Hand Hygiene and Glove Use for EMS

Centers for Disease Control (CDC)

World Health Organization (WHO)

Standard and Expanded Isolation Precautions

Standard Precautions

• Previously called Universal Precautions

• Assumes blood and body fluid of ANY patient could be infectious

• Recommends PPE and other infection control practices to prevent transmission in any healthcare setting

• Decisions about PPE use determined by type of clinical interaction with patient

PPE Use in Healthcare Settings

PPE for Standard Precautions

• Gloves – Use when touching blood, body fluids, secretions, excretions, contaminated items; for touching mucus membranes and nonintact skin

• Gowns – Use during procedures and patient care activities when contact of clothing/ exposed skin with blood/body fluids, secretions, or excretions is anticipated

PPE Use in Healthcare Settings

PPE for Standard Precautions

• Mask and goggles or a face shield – Use during patient care activities likely to generate splashes or sprays of blood, body fluids, secretions, or excretions

PPE Use in Healthcare Settings

What Type of PPE Would You Wear?

• Giving a bed bath?

• Suctioning oral secretions?

• Transporting a patient on a stretcher?

• Responding to an emergency where blood is spurting?

• Drawing blood?

• Cleaning an incontinent patient with diarrhea?

• Irrigating a wound?

• Taking vital signs?

PPE Use in Healthcare Settings

What Type of PPE Would You Wear?

• Giving a bed bath?• Generally none

• Suctioning oral secretions?• Gloves and mask/goggles

or a face shield – sometimes gown

• Transporting a patient on a stretcher?

• Generally none required

• Responding to an emergency where blood is spurting?

• Gloves, fluid-resistant gown, mask/goggles or a face shield

• Drawing blood?• Gloves

• Cleaning an incontinent patient with diarrhea?

• Gloves w/wo gown

• Irrigating a wound?• Gloves, gown,

mask/goggles or a face shield

• Taking vital signs?– Generally none

Gloves

Ignaz Semmelweis, 1815-1865

1840’s: General Hospital of Vienna

Divided into two clinics, alternating admissions every 24 hours:– First Clinic: Doctors

and medical students– Second Clinic:

Midwives

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The Intervention:Hand scrub with chlorinated lime solution

Hand hygiene basin at the Lying-In Women’s Hospital in Vienna, 1847.

Hand Hygiene: Not a New ConceptMaternal Mortality due to Postpartum Infection General Hospital, Vienna, Austria, 1841-1850

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Semmelweis’ Hand Hygiene Intervention

~ Hand antisepsis reduces the frequency of patient infections ~

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

Colonized or Infected:What is the Difference?

People who carry bacteria without evidence of infection (fever, increased white blood cell count) are colonized

If an infection develops, it is usually from bacteria that colonize patients

Bacteria that colonize patients can be transmitted from one patient to another by the hands of healthcare workers

~ Bacteria can be transmitted even if the patient is not infected ~

The Iceberg Effect

Infected

Colonized

Hand transmission– Hands are the most

common vehicle to transmit health care-associated pathogens

– Transmission of health care-associated pathogens from one patient to another via health-care workers’ hands requires 5 sequential steps

5 stages of hand transmission

Germs present on patient skin and immediate environment surfaces

Germ transfer onto health-care worker’s hands

Germs survive on hands for several minutes

Suboptimal or omitted hand cleansing results in hands remaining contaminated

Contaminated hands transmit germs via direct contact with patient or patient’s immediate environment

one two three four five

Why should you clean your hands?

■ Any health-care worker, caregiver or person involved in patient care needs to be concerned about hand hygiene

■ Therefore hand hygiene concerns you!

■ You must perform hand hygiene to:

■ protect the patient against harmful germs carried on your hands or present on his/her own skin

■ protect yourself and the health-care environment from harmful germs

The “My 5 Moments for Hand Hygiene” approach

How to clean your hands

■ Handrubbing with alcohol-based handrub is the preferred routine method of hand hygiene if handsare not visibly soiled

■ Handwashing with soap and water – essential when when hands are visibly dirty or visibly soiled (following visible exposure to body fluids)1

■ DO NOT use antimicrobial hand soaps – these disrupt normal skin flora, increasing susceptibility to infection.

