Posted by admin on October 31st, 2011
Two levels of decontamination (treatment) of hands.
1.Hygienic treatment hands: removal or destruction of transient microflora, partial destruction of resident microflora.
2.Surgical treatment of hands: complete destruction of transient microflora and a significant amount of resident microflora.
Requirements for the hands of a healthcare professional :
Hands should have intact skin, if there are wounds and abrasions, they should be treated with an antiseptic and covered with a plaster;
The hands of a medical worker should not show signs of pustular diseases;
Nails should be clean, cut short, and free from varnish (microorganisms accumulate in the cracks of the varnish);
There should be no rings, rings, bracelets on the hands (since any jewelry prevents the full processing of hands and is a place of accumulation of microorganisms).
Soap requirements:
Soap can be used in any standard form(liquid, solid, granular, powder, etc.);
The soap should be simple, no antimicrobial additives;
Bars should be stored in soap dishes that have good drainage to ensure that the soap dries;
Preference is given to liquid soap in standard dispensers, because in this case, contact of the skin of personnel with soap is excluded, which excludes its infection;
When using reusable dispensers: Do not add soap to a partially emptied dispenser. After the dispenser has been completely emptied of soap, it is thoroughly washed, disinfected, dried and only then refilled with soap.
Indications for hygienic treatment of hands:
Before performing any invasive procedures;
Before working with particularly susceptible (immune-compromised) patients and newborns;
Before and after manipulating wounds and catheters;
Before putting on and after taking off gloves;
After contact with the patient's biological fluids or with objects that have the likelihood of microbial contamination (examination of an infectious patient, measurement of rectal temperature, etc.).
Hand washing technique.
Hand washing with soap is carried out under a moderate stream of comfortably warm water for 1 minute. Hands are generously lathered with soap and then, 6 standard steps are sequentially carried out:
After completing all stages of washing, hands are rinsed abundantly under running water... Next, wipe your hands dry with a disposable paper towel or reusable disposable textile napkins. Textile napkins must be washed after each use (used napkins are collected during a shift in a container and sent to the laundry). Only sterile hand wipes are used in the delivery rooms and the operating room.
Using a skin antiseptic.
In Russia, in health care facilities, alcohol-based antiseptics are used that do not require wiping their hands after treatment. Skin antiseptics are used strictly according to the instructions for the drug used..
When using most alcohol-containing skin antiseptics, 2.5 - 5 ml of the drug is poured into the palm of your hand and rubbed into the skin of the hands for 2.5 -3 minutes, repeating the technique of washing hands until they are completely dry.
1. General Provisions
1.2. Definition of terms
- Antimicrobial agent- an agent that suppresses the vital activity of microorganisms (disinfectants, antiseptics, sterilants, chemotherapeutic agents, including antibiotics, cleaning agents, preservatives).
- Antiseptics- chemical substances of microbostatic and microbicidal action used for preventive and therapeutic antiseptics of intact and damaged skin and mucous membranes, cavities, wounds.
- Hand antiseptic- a product based on alcohol with or without the addition of other compounds, intended for decontamination of the skin of the hands in order to interrupt the chain of transmission of infection.
- Hospital-acquired infection (nosocomial infection)- any clinically expressed disease of an infectious nature that affects the patient as a result of being in a hospital or visiting a medical institution, as well as infections arising among the personnel of a healthcare institution as a result of their professional activity.
- Hygienic hand antiseptic- This is the treatment of hands by rubbing an antiseptic into the skin of the hands to eliminate transient microorganisms.
- Invasive interventions- the use of apparatuses and devices that overcome the natural barriers of the body, with which the pathogen can penetrate directly into the bloodstream, organs and systems of the patient's body.
- Routine hand washing- washing procedure with water and ordinary (without antimicrobial action) soap.
- Irritant contact dermatitis (CD)- discomfort and changes in the condition of the skin, which can manifest itself in dry skin, itching or burning, redness, peeling of the epidermis and the formation of cracks.
- Resident microorganisms- microorganisms that constantly live and multiply on the skin.
- Spore-forming bacteria- these are bacteria that have the ability to form special structures covered with a dense shell, they are conventionally called spores, they are highly resistant to the action of many physicochemical factors.
- Transient microorganisms- microorganisms that temporarily fall on the surface of the human skin in contact with various living and inanimate objects.
- Surgical hand antisepsis is a procedure for rubbing an antimicrobial agent (antiseptic) into the skin of the hands (without the use of water) to eliminate transient microorganisms and reduce the number of resident microorganisms as much as possible.
- Surgical hand washing is a hand washing procedure using a special antimicrobial agent to eliminate transient microorganisms and to reduce the number of resident microorganisms as much as possible.
1.3. Hand hygiene involves the surgical and hygienic treatment of the hands, simple washing and protection of the skin of the hands.
1.4. For hand hygiene of medical personnel, antiseptic agents are used, registered in Ukraine in accordance with the established procedure.
2. General requirements
2.1. Healthcare staff keep their hands clean. It is recommended that the nails be trimmed short to the level of the fingertips, without varnish and cracks on the surface of the nails, without false nails.
2.2. Before hand processing, bracelets, watches, rings are removed.
2.3. Hand hygiene equipment
Tap water.
- washbasin with cold and hot water and a mixer, which is desirably operated without touching the hands.
- Closed containers with taps for water in case of problems with the supply of water.
- Liquid soap with neutral pH.
- Alcohol antiseptic.
- Antimicrobial detergent.
- Skin care product.
- Non-sterile and sterile disposable towels or wipes.
- Dispensing devices for detergents and disinfectants, skin care products, towels or napkins.
- Containers for used towels and napkins.
- Non-sterile and sterile disposable rubber gloves.
- Household rubber gloves.
2.4. In the room where the hands are treated, the washbasin is located in an easily accessible place, equipped with a tap with cold and hot water and a mixer, which it is desirable to operate without touching the hands, and the water jet should be directed directly into the drain siphon to prevent water splashing.
2.5. It is advisable to install three dispensers near the washbasin:
- with a means for antimicrobial treatment of hands;
- with liquid soap;
- with a skin care product.
2.7. Each place for washing hands is, if possible, equipped with dispensers for disposable towels, napkins and a container for used products.
2.9. Do not add product to antiseptic dispensers that are not completely emptied. All emptied containers must be filled aseptically to prevent contamination. It is recommended to use disposable containers.
