include "_nav_tab.php";Hand hygiene is the front line of defense against nosocomial infections, which affect more than 2 million patients each year. Unfortunately, non-compliance with hand washing is a common problem in many facilities. Nurses say they wash their hands up to three times more often than they actually do,[1] and one report showed that doctors washed their hands just 9 percent of the time before patient contact, even though they estimated their hand-washing frequency at 73 percent.[2] In addition, when they do wash or scrub, many clinicians unknowingly use improper procedure. There are many reasons for this, including growing demands on practitioners, forgetfulness and skin irritation that can result from repeated hand washing. This 18-question quiz will help you review the basics of good hand hygiene.

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1. The most pathogenic type of bacteria found on the hands is typically
echo" Answer: ".strtoupper("b) Transient flora")."
"; There are two major types of bacteria on the skin: Resident flora and transient flora. Resident flora are typically not pathogenic, whereas transient flora cause most hospital infections that result from cross-contamination. Proper hand washing, however, easily removes transient flora. Some practitioners believe that hand washing is less important in the outpatient environment, since nosocomial infections are more common in the hospital setting where patients tend to be more vulnerable to infection. In every healthcare setting, however, there is potential for surgical site infections and deadly bacterial outbreaks; and good hand hygiene practices are essential for protecting patients and practitioners alike. In fact, improved adherence to hand hygiene can reduce transmission of antimicrobial resistant organisms (e.g., methicillin-resistant Staphylococcus aureus), terminate outbreaks in facilities, and reduce overall infection rates.[3-5] In one study, good hand washing initiatives cut hospital-acquired infections by about half.[6]

2. Pathogens can be transferred to practitioners' hands from:
echo" Answer: ".strtoupper("e) all of the above")."
"; Practitioners can contaminate their hands with pathogens while performing clean activities like taking vital signs; touching a patient's hand, shoulder or groin; performing "clean procedures;" and touching colonized inanimate objects. In one study, nurses who palpated the femoral pulse of a patient with intact, moist skin heavily colonized with pathogenic bacteria transferred the bacteria to urinary catheters, even after washing their hands with soap and water or using an alcohol hand rinse.[7] Pathogenic colonization on patients' skin is typically heaviest near the perineal or inguinal areas, but colonization also occurs frequently on the axillae, trunk and upper extremities (including hands). The bacterial load, however, can vary dramatically from person to person. Skin tends to be colonized with typical skin flora (S. aureus, Proteus mirabilis, Klebsiella, Acinetobacter, for example), although patients with diabetes and those with chronic dermatitis are more likely to have S. aureus colonization. Inanimate objects, on the other hand, are more likely to be contaminated with staphylococci or enterococci from patients' flora because these pathogens are more resistant to desiccation.

3. It is important for healthcare workers to have healthy, intact skin because:
echo" Answer: ".strtoupper("e) all of the above")."
"; Healthy, intact skin is an important defense against cross contamination, as the epidermis acts as a major barrier to pathogenic bacteria. When skin is damaged, its ability to act as a barrier is compromised. The normal flora change, and damaged skin tends to harbor and shed more pathogens (namely, staphylococci and gram-negative bacilli) than intact skin. In addition, hand washing is less effective when skin is damaged; that is, the bacterial load tends to remain higher on damaged skin, even after hand washing. Unfortunately, repeated hand washing itself can be the cause of chronic skin damage, such as irritant contact dermatitis, eczema and compromised resident flora; so the choice of soap or antiseptic formula-as well as the hand washing procedure-are critical to maintaining skin integrity.

4. In the healthcare setting, there are three basic approaches to hand hygiene: hand washing, hand antisepsis, and surgical hand scrubbing. The primary intent of hand washing is to:
echo" Answer: ".strtoupper("a) Remove visible dirt, contaminants, and/or bodily fluids while reducing transient organisms")."
"; Hand washing is the process of using a non-antimicrobial or antimicrobial soap with water to cleanse the hands. Both non-antimicrobial and antimicrobial soaps will remove physical dirt as well as some transient organisms. However, many facilities simply use an antimicrobial soap for all hand washing indications to help reduce transient organisms.

5. Hand antisepsis is intended to:
echo" Answer: ".strtoupper("b) Remove or destroy transient organisms")."
"; The aim of hand antisepsis is to remove or destroy transient microorganisms. To do so, you must use either an antimicrobial soap or an alcohol-based hand rub.

6. Surgical scrubbing is intended to:
echo" Answer: ".strtoupper("e) all of the above")."
"; The primary goal of surgical scrubbing is to remove visible dirt, contaminants, and bioburden (such as when an operation is completed or when there is a hole in a glove), remove or destroy transient organisms and reduce resident flora.

7. It is necessary to perform a 'soap-and-water' hand wash:
echo" Answer: ".strtoupper("f) all of the above")."
"; Experts agree that hand washing is necessary whenever hands are visibly dirty or contaminated with proteinaceous material, or when they are visibly soiled with blood or other bodily fluids. The current Centers for Disease Control and Prevention (CDC) Guideline for Hand Hygiene in Healthcare Settings also recommend hand washing before eating and after using a restroom. While not all guidelines recommend hand washing upon arrival to and departure from work, this is a wise practice. Doing so will ensure that you do not introduce new pathogens into the facility or transport pathogens out of the facility.

