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Hands - Procedures and Products to Protect Health
Introduction Thirteen laboratories in ten countries have worked around the clock to identify the cause of the atypical pneumonia, Severe Acute Respiratory Syndrome (SARS). The SARS virus, a virus from the coronavirus family never before seen in humans, has been identified in all SARS cases. Using the latest technology to decipher this new virus, an old procedure to prevent the spread of disease, handwashing, has been declared by the World Health Organization (WHO) as crucial to reducing the spread of SARS (WHO, 2003). Historically, Ignaz Semmelweis and Oliver Wendell Holmes observed independently in the 19th century that handwashing with an antiseptic agent reduced the spread of contagious diseases. It was not until 1961 that the United States Public Health Service developed training videos and handwashing procedures for health-care workers. In 1975 and 1985, the Centers for Disease Control and Prevention (CDC) issued formal handwashing guidelines that recommended using plain soap for patient contact and anti-microbial soap before and after invasive procedures. Alcohol-based hand rubs were only recommended in situations where sinks were unavailable. In 1995 the Association for Professionals in Infection Control (APIC) included more support but no recommendations for alcohol-based hand rubs in the clinical setting. Most recently the Guideline for Hand Hygiene in Health-Care Settings (CDC, 2002) recommends the use of alcohol-based hand rubs for patient care in the clinical setting. Clean hands are considered the single most important factor in reducing the transmission and overall incidence of health-care related infections (CDC, 2002). Microorganisms occur naturally on skin. These organisms are called normal flora or resident flora. Normal flora are usually aerobic, gram-positive organisms. Normal flora can grow and multiply on the skin without invading or damaging the skin tissue. Handwashing does not easily remove these organisms. Staphyloccus epidermidis is a common resident flora. On the other hand, transient organisms contaminate skin and live for less than 24 hours unless invasively introduced into the skin tissue. These organisms are often anaerobic, gram-negative organisms and readily cause infection. These organisms are easily removed by handwashing. Escherichia coli is a common transient organism. The largest colonization of pathogens exists in the perineum or inguinal areas, axillae, trunk, upper extremities, and hands. Inanimate objects like patient gowns, bed linen, and bedside furniture that are exposed by skin can be exposed to patient flora. Transmission of microorganisms increases if hands or donor fabrics are wet (CDC, 2002). Plain or non-antimicrobial soap removes dirt, soil, and some organic substances from hands by the detergent properties. Plain soap has minimal antimicrobial activity. Plain soaps come in the form of bar soap, tissues, and liquid preparations. Bar soaps must be properly drained in order to reduce the chance of colonization of gram-negative bacilli. Antimicrobial soap removes dirt, soil, organic substances, and disrupts cytoplasmic membranes to kill microbes. Antimicrobial soaps also work against enveloped viruses like human immunodeficiency virus (HIV), herpes simplex virus (HSV), influenza, and respiratory syncytial virus (RSV). Several different antimicrobial substances are found in antimicrobial soap and have various methods of action and affect various pathogens. For a complete list of antimicrobial agents found in soaps see the CDC's Guideline for Hand Hygiene in Health -Care Settings. An important feature of antimicrobial soaps is the persistent residual germicidal activity. This hand hygiene procedure requires a minimum of 15 seconds. When performed correctly in a busy clinical setting, handwashing with antimicrobial soap and water can result in substantial health protection but also lost productivity. Alcohol-based hand rubs are antiseptics that contain isopropanol, ethanol, n-propanol or a combination of these products. Solutions that contain 60%-95% are most effective to denature microbial proteins (CDC, 2002). Alcohol has germicidal activity against gram-positive and gram-negative bacteria, multidrug-resistant pathogens, Mycobacterium tuberculosis, fungi, as well as lipophilic viruses (HIV, HSV, RSV, influenza, and rotavirus). The CDC has suggested that the short duration of hand antisepsis with alcohol-based hand rubs could save one hour of nurses' time in a busy clinical setting. However, alcohol-based hand rubs do not remove dirt, soil, or organic substances. They also have no persistent residual germicidal activity. More research needs to be conducted to determine the concentration of alcohol and quantity of solution per application to best prevent the spread of pathogens.
Procedures for hand hygiene:
Other facts related to proper hand antisepsis include:
As the CDC and WHO embark on further tools to fight the SARS virus, further research on handwashing products and procedures becomes even more important. The speed at which the SARS virus was identified was the work of dedicated scientists and cooperating multinational disease agencies. The time invested at a sink with plain or anti-microbial soap and water or alcohol-based hand rubs is an investment that can pay huge health dividends. References: Centers for Disease Control and Prevention. (2002). Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR, 51 (No. RR-16). CDC. (2002). Hand Hygiene Guidelines Fact Sheet. Retrieved April 18, 2003 from http://www.cdc.gov/od/oc/media/pressrel/fs021025.htm. World Health Organization. Hospital Infection Control Guidance for Severe Acute Respiratory Syndrome (SARS). Retrieved April 22, 2003 from http://www.who.int/csr/sars/infectioncontrol/en/. Stefanie J. Kelley, ND, RN, CS has been in the nursing field for over 10 years. She has clinical expertise in general pediatrics and pediatric hematology, oncology, and bone marrow transplantation. As a family nurse practitioner she has advanced practice expertise in internal medicine, urban health care, and general pediatrics. As a faculty member at Texas A&M University and Case Western Reserve University, she has taught in the undergraduate and graduate didactic and clinical portions of nursing. Dr. Kelley's interest in web-based instruction and health care has been a part of her academic, clinical, and research practice. Dr. Kelley welcomes your comments about her article or suggestions for future topics. She can be emailed at sjkelley6@yahoo.com. .  Recommended Products related to hand washing:
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