Author: Dr. Narotam, Dr. Nisha.
Shimla, India.

Healthcare associated infections (HAIs) are a serious problem in health care services as they are common cause of morbidity and mortality among hospitalized patients. ^1,2 Transmission of healthcare - associated pathogens generally occurs via the contaminated hands of healthcare workers.² General hygiene and hand washing are important to minimize the transmission of pathogenic organisms in hospital and together with disinfection of environmental surfaces are fundamental measures in reducing the incidence of (HAIs).¹ However compliance by health workers with recommended hand hygiene procedures has remained unacceptable with compliance rates generally below 50% of hand hygiene oppurtunities.²

Hand Pathogens:
Larson has provided an extensive review of the physiologic and bacteriologic characteristic of the skin. The finger nail area is associated with a major portion of the hands flora. The subungual area (located under the fingernail) often harbour high number of microorganisms, which may serve as a source of continued shedding, especially under the gloves. The microbial flora of the skin consists of resident (colonizing) and transient (contaminating) microorganisms. The resident microorganisms survive and multiply on the skin. Resident flora include the coagulase-negative staphylococci, member of genus Corynebacterium, Acinetobacter species, and occasionally member of Enterobacteriaceae group.In contrast to resident flora, the transient flora, the transient microorganisms found on the hands of healthcare professional are more frequently implicated in nosocomial infections. The most common transient flora includes the gram negative coliforms and staphylococcus aureus. Healthcare associated pathogens can be recovered not only from infected or draining wounds, but also from frequently colonized area of normal intact patient skin. Organisms are transferred to various types of surfaces in much larger numbers (i.e >10 4) from wet hands than from hands that are thoroughly dried.² The resident flora is more difficult to remove by hand washing than the transient organisms.³


Hand Hygeine In Dental Surgery:
WHO regards the matter so seriously that it has instituted a worldwide programme entitled “Savelives-clean your hand” aimed at small and large hospitals. In case of bedridden hospital patients, the WHO has identified five situations when hands must be washed:⁴

• Before touching a patient;
• Before carrying out a procedure;
• After procedure is completed;
• After exposure to body fluids; and
• After touching a patient or the patient’s surroundings.

Transposing these recommendations to the dental patient undergoing treatment we have:

• Dentist and/or nurse touching the patient when first placed in the dental chair;
• The dentist/nurse washing hands before putting gloves on and then again after completion of the procedure and taking gloves off;
• The wearing of gloves providing protection against contact with saliva, blood, nasal secretions and tear; and
• The dentist/nurse touching equipment items (some barrier protected) in the contaminated zone around the patient and chair/unit with contaminated gloves and then these areas are thoroughly cleaned or barriers changed after completion of treatment.

Recomendations For Hand Hygeine Protocol: ⁵
Repeated use of hand hygiene products can damage both the cells of the epidermis and its intercellular material thus impairing the protective mechanism of the skin. Some surfactants such as sodium lauryl sulphate bind to the skin cells, changing their structure and may cause skin reactions, whilst others can increase water loss through the skin or increase the permeability to exogenous chemicals. Natural soaps, as found in bar soaps, are alkaline and repeated use can raise the pH of the skin to above 6.0 for several days, thus interfering with the skin’s buffering capacity which in turn may cause skin cracking and sometimes colonization with coagulase negative staphylococci. Other surfactants can also interfere with the natural moisturizing factors of the skin and interfere with its water content causing dry skin and the shedding of large flakes of skin rather that individual squames. This damage to the epidermis can make the cells more susceptible to surfactant damage and the cycle perpetuates. In addition, factors such as the prolonged wearing of gloves, the use of brushes to scrub the hands and failure to adequately rinse and dry the hands can have a deleterious effect. In a busy general dental practice, the dentist and assisting staff might wash their hands 20-30 times a day, so a balance is needed between the possible deleterious effects of the cleaning agents on the skin and the need to meet hand hygiene guidelines. Many authorities recommend that a liquid soap of neutral ph containing a mild surfactant such as isethionates, amphodiacetates or sulphosuccinates rather than the harsher sodium lauryl sulphate be used. Some dental care providers find that alcohol hand gels containing emollients are useful but many find that moisturisers used both at work and in the home help reduce skin irritation. Which product to use can be a matter of trial for each individual but as a general rule the following should be considered:

• For normal skin, which is neither too dry or too moist, a non-greasy waterbased moisturiser containing a light oil such as cetyl alcohol or a silicone will usually maintain natural water balance;
• For dry skin use, an oil-based moisturizer containing urea, propylene glycol, glycerin or petrolatum. These reduce the rate of water loss and assist the build-up of water in the upper layer of the stratum corneum. Petrolatum has been shown to penetrate deeply into the epidermis with healing effects. Glycerin in concentrations of 5% or higher increases the hydration and elasticity of the skin
• For oily skin, use a water-based light moisturiser after washing the hands assurfactants can remove oils and dry out the skin; and
• For persons in the older age groups, an oil-based moisturiser preferably containing petrolatum is necessary as oil producing glands in the skin become less active with age.

Many commercially available hand care preparations contain fragrances and colourings to make the products attractive to users but also preservatives to prevent bacterial contamination. Individuals, particularly those with a sensitive skin, might experience skin irritation or have allergic reactions to one or more of these ingredients. Further, some of the oils and other additives may affect the integrity of latex gloves and/or inactivate antiseptics used in preparations for hand surgical scrub-up.

