HealthStream Regulatory Script

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1 HealthStream Regulatory Script Hand Hygiene Release Date: June 2011 HLC non-ce Version: 603 HLC CE Version: 1 Lesson 1: Introduction Lesson 2: Background & History Lesson 3: Importance of Hand Hygiene Lesson 4: Handwashing & Hand Antisepsis

2 Lesson 1: Introduction 1001 Introduction Welcome to the introductory lesson on hand hygiene. As your partner, HealthStream strives to provide its customers with excellence in regulatory learning solutions. As new guidelines are continually issued by regulatory agencies, we work to update courses, as needed, in a timely manner. Since responsibility for complying with new guidelines remains with your organization, HealthStream encourages you to routinely check all relevant regulatory agencies directly for the latest updates for clinical/organizational guidelines. If you have concerns about any aspect of the safety or quality of patient care in your organization, be aware that you may report these concerns directly to The Joint Commission. Page 1 of 4 2

3 1002 Course Rationale According to the Centers for Disease Control and Prevention (CDC), proper hand hygiene is the single most important way to stop the spread of infection. This course will teach you how to do your part in: Promoting proper hand hygiene Helping to prevent the spread of infection in your facility You will learn about: The history of hand hygiene Why hand hygiene is so important How to keep your hands as clean and germ-free as possible Reference 1 Page 2 of 4

4 1003 Course Goals After completing this continuing education activity, you should be able to: List important milestones in the history of hand hygiene that relate to current guideline recommendations for patient safety. Recognize why hand hygiene in the healthcare setting is important to control the spread of infection. Identify best practices for hand hygiene to control the spread of infection and improve patient outcome. NO IMAGE Page 3 of 4

5 1004 Introduction This introductory lesson gave the course rationale and goals. Lesson 2 gives a brief background and history on hand hygiene. Lesson 3 discusses the importance of hand hygiene in the healthcare setting. Finally, lesson 4 describes best practices for hand hygiene. Lesson 1: Introduction Lesson 2: Background & History Early experiences with hand hygiene Hand hygiene guidelines Lesson 3: Importance of Hand Hygiene Healthcare-associated infection Bacterial flora Risk of contamination & cross-contamination Lesson 4: Handwashing & Hand Antisepsis Hand hygiene products Soap & water Alcohol rubs Surgical hand hygiene Other hand hygiene practices Page 4 of 4

6 Lesson 2: Background & History 2001 Introduction Welcome to the lesson on background and history of hand hygiene. This lesson will discuss early experiences with hand hygiene and the importance of complying with current guidelines. Lesson 2: Background & History Early experiences with hand hygiene Hand hygiene guidelines Page 1 of 10

7 2002 First Evidence In the 1800s, medical professionals first saw evidence of the importance of hand decontamination. In 1846, Ignaz Semmelweis noticed that many women developed childbed fever [glossary] and died after delivering babies in the clinic in Vienna where he worked. References 1, 2 Page 2 of 10

8 2003 Cadaverous Particles Semmelweis also noticed that physicians and students had an odor on their hands when they left the autopsy area. He guessed that healthcare workers were carrying cadaverous particles from dead bodies to obstetric patients. He thought these particles must carry disease. This was happening even though workers washed their hands with soap and water before leaving the autopsy area. References 1, 2 Page 3 of 10

9 2004 New Policy In 1847, Semmelweis began a new policy. Clinic workers would now clean their hands with a chlorine solution between patient contacts. After this policy was put in place, maternal death rates in the clinic dropped. This gave the first evidence of the importance of disinfecting [link to glossary] hands between patient contacts. Disinfecting decreased the spread of disease more effectively than handwashing with plain soap and water. References 1, 2 Page 4 of 10

10 2005 Early Guidelines In short, clinicians were looking at the importance of disinfecting hands as early as the middle 1800s. However, this did not affect early hand hygiene guidelines. Until 1995, guidelines for hand hygiene in the United States focused on the use of plain soap and water. References 1, 3, 4 Page 5 of 10

11 2006 HICPAC Guidelines In 1995, the Healthcare Infection Control Practices Advisory Committee (HICPAC) first recommended hand antisepsis [glossary]. After contact with a patient infected with a drug-resistant [glossary] pathogen, healthcare workers were advised to decontaminate their hands with either: Antimicrobial soap and water A waterless antiseptic agent Reference 4 Page 6 of 10

12 2007 CDC Guidelines Finally, in 2002, the CDC released an extensive Guideline for Hand Hygiene in Health-Care Settings. The World Health Organization (WHO) also published a guideline for hand hygiene in Both of these guidelines recommend alcohol-based hand rubs for routine decontamination of hands in most clinical situations. Note: The Joint Commission allows hospitals to follow either the CDC or WHO guideline recommendations. This course will discuss CDC recommendations. References 1, 5 Page 7 of 10

