Hand Hygiene and Infection Control: Skin Care Supports Patient Care

Clean, healthy hands, appropriate glove use and a solid hand hygiene protocol are the first lines of defense for patients and healthcare professionals against potentially infectious agents. And the U.S. Centers for Disease Control and Prevention (CDC) “Guideline for Hand Hygiene in Healthcare Settings” focuses on just this.¹ As noted by the Association for Professionals in Infection Control and Epidemiology (APIC), “hand hygiene is the cornerstone of any infection control program and plays an integral role in reducing the transmission and occurrence of infection. All hospitals must have comprehensive hand hygiene programs in place.”²

A Handwashing/Hand Antisepsis Protocol

By establishing a protocol and undertaking a consistent, effective hand-care regimen, clinicians can maintain the integrity of their skin against bloodborne pathogens and other infectious materials.

The purpose of handwashing is to remove soil and transient microorganisms. Soaps and detergents are among the most damaging substances applied to the skin. In occupations requiring frequent handwashing, 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 bacteria than washing normal skin.

Consistency is Key

A hand-care protocol should address the following:

Handwashing

Use of lotions/moisturizers

Appropriate glove usage

When hands are visibly dirty or contaminated with proteinaceous material, clinicians should wash with soap and follow protocols established in their organizations. If hands are not visibly soiled, alcohol-based hand rubs may be used instead.

Hands-on Help

Studies show at least one-third of all hospital infections are preventable.³ Recent reports of outbreaks and endemic infections caused by enterococci, including vancomycin-resistant enterococci (VRE) indicate that patient-to-patient transmission of microorganisms can occur through direct or indirect contact via the hands of healthcare professionals or through contaminated equipment or environmental surfaces.

Today, healthcare-associated infections (HAIs) cost more than $5 billion annually and result in almost 100,000 deaths in the United States. Additionally, the 4 percent of patients with an HAI reduced operating margins by more than $286 million. Patients infected with MRSA are hospitalized for an average of 12 days longer than otherwise necessary, at an average additional cost of $27,082.⁴

Factors in Noncompliance

One hospital-wide survey showed that in 2,834 observed opportunities for hand hygiene, compliance was 48 percent. The lowest rate (36 percent) was in intensive care units where indications for handwashing were typically more frequent.⁵

Healthcare professionals report a number of reasons for not adhering to hand hygiene recommendations including skin irritations, interference with patient care, forgetfulness, lack of scientific evidence, disagreement with guidelines, insufficient time, high workload and understaffing, and the belief that wearing gloves negates the need for proper handwashing.

Compliance Improvement Strategies

Strategies to improve compliance should be individual- and system-based. Individual-based strategies effect behavioral changes, i.e., education and motivation. System-based strategies include physical plant considerations and policies and procedures, such as accessibility of sinks or hand rubs, support and role modeling of management, and the promotion and facilitation of skin care for healthcare professionals.

Continuing education and motivational efforts may help with acceptance and frequent use of disinfectants and other hand hygiene products.

Additionally, making a rapidly effective, waterless antiseptic agent available at the bedside should improve compliance with recommended hand hygiene practices.

Maintaining Skin Barrier

Frequent handwashing is a primary cause of irritant contact dermatitis. Recently developed formulations may be superior to antiseptic detergents for rapid microbial killing on skin, and are milder due to the addition of emollients.

Preventing dry skin and reducing the risk of dermal irritation and contact dermatitis should be a high priority for every healthcare employer and employee. Moisturizing improves skin health and reduces microbial shedding from the skin. The “Guideline for Hand Hygiene in Healthcare Settings” recommends that healthcare professionals be provided with products that minimize irritant dermatitis associated with hand antisepsis or handwashing.⁶

Moisturizing products should be assessed for compatibility with natural rubber latex gloves, for compatibility with any topical antimicrobial products being used and for physiological effects on the skin.

Gloving and Skin Wellness

Medical gloves are the most frequently worn item in healthcare. The Centers for Disease Control and Prevention (CDC)’s Hospital Infection Control Practices Advisory Committee (HICPAC) recommends the use of gloves, gowns, and handwashing to prevent person-to-person transmission of VRE.⁷

Wearing gloves may lower hand hygiene compliance since some clinicians believe that it makes handwashing unnecessary. Handwashing is recommended after glove removal because of the potential for contamination to occur during glove removal or from glove leaks.

The Impact of Dermatitis on Clinical Practice and Employee Safety

The CDC’s “Guideline for Hand Hygiene in Healthcare Settings” addresses issues that can result in a higher incidence of HAIs among patients such as skin dermatitis and its role in the spread of these infections.⁸

In addition to possibly transferring infection to patients, employees with compromised skin are at increased risk of occupational exposure to potentially infectious organisms such as hepatitis B, C or even HIV. Broken skin provides a more direct route for organisms to enter the individual’s bloodstream. Employees with dermatitis may experience greater loss in productivity, lower job satisfaction and low morale.

Hand Dermatitis — a Significant Issue

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 manifest as irritations, contact dermatitis, or allergic reactions defined as Type IV or Type I hypersensitivity. Though clinicians frequently describe their reactions as allergic in nature, irritations are not an immunological response, but simply an irritant response to any number of substances or factors. Most can be managed by improved hand care and appropriate gloving practices.

