Download Hand Hygiene – Skin and Hand Care in the Dental Setting

EVIDENCE
EDUCATION
ENGAGEMENT
SKIN
HAND HYGIENE –
AND HAND CARE IN
THE DENTAL SETTING
ENGAGEMENT
EDUCATION
EVIDENCE
A SELF STUDY GUIDE
Dental Professionals
OVERVIEW
Healthcare-Associated Infections (HAIs) are infections acquired in healthcare settings and are the most frequent adverse
events in healthcare. Hundreds of millions of patients are affected by HAIs worldwide each year, leading to significant
mortality and financial losses for health systems. Of every 100 hospitalized patients at any given time, 7 in developed and
10 in developing countries will acquire at least one HAI.1 The endemic burden of HAI is also significant. The prevalence
of HAIs in developed countries varies between 3.5% and 12%. The European Centre for Disease Prevention and Control
reports an average prevalence of 7.1% in European countries. The estimated incidence rate in Canada is 11.6% and in the
U.S. is 4.5%, corresponding to 2 million affected patients annually.1 It has been estimated that overall prevalence of HAIs
in Australia is 9.7%, affecting as many as 150,000 patients each year.2
Cross-infection and cross-contamination can occur multiple ways in various healthcare settings. In the dental setting, the
oral cavity is a perfect environment for bacteria and viruses from the nose, throat and respiratory tract and transmission
of healthcare-associated pathogens most often occurs via the contaminated hands of healthcare professionals (HCPs).3, 4
Accordingly, hand hygiene (i.e. hand washing with soap and water or use of a waterless, alcohol-based hand rub) has long
been considered one of the most important infection control measures for preventing HAI. However, compliance by HCPs
with recommended hand hygiene procedures has remained unacceptable, with compliance rates generally below 50% of
hand hygiene opportunities.
LEARNER OBJECTIVES
HAND HYGIENE –
SKIN AND HAND
Upon completion of this educational activity, the learner should be able to:
1. Describe three functions of the skin.
2. List two reasons why HCPs may not be compliant with hand hygiene guidelines.
3. Describe rationale for maintaining good skin integrity.
4. List three hand hygiene products used by healthcare providers.
5. Describe methods to enhance skin health.
INTENDED AUDIENCE
CARE IN THE
DENTAL SETTING
The information contained in this self-study guidebook is intended for use by healthcare professionals
who are responsible for or involved in the following activities related to this topic:
• Educating healthcare personnel
• Establishing institutional or departmental policies and procedures
• Decision-making responsibilities for hand-barrier products
• Maintaining regulatory compliance with agencies
• Managing employee health and infection prevention services
INSTRUCTIONS
Ansell is approved for 2 hours of verifiable CPD by the New Zealand Dental Council and is an ADA CERP Recognized
Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does
it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about the CE provider may be directed
to the provider or to ADA CERP and ADA.org/CERP. Obtaining the full 2.25 contact hour credit for this offering depends on
completion of the self-study materials on-line as directed below.
Approval refers to recognition of educational activities only and does not imply endorsement of any product or company
displayed in any form during the educational activity.
To receive contact hours for this program, please go to the “Program Tests” area and complete the post test. You will
receive your certificate via email.
AN 85% PASSING SCORE IS REQUIRED FOR SUCCESSFUL COMPLETION.
Any learner who does not successfully complete the post test will be notified and given an opportunity to resubmit
for certification.
Ansell Healthcare Products LLC has an ongoing commitment to the development of quality products and services for
the healthcare industry. This self-study is one in a series of continuing educational services provided by Ansell.
For more information about our educational programs or perioperative safety solution topics, please contact
Ansell Healthcare Educational Services at 1-732-345-2162 or e-mail us at [email protected]
Planning Committee Members:
Luce Ouellet, BSN, RN
Latisha Richardson, MSN, BSN, RN
Patty Taylor, BA, RN
Pamela Werner, MBA, BSN, RN, CNOR
2
Original release date – March 2007
Last review date – August 2016
Expiration date – June 2020
As employees of Ansell Ms. Ouellet, Mrs. Richardson, Mrs. Taylor and Ms. Werner have declared an affiliation that could be
perceived as posing a potential conflict of interest with development of this self-study module.
This module will include discussion of commercial products referenced in generic terms only.
TABLE OF CONTENTS
OVERVIEW ........................................................................................................................2
INTRODUCTION ...............................................................................................................4
FUNCTIONS OF SKIN .......................................................................................................5
SKIN COMPONENTS .......................................................................................................5
LAYERS OF THE SKIN .....................................................................................................6
SKIN PERMEABILITY ......................................................................................................8
HISTORY OF HAND HYGIENE ..........................................................................................9
CLINICAL SKIN ISSUES ..................................................................................................10
HAND CARE OPTIONS ...................................................................................................12
HAND HYGIENE COMPLIANCE ......................................................................................14
MEDICAL GLOVES ...........................................................................................................18
NEW INNOVATIONS & NEXT GENERATION ................................................................ 19
SUMMARY .......................................................................................................................20
GLOSSARY .......................................................................................................................21
BIBLIOGRAPHY ................................................................................................................22
REFERENCES ....................................................................................................................23
3
INTRODUCTION
Intact skin is the best barrier protection against
microorganisms. The skin is the body’s largest organ, covering
a surface of approximately 2 square meters. It varies in
thickness from 2-3 mm. It is remarkably resilient and is an
effective barrier to microorganisms. The human skin has
an amazing ability to regenerate and renew itself in an
orderly fashion.