2.10. It is recommended that the dispensers of detergents and skin care products be thoroughly washed and disinfected before each refill.
2.12. In the absence of a centralized water supply or in the presence of another problem with water, the compartments are provided with closed water tanks with taps. Boiled water is poured into the container and changed at least once a day. Before the next filling, the containers are thoroughly washed (if necessary, disinfected), rinsed and dried.
3. Surgical treatment of hands
Surgical treatment of hands is an important and responsible procedure that is performed before any surgical intervention in order to prevent infection. surgical wound the patient and at the same time protecting personnel from infections transmitted through the blood or other secretions of the patient's body. It consists of several stages:
- routine hand washing;
- surgical hand antiseptics, or washing them with a special antimicrobial agent;
- putting on surgical gloves;
- Hand treatment after surgery;
- hand skin care.
3.1. Routine hand washing before hand surgery
3.1.1. Routine washing before surgical treatment of hands is carried out in advance in the department or airlock of the operating unit, alternatively in the room for antiseptic treatment of hands, in the preoperative room before the first operation, and later on as needed.
Routine washing is intended exclusively for mechanical cleaning of hands, while removing dirt, sweat from hands, partly washing off spore-forming bacteria, as well as partly transient microorganisms.
3.1.2. Use regular liquid, powder, or pH neutral washing lotion to wash your hands. Liquid soap or washing lotion should be preferred. The use of bar soap is not permitted.
3.1.4. Considering the large number of microorganisms under the nails, it is recommended that the subungual zones be processed. To do this, use special sticks or soft disinfected brushes, preferably one-time use.
3.1.5. Hands are washed with warm water. Hot water degreases and irritates the skin as it increases the penetration of detergents into the skin's epidermis.
3.1.6. The conventional washing technique is carried out as follows:
- the hands and forearms are moistened with water, then the detergent is applied so that it covers the entire surface of the hands and forearms. Hands with the tips of the fingers and forearms raised up, with the elbows lowered, should be washed for about one minute. Particular attention should be paid to the processing of the subungual zones, nails, periungual ridges and interdigital zones;
3.2. Surgical hand antisepsis
3.2.1. Surgical hand antiseptics is performed using various alcohol antiseptics by rubbing them into the hands and forearms, including the elbow bends.
3.2.2. Rubbing in the funds is carried out in accordance with the developed standard procedure:
If necessary, wash your hands with detergent, rinse thoroughly;
- Thoroughly dry your hands with a disposable towel;
- using the dispenser (press the lever with your elbow), pour the antiseptic into the recess of the dry palm;
- first of all, moisten the hands with an antiseptic, then the forearms and elbows;
- rub the antiseptic in separate portions for the time specified by the developer, while holding the hands above the elbow bends;
- after antiseptic treatment, do not use a towel, wait until your hands are completely dry, wear gloves only on dry hands.
3.2.3. The antiseptic is applied to the hands in portions (1.5-3.0 ml), including the elbows, and rubbed into the skin for the time specified by the developer. The first portion of the antiseptic is applied only to dry hands.
3.2.4. Throughout the entire time of rubbing in the antiseptic, the skin is kept moist from the antiseptic, therefore, the number of servings of the rubbed in, and its volume are not strictly regulated.
3.2.5. During the procedure, special attention is paid to the standard method of treating the hands with an antiseptic according to EN 1500.
Each stage of processing is repeated at least 5 times. When performing the hand treatment technique, the presence of so-called "critical" parts of the hands, which are not sufficiently wetted by the product, is taken into account: thumbs, fingertips, interdigital zones, nails, periungual ridges and subungual zones. Surfaces are treated most carefully thumb and the tips of the fingers, since they are the largest concentration of bacteria.
3.2.6. The last portion of the antiseptic is rubbed in until it is completely dry.
3.2.7. Sterile gloves should only be worn on dry hands.
3.2.8. After the end of the operation / procedure, the gloves are removed, the hands are treated with an antiseptic for 2 x 30 s, and then with a hand skin care product. If blood or other secretions get on the hands under the gloves, these contaminants are first removed with a swab or napkin moistened with an antiseptic, washed with detergent. Then they are thoroughly washed with water to remove soap and dried with a disposable towel or napkins. After that, the hands are treated with an antiseptic 2 x 30 s.
3.3. Surgical hand washing
Surgical hand washing consists of two phases: phase 1 - regular washing and phase 2 - washing with a special antimicrobial agent.
3.3.1. Phase 1 - regular hand washing - is carried out in accordance with clause 3.1.
3.3.2. Before the start of phase 2 of surgical washing, the hands, forearms and elbows are moistened with water, with the exception of those products that, as directed by the developer, are applied to dry hands, and then water is added.
3.3.3. Antimicrobial detergent in the amounts prescribed by the developer is applied to the palms and distributed over the surface of the hands, including the elbows.
3.3.4. Hands with upward fingertips and forearms, with low elbows, are treated with the product for the time specified by the developer of the product.
3.3.5. Throughout the entire time of washing, the hands and forearms are moistened with an antimicrobial detergent, therefore the amount of the agent is not strictly regulated. The hands are held up all the time.
3.3.6. During washing, follow the sequence of actions in accordance with the specified in p. 3.2.2 and 3.2.5.
3.3.7. Hands are dried with a sterile towel or sterile wipes in compliance with the rules of asepsis, starting from the fingertips.
3.3.8. Surgical sterile gloves should only be worn on dry hands.
3.3.9. After the operation / procedure, the gloves are removed and the hands are treated with an antiseptic according to clause 3.2.8.
3.4. If no more than 60 minutes pass between operations, only antiseptic surgical treatment of the hands is performed.
4. Hygienic treatment of hands
Hygienic treatment of hands includes routine hand washing water with ordinary (non-antimicrobial) soap and hygienic hand antiseptic, i.e. rubbing an alcohol antiseptic, without the use of water, into the skin of the hands in order to reduce the number of microorganisms on them.
