who “my five moments for hand hygiene” concept who “my five

WHO“My Five Moments for Hand Hygiene”

Concept

(World Health Organization)WHO“My Five Moments for Hand Hygiene”

Concept

(World Health Organization)

A Manual for

Edited by:Dr. Hammad ur Rehman Malik

A Manual for

WHO “My Five Moments for Hand Hygiene” Concept

A Manual for WHO “My Five Moments for Hand Hygiene” Concept

ACKNOWLEDGMENTS

I would like thankful to following persons for their contributions andencouragement to develop this manual.

Deputy Lead, WHO First Global Patient Safety ChallengeGeneva, Switzerland.

Infection Control Department, Geneva University HospitalGeneva, Switzerland.

Project Manager WHO First Global Patient Safety ChallengeLondon UK

Member WHO “Clean Care is Safer Care” Core GroupBelfast, UK.

Infection Control Department, Geneva University HospitalGeneva Switzerland.

Director MCHC, PIMSIslamabad, Pakistan.

Community Medicine Department, Nishtar Medical CollegeMultan, Pakistan.

Dr. Benedetