PRINCIPLES OF HAND DECONTAMINATION

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Consider all equipment as being contaminated:

minimal handling of taps, soap dispenser, sinks, drying equipment, especially after washing; the use of foot-operated pedal bins and elbow taps is advised.

Sinks should not have plugs as they can be dificult to clean and can act as a reservoir for microorganisms, e.g. Pseudomonas.

•

Use running water at a comfortable temperature.

Water temperature for handwashing is often recommended to be ‘warm’ or ‘hot’ but hot water opens the pores predisposing to skin irritation.

It can also be drying to the skin which in turn can result in the skin being less resistant to bacterial colonization (Carrico et al 2013). Carrico et al (2013) discuss water temperature and found having the water at a temperature that is comfortable encourages more frequent handwashing for longer periods and lower water temperatures makes no difference to the effectiveness of removal of microorganisms.

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The low of the water should be regulated to avoid splashing water, especially over clothes, as

microorganisms can be transferred and multiply in moisture.

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Hands should be wet before applying liquid soap (NICE 2012).

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Use appropriate antimicrobial liquid soap and work up a lather as the soap will emulsify fat and oil and lower the surface tension, making cleaning easier.

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Use a circular motion, encouraging rubbing and friction which loosens and removes dirt and transient microorganisms.

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Rinse hands thoroughly to reduce the risk of irritant hand dermatitis.

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Hand drying is an important component of hand hygiene as hands that retain moisture after

handwashing have more microorganisms remaining than very dry hands. Loveday et al (2014) suggest that good-quality disposable paper towels are better at removing microorganisms because of the friction used during drying compared with hot air driers and

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Principles of infection control: hand hygiene

Figure 9.1 Medical/social scrub. A, Rinsing with water. B, Washing the palms. C, Washing the top surfaces of the ingers and hand. D, Interlacing the ingers. E, Washing the ingertips. F, Washing the thumbs. G, Washing the wrists.

A B

C D

E

G

F

SUMMARY

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Hand decontamination is an important means of infection control.

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The use of soap and water will remove almost all transient microorganisms, blood, body luid and dirt but does not signiicantly reduce the number of resident microorganisms.

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Healthcare professionals involved in direct patient care should be ‘bare below the elbows’.

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Alcohol handrubs remove almost all transient microorganisms and signiicantly reduce the number of resident microorganisms but do not remove blood, body luid, dirt, and spores, e.g. from C. difficile.

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Disposable paper towels should be used to dry hands.

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A ‘medical/social scrub’ involves washing for a minimum of 15 seconds.

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A ‘surgical scrub’ involves washing for at least 3–5 minutes, with the hands above the elbows.

PROCEDURE: surgical scrub

This involves washing the hands and forearms to remove as many transient and resident microorganisms as possible from these areas and maintain the lowest possible micro-bial count throughout the surgical procedure; washing should take at least 3–5 minutes (Spruce 2013).

•

Remove all jewellery (except for plain gold band), including wrist watch (however these should not be worn as the midwife should be ‘bare below the elbows’).

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Turn the taps on and adjust the water low and temperature to warm, taking care not to splash the water.

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Keeping the hands above the level of the elbows, wet the hands and forearms to the elbows.

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Using an antiseptic soap, e.g. 4% chlorhexidine solution, povidone–iodine, wash ingers and hands as for medical scrub and extend washing to include forearms (this may require several applications of antiseptic soap) using brush/sponge if it is the irst surgical scrub of the day.

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Rinse the soap from hands and elbows, keeping the hands above the level of the elbows, allowing the water to run from the ingertips down to the elbows.

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Turn off the taps using elbows.

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Dry each hand and arm separately with a disposable towel, drying from the ingertips towards the elbows, keeping the hands above waist level.

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Dispose of the towel using a foot-operated pedal bin.

ROLE AND RESPONSIBILITIES OF THE MIDWIFE These can be summarized as:

• recognizing the importance of correct hand hygiene

• following the principles of hand care

• recognizing when and how hand decontamination should be undertaken

• reducing the risk of contamination to self and others through appropriate hand hygiene.

SELF-ASSESSMENT EXERCISES

The answers to the following questions may be found in the text:

1. Why is hand hygiene important?

2. What are the general principles of hand care and why are they important?

3. In what situations would the midwife use an AHR?

4. When should the midwife undertake hand decontamination?

5. What are the principles of hand decontamination?

6. What are the main differences between a ‘medical/

social’ and a ‘surgical’ scrub?

REFERENCES

Ahmed-Lecheheb, D., Cunat, L., Hartemann, P., Hautemaniere, A., 2012. Prospective observational study to assess hand skin condition after application of alcohol-based handrub solutions. Am. J. Infect. Control 40 (2), 160–164.

Al-Allah, A., Sarasin, S., Key, S., Morris-Stiff, G., 2008. Wedding rings are not a signiicant source of bacterial

contamination following surgical scrubbing. Ann. R. Coll. Surg. Engl.

90 (2), 133–135.

Besta, E.L., Parnella, P., Wilcox, M.H., 2014. Microbiological comparison of hand-drying methods: the potential for contamination of the environment, user, and bystander. J. Hosp. Infect. 88 (4), 199–206.

Carrico, A.R., Spoden, M., Wallston, K.A., Vandenbergh, M.P., 2013. The environmental cost of misinformation: why the recommendation to use elevated temperatures for handwashing is problematic. Int. J. Consum. Stud. 37 (4), 433–441.

CDC (Centres for Disease Control and Prevention), 2002. Guideline for

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Principles of infection control: hand hygiene

Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Available online:

<www.cdc.gov/mmwr/pdf/rr/rr5116 .pdf> (accessed 2 March 2015).