13 2008 Adherence to Guidelines Many healthcare workers have poor compliance with recommended practices. Compliance is still not at the level needed for patient safety for several reasons. These include: Skin irritation and dryness caused by washing hands Not enough sinks for washing hands Inconvenient location of sinks Not enough time to wash hands Individual preferences or habits Ignorance about the need for hand hygiene Regardless of the reason, poor compliance increases the risk of spreading infection. References 5, 9 Page 8 of 10

14 2009 Review Select the answer that best fits the question. The observations of Ignaz Semmelweis suggested that: a. Washing with soap and water removes all germs from the hands. b. Germs remain on the hands even after washing with soap and water. c. More germs remain on the hands after cleaning with a chlorine solution than after washing with soap and water. d. Both B and C e. All of the above [CORRECT ANSWER: B] [RESPONSE FOR A: Incorrect. The correct answer is B.] [RESPONSE FOR B: Correct.] [RESPONSE FOR C: Incorrect. The correct answer is B.] [RESPONSE FOR D: Incorrect. The correct answer is B.] Page 9 of 10

15 2010 Summary You have completed the lesson on background and history. NO IMAGE Remember: In the 1800s, medical professionals first saw evidence of the importance of disinfecting hands. Disinfecting was more effective in preventing the spread of disease than washing with plain soap and water. Over the years, there have been various guidelines for hand hygiene in healthcare. Many healthcare workers do not comply with recommended practices. This increases the risk of spreading infection. Page 10 of 10

16 Lesson 3: Importance of Hand Hygiene 3001 Introduction Welcome to the lesson on the importance of hand hygiene. This lesson will discuss tasks that put caregivers at risk of hand contamination. The role of hand antisepsis in blocking cross-contamination also will be discussed. Lesson 3: Importance of Hand Hygiene Healthcare-associated infection Bacterial flora Risk of contamination & cross-contamination Page 1 of 17

17 3002 Preventing the Spread of Disease Remember: Medical professionals first saw the importance of disinfecting hands in the 1800s. NO IMAGE Disinfecting was more effective in preventing the spread of disease than washing with soap and water Preventing the spread of disease is just as important today as it was in the 1800s. Reference 1 Page 2 of 17

18 3003 Healthcare-Associated Infection According to the CDC, each year in the United States, an estimated 1.7 million hospitalized patients develop healthcareassociated infections (HAI). Of these, up to 99,000 die as a result of the HAI. Fortunately, proper hand hygiene can help: Stop outbreaks of HAI in healthcare facilities Decrease the overall HAI rate Reference 10 Page 3 of 17

19 3004 Patient Care Tasks & Contamination Most healthcare workers are aware of the risk of infection during activities such as: Contact with a patient s blood or body fluids Care of an infected or draining wound Intravascular catheter care Respiratory tract care Handling of patient secretions Changing diapers But are you aware of the risk of infection with clean patient care tasks? Reference 10 Page 4 of 17

20 3005 Clean Patient Care Tasks & Contamination Studies have shown that the hands of a caregiver can become contaminated during routine, non-invasive, clean patient care. For example, contamination can result from: Lifting a patient Taking a pulse, blood pressure, or oral temperature Touching a patient s hand, shoulder, groin, or other body area Feeding an infant Playing with an infant Touching items in a patient s room How does this contamination happen? Let s answer this question by first considering the human body s flora. References 1, 11, 12 Page 5 of 17

21 3006 Bacterial Skin Flora Flora is the bacteria and other microbes that normally live in and on our bodies. All people carry millions of bacteria. This includes you and your patients. Let s focus on skin flora. Reference 13 Page 6 of 17

22 3007 Where Flora Live Skin flora is often found in high numbers on the hands of healthcare workers. In most people, skin flora tends to be most concentrated in the: Perineal [link to glossary] area Groin Armpits Trunk Arms Reference 13 Page 7 of 17

23 3008 What Flora Do Most of the body s bacterial flora does not cause disease in healthy people. However, potentially pathogenic [glossary] bacteria can be present. For example, Staphylococcus aureus is common on intact skin. Reference 13 Page 8 of 17

24 3009 Colonization Staph and other potentially pathogenic bacteria can live on the skin for a long time without causing infection. This long-term presence without infection is called colonization. Reference 13 Page 9 of 17

25 3010 Shedding Both you and your patients are likely to have some bacterial colonization of intact skin. In addition, all people shed skin with large amounts of viable [link to glossary] bacteria, every day. Thus, bacteria on a patient s skin are also likely to contaminate the patient s: Gown Bed linens Bedside furniture Equipment Other nearby items Bacteria are also likely to contaminate your: Hands Clothing Reference 14 Page 10 of 17

