Rate

No hospital, country, healthcare-system in the world can claim to have solved the

challenge of Healthcare Associated Infection!

　Dr. Ojan Assadian, 2012


HAI can affect 9–37% of those admitted to intensive care units (ICUs)

An estimated five million HCAI at least occur in acute care hospitals in Europe every year

HAI contribute to 135,000 deaths per year in Europe

Burden of HAI - LifeBurden of HAI - Life

WHO Guidelines for Hand Hygiene in Healthcare


The estimated HCAI incidence rate in the United States of America (USA) was 4.5% in 2002, with about 1.7 million patients and an annual economic impact of US$ 6.5 billion in 2004.

Approx. 99,000 deaths in 2002, USADevice-associated infections have a great economic impact; for example catheter-related bloodstream infection caused

by methicillin-resistant Staphylococcus aureus (MRSA) may cost as much as US$ 38,000 per episode in the USA.

　

Burdon of Infection - CostBurdon of Infection - Cost

WHO Guidelines for Hand Hygiene in Healthcare

Fundamentals of Hand Hygiene


Droplet Airborne

MRSA 、 VRE 、 MDRP, C. Difficile, Scabies Norovirus,

Varicella

Tuberculosis

Influenza, 、Whooping cough, 、Rubella 、Mumps

MeaslesMeasles

Contact


Importance of Hand Hygiene

患者に触れる医療行為は多い

CDC,APIC,SHEA:How-to Guide: Improving Hand Hygiene –A Guide for Improving Practices among Health Care Workers

. . Hand Hygiene is the most important Hand Hygiene is the most important way to prevent HAIsway to prevent HAIs


Goal and Principles of Hand Hygiene

STOP Cross Contamination To Patients

PROTECT YourselfPREVENT Infection and PROMOTE

Treatment

To Remove Soil and Infectious Microorganisms

Infection Prevention


3 Types of Hand Hygiene

Skin

Resident Flora

Visible Soiling

Transient Flora

DailyHH

HygienicHH

SurgicalHH


●● Visible SoilingVisible Soiling

●● No Visible SoilingNo Visible Soiling

WHO Guidelines for Hand Hygiene in Healthcare 　 2009CDC Guidelines for Hand Hygiene in Healthcare 　2002

Hygienic Hand Hygiene Practice

Soap and Running Water

Quick Drying Alcohol Hand Disinfectant


'Based on the 'My 5 moments for Hand Hygiene', URL: ttp://www.who.int/gpsc/5may/background/5moments/en/index.html© World Health Organization 2009. All rights reserved.'

Hand Hygiene Timing


「 Patient Zone 」 & 「 Care Area 」

Patient Zone

Care Area

Patient Infection Risk Point

Liquid Exposure Risk Point

““5 Moments of Hand Hygiene5 Moments of Hand Hygiene”” Focuses on the Focuses on the Patient ZonePatient Zone


Patient ZoneThe Patient and the Items and

Environment SurroundingEnvironment and Items Surrounding

・ All surfaces accessible to the patient and touching the patient’s body. 　 Environmental Surfaces　（ Bed rails, table, linens, tubes, other medical devices)・ Items touched and used by Medical Staff. (Monitor, handles, buttons, doorknobs)


Patient ZoneThe patient zone is not geographically

set. It is the constant area, items and environment that surround the patient.

患者が移動すれば、患者ゾーンも移動If the patient moves, so does the ZoneIf the patient moves, so does the Zone

This means patients in a wheelchair or under treatment has a Patient Zone as well.


Care AreaAll areas outside the Patient Zone

In other words・ Another Patient Zone・ The Greater Hospital Environment


Before Patient Contact

1.Before Touching a Patient


1. Before Touching a Patient

Before touching a patient’s intact skin or clothing. For example, these situations・ Before shaking hands with a patient or holding a child・ Before care in a patient’s surroundings: Moving, Bathing, Meals, Changing Clothes・ Before non-invasive care, applying an oxygen mask, physical therapy. ・ Physical check-up, non-invasive exam (Checking heart rate, blood pressure, chest exam, cardiac electrogram)


Before a clean operation

2. Before a Clean Operation


2. Before a Clean OperationHand hygiene before an operation

that accesses a critical risk to patients. For example, these situations

・ Before brushing teeth, eye drops, vaginal/rectal exam, mouth-nose-ear exam (with or without tools), suppository/diaphragm insertion, mucous extraction・ Before dressing wounds (with or without tools), treating blisters, puncturing・ Invasive procedure (nasal tubing, feeding tube, etc.) ・ Before preparing meals, medicine, sterile materials.


