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					Standard Infection Control Precautions
Literature Review: Hand Hygiene

Date of issue: 2008 Date of review: 2009

HPS SICP: 2008 Page 1 of 12

Literature Review: Hand Hygiene

REVIEW OF LITERATURE
PRINCIPAL RESEARCH QUESTION/OBJECTIVE:

o To assess the evidence in relation to hand drying methods following hand hygiene/decontamination. o To assess the evidence in relation to hand hygiene being a method of reducing the spread of infection. o To assess the evidence in relation to the effect of wearing jewellery on hand hygiene. o To assess the evidence in relation to the effect of nail hygiene on general hand hygiene. o To assess the evidence in relation to the effectiveness/appropriate application of alcohol hand rub/gel as a
method for decontaminating hands.

o To assess the evidence in relation to hand hygiene being a method of reducing the spread of infection. o To assess the evidence in relation to hand hygiene and its application.

i) Search strategy for identification of studies 1997-2007 Period of publication Strategy key words hand hygiene

hand washing handwashing hand sanitizing hand cleansing hand decontamination Handwashing/ cross infection nosocomial healthcare associated infection healthcare-associated infection healthcare acquired infection hospital acquired infection compliance adherence attitudes perceptions Health Behaviour/ Guideline Adherence/ attitude/ or "attitude of health personnel"/ care care equipment environment contaminated contact "Delivery of Health Care"/ exp "Equipment and Supplies, Hospital"/ Health Facility Environment/ Equipment Contamination/
HPS SICP: 2008 Page 2 of 12

hospital healthcare occupational transmission focal infection Cross Infection/ exp Hospitals/ Occupational Diseases/ Infection/ Focal Infection/ Infection Control/ bacteri$ virus$ handwashing solution hand washing solution procedure Soaps/ Chlorhexidine/ air dryer procedure paper towel$ hand towel$ ring$ jewellery nail$ nail polish Nails/ Cosmetics/ alcohol gel alcohol rub
Literature Review: Hand Hygiene

soap liquid soap soap solution
Electronic databases (tick as appropriate)

alcohol solution alcohol

Additional Resources (tick as appropriate)

MEDLINE X PsycINFO Science Direct EMBASE CINAHL X SIGLE Cochrane Library X Web of Science British Nursing Index X JBI COnNECT References checked for relevant articles Review of abstracts of professional meetings/ conferences Personal libraries consulted Experts consulted (give details if applicable)

X X X

Handsearching of journals (name relevant journals e.g. Journal of Hospital Infection, Infection Control and Hospital Epidemiology) Websites (tick as appropriate) How many papers found How many papers included How many papers excluded CDC Department of Health HPA 260 8 (+ 3 guidance documents) 252 X X X WHO X Scottish Government X Scottish Government Health Dept. X

ii) Selection criteria for inclusion of studies All health and social care workers. Sample Outcome measure(s)

o Bacterial count on hands following different hand drying interventions. o Effectiveness of intervention to reduce bacterial count on hands. o To assess the evidence in relation to the effect of wearing jewellery on hand
hygiene.

o Bacterial count on hands following intervention. o Effectiveness of intervention to reduce bacterial count on hands. o Effectiveness of hand hygiene as a measure for preventing the spread of
infection.

o Bacterial count on hands following intervention.
Other inclusion criteria Language Limitations N/A English language only

HPS SICP: 2008 Page 3 of 12

Literature Review: Hand Hygiene

1

Results

The annual review aims to identify, review and critique any scientific studies or guidance, which have been published in the intervening period since the last update (2007), to determine if changes to guidance are required. 1.1 Why perform hand hygiene?