26 3011 Contamination Risk In short: Bacteria are everywhere, on and around you and your patients. As a result, there is a high risk that your hands will become contaminated, even during clean patient care activities. Page 11 of 17

27 3012 Cross-Contamination When your hands become contaminated from one patient, other patients are at risk for cross-contamination. Cross-contamination happens as follows 1. Bacteria are present on a patient s skin or items. 2. A healthcare worker touches the patient s skin or items. Flora is transferred to the worker s hands. Note that this transfer is especially likely if the skin is wet. 3. The transferred flora survives on the worker s hands for several minutes. 4. The worker does not wash or decontaminate his or her hands adequately. 5. The hands of the worker contact another patient. This transfers bacteria to the second patient. Note: A healthcare worker can also transfer bacteria to the surrounding environment. A patient can then become infected by touching the contaminated surface. Reference 15 Page 12 of 17

28 3013 Cross-Contamination Risks Remember: Bacteria are everywhere! With this in mind, let s think about the likelihood of each of the steps in the process of cross-contamination. Review the table to the right. As you can see, all steps are likely, except for step 4: inadequate handwashing. This step depends on the healthcare worker. In other words, the best way to block crosscontamination is to always disinfect hands between patient contacts. Reference 15 Page 13 of 17

29 3014 What about Gloves? In certain cases, gloves should be used during patient care. In these cases, gloves help to prevent: Transfer of microbes from caregiver to patient Transfer of microbes from patient to caregiver Cross-contamination between patients (if gloves are properly removed and replaced between patient contacts) However, keep in mind that gloves and hand hygiene do not replace one another. Both should be used, as appropriate. References 1, Page 14 of 17

30 Moments for Hand Hygiene There are 5 Moments for Hand Hygiene. They are: 1 Before patient contact 2 Before clean/aseptic tasks 3 After body fluid exposure risk 4 After patient contact 5 After contact with the patient s environment 1 Before patient contact 2 Before clean/aseptic tasks Reference 5 3 After body fluid exposure risk 4 After patient contact 5 After contact with the patient s environment Page 15 of 17

31 3016 Review Select the answer that best fits the question. Choose the true statement(s): a. S. aureus is common on intact skin. b. Bacterial colonization always leads to infection. c. Viable bacteria are shed with the skin every day. d. Both A and C e. All of the above [CORRECT ANSWER: D] [RESPONSE FOR A: Not quite. The correct answer is D.] [RESPONSE FOR B: Incorrect. The best answer is D.] [RESPONSE FOR C: Not quite. The best answer is D.] [RESPONSE FOR D: Correct.] E: Incorrect. The correct answer is D. Page 16 of 17

32 3017 Summary You have completed the lesson on the importance of hand hygiene. NO IMAGE Remember: A caregiver s hands may become contaminated during clean patient-care tasks. All people have millions of bacteria in and on their bodies at all times. Potentially pathogenic bacteria such as S. aureus can be common on intact skin. Viable bacteria are shed with the skin every day. This contaminates nearby items. Cross-contamination happens when a healthcare worker spreads bacteria from one patient to another. Cross-contamination may also occur from equipment to healthcare workers and then to patients. Proper hand antisepsis between patient contacts is the best way to block cross-contamination. Gloves and hand hygiene do not replace one another. Each should be used when appropriate to prevent the spread of disease. Page 17 of 17

33 Lesson 4: Handwashing and Hand Antisepsis 4001 Introduction Welcome to the lesson on handwashing and hand antisepsis. This lesson will discuss hand hygiene products and their use. Handwashing and decontamination will also be covered. Lesson 4: Handwashing & Hand Antisepsis Hand hygiene products Soap & water Alcohol rubs Surgical hand hygiene Other hand hygiene practices Page 1 of 26

34 4002 Products Products used for hand hygiene are: Non-antimicrobial (plain) soap Antimicrobial soap and non-alcohol antiseptics Alcohol-based products Click on each of the products to learn more. Reference 1 Plain soap Plain soaps are detergent-based. They remove dirt, soil, and organic substances from hands. These soaps have little activity against microbes. However, they can help remove loosely clinging skin flora. Antimicrobial soaps and non-alcohol antiseptics These products contain one or more antimicrobial agents. Each class of antimicrobial agent has a unique spectrum [link to glossary]. Depending on its spectrum, an agent may be active against: Gram-positive bacteria Gram-negative bacteria Mycobacteria Fungi Viruses Iodine compounds and iodophors are the antimicrobial agents with the broadest spectra. Quaternary ammonium compounds are least effective against most types of microbe. Alcohol-based products These products include hand rinses, gels, and foams. They contain isopropanol, ethanol, or n-propanol. All of these alcohols are highly effective antimicrobial agents with activity against a broad spectrum of microbes. Alcohol-based products are more effective than plain soap or antimicrobial soap for standard hand hygiene in the healthcare setting. In addition, they address some of the obstacles to hand hygiene that healthcare workers face. Therefore, the CDC currently recommends alcohol rubs for routine hand decontamination. Page 2 of 26