8. According to most hand hygiene recommendations, it is necessary to perform hand antisepsis:
echo" Answer: ".strtoupper("g) all of the above")."
"; Each of these situations increases the risk of cross contamination, rendering it necessary to perform some type of hand antisepsis (i.e., either antimicrobial soap and water or an alcohol-based hand rub). Do not allow gloves to lull you into a false sense of security. Gloves do not eliminate the need for hand hygiene, nor do good hand hygiene practices obviate the need for gloves. While gloves reduce hand contamination significantly (by 70 to 80 percent), they do not provide 100 percent protection against bacterial transmission. Pathogens can pass through both vinyl and latex gloves. In addition, accidents such as punctures and tears can occur.

9. When should you apply soap during a 'soap-and-water' hand antisepsis or hand wash?
echo" Answer: ".strtoupper("b) After wetting hands")."
"; When you apply soap to dry hands, the soap imbeds into the pores of the skin. When this occurs, water cannot get under the soap to dilute it, leaving a soapy residue even after thorough rinsing. This residue can cause the skin breakdown, which in turn increases the potential for bacterial colonization and shedding. Detergents, in particular, break down the outermost layer of the skin (stratum corneum) by altering lipids and inhibiting the cells' ability to cohere and bind to water. It is essential to wet hands before applying any hand hygiene agent.

10. What temperature should water be during a 'soap-and-water' hand antisepsis or hand wash?
echo" Answer: ".strtoupper("b) Warm")."
"; It is difficult to recommend an exact water temperature, but experts agree that you should use warm water. Repeated exposure to hot water removes protective oils from the skin and can cause drying and breakdown. Hot water is also uncomfortable and can therefore shorten wash time. Water that is too cold can inhibit lathering.

11. For how long should you rub your hands together during a 'soap-and-water' hand antisepsis?
echo" Answer: ".strtoupper("c) 15 seconds")."
"; The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and the CDC recommend rubbing hands together vigorously for 15 seconds, covering and generating friction on all surfaces of the hands and fingers. This is about how long it takes to sing the "happy birthday" song. You should also dry hands thoroughly with a disposable towel, as leaving them partially wet can cause chapping and skin breakdown. When using an alcohol-based hand rub for hand antisepsis, continue rubbing until your hands are dry.

12. Clinical studies show that surgical hand scrubs that most effectively reduce bacterial counts on the skin all contain the following ingredient:
echo" Answer: ".strtoupper("b) Alcohol ")."
"; Research shows that formulations containing 60 to 95 percent alcohol alone - or as little as 50 percent alcohol combined with small amounts of a quaternary ammonium compound, hexachlorophene (HCP) or chlorhexidine gluconate (CHG) - have the quickest and most thorough antimicrobial action. According to the CDC hand hygiene guidelines, the next most effective agents (in order of effectiveness) are: CHG, iodophors, triclosan and plain soap. The jury is still out on PCMX, as study results are inconsistent. According to the FDA, only surgical scrub products containing alcohol or povidone iodine have enough supporting data to qualify them as safe and effective. Although alcohol-based products have been common in European healthcare settings for some time, they are only now gaining some popularity in the United States, thanks to the recent CDC guidelines. The most popular surgical scrub formulations in the United States have been those containing povidone iodine, CHG, or PCMX. Practitioners typically reserve HCP- and triclosan-containing products for practitioners with skin sensitivity to the more widely used products. The major concerns about alcohol are that it is drying to skin, does not have significant 'detergency' for removing organic debris, and does not have a lasting antimicrobial effect (antimicrobial persistence). According to APIC, however, persistence may be less important with alcohol-based formulations because they reduce bacterial counts to such a low level that it takes several hours for the normal flora to regrow to pre-scrub levels. In addition, according to the CDC guidelines, hand lotions and creams can prevent alcohol-induced irritant contact dermatitis. In fact, according to the guidelines, adding 1 to 3 percent glycerol or other skin-conditioning agent can reduce or eliminate the drying effect of alcohol; and recent studies show that alcohol-based rinses or gels containing emollients caused less skin irritation and dryness than even the soaps or antimicrobial detergents tested. Alcohol is also flammable and requires special storage.

13. In addition to antibacterial potency, what other factors are important to consider when evaluating the efficacy of surgical hand scrubs?
echo" Answer: ".strtoupper("e) All of the above")."
"; All of these factors are important to consider when evaluating the efficacy of a surgical hand scrub. Here is an easy-reference overview of how each ingredient you may find in a hand-hygiene antiseptic formulation performs:

14. To be as effective as possible, the pre-op surgical scrub should last at least:
echo" Answer: ".strtoupper("c) 2 to 6 minutes")."
"; Traditionally, OR staffers scrubbed for 10 minutes before surgery. However, this can cause skin breakdown, and research shows that 5 minutes or less is sufficient. In fact, researchers have shown that scrubbing for as little as 2 to 3 minutes with an alcohol-based product effectively reduces bacterial counts. As a result, experts typically recommend scrubbing for 2 to 6 minutes, depending on the formula and manufacturer's recommendations.