Lack of or insufficient hand hygiene continues to be highlighted as a major problem and has been identified as the cause of a number of outbreaks of HAI in healthcare settings. The epic2: National Evidence Based Guidelines for preventing healthcare associated infections in hospitals in England (Pratt et al., 2007) has included a considerable literature review specifically on this subject and concludes that current national and international guidance consistently present supporting evidence that effective hand hygiene practice reduces the incidence of HAI. Hand hygiene compliance remains a significant issue and this has been the focus of the Hand Hygiene Campaign (http://www.washyourhandsofthem.com), which was launched in January 2007. This campaign is aimed at the NHS in Scotland and also at the general public to raise awareness of the importance of hand hygiene. One major component of the NHS campaign is to measure hand hygiene compliance across NHS boards in Scotland. This has been achieved by the use of a standardised approach involving an audit tool and protocol. The first mandatory audit took place in February 2007 and the results showed that hand hygiene compliance rates were 68% across Scotland, with compliance rates varying across boards from 50-94%. The results of the second mandatory audit which took place in October showed an overall compliance rate of 79% with a range from 59-94%. As the SGHD current target for compliance has now been set as 90% (This is the figure recommended by the Institute for Healthcare Improvement (IHI) (http://www.ihi.org/ihi), as a means to change culture in that hand hygiene is viewed as a mandatory procedure) by November 2008, there has been a decision to continue the Hand Hygiene Campaign to support this and this includes continuation of funding of LHBCs who are responsible for implementing the campaign within their local health boards and for carrying out quarterly audits. (http://www.washyourhandsofthem.com) 1.2 Nail care

The literature search identified few publications within the period under review, which were specifically concerned with nails and hand hygiene. The recently published epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (Pratt et al., 2007) recommend that before a shift of clinical work begins, all wrist and hand jewellery should be removed and that fingernails should be kept short, clean, free polish and that false nails should not be worn. Artificial nails have been previously reported as causing outbreaks of HAI and another recently published paper details a further outbreak traced to a HCW wearing false nails, which resulted in five patients developing gram-negative bacteraemia within a haemodialysis unit, which therefore adds further support to this recommendation. (Gordin et al., 2007) There are no changes recommended to the Hand Hygiene policy associated with nails and nail care as a result of this annual review.

HPS SICP: 2008 Page 4 of 12

Literature Review: Hand Hygiene

1.3

Hand hygiene and jewellery

Only one relevant study was identified (Fagernes et al., 2007) specifically on hand hygiene and jewellery. This study aimed to measure the bacterial load present on the hands of HCWs’ and to assess the effect of wearing a single plain finger ring. The result of microbiological sampling showed no overall significant difference of total bacterial load from hands with and without a plain band ring. The model policy as present states that wearing of a plain band ring when performing care is acceptable and there is no new evidence to the contrary. Therefore there are no changes recommended to the Hand Hygiene policy associated with jewellery as a result of this annual review. 1.4 When to perform hand hygiene?

Some recent studies document the use of novel methods to improve hand hygiene compliance and one notes that there was a rise in hand hygiene compliance following introduction of voice prompts in an isolation facility in the USA which demonstrates that innovative methods can be useful. (Swoboda et al., 2007) The epic2 guidelines (Pratt et al., 2007) state that there are a number of key factors which must be considered when deciding when hand hygiene should be performed including the level of expected contact with patients or objects; the extent of contamination that may occur; the patient care activities being performed; the susceptibility of the patient to infection. These guidelines state that current scientific evidence and expert opinion recommend that hand hygiene should be performed after an episode of patient care and also after removal of gloves in order to be effective. It is widely acknowledged that there is still a significant issue with lack of compliance with hand hygiene. In a recently published article (Sax et al., 2007) the authors state that one reason for this may be due to deficiencies in training and information provided to HCWs on this subject. This paper highlights a lack of consensus of opinion within infection control experts on the relative risk attached to different healthcare activities and the authors stress the importance of identification of the key times that hand hygiene must be performed. Therefore the researchers set out to define a user centred concept of when hand hygiene should be performed in order to provide a protocol, which could integrate into healthcare activities and ensure consistent training is provided. The authors of this research conclude that there are fundamental points and times when hand hygiene is essential in order to prevent the spread of infection during the delivery of care. As a result of this research, the authors have introduced a concept of ‘my five moments for hand hygiene’ which is defined as; before patient contact; before an aseptic task; after body fluid exposure risk; after patient contact and after contact with patient surroundings. The 5 moments aim to bring together the evidence for hand hygiene and the daily routines undertaken in healthcare, particularly when care is being provided to those who are sick and vulnerable. The authors anticipate that this model will be used to provide consistency of approach in training, audit and guidance to be given to HCWs. This concept has been adopted within the national Hand Hygiene Campaign (http://www.washyourhandsofthem.com) in order to provide clear direction and consistency across available guidelines and as a method of auditing current hand hygiene practice within NHSScotland (http://www.hps.scot.nhs.uk/haiic/ic/nationalhandhygienecampaign.aspx). It is therefore recommended that information on the ‘5 moments for hand hygiene’ including flow diagram should be included as appendix to the hand hygiene policy, for consistency with the information made available to NHSScotland through the Hand Hygiene Campaign.

