Neobook — clinical reference

Hand Hygiene Multimodal Approach
Personal Protective Equipment
Gloves
Other PPE

Hand Hygiene Multimodal Approach

A significant amount of information is available on hand hygiene within the NDoH Cleanliness Guideline for Health Workers document.⁵¹ Ensuring hand hygiene is effectively implemented requires a multimodal approach.

Strategy	Action/ Reference
Systems adoptions	Attitude change towards hand hygiene. Make hand hygiene possible, easy and convenient. Make alcohol-based hand-rub available at bed side. Make water and soap available (place basin outside ward). Have champion in each ward.
Hand hygiene education	Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.⁵²
Promote/facilitate skin care for HCW’s hands	Involve dermatology in cases of skin irritation.
Routine observation and feedback	Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.
Reminders in the workplace	Wall mounted visual reminders.
Improve institutional safety climate	General attitude improvement. Promote active participation at individual and institutional level. Avoid overcrowding, understaffing and excessive workload. Institute administrative sanction/ rewarding.Ensure patient empowerment.
Combination of several of the above strategies	Effectiveness of a hospital-wide programme to improve compliance with hand hygiene.

For hand hygiene to be effectively implementation in health facilities, the following needs to be in place as basics:

Multimodal strategy	Minimum criteria for implementation
Systems change: Alcohol based hand-rub next to bed	Bottles of alcohol-based hand-rub positioned at the point of care in each ward or given to staff.
Systems change: Access to safe continuous water supply and towels	One sink (outside ward) to at least every 10 beds. Soap and paper towels available at every sink.
Training and education	All staff involved in the test phase receive training. Follow WHO hand wash evaluation method. Long term programme must be planned and executed.
Observation and feedback	Two periods of observational monitoring are undertaken and feedback immediately.
Reminders in the workplace	Hand washing “How-to” and “5 Moments” posters are displayed in all wards.
Institutional safety climate	The Chief Executive Officer and Chief Nurse need to make a visible commitment to support hand hygiene improvement.

Personal Protective Equipment

Personal Protective Equipment (PPE) includes the following pieces of equipment which should be available to all HCWs and staff near patient care areas in every hospital as a minimum:

Eye and face protection
Respiratory protection
Hand protection
Body protection
Head protection
Foot protection (change footwear to closed shoes)

Some basic principles to follow in the use of PPE:

No white coats should be used by clinical staff.
Scrubs must be seen as preferred clothing. Scrubs should be put on at work and removed before going home and washed daily. This is not for every situation and is only recommended in high risk areas. PPE is used in addition to normal clothing and uniforms.
The use of PPE should be task-related rather than disease related, with the aim of preventing exposure. For example, wearing gloves when coming into contact with blood or body fluids is task related as this is done regardless of the patient’s disease status.
PPE will not protect against sharps injuries; however, risk can be reduced by using safety engineered devices.
Protective equipment should be selected on the basis of an assessment of the risks of transmission of micro-organisms as performed annually by the health facility.
PPE only protects intact skin of the HCWs. Therefore, cuts, abrasions, exposed fresh unhealed body piercings and unhealed tattoos must be covered by a waterproof plaster or other suitable dressing in addition to PPE.
Hand decontamination must be used before and after using PPE.
Arms must be ‘bare below the elbow’ to prevent contamination, including no jewellery or watches to be worn – this applies to all clinical staff including doctors.
PPE identified by the manufacturer as single use must be discarded after a single use and not re-used under any circumstances.

When PPE should be used

Situation	PPE to be used
NO risk of exposure	Hand hygiene essential.
LOW risk of exposure	Gloves should be available.
LOW risk of exposure	Hand hygiene should be instituted after removal of gloves.
PROBABLE risk of exposure (e.g. contact with blood/ bodily fluids with a risk of splashing to face deemed unlikely)	Gloves need to be worn. Disposable apron, safety goggles and mask should be available.
DEFINITE risk of exposure (e.g. contact with blood, with a risk of uncontrolled bleeding or splashing to face considered likely)	Gloves and an apron need to be worn. Water repellent gown, safety goggles and masks should be readily available.

Choice of PPE

GLOVES

Type of Glove	Function	Examples of use
Clinical: non-sterile Standard length	Minimise cross infection (patients to staff and staff to patients). Reduce transmission of blood and body fluids.	• Potential exposure to blood. • Contact with mucous membranes. • Contact with non-intact skin.
Clinical: sterile Standard mid-forearm length	Ensure minimum contamination of site.	• Invasive procedures - surgery. • Contact with sterile sites - insertion of devices.
Long cuff gloves	Used in cases where fluid may enter over the cuff of the glove.	• Cleaning of leg ulcers in deep water. • Certain emergency situations in obstetrics and gynaecology.
Nitrile glove	Substitute for latex gloves. Used when handling chemicals.	• Mixing chemicals such as chlorine. • Soaking endoscopes in glutaraldehyde.
Domestic gloves	Environmental cleaning.	• When carrying out daily or routine cleaning in clinical areas.
Heavy duty gloves	Handling healthcare waste.	• When lifting, transporting or disposing of healthcare waste.

OTHER PPE

Function		Examples of use
Aprons	Standard plastic disposable apron: • Protect HCWs clothes from contamination.	• For direct contact with infectious patients and their environment. • Cleaning contaminated equipment. • Contact with blood/ bodily fluids, secretions and excretions. • When clothes are likely to become wet or soiled.
Aprons	Long sleeved disposable apron or gowns.	• Use where standard disposable aprons give insufficient coverage of exposed skin and clothing e. g. viral haemorrhagic fever cases.
Masks	Face mask: • Protects HCWs from exposure to microorganisms via splashes of blood and body fluids; • Protects patient from HCW particles; • Decrease airborne infections to environment. N95 mask: • Protect HCWs where high level of particle filtration is required. • Needs individual assessments and fittings.	• Healthcare where treatment may cause facial splashing. • Dental treatments. • Cleaning of contaminated surgical equipment. • For close patient care in pandemic situation. • Cough-inducing procedures. • Airborne diseases.
Eye protection	• Protects eyes from splash or spray of blood and bodily fluids. • Protects eyes from chemicals. • Includes safety spectacles. • Combined single use visor and facemask.	• During aerosol-prone procedures (dental and other surgical interventions). • During procedures where splashing is possible (cleaning equipment).
Overshoes	• Overshoes are not recommended. • Change into closed toe footwear if indicated and working in Sterile Services Department to package equipment.
Head gear	• Not recommended for routine use. • Indications- sterile areas only such as: - Operating theatre, -Preparing sterile fluids in pharmacy. • To be worn while inspecting/assembling sterile equipment packs.

⁵¹National Department of Health. A Cleanliness Guideline for Health Workers (Draft). Pretoria; 2015. Available from: https://www.idealclinic.org.za/#documents

⁵² Pittet D, et. al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Infection Control Programme. Lancet 2000; 356(9238): 1307-12.