Evidence based Hand Hygiene recommendations

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1 : Evidence-Based Recommendations for Hand Hygiene for Health Care Workers in New Zealand NZMJ 18 April 2008, Vol 121 No 1272 Peter Larmer Trish Tillson Faye Scown Philippa Grant Jamie Exton
2 :
3 : Introduction Hand hygiene policies vary between countries Vary between healthcare institutions within NZ Usually based on a combination of evidence from RCT and expert opinion
4 : Drug resistant infections MRSA causes: skin abscesses, gastroenteritis, septicaemia, pneumonia… Rates of drug resistant infections are constantly increasing in NZ hospitals. Cost NZ $136 million in 1999. Infected patients cost on average 2.9 times more than uninfected patients.
5 : Skin Condition Poor skin condition is a known risk factor for hand contamination 74% of NZ and Australian HCW report dry/damaged hands 13.7% reporting symptoms severe enough to seek medical treatment Consideration of products that have good antimicrobial efficacy whilst minimising skin damage
6 : Definition Hand hygiene is defined as the reduction of harmful infectious agents by handwashing with plain or medicated / antimicrobial soap, or by the application of an alcohol based hand rub (ABHR) without the addition of water. Jumma, 2005
7 : What is currently recommended? Handwashing with plain or medicated soap is recommended by some European countries, in the WHO Guidelines on Basic Training in Acupuncture, by the Auckland District Health Board & by PAANZ, NZASA, NZRA. ABHR is recommended for routine decontamination in central European countries, by the (American) National Center for Infectious Diseases, the NZ Ministry of Health and the World Alliance for Patient Safety (WHO). Despite guidelines in existence, compliance ranges from 4-51%, adversely affecting infection control.
8 : Legislation The Health and Safety in Employment Act requires employers to identify all hazards to which employees could be exposed, and to eliminate, isolate or minimise the hazard. (Labour., 1992)
9 : Systematic review of the literature Determine whether ABHR, plain soap, or medicated soap has the superior antimicrobial efficacy. Determine which product has the least irritating effect on the skin. Determine the most effective method of hand drying. Provide hand hygiene guidelines based on the best evidence available & standardise the approach to hand hygiene in the NZ acupuncture setting.
10 : Systematic Review Methodology Medline, Cochrane Library, CINAHL and AMED databases Keywords References checked Reviewers blinded - GATE tool and scoring system Significance levels were set at p<0.05 for each of the review outcome measures
11 : Systematic Review Methodology - Exclusions Studies investigating surgical hand asepsis In-vitro suspension studies Case studies Observational studies Studies within the community, day-care centres or schools.
12 : Grading the Evidence Best evidence synthesis: Level 1: Strong evidence – provided by generally consistent findings in multiple, relevant, high quality RCT. Level 2: Moderate evidence – provided by one relevant, high quality RCT and/or generally consistent findings in multiple, relevant, moderate quality RCT. Level 3: Limited evidence – provided by one RCT of moderate quality rating. Level 4: Conflicting evidence – inconsistent findings among multiple RCT. Level 5: No evidence – no RCT.
13 : Results 12 studies met the inclusion criteria
14 : ABHR versus medicated or plain soap 12 studies 35 comparisons 24 +ve 11 NSD 0 -ve Moderate evidence (level 2) that ABHRs have greater antimicrobial efficacy than medicated &/or plain soap. 70% ethanol 45% 2-propanol/30% 1-propanol 70% isopropanol 61% ethanol
15 : Medicated soap versus plain soap 12 studies 22 comparisons 10 +ve 11 NSD 1 -ve Conflicting evidence (level 4) whether medicated soap is more efficacious than plain soap at reducing hand contamination. 2-4% chlorhexadine gluconate Triclosan Parachlorometaxylenol
16 : Types of Soap Because of the lack of data it is not possible to make recommendations on the use of either medicated soap, plain soap.
17 : Skin condition – are ABHRs less irritating than soap? 6 studies 6 +ve 0 NSD 0 -ve Moderate evidence (level 2) that ABHRs are less irritating than medicated &/or plain soap. Most studies - ABHR improved, & soap worsened, skin condition
18 : Skin Condition Repetitive washing over one week using either a mild or strong soap caused significant harmful changes such as alteration of stratum corneum moisture content, skin barrier function, skin surface pH, skin blood flow and the amount of skin surface lipids. Grunewald et al, 2001 As the number of wash cycles increases, the worsening of skin condition becomes more pronounced. Grove et al, 2001
19 : Skin Condition In contrast repeated use of ABHR tended to improve skin condition. Additionally, skin condition can be preserved and improved by moisturising. Liberal application of an oil-based lotion or a barrier cream significantly improved skin condition in HCW with severe hand irritation within 1 week, and that the improvement was sustained throughout the 4 week study period. McCormick et al, 2000
20 : Hand drying 2 studies 1 +ve 1 NSD Stationary hands under warm air dryer cf rubbing hands under warm dryer or 3 paper towels Paper towel 15 sec cf cloth towel 15 sec cf air dryer 30 sec cf spontaneous evaporation until dry Conflicting evidence (level 4) that any particular method of hand drying is any more effective than another.
21 : Hand Drying Because of the lack of data it is not possible to make recommendations on the use of any particular method to dry hands.
22 : Another risk factor for hand contamination Ring wearing – proportional increase in risk of contamination with the number of rings worn. Trick et al., 2003 Limited evidence (level 3) that hand contamination increases with the number of rings worn.
23 : Hand Washing Evidence Level 2 Evidence: ABHR containing 70% alcohol are the preferred products for hand hygiene. They must contain an emollient, and preferably contain 0.5% Chlorhexidine Gluconate (CHG). If using soap instead of ABHR, hand moisturisers should be used liberally and at regular intervals. Latex or nitrile gloves should be worn in the presence of any cuts or abrasions on the HCW’s hands.
24 : Hand Washing Evidence Level 3 Evidence: The hands must be washed with soap when visibly soiled. The number of rings worn should be minimised.
25 : Recommendations for hand hygiene for HCW Hand hygiene should be performed immediately before and after all patient contact and after removal of gloves. The volume and method recommended by the manufacturer for use of ABHR must be adhered to. The hands must be washed with soap to remove any ABHR residue as necessary. Hands must be thoroughly dry after hand hygiene.
26 : Implementation There is evidence that in order to make new hand hygiene guidelines gain sustained compliance it is necessary to implement multifaceted programmes combining education, reminders and feedback. Creedon, 2005; Naikoba & Hayward, 2001; Pittet et al., 2000


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