HPS SICP: 2008 Page 5 of 12

Literature Review: Hand Hygiene

1.5

How to perform hand hygiene?

The literature search performed for this annual review did not identify any new scientific publications specifically concerned with the technique of hand hygiene. Therefore there are no changes recommended to the policy on how to perform hand hygiene as a result of this annual review. One recent guidance document published by the DH (DH, 2007), stated that the wearing of short sleeve shirts and not long sleeved white coats by HCWs, is considered good practice to prevent spread of infection and is termed ‘bare to the elbows’. The evidence for this comes from studies identifying contamination on the cuffs of uniforms and is not specifically concerned with hand hygiene. However, it is considered common sense and good practice to remove jackets and coats; hand and wrist jewellery and ensure that wrists and forearms are exposed before performing hand hygiene. 1.6 Drying hands

There were no additional scientific papers published during the period of the review, which specifically covered hand drying and therefore no changes to practice were identified. 1.7 Alcohol based hand hygiene products

Current reviews and scientific publications still report that there is a reluctance to use alcohol hand gels by healthcare workers due to reasons of perceived drying of the skin. One recently published study (Loffler et al., 2007) attempts to specifically address this by conducting a comprehensive study of the effects of alcohols commonly used in hand hygiene products in comparison to washing with soap. The results show that alcohol hand gels caused less skin irritation than hand washing in terms of skin physiology and sensation. However, the group tested excluded atopic individuals, which is therefore not totally representative and it should also be noted that a manufacturer of alcohol hand hygiene products funded the study leaving it open to potential bias. Despite this, it is clear from this study and previously reviewed literature that the occurrence of skin irritation has not increased in line with use of alcohol-based hand hygiene products. The epic2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England was published in February 2007 (Pratt et al., 2007) and includes a substantial section and literature review on the choice of methods available for performing hand hygiene. This systematic review discusses the scientific evidence on the use of hand washing versus use of alcohol hand gels and includes a section on the potential problems associated with irritation and drying effects of hand hygiene products. A number of studies were evaluated during the preparation of these guidelines specifically on this subject, which showed that the use of soap and water was associated with an increased risk of skin irritation. The literature review within these guidelines also presents evidence that substantiates that hand washing with soap and water and not alcohol hand gels should be used when C difficile is present. Evidence is presented and critiqued within the CDC guidelines on Isolation (Siegel et al., 2007) that alcohol hand gels should not be used when infection with spore forming organism such as C difficile is known or suspected and furthermore states that there is insufficient data currently available to reliably inform the efficacy of alcohol hand gels against viruses such as noroviruses and rotaviruses and this may be an area which may have to undergo further review in the future. However it is clear that for routine use outside outbreak situations the use of alcohol hand gels is convenient and effective unless there is obvious visible contamination of the hands.
HPS SICP: 2008 Page 6 of 12 Literature Review: Hand Hygiene