HAND HYGIENE –
SKIN AND HAND
Today’s healthcare environment is demanding on the skin.
The hands of healthcare professionals (HCPs) are a frequent
vehicle for the transmission of pathogens to the patient and to
the environment. The importance of hand hygiene in our ever
changing world of bloodborne pathogens (BBP), healthcareassociated infections (HAI), multiple drug-resistant organisms
(MDRO), influenza and pandemic potentials (H1N1, Ebola, etc.)
makes it crucial for us to be mindful of the recommended hand
hygiene practices.
CARE IN THE
DENTAL SETTING
Vancomycin-resistant Staphylococcus aureus
With dental professionals working outside the acute care
setting without the guidance and monitoring of an infection
preventionist or epidemiologist, tracking possible HAIs and
associated infection prevention practices is a difficult task.5
Due to these heightened concerns, there has been a focus by
a number of professional organizations, government agencies
and regulating bodies on improving handwashing compliance
among all HCPs across all settings.
Being unacquainted with effective hand hygiene practices may
be a contributing factor in noncompliance to recommended
hand hygiene protocols. Education is a vehicle to provide
knowledge, awareness, and information so that HCPs; nurses,
technicians, physicians dental practitioners, dental assistants,
dental hygienists, and all allied healthcare providers such
as Life Science, Emergency Medical Services (EMS), and
Correctional Services, can make the informed, committed
decision to do the right thing, improve compliance and have an
impact on bringing and keeping infections under control.
4
FUNCTIONS OF SKIN
Because it interfaces with the environment, skin plays a key
role in protecting the body against pathogens and excessive
water loss. Its other functions are insulation, temperature
regulation, sensation, synthesis of vitamin D, and the
protection of vitamin B folates.
Skin performs the following functions:
1. Protection: an anatomical barrier from pathogens and
damage between the internal and external environment
in bodily defense; Langerhans cells in the skin are part
of the adaptive immune system.
6. Storage and synthesis: acts as a storage center for
lipids and water, as well as a means of synthesis of
vitamin D by action of UV on certain parts of the skin.
7. Excretion: sweat contains urea, however its
concentration is 1/130th that of urine, hence excretion by
sweating is at most a secondary function to temperature
regulation.
8. Absorption: the cells comprising the outermost 0.250.40 mm of the skin are “almost exclusively supplied by
external oxygen” (Stücker, 2002). In addition, medicine
can be administered through the skin, by ointments or by
means of adhesive patch. The skin is an important site of
transport in many other organisms.
9. Water resistance: The skin acts as a water resistant
barrier so essential nutrients aren’t washed out of
the body.
SKIN COMPONENTS
Langerhans cells
2. Sensation: contains a variety of nerve endings that
react to heat and cold, touch, pressure, vibration, and
tissue injury.
3. Heat regulation: the skin contains a blood supply far
greater than its requirements which allows precise
control of energy loss by radiation, convection and
conduction. Dilated blood vessels increase perfusion
and heat loss, while constricted vessels greatly reduce
cutaneous blood flow and conserve heat.
4. Control of evaporation: the skin provides a relatively
dry and semi-impermeable barrier to fluid loss. Loss
of this function contributes to the massive fluid loss
in burns.
5. Aesthetics and communication: others see our
skin and can assess our mood, physical state and
attractiveness.
Skin has mesodermal cells, pigmentation, or melanin
provided by melanocytes, which absorb some of the potentially
dangerous ultraviolet radiation (UV) in sunlight. Skin also
contains DNA-repair enzymes that help reverse UV damage,
such that people lacking the genes for these enzymes suffer
high rates of skin cancer. One form predominantly produced by
UV light, malignant melanoma, is particularly invasive, causing
it to spread quickly, and can often be deadly. Human skin
pigmentation varies among populations in a striking manner.
This has led to the classification of people(s) on the basis
of skin color.
The skin is the largest organ in the human body. For the average
adult human, the skin has a surface area of between 1.5-2.0
square meters (16.1-21.5 sq. ft.), most of it between 2–3 mm
(0.10 inch) thick. The average square inch (6.5 cm²) of skin holds
650 sweat glands, 20 blood vessels, 60,000 melanocytes, and
more than 1,000 nerve endings.
5
SKIN LAYERS
Skin is composed of three primary layers:
• the epidermis, which provides waterproofing and serves
as a barrier to infection;
• the dermis, which serves as a location for the
appendages of skin; and
• the hypodermis (subcutaneous adipose layer).
