2003 Prevention of Wound Infection

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2003 Prevention of Wound Infection

  1. 1. PREVENTION OF WOUND INFECTION USING PROPER HAND DISCIPLINES Dee May RGN, DMS Queens Medical Centre Nottingham, England PREVENTION OF WOUND INFECTION USING PROPER HAND-WASHING DISCIPLINES Dee May RGN, DMS Queens Medical Centre Nottingham, England
  2. 2. Approx 20% of all hospital occur in surgical wounds (Meers 1981; Haley 1985) Prospective surveillance shows an overall surgical wound infection rate of < 5% (Cruse and Foord 1973, 1980, 1992) Approx 20% of all hospital-acquired infections occur in surgical wounds (Meers 1981; Haley 1985) Prospective surveillance shows an overall surgical wound infection rate of < 5% (Cruse and Foord 1973, 1980,
  3. 3. Acute and Chronic Wounds Acute wounds are: - less heavily colonised with micro - produced on healthy event e.g. surgery - heal well if the wound is well vascularised - infection delays normal healing and this may lead to an acute wound becoming chronic Acute and Chronic Wounds less heavily colonised with micro-organisms healthy tissue by a traumatic heal well if the wound is well vascularised infection delays normal healing and this may lead to an acute wound becoming chronic
  4. 4. Acute and Chronic Wounds (2) Chronic wounds are: - rarely, if ever, sterile - may be heavily colonised with micro depending on:depending on: - length of time wound has been present - underlying patient risk factors e.g. vascularity metabolic impairment e.g. diabetes Acute and Chronic Wounds (2) may be heavily colonised with micro-organisms length of time wound has been present underlying patient risk factors vascularity metabolic impairment e.g. diabetes
  5. 5. Post-surgical infection rates 3 prospective studies by Cruse and Foord Clean 1.4 Clean-contaminated 8.9Clean-contaminated 8.9 Contaminated 13.3 Dirty 38.3 All Wounds 4.8 surgical infection rates 3 prospective studies by Cruse and Foord 1973 1980 1992 1.8 1.5 8.9 7.7 6.38.9 7.7 6.3 21.5 15.2 38.3 40.0 39.9 4.8 4.7 4.4
  6. 6. Potentially pathogenic bacteria commonly found in wounds Staphylococcus aureus Escherichia coli Proteus Enterococcus fuecalis Streptococcus pyogenes Bacteroids Klebsiella Acinetobacter anitratus Pseudomonas aeruginosa Potentially pathogenic bacteria commonly found in wounds Staphylococcus aureus Escherichia coli Proteus species Enterococcus fuecalis Streptococcus pyogenes Bacteroids species Klebsiella species Acinetobacter anitratus Pseudomonas aeruginosa
  7. 7. Wound Classification - Clean Operations Gastro-intestinal, genitourinary and respiratory tracts intact. No inflammation encountered. Asepsis maintainedmaintained - e.g. varicose vein surgery. - Clean-contaminated Operations Viscus opened but with minimal spillage e.g. elective cholecystectomy. Wound Classification intestinal, genitourinary and respiratory tracts intact. No inflammation encountered. Asepsis e.g. varicose vein surgery. contaminated Operations Viscus opened but with minimal spillage e.g. elective cholecystectomy.
  8. 8. Wound Classification(2) - Contaminated Operations Gross spillage from an opened viscus. Acute inflammation without pus. Traumatic wound < 4 hours old. Breach in asepsis. e.g. appendicitise.g. appendicitis - Dirty Operations Pus encountered or perforation. Traumatic wound > 4 hours old. e.g. perforated diverticulum Council 1964) Wound Classification(2) Gross spillage from an opened viscus. Acute inflammation without pus. Traumatic wound < 4 hours old. Breach in asepsis. Pus encountered or perforation. Traumatic wound > 4 hours old. (National Research
  9. 9. Routes of spread of micro organisms causing wound infection - hands Contact - equipment etc. - droplet nuclei Airborne - skin scales Blood-borne Routes of spread of micro- organisms causing wound infection hands equipment etc. droplet nuclei skin scales
  10. 10. Prevention of Wound Infection - minimise pre-operative stay - reduce skin shaving - adequate skin preparation - high quality surgical technique - antibiotic prophylaxis - clean operating environment and air filtration - sterile equipment - protective clothing - closed vacuum drainage of wound - optimum wound dressing - aseptic technique - HAND WASHING Prevention of Wound Infection operative stay adequate skin preparation high quality surgical technique clean operating environment and air filtration closed vacuum drainage of wound optimum wound dressing
  11. 11. Ignaz Semmelweis 1847 Hungarian Obstetrician Reduced puerperal fever death rate from 11% to 1% by introducing hand Ignaz Semmelweis 1847 Hungarian Obstetrician Reduced puerperal fever death rate from 11% to 1% by introducing hand-washing
  12. 12. Resident Hand Flora Characteristics: - micro-organisms protect skin - survive and multiply on skin - not easily removed by scrubbing- not easily removed by scrubbing - inactivated by topical antimicrobial agents - can cause infection when enter through breaks in the skin - “invasiveness” - can rapidly become highly pathogenic Resident Hand Flora organisms protect skin survive and multiply on skin not easily removed by scrubbingnot easily removed by scrubbing inactivated by topical antimicrobial agents can cause infection when enter through “invasiveness” can rapidly become highly pathogenic