There have been a number of recently published studies looking at the use of alcohol hand gels as a method to increase hand hygiene compliance. A well written systematic review by QIS (Stout et al., 2007) examined the clinical effectiveness of this as a method of increasing hand hygiene compliance and reducing infection rates. This review noted that it was difficult to establish measures of clinical effectiveness of alcohol based products as their use tends to form part of multi factorial intervention studies and it is therefore difficult to elucidate the impact of one individual component. Indeed, the evidence uncovered during this review, showed no demonstrable difference between multi-factorial interventions with and without the use of alcohol-based products and overall increases in hand hygiene compliance. The authors note that there are particular difficulties associated with assessing this particular evidence base, however point out that two recent economic evaluations have shown that even a 1% reduction in the HAI rate attributable to alcohol based products would be considered cost effective. Therefore there are no changes recommended to the policy specifically on alcohol-based hand hygiene products as a result of this annual review. 1.8 Respiratory Hygiene / Cough Etiquette

The importance of swift implementation of infection control precautions was highlighted during the SARS outbreak as extensive transmission of the disease occurred to patients and staff at the triage stage of point of entry to healthcare. The importance of a strategy to deal with this has been stressed and the approach which is recommended is the introduction of respiratory hygiene / cough etiquette as part of standard infection control precautions and additional transmission based precautions. (Siegel et al., 2007, SEHD and HPS, 2005) The introduction of respiratory hygiene / cough etiquette is aimed at patients and their families particularly with respiratory illnesses (coughing, sneezing etc) and is a fundamental component of droplet precautions. The literature suggests that application of this precaution at the point of entry into healthcare facilities reduces the transmission of respiratory infections via droplets. (Siegel et al., 2007) and may be useful for inclusion as part of standard infection control precautions. To encourage compliance with respiratory hygiene / cough etiquette by HCWs, patients and visitors it is clear that education and training is required and this can be achieved by use of posters and signs describing these precautions. (Siegel et al., 2007) The main components of respiratory hygiene / cough etiquette, contained within the reviewed scientific literature are; covering the mouth and nose with a disposable tissue when coughing or sneezing followed by prompt disposal of the tissue in a suitable waste receptacle. Use of surgical mask by the patient if possible; performance of hand hygiene following contact with respiratory secretions and separation of at least 3 feet between patients / families etc suffering from respiratory infections within communal areas such as waiting rooms etc if achievable. (Siegel et al., 2007, SEHD and HPS, 2005)

HPS SICP: 2008 Page 7 of 12

Literature Review: Hand Hygiene

2
2.1 2.1.1 Why perform hand hygiene?

Conclusions

Lack of or insufficient hand hygiene continues to be highlighted as a major problem and the cause of a number of outbreaks of HAI in healthcare settings. Hand hygiene compliance remains a significant issue and this has been the focus of the Hand Hygiene Campaign, which was launched in January 2007. This campaign was aimed at the NHS in Scotland and also at the general public to raise awareness of the importance of hand hygiene. One main component of the NHS campaign was to measure compliance with hand hygiene across health boards in Scotland and this has been achieved using a standardised approach involving an audit tool. The first mandatory audit took place in February 2007 and the results showed that hand hygiene compliance rates were 68% across Scotland. The results of the second mandatory audit, which took place in October showed an overall compliance rate of 79%. The current target for hand hygiene compliance has now been set at 90% by November 2008, and there has been a decision to continue the Hand Hygiene Campaign to support this This includes continuation of funding of LHBCs who are responsible for implementing the campaign within their local health boards and for carrying out quarterly audits. Nail care The epic2 guidelines recommend that before a shift of clinical work begins, all wrist and hand jewellery should be removed and that fingernails should be kept short, clean, free from nail polish and of false nails. Therefore there are no changes recommended to the Hand Hygiene policy associated with nails and nail care as a result of this annual review. Hand hygiene and jewellery Only one relevant study was identified specifically on hand hygiene and jewellery and aimed to measure the bacterial load present on the hands of HCWs’ and to assess the effect of wearing a single plain finger ring. The result of microbiological sampling showed no overall significant difference of total bacterial load from hands with and without a plain band ring. The epic2 guidelines recommend that before a shift of clinical work begins, all wrist and hand jewellery should be removed and that fingernails should be kept short, clean, free from nail polish and of false nails.

