hand hygiene PPE , surviellance system.

1. Types of Hand hygiene
Personal protective equipment
Surveillance system

2. Hand hygiene
The extreme importance of hand washing has been known since at least 1847,
when Dr Ignaz Semmelweis discovered that washing hands before performing
obstetric exams on pregnant women reduced childbirth-related infectious mortality
from more than 10% to less than 1% .
However, rates of hand washing among healthcare providers usually range from
only about 20 to 50% per hospital patient encounter, although some studies have
reported hand-washing rates as high as 81%. Viable pathogens are often found on
hands of healthcare providers .
The skin is an inhospitable environment for most micro-organism as it is dry ,
acidic and poor in nutrients. However , some micro-organism have adapted to these
conditions and exist in stable population known as the resident or normal flora .
These organism live in deep crevices in the skin , in hair follicle and sebaceous
glands .

3. Micro org on hands
Resident flora
 As CON Staph , corynebacterium spp , propionibaterium
 Deep seated in epidermis ,act as microbial anatagonism and competition for
nutrient in the ecosystem
 Reduction of them before surgical procedure
Transient flora
 as E.coli , Klebsiella , Acinetobacter , Staph aureus , C.difficicle ,viruses
 Present on superficial layers of skin and acquired by direct , indirect contact to
patient
 Removed by hand washing

4. The micro-organism present in largest numbers are Gram –positive
bacteria , mainly coagulase negative staphylococci, micrococci and
coryneform . Viruses are also easily acquired .
The ‘‘My Five Moments for Hand Hygiene’’ program included in the
WHO guidelines in 2006 to 2008. The evidence-based program is easy
to follow and reminds the health care worker to practice good hand
hygiene:
1. before touching a patient
2. before a clean/aseptic procedure
3. after body fluid exposure risk
4. after touching a patient
5. after touching patient surroundings .

5. Indications for hand washing and hand antisepsis:
 When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled
with blood or other body fluids, wash hands with either a non antimicrobial soap and water or an
antimicrobial soap and water.
- Proper hand washing technique is essential for best results:
Wet hands with water- Apply enough soap to cover all surfaces- Rub hands palm to palm
Right palm over left dorsum with interlaced finger and vice versa
Palm to palm with fingers interlaced-Backs of fingers to opposing palms with fingers interlocked-
Rotational rubbing of left thumb clasped in right palm and vice versa
Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice
versa
Rinse hands with water-Dry thoroughly with a single-use towel
Use towel to turn off faucet/tap
Duration of entire procedure: 40 to 60 sec and your hands are safe.

6. - Paper towels, warm air dryers, and cloth towels were no different in the
efficiency to dry wet hands. - When using towels, pat dry instead of rubbing dry to
avoid cracking
 If hands are not visibly soiled, use an alcohol-based hand rub for routinely
decontaminating hands or wash hands with an antimicrobial soap and water.
- Proper hand rubbing with alcohol-based hand rub is:
Apply a palm full of the product in a cupped hand and cover all surfaces
Rub hands palm to palm- Right palm over left dorsum with interlaced finger and
vice versa - Palm to palm with fingers interlaced
Backs of fingers to opposing palms with fingers interlocked
Rotational rubbing of left thumb clasped in right palm and vice versa
Rotational rubbing, backwards and forwards with clasped fingers of right hand in
left palm and vice versa
Duration of the entire procedure: 20 to 30 sec and, once dry, your hands are safe .

8. It is estimated that hand washing with plain soap for 30 second (s) removes
most soil and dirt, eliminates about 90% of transient hand flora but a low percentage
of resident hand flora. Hand washing for 15 s with a soap containing chlorhexidine
or triclosan removes most soil and dirt and about 99.9% of transient flora and about
50% of resident flora.
Hand rubbing for 15 s with an alcohol-based gel does not remove soil or dirt, but
kills about 99.9% of transient flora and about 99% of resident flora . Alcohol-based
hand-washing solutions are generally considered to be more effective than soap and
water.
Compared with plain soap and water, some studies have reported significantly lower
rates of nosocomial infections when alcohol-based solutions or chlorhexidine- or
triclosan-based hand-washing agents are used .

9. Many healthcare providers prefer using alcohol based solutions instead of soap
and water, and compliance rates are generally higher when alcohol- based hand-
washing solutions are used.
Use of alcohol-based cleaners saves time and these generally abrade and irritate the
skin less than antiseptic soaps.
However, some people complain that alcohol-based cleaners dry out and crack their
skin. Hospitals and healthcare providers may want to experiment with several
alcohol or chlorhexidine-based hand cleaners.
Soap and water may still have to be used in cases when hands are visibly soiled. In
that case, staff and visitors should wash hands carefully for at least 15 s with soap
and water .

