This article describes the link between handwashing, hand hygiene, and infection prevention; differentitates between resident and transient bacteria; lists when handwashing and/or hand antisepsis should occur; and explains the factors that lead to damaged skin.
All of us can remember our parents and teachers telling us to wash our hands so we wouldn't spread germs. This statement couldn't be any more true than in today's food manufacturing setting. Since the time of Semmelweis in the mid-1800s, handwashing has become a major part of aseptic practice.
It is well documented that handwashing (with plain soap and water) and hand antisepsis (with an antimicrobial agent) significantly reduces the number of potential pathogens on the hands and can reduce spreading bacteria amongst staff and contaminating food. In spite of all the research to support this simple practice, compliance to handwashing is less than optimal.
Handwashing is said to be the single most important practice for preventing bacteria form being spread around.
The skin, an excellent barrier to microorganisms, harbors a large variety and number of bacteria, both infectious and noninfectious. The bacterial flora of the skin includes both resident and transient microbes.
Resident flora, also called “colonizing flora” are considered permanent flora of the skin and can be isolated from the skin of most people. They are not readily removed by mechanical friction. Resident flora include coagulase-negative staphylococci, some species of the Corynebacterium, Propionibacterium, Acinetobacter, and Enterobacteriaceae family.
Transient flora, also called “non-colonizing or contaminating flora” are present on the skin but are not consistently found on the majority of people. Although not consistently present on the skin of the hands, they are readily transferred from the hands to food or other persons. These organisms that “hitchhike” on the skin are easily removed by mechanical action, soap, and water washing, or are destroyed by antiseptic handwashes. Transient organisms include such bacteria as Escherichia coli.
Hand Hygiene and Hand Scrubbing
The CDC reports that an estimated 2.4 million hospital acquired infections occur each year in the US and that half of these infections are preventable by proper handwashing. Handwashing is the least expensive and simplest way to break the chain of transmission. It is also one of the most underused. Hand cleansing procedures can be segregated into two distinct categories, namely hand hygiene and hand scrub.
Because of the continuing need for vigilance, handwashing standards and guidelines that had their basis in the 19th century are continuously undergoing revision.
1. Hands must be washed thoroughly with soap and water when visibly soiled.
2. Hands must be cared for by handwashing with soap and water or by hand antisepsis with alcohol-based handrubs (if hands are not visibly soiled):
· Before and after food contact.
· After contact with a source of microorganisms (body fluids and substances, mucous membranes, non-intact skin, inanimate objects that are likely to be contaminated).
· After glove removal.
The principle objective of handwashing is to remove dirt, organic debris, and transient microorganisms as quickly and completely as possible. Handwashing is defined as a vigorous, brief rubbing together of all surfaces of lathered hands for 10-15 seconds and can be classified in two ways.
1.the mechanical removal of microorganisms uses basic soaps or detergents to suspend the flora from the skin and allow them to be rinsed off; and
2. the chemical removal of microorganisms uses antimicrobial products to kill or inhibit the growth of microorganisms. This procedure depends on technique as well as a sufficient amount of product.
The purpose of hand antisepsis is to destroy transient microorganisms on hands. Hand antisepsis can occur simultaneously with handwashing when antisepsis soaps are used. It can also be obtained by use of alcohol containing antiseptic handscrubs when hands are not soiled with dirt or organic material. The same concerns regarding adequacy of handwashing technique also apply to the use of alcohol handscrubs. Contaminated surfaces will exist if an insufficient amount of solution is used or there is failure to cover all surfaces of the hands. The alcohol handscrubs can increase compliance in facilities where soap and water are not always readily available. Remember that alcohol handrubs are a complement to, not a replacement for, handwashing.
Despite a general understanding that proper handwashing can result in a significant reduction in the number of potential pathogens carried on the hands, recent studies indicate handwashing practices are less than optimal in food processing facilities. Handwashing is recognized as a very tedious, repetitive task that can easily be displaced by other, more appealing tasks. With increasing budget cuts, many food processors are seeing an increase in recalls, along with greater focus on HACCP documentation. It is not surprising that under such circumstances, proper handwashing has taken a lower priority in a processor's daily routine.
The inconvenience of handwashing facilities is another factor involved with lower compliance. Due to increased workloads, the amount of time processors have between shifts to wash their hands has decreased. Because of time constraints, processors are less likely to go out of their way to find handwashing facilities. Also, many processors feel less urgency to wash their hands if they have not come in direct contact with other staff, contaminated surfaces or raw product, or their hands are not visibly soiled.
Other factors adding to noncompliance are poor skin health and increased glove usage. Skin condition is emerging as an increasingly important factor in personnel handwashing compliance and infection prevention. Frequent handwashing can overdry skin, while soaps can alter skin pH, making it more alkaline than normal, which can affect the skin’s ability to act as a barrier. When the epidermal barrier is disrupted, the potential for skin damage escalates. The potential for adverse effects should not be misinterpreted as a reason for reducing or abandoning handwashing. Maintenance of skin health requires appropriate prevention strategies, including education and training programs.