35 4003 Products The table here provides more detailed information about available hand hygiene preparations. [[V/O for table to be included same audio file as sentence above]]: Notice that alcohols effectively reduce bacterial counts on hands and can prevent transmission of healthcare-associated pathogens. Alcohol is more effective than soap. However, alcohol is not effective against all viruses. As we will discuss, use of alcohol for hand hygiene is not appropriate when the hands are visibly soiled and can cause drying of the hands. Efficacy is affected by contact time and may vary with formulation. It is important to note that alcohol is flammable. Hand Hygiene Preparations Preparation Advantages Disadvantages Non-antimicrobial soap Remove dirt, soil, some organic substances Can remove loose transient flora Alcohols Effectively reduce bacterial counts on hands Can prevent transmission of healthcare-associated pathogens More effective than soap Chlorhexidine gluconate Has substantial residual activity Has a good safety record Skin irritation frequency is concentration-dependent Chloroxylenol Not affected by presence of organic matter Usually well-tolerated Hexachlorophene Effective against S. aureus Has residual activity Not classified as safe and effective for antiseptic handwash Has minimal antimicrobial activity Associated with skin dryness and irritation May become contaminated Not effective against all viruses Not appropriate when hands are visibly soiled Efficacy is affected by contact time and may vary with formulation Can cause drying of the hands Flammable Immediate activity is slower than alcohol Not as effective against gram-negative bacteria Not sporicidal Iodine and Iodophors Broad antimicrobial activity Does not kill spores Skin irritation Triclosan Broad activity Bacteriostatic [glossary] Has persistent activity Has been associated with decreased MRSA infections Fair activity against gram-negative bacteria, mycobacteria, and viruses Studies are limited and some are contradictory Weak activity against gram-negative bacteria, fungi, and viruses Modest efficiency with single handwash Reference 1 Page 3 of 26

36 4004 When to Use Soap and Water Hands must be washed with soap and water: When hands are visibly dirty or contaminated Before eating After using a restroom If Clostridium difficile [glossary] is suspected or proven In these situations: Soap may be plain or antimicrobial. Antimicrobial wipes may be used as an alternative to handwashing with soap. References 1-5 Page 4 of 26

37 4005 When to Use an Alcohol Rub If hands are not visibly soiled, use an alcohol-based rub for routine hand decontamination. Antimicrobial wipes contain less alcohol than rubs. They should not be used for decontamination. References 1, 5, 16 Page 5 of 26

38 4006 Routine Hand Decontamination Routine hand decontamination includes: Before direct contact with patients Before putting on sterile gloves to insert a central intravascular catheter Before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure After contact with intact patient skin (e.g., after taking a pulse or blood pressure, after assisting in a patient lift or transfer) After contact with bodily fluids or excretions, mucous membranes, non-intact skin, or wound dressings When moving from a contaminated body site to a clean body site on a single patient After contact with items near a patient After removing gloves NO IMAGE References 1, 5, 16 Page 6 of 26

39 4007 How to Use Soap and Water When using soap and water to wash hands: 1. Wet hands with warm water. Do not use hot water. Hot water can contribute to skin irritation. 2. Apply soap. Use enough soap to give a good lather. 3. Rub hands together vigorously for at least 15 seconds. Cover all surfaces of the hands and fingers. Do this away from the running water so that you do not wash the lather away. Remember to scrub between your fingers and under your nails. 4. Rinse hands with water. Keep arms angled downward in the sink, so that water from your hands goes down the sink, not down your elbows. 5. Dry with a disposable towel. 6. Use the towel to turn off the faucet. 7. Dispose of the towel in an appropriate bin. References 2, 5 Page 7 of 26

40 4008 How to Use an Alcohol Rub When using an alcohol rub: 1. Apply the rub to the palm of one hand. Use the volume of product recommended by the manufacturer. You should have enough to wet all surfaces of the hands. 2. Rub hands together until they are dry. Be sure to rub over all surfaces of the hands and fingers. Do not wash hands after using an alcohol rub. This is not necessary or recommended. *Note: Rubbing the hands together until they are dry ensures that the flammable alcohol in the product has evaporated and is no longer a fire hazard. References 1, 5 Page 8 of 26