2.1.2

2.1.3

2.1.4

2.1.5

2.1.6

2.1.7

2.1.8

2.2 2.2.1

2.2.2

2.3 2.3.1

2.3.2

2.3.3

HPS SICP: 2008 Page 8 of 12

Literature Review: Hand Hygiene

2.4 2.4.1

When to perform hand hygiene? The epic2 guidelines state that there are a number of key factors which must be considered when deciding when hand hygiene should be performed including the level of expected contact with patients or objects; the extent of the contamination that may occur; the patient care activities being performed; the susceptibility of the patient to infection. These guidelines state that current scientific evidence and expert opinion recommends that hand hygiene should be performed after an episode of patient care and also after removal of gloves in order to be effective. In a recently published review article from WHO, the authors state that one reason for lack of compliance with hand hygiene may be due to deficiencies in training and information provided to HCWs specifically on this subject. This paper highlights that there is a lack of consensus of opinion within infection control experts on the relative risk attached to different healthcare activities and the authors stress the importance of identification of the key times that hand hygiene must be performed. The researchers set out to define a user centred concept of when hand hygiene should be performed in order to provide a consistent protocol, which could integrate into healthcare activities and ensure consistent training is provided. The concept presented is ‘my five moments for hand hygiene’ which is defined as; before patient contact; before an aseptic task; after body fluid exposure risk; after patient contact and after contact with patient surroundings. This concept has been adopted within the national Hand Hygiene Campaign in order to provide clear direction and consistency across available guidelines and approaches and as a method of auditing current hand hygiene practice within NHSScotland How to perform hand hygiene? The literature search performed for this annual review did not identify any new scientific publications specifically concerned with the technique of hand hygiene during therefore there are no changes to the policy on how to perform hand hygiene recommended. Drying hands There were no additional scientific papers published during the period of the review, which specifically covered hand drying and therefore no changes to practice were identified. Alcohol based hand hygiene products Current reviews and scientific publications still report that there is a reluctance to use alcohol hand gels due to reasons of perceived drying of the skin. One recently published study attempts to specifically address this by conducting a comprehensive study of the effects of alcohols commonly used in hand hygiene products in comparison to washing with detergent.

2.4.2

2.4.3

2.4.4

2.4.5

2.4.6

2.4.7

2.5 2.5.1

2.6 2.6.1

2.7 2.7.1

2.7.2

HPS SICP: 2008 Page 9 of 12

Literature Review: Hand Hygiene

2.7.3

The results show that alcohol hand gels caused less skin irritation than hand washing in terms of skin physiology and sensation. The epic2 guidelines include a substantial section and literature review on the choice of methods available for performing hand hygiene. This systematic review discusses the scientific evidence on the use of hand washing versus use of alcohol hand gels and includes a section on the potential problems associated with irritation and drying effects of hand hygiene products. A number of studies were evaluated during the preparation of these guidelines specifically on this subject, which showed that the use of soap and water was associated with an increased risk of skin irritation. The literature review within these guidelines also presents evidence that substantiates that hand washing with soap and water and not alcohol hand gels should be used when C difficile is present. It is clear that for routine use outside outbreak situations and in cases of known or suspected Clostridium difficile associated disease (CDAD) that the use of alcohol hand gels is convenient and effective unless there is obvious visible contamination of the hands. There are no changes recommended to the policy specifically on alcohol-based hand hygiene products as a result of this annual review. Respiratory Hygiene/Cough Etiquette Review of studies on the SARS outbreak showed the importance of swift implementation of infection control precautions as transmission to patients and staff often occurred at the triage stage of point of entry to healthcare. A strategy to deal with this has been recommended which is the introduction of respiratory hygiene / cough etiquette as part of standard infection control precautions and transmission based precautions Respiratory hygiene / cough etiquette is aimed at patients with undiagnosed respiratory illnesses (cough, sneezing etc) and is a fundamental component of droplet precautions. Review of scientific literature shows that application of this precaution reduces the transmission of respiratory infections via droplets. Education and training of HCWs, patients and visitors specifically on rationale and technique of respiratory hygiene / cough etiquette is required to promote compliance This can be achieved by the use of posters, leaflets and signs, in languages appropriate to the target audience Respiratory hygiene / cough etiquette consists of covering the mouth and nose with disposable tissue when coughing or sneezing followed by prompt disposal in suitable waste receptacle; use of surgical masks by patient if possible; performance of hand hygiene following contact with respiratory secretions; separation of at least 3 feet between patients suffering from respiratory infections within communal areas such as waiting rooms
Literature Review: Hand Hygiene Page 10 of 12

