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Centers for Disease Control Recommendations for Hand Hygiene

in Health Care Settings (edited for long-term care)1

1. Indications for hand washing and hand antisepsis

Ideal Product Placement:

A. Wash hands with either a non-antimicrobial soap and water or an

antimicrobial soap and water,

- Alcohol-based hand rub dispenser inside each resident room (Hallway

dispensers between resident rooms are too far from the point of contact
inside the resident rooms to be highly effective)

When hands are visibly dirty or contaminated with proteinaceous

material or are visibly soiled with blood or other body fluids.

- Mild, non-antibacterial hand wash in resident bathrooms

Before eating and after using a restroom.

B. If hands are not visibly soiled, use an alcohol-based hand rub for
routinely decontaminating hands in following clinical situations (Preferred):

Alternate Product Placement:

(where alcohol-based hand rub is not inside each resident room:)

1. Before having direct contact with residents.

- Mild, efficacious anti-bacterial hand wash at each resident sink

2. Before donning sterile gloves.

3. Before inserting catheters or other invasive devices that do not require
a surgical procedure
4. After contact with a residents intact skin.
5. After contact with body fluids/excretions, mucous membranes,
non intact skin, and wound dressings IF hands are not visibly soiled.
6. If moving from a contaminated-body site to a clean-body site
during resident care.
7. After contact with inanimate objects in the immediate vicinity of
the resident.
8. After removing gloves.
(Alternatively), wash hands with an antimicrobial soap and water in all clinical
situations above. (If alcohol-based hand rub is not available.)

Alcohol wipes should not be used for hand antisepsis as a substitute for
alcohol-based hand rubs because they are not as effective.
Use only alcohol-based hand rubs or antimicrobial soap products which have
Drug Facts Labeling.

Alcohol-based hand rubs are the only products acceptable to FDA for leave-on,
no-rinse application to perform antisepsis. Leave-on antiseptic hand rubs
containing, e.g., benzalkonium chloride or benzathonium chloride are not
permitted for use as antiseptic products to be left on the hands, they are only
approved for use as rinse-off products.

Periodically evaluate employees for proper hand antisepsis and hand washing
technique and demonstrate the proper method. Pay close attention to duration of
application (at least 15 seconds), amount of product applied (some dispensers
dispense too little product; 2 3 ml is typically required for proper antisepsis)
and technique (whether product is applied to all surfaces of hands, fingers
and nails).

2. Hand-hygiene technique
A. When decontaminating hands with an alcohol-based hand rub, apply product
to palm of one hand and rub hands together, covering all surfaces of hands
and fingers, until hands are dry.
B. When washing hands with soap and water, wet hands first with water, apply
an amount of product recommended by the manufacturer to hands, and rub
hands together vigorously for at least 15 seconds, covering all surfaces of the
hands and fingers. Rinse hands with water and dry thoroughly with a
disposable towel.

Beware of foams and sprays which usually dispense .4 - .6 ml of product.

There is not enough active ingredient in this little product to achieve adequate
efficacy against bacteria which typically cause infection.

4. Selection of hand-hygiene agents

A. Provide personnel with efficacious hand-hygiene products that have low

irritancy potential, particularly when these products are used multiple times per
shift. This recommendation applies to products used for hand antisepsis before
and after patient care in clinical areas..

B. To maximize acceptance of hand-hygiene products by Health Care Workers

(HCWs), solicit input from these employees regarding the feel, fragrance, and
skin tolerance of any products under consideration. The cost of hand-hygiene
products should not be the primary factor influencing product selection.

C. When selecting non-antimicrobial soaps, antimicrobial soaps, or

alcohol-based hand rubs, solicit information from manufacturers regarding
any known interactions between products used to clean hands, skin care
products, and the types of gloves used in the institution.

D. Before making purchasing decisions, evaluate the dispenser systems of

various product manufacturers or distributors to ensure that dispensers function
adequately and deliver an appropriate volume of product.
E. Do not add soap to a partially empty soap dispenser. This practice can lead
to bacterial contamination of soap.

When evaluating alcohol sanitizer and antiseptic hand wash products,

including your existing products, request the following test results from the
manufacturer as specified by FDA to ensure adequate efficacy against bacteria :
- Time Kill, Minimum Inhibitory Concentration and Health Care Personnel Hand
Wash tests.2
To evaluate hand hygiene products, hang trial dispensers at high traffic common
areas near all nurses stations. Place trial sheets next to dispensers so employees
can record their feedback in writing.
If latex gloves are used, select moisturizing lotion documented not to break down
the latex. Two commonly found ingredients that can lead to latex degradation are
petrolatum and mineral oil.