41 4009 Surgical Hand Hygiene: Products Prior to surgery, a surgical hand scrub with antimicrobial soap or an alcohol rub with persistent activity is recommended. These products help to slow the growth of bacteria under sterile surgical gloves. This reduces the risk that bacteria will escape from gloves onto the sterile field. References 1, 5 Page 9 of 26

42 4010 Surgical Hand Hygiene: Jewelry Prior to the surgical hand scrub, remove all: Rings Watches Bracelets Clean underneath the fingernails, using a nail cleaner under running water. References 1, 5 Page 10 of 26

43 4011 Surgical Hand Hygiene: Soap Scrub For surgical hand antisepsis using an antimicrobial soap: Scrub hands and forearms for the length of time recommended by the product manufacturer (usually two to six minutes). Extended scrub times (ten minutes or more) are not necessary. References 1, 5 Page 11 of 26

44 4012 Surgical Hand Hygiene: Alcohol Rub For surgical hand antisepsis using an alcohol product: Choose a surgical hand-scrub product with persistent activity [link to glossary]. Before applying the rub, pre-wash hands and forearms with plain soap and water. Dry completely. Apply the alcohol product according to manufacturer instructions. Allow hands and forearms to dry completely before putting on sterile surgical gloves. Caution: Products containing alcohol are flammable. They should be placed away from flames and high temperatures. Alcohol-based products may cause dry skin. Look for products containing skin-conditioning agents. References 1, 5 Page 12 of 26

45 4013 Other Hand-Hygiene Practices: Fingernails Hand hygiene is not just about washing and decontaminating hands when necessary. In addition, do not wear artificial fingernails or nail enhancements. Keep natural nail tips less than ¼-inch long. References 1, 5 Page 13 of 26

46 4014 Other Hand-Hygiene Practices: Gloves Use gloves whenever you might have contact with: Blood Other potentially infectious materials Mucous membranes Non-intact skin Always: Remove and dispose of gloves between patient contacts Decontaminate hands after removing gloves Change gloves during patient care when moving from a contaminated body site to a clean body site. References 1, 5, 16 Page 14 of 26

47 4015 Compliance Issues A recently published study cited several factors associated with ineffective alcohol hand rub use. These included: Wearing rings other than a wedding ring Wearing a bracelet Having long nails Reference 17 Page 15 of 26

48 4016 Your Role in Increasing Hand-Hygiene Compliance Knowing the guidelines for hand hygiene is not enough. To protect yourself and your patients from infection, you must practice proper hand hygiene. Give your employer input about hand-hygiene products. Encourage your facility to purchase and provide products that you will use. References 1, 5 Page 16 of 26

49 4017 Your Role in Increasing Hand-Hygiene Compliance (2) Many studies have shown that compliance with hand hygiene recommendations is often low but can be improved. For example, a recent study documented increased compliance with: Access to alcohol sanitizer Education Ongoing audit and feedback Impact of multidimensional compliance improvement project Time Period Compliance Baseline 19-41% of 4,174 opportunities Year % of 6,420 opportunities Year % of 4,990 opportunities As you can see in the table on the right, compliance increased and remained improved 6 years after the multidimensional improvement project. Reference 18 Page 17 of 26

50 Moments for Hand Hygiene Remember: There are 5 Moments for Hand Hygiene. They are: 1 Before patient contact 2 Before clean/aseptic tasks 3 After body fluid exposure risk 4 After patient contact 5 After contact with the patient s environment For routine patient care: Perform hand hygiene with an alcohol-based hand rub if hands are not visibly soiled. Perform hand hygiene after glove removal. 1 Before patient contact 2 Before clean/aseptic tasks 3 After body fluid exposure risk Reference 5 4 After patient contact 5 After contact with the patient s environment Page 18 of 26

51 4019 Hand Hygiene Compliance How often do healthcare workers comply with the 5 Moments for Hand Hygiene? A study published in 2010 looked at compliance over a 24h period in two hospital wards. Overall, compliance was: 78% for allied health professionals 75% for nurses 59% for other staff 57% for visitors 56% for patients 47% for doctors Compliance during each of the 5 Moments for Hand Hygiene also varied. Let s take a closer look on the next screen. Reference 19 Page 19 of 26

52 4020 Hand Hygiene Compliance Compliance varied from 50% to 100%. All workers in this study complied with recommendations for hand hygiene before clean or aseptic tasks. However, only 50% of workers performed hand hygiene after contact with the patient s environment, as recommended. Less than 70% of workers performed hand hygiene before patient contact. Moment Compliance Moment Compliance 1 Before patient contact 2 Before clean/aseptic tasks 68% 100% 3 After body fluid exposure risk 93% 4 After patient contact 80% 5 After contact with the patient s environment 50% Reference 19 Page 20 of 26

