Hand Hygiene and Gloves:
Infection Control is Within Your Grasp
By Deborah Davis, MS, MBA
Next to your own intact skin, the gloves you wear are the first line of defense against potentially infectious agents for you and your patients. Studies have shown that at least one-third of all hospital infections are preventable. Recent reports of outbreaks and endemic infections caused by enterococci, including vancomycin-resistant enterococci (VRE), have indicated that patient-to-patient transmission of the microorganisms can occur either through direct or indirect contact via the hands of healthcare workers or through contaminated patient-care equipment or environmental surfaces.
Promotion of hand hygiene and the appropriate use of gloves are major challenges for infection control professionals (ICPs). Hand hygiene is the simplest, most effective measure for preventing nosocomial infection, yet, for a variety of reasons, it is often difficult to achieve compliance.
The Role of Gloves
Robert A. Weinstein, MD, director of infectious disease services for the Cook County Bureau of Health Services and co-chair of the Healthcare Infection Control Practices Advisory Committee (HICPAC), discussed the roles of hospital hygiene and antibiotic use in the control of antimicrobial resistance at a recent international conference on nosocomial infection. He noted that the relative contribution of epidemiological factors to the occurrence of endemic antimicrobial resistance suggests that 30% to 40% of resistant infections result from cross-infection via hands of hospital personnel.
Weinstein cited studies of antimicrobial-resistant, gram-negative rods of Clostridium difficile diarrhea and VRE hand carriage, which showed that a strategy of universal gloving resulted in effective control of resistant bacteria, as well as C. difficile diarrhea.
The Bad Actors
Since their discovery in 1928, antibiotics have been hailed as miracle drugs and have been used for a multitude of illnesses. Antibiotics have saved countless lives, but they are becoming less effective. Their overuse and misuse have caused once-rare, antibiotic-resistant mutant bacteria to flourish and produce a large percentage of bacterial infections.
Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that has plagued hospitals for years. The only effective treatment is the antibiotic vancomycin. In 1988, however, another "super bug," VRE, appeared in hospitals. VRE are extremely communicable and have a 40% mortality rate. In vitro studies have shown that VRE can transfer the vancomycin resistance gene to other gram-positive bacteria, such as Staphylococcus aureus. Staphylococcus aureus infections are common in surgical wounds and in patients with artificial implants. This is a major concern to infectious disease experts since a vancomycin-resistant strain of MRSA (or VRSA) would be virtually untreatable.
Today, nosocomial infections affect more than 2 million patients annually in the US at a cost of more than $4.5 billion. Patients infected with a strain of methicillin-resistant S. aureus are hospitalized for an average of 12 days longer than otherwise necessary at an average additional cost of $27,082. In addition, infections caused by S. aureus that are not resistant to methicillin still lengthen hospitalization by an average of four days and add $9,661 to hospital costs. In 1981, about 5% of hospital S. aureus organisms were resistant to methicillin; by 1991, methicillin resistance had grown to 38% and may have reached 50% in many hospitals today, according to Murray Abramson, MD, an infectious disease specialist at Duke University.
A Frontline of Defense
Keeping the skin of the hands intact and healthy is key to infection control. The skin is our largest organ, having a total area of almost two square meters. The epidermis provides the major barrier. The outermost layer is the stratum corneum, which is composed of flattened, dead cells that are attached to each other to form a tough layer of keratin mixed with various lipids. This layer helps maintain the hydration, pliability, and barrier effectiveness of the skin. The stratum corneum consists of approximately 15 layers of cells, with a new layer formed daily as old cells are shed. From healthy skin, approximately 10 particles are disseminated into the air each day, and 10% of these contain viable bacteria. Water content, humidity, pH levels, intracellular lipids, and rates of shedding help retain the protective barrier properties of the skin.
Two Kinds of Flora
The purpose of hand washing is to remove soil and transient microorganisms. Two major groups of microorganisms are found on the skin: resident flora (organisms that normally reside on the skin) and transient flora (contaminants). The pathogenic potential of the resident flora is typically low. Transient flora, which are easily removed by handwashing, cause most hospital infections resulting from cross-transmission, i.e., touch contamination. After glove removal, hand washing rids the hands of powder and other debris.