What soap to use?:
Bar soap should not be used in any circumstances due to the associated risk of cross contamination. Research has shown that the use of non-antimicrobial soap is more effective than antibacterial alternatives at removing transient organisms. The use of antibacterial l soaps have begun to create concern around the emergence of antibiotic-resistant bacteria and should therefore be avoided. A mild nonantimicrobial liquid soap should be dispensed from a disposable cartridge type container fitted into a closed wall-mounted dispenser unit at each handwash sink area.³
The most commonly used products for surgical hand antisepsis are chlorhexidine or povidone-iodine-containing soaps. The most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and plain soap.Triclosan-containing products have also been tested for surgical hand antisepsis, but triclosan is mainly bacteriostatic, inactive against P. aeruginosa, and has been associated with water pollution in lakes.Hexachlorophene has been banned worldwide because of its high rate of dermal absorption and subsequent toxic effects.Application
of chlorhexidine or povidone-iodine result in similar initial reductions of bacterial counts (70–80%), reductions that achieves 99% after repeated application. Rapid regrowth occurs after application of povidone-iodine, but not after use of chlorhexidine. Hexachlorophene and triclosan detergents show a lower immediate reduction, but a good residual effect. These agents are no longer commonly used in operating rooms because other products such as chlorhexidine or povidone-iodine
provide similar efficacy at lower levels of toxicity, faster mode of action, or broader spectrum of activity. Despite both in vitro and in vivo studies demonstrating that it is less efficacious than chlorhexidine, povidone-iodine remains one of the widely-used products for surgical hand antisepsis, induces more allergic reactions, and does not show similar residual effects.At the end of a surgical intervention, iodophor treated hands can have even more microorganisms than before surgical scrubbing. Warm water makes antiseptics and soap work more effectively, while very hot water removes more of the protective fatty acids from the skin. Therefore, washing with hot water should be avoided.⁵

Surgical hand preparation with alcohol-based hand rubs ⁵
Several alcohol-based hand rubs have been licensed for the commercial market,frequently with additional, long acting compounds (e.g. chlorhexidine gluconate or quaternary ammonium compounds) limiting regrowth of bacteria on the gloved hand. The antimicrobial efficacy of alcohol based formulations is superior to that of all other currently available methods of preoperative surgical hand preparation.Numerous studies have demonstrated that formulations containing 60–95% alcohol alone, or 50–95% when combined with small amounts of a QAC, hexachlorophene or chlorhexidine gluconate, reduce bacterial counts on the skin immediately post-scrub more effectively than do other agents. Institutions opting to use the WHO-recommended formulations for surgical hand preparation should ensure that a minimum of three applications are used, if not more, for a period of 3 to 5 minutes. For surgical procedures of more than a two hours’ duration, ideally surgeons should practise a second handrub of approximately 1 minute, even though more research is needed on this aspect.

Hand-washing technique ³
The correct hand-washing technique is crucial for the effective removal of microorganisms from the hands of dental practitioners. The technique selected by dental professionals should consist of three main stages: preparation, washing
and rinsing, and hand drying. The preparation ritual of wetting hands under warm running water has remained consistent and ensures that there is a more thorough lather of soap over all areas of the hands. All areas of the hands, including finger tips, thumbs and in between fingers, should be covered.

Steps before starting surgical hand preparation⁵

• Keep nails short and pay attention to them when washing your hands – most microbes on hands come from beneath the fingernails.
• Do not wear artificial nails or nail polish.
• Remove all jewellery (rings, watches, bracelets) before entering the operating theatre.
• Wash hands and arms with a non-medicated soap before entering the operating theatre area or if hands are visibly soiled.
• Clean subungual areas with a nail file. Nailbrushes should not be used as they may damage the skin and encourage shedding of cells. If used, nailbrushes must be sterile, once only (single use). Reusable autoclavable nail brushes are on the market.

Protocol for surgical scrub with a medicated soap ⁵

• Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes.
• Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands.
• Wash each side of the arm from wrist to the elbow for 1 minute. Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything at any time,the scrub must be lengthened by 1 minute for the area that has been contaminated.
• Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.
• Proceed to the operating theatre holding hands above elbows.
• At all times during the scrub procedure, care should be taken not to splash water onto surgical attire.
• Once in the operating theatre, hands and arms should be dried using a sterile towel and aseptic technique before donning gown and gloves.

Hand drying: What is best practice? ³
Hand drying should not be underestimated; it is a vital component in the hand hygiene process. There is conflicting evidence around the effectiveness of paper towels vs hand dryers. However, paper towels are the preferred option for removal of bacterial organisms. The risk of cross infection must always be considered and therefore the reuse of cloth towels, for example, should be avoided at all times. When drying hands with disposable paper towels, it is recommended that the skin is patted dry. This action alone will help in the prevention of damaged skin and consequently discourage the colonization of bacteria on the hands.

Conclusion
The importance of proper hand washing before and during food preparation and by health care providers providing patient treatments cannot be overemphasized. It is a simple procedure first taught to children and then emphasized and practised in daily and professional life. It is estimated that proper hand hygiene would significantly lessen the 2 million infections and 90,000 deaths suffered each year by hospital patients throughout the world. Surveys have shown that it has a very significant role to play in preventing the spread of gastro intestinal illness and as the basis of Standard Precautions it has helped prevent the transmission of infectious diseases within the dental surgery.

References:

1. Hassan AN, Hassan MA, Abdrahman AA, Elshallaly GH, Saleh MA. Assessment of existing practices in the operating theatre in the Khartoum North Teaching Hospital, Sudan. South Afr J Epidemiol Infect 2011;26(2):79-82.
2. Mani A, Shubhangi AM, Saini R. Hand hygiene among health workers. Indian J Dent Res 2010;21(1):115-118.
3. Walton E. Hand hygiene for dental nurses. Dental Nursing September 2011;16-23.
4. Amerena VC. Skin:Our protective cover-Part 3 -The importance of hand hygiene. Australasian Dental Practice September/October2010;98-100.
5. World Health Organization. WHO Guidelines on hand hygeine in health care 2009.54-60.