2. Before a Clean Operation

●● Prevent the transfer of pathogens from Prevent the transfer of pathogens from one patient/environment to another!one patient/environment to another!

When doning gloves before a clean operation: hand hygiene!


After Body Fluid Exposure Risk

3. After Body Fluid Exposure Risk



Disinfect hands after a procedure with body fluid exposure risk (and after removing gloves)

For example, in these situations・ After touching mucous membranes, wounded skin・ After puncture, invasive procedure (blood access, catheter, tube, etc.)・ Invasive equipment removal・ After removing protective tools (Napkin, dressings, gauze, etc.)・ After cleaning up body fluids, cleaning contaminated surfaces (bed pan)



When wearing gloves for an exposure risk, quickly remove gloves and disinfect hands after the procedure.

●● Protect you and your team from Protect you and your team from pathogens. pathogens. ●● Keep the environment clean and Keep the environment clean and contained from cross contamination!contained from cross contamination!


After Touching a Patient

4.After Touching a Patient


4. After Touching A PatientAfter patient care, disinfect hands

when leaving the patient zone. For example, these situations. ・ After shaking hands, holding a child. ・ After patient care (bathing, feeding, moving, changing)・ Non-invasive examinations・ Physical check-up, non-invasive exam (Checking heart rate, blood pressure, chest exam, cardiac electrogram)


5. After Touching a Patient’s Surroundings

After touching a patient’s surroundings


5.After Touching a Patient’s Surroundings

Even when not touching a patient, disinfect hands after touching the environment in a patient zone.

For example, these situations.・ After changing bed linens, touching a bed rail, arranging a bed side table. ・ After adjusting perfusion rate for a patient


5.After Touching a Patient’s Surroundings

●● A patient has access to the surrounding A patient has access to the surrounding environment, prevent cross contamination environment, prevent cross contamination to other patients by disinfecting after to other patients by disinfecting after touching the environment. touching the environment.


〔 Tips on Gloves 〕

When gloves are required, always disinfect hands before doning if a hand hygiene moment is expected.

Disinfect hands after removing gloves when a hand hygiene moment occurred during care.

When a hand hygiene moment occurred while doning gloves, remove, toss, disinfect and re-don.

GLOVES ARE NOT A REPLACEMENT FOR HAND GLOVES ARE NOT A REPLACEMENT FOR HAND HYGIENE!HYGIENE!

Alcohol Hand Alcohol Hand DisinfectantDisinfectant

The best way to prevent healthcare associated infections


Ideal Hand DisinfectantAlcohol based

Skin protecting emollients

Wide range of efficacy

Usability and tolerability

80~85% ethanol or 70% isopropanol

To heal and moisturize the skin

EN 1500 HHD ≤ 30s, EN 12791 SHP ≤ 90s

Low irritants (colors, fragrance), fragrance freeAssadian, O, Criteria for ABHR, 2013


• Ethanol 80v/v% CHG 0.2% • Emollients for skin health• Applicable for Saraya No-touch

dispensers.• EN1500, EN12791, etc.

Alsoft A

Antibacterial: MRSA, Tuberculosis, etc. Antifungal: C. albicans, yeast, etc. Antiviral : HIV, Influenza, HVB, HCB, etc.

Non-Irritation: Fragrance-free, Color-free. Emollients for skin protection.

Non-irritation increases skin tolerability and hand hygiene compliance

Saraya Hand Disinfectants


• Isopropanol 70% • Low irritation formula• Applicable for Saraya No-touch

dispensers.• EN1500, EN12791, etc.

Alsoft Pure

Antibacterial: MRSA, Tuberculosis, etc. Antifungal: C. albicans, yeast, etc. Antiviral : HIV, Influenza, HVB, HCB, etc.