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
Epidermis
Epidermis, coming from the Greek “epi” meaning “over”
or “upon," is the outermost layer of the skin. It forms the
waterproof, protective wrap over the body’s surface and is
made up of stratified squamous epithelium with an underlying
basal lamina. The epidermis is the thinnest at eyelids being
approximately 0.05 mm and thickest at the palm or soles,
approximately 1.5 mm.
The epidermis contains no blood vessels, and cells in the
deepest layers are nourished almost exclusively by diffused
oxygen from the surrounding air and to a far lesser degree by
blood capillaries extending to the upper layers of the dermis.
The main type of cells which make up the epidermis are Merkel
cells and keratinocytes, with melanocytes and Langerhans cells
also present.
The epidermis can be further subdivided into the following
strata (beginning with the outermost layer): corneum,
lucidum (only in palms of hands and bottoms of feet),
granulosum, spinosum, and basale. The corneum layer of
the epidermis consists of 25 to 30 layers of dead cells.
This layer regulates water loss and prevents harmful
pathogens from entering the body.
6
Dermis
The dermis is the layer of skin beneath the epidermis that
consists of connective tissue and cushions the body from stress
and strain. The dermis is tightly connected to the epidermis
by a basement membrane. It also harbors many nerve endings
that provide the sense of touch and heat. It contains the hair
follicles, sweat glands, sebaceous glands, apocrine glands,
lymphatic vessels and blood vessels. The blood vessels in the
dermis provide nourishment and waste removal from its own
cells as well as from the Stratum basale of the epidermis.
The dermis is structurally divided into two areas: a superficial
area adjacent to the epidermis, called the papillary region, and
a deep, thicker area known as the reticular region.
Hypodermis
The hypodermis is not part of the skin, and lies below the
dermis. Its purpose is to attach the skin to underlying bone and
muscle as well as supplying it with blood vessels and nerves.
It consists of loose connective tissue and elastin. The main
cell types are fibroblasts, macrophages and adipocytes (the
hypodermis contains 50% of body fat). Fat serves as padding
and insulation for the body.
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SKIN PERMEABILITY
Human skin has a low permeability; that is, most foreign
substances are unable to penetrate and diffuse through
the skin. However, dry skin may occur reducing the barrier
effectiveness of the skin. Dry skin is a result of decreased
water content in the outermost layers of the stratum corneum
(Rawlings). This disruption of the skin’s natural barrier function
has a number of causes unique in the healthcare setting. The
constant need to wear gloves, due to Standard Precautions
guidelines, means hands are in a perspiration environment
that softens the skin and weakens the epidermis.
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
8
Additionally, frequent handwashing with detergents or soaps
and/or use of alcohol-based hand rubs can attack the skin’s
lipid layer. Seasonal changes in humidity, soaps, detergents,
caustic chemicals, and metals commonly used in the dental
setting, like nickel, chromium, mercury, amalgam, glutaraldehyde, can affect the skin.4,6 Glove powders can be irritating
to the skin, like sand in your shoe. And the friction of donning
and removing gloves numerous times during the workday can
increase skin irritation.
HISTORICAL REVIEW
OF HAND HYGIENE
A number of historic events and discoveries that occurred in
the U.S. and Europe in the 1800s set the stage for our current
knowledge in microorganisms and disease processes.
1825 – Earliest paper on hand hygiene published. It
suggested that utilizing a liquid chlorine solution would
benefit healthcare workers.
1843 – Oliver Wendell Holmes (1809-1894) – His independent
work on spread of puerperal fever, The Contagiousness of
Puerperal Fever.
1847 – Ignaz Semmelweis (1818-1865) – work utilizing
chlorinated lime solutions for washing hands to decrease the
incidence of puerperal fever.
1865 – Louis Pasteur (1822–1895) – Germ Theory – explains
that germs can cause infectious diseases.
1867 – Joseph Lister (1827-1912) – Carbolic acid solution to
cleanse and dress wounds.
1878 – Robert Koch (1843-1910) – Utilizes steam sterilization
for surgical instruments and dressings.
1896 – William Halsted requests that a surgical glove be
made for his assistant.
Ignaz Semmelweis
Regulatory agencies and professional
organizations develop and refine hand hygiene
guidelines to meet patient and staff safety
needs.
1961 – U.S. Public Health Service – Recommended hand
washing prior to having patient contact.
1975 – CDC writes formal guidelines for handwashing.
1985 – CDC revises written guidelines for handwashing.
1987 – Universal Precautions/Standard Precautions
1988 – APIC guidelines for hand washing and hand
antisepsis.
