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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Resident Micro
Staphylococcus epidermidis
micrococcimicrococci
diphtherroids
anaerobic cocci
propionibacteria
Resident Micro-organisms
Staphylococcus epidermidis

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. Transient micro
Staphylococcus aureus
Streptococci
Gram-negative bacilli including
Escherichia coli
Pseudomonas
Viruses
Transient micro-organisms
Staphylococcus aureus
negative bacilli including

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. 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. 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. 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. 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. 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. 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. 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. Handwashing Agents
Soap and Water
Antiseptic handwashes and water
Alcohol hand-rubs
Handwashing Agents
Soap and Water
Antiseptic handwashes and water
rubs

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. Active Ingredients in Antimicrobial Agents
- alcohols
- iodophors
- chlorhexidine gluconate
- triclosan
- chloroxylenol (pcmx)
- hexachlorophene
Active Ingredients in Antimicrobial Agents
chlorhexidine gluconate
chloroxylenol (pcmx)
hexachlorophene

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. “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. 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. 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. 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. 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. 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. 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