Requirements for antimicrobial agents and alcohol antiseptics
1. Antimicrobial and antiseptic alcohol-containing rubbing agents must meet the following requirements:
- a wide range of antimicrobial action in relation to transient (hygienic hand treatment) and transient and resident microflora (surgical hand treatment);
- fast action, that is, the duration of the hand treatment procedure should be as short as possible;
- prolonged action (after treating the skin of the hands, the antiseptic should delay the multiplication and reactivation of resident microorganisms (3 hours) under medical gloves);
- activity in the presence of organic substrates;
- absence negative impact on the skin;
- the lowest dermal resorption;
- lack of toxic, allergenic side effects;
- lack of systemic mutagenic, carcinogenic and teratogenic effects;
- low probability of development of resistance of microorganisms;
- readiness for direct use (does not require advance preparation);
- acceptable consistency and smell;
- easy rinsing from the skin of the hands (for detergent compositions);
- long shelf life.
2. All antimicrobial agents, regardless of the method of their application, must be active against transient bacteria (with the exception of mycobacteria), fungi of the genus Candida, as well as enveloped viruses.
3. Funds used in phthisiatric, dermatological, infectious wards should be further investigated in tests for Mycobacterium terrae (tuberculosis activity) for use in phthisiatric wards, for Aspergillus niger (fungicidal activity) for use in dermatological wards, for Poliovirus, Adenovirus (virucidal activity) for use in infectious wards if necessary.
The standard procedure during the working day is a water-free hand antiseptic. rubbing alcohol antiseptic into the skin of the hands.
4.1. Indications
4.1.1. Routine hand washing with a non-antimicrobial detergent it is recommended to carry out:
- at the beginning and at the end of the working day;
- before preparing and serving food;
- in all cases, before treatment with an antiseptic, when the hands are visibly dirty;
- in case of contact with pathogens of enterovirus infections, in the absence of appropriate antiviral agents, mechanical elimination of viruses is recommended with prolonged hand washing (up to 5 minutes);
- in case of contact with spore microorganisms - prolonged hand washing (at least 2 minutes) for mechanical elimination of spores;
- after using the toilet;
- in all other cases, unless there is a risk of infection or special instructions.
4.1.2. It is recommended to carry out hygienic treatment of hands using alcohol antiseptics before:
... entrance to aseptic rooms (preoperative, sterilization departments, intensive care, hemodialysis, etc.);
... performing invasive interventions (installing catheters, injections, bronchoscopy, endoscopy, etc.);
... activities in which infection of the object is possible (for example, preparation of infusions, filling containers with solutions, etc.);
... every direct contact with patients;
... the transition from an infected to an uninfected area of the patient's body;
... contact with sterile material and instruments;
... using gloves.
After:
... contact with contaminated objects, liquids or surfaces (for example, with a urine collection system, contaminated linen, biosubstrates, patient secretions, etc.);
... contact with already inserted drains, catheters or with the place of their introduction;
... every contact with wounds;
... every contact with patients;
... removing gloves;
... using the toilet;
... after cleansing the nose (with rhinitis, there is a high probability of having a viral infection with subsequent excretion of S. aureus).
4.1.3. These indications are not final. In a number of specific situations, the staff takes independent decision... In addition, each healthcare institution can develop its own list of indications, which is included in the nosocomial infection prevention plan, taking into account the specifics of a particular department.
4.2. Regular wash
4.2.1. Routine washing is intended exclusively for mechanical cleaning of hands, while dirt, sweat is removed from the hands, spore-forming bacteria are partly washed off, as well as partly other transient microorganisms. The procedure is carried out in accordance with paragraphs. 3.1.2.-3.1.5.
4.2.2. The conventional washing technique is carried out as follows:
- the hands are moistened with water, then the detergent is applied so that it covers the entire surface of the hands and wrists. Hands wash for about 30 seconds. Particular attention is paid to the processing of the subungual zones, nails, periungual ridges and interdigital zones;
- after treatment with a detergent, hands are thoroughly washed with water from soap and dried with disposable towels or napkins. With the last napkin, close the tap with water.
4.3. Hygienic antiseptic
4.3.1. The standard method for rubbing in an antiseptic includes 6 stages and is presented in clause 3.2.5. Each stage is repeated at least 5 times.
4.3.2. An antiseptic in an amount of at least 3 ml is poured into the recess of a dry palm and vigorously rubbed into the skin of the hands and wrists for 30 seconds.
4.3.3. During the entire time of rubbing in the product, the skin is kept moist from an antiseptic, therefore, the number of servings of the rubbed product is not strictly regulated. The last portion of the antiseptic is rubbed in until it is completely dry. Drying your hands is not allowed.
4.3.4. When processing hands, take into account the presence of so-called "critical" areas of the hands that are not sufficiently wetted with an antiseptic: thumbs, fingertips, interdigital zones, nails, periungual ridges and subungual zones. The surfaces of the thumb and the tips of the fingers are most carefully treated, since these are the largest concentrations of bacteria.
4.3.5. If there is visible contamination of hands, remove it with a napkin moistened with an antiseptic, and wash hands with detergent. Then they are thoroughly washed with water to remove soap and dried with a disposable towel or napkins. The faucet is closed with the last napkin. After that, the hands are treated with an antiseptic twice for 30 seconds.
5. Use of medical gloves
5.1. The use of gloves does not provide an absolute guarantee that patients and staff will be protected from infectious agents.
5.2. The use of medical gloves protects patients and medical personnel from the spread of transient and resident microflora directly through the hands and indirectly through contact with contaminated objects in the environment.
5.3. Three types of gloves are recommended for use in medical practice:
- surgical- are used when carrying out invasive interventions;
- lookouts- provide protection for the medical staff when performing many medical procedures;
- household- provide protection for medical personnel when processing equipment, contaminated surfaces, instruments, when working with waste from medical institutions, etc.
5.4. Sterile gloves are recommended for:
- all surgical interventions, to reduce the frequency of punctures, it is recommended to use two gloves on top of each other, replace the upper glove every 30 minutes. during the operation; it is also recommended to use gloves with a perforation indicator, in which damage to the glove quickly leads to a visible discoloration at the puncture site;
- invasive manipulations (intravenous infusion, selection of biological samples for research, etc.);
- insertion of a catheter or guide through the skin;
- manipulations associated with the contact of sterile instruments with intact mucous membranes (cystoscopy, bladder catheterization);
- vaginal examination;
- bronchoscopy, endoscopy of the gastrointestinal tract, sanitation of the trachea;
- contact with endotracheal suction and tracheostomy.
5.5. It is recommended to use non-sterile gloves when:
- contact with the hoses of artificial respiration apparatus;
- work with biological material from patients;
- blood sampling;
- carrying out intramuscular, intravenous injections;
- carrying out cleaning of equipment and disinfection;
- removal of secretions and vomiting.
5.6. Requirements for medical gloves:
- for operations: latex, neoprene;
- for examinations: latex, tactilone;
- when caring for the patient: latex, polyethylene, polyvinyl chloride;
- it is allowed to use gloves made of fabric under rubber;
- gloves must be of appropriate size;
- gloves should provide high tactile sensitivity;
- contain a minimum amount of antigens (latex, latex proteins);
- when choosing medical gloves, it is recommended to take into account possible allergic reactions in the patient's history to the material from which the gloves are made;
- for carrying out pre-sterilization cleaning of acute medical instruments Gloves with a textured outer surface must be worn.
5.7. Immediately after use, medical gloves are removed and immersed in a disinfectant solution, directly at the place of use.
5.8. After decontamination, disposable gloves must be disposed of.
5.9. Rules for the use of medical gloves:
- the use of medical gloves does not create absolute protection and does not exclude the observance of the hand treatment technique, which is used in each individual case immediately after removing the gloves when there is a threat of infection;
- disposable gloves cannot be reused, non-sterile gloves cannot be sterilized;
- gloves should be changed immediately if they are damaged;
- it is not allowed to wash or handle hands with gloves between "clean" and "dirty" manipulations, even for one patient;
- movement with gloves in the department (s) of the hospital is not allowed;
- Before putting on gloves, do not use products containing mineral oils, petroleum jelly, lanolin, etc., as they may impair the strength of the gloves.
5.10. The chemical composition of the glove material can cause instant and delayed allergies or contact dermatitis (CD). CD can appear when using gloves made of any material. This is facilitated by: prolonged continuous use of gloves (more than 2 hours), use of gloves powdered from the inside, use of gloves with existing skin irritation, wearing gloves on wet hands, too frequent use of gloves during the working day.
5.11. Mistakes that often occur when using gloves:
- the use of medical disposable gloves when working in the catering unit. In these cases, preference should be given to reusable (household) gloves;
- improper storage of gloves (in the sun, with low temperatures hitting gloves chemical substances etc.);
- putting on gloves on hands moistened with antiseptic residues (additional stress on the skin;
- ignoring the need for antiseptic treatment of hands after removing gloves in contact with potentially infectious material;
- the use of surgical gloves for aseptic work, while the use of sterile examination gloves is sufficient for this;
- the use of ordinary medical gloves when working with cytostatics (insufficient protection of the medical staff;
- insufficient care of the skin of the hands after using gloves;
- refusal of gloves in situations that at first glance seem to be safe.
5.12. The reuse of disposable gloves or their disinfection is prohibited. Disposable gloves should only be handrubbed in situations requiring frequent glove replacement, such as when taking blood. In these cases, the gloves should not be punctured or contaminated with blood or other secretions.
5.13. Disinfection of gloves is carried out according to the manufacturer's instructions.
6. Advantages and disadvantages of hand treatment methods
6.1. Effectiveness, practical use and the acceptability of hand treatment depends on the method and the associated handling conditions that are in place at the health care facility.
6.2. Routine washing is ineffective in eliminating both transient and resident microorganisms. At the same time, microorganisms do not die, but with splashes of water fall on the surface of sinks, personnel clothing, and surrounding surfaces.
6.3. During the washing process, secondary contamination of hands with microorganisms from tap water is possible.
6.4. Routine washing has a negative effect on the skin of the hands, since water, especially hot water, and the detergent lead to a violation of the surface water-fat layer of the skin, which enhances the penetration of the detergent into the epidermis. Frequent washing with a detergent leads to skin edema, damage to the epithelium of the stratum corneum, leaching of fats and natural moist-containing factors, which can lead to skin irritation and cause CD.
6.5. Hygienic hand antiseptics has several practical advantages over washing, which makes it possible to recommend it for wide practical use.
Benefits of Alcohol Handrub versus Conventional Handrub
6.6. Errors of hygienic antiseptics include the possible rubbing of an alcohol antiseptic into hands that are damp from the antiseptic, which reduces its effectiveness and skin tolerance.
6.7. The savings in antimicrobial agent and reduced exposure time make any hand treatment method ineffective.
7. Possible negative consequences of hand treatment and their prevention
7.1. If the requirements of the instructions / guidelines for the use of hand care products are violated and if the preventive skin care is neglected, CD may occur.
7.2. CD can also be caused by:
- frequent use of antimicrobial detergent;
- long-term use of the same antimicrobial detergent;
- hypersensitivity of the skin to the chemical composition of the products;
- the presence of skin irritation;
- too frequent routine hand washing, especially with hot water and alkaline detergents or products without emollients;
- long work gloved;
- putting gloves on wet hands;
- lack of a sound skin care system in a medical facility;
7.3. For the prevention of CD, in addition to avoiding the causes of CD according to paragraphs. 7.1-7.2, it is recommended to fulfill the following basic requirements:
- provide personnel with hand treatments that are potentially mild hand irritants and are effective at the same time;
- when choosing an antimicrobial agent, take into account its individual acceptability for the skin, smell, consistency, color, ease of use;
- in a medical institution it is recommended to have several means so that employees with increased skin sensitivity have the opportunity to choose a means that is acceptable for themselves;
- to introduce into practice antiseptics made on the basis of alcohol with various softening additives, since pure alcohols dry out the skin of the hands with frequent use;
Alcohol-based antiseptic properties
Indicators |
Action result |
|---|---|
| Spectrum of antimicrobial action | Bactericidal (including antibiotic-resistant strains), fungicidal and virucidal |
| Creation of resistant strains | missing |
| Antimicrobial detection rate | 30 s - 1.5 min - 3 min |
| Skin irritation | With prolonged violation of the rules of use, dry skin may occur. |
| Retention of skin lipids | Virtually unchanged |
| Transdermal water loss | Practically absent |
| Skin moisture and pH | Virtually unchanged |
| Protective effect on the skin | The presence of special moisturizing and fat-reducing additives |
| Allergenic and sensitizing effects | Not visible |
| Resorption | Missing |
| Long-term side effects (mutagenicity, carcinogenicity, teratogenicity, ecotoxicity) | Absent |
| Economic expediency | High |
Conduct mandatory periodic instruction on the use of antimicrobial agent (dose, exposure, treatment technique, sequence of actions) and skin care.
8. Hand care
8.1. Hand skin care is important condition prevention of transmission of nosocomial infections, because only intact skin can be effectively treated with an antimicrobial agent.
8.2. CD can only be avoided if a skin care system is implemented in the healthcare facility, as there is a potential risk of skin irritation with any antimicrobial agent.
8.3. When choosing a skin care product, the type of hand skin and the following properties of the product are taken into account: the ability to maintain the normal state of the skin's oil lubrication, moisture, pH at 5.5, ensure skin regeneration, good absorption, the ability of the product to give the skin elasticity.
8.4. It is recommended to use the type of emulsion opposite to the emulsion shell of the skin: emulsions of the O / W type (oil / water) should be used for oily skin, as well as at elevated temperature and humidity; for dry skin it is recommended to use W / O emulsions (water / oil), especially at low temperature and humidity.
The choice of skin care products depending on its type
8.5. When selecting skin care products, it is important to consider their compatibility with antimicrobial hand care products to prevent the negative effects of creams or lotions on the antimicrobial effect of the product.
8.6. It is advisable to apply a cream or other product to your hands several times during the working day, rub it thoroughly into the skin of dry and clean hands, pay special attention to the treatment of skin areas between fingers and periungual rollers.
The purpose of the household level of hand treatment is the mechanical removal of most of the transient microflora from the skin (antiseptics are not used).
A similar hand treatment is carried out:
- after using the toilet;
- before eating or before handling food;
- before and after physical contact with the patient;
- with any contamination of hands.
Necessary equipment:
- Liquid dosed neutral soap or individual disposable soap in bars. It is desirable that the soap does not have a pungent odor. Opened liquid or bar soap, reusable non-personalized soap quickly becomes infected with microbes.
- Disposable wipes 15x15 cm in size, clean for getting hands wet. The use of a towel (even an individual one) is not advisable, since it does not have time to dry out and, moreover, is easily contaminated with microbes.
Hand processing rules:
All jewelry and watches are removed from the hands, since they make it difficult to remove microorganisms. Hands are soaped, then rinsed with warm running water and everything is repeated from the beginning. It is believed that the first time you soap and rinse with warm water, germs are washed off the skin of your hands. Under the influence of warm water and self-massage, the pores of the skin open, therefore, with repeated soaping and rinsing, microbes are washed away from the opened pores.
Warm water makes the antiseptic or soap more effective, while hot water removes the protective grease layer from the surface of the hands. Therefore, you should avoid using too hot water for washing your hands.
Hand treatment - the necessary sequence of movements
1. Rub one palm on the other palm in a reciprocating motion.
- Rub the back of the left hand with the right palm, change hands.
- Connect the fingers of one hand in the interdigital spaces of the other, rub inner surfaces fingers up and down.
- Connect the fingers in a "lock", rub the palm of the other hand with the back of the bent fingers.
- Grasp the base of the left thumb between the thumb and forefinger of the right hand, rotational friction. Repeat on wrist. Change hands.
- Rub the palm of the left hand with your fingertips in a circular motion right hand, change hands.
Each movement is repeated at least 5 times. Hand processing is carried out within 30 seconds - 1 minute.
It is very important to follow the described hand washing technique, as special studies have shown that during routine hand washing, certain areas of the skin (fingertips and their inner surfaces) remain contaminated.
After the last rinse, hands are wiped dry with a napkin (15x15 cm). The same napkin is used to close the water taps. The napkin is dropped into a container with a disinfectant solution for disposal.
In the absence of disposable wipes, it is possible to use pieces of clean cloth, which after each use are dumped into special containers and, after disinfection, are sent to the laundry. Replacing disposable wipes with electric dryers is impractical because they do not rub the skin, which means that there is no removal of the residues of the detergent and desquamation of the epithelium.
It is known that human skin performs a number of important functions, one of which is protection against harmful factors. environment... The skin, especially the skin of the hands, is constantly inhabited by microorganisms. Intact (intact) human skin, even if it is thoroughly washed, is colonized by microorganisms that can be different for individual skin areas and are relatively constant for each person.
The microflora of human skin is divided into resident and transitory.
Resident (permanent) microflora is represented by bacteria that constantly live and multiply in the skin. These microorganisms colonize the deeper layers of the skin, including the sebaceous, sweat glands and hair follicles, and are represented mainly by coagulase-negative staphylococci (usually Staphylococcus epidermidis) and diphtheroids (Coryntbacterium spp.) In general, the resident microflora does not cause pathological processes in patients however, it can cause an infectious process when it enters the sterile cavities of the human body. Resident microorganisms are almost impossible to remove, but their numbers can be significantly reduced. In the same time sterilization of hands not only impossible, but also undesirable, because the resident microflora prevents the colonization of the skin by more dangerous microorganisms, and also synthesizes fatty acids that have antimicrobial effect.
Transient (temporary) microflora is represented by microorganisms, temporarily settled on the skin of the hands, they colonize the surface layers of the skin and are of the greatest epidemiological significance. Transient microflora can consist of any microorganisms, including pathogenic, including causative agents of nosocomial (nosocomial) infections, such as Escherihia coli, Klebsiella spp, Pseudomonas spp, Salmonella spp., St. Aureus (including MRSA), Candidae albicans, rotaviruses, etc. In case of damage to the skin, including during the use of inadequate methods of washing and disinfecting hands, the transient microflora penetrates deeper into the skin, displacing the resident flora from there.
Hand transmission of microorganisms depends on various conditions, including the type of microorganisms, the possibility of their survival on the hands, the degree of insemination of the skin by microorganisms, etc. In this case, the species composition of the microflora of the skin of the hands of medical personnel depends on the profile of the institution or department and the nature professional work... According to the Central Research Institute of Epidemiology (Moscow, Corresponding Member of the Russian Academy of Medical Sciences, Professor N. A. Semina, Professor A. P. Kovaleva), the number of nosocomial infections in Russia is 52-60 thousand annually. It has been proven that the cause of infections in hospitals in 50-80% of cases is the hands of medical personnel, that is, hands are one of the key factors in the transmission of pathogenic microorganisms both from medical personnel to patients and vice versa. According to the analysis of statistics from the American Society for Disease Control and Prevention (CDC), about 2 million patients annually receive nosocomial infections during treatment. The so-called nosocomial or hospital, hospital infections are not only the cause of suffering and death of patients. They also cause significant economic damage and cost the United States $ 5 billion annually in additional hospitalization costs and expensive antibiotic treatment. All of the above underlines the extreme importance of strict adherence to the principles of hand hygiene.