Non-Irritation: Fragrance-free, Color-free.

Non-irritation increases skin tolerability and hand hygiene compliance

Saraya Hand Disinfectants


Hand Hygiene Efficacy (Water)


Hand Hygiene Efficacy (Soap)


L.J.Taylor,SRN,SCM:An evaluation of hand washing techniques-1,NURSING TIME 1978 ; JANUARY(12):54

Regularly Missed Areas


Hand Disinfection Method

①Palms ③Dorsal surface

④Between the fingers ⑤Thumbs

②Finger Tips

⑥Wrists


Hand Hygiene Efficacy (AHR)


Effect of Hand Contamination

Ever touch your head at work?Without Noticing?Without Noticing?


Contaminating Hands

After Disinfection

Disinfection → Touching Hair

“Alcohol Hand Disinfectant is the Best Way to Prevent

Healthcare Associated Infections”

２０１３年度版Consensus was based on speed of action and applicability in clinical setting

Adapted from: Rotter ML. Hosp Epidemiol Infect Control, 2nd Edition, 1999.

0.0

1.0

2.0

3.0 0 60 180 minutes

0.0

90.0

99.0

99.9log%

Bact

eria

l Red

uctio

n

Alcohol-based handrub(70% Isopropanol)

Antimicrobial soap(4% Chlorhexidine)

Plain soap

Time After Disinfection

Baseline

x10

x100

x1000

EN 1500:1997


Limitations of scrubs

Active agent exposure (s) conc. (%) lg reduction

Propan-1-ol/ Propan-2-ol

1530/45

4.220 4.330 4.9

Propan-1-ol 20 70 4.3Ethanol 30 75 4.8Chlorhexidin based detergent

60 4 3.1

Triclosan based detergent

60 0.1 2.8

Lower efficacy + longer duration of the procedure of scrubstested by EN 1500


48%

66%

17%10%0%

10%20%30%40%50%60%70%

1994 1997

Compliance HAI Prevalence

Pittet et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet 2000; 356: 1307-12

Decrease of HAI rateparallel to increase of compliance from48 to 66% the rate Of HAI significantly decreased from16.9 to 9.9%


Decrease of urinary tract infections and SSI

In an 498-bed acute care of orthopedic surgery after introduction of alcohol based hand gel for bedside use within 16 months the infection rates as sum of both was decreased by 36.1% Hilburn et al. Use of alcohol hand sanitizer as an infection control strategy in an acute care facility. Am J Infect Control 2003;31(2):109-16.


Prevention of HAI in very low birth weight (VLBW) neonates

Handwashing with detergent (0.5% triclosan) vs. hand hygiene program using antimicrobial soap (4% chlorhexidine gluconate) + alcohol-based hand rub: - HAI after 72 hours of life 18.8% vs. 6.3% - rate of central venous catheter colonization 16.6% vs. 5.8%

Capretti et al. Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants.Am J Infect Control 2008;36(6):430-5


Reducing spread of multi-resistant bacteria

Introduction of alcohol/chlorhexidine based rub

use increased from 5.7 to 28.6 L/1000 bed-days

46 months post intervention reduction of- total MRSA isolates 40% (p < 0.001)- patient-episodes of MRSA bacteraemia 57% (p = 0.01)- clinical isolates of ESBL-producing E. coli and Klebsiella spp. 90% (p < 0.001). Johnson et al. Efficacy of an alcohol/chlorhexidine hand hygiene program in a hospital with high rates of noso-comial methicillin-resistant Staphylococcus aureus (MRSA) infection. Med J Aust 2005 21;183(10):509-14


Influence on MRSA rateStudy desing Introduction of gel rinse disinfection in 250-bed

community hospital Comparison of the nosocomial infection rate

during one year with retrospective rate. ResultThe rate of MRSA nosocomial infections

per thousand admissions decreased by 51%

Gagne et al. Systematic patients' hand disinfection: impact on meticillin-resistant Staphylococcus aureus infection rates in a community hospital- J Hosp Infect 2010; 29 2010, p S1532-2939


Reasons for non-compliance

No time for hand hygiene (ABHS: 15 -30 seconds)

Forgetting to disinfect handsLimited access to hand hygiene productsWearing gloves as an alternativeSkin irritation when using hand disinfectantsDislike of provided hand disinfectantsMissing role model of superiors

Patarakul K et al. J Med Assoc Thai 2005; 88Suppl 4: S287-93.