Determining whether a dispenser delivers an appropriate volume of product

should be based on the amount of product used in the manufacturers efficacy
testing. Consider how long the exposure time is in their time kill test, e.g., 15
second or 30 second time kill.

In one study, 23% of refillable soap dispensers tested showed bacterial

contamination. Much of the contamination was bacteria which potentially
causes outbreaks.3

5. Skin care
A. Provide HCWs with hand lotions or creams to minimize the occurrence of
irritant contact dermatitis associated with hand antisepsis or hand washing.
B. Solicit information from manufacturers regarding any effects that hand
lotions, creams, or alcohol-based hand antiseptics may have on the persistent
effects of antimicrobial soaps being used in the institution.

Nurses with dermatitis have a greater number of colonizing germ species on their
hands than nurses with healthy skin.4 Select a non-greasy formulation which
contains no mineral oil or petrolatum for compatibility with latex gloves.
The active ingredient Chlorhexidine Gluconate (CHG) is seldom used in antiseptic

hand washes in long-term care facilities. If used, make certain that moisturizing
lotions used in the facility are cationic emulsions or they can neutralize the
efficacy of the CHG.

7. Health-care worker educational and motivational programs

A. As part of an overall program to improve hand-hygiene practices of HCWs,

educate personnel regarding the types of patient-care activities that can result
in hand contamination and the advantages and disadvantages of various
methods used to clean their hands.

B. Monitor HCWs adherence with recommended hand-hygiene practices and

provide personnel with information regarding their performance.
C. Encourage residents and their families to remind HCWs to decontaminate
their hands.

In-service on hand hygiene at regular intervals throughout the year. Repetition

is key in effecting behavior change, especially for a group of people.
Make random observations of employees for hand hygiene behavior compliant
with CDC Recommendations:

1. A. & B. Indications for hand washing and hand antisepsis;

2. A. & B. Hand-hygiene Technique.

Studies show that hand hygiene compliance can increase when residents give a
friendly reminder to staff to wash their hands.5
Resident and family council meetings are great venues to conduct hand hygiene
night with demonstrations and in-servicing for residents and family members.
Residents and family members can spread bacteria through the facility if they do
not practice hand hygiene.

8. Administrative measures
A. Make improved hand-hygiene adherence an institutional priority and provide
appropriate administrative support and financial resources.
B. Implement a multidisciplinary program designed to improve adherence of
health care personnel to recommended hand-hygiene practices.

D. To improve hand-hygiene adherence among personnel who work in areas in

which high workloads and high intensity of patient care are anticipated,
make an alcohol-based hand rub available at the entrance to the patients room
or at the bedside, in other convenient locations, and in individual pocket-sized
containers to be carried by HCWs.

Invest in alcohol hand rub dispensers to help drive infection costs down.
Administrator attendance at hand hygiene in-services sends a message that hand
hygiene is a facility priority.
Several studies document that ongoing, multi-disciplinary approaches to hand
hygiene compliance are the most effective at achieving sustainable increases
in compliance.6
See 1. A. B. Comments above

Part III. Performance Indicators

A. Provide feedback to personnel regarding their performance.

B. Monitor the volume of alcohol-based hand rub (or detergent used for
handwashing or hand antisepsis) used per 1,000 resident-days.

Update staff at monthly meetings or with posters/signage in common

areas with information determined using below calculation.
Calculate your facility hand hygiene rate per 1000 resident days: Total # of
milliliters (ml) used/month, divided by the # of ml used per average hand wash
(the # of ml per pump from your dispenser divided by the total # of resident
days/month). (Calculate hand washing rate using soap and antisepsis rate using
alcohol hand rub).

(1) Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force, John M. Boyce, M.D., Hospital of Saint Raphael,
New Haven, Connecticut, Didier Pittet, M.D., University of Geneva, Geneva, Switzerland
(2) Tentative Final Monograph for Health Care Antiseptic Drug Products, Federal Register, Vol. 59, No. 116, p. 31444.
(3) Bacterial Contamination of Liquid Hand Soaps, Marisa Chattman, Sheri L. Maxwell, and Charles P. Gerba, Department of Soil, Water and Environmental Science, University of Arizona, Tucson, AZ 85721.
(4) Changes in bacterial flora associated with skin damage on hands of health care personnel, Elaine L., Larson, PhD, et al., American Journal of Infection Control, Vol 26, No. 5, pp. 513-521
(5) Validation of a Comprehensive Infection Control Program in LTC, Maryanne McGuckin, Dr. Sced., MT, et.al., The Director, Vol. 12 and No. 1, pp. 14-17
(6) Testing the WHO Guidelines on hand hygiene in health care in eight pilot sites worldwide, World Health Organization www.who.int/gpsc/country_work/pilot_sites/introduction

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