53 4021 Review Select the answer that best fits the question. Before inserting an indwelling catheter, wash your hands with plain soap and water. a. True b. False [CORRECT RESPONSE: B] [RESPONSE FOR A: Incorrect. You should use antimicrobial soap and water or an alcohol-based hand rub. Then you should put on sterile gloves to place the catheter.] [RESPONSE FOR B: Correct. You should use antimicrobial soap and water or an alcohol-based hand rub. Then you should put on sterile gloves to place the catheter.] Page 21 of 26

54 4022 Review Select the answer that best fits the question. Choose the true statement(s): a. Wash hands after removing gloves. b. Change gloves between patient contacts. c. Wear gloves when you might have contact with blood. d. Both A and B e. All of the above [CORRECT ANSWER: E] [RESPONSE TO A: Not quite. The best answer is E. [RESPONSE TO B: Not quite. The best answer is E. [RESPONSE TO C: Not quite. The best answer is E. [RESPONSE TO D: Not quite. The best answer is E. E: Correct Page 22 of 26

55 4023 Summary You have completed the lesson on hand hygiene recommendations. NO IMAGE Remember: Proper hand hygiene between patient contacts is the best way to prevent cross-contamination. Alcohol rubs are recommended for routine hand decontamination. Soap and water should be used when hands are visibly soiled. Decontaminate hands at appropriate times. Fingernails should be kept short. Artificial fingernails should not be used. Gloves should be used when appropriate. Gloves must be changed between patient contacts. Page 23 of 26

56 References 1. CDC. Guideline for hand hygiene in health-care settings: Recommendations of the healthcare infection control practices advisory committee and the HIPAC/SHEA/APIC/IOSA Hand Hygiene Task Force. MMWR. 2002;51(No.RR-16): Lane HJ, Blum N, Fee E. Oliver Wendell Holmes ( ) and Ignaz Philipp Semmelweis ( ): preventing the transmission of puerperal fever. Am J Public Health. 2010;100: Garner JS, Favero MS. CDC guideline for handwashing and hospital environmental control, Infect Control. 1986;7: Larson EL, APIC Guidelines Committee. APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control. 1995;23: WHO. WHO guidelines on hand hygiene in healthcare Keeping Germs Out. US News & World Report. July 18, Joint Commission. Measuring hand hygiene adherence: Overcoming the challenges. Joint Commission Monograph Alemagno SA, Guten SM, Warthman S, Young E, Mackay DS. Online learning to improve hand hygiene knowledge and compliance among health care workers. J Cont Educ Nurs. 2010;14: Haas JP, Larson EL. Compliance with hand hygiene guidelines: where are we in 2008? Am J Nurs. 2008;108: CDC. Estimates of healthcare-associated infections. Available at: Accessed September 1, Morgan DJ, Liang SY, Smith CL, Johnson JK, Harris AD, Furuno JP, Thom KA, Snyder GM, Day HR, Perencevich EN. Frequent multidrug-resistant Acinetobacter baumannii contamination of gloves, gowns, and hands of healthcare workers. Infect Control Hosp Epidemiol. 2010;31: Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of healthcare workers white coats. Am J Infect Control Ryan KJ, Ray CG. Sherris Medical Microbiology. 5 th ed. McGraw-Hill Medical Treakle AM, Thom KA, Furuno JP, Strauss SM, Harris AD, Perencevich EN. Bacterial contamination of health care workers' white coats. Am J Infect Control. 2009;37: Rosdahl CB, Kowalski MT. Textbook of Basic Nursing. 9 th ed. Philadelphia, PA: Wolter Kluwer Health/Lippincott Williams & Wilkins Siegel JD, 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. Available at: Accessed August 11, Hautemaniere A, Cunat L, Diguio N, Vernier N, Schall C, Daval MC, Ambrogi V,Tousseul S, Hunter PR, Hartemann P. Factors determining poor practice in alcoholic gel hand rub technique in hospital NO IMAGE

57 workers. J Infect Public Health. 2010;3: Mayer J, Mooney B, Gundlapalli A, Harbarth S, Stoddard GJ, Rubin MA, Eutropius L, Brinton B, Samore MH. Dissemination and sustainability of a hospital-wide hand hygiene program emphasizing positive reinforcement. Infect Control Hosp Epidemiol. 2011;32: Randle J, Arthur A, Vaughan N. Twenty-four-hour observational study of hospital hand hygiene compliance. J Hosp Infect. 2010;76: Please remember that compliance is the responsibility of each organization. Provision of this list does not imply that the content of this course wholly or partially addresses the guidelines and references provided here. Page of 26