1 If exposure to spore forming organisms e.g. Clostridium difficile is strongly suspected or proven, including during outbreaks – clean hands using soap and water

To effectively reduce the

growth of germs on hands,

handrubbing must be

performed by following all of

the illustrated steps.

This takes only 20–30

seconds!

How to handrub

How to handwash

To effectively reduce the

growth of germs on hands,

handwashing

must last 40–60 secs

and should be performed by

following all of the illustrated

steps

Hand hygiene and glove use

■ The use of gloves does not replace the need to clean your hands!

■ You should remove gloves to perform hand hygiene, when an indication occurs while wearing gloves

■ You should wear gloves only when indicated – otherwise they become a major risk for germ transmission

The impact of HCAI

HCAI can cause:

■ more serious illness

■ prolongation of stay in a health-care facility

■ long-term disability

■ excess deaths

■ high additional financial burden

■ high personal costs on patients and their families

Most frequent sites of infection and their risk factors

LOWER RESPIRATORY TRACT INFECTIONSMechanical ventilationAspirationNasogastric tubeCentral nervous system depressantsAntibiotics and anti-acidsProlonged health-care facilities stayMalnutritionAdvanced ageSurgeryImmunodeficiency

13%

BLOOD INFECTIONSVascular catheterNeonatal ageCritical care Severe underlying diseaseNeutropeniaImmunodeficiencyNew invasive technologiesLack of training and supervision

14%

SURGICAL SITE INFECTIONSInadequate antibiotic prophylaxis

Incorrect surgical skin preparationInappropriate wound care

Surgical intervention durationType of wound

Poor surgical asepsisDiabetes

Nutritional stateImmunodeficiency

Lack of training and supervision 17%

URINARY TRACT INFECTIONSUrinary catheter

Urinary invasive proceduresAdvanced age

Severe underlying diseaseUrolitiasis

PregnancyDiabetes

34%

Most common sites of health care-associated infection and the risk factors

underlying the occurrence of

infections

LACK OF HAND

HYGIENE

Recovery of VRE from Hands and Environmental Surfaces

Up to 41% of healthcare worker’s hands sampled (after patient care and before hand hygiene) were positive for VRE1

VRE were recovered from a number of environmental surfaces in patient rooms

VRE survived on a countertop for up to 7 days2

1 Hayden MK, Clin Infect Diseases 2000;31:1058-1065.2 Noskin G, Infect Control and Hosp Epidemi 1995;16:577-581.

The Inanimate Environment Can Facilitate Transmission

~ Contaminated surfaces increase cross-transmission ~Abstract: The Risk of Hand and Glove Contamination after Contact with a VRE (+) Patient Environment. Hayden M, ICAAC, 2001, Chicago, IL.

X represents VRE culture positive sites

What is the single most important reason for EMS workers to practice good hand

hygiene?

1. To remove visible soiling from hands

2. To prevent transfer of bacteria from the home to the ambulance

3. To prevent transfer of bacteria from the ambulance to the home

4. To prevent infections that patients acquire in the ambulance

What is the single most important reason for EMS workers to practice good hand

hygiene?

1. To remove visible soiling from hands

2. To prevent transfer of bacteria from the home to the ambulance

3. To prevent transfer of bacteria from the ambulance to the home

4. To prevent infections that patients and EMS staff acquire in the ambulance

How often do you clean your hands after touching a PATIENT’S INTACT

SKIN (for example, when measuring a pulse or blood pressure)?

1. Always

2. Often

3. Sometimes

4. Never

How often do you clean your hands after touching a PATIENT’S INTACT

SKIN (for example, when measuring a pulse or blood pressure)?