10. Hand care
Frequent hand washing lead to surface lipid depletion either by soap
and water or alcohol , humectants and emollients preparation should
be used
Hand washing with soap &water and other product lead to dermatitis
Donning of gloves while hand are wet , increase skin irritation
Dry hand with good quality towel paper
Suitable hand cream / lotions used so it is not interact with antiseptics
or gloves
Cuts , abrasions cuts covered by water resistant occlusive dressing
Seek medical advice if HCW have skin problems

11. Personal protective equipment
Gloves
Sterility – material – latex allergy
Aprons –gowns
Types
Protective eye and face wear
Surgical face mask – respirators –fit testing – reuse and
extended use -aerosol generating procedure
Shoe and head covers

12. Gloves
Sterile
Prevent transfer of micro org from HCWs to patients
Used for all surgical and aseptic procedures
 protect against blood , body fluids
Non sterile
Protect HCW form acquiring micro org from patients , and
contaminated environment
Used for direct ( non intact skin or mucous membrane and potential
presence of infectious agent ) and indirect contact ( handling ,
cleaning of contaminated items as specimens or equipement )

13. Donning – doffing sequences
Donning Hand hygiene → aprons/ gowns → mask /respirators → eye
protecting / face shield → gloves and Doffing is reverse
Gloves materials
plastic – sterile , non sterile natural rubber latex – polyvinyl chloride –
nitrile –neoprene –house hold / thick latex
Features and suggested use for every material
sterile , non sterile natural rubber latex common medically used
polyvinyl chloride for cytotoxic agents
Neoprene for HCW sensitive to latex

14. Gloves are used to prevent contamination of healthcare personnel
hands when ;
1) anticipating direct contact with blood or body fluids, mucous
membranes, non intact skin and other potentially infectious material.
2) having direct contact with patients who are colonized or infected
with
pathogens transmitted by the contact route e.g., vancomycin-resistant
enterococci (VRE), meticillin-resistant Staphylococcus aureus
(MRSA), Respiratory Syncential Virus (RSV) .
3) handling or touching visibly or potentially contaminated patient care
equipment and environmental surfaces .

15. Gloves can protect both patients and healthcare personnel from
exposure to infectious material that may be carried on hands .
The extent to which gloves will protect healthcare personnel from
transmission of blood borne pathogens (e.g., HIV, HBV, HCV) following
a needle stick or other puncture that penetrates the glove barrier has not
been determined.
Although gloves may reduce the volume of blood on the external
surface of a sharp by 46 to 86% , the residual blood in the lumen of a
hollow bore needle would not be affected; therefore, the effect on
transmission risk is unknown .

16. It is not certain what type of glove provides the best protection for
infection control. Some studies have suggested that latex gloves are
somewhat better in preventing penetration of water and virus than vinyl
gloves.
However, about 3 to 16% of healthcare workers are sensitive to latex
and sometimes experience severe respiratory reactions to it. If latex
gloves are used in the healthcare setting, only the powder-free gloves
should be used since these release much lower levels of latex allergens
than the powdered latex gloves.
Nitrile gloves also have good barrier penetration but are more
expensive and heavier than either latex or vinyl gloves .

17. Aprons –gowns
Disposable plastic
• Prevent contamination and getting wet during patient care
• Used in suspect splash of blood or contact with MDROs patients
Full length water impervious
• Prevent contamination of clothing
• Used in suspect splash large amount of blood or extensive contact with MDROs
patients
Sterile water impervious
• prevent spread of micro org and contamination of clothing & skin
• During surgical and aseptic procedures

18. Protective eye and face wear
Types glasses – face shield - Surgical face mask – respirators
fit testing – reuse and extended use
Surgical face mask
• Protect aginst droplet nuclei
• Changed if contaminated or moist
• Wearing in routine ward procedures & in the operating theatre
Respirators
• Protect against tiny airborne particles
• Ex asFFP2 & N95 Protect against aerosol including MTB
• Changed if contaminated or difficult breathing or damaged or face fit

19. fit testing – reuse and extended use
Fit test in respirators if fails repeated if fails alternatives types are
considered .
Fit test done yearly or when purchase additional types
reuse and extended use
Reuse N95 ,FFP2 def. wear same respirator with several patient but
remove it after each use - up to 7 days
Extended use def ; wear same respirator with several patient during
outbreaks , pandemics - Used only for 8 h ( continuous / intermittent )

20. • Check integrity not compromised
• Kept in clean container , user name .
• Changed if contaminated , wet , damaged , difficult breath
• seal check before using it
Shoe and head covers
are often recommended for use in areas containing immune compromised or
surgical patients.
Although bacterial pathogens have been collected from shoes, research on the use of
shoe covers and/or separate hospital shoes and spread of pathogens has been meager
.

21. Surveillance
On going systematic collection , analysis , interpretation of health data
essential to planning , implementation , evaluation of public health
practice , closely integrated with timely dissemination of these data to
those who need to know
Objectives
• Establish HAIs rate – compare rates between facilities
• Reduce infection rate - implement cost effective interventions
• Identify , monitor , control outbreak
• Evaluate success and sustainability of IPC interventions

22. Methods
1- case finding ( active – passive )
2- hospital wide surveillance ( incidence – prevalence )
3- targeted surveillance ( site – unit – rotating – outbreak –
syndromic )
4- limited periodic surveillance
5-objective / periodic based surveillance
6-post discharge surveillance