58 Glossary # Term Definition 1. Antimicrobial capable of harming or killing microorganisms 2. Antisepsis the state of being free of pathogenic organisms 3. Clostridium difficile. the organism that causes diarrhea 4. Biostatic limiting the growth of bacteria 5. Contaminate to make impure or unclean 6. Cross-contamination transmission of microorganisms from one person, place, or item to another person, place, or item 7. Decontaminate to rid of impurities 8. Disinfect to destroy microorganisms or pathogens 9. Drug-resistant unable to be harmed by certain drugs 10. Flora microbial life normally found on and in the human body 11. HICPAC Healthcare Infection Control Practices Advisory Committee 12. Pathogenic able to cause disease 13. Perineal of or relating to the area between the anus and the sex organs 14. Persistent activity prolonged or extended antimicrobial activity that prevents or inhibits proliferation or survival of microorganisms after application of a hand-hygiene product 15. Childbed fever fever due to infection, occurring within ten days after a woman has a baby, and lasting more than 24 hours 16. Spectrum types of microorganisms against which an antimicrobial agent is effective 17. Spore small, highly resistant, single-celled reproductive body produced by certain bacteria 18. Toxic shock syndrome a potentially serious, sometimes fatal bacterial infection, commonly associated with tampon use 19. Viable capable of life or normal growth and development

59 ASSESSMENT 1. When did healthcare workers first use chlorine solution to decontaminate their hands? a. In the 1600s b. In the 1700s c. In the 1800s d. In the 1900s Correct: In the 1800s Rationale: In the 1800s, healthcare workers first used a chlorine solution for hand hygiene. 2. Until 1995, guidelines for hand hygiene in the United States focused on the use of: a. Plain soap and water b. Iodine-based solutions c. Chlorine-based solutions d. Antimicrobial soap and water Correct: Plain soap and water Rationale: Early hand hygiene guidelines in the U.S. focused on the use of plain soap and water. 3. In most people, skin flora tends to be most concentrated in particular areas, including: a. The groin b. The scalp c. Behind the knees d. The feet and ankles Correct: The groin Rationale: The groin is one area where skin flora is concentrated. 4. A healthcare worker is providing care to a patient without active infection. The healthcare worker's hands may become contaminated with bacteria during: a. "Clean" care activities only b. Invasive care activities only c. Either invasive or "clean" care activities d. Neither invasive nor "clean" care activities Correct: Either invasive or "clean" care activities Rationale: All people have bacteria in and on their bodies. This is true whether or not the person has an active infection. Therefore, contamination can happen during "clean" or invasive care on any patient.

60 5. To block cross-contamination, the best practice for healthcare workers is: a. Disinfect hands between all patient contacts b. Disinfect patient skin before all care activities c. Avoid all direct contact with non-intact patient skin d. Avoid caring for both infected and uninfected patients during the same shift Correct: Disinfect hands between all patient contacts Rationale: The best practice to block cross-contamination of patients is to disinfect hands between patient contacts. 6. The hand hygiene product with the LEAST activity against microbes is: a. A plain soap b. An iodine compound c. An alcohol-based rub d. An ammonium compound Correct: A plain soap Rationale: Plain soap has the least activity against microbes. 7. According to CDC guidelines, use for routine decontamination of hands that are not visibly soiled. a. Antimicrobial wipes b. Alcohol-based rubs c. Plain soap and water d. A stiff-bristled brush and water Correct: Alcohol-based rubs Rationale: The CDC recommends the use of alcohol-based rubs for routine decontamination of hands that are not visibly dirty. 8. According to CDC guidelines, when using soap and water to wash hands, apply soap and then rub hands together for at least: a. 5 seconds b. 15 seconds c. 30 seconds d. 60 seconds Correct: 15 seconds Rationale: Soap lather should be rubbed over all hand surfaces for at least 15 seconds. 9. A best practice for using an alcohol rub to decontaminate hands is: a. Rinse hands with water after using the rub b. Rub hands together until dry after applying the rub

61 c. Use only enough rub to wet the palms of the hands d. Dry hands with a disposable towel after applying the rub Correct: Rub hands together until dry after applying the rub Rationale: To use an alcohol rub, apply enough of the product to wet all hand surfaces. Then rub hands together until dry. Do not wash hands after using the rub. 10. For proper hand hygiene, natural nail tips should be kept: a. Less than 1-inch long b. Less than ¼-inch long c. Between ½-inch and 1-inch long d. Between ¼-inch and ½-inch long Correct: Less than ¼-inch long Rationale: Natural nail tips should be kept less than ¼-inch long. Artificial nails should not be worn. 11. In the 1800s, Ignaz Semmelweis found that removal of "cadaverous particles" was more effective when clinic workers: a. Cleaned their hands with a chlorine solution b. Washed their hands with plain soap and water c. Scrubbed their hands with a stiff-bristled brush d. Removed their gloves after leaving the autopsy area Correct: Cleaned their hands with a chlorine solution Rationale: Semmelweis noticed a high death rate in the maternal clinic. He asked workers to start disinfecting their hands with a chlorine solution between patient contacts. With this new policy, maternal death rates dropped. 12. Becky s hands are visibly soiled after contact with her patient. When washing her hands, she: First: Wets her hands with warm water. Second: Rubs her hands together vigorously for at least 15 seconds away from running water. Covers all surfaces of the hands and fingers. Do this away from the running water so that you do not wash the lather away. She remembers to scrub between her fingers and under her nails. Third: She rinses her hands with water. She keeps her arms angled downward in the sink. Fourth: She turns off the faucet with her wet hand, Finally: She dries her hands with a disposable towel and disposes of the towel in the trash. Has Becky correctly washed her hands? a. Yes b. No Correct: No

62 Rationale: Becky has not washed her hands correctly. She turned off the faucet with her wet hand. Becky should have turned off the faucet with the paper towel she used to dry her hands. 13. Becky is using an alcohol hand rub for hand hygiene before providing patient care. Her hands were not visibly soiled. When using the rub, Becky: Applies the rub to the palm of one hand. Uses the volume of product recommended by the manufacturer and has enough to wet all surfaces of the hands. Rubs her hands together until they are dry. She also ensures that all surfaces of her hands and fingers are rubbed. Then washes her hands to ensure that any residual rub has been removed from her hands. Has Becky correctly sanitized her hands? A. Yes B. No Correct: No Rationale: Becky should not wash her hands after using an alcohol rub. This is not necessary or recommended. 14. Bacterial colonization is: a. Killing bacteria using an antiseptic b. Treating bacterial infection with antibiotics c. Presence of active bacterial infection in a chronic non-healing wound d. Long-term presence of bacteria on the body without causing infection Correct: Long-term presence of bacteria on the body without causing infection. Rationale: All people have some degree of bacterial colonization. This refers to bacteria that live on the body but do not cause infection 15. Cross-contamination happens when: a. A patient has a drug-resistant infection. b. A patient's skin is free of bacterial colonization. c. A healthcare worker transfers bacteria from one patient to another. d. A healthcare worker decontaminates his or her hands between patient contacts. Correct: A healthcare worker transfers bacteria from one patient to another. Rationale: Cross-contamination is the transfer of contaminating bacteria from one place to another. In the healthcare setting, cross-contamination most often happens when a healthcare worker transfers bacteria from one patient to another, or from an environmental surface to a patient. 16. Regarding gloves and hand antisepsis: The best practice is to use gloves: a. Together with hand antisepsis b. As a substitute for hand antisepsis

63 c. As a replacement for hand antisepsis d. Only when hand antisepsis is not performed Correct: Together with hand antisepsis Rationale: Hand antisepsis and gloves both should be used as appropriate. Hands should be decontaminated before and after glove use. 17. For routine hand hygiene in the healthcare setting, the MOST effective products are: a. Plain soaps b. Iodine compounds c. Alcohol-based rubs d. Ammonium compounds Correct: Alcohol-based rubs Rationale: For routine hand hygiene, the best product to use is an alcohol-based rub. 18. According to CDC guidelines, an acceptable substitute for an alcohol-based rub is: a. Use of gloves b. Antimicrobial wipes c. Plain soap and water d. Antimicrobial soap and water Correct: Antimicrobial soap and water Rationale: In situations calling for an alcohol-based rub, antimicrobial soap and water may be used instead. 19. For surgical hand antisepsis using an alcohol-based product, choose a surgical hand scrub product with: a. Persistent activity b. Antibiotic additives c. A detergent component d. Activity against bacterial spores Correct: Persistent activity Rationale: For surgical hand antisepsis, it is important to choose a product with persistent activity against microbes. 20. Regarding hand hygiene, spread of infection, and artificial fingernails: a. Artificial fingernails are preferable to natural nail tips. b. Artificial fingernails are compatible with good infection control. c. Artificial fingernails are acceptable if kept less than ¼-inch long. d. Artificial fingernails are associated with spread of Gram-negative bacteria. Correct: Artificial fingernails are associated with spread of Gram-negative bacteria.

64 Rationale: Healthcare workers should not wear artificial fingernails. Gram-negative bacteria persist on artificial nails even after proper hand hygiene is performed.