شستشوی دست و کنترل عفونت در آی سی یو
Wash Your Hands
Sandra Swoboda MSN
â€œWash your hands!â€ Most health care providers have heard these simple words over and over again their entire livesâ€”whether from their mother in childhood or at work from infection-control colleagues. Despite the fact that this simple action decreases nosocomial infection and constitutes only a fraction of a provider's day, compliance with hand hygiene is dismal. Alarmingly the intensive care unit (ICU) is associated with the lowest overall hand-hygiene compliance rates (about 50%) in the hospital, despite the fact that the need for frequent and effective hand hygiene is paramount. The consequences of poor hand hygiene are uniformly injurious and contribute to nosocomial infections that are an important source of morbidity and mortality in patients. On average, infections can complicate 8% to 10% of all hospital admissions; infection rates in the ICU occur at an even increased incidence. Studies have shown that as hand-hygiene rates improve, nosocomial infection rates go down. Reasons associated with poor compliance for proper hand hygiene include higher professional status; reluctance to experience skin irritation; poor access to supplies; â€œbeing too busy;â€ inattention to existing protocols; and the wearing of gloves (which is thought to â€œnegateâ€ the need for hand hygiene).
To briefly review, hand hygiene encompasses both hand washing with soap and water and hand rubbing with waterless alcohol-based solutions. Many health care workers falsely believe that traditional hand washing is both more efficacious and gentle on the skin. However, alcohol-based solutions are microbiologically superior, gentler on skin with less disruption to the skin's lipid layers, and more likely to be used correctly when compared with soap-and-water washing.
Some common definitions pertaining to hand hygiene are as follows:
- Hand hygiene: hand washing, antiseptic hand wash, antiseptic hand rub, surgical hand antisepsis
- Hand washing: washing hands with plain (nonantimicrobial) soap and water
- Hand antisepsis: antiseptic hand wash or antiseptic hand rub
- Antiseptic hand wash: washing hands with soap and water or detergents containing an antiseptic agent
- Antiseptic hand rub: application of waterless antiseptic agent to hands. Does not require the use of water (alcohol-based product)
The Centers for Disease Control and Prevention (CDC) guidelines for hand hygiene in the health care setting suggest the following:
- If hands are visibly dirty or contaminated or soiled with blood or other body fluids, wash hands with nonantimicrobial soap and water or an antimicrobial soap and water.
- If hands are not visibly soiled, use a waterless antiseptic agent (an alcohol-based hand rub) for routine decontamination.
- Perform hand hygiene after touching blood, body fluids, secretions, excretions, and contaminated items, whether or not gloves are worn. Perform hygiene immediately after gloves are removed, between patient contacts, and when otherwise indicated to avoid transfer of micro-organisms to other patients or environments. It may be necessary to perform hand hygiene between tasks and procedures on the same patient to prevent cross-contamination of different body sites.
Listed below are some of the â€œnasty bugsâ€ that surround patients in the ICU and procedures for performing hand hygiene when providers are exposed to them.
Methicillin-Resistant Staphylococcus Aureus (MRSA)
Staphylococcus aureus is a common bacterium found on the skin, and strains that are resistant to methicillin are becoming increasingly common. MRSA can be present in the nose, on the skin, or in the blood or urine and is spread through physical contact. MRSA is transferred to patients by the hands of health care workers who have been contaminated by contact with patients, surfaces in the workplace, or medical devices. This organism can survive for an hour or more on environmental surfaces such as floors, sinks, and blood-pressure cuffs. Hand hygiene with waterless antiseptic agents is recommended.
Vancomycin-Resistant Enterococci (VRE)
There are two common clinical isolates of enterococci that are resistant to vancomycin (Enterococcus faecalis and Enterococcus faecium). These strains can survive for 60 minutes on gloved and ungloved fingers. E. faecalis has been recovered on countertops for up to 5 days and E. faecium for 7 days. Both can survive on bedrails for up to 24 hours;
for 60 minutes on a telephone receiver; and for 30 minutes on the diaphragm of a stethoscope. VRE can be spread person to person by the hands of health care workers or in directly on contaminated environmental surfaces and patient care equipment. Hand hygiene with waterless antiseptic agents is recommended.
Clostridium difficile (C. difficile) is a spore-forming, Gram-positive anaerobic bacillus that produces two endotoxins: endotoxin A and endotoxin B. It accounts for 15% to 25% of all episodes of antibiotic-associated diarrhea. It is shed in feces and any surface, device, or material (bedpan, toilet, thermometer, bedside commode, equipment, bedrails, etc.) that is contaminated with feces serves as a reservoir. Spores are transferred to patients by the hands of health care workers who have touched the contaminated skin of a patient, a contaminated surface, or a contaminated piece of equipment.
Alcohol-based products are not effective against this spore-forming bacterium; thus the use of nonantimicrobial soap and water or antimicrobial soap and water, which helps to physically remove spores from the surface of contaminated hands, is required. This is indicated especially in an outbreak situation.
Bacillus Anthracis (Anthrax)
Bacillus anthracis is a spore-forming bacterium. It is most commonly found in the wild in cattle, sheep, goats, camels, antelopes, and other herbivores. However, it can also occur in humans when they are exposed to infected animals or tissue from infected animals.
Alcohol-based products do not have activity against this spore so hands must be washed with either antimicrobial or nonantimicrobial soap and water.
Acinetobacter is a group of Gram-negative bacteria that is commonly found in soil and water. It can also be found on the skin of healthy people, especially health care workers. While there are many types or species of Acinetobacter and all can cause human disease, infections with Acinetobacter are fortunately not common. Acinetobacter baumannii is a waterborne organism that is sensitive to few antibiotics. This multiresistant pathogen is often cultured from patient sputum, respiratory secretions, wounds, and urine. It has also been found in irrigating
solutions. Outbreaks typically occur in ICUs and this organism can be spread by person-to-person contact, contact with contaminated surfaces, or environmental exposure. It can live on the skin and survive on environmental surfaces for several days. Use of alcohol-based hand rub between and before patient and equipment contact has been shown to decrease transmission during outbreaks.