23. * Surveillance Methods
1- Case-finding Issues
First, should infections be sought by passive or active means .
In passive surveillance, persons who do not have a primary surveillance
role, that is, persons other than ICPs , are relied on for identification
and reporting of infections.
Active surveillance is the process of vigorously looking for nosocomial
infections using trained personnel, nearly always ICPs. ICPs seek out
nosocomial infections by using various data sources to accumulate
information and decide whether or not a nosocomial infection has
occurred

24. Second, should infection detection be patient- or laboratory-based .
Patient-based surveillance includes counting nosocomial infections, assessing risk
factors, and monitoring patient care procedures and practices for adherence to
infection control principles. It requires ward rounds and discussions with caregivers.
In laboratory-based surveillance, detection is based solely on the findings of
laboratory studies of clinical specimens.
Third, should infections be detected prospectively or retrospectively . Prospective
surveillance refers to monitoring patients while they are still hospitalized and, for
SSIs, includes the postdischarge period. Retrospective surveillance uses chart
review after patient discharge as the sole means of identifying infections

25. 2- Incidence Versus Prevalence in Hospital-Wide Surveillance
Incidence surveillance is continual monitoring of all patients for new
nosocomial infections of all kinds on all wards. It has also been termed ongoing,
total, house wide, or comprehensive surveillance .
Hospital-wide surveillance has the advantage of providing a global view of what is
happening in the hospital so that potential clusters of infection or antibiotic
resistance can be detected anywhere .
The advantage of prevalence surveillance is that it is a rapid inexpensive way to
estimate the magnitude of nosocomial infection problems in a hospital . There are
two major disadvantages of prevalence surveillance.
First, in small hospitals, the number of patients surveyed is insufficient to detect
important differences among patient populations .

26. Second, patients' risk of infection is overestimated with the prevalence rate,
which is calculated as the number of active infections on the day of the visit divided
by the number of beds visited
3- Targeted Surveillance
These strategies focused or targeted efforts on certain areas in the hospitals
(e.g., ICUs), patient groups (e.g., surgical patients), or infection sites (e.g.,
bloodstream infections).
These targeted efforts have become increasingly common in this decade not only
because of their positive impact on resource management but because they have the
potential for yielding more meaningful results than hospital-wide surveillance.
A disadvantage of these limited strategies is that clusters of infection in areas not
under surveillance may be missed

27. 4- Objective/Priority-Directed Surveillance
Accordingly, SSIs and pneumonias would be allocated the most
surveillance resources (one half and one third, respectively), with much
less for bloodstream and urinary tract infections.
Objectives for surveillance should be evaluated annually and adjusted as
necessary. The obvious advantage of this method is that specific
measurable objectives are set and attainment is carefully evaluated.
Therefore, ICP time and effort are directed in a very productive manner.
A potential disadvantage is undetected outbreaks, although some studies
recommended that the ICP train other hospital staff to be alert for and
report unusual clustering

28. 5- Limited Periodic Surveillance
This method is a combination of hospital-wide and site-specific targeted
surveillance. Some studies used total surveillance for 1 month per quarter and
targeted bloodstream infection surveillance during the other 8 months.
Although the potential for missing clusters is less than for targeted methods, it still
exists during two thirds of the year
6- Post discharge Surveillance
Because of the shorter postoperative stay, it is estimated that as many as 50%
of SSIs may be missed if a formal post discharge surveillance system is not in place
.
Significant methodological problems with post discharge surveillance include
reliance on physicians to return information on patients to the ICP in a timely
manner, patients' inability to accurately diagnose infection , and determination of
how to handle patients lost to follow-up .

29. Stages of surveillance
 Data collection
 Alert infectious conditions and alert infectious organism
 Calculating HAI rates
 Public reporting of HAIs
Types of surveillance
1- Outcome surveillance
Count HAIs by applying agreed definitions
2- Process surveillance
Monitor effectiveness , implementation of good and evidence based IPC practice

30. Surveillance & Outbreak control
Infection surveillance may either include all residents in a facility or be
targeted at specific subpopulations. Although facility-wide surveillance is useful
for calculating baseline rates and detecting outbreaks, a more focused analysis could
include examination of infection rates in residents who are at risk for certain kinds
of infection (such as aspiration pneumonia in residents receiving tube feedings or
bloodstream infection among residents with indwelling vascular catheters).
These surveillance data are used primarily to guide control activities, to plan
educational programs, and to detect epidemics, but surveillance also may detect
infections that require therapeutic action

31. Prevalence studies detect the number of existing (old and new) cases in
a population at a given time, whereas incidence studies find new cases
during a defined time period. The latter is preferred because more
concurrent information can be collected by an incidence study if data
are collected with regularity
Surveillance systems must be extremely flexible; effective infection
control teams will not use a “one size fits all” approach for surveillance.
Some hospitals should focus on patients at high risk, such as those
hospitalized in intensive care and neonatal units .

32. After defining the priorities of the institution, the focus could also
be on specific problems, such as bacteremia or surgical site infection.
Focusing on neonatal bacteremia pays high because extrinsic
contamination of IV fluids seems to be a common problem in many
settings
Automated surveillance (AS) is the process of obtaining useful
information from infection control data through the systematic
application of medical informatics and computer science technologies.

33. Thank You