Soaps and detergents have been described as the most damaging of all substances applied to the skin. Each time the skin is washed, it undergoes change, most of which is temporary. However, in occupations that require frequent hand washing, such as in healthcare, changes in the skin can result in chronic damage, irritant contact dermatitis, eczema, and changes in normal skin flora. Damaged skin may harbor increased numbers of pathogens and often sheds higher numbers of organisms. Additionally, washing damaged skin is less effective at reducing numbers of bacteria than washing normal skin.
Factors in Noncompliance
One hospitalwide survey showed that in 2,834 observed opportunities for hand hygiene, average compliance was 48%. The lowest compliance rate (36%) was found in ICUs where indications for hand washing were typically more frequent.
Healthcare workers (HCWs) report a number of reasons for not adhering to hand hygiene recommendations. These include: skin irritations, interference with patient care, forgetfulness, lack of scientific evidence of impact, disagreement with guidelines, insufficient time, high workload and understaffing, and the belief that wearing gloves obviates the need for proper hand washing.
Wearing gloves may actually represent a barrier for compliance with hand hygiene due to the belief by some clinicians that wearing gloves makes hand washing unnecessary. Hand washing is recommended after glove removal because of the potential for contamination of the hands to occur during glove removal or via glove leaks.
The Centers for Disease Control and Prevention's Hospital Infection Control Practices Advisory Committee (CDC-HICPAC) recommends the use of gloves, gowns, and hand washing to prevent person-to-person transmission of VRE. Failure to remove gloves after patient contact or between dirty and clean body site care for the same patient is considered to be noncompliant with hand hygiene recommendations.
Washing and reusing gloves between patient contact is ineffective. In fact, OSHA's Bloodborne Pathogens Standard specifically prohibits washing or decontaminating disposable (single-use) gloves for reuse.
Strategies for Improving Compliance
Patient populations that are becoming increasingly vulnerable, such as older, more immunocompromised individuals, require even greater vigilance in hand hygiene compliance from HCWs. Strategies for improving compliance need to be both individual- and system-based. Individual--based strategies effect behavioral changes, i.e., education and motivation. System-based strategies include physical plant considerations as well as policies and procedures, such as the accessibility of sinks or other facilities, the support and role modeling of management, and the promotion and facilitation of skin care for HCWs.
By establishing a protocol and undertaking a consistent, effective hand care regime, HCWs will maintain the integrity of their skin against bloodborne pathogens and other infectious material. A hand care protocol should address the following: hand washing, use of lotions/moisturizers, and appropriate glove usage.
Frequent hand washing has been shown to be damaging to skin, and a mild emulsion cleaning rather than hand washing with liquid soap was associated with significant improvement in the skin of nurses' hands. Additionally, formulations that were developed more recently may be superior to antiseptic detergents for rapid microbial killing on skin and are probably milder due to the addition of emollients.
Moisturizing improves skin health and reduces microbial shedding from the skin. Skin moisturizing products should be carefully assessed for compatibility with natural rubber latex gloves, for any topical antimicrobial products being used, and for physiological effects on the skin.
The level of acceptance of products by personnel can also increase compliance with recommended hand hygiene practices. Continuing education and motivational efforts may be necessary for wide acceptance and frequent use of disinfectants and other hand hygiene products.
Some individuals may be sensitive to either the chemicals used in the manufacturing of gloves or the protein allergens in natural rubber latex. These sensitivities may be manifested as irritations, contact dermatitis, or allergic reactions defined as Type IV or Type I hypersensitivity. Most skin reactions are irritations that can be managed by improved hand care and appropriate gloving practices.
The accessibility of sinks or antiseptic products may be another mportant factor in compliance to hand hygiene. Additionally, making a rapidly effective, waterless antiseptic agent accessible at each patient's bedside should make it easier to comply with recommended hand hygiene practices.
The Best Hygiene Strategy, Hands Down
HCWs are aware of the reasons hand washing should be done. There are many behavioral and logistical reasons why compliance is a continual challenge. A number of studies suggest that sustained data (daily memos with feedback on handwashing practices or information about patient infections) can positively influence performance. Additionally, the use of role models or mentors can influence behavior and demonstrate management support for a culture of HCWs and patient safety.
Compliance to hand hygiene recommendations is a complex issue, so there is no simple solution. Effective strategies must recognize that individual and institutional factors are interdependent and incorporate a mix of individual behavioral and system change approaches.
Deborah Davis, MS, MBA, is technical director for Allegiance Healthcare Corporation's gloves business.
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