  13. 13. Resident Micro Staphylococcus epidermidis micrococcimicrococci diphtherroids anaerobic cocci propionibacteria Resident Micro-organisms Staphylococcus epidermidis
  14. 14. Transient hand flora Characteristics: - loosely attached to skin surface- loosely attached to skin surface - usually removed with friction, soap and water - acquired by direct contact - most abundant around fingertips - an important cause of cross infection Transient hand flora loosely attached to skin surfaceloosely attached to skin surface usually removed with friction, soap and water acquired by direct contact most abundant around fingertips an important cause of cross infection
  15. 15. Transient micro Staphylococcus aureus Streptococci Gram-negative bacilli including Escherichia coli Pseudomonas Viruses Transient micro-organisms Staphylococcus aureus negative bacilli including
  16. 16. All micro-organisms found on hands are capable of colonising and infecting wounds. Microbial counts usually increase inMicrobial counts usually increase in warm and moist conditions: - under gloves - beneath rings organisms found on hands are capable of colonising and infecting Microbial counts usually increase inMicrobial counts usually increase in warm and moist conditions: under gloves beneath rings
  17. 17. Gram Negative Bacilli Colonising Skin under Wedding Rings Organisms No. of Staff Ent. cloacae 10 Kleb. pneumoniae 5Kleb. pneumoniae 5 Acinet. calcoaceticus 3 Ps. aeruginosa 2 Serratia marcescens 1 Proteus mirabilis 1 Prov. stuartii 1 Gram Negative Bacilli Colonising Skin under Wedding Rings No. of Staff CFU’s per swab 10 - 24,000 10 - 2,200,00010 - 2,200,000 110 - 560,000 7,200 - 40,000 48,000 50 14,000 Hoffmann et al 1985
  18. 18. Jewellery esp. rings - Total bacterial counts are higher - Handwashing still removes bacteria under- Handwashing still removes bacteria under rings - Difficulty donning gloves - Gloves may tear Jewellery esp. rings Total bacterial counts are higher Handwashing still removes bacteria underHandwashing still removes bacteria under Difficulty donning gloves
  19. 19. Nails, nail polish, artificial nails Nails should be kept short. Artificial nails may increase microbial load. Thorough, effective handwashing difficult. Theatre staff should not wear artificial nails. Clear nail polish only. Nails, nail polish, artificial nails Nails should be kept short. Artificial nails may increase microbial load. Thorough, effective handwashing difficult. Theatre staff should not wear artificial nails.
  20. 20. Gloves Gloves are not a substitute for handwashing. Massive increase in use in recent years. Hand contamination remains possible. Handwashing after glove removal essential andHandwashing after glove removal essential and before sterile glove use. Hypersensitivity to latex increasing. Gloves must be changed: - between clean and dirty procedures - between patients Gloves a substitute for handwashing. Massive increase in use in recent years. Hand contamination remains possible. glove removal essential andglove removal essential and sterile glove use. Hypersensitivity to latex increasing. Gloves must be changed: between clean and dirty procedures
  21. 21. Gloves (2) Glove quality very variable Beware re-use of disposable gloves. If absolutely necessary, latex gloves can be washed and dried, powdered and re availability is scarce. Gloves (2) Glove quality very variable use of disposable gloves. , latex gloves can be washed and dried, powdered and re-used where their
  22. 22. Handwashing Mechanical - removes soil and debris with abrasive action ChemicalChemical - uses antimicrobial chemical agents to destroy or suppress growth of micro-organisms - chemical agents are: - cidal or - static Handwashing removes soil and debris with abrasive action uses antimicrobial chemical agents to destroy or organisms
  23. 23. Choice of Handwashing Agents Dependent on: - task to be undertaken- task to be undertaken - inherent characteristics - type and spectrum of activity Choice of Handwashing Agents task to be undertakentask to be undertaken inherent characteristics type and spectrum of activity
  24. 24. Handwashing Agents Soap and Water Antiseptic handwashes and water Alcohol hand-rubs Handwashing Agents Soap and Water Antiseptic handwashes and water rubs
  25. 25. Soap and Water “Should be used for handwashing unless otherwise indicated”unless otherwise indicated” Centers for Disease Control 1985 Soap and Water “Should be used for handwashing unless otherwise indicated”unless otherwise indicated” Centers for Disease Control 1985
  26. 26. Active Ingredients in Antimicrobial Agents - alcohols - iodophors - chlorhexidine gluconate - triclosan - chloroxylenol (pcmx) - hexachlorophene Active Ingredients in Antimicrobial Agents chlorhexidine gluconate chloroxylenol (pcmx) hexachlorophene
