9. Principles of infection control
General hand care 74
Indications for hand decontamination 74
Role and responsibilities of the midwife 77
Self-assessment exercises 77
Having read this chapter the reader should be able to:
• discuss the principles of general hand care
• identify the occasions when the midwife should undertake hand decontamination
• describe the main differences between ‘medical’ and ‘surgical’ scrub
• discuss the role and responsibilities of the midwife in relation to hand hygiene.
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This chapter focuses on the principles of hand hygiene, an important means of infection control. Hand hygiene encompasses both hand care and hand decontamination:
Hand decontamination is the most effective and certainly the most cost effective method of preventing health-related infection.
Healthcare-acquired infections (HCAIs) are infections acquired when in hospital as a result of healthcare intervention; they are caused by a wide variety of microorganisms, many of which are commensals. Approximately 30% of the population has Staphylococcus aureus living on their skin or in their nose with no ill effects. The methicillin-resistant Staphylococcus aureus (MRSA) strain of this microorganism is found in 3% of the population and is difficult to treat because of its resistance to antibiotics. MRSA is spread by direct contact with a contaminated surface/material or skin-to-skin. Hand washing and the use of alcohol hand rub help to reduce the incidence. Another bacterium that is a source of HCAIs is Clostridium difficile, which lives in the intestine of approximately 3% of the population. Usually, the normal gut bacteria prevent C. difficile from affecting the person; however, if these are destroyed by antibiotics, C. difficile multiplies, producing toxins that can cause diarrhoea. These spores are not killed by alcohol hand rub.
HCAIs are troublesome to those affected because they are likely to stay in hospital three times longer than those who are not affected and they will require longer-term follow-up and care; from a financial perspective, HCAIs cost up to three times more to treat (Gould et al 2007). The Department of Health (DH) estimates that it costs £4000–10 000 more to treat a patient who develops an infection and adds between 3 and 10 days on the length of stay (DH 2008).
General hand care
• Keep nails short and filed: long or ragged nails can scratch women and babies or tear gloves and introduce infection. Dirt and secretions might be found under the nails, which can harbour microorganisms.
• Avoid using false nails or nail extensions: bacteria can flourish in the ridge that appears as the nail grows. Additionally, Ward (2007) suggests the percentage of Gram-negative bacteria found on false nails is higher than on natural nails.
• Apply an emollient hand cream/moisturizer to the hands on a regular basis to prevent them from drying out and cracking.
Hand washing refers to both social and clinical situations where hands are washed. Social hand washing is generally ineffective in destroying bacteria due to incorrect washing technique or inappropriate cleansing agents used. Hand decontamination is a more accurate term that refers to the removal of blood, body fluids, microorganisms and their debris by mechanical means or their destruction (Gould, 2002 and Pratt et al., 2007).
The use of soap and water removes almost all transient microorganisms but does not reduce the number of resident microorganisms (e.g. Staphylococcus aureus) by any significant amount (Mallett & Dougherty 2000). Although this is acceptable in non-invasive situations with a low-risk population, there are many situations where the resident microorganisms also need to be reduced (e.g. aseptic procedures). Antiseptics (e.g. chlorhexidine) reduce the transient and resident microorganisms at the time of application, with some residual activity keeping bacterial counts low over several days as the chlorhexidine binds to the stratum corneum (Gould, 2002 and Gould et al., 2007). Pratt et al (2007) reviewed the effectiveness of different hand washing preparations and concluded that soap was as effective as antiseptic agents.
Both soap and antiseptics usually involve the use of running water following one of two procedures: the ‘medical/social’ or the ‘surgical’ scrub. The former is used for normal hand washing and prior to aseptic techniques, whereas the latter is used when scrubbing for an operative procedure; this is a lengthier procedure involving the hands and arms.
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