1991 – Bloodborne Pathogens (BBP) Standard
1995 – APIC guidelines published with detailed discussion on
alcohol-based hand rubs
1995 and 1996 – HICPAC recommends antimicrobial soap or
waterless antiseptic agent for cleaning hands for multiple
drug-resistant organisms (MDRO)
2003 – CDC Recommended Infection Control Practices for
Dentistry Update
2016 – CDC Summary of Infection Prevention Practices in
Dental Settings: Basic Expectations for Safe Care
William Halsted
9
CLINICAL SKIN ISSUES
The healthy, intact condition of our skin is our best barrier
protection, but there are a number of factors in the healthcare
environment that affect the skin’s condition. The need to
perform hand hygiene activities throughout the day with
soaps, detergents, alcohol-based rubs and antimicrobials sets
the stage for local skin reactions. One of the most frequent is
irritant contact dermatitis (ICD) which is simply an irritation of
the skin and should not be confused with an allergy. Symptoms
can include redness, chapping, chafing, dryness, scaling,
cracking and subjective symptoms such as itching and burning.
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
In the CDC Guideline for Hand Hygiene in the Health-Care
Setting (2002) the reports of contact dermatitis are frequently
reported as an explanation for non-compliance by HCPs. An
HCP with an ICD is a potential threat to their patient and it is a
serious occupational issue. HCP skin disorders are the number
one occupational illness across all occupations and costs
$1 billion annually (Cantrell 2005).
An ICD is a surface condition affecting the skin. Avoiding
contact with the irritants, including glove powders, and
maintaining a regular regimen of proper skin care will help keep
hands healthier and free of irritation. Damaged skin more often
harbors increased numbers of pathogens. Moreover, washing
damaged skin is less effective at reducing numbers of bacteria
than washing normal skin, and the number of organisms shed
from damaged skin is often higher than from healthy skin.
Irritant contact dermatitis (ICD)
10
Moisturizing is beneficial for skin health and reducing microbial
dispersion from the skin. These are important concepts when
discussing hand washing techniques and products for hand
washing compliance and skin care.
Any of the antiseptic agents used in healthcare can cause ICD.
It is most commonly reported with iodophors, but chlorhexidine,
PCMX, triclosan and alcohol-based products can also cause
local skin reactions. Industry addresses this issue by its
continued improvement to products.
Today, chemical allergy, or allergic contact dermatitis (ACD),
remains an even more important cause of disability and loss
of work than latex allergy. A chemical allergy is an expansive
allergic condition; combined with ICD, these conditions
represent the second largest occupational disability reported
to U.S. OSHA.7 In Norway, one study discovered that 40% of
dentists suffer from occupational skin disorders. In a Belgian
study, researchers found that 32% of dental practitioners suffer
from job related skin disorders, while another study in Australia
revealed that 9-22% of those employed in dentistry suffer from
the same.8 Occupational contact dermatitis is the most common
occupational skin disease (OSD) in westernized industrial
countries – about 90-95% of all OSD (Lushniak 2000).
A survey of U.K. National Health Service (NHS) staff showed
that 43% had signs or symptoms of ICD or allergic ACD, and
10% showed latex hypersensitivity. (Johnson G.1997) In
addition, ACD brings a greater risk of bloodborne pathogen
infection, because the body’s most effective barrier – intact
skin – becomes compromised. The breakdown of the dermis
may also allow latex proteins to enter the body, which may
facilitate latex protein hypersensitivity in some individuals.7
Chemical allergies to glove products are generally associated
with the chemicals used in the glove manufacturing process.
A chemical allergy is due to an immunological reaction to a
residual chemical leached from finished glove products into
the skin of the wearer.
The chemicals used in the glove manufacturing process fall into
the following
broad classifications:
• Accelerators
• Accelerator activators
• Stabilizers
• Antidegradants
• Retarders
• Fillers
• Extenders
The chemical accelerators induce the majority of chemical
allergies. The residues from these accelerators have become
a major concern because of their ability to sensitize users and
elicit chemical allergic reactions. Over 80% of reported gloveassociated ACD is attributable to chemical accelerators.9
It is important to note that chemical allergy can occur from the
use of both latex and non-latex medical gloves as both types of
gloves are generally manufactured using accelerators.
These figures demonstrate that contact dermatitis—whether
irritant or allergic—is a significant issue for those providing
medical and technical services.
Chemical allergy reaction
11
HAND CARE OPTIONS
There is an abundant offering of hand care options in the
medical marketplace. For ease of discussion they are split into
two categories: hand hygiene products and skin care products.
Hand Hygiene Products – Products used in handwashing,
antiseptic handwash, antiseptic hand rub or surgical hand
antisepsis.
Skin Care Products – Products provided for hydration and
improved water retention of the skin.
HAND HYGIENE PRODUCTS
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
The primary consideration when selecting handwashing/
sanitizing products must be efficacy. Other factors include,
dermal tolerance, aesthetic preferences (fragrance, foaming,
color), costs, accessibility, and dispensing.
Handwashing products used by HCPs are regulated by
government agencies. There are specific test protocols,
procedures and log reductions that must be achieved for the
products to be available in the marketplace. This is also true of
surgical hand antisepsis products.
DENTAL SETTING
The following are some of the preparations used for hand
hygiene. These will vary pending government approval.
1. Plain (non-antimicrobial) soap
Soaps are detergent-based products that contain esterified
fatty acids and sodium or potassium hydroxide. They are
available in various forms including bar soap, tissue, leaflet, and
liquid or foaming preparations. Their cleaning activity can be
attributed to their detergent properties, which result in removal
of dirt, soil and various organic substances from the hands.
Plain soaps have minimal, if any, antimicrobial activity.
2. Alcohol
The majority of alcohol-based hand antiseptics contain either
isopropanol, ethanol, n-propanol, or a combination of two
of these products. Although n-propanol has been used in
alcohol-based hand rubs in parts of Europe for many years, it is
not listed in Tentative Final Monograph (TFM) as an approved
active agent for HCP handwashes or surgical hand-scrub
preparations in the U.S. A concentration of 60% or higher
is generally required for efficacy. Alcohols have excellent
in vitro germicidal activity against gram-positive and gramnegative vegetative bacteria, including multi-drug resistant
organisms (MDRO) (e.g., methicillin-resistant Staphylococcus
aureus (MRSA) and vancomycin-resistant enterococcus (VRE),
Mycobacterium tuberculosis, and various fungi). Alcohols
are not appropriate for use when hands are visibly dirty or
contaminated with proteinaceous materials. It is recommended
12
you wash your hands when visibility dirty. When hands are
not visibility dirty, alcohol hand rub is the preferred method of
decontaminating hands. Alcohols are effective for preoperative
cleaning of the hands of surgical personnel. Some products
have combined alcohol with antimicrobial products such as CHG
to increase efficacy.
3. Antimicrobial Handwash
•
•
since the 1800s. However, because iodine often causes
irritation and discoloring of skin, iodophors have largely
replaced iodine as the active ingredient in antiseptics.
Iodine and iodophors have bactericidal activity against
gram-positive, gram-negative, and certain spore-forming
bacteria (e.g., clostridia and Bacillus spp.) and are active
against mycobacteria, viruses and fungi.
Quaternary ammonium compounds. Of this large
group of compounds, alkyl benzalkonium chlorides are
the most widely used as antiseptics. Other compounds
that have been used as antiseptics include benzethonium
chloride, cetrimide, and cetylpyridium chloride. The
antimicrobial activity of these compounds was first
studied in the early 1900s, and a quaternary ammonium
compound for preoperative cleaning of surgeons’ hands
was used as early as 1935.
Triclosan is a colorless substance that was developed
in the 1960s. It has been incorporated into soaps for use
by HCPs and the public and into other consumer products.
Concentrations of 0.2%–2% have antimicrobial activity.
SKIN CARE PRODUCTS
Handwash preparations containing antimicrobial agent/s which
demonstrate efficacy against various microorganisms.
• Chlorhexidine gluconate, was developed in England
in the early 1950s and was introduced into the U.S. in the
1970s. Chlorhexidine gluconate has been incorporated
into a number of hand-hygiene preparations. Aqueous
or detergent formulations containing 0.5% or 0.75%
chlorhexidine are more effective than plain soap, but they
are less effective than antiseptic detergent preparations
containing 4% chlorhexidine gluconate (CDC). Preparations
with 2% chlorhexidine gluconate are slightly less effective
than those containing 4% chlorhexidine (CDC).
• Chlorhexidine has substantial residual activity and
often used as a surgical scrub. Chlorhexidine has a good
safety record with minimal, if any, absorption of the
compound through the skin. (CDC)
• Chloroxylenol, also known as
parachlorometaxylenol (PCMX), was developed
in Europe in the late 1920s and has been used in the
U.S. since the 1950s. PCMX is not as rapidly active as
chlorhexidine gluconate or iodophors, and its residual
activity is less pronounced than that observed with
chlorhexidine gluconate.
• Hexachlorophene was first used in the 1950s. Studies
of hexachlorophene as a hygienic handwash and surgical
scrub demonstrated only modest efficacy after a single
handwash. Hexachlorophene has residual activity for
several hours after use and gradually reduces bacterial
counts on hands after multiple uses.
• Iodines have been recognized as an effective antiseptic
One has only to look in any grocery store to see the number
of products available for skin care. These products do not
necessarily work well in the healthcare facility, but they do
find their way through the door. The products that should be
provided by the healthcare facility should meet the needs of
HCPs to help minimize ICD that may be associated with their
hand hygiene practices. Additionally, skin care products in
the healthcare environment must not negate the effects of
antimicrobial soaps and rubs used in the facility or compromise
glove barrier materials like latex. Hydrocarbon lotions that
contain petroleum, mineral oil or lanolin fall into this category
(Davis 2008). such products may affect the barrier property of
glove films and particularly latex.
Moisturizing and hydrating ingredients found in skin care
products may include the following:
• Glycerin is noted as being one of the best moisturizers.
It hydrates the dermis due to its water-retaining abilities.
• Citric acid is a pH adjuster that balances acidity
and alkalinity.
• Sorbitol is also used as a moisturizer.
• Gluconolactone helps minimize skin flaking.
• Chitosan helps to retain moisture.
• Panthenol is a vitamin with moisturizing effects.
13
HAND HYGIENE COMPLIANCE
Transmission of pathogens most often occurs via the
contaminated hands of HCPs. Hand hygiene (i.e., handwashing
with soap and water or use of a waterless, alcohol-based hand
rub) has been considered one of the most important infection
control measures for preventing HAIs. However, compliance
by healthcare professionals with recommended hand hygiene
procedures has remained unacceptable, with compliance rates
generally below 50% of hand hygiene opportunities. (CDC,
WHO, ECDC)
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
Alcohol-based hand rub use
Observed risk factors for poor adherence to recommended hand
hygiene practices*
• Physician status (rather than a nurse)
– Nursing assistant status (rather than a nurse)
– Male sex
• Working in an intensive-care unit
• Working during the week (versus the weekend)
• Wearing gowns/gloves
• Automated sink
• Activities with high risk of cross-transmission
• High number of opportunities for hand hygiene per hour of
patient care
Self-reported factors for poor adherence with hand hygiene*
• Handwashing agents cause irritation and dryness
• Sinks are inconveniently located/shortage of sinks
• Lack of soap and paper towels
• Often too busy/insufficient time
• Understaffing/overcrowding
• Patient needs take priority
• Hand hygiene interferes with healthcare worker
relationships with patients
14
•
•
•
•
•
•
•
Low risk of acquiring infections from patients
Wearing of gloves/belief that glove use obviates the
need for hand hygiene
Lack of knowledge of guidelines/protocols
Not thinking about it/forgetfulness
No role model among colleagues or superiors
Skepticism regarding the value of hand hygiene
Disagreement with the recommendations
Additional perceived barriers to appropriate hand hygiene*
• Lack of active participation in hand hygiene promotion
at individual or institutional level
• Lack of role model for hand hygiene
• Lack of institutional priority for hand hygiene
• Lack of administrative sanction of non-compliers/
rewarding compliers
• Lack of institutional safety climate
Members of ECDC
1. European Centre for Disease Prevention and Control, Stockholm
2. National Services Scotland, Edinburgh, United Kingdom
3. General Directorate of Health, Lisbon, Portugal
4. Health Protection Surveillance Centre, Dublin, Ireland
5. Ministry of Health, Youth and Sport, Paris, France
6. Mater Dei Hospital, Malta
7. Quality Agency, Ministry of Health and Consumer Affairs, Madrid, Spain
8. Norwegian Institute of Public Health, Oslo, Norway
9. Scientific Institute of Public Health, Brussels, Belgium
10. Ministry of Health, Nicosia, Cyprus
11. Regional Health and Social Agency, Infectious Risk Unit, Region
Emilia-Romagna, Bologna, Italy
12. Institute of Hygiene and Environmental Medicine, Berlin, Germany
* CDC Hand Hygiene Guidelines
13. Institute of Public Health, Bucharest, Romania
Recognizing a need to improve hand hygiene in healthcare
facilities, a number of organizations launched Guidelines
on Hand Hygiene in Healthcare. These global consensus
guidelines reinforce the need for multidimensional strategies
as the most effective approach to promote hand hygiene. Key
elements include staff education and motivation, adoption of
an alcohol-based hand rub as the primary method for hand
hygiene, use of performance indicators, and strong commitment
by all stakeholders, such as front-line staff, managers and
healthcare leaders, to improve hand hygiene.
14. National Centre for Nosocomial Infection, Sofia, Bulgaria
15. National Patient Safety Agency, London, United Kingdom
16. Health Directorate, Luxembourg
17. Hellenic Centre for Disease Control and Prevention, Athens, Greece
18. National Ministry of Health, Vienna, Austria
19. National Center for Epidemiology, Budapest, Hungary
20. University Medical Centre, Ljubljana, Slovenia
21. Stradins University Hospital, Riga, Latvia
2002 CDC Guideline for Hand Hygiene in Health-Care Settings
2003 National Patient Safety Standards
2005
World Health Organization (WHO) launched its Guidelines on Hand
Hygiene in Health Care (Advanced Draft) in October 2005
2006
Institute for Healthcare Improvement
– How To Guide: Improving Hand Hygiene
2008 Hand Hygiene Australia
22. Office for Public Health, Vaduz, Liechtenstein
23. Landspitali University Hospital, Reykjavik, Iceland
24. Jagiellonian University Medical College, Cracow, Poland
25. Central Military Hospital, Prague, Czech Republic
26. Statens Serum Institut, Copenhagen, Denmark
27. Health Protection Inspectorate of Estonia, Tallinn, Estonia
2000European Center for Disease Prevention and Control (ECDC)
2009
28. National Institute for Health and Welfare, Helsinki, Finland
2009
WHO re-launched their campaign as “Save Lives: Clean Your Hands”
30. Regional Public Health Authority, Trenčín, Slovakia
2013
Hand Hygiene Practices in Healthcare Settings, Public Health Agency
of Canada (PHAC) 2013
2014
Hand Hygiene Australia
2016
CDC Summary of Infection Prevention Practices in Dental Settings:
Basic Expectations for Safe Care
29. The National Board of Health and Welfare, Stockholm, Sweden
31. Institute of Hygiene, Vilnius, Lithuania
32. Radboud University Nijmegen Medical Centre and Canisius-Wilhelmina
Hospital, Department of Clinical Microbiology and Infectious Diseases,
Nijmegen, The Netherlands
15
Studies indicate sustained improvements in hand hygiene
are attainable through the application of broad, multimodal
programs that include a communications campaign, education,
leadership engagement, environmental modifications, team
performance measurement, and feedback. According to the
WHO, there is convincing evidence that good hand hygiene
practices lead to a reduction of infections caused by multidrug
resistant bacteria in health facilities. For example, when hand
hygiene compliance in health facilities increases from <60% to
90%, there can be a 24% reduction in MRSA acquisition.
