CorrectCare

Hand Hygiene: Can We Learn a Lesson From the OR?
By Peter Graves, RN, BSN, CNOR

Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus have become alarmingly common in correctional facilities. Clostridium difficile looms as a potential threat, while others could be lurking in the wings. The risk of transmission and exposure may extend well beyond correctional workers and inmates. Bacteria can be brought home on the hands and clothing of the correctional health care worker, by visitors and by inmates upon release or transfer.

The Centers for Disease Control and Prevention states that the single most important method to reduce the risk of cross-contamination and infection is good hand hygiene. Proper hygiene interrupts the chain of infection and reduces the potential for transmission of infectious agents from the hands of a health care worker. One can never render the skin sterile, but proper hygiene can reduce bacterial counts.

On first glance it seems quite simple, but routine proper performance of hand hygiene is no easy task. In hospitals, where antimicrobial soap, water and waterless hand antiseptics are readily available, hand hygiene compliance has been reported to be surprisingly low. One study found only 48% compliance in a university teaching hospital.

Correctional facilities face even greater impediments, including physical barriers, security and lack of washing facilities. Yet, proper hand hygiene in correctional settings is vital to preventing infections. It must be the cornerstone of every facility’s infection control plan.

So the questions that beg asking in corrections are:
• Does hand hygiene occur with adequate frequency?
• Do the chosen hand hygiene agents have the qualities necessary to disinfect correctional health care providers’ hands?

Back to Basics
To better understand why hand hygiene is so important, we must understand some of the basics, starting with the skin.

Skin is our largest organ and serves many roles, one of which is protection. The outer layer is called the stratum corneum. It consists of several layers of cells, layered like loose stonework, which provides an ideal structure and location for bacteria, often called colonizing bacteria, to reside and reproduce.

Bacteria on the skin are classified as either transient or resident. Transient bacteria, such as S. aureus, exist on the surface and are more easily removed or killed with hand hygiene. Resident bacteria reside in the deeper layers and are difficult to remove. Soap (plain or antimicrobial), water and a friction source (e.g., opposing hand) or a waterless antiseptic (alcohol or a combination of alcohol plus an active agent) hand rub are used to remove and/or kill the transient bacteria and as many resident bacteria as possible.

Germs can be passed between people and objects by direct and indirect contact. Hands can become contaminated with bacteria, viruses and soils during normal activities such as unlocking doors or typing on a keyboard, as well as physical contact.

A recent study found that for every 1,000 hospital admissions, 46 patients were infected or colonized with MRSA. This rate is about 10 times greater than previous findings. Are correctional facilities cleaner than hospitals? Anecdotal data indicates that the MRSA infection/colonization rate among inmates probably exceeds that in hospitals.

Clearly, it is important to break the chain of infection. When an opportunity for hand hygiene is missed or it is done improperly, bacteria and soils can be left on the skin. All it takes is a break in the skin for those germs to penetrate the body’s protective system. They only need an opportunity to cause an infection or to be transferred.

Simple Prevention
Routinely washing the hands when gloves are removed or when hands become soiled will increase hand hygiene frequency compared with the current norm. The Association of Professionals in Infection Control and Epidemiology states that gloves should not be a substitute for hand washing.

There are several cleansing agents from which to choose. One obvious choice is plain soap and water. This is recommended when hands are visibly soiled and when persistence and cumulative effect are not important. When the stakes are higher, additional active agents should be considered.

One of the most important ways we can prevent health-care-associated infections is to choose and use hand hygiene products wisely. The Association of periOperative Registered Nurses recommends that hand antiseptics used in surgery be broad spectrum, fast acting, nonirritating and have a residual effect. While most hand hygiene agents do not garner as much attention as surgical antiseptics, it is important to learn the lessons of their use.

In correctional health care, the ideal agent is one that has persistence, cumulative effect and residual kill against bacteria (see box above). These qualities are critical to reducing and keeping bacterial counts in check. The product also should enhance the skin’s natural protection.

Persistence can inhibit regrowth of bacteria even after the hands are dry and while gloves are worn. Cumulative effect means that when an antimicrobial agent is used repeatedly over time, the bacterial count is progressively reduced. By the end of the workweek, the count will be lower than at the start. This reduction may help enhance the skin’s natural ability to defend against transient bacteria.

Look for a product that has of all these attributes, plus the ability to kill microbes residually. Residual kill is often the missing element by which a product gives added protection long after use.

Workers in high-risk environments, such as correctional facilities, also should seek antimicrobial agents with a broad spectrum of activity. A broad-spectrum agent will kill a wide array of microorganisms.

Compliance Is Essential
When should one perform hand hygiene in correctional facilities? In a word, frequently! The longer answer is whenever there is contact with a potentially contaminated individual or surface. But does this really happen? Unfortunately, it does not. To increase compliance, there must be a greater focus on education and performance of all staff in the health care setting.

Understandably, access to hand washing facilities can be difficult in correctional settings. Furthermore, the use of waterless, alcohol-based agents may be restricted facilitywide due to safety, health and inmate welfare concerns. But hand wipes with a combination of alcohol and CHG (chlorhexidine gluconate) could be individually dispensed and used by health and corrections staff in situations where access and security issues are barriers (e.g., towers, corridors, exercise areas).

Correctional facilities should evaluate hand hygiene antiseptic agents for their persistence, acceptability to staff, dispenser system, portability, etc. While cost cannot be ignored, it should not be the primary factor. The goal is not to save money by buying less expensive products; it is for all staff to increase compliance by using them frequently due to good end-user acceptance.

In the long term, programs that reduce infection rates may pay for themselves by reducing medical expenses and employee down time. Ponder the treatment costs for one MRSA infection. Prevention of one infection would likely more than offset the cost of hand hygiene.

— About the author: Peter Graves, RN, BSN, CNOR, is a senior clinical nurse consultant with Mölnlycke Health Care US, Norcross, GA. Reach him by e-mail at peter.graves@molnlycke.com.

[This article first appeared in the Summer 2007 issue of CorrectCare.]