Hand treatment methods for medical personnel
Hand hygiene is a general term used to define procedures such as routine hand washing, hygienic hand disinfection and surgical hand disinfection.
Routine hand washing- washing hands with water and regular (non-antiseptic) soap.
Hygienic hand disinfection is carried out in order to reduce the number of pathogenic microorganisms on the skin of the hands, it is used in the following cases:
- before direct contact with the patient;
- before performing invasive procedures;
- before and after manipulating wounds and catheters.
- before and after putting on gloves;
- after contact with body fluids or after possible microbial insemination;
- before procedures for patients with weakened immunity;
- before examining a clean area after contact with a contaminated area of the body, etc.
It has been proven that the cause of infections in hospitals in 50-80% of cases is the hands of medical personnel, that is, hands are one of the key factors in the transmission of pathogenic "microorganisms, both from medical personnel to patients, and vice versa.
Can be performed using special antiseptic formulations during surgical cleaning. There are two methods for hygienic hand disinfection: hygienic hand washing and hand sanitizing (wiping).
Hygienic hand washing - it is washing hands with water and soap or other detergent containing an antiseptic preparation. As a result of hygienic washing, most of the transient microflora is removed, however, even with routine washing, some areas of the skin (inner surfaces, fingertips) remain contaminated.
Hand antiseptic is more often used in practice and, according to the results of laboratory tests, is more effective. Hands rub enough an antiseptic agent without adding water to it before and during the procedure (most often this is a drug based on a combination of alcohols with various antiseptic additives) so that the skin remains moist for the required exposure time from 30 to 60, depending on the manufacturer's recommendations. Most thoroughly, you need to process your nails and fingertips.
Hygienic treatment of hands(using an antiseptic) after performing medical procedures should be carried out before washing, and not vice versa, in order to avoid contamination of the surrounding surfaces by pouring out contaminated water. When caring for patients with infections caused by spore-forming bacteria (for example, Clostridium difficile), using only antiseptics without first washing your hands will not provide reliable decontamination due to the fact that they do not have a sporicidal effect. activity. In such cases, as well as if the skin needs to be cleaned of visible contaminants (including organic), a previous hygienic hand washing is mandatory before treating your hands with an antiseptic.
An important condition for the effectiveness of hand hygiene is the observance of the following rules:
- when carrying out hygienic disinfection of hands by rubbing with an alcohol antiseptic, it is necessary to apply the agent to the palm of one hand and rub over the entire surface of the hands and fingers of both hands until they are completely dry.
- when washing your hands, you must first moisten them with water, then apply required amount products and wipe your hands thoroughly for at least 15 seconds in order to treat the entire surface of the hands and fingers, then wash your hands with water and dry them thoroughly with a disposable towel, which should be used to close the tap;
- it is advisable to use small pieces of soap and use lattice coasters to dry it quickly.
- it is not recommended to use reusable cloth towels.
Surgical hand disinfection- This is the treatment of hands before surgery, ensuring the removal of transient and reduction in the amount of resident microflora of the hands.
Surgical hand disinfection can be performed using special antiseptic formulations during surgical washing. This method has been used for a long time, and the formulations used have been known for a long time. These are such as treatment with chlorhexidine bigluconate (Gibitan), recipe C-4 (Pervomur), etc. These antiseptic formulations are quite aggressive for the skin, especially considering the frequency of their use by medical personnel who take part in surgical interventions. In addition, the use of special brushes during surgical washing with the use of the aforementioned antiseptic formulations also leads to mechanical damage to the skin, the appearance of microtraumas.
Promising today is the use of antiseptic agents made on the basis of a combination of alcohols with other antimicrobial additives for the surgical disinfection of hands. Such drugs are characterized by a quick detrimental effect on the microflora, high antimicrobial properties. For surgical hand disinfection, the same preparations can be used as for hygienic disinfection, with the difference being in the increase in the amount of antiseptic per treatment (from 6-10 ml - the wrists and forearms need additional treatment) and the extension of the time and exposure up to five minutes , depending on the manufacturer's recommendations. It is not necessary to use brushes during processing.
In order to reduce the number of microorganisms that multiply on the skin of the hands under gloves, the use of antiseptics with components that provide an antimicrobial effect prolonged in time is quite effective. Reducing the number of resident bacteria in the skin of the hands of members of the surgical team during surgery reduces the risk of bacteria getting into the area of the operating field in cases of piercing or breaking of gloves during surgery.
For effective surgical hand disinfection, you must strictly adhere to the following rules:
- before surgical disinfection, you need to remove rings, rings, watches and bracelets;
- wash hands with water and soap, preferably liquid (using an antiseptic soap is not necessary);
- dry thoroughly with sterile wipes (before starting treatment with an antiseptic, the skin must be absolutely dry, therefore rubbing the antiseptic into moist skin leads to its dilution, a decrease in effective concentration and, as a result, to the impossibility of achieving the desired result.
- during treatment, skin areas should remain moistened with an antiseptic, while the drug is applied to the hands in 3-5 ml portions;
- completely dry the skin before putting on sterile gloves in order to prevent intensive growth of microorganisms, which can occur in the wet layer.
The safest antiseptics available are alcohols, with ethyl alcohol being less irritating than propyl or isopropyl alcohol.
Side effects of antiseptics on the skin of the personnel's hands.
According to various studies, approximately 25% of nursing staff experience symptoms and signs of dermatitis localized on the skin of the hands. Skin irritation associated with the use of an antiseptic soap can be caused by both the antimicrobial agent it contains and other ingredients. Damage to the skin also leads to a change in the composition of its microflora, increasing the frequency of colonization by staphylococci and gram-negative microorganisms.
Of the antiseptics available, alcohols are the safest, while ethyl alcohol is less irritating than n-propyl or isopropyl alcohol. Most often, contact dermatitis is observed with the use of iodoform. Other antiseptics that can cause contact dermatitis are chlorhexidine, chloroxylene, triclosan, and alcohol. However, factors that cause contact dermatitis associated with frequent hand washing include: using very hot water for washing, low relative humidity (especially in winter period), inadequate use of protective creams, poor quality paper towels, and latex allergies.