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
It is important to understand when hand hygiene should
be practiced. A 2011 study published in Infection Control
and Hospital Epidemiology observed that the rate of HCPs
practicing hand hygiene when exam gloves were worn was
worse than when exam gloves were not worn. The chances of
hands being cleaned before or after patient contact appear to
be substantially lower if gloves were being worn10.
These findings reinforce the need to continue educating on the
importance of hand hygiene and when it should be practiced.
According to the 2016 CDC Summary of Infection Prevention
Practices in Dental Settings: Basic Expectations for Safe Care,
the following are key recommendations for hand hygiene in the
dental setting:
Wash hands:
• When hands are visibly soiled
• After barehanded touching of instruments, equipment,
materials, and other objects likely to be contaminated by
blood, saliva, or respiratory secretions
• Before and after treating each patient
• Before putting on gloves and again immediately after
removing gloves
Use soap and water when hands are visibly soiled (e.g., blood,
body fluids); otherwise, an alcohol-based hand rub may be
used.
16
17
MEDICAL GLOVES
Medical gloves are an important personal protective device
and should be worn during all patient care activities that may
involve exposure to blood and other bodily fluids, including
contact with mucus membranes and non-intact skin.
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
Medical gloves serve many purposes, including to help reduce
the risk of:
• Contamination of HCPs hands with blood and other
body fluids
• Pathogen dissemination to the environment
• Transmission from the HCP to the patient and vice versa,
as well as from one patient to another
Gloves should always be changed or removed:
• AFTER contact with blood or body fluids
• BEFORE seeing a new patient
• NEVER wear the same pair of gloves for the care of
more than one patient
• BETWEEN clean and contaminated sites on the
same patient
NEVER wash and reuse gloves since this practice has been
associated with transmission of pathogens.11,12
Unfortunately, glove misuse is regularly present in healthcare
facilities, and medical staff often fail to follow gloving best
practices, thus facilitating the spread of microorganisms.
Studies have demonstrated that HCPs acquire microorganisms
on gloved hands when touching contaminated surfaces, which
could result in transmission to patients. Bacterial contamination
of unused disposable gloves from recently open boxes has
also been demonstrated. The unwashed contaminated hand of
the HCP reaching into glove boxes has been identified as the
source.13
18
NEW INNOVATIONS &
NEXT GENERATION
MEDICAL GLOVES WITH ENHANCED SKIN
CARE PROPERTIES.
The newest innovations for HCPs have come in the form of
protective hand-healthy coatings applied to the inside of
surgical and examination gloves. These coatings offer specific
benefits to retain moisture and rehydrate skin, despite the
negative effects of continual glove-wearing and frequent
contact with anti-bacterial handwashing products. Glycerin
is found in numerous skin care lotions and has made the
transition into a coating for gloves in healthcare. Glycerin is
a skin-friendly humectant moisturizer that penetrates into
the stratum corneum, where it attracts and retains water.
Dimethicone used for decades to protect the skin of babies
from diaper rash, is also being incorporated as a coating inside
examination gloves. Dimethicone, forms a protective barrier
that blocks attack from foreign substances and prevents the
skin from drying out has also been utilized in glove coatings.
There is a “Dry Skin Model” (Dermatology Foundation) that
describes the path to dry skin and further describes that if there
are interventions along this path then this cycle can be broken.
Prudent use of proper skin care products and gloves enhanced
with skin care ingredients may be of significant help, especially
to those HCPs who have skin prone to drying.
ANTIMICROBIAL MEDICAL GLOVES
New innovations are being explored to make medical gloves
safer, reducing the risk of surface contamination and ease
of use for HCPs. A new breed of examination gloves is being
equipped with antibacterial coating on its external surface that
reduces the risk of bacterial cross-contamination following
glove contact with patients and surfaces by HCPs.
A research article published in Antimicrobial Resistance and
Infection Control 2013, demonstrated that an antibacterial
examination glove coated on its outside surface with
polyhexanide (PHMB), was able to reduce cross-contamination
by > 4 log10, compared to a control non-coated examination
glove. The results are encouraging and bolster further
clinical investigation on the impact of an antibacterial
examination glove.14
Petrie Dish
Bacterial Growth
No Bacterial Growth
Additionally, surgical gloves coated on the internal surface with
a topical antimicrobial known as chlorhexidine gluconate (CHG)
demonstrated the ability to reduce the microbial growth on the
hands of the wearer. (Reitzel 2009)
The science of this antimicrobial technology is both
theoretically and practically sound and has the potential
to prevent microbial transmission in conjunction with good
hand hygiene.