1. Always

2. Often

3. Sometimes

4. Never

Estimate how often YOU clean your hands after touching a patient or a contaminated surface in the ambulance?

1. 25%

2. 50%

3. 75%

4. 90%

5. 100%

Which method do you use to clean your hands at work?

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

Which hand hygiene method is best at killing bacteria?

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

Which hand hygiene method is best at killing bacteria?

At least 60% alcohol concentration

Which of the following hand hygiene agents is LEAST drying to

your skin?

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

Which of the following hand hygiene agents is LEAST drying to

your skin?

1. Plain soap and water

2. Antimicrobial soap and water

3. Alcohol-based handrub

How often do you clean your hands after touching an ENVIRONMENTAL

SURFACE near a patient (for example, a clipboard or radio)?

1. Always

2. Often

3. Sometimes

4. Never

How often do you clean your hands after touching an ENVIRONMENTAL

SURFACE near a patient (for example, a clipboard or radio)?

1. Always

2. Often

3. Sometimes

4. Never

Use of artificial nails by healthcare workers poses no

risk to patients.

1. Strongly agree

2. Agree

3. Don’t know

4. Disagree

5. Strongly disagree

Use of artificial nails by healthcare workers poses no

risk to patients.

1. Strongly agree

2. Agree

3. Don’t know

4. Disagree

5. Strongly disagree

Can a Fashion Statement Harm the Patient?

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Edel et. al, Nursing Research 1998: 47;54-59

Avoid wearing artificial nails, keep

natural nails <1/4 inch if caring for

high risk patients (ICU, OR, EMS)

When do you need gloves?

Whenever risk for exposure to bloodborne pathogens exists

Definition of Bloodborne Pathogens

Bloodborne pathogens are disease-causing microorganisms such as bacteria and viruses found in:– Blood– Body fluids

containing blood

Definition of Blood

The term “blood” applies to:

– Human blood

– Components of human blood

– Any product containing human blood

OPIM Other potentially infectious materials (OPIM)

include fluids such as those found:– In the joints– Around the heart– In the abdomen– In the chest cavity– Cerebrospinal fluid– Amniotic fluid– Any fluid or unfixed tissues containing gross

visible blood

No-Risk Fluids

As long as there are NO visible signs of blood, no-risk fluids include:– Sweat– Tears– Saliva– Urine– Vomit– Sputum

Definition of an Exposure An exposure

occurs when a pathogen makes direct or indirect contact with:– Mucous

membranes– Non-intact skin

Minimize the Risk The best way to minimize the risk of

contracting a bloodborne pathogen is to treat ALL body fluids as if they are infectious.

Glove use for all patient care contacts is a useful strategy for reducing risk of

transmission of organisms.

1. Strongly agree

2. Agree

3. Don’t know

4. Disagree

5. Strongly disagree

Glove use for all patient care contacts is a useful strategy for reducing risk of

transmission of organisms.

1. Strongly agree

2. Agree

3. Don’t know

4. Disagree

5. Strongly disagree

The Glove Problem

Wilson J, Lynam S, Singleton J, Loveday H. The misuse of clinical gloves: risk of cross-infection and factors influencing the decision of health care workers to wear gloves. Antimircob Resis Infect Contr. 2013; 2(Suppl 1):03

The Glove Problem

Wilson J, Lynam S, Singleton J, Loveday H. The misuse of clinical gloves: risk of cross-infection and factors influencing the decision of health care workers to wear gloves. Antimircob Resis Infect Contr. 2013; 2(Suppl 1):03

• Gloves used inappropriately 42% of time Inappropriate = no risk of BBP exposure

• 39% uses involved cross-contamination More likely with inappropriate use (58% vs.

28%)• 24% involved > 5 objects touched by

gloved hand prior to performing procedure

Gloves

For people, not equipment

The “My 5 Moments for Hand Hygiene” approach – includes changing gloves

This presentation created in 2013 by Mike McEvoy using slide from CDC and WHO. Power Point version available at www.mikemcevoy.com.