The use of gloves may be considered by some as an alternative to handwashing. In theory, handwashing should follow every time gloves are removed. In reality, glove usage gives a false sense of security, and there is a decrease in compliance to handwashing. Gloves provide an ideal environment for bacterial growth, moisture and warmth, which makes handwashing critical each time gloves are removed.
A hand scrub is performed prior to entering the food manufacturing and handling areas. The goal is to remove transient flora and reduce resistant flora for the duration of the food preparation and processing in the event of a glove tear.
It is recommended that fingernails must be kept short, clean, and healthy since the subungual region harbors the majority of microorganisms found on the hands. Artificial nails should not be worn. Recent studies, however, have not found any increase in microbial growth related to wearing freshly applied fingernail polish. Concerns have been raised with this issue because staff who spend time and money to maintain their nails may not scrub as vigorously in order to protect their nails.
The cuticles, hands, and forearms should be free of open lesions and breaks in skin integrity, which increase the risk of infection to the food or other staff. Breaks in skin integrity tend to ooze serum that may contain pathogens as well as provide an ideal bacterial breeding ground.
Choose an antimicrobial agent that provides the following characteristics:
1. broad spectrum
2. rapid reduction in flora
Always review and evaluate the safety and efficacy date of any antimicrobial under consideration for use as all products perform differently. The most common antimicrobial agents used in the operating room include: iodophors, chlorhexidine gluconate (CHG), alcohol, para-chloro-meta-xylenol (PCMX), and triclosan. For staff who have skin sensitivities to antimicrobial agents, washing with a non-medicated soap followed by an alcohol-based hand cleanser.
Because gloves are worn for extended periods of time in the factory and the warm, moist environment under the gloves is ideal for bacterial proliferation, a product that provides persistence is ideal. Studies show that CHG products have the highest residual activity followed by iodophors and triclosan. While alcohols have no persistent activity, in appropriate concentrations (60% to 70%), they provide the most rapid and greatest reduction in microbial counts on the skin.
The most common method of hand preparation is the hand scrub method, and it may involve either a timed scrub or a counted stroke method. It is recommended that the scrub should include but not be limited to the following:
1. The hands and forearms should be thoroughly washed and rinsed before beginning the scrub procedure.
2. The subungual areas should be cleaned with a nail cleaner under running water.
3. An antimicrobial agent should be applied with friction to the wet hands and arms.
4. Fingers, hands, and arms should be scrubbed on all four sides.
5. Hands should be held higher than the elbows and away from ones attire.
6. Care should be taken to avoid splashing water onto the attire.
7. Discard brushes and sponges as appropriate.
It is unclear what the optimal scrub time should be. The efficacy of a handwash is dependent on the technique and products used. Traditionally it has been recommended that a minimum of 20 seconds wash is required and people suggest singing a song like Happy Birthday as a timer. Always follow manufacturers written instructions when establishing your institution’s policy.
At the end of the food handling, or whenever the gowns and gloves are removed, it is important to wash the hands. Bacterial recolonization of the hands, in addition to contamination from glove pinholes, makes handwashing a critical link to infection prevention. All workers in food processing areas should follow the above hand hygiene guidelines when contacting the food or contaminated articles or when removing gloves.
Like handwashing and hand antisepsis, one of the issues related to surgical hand scrubbing is hand health. The use of scrub brushes and sponges coupled with antimicrobial agents often leave the hands dry, red, and chapped and can lead to breaks in skin integrity. In a recent survey of operating room nurses, those nurses who scrubbed their hands five or more times per day rated their hands lower (more damaged) in hand health characteristics than those who scrubbed fewer than five times a day.
Other influencing factors included the weather and sensitive skin. People who live in cold, dry climates rate their hand health conditions worse than those living in warmer climates. In addition, 97% of respondents with sensitive skin reported dry, scaly, and cracked skin. Solutions to this problem can include a change in job role until skin health is restored and the use of lotions. Managers can be left short staffed when personnel are not able to scrub and not qualified to perform other jobs. Lotions are used to help maintain and improve skin health. Choose a lotion that is aqueous based and not oil based. Oil based lotions will break down latex gloves and interfere with their barrier properties. In addition, many lotions are not compatible with CHG products and will negate their persistent activity. In the above-mentioned study, nurses used lotion one to four times in an 8-hour day.
Effective handwashing is the most powerful strategy in disease prevention. Because of decreased compliance in handwashing, it is important for food processing management to focus on education to help staff to understand the cause/effect cycle of handwashing as it relates to preventing potential food poisoning. In addition, it is important to work closely with in helping the staff maintain their hand health. And lastly, it is critical to consider skin health properties when making selections around hand antisepsis and hand scrub products.
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