  27. 27. Alcohols (70% - Inexpensive - Do not require water or facilities - but will not remove dirt or debris - Provide rapid and greatest reduction in microbial countscounts - but no residual activity - Dry and irritate skin - Irritation reduced by adding emollients - Standard scrub solution in some European countries - Volatile and flammable Alcohols (70%-90%) Do not require water or facilities but will not remove dirt or debris Provide rapid and greatest reduction in microbial Irritation reduced by adding emollients Standard scrub solution in some European countries
  28. 28. Iodophors e.g. povidone-iodine - used primarily for surgical scrubbing - wide range of microbial activity- wide range of microbial activity - rapidly neutralised in presence of organic material e.g. blood - cause skin irritation and hypersensitivity Iodophors used primarily for surgical scrubbing wide range of microbial activitywide range of microbial activity rapidly neutralised in presence of organic cause skin irritation and hypersensitivity
  29. 29. Chlorhexidine gluconate - wide range of microbial activity - initially slow acting - but persistent chemical activity (up to 6 hours)- but persistent chemical activity (up to 6 hours) - less irritating than alcohols or iodophors - not significantly affected by organic material - available in combination with alcohol as a highly-effective hand-rub Chlorhexidine gluconate wide range of microbial activity but persistent chemical activity (up to 6 hours)but persistent chemical activity (up to 6 hours) less irritating than alcohols or iodophors not significantly affected by organic material available in combination with alcohol as a rub
  30. 30. Triclosan - wide range of bacterial activity - excellent residual activity - minimally affected by organic material eg blood - commonly used in commercial soaps - more data needed Triclosan wide range of bacterial activity excellent residual activity minimally affected by organic material eg commonly used in commercial soaps
  31. 31. Chloroxylenol (Para-chloro-meta - less active than chlorhexidine gluconate - reasonable residual activity - minimally affected by organic material Chloroxylenol meta-xylenol) less active than chlorhexidine gluconate reasonable residual activity minimally affected by organic material
  32. 32. Hexachlorophene - inferior microbial activity - potentially toxic - slow-acting - minimally affected by organic material - must not be used on broken skin Hexachlorophene inferior microbial activity minimally affected by organic material be used on broken skin
  33. 33. Emollients (Hand lotion or cream) - highly effective in protecting skin from excessive drying or cracking - however, may reduce or neutralise effect of antimicrobial agents - container can become contaminated - essential to consider possible interactions before purchase Emollients (Hand lotion or cream) highly effective in protecting skin from excessive however, may reduce or neutralise effect of container can become contaminated essential to consider possible interactions before
  34. 34. Summary of Handwashing Agents Most widely used agents are: - chlorhexidine gluconate - alcohol - povidone iodine Summary of Handwashing Agents Most widely used agents are: chlorhexidine gluconate povidone iodine
  35. 35. Reasons for Noncompliance with Handwashing - insufficient time available between tasks - inconvenience/lack of facilities - perceived lack of need - poor skin condition resulting from repeated handwashing or harsh products Also Cultural factors lack of education lack of role models Reasons for Noncompliance with Handwashing insufficient time available between tasks inconvenience/lack of facilities poor skin condition resulting from repeated handwashing or harsh products
  36. 36. Other Considerations Soap - bar soap keep dry (magnet, ring, string) - liquid soap dispensers- liquid soap dispensers ideally cartridge use otherwise clean nozzles regularly - antiseptic soap dispensers ideally wall-mounted and elbow should be sterile and disposable with a measured dose Other Considerations keep dry (magnet, ring, string) liquid soap dispensersliquid soap dispensers ideally cartridge use otherwise clean nozzles regularly antiseptic soap dispensers mounted and elbow-operated should be sterile and disposable with a measured dose
  37. 37. Further Considerations - preferably use a separate sink for handwashing. - elbow operated taps if possible. - paper towels are best method of drying hands. - nail brushes should ideally be single use. - handwash dispensers should be wall elbow-operated pump Further Considerations preferably use a separate sink for handwashing. elbow operated taps if possible. paper towels are best method of drying hands. nail brushes should ideally be single use. handwash dispensers should be wall-mounted with
  38. 38. Limited/Restricted Resources In absence of running water: - clean bowl of water change water after each use - drum with a spout- drum with a spout elevate to serve as running water - store water in large clean receptacles whenever a water supply is available - ensure water is pathogen- consider chlorination/filtration/boiling Limited/Restricted Resources In absence of running water: change water after each use elevate to serve as running water store water in large clean receptacles water supply is available -free e.g. cholera consider chlorination/filtration/boiling