It is worth noting that the most common cause of contact allergy when using hand hygiene products is flavors and preservatives, and less often emulsifiers. Liquid soaps, lotions, and creams may contain ingredients that can cause contact allergic reactions in healthcare workers. Alcohol-containing products for hygienic disinfection rarely cause allergic dermatitis, but it must be borne in mind that to enhance the antimicrobial properties, alcohol-containing drugs are combined with various substances, for example, with quaternary ammonium compounds (QAC), lactic acid, chlorhexidine bigluconate, octenidine hydrochloride, etc.
Recently, new antiseptics in the form of gels have been offered on the antiseptic market.
Due to their formulation, such preparations are suitable for antiseptic treatment of skin that is particularly sensitive to irritation.
To prevent contact dermatitis, it is advisable to consider ways to reduce the risk of contact dermatitis, which may include:
- reducing the frequency of use of irritants (especially anionic detergents);
- replacement of funds that have a strong irritant effect with those that are less irritating to the skin;
- training of health workers correct use antiseptics;
- providing health workers with skin care products and protective creams.
Reducing the use of hand sanitizers is an undesirable strategy given the poor hand hygiene practices of health care workers. The introduction into practice of alcohol-containing antiseptics with emollient additives makes it possible to reduce the frequency of exposure of personnel to irritating substances (soap and detergents).
General approaches to the choice of antiseptic agents
The administration of a medical and preventive institution should take into account that, thanks to the acquisition of more effective antiseptics, hand hygiene practices are improved, which means that it is possible to prevent the occurrence of nosocomial infections. The attention of just a few cases of nosocomial infections compensates for the additional costs of health care facilities associated with the acquisition of more effective means for hand hygiene.
When choosing an antiseptic product for hand hygiene, it is necessary to take into account the opinion of personnel of the compatibility of antiseptics with the skin, the frequency of irritation due to their use.
The cost of hand hygiene products should not be the main factor when choosing them, because disinfectants with a low price may not contain highly effective skin care additives that prevent allergies and skin irritations.
Filonov V.P., Doctor of Medical Sciences, Professor,
Dolgin A.S.,
CJSC "BelAseptika"
According to the World Health Organization (hereinafter - WHO), infections associated with the provision of medical care (hereinafter - HAI) are the main problem of patient safety, and their prevention should be a priority for medical institutions and institutions that are obliged to provide safer medical care.
Hand hygiene is a first-line measure that has proven to be effective in preventing HAI and spreading antimicrobial resistance.
The history of antiseptics is associated with the names of the Hungarian obstetrician Ignaz Philip Semmelweis and the English surgeon Joseph Lister, who scientifically substantiated and introduced antiseptics into practice as a method of treating and preventing the development of suppurative processes, sepsis. So, Semmelweis, on the basis of long-term observations, came to the conclusion that maternity fever, which gave a high mortality rate, is caused by cadaveric poison transmitted through the hands of medical personnel. He conducted one of the first analytical epidemiological studies in the history of epidemiology and convincingly proved that decontamination of the hands of medical personnel is the most important procedure for preventing the occurrence of nosocomial infections. Thanks to the introduction of antiseptics into practice in the obstetric hospital where Semmelweis worked, the mortality rate from nosocomial infections was reduced by 10 times.
Practical experience and a huge number of publications devoted to the issues of handling the hands of medical personnel show that this problem, more than one and a half hundred years after Semmelweis, cannot be considered solved and remains relevant. Currently, according to the WHO, up to 80% of HAIs are transmitted through the hands of medical workers.
Good hand hygiene of health care workers is the most important, simplest and least expensive way to reduce the incidence of HAI and the spread of antibiotic-resistant strains of pathogens, and to prevent the occurrence of infectious diseases in healthcare organizations.
Hand skin treatment includes a number of complementary methods (levels): hand washing, hygienic and surgical hand antiseptics, each of which plays a role in preventing the occurrence of infections.
It should be noted that all these methods to one degree or another affect the microflora of the skin of the hands - resident (permanent) or transient (temporary). Microorganisms of the resident flora are located under the surface cells of the stratum corneum of the epithelium, this is a normal human microflora. Transient microflora gets on the skin of the hands as a result of work and contact with infected patients or contaminated environmental objects, remains on the skin for up to 24 hours, and its species composition is directly dependent on the profile of the healthcare organization and is associated with the nature of the health worker's activity. Most often, these microorganisms are associated with HAI, and are represented by pathogenic microorganisms: methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), multi-resistant gram-negative bacteria, fungi of the genus Candida, clostridia.
Transient microflora in epidemiological terms is the most significant. So, in case of damage to the skin, in particular during the use of inadequate methods of hand treatment (use of hard brushes, alkaline soap, hot water, excessively unreasonable use of hand washing instead of antiseptics), the transient microflora penetrates deeper into the skin, displacing the permanent microflora from there, disrupting its stability, which in turn leads to the development of dysbiosis. In this case, the hands of medical workers become not only a factor in the transmission of opportunistic and pathogenic microorganisms, but also their reservoir. Unlike the resident microflora, the transient microflora is completely removed during antiseptic treatment.
Hand hygiene recommendations are provided in the relevant WHO guidelines. General recommendations to hand hygiene of medical personnel are reduced to the following positions:
1. Wash your hands with soap and water when visibly dirty, stained with blood or other body fluids, or after using the toilet.
2. If contact with a potential spore-forming pathogen is high (suspected or proven), including cases of C. Difficile outbreaks, washing hands with soap and water is the preferred measure.
3. Use an alcohol-based handrub as the preferred routine antiseptic measure in all of the other clinical situations listed in step 4, unless the hands are visibly dirty. If an alcohol-based antiseptic is not available, wash your hands with soap and water.
4. Perform hand hygiene:
before and after contact with the patient;
before touching an invasive patient care device, whether you are using gloves or not;
after contact with body fluids or secretions, mucous membranes, damaged skin or wound dressings;
if, when examining a patient, you move from a contaminated part of the body to a non-contaminated one;
after contact with objects (including medical equipment) from the patient's immediate environment;
after removing sterile or non-sterile gloves.
5. Before handling medication or preparing food, practice hand hygiene with an alcohol-based handrub or wash your hands with soap and water or soap and water.