Chamorey, E., Marcy, P.-Y., Dandine, M., et al., 2011. A prospective multicenter study for evaluating skin tolerance to standard hand hygiene technique.

Am. J. Infect. Control 39 (1), 6–13.

Cook, H.A., Jeannie, M.P.H., Cimiotti, P., et al., 2007. Antimicriobial resistance patterns of colonizing lora on nurses’

hands in the neonatal intensive care unit. Am. J. Infect. Control 35 (4), 231–236.

Fagernes, M., Lingaas, E., 2010. Factors interfering with the microlora on hands: a regression analysis of samples from 465 healthcare workers.

J. Adv. Nurs. 67 (2), 297–307.

Fuller, C., Savage, J., Besser, S., et al., 2011. The dirty hand in the latex glove: A study of hand hygiene compliance when gloves are worn.

Infect. Control Hosp. Epidemiol. 32 (12), 1194–1199.

Gould, D.J., Hewitt-Taylor, J., Drey, N.S., et al., 2007. The clean your hands campaign: Critiquing policy and evidence base. J. Hosp. Infect. 65 (2), 95–101.

Harper, A., 2011. Sepsis. In: Centre for Maternal and Child Enquiries (CMACE). Saving Mothers’ Lives:

reviewing maternal deaths to make motherhood safer: 2006–08. The eighth report on conidential enquiries into maternal deaths in the United Kingdom. Br. J. Obstet.

Gynaecol. 118 (Suppl. 1), 85–96.

Hautemaniere, A., Cunat, L., Diguio, N., et al., 2010. Factors determining poor practice in alcoholic hand gel rub

technique in hospital workers. J.

Infect. Public Health 3 (1), 25–34.

Hsieh, H., Chiu, H., Lee, F., 2006.

Surgical hand scrubs in relation to microbial counts: systematic literature review. J. Adv. Nurs. 55 (1), 68–74.

Huang, C.L., Ma, W., Stack, S., 2012. The hygienic eficacy of different hand-drying methods: a review of the evidence. Mayo Clin. Proc. 87 (8), 791–798.

Hübner, S.-O., Hübner, C., Kramer, A., Assadian, O., 2011. Survival of bacterial pathogens on paper and bacterial retrieval from paper to hands: preliminary results. Am. J.

Nurs. 111 (12), 30–34.

Jabbar, U., Leischner, J., Kasper, D., et al., 2010. Effectiveness of alcohol-based hand rubs for removal of Clostridium dificile spores from hands. Infect.

Control Hosp. Epidemiol. 31 (6), 565–570.

Kilpatrick, C., Hosie, L., Storr, J., 2013.

Hand hygiene – when and how should it be done? Nurs. Times 109 (38), 16–18.

Khodavaisy, S., Nabili, M., Davari, B., Vahedi, M., 2011. Evaluation of bacterial and fungal contamination in the health care workers’ hands and rings in the intensive care unit. J.

Prev. Med. Hyg. 52 (4), 215–218.

Loveday, H.P., Wilson, J.A., Pratt, R.J., et al., 2014. epic3: National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. J. Hosp. Infect. 86 (Suppl. 1), S1–S70.

Martirani, R., Weaving, A.P., 2011.

Infection prevention and control. In:

Dougherty, L., Lister, S. (Eds.), The Royal Marsden Hospital Manual of Clinical Nursing Procedures, eighth ed. Wiley-Blackwell, Oxford, pp.

93–154.

Moore, G., Dunhill, C., Wilson, A., 2013.

The effect of glove material upon the transfer of methicillin-resistant Staphylococcus aureus to and from a gloved hand. Am. J. Infect. Control 41, 19–23.

NICE (National Institute for Health and Care Excellence), 2012. Infection:

prevention and control of healthcare-associated infections in primary and community care. Available online:

<www.nice.org.uk> (accessed 2 March 2015).

NICE (National Institute for Health and Care Excellence), 2014. Infection prevention and control Quality Standard 61. Available online:

<www.nice.org.uk> (accessed 23 February 2015).

Patrick, M., Van Wicklin, S., 2012.

Implementing AORN recommended practices for hand hygiene. AORN J.

95 (4), 492–509.

Spruce, L., 2013. Back to basics: hand hygiene and surgical hand antisepsis.

AORN J. 98 (5), 449–460.

Tanner, J., Swarbrook, S., Stuart, J., 2008.

Surgical hand antisepsis to reduce surgical site infection. Cochrane Database Syst. Rev. (1), Art. No.:

CD004288, doi:10.1002/14651858.

CD004288.pub2.

Visscher, M., Said, D., Wickett, R., 2010.

Stratum corneum cytokines structural proteins and transepidermal water loss: effect of hand hygiene. Skin Res.

Technol. 16, 229–236.

Ward, D., 2007. Hand adornment and infection control. Br. J. Nurs. 16 (11), 654–656.

WHO (World Health Organisation), 2009. Guidelines on Hand Hygiene in Health Care. WHO, Geneva.

Wyeth, J., 2013. Hand hygiene and the use of personal protective equipment. Br. J. Nurs. 22 (16), 920, 922–925.

Principles of infection control: principles of asepsis

Chapter

It is the principles of asepsis that midwives need to understand in order to then apply them across a range of care situations. This chapter should be read in conjunction with several others including hand hygiene, obtaining swabs, intravenous medicines, epidural analgesia, wound care, etc. This chapter reviews the principles of aseptic prac-tice, particularly with regard to the ANTT (Aseptic Non Touch Technique) framework (Rowley et al 2010).