• Sensor Activated Hand Hygiene • No cross contamination• Intuitive support for increased

compliance• Disposable pump system

GUD-1000

Proven support for increased compliance and hand hygiene usage Battery life of 1 year. No contamination risk for bottle or nozzle

Hand hygiene should always be at the point of care

Saraya Automatic Dispenser


3 months observational study Installation of different dispenser modelsNo pre-study teaching or demonstration of usage.

Influence of the dispenser type on consumption of hand rub

Assadian, O., 2005, Observational Study


Increased usage with sensor dispensers

0.0

0.4

0.8

1.2

1.6

2.0

Pump D Elbow D 1 Elbow D 2 Sensor D

L / week

p < 0.01

p < 0.05

p < 0.05

p < 0.05

0.15

0.700.85

1.80

NS


Hand CareHand Care


More bacteria, more danger to health

Skin carries bacteria to Contaminate the Area

A breeding ground for bacteria

Dry skin willShed and Fall

The Skin’s NaturalBarrier Weakens

Hand Roughness

The Adverse Effects of Hand Roughness

Lower Compliance in Hand Hygiene!


Hand Care PointsChoose a Product That Is Gentle　・ Less Irritants (Fragrance, Colors)Rethinking Hand Hygiene Methods　・ Rinse Well, Wash Less　・ Use cold water　・ Use soft paper towels　・ Always use disinfectant when hands are

not visibly dirty!Emollient ・ Hand Lotion if Necessary

【【 Prevent RoughnessPrevent Roughness 】】


Time interval after one hand disinfection

µg/cm2

Alcohols no affect content of sebum (µg/cm2) after one single hand rub for 1 minute

No Effect on Sebum


Soaps decrease sebum content (µg/cm2) after one single hand scrub of 30 s > 1 hour

µg/cm2

Time interval after one hand wash


Absorption of AlcoholsInvestigation after excessive hygienic and surgical hand disinfectionalcohol-based hand sanitizer rubs or gel under identical test conditions with the same test persons to determine the application security Reasons of the high chosen expositions

no knowledge about the expected resorption rate detection limit of the concentration for the

chemical analysis

the highest measured blood level of ethanol was 0.03 ‰, for propanols 0.02 ‰

Kramer A, Below H, Bieber N, Kampf G, Toma CD, Hübner NO, Assadian O. BMC Inf Dis. 2007; 7: 117.

Below H, Partecke I, Huebner NO, Bieber N, Nicolai T, Usche A, Assadian O, Below E, Kampf G, Parzefall W, Heidecke CD, Zuba D, Bessonneau V, Kohlmann T, Kramer A. Dermal and pulmonary absorption of propan-1-ol and propan-2-ol from hand rubs.Am J Infect Control 2012; 40(3): 250-7.


Risk AssessmentApple juice contain up to 2 g ethanol/l1 0.5 l

apple juice resulted in an ethanol level forMale (75 kg) 0.17‰Female (60 kg) 0.25‰

~ 10-fold higher than after an excessive surgical hand disinfection

1Windirsch B, Brinkmann B, Taschan H. Alkoholgehalte ausgewählter Lebensmittel. Lebensmittelchemie 2005; 59: 149-150


Conclusion Absorption of all 3 alcohols < 0.03 ‰ (under real

conditions ~ 0,003 ‰) no systemic risk

however the exposure duration should be limited to the time period which is necessary for the disinfection effect, because: - skin tolerability- compliance- systemic tolerance

prefer 1,5 min preparations

For skin antisepsis of newborns, use ethanol- instead propanol- based preparations, for immature premature infants use non-absorbable antiseptics


"Instead of trying to kill bacteria in a wound, wouldn't it be easier if they never had entered the wound in the first place?" Louis Pasteur


Thank you for listening.

Hand hygiene is essential to patient safety in in hospitals no matter the situation or symptom.

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Saraya Hand Hygiene and Tb Patient Safety Mar 6 2014

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