6. Soap and alcohol-based hand sanitizer should not be used at the same time.
At the same time, the WHO states that the highest frequency of adherence by health workers to the recommended hygiene measures, at best, is up to 60%. WHO experts identify the main factors associated with insufficient adherence to hand treatment: doctor status (hand hygiene is less common than nursing staff); work in intensive care, work in the surgical department; work in emergency care, work in anesthesiology; work during the week (versus work on weekends); shortage of staff (excess of patients); wearing gloves; a large number of indications for hand hygiene during an hour of patient care after contact with objects of the external environment in the patient's environment, for example, with equipment; before contact with objects of the external environment in the patient's environment, etc.
Speaking about the three levels of hand treatment (hygienic washing, hygienic antiseptics, surgical antiseptics), it should be noted that their purpose is not to replace each other, but to complement each other. So, hand washing allows mechanical cleaning of organic and inorganic contaminants and only partially removes transient microflora from the skin. At the same time, in health care organizations, for hygienic hand washing, soaps should be used that will cause the least harm to the skin, while ensuring the maximum effect. These are liquid, pH neutral soaps containing bactericidal and fungicidal components, as well as softening and moisturizing additives for the skin. At the same time, it is necessary to pay close attention to the hand processing technique and its duration, which should be 40-60 seconds, as well as the hand drying procedure. On the one hand, complete and correct drying of the skin of the hands after washing prevents the occurrence of dermatitis with the subsequent use of alcohol-containing antiseptics, and on the other hand, it is an important condition for proper decontamination. Studies carried out in different countries (including the accredited laboratory of BelAseptica CJSC) show that microbiological contamination of the skin of hands does not decrease after going to the toilet, washing hands and using an electric towel, but increases by 50%. The indicators of microbiological contamination of the skin of the hands in persons who, after visiting the toilet, washed their hands and used a paper (disposable) towel are reduced by almost 3 times, and in those who additionally apply an antiseptic gel up to 10 times.
Therefore, the use of disposable paper towels for drying hands is much more epidemiologically optimal than electric towels. The additional use of antimicrobial hand gels is the most promising solution. This practice can provide both greater comfort and protection to the skin of the hands and the effectiveness of the treatment.
The procedure for conducting hand antiseptics in our country is currently determined by the Instruction "Hygienic and surgical antiseptics of the skin of the hands of medical personnel", approved by the Chief State Sanitary Doctor of the Republic of Belarus on September 5, 2001 N 113-0801 and fully complies with the international standard EN-1500.
Hygienic antiseptics of the skin of the hands is aimed at destroying the transient microflora of the skin.
At the same time, the treatment procedure itself includes the application of an antiseptic to the hands in an amount of 3 ml and thorough rubbing into the palmar, dorsal and interdigital surfaces of the skin of the hands for 30 - 60 seconds until completely dry, strictly observing the sequence of movements according to the European processing standard EN-1500.
To implement the right choice drugs, which are often difficult due to the abundance of offers on the domestic market, it is necessary to consistently take into account their key properties: the presence of a wide range of antimicrobial action, the absence of allergic and irritating effects on the skin, registration as a drug, and economy. At the same time, the use of alcohol-based antiseptics - the most effective against HAI pathogens and compatible with the skin - is also recognized by WHO as the "gold standard". The use of just such antiseptics is one of the main key points in hand hygiene of medical workers.
According to the Law of the Republic of Belarus "On Medicines", antiseptics in our country are classified as medicines, and therefore undergo clinical trials confirming their safety and are produced at enterprises that have implemented and certified the system of good manufacturing practice (GMP) in the Ministry of Health. The water used for the production of antiseptic medicines is purified in reverse osmosis plants, and the finished antiseptic itself is microfiltered before bottling, which excludes the presence of any infectious agents in it. It is this approach to ensuring the production of high-quality antiseptics that has made it possible today to reduce the exposure of hygienic antiseptics, in comparison with the previously adopted one. Currently, some drugs have been confirmed to be effective with a 12-second hygienic antiseptic (Septocid-synergy, Septocid P +).
Along with this, the use of "aqueous" alcohol-free solutions of antiseptics in health care organizations is not so effective, convenient and safe. So, such components as triclosan, HOURS can cause allergic reactions. Guanidine film can contribute to the formation of biofilms in cases where the skin of the health worker's hands is unhealthy, there are signs of dysbiosis, a violation of the integrity of the skin, the presence of infection. In addition, the 5-7 minute "stickiness" of the skin of the hands, which occurs after the use of alcohol-free antiseptics, also reduces the convenience of their use, especially when using gloves. Alcohol-containing antiseptics, according to WHO recommendations, are the most reliable in this regard. The concentration of alcohols (ethyl, isopropyl) in the range from 60% to 80% allows you to achieve maximum efficiency. In addition, the advantage of antiseptics over the usual 70% alcohol is that they contain special emollient components that neutralize the drying effect of alcohols.
Surgical antiseptics of the skin of the hands ensures the destruction of transient microflora and reduces the amount of resident microflora to a sub-infectious level and is carried out during medical procedures associated with contact (direct or indirect) with the internal sterile environments of the body (catheterization of central venous vessels, puncture of joints, cavities, surgical interventions, etc.) etc.).
In the course of the professional activity of medical workers, the skin may lose its ability to perform a barrier function - it becomes irritated, dry and cracked. The most common personnel reactions are contact dermatitis and allergic reactions. Experts believe that 2/3 of all skin problems arise from improper skin care, including the application of alcohol-based antiseptics to wet hands. Regular and intensive care for the skin with the use of creams, lotions, balms in the workplace, such as for example: Dermagent C, Dermagent P, is a preventive measure against profession-related dermatoses.
To ensure the prevention of HCAI in health care organizations, it is necessary to carry out targeted work to increase the adherence of medical personnel to hand hygiene. Special attention should be paid by the administration of the institution to effective training of medical personnel using interactive technologies and ensuring the availability of alcohol antiseptics for medical workers in places of medical care.
Most effective in promoting adherence to health-care workers' hand hygiene can be management support and encouragement of good hand hygiene, developing a system for auditing the use of alcohol-based antiseptics, and monitoring hand hygiene compliance. The hand hygiene adherence of the older generation of healthcare workers also influences adherence among young staff, interns and students.
Combining the efforts of medical workers, the administration of healthcare organizations, specialists from hygiene and epidemiology centers, teachers of educational institutions in the step-by-step implementation and formation of sustainable hand handling practices, as well as own example, will allow to instill simple and effective hand hygiene practice in daily activities in the provision of medical care in present and future generations of medical workers, thereby ensuring the stable safety of medical care.