15. While performing a surgical hand scrub, the following aide(s) help remove pathogens:
echo" Answer: ".strtoupper("c) A device for removing debris under fingernails")."
"; Recent research shows that the long-held practice of scrubbing with a brush tends to damage skin and thereby increases bacterial colonization and shedding. Although many practitioners still prefer to use a sponge to ensure good friction, recent data strongly support scrubbing without the aid of a brush or a sponge, especially when using an alcohol-based product.8 During surgical scrubbing, however, it is important to thoroughly clean under the nails. This is especially true for the first scrub of the day. Studies show that the subungual areas of the hand, even after scrubbing or hand washing, harbor high concentrations of bacteria-namely, coagulase-negative staphylococci, gram-negative rods, corynebacteria and yeasts.

16. According to the new CDC hand hygiene guidelines, alcohol-based hand rubs can take the place of the traditional hand scrub provided you:
echo" Answer: ".strtoupper("e) all of the above")."
"; The CDC guidelines support the use of alcohol-based hand rubs for surgical scrubbing provided you follow these three important steps. Studies suggest that these rubs may be relatively well tolerated, since they do not require water and typically contain emollients, humectants, or other skin-conditioning agents. However, use caution until more data are available; the guidelines clearly note that efficacy data for these rubs are limited and that the different formulations (gels, rinses, foams) may perform differently. According to the CDC guidelines, studies indicate that an initial 1- or 2-minute scrub with 4 percent CHG or povidone-iodine followed by application of an alcohol-based product is as effective as a 5-minute scrub with an antiseptic detergent.

17. When selecting hand hygiene formulations, you should evaluate them for efficacy as well as:
echo" Answer: ".strtoupper("f) all of the above")."
"; Beyond efficacy, the criteria for selecting hand-hygiene products can be very subjective. Practitioners tend to prefer these products based on smell, feel, consistency and color. Objective criteria should include the time needed for alcohol rubs to dry, skin integrity after use (both initially and long term), dispensing methods and cost. To help measure product performance, you should create written assessment measures before conducting a facility-wide evaluation. It is essential to allow everyone who will use the products evaluate them, as acceptance is key to hand hygiene compliance. It is also important to perform a follow-up assessment once you use a product for some time (3 to 6 months after implementation, for example).

18. What are the best ways to reduce the irritating effects of hand hygiene agents?
echo" Answer: ".strtoupper("e) both c & d")."
"; To reduce skin irritation, offer products that contain moisturizers and offer hand lotions or creams, and teach personnel how and why to use them. Importantly, select hand creams that will not threaten the integrity of rubber gloves or hinder the efficacy of antiseptic agents that you use. For example, do not use petroleum-based moisturizers with latex gloves or anionic moisturizers in combination with CHG hand washing agents. It also makes sense to use less irritating soaps and antiseptic formulas whenever possible. In addition, the CDC guidelines caution against barrier creams, which are marketed for preventing hand-hygiene-related irritant contact dermatitis. These creams do not yield better results than standard lotions or creams and may alter the integrity of rubber gloves. Do not use non-antimicrobial soaps for routine hand washing in an effort to reduce skin irritation. According to the CDC guidelines, studies indicate that these soaps can cause greater irritation and dryness than antiseptic preparations. Finally, do not reduce exposure to hand hygiene products in an attempt to alleviate skin irritation problems. Rather, given that good hand hygiene is essential in the fight against infection, make hand washing and antiseptic agents and sinks readily available, and use other methods to help reduce skin problems. Multifaceted approaches combining education, written materials, reminders and continued feedback have the most marked and durable effect on product acceptance and hand hygiene compliance.

References
1. O'Boyle CA, Henly SJ, Duckett LJ. Nurses' motivation to wash their hands: a standardized measurement approach. Appl Nurs Res. 2001;14(3):136-45.
2. Bandolier Journal. Internet journal for evidence-based healthcare. http://www.jr2.ox.ac.uk/bandolier/band67/b67-3.html.
3. Doebelling BN, et al. Comparative efficacy of alternative hand-washing agents in reducing nosocomial infections in intensive care units. New Engl J Med. 1992;327: 88-93.
4. Stone SP, et al. The effect of an enhanced infection-control policy on the incidence of Clostridium difficile infection and methicillin-resistant Staphylococcus aureus colonization in acute elderly medical patients. Age and Aging. 1998;27:561-568.
5. Pittet D, et al. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Internal Med. 1999;159:821-6.
6. Pittet D, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356:1307-1312.
7. Ehrenkranz NJ, Alfonso BC. Failure of bland soap handwash to prevent hand transfer of patient bacteria to urethral catheters. Infect Control Hosp Epidem. 1991;12:654-62.