19
SUMMARY
As the body’s largest organ, the skin serves as a waterproof
covering that prevents excessive loss or gain of bodily moisture,
provides a barrier against invasion by outside organisms that
helps keep out disease causing pathogens (bacteria, viruses,
fungi). The skin protects underlying tissues and organs from
abrasion and other injury, and its pigments shield the body from
the dangerous ultraviolet rays in sunlight.
HAND HYGIENE –
SKIN AND HAND
CARE IN THE
DENTAL SETTING
20
HCPs have a high prevalence of skin irritation because of the
need for frequent hand washing during patient care. Hand
problems associated with the hand hygiene of HCPs is due to
a combination of damaging factors: (1) the removal of barrier
lipids by detergent cleaning and alcohol antisepsis followed
by a loss of moisturizers and stratum corneum water and (2)
the over hydration of the stratum corneum by sweat trapped
within gloves. Together they facilitate the invasion of irritants
and allergens which elicit inflammatory responses in the
dermis.
Ways to minimize adverse effects of hand hygiene include
selecting less irritating products, using skin moisturizers,
and modifying certain hand hygiene practices such as
unnecessary washing. Institutions need to consider several
factors when selecting hand hygiene products: dermal
tolerance and aesthetic preferences of users as well as
practical considerations such as convenience, storage,
and costs. (E. Larson)
GLOSSARY
ACCELERATORS
KERATINOCYTE
A substance that increases the rate of a chemical reaction
The predominant cell type in the epidermis, the outermost layer
of the skin, constituting 90% of the cells found there.
ADIPOCYTES
PIGMENT
Also known as lipocytes and fat cells, are the cells that
primarily compose adipose tissue, specialized in storing
energy as fat
In biology, a pigment is any colored material found in plant or
animal cells. Many biological structures, such as skin, eyes, fur
and hair contain pigments (such as melanin).
ANTI-DEGRADANT, OR
DETERIORATION INHIBITOR
MACROPHAGES
Is an ingredient in rubber compounds
EPITHELIUM
Is one of the four basic types of animal tissue, along with
connective tissue, muscle tissue and nervous tissue. Epithelial
tissues line the cavities and surfaces of structures throughout
the body. Many glands are made up of epithelial cells. Functions
of epithelial cells include secretion, selective absorption,
protection, trans-cellular transport and detection of sensation.
ENZYMES
Enzymes are macromolecular biological catalysts which are
responsible for thousands of metabolic processes that sustain
life. They are highly selective catalysts, greatly accelerating
both the rate and specificity of metabolic reactions, from the
digestion of food to the synthesis of DNA. Most enzymes
are proteins, although some catalytic RNA molecules have
been identified. Enzymes adopt a specific three-dimensional
structure, and may employ organic (e.g. biotin) and inorganic
(e.g. magnesium ion) cofactors to assist in catalysis.
FIBROBLAST
A type of cell that synthesizes the extracellular matrix and
collagen and plays a critical role in wound healing.
Are a type of white blood cell that engulf and digest cellular
debris, foreign substances, microbes, and cancer cells in a
process called phagocytosis.
MELANOCYTES
Melanin-producing cells located in the bottom layer (the
stratum basale) of the skin’s epidermis, the middle layer of the
eye (the uvea), the inner ear, meninges, bones, and heart.
MERKEL OR MERKEL-RANVIER CELLS
Oval receptor cells found in the skin of vertebrates that have
synaptic contacts with somato-sensory afferents. They are
associated with the sense of light touch discrimination of
shapes and textures. They can turn malignant and form the skin
tumor known as Merkel cell carcinoma.
POLYHEXANIDE
(polyhexamethylene biguanide, PHMB)
A polymer used as a disinfectant and antiseptic. Some products
containing PHMB are used for inter-operative irrigation, preand post-surgery skin and mucous membrane disinfection, postoperative dressings, surgical and non-surgical wound dressings,
surgical bath/hydrotherapy, chronic wounds like diabetic foot
ulcer and burn wound management, routine antisepsis during
minor incisions, catheterization, first aid, surface disinfection,
and linen disinfection.
LANGERHANS CELL
Langerhans cells are dendritic cells (antigen-presenting immune
cells) of the skin and mucosa. They are present in all layers of
the epidermis, but are most prominent in the stratum spinosum.
They are named after Paul Langerhans, a German physician and
anatomist, who discovered the cells at the age of 21 while he
was a medical student.
21
BIBLIOGRAPHY
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Cook D, Rubbed the Wrong Way, Outpatient Surgery, Nov 2006;32-38.
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SKIN AND HAND
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Antimicrobial Resistance and Infection Control 2013, 2:27. *
* Some of the authors listed above are employees of Ansell.
23
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