2.7.4

2.7.5

2.7.6

2.7.7

2.7.8

2.7.9

2.8 2.8.1

2.8.2

2.8.3

2.8.4

2.8.5

2.8.6

2.8.7

HPS SICP: 2008

2.8.8

The wearing of masks by certain patient groups may not be practical within healthcare settings such as paediatrics

3

Recommendations

The only change to the policy recommended as a result of this annual review is that information on the ‘5 moments for hand hygiene’ including flow diagram should be included as appendix to the hand hygiene policy, for consistency with the information made available to NHSScotland through the Hand Hygiene Campaign.

4

Practical Application

No change to practice is recommended.

5

Resource Implications

As per current policies, all resources required for hand hygiene should already be in place.

6

Key References

Department of Health (2007) Uniforms and Workwear - An evidence base for developing local policy, DH, London. Fagernes, M., Lingaas, E. and Bjark, P. (2007) Impact of a single plain finger ring on the bacterial load on the hands of healthcare workers, Infection Control & Hospital Epidemiology, 28, 1191-5. Gordin, F. M., Schultz, M. E., Huber, R., Zubairi, S., Stock, F. and Kariyil, J. (2007) A cluster of hemodialysis-related bacteremia linked to artificial fingernails, Infection Control and Hospital Epidemiology, 28, 743-4. Loffler, H., Kampf, G., Schmermund, D. and Maibach, H. I. (2007) How irritant is alcohol?, British Journal of Dermatology, 157, 74-81. Pratt, R. J., Pellowe, C. M., Wilson, J. A., Loveday, H. P., Harper, P. J., Jones, S. R., McDougall, C. and Wilcox, M. H. (2007) epic2: National evidence-based guidelines for preventing healthcareassociated infections in NHS hospitals in England, Journal of Hospital Infection, 65, S1-64. Sax, H., Allegranzi, B., Uckay, I., Larson, E., Boyce, J. and Pittet, D. (2007) 'My five moments for hand hygiene': a user-centred design approach to understand, train, monitor and report hand hygiene, Journal of Hospital Infection, 67, 9-21. Scottish Executive Health Department and Health Protection Scotland (2005) Pandemic Influenza Infection Control Guidelines for use in hospitals and primary care settings, SEHD and HPS, Scotland. Siegel, J., Rhinehart, E., Jackson, M., Chiarello, L. and The Healthcare Infection Control Practices Advisory Committee (2007) Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings 2007, June 2007. Stout, A., Ritchie, K. and Macpherson, K. (2007) Clinical effectiveness of alcohol-based products in increasing hand hygiene compliance and reducing infection rates: a systematic review, Journal of Hospital Infection, 66, 308-12.
HPS SICP: 2008 Page 11 of 12 Literature Review: Hand Hygiene

Swoboda, S. M., Earsing, K., Strauss, K., Lane, S. and Lipsett, P. A. (2007) Isolation status and voice prompts improve hand hygiene, American Journal of Infection Control, 35, 470-6.

HPS SICP: 2008 Page 12 of 12

Literature Review: Hand Hygiene


				
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