Other causes of irritation/contact dermatitis include:

Frequent occupational exposure to various soaps, detergents, disinfectants and other caustic chemicals known to cause changes to the skin

Seasonal low humidity

Glove powder, especially among exam glove wearers

Donning and removal of gloves, especially if not properly sized, can cause friction across the knuckles and develop into a reddened irritant reaction

Hand-Care Product Usage

Moisturizing with an appropriate, compatible product can help prevent dehydration, damage to barrier properties, excessive skin cell shedding and loss of skin lipids. It can also restore the water-holding capacity of the keratin layer. Several controlled trials demonstrated that regular use of hand lotions or creams helps prevent and treat irritant contact dermatitis. There is even biological evidence to support the idea that using emollients on the skin of clinicians may protect against cross-infection. And numerous articles note that failure to use supplemental hand lotions or creams is a contributing factor to dermatitis associated with frequent handwashing.⁹

Once the skin is damaged, barrier repair can only occur if moisture loss is inhibited. This requires protectants for the skin, in addition to skin restoration and healing.

The “Guideline for Hand Hygiene in Healthcare Settings” provides further evidence that addressing skin dermatitis is a critical healthcare issue.¹⁰ In light of this guideline, clinicians — and particularly infection control professionals — have a renewed interest in products that:

Promote and maintain healthy skin

Reduce transepidermal water loss

Increase skin hydration (moisturization)

Have low irritancy potential

Improve overall skin tolerance

The added cost of these products may easily be justified by the increased adherence to handwashing protocols and the impact on clinician and patient health.

Using Gloves and Skin Protectants Effectively

For skin-care products to be most effective, emphasis must be placed on regular, frequent and correct application. And adequate coverage of the hands with emollient is essential to ensure full protection. Trials have demonstrated that application is often poor, and most people do not adequately protect their hands.

Not all lotions are compatible with all antiseptic types or all glove types. Products with mineral oil, petrolatum, or lanolin should not be used when wearing NRL gloves. Water-based options are preferred.

Another way to reduce contact dermatitis is to provide gloves in a variety of materials, since some individuals may be sensitive to a chemical used in manufacturing a particular type of glove or to the protein allergen in NRL.

Compliance Without Compromise

Choosing skin-care products on the basis of cost is false economy, because the costs associated with just a few HAIs can equal the entire annual budget for hand-hygiene products. Simply purchasing more effective or more acceptable hand-hygiene products can have a positive impact on the prevention of HAIs. However, the availability of appropriate hand-hygiene products addresses only half the issue. Compliance with recommended skin-care protocols is key, and is a common weak link in many skin wellness programs.

One important development is the introduction of products that deliver moisturizing agents in new ways. For example, medical gloves coated with skin-care ingredients have a significant impact on skin health. It is important to review the formulation and efficacy of the ingredients selected – and the test data demonstrating these benefits — before gloves are selected.

Skin Health in the Operating Room

Skin health presents a challenge for surgeons and surgical team members. Frequent surgical scrubbing and skin occlusion from extensive glove use is hard on the hands. The ramifications of chronic dry skin and dermatitis go beyond personal discomfort and to the issue of personal health and safety. Cracks and fissures in the skin of dry, dermatic hands increase occupational exposure of healthcare personnel to bloodborne viruses, such as hepatitis C and HIV.¹¹

Dry, irritated skin is more difficult to disinfect than healthy skin, and is more likely to be colonized with non-resident pathogenic bacteria that are responsible for most HAIs. Studies published in the American Journal of Infection Control demonstrate there is increased shedding of damaged skin cells with skin trauma.¹² Chronic dermatitis is associated with heavier colonization of bacteria, yeast, staphylococci, and other potential pathogens and outbreaks of HAIs. In addition, the flaking associated with dry, irritated skin increases the risk of transmitting an infection due to the larger numbers of microorganisms shed into the environment with the skin flakes. As a result, skin emollients and barrier creams are receiving new attention. ICT

Deborah Davis’ primary responsibilities include driving clinical research initiatives, coordinating various aspects of product development among the marketing, regulatory, manufacturing and research and development organizations, and overseeing the publication and presentation of technical information for clinician customers. Davis received her doctorate in administrative leadership from the University of Wisconsin-Milwaukee; her MBA from Loyola University and her MS in Biology from Northeastern Illinois University.

References

1. Association for Professionals in Infection Control and Epidemiology. Guide to the Elimination of Methicillin-Resistant Staphylococcus aureus (MRSA) Transmission in Hospital Settings, 2007.

2. Murphy D, Whiting J, Hollenbeak C. Dispelling the myths: the true cost of healthcare-associated infections, 2007. Association for Prefessionals in Infection Control and Epidemiology, Washington, D.C.

3. Davis D. Hand hygiene and gloves: infection control Is within your grasp. Infection Control Today. 2001. Vol. 5, No.7: 40-42.

4. Murphy D, Whiting J, Hollenbeak C. Dispelling the myths: the true cost of healthcare-associated infections, 2007. Association for Prefessionals in Infection Control and Epidemiology, Washington, D.C.

5. Davis D. Hand hygiene and gloves: infection control Is within your grasp. Infection Control Today. 2001. Vol. 5, No.7: 40-42.

6. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Healthcare Settings.

7. Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee. Guideline for Environmental Infection Control in Healthcare Facilities, 2003.

8. Centers for Disease Control and Prevention. Guideline for Hand Hygiene in Healthcare Settings.

9. Davis D. Gloving and skin wellness: resolving the paradox. Managing Infection Control. 2003. Vol. 3, Issue 11: 28-34.

10. Centers for Disease Control and Prevention, op. cit.

11. Ojajarvi J. Evaluation on handwashing and disinfection methods used in hospital wards. Academic Dissertation, Helsinki, 1981.

12. Larson EL, Hughes, CA, Pyrek, JD, Sparks SM, Cagatay EU, Bartkus JM. Changes in bacterial flora associated with skin damage on hands of healthcare personnel. Am J Infection Control, 1998; 26: 513-521.