  39. 39. Limited Resources In absence of paper towels: - clean cloth (12” x 12”) single person use and use once only launder after use - air dryers preferably non-touch Limited Resources In absence of paper towels: clean cloth (12” x 12”) single person use and use once only touch
  40. 40. “Hand-washing using an appropriate technique covering all surfaces ... at the right time is more important than the agent used or the length of timethe agent used or the length of time of handwashing” washing using an appropriate technique covering all surfaces ... at the right time is more important than the agent used or the length of timethe agent used or the length of time Ayliffe 1992
  41. 41. Optimum Handwashing Technique (social and hygienic wash) Remove jewellery if possible. Roll back sleeves. Wet hands under running water. Apply soap to all areas of hands. Rub hands together vigorously and cleanse all areas of hands and wrists. Keep hands lower than elbows and do not touch equipment. Rinse hands thoroughly under running water. Dry hands thoroughly. Optimum Handwashing Technique (social and hygienic wash) Remove jewellery if possible. Roll back sleeves. Rub hands together vigorously and cleanse all areas of Keep hands lower than elbows and do not touch equipment. Rinse hands thoroughly under running water.
  42. 42. Surgical Scrub Technique Remove all jewellery. Wet hands under running water. Wash hands to remove soil and debris.Wash hands to remove soil and debris. Using antimicrobial agent and nail sponge/brush, clean under nails. Discard sponge/brush. Scrub all surfaces of hands, wrists and forearms up to elbows. Keep hands higher than elbows. Surgical Scrub Technique Wash hands to remove soil and debris.Wash hands to remove soil and debris. Using antimicrobial agent and nail sponge/brush, clean under Scrub all surfaces of hands, wrists and forearms up to elbows.
  43. 43. Surgical Scrub Technique (2) If there is any contact with unclean surfaces during scrubbing, restart procedure with a fresh sponge/brush. Once an area has been cleaned, do area again.area again. Rinse hands and arms thoroughly. Avoid wetting clothes. Dry all areas with sterile cloth or towels. Surgical Scrub Technique (2) If there is any contact with unclean surfaces during scrubbing, restart procedure with a fresh sponge/brush. Once an area has been cleaned, do not return to the cleaned Rinse hands and arms thoroughly. Avoid wetting clothes. cloth or towels.
  44. 44. Hand Drying Wet surfaces - encourage multiplication of micro transfer micro-organisms more effectively than dry High risk of contamination: communal hand towelscommunal hand towels roller towels Warm air dryers: cycle time often inadequate can be a source of cross research is scanty Hand Drying encourage multiplication of micro-organisms organisms more effectively than dry cycle time often inadequate can be a source of cross-infection
  45. 45. TYPES OF HAND CARE Type Objective Handwash Remove soil and transient micro-organisms Hand antisepsis Remove or destroy transient micro-organismsmicro-organisms Surgical hand Remove or destroy transient scrub micro-organisms and reduce resident flora APIC Guidelines 1995 TYPES OF HAND CARE Method Remove soil and transient Soap or detergent for at least 10-15 seconds Remove or destroy transient Antimicrobial soap/ detergent/alcohol-baseddetergent/alcohol-based hand rub for at least 10-15 seconds Remove or destroy transient Antimicrobial soap/detergent organisms and reduce with brush to achieve friction for at least 2 minutes OR alcohol-based preparation for at least 20 seconds
  46. 46. How do I know which procedure to use? Handwash Antisepsis * before and after routine * before performing invasive procedures patient contact * before care of susceptible patients * before and after contact with wounds * before handling food or invasive devices (e.g. IV cannula) * after situations where contamination of * after using toilet hands with blood or body fluids is likely* after using toilet hands with blood or body fluids is likely to occur * whenever hands are * after caring for patients with a known soiled infection or colonised with micro organisms of significance (e.g. resistant strains) * between contact with different patients in high-dependency units How do I know which procedure to use? Surgical Scrub * before performing invasive procedures * prior to any surgical * before care of susceptible patients (operative) * before and after contact with wounds procedure or invasive devices (e.g. IV cannula) * after situations where contamination of hands with blood or body fluids is likelyhands with blood or body fluids is likely * after caring for patients with a known infection or colonised with micro- organisms of significance (e.g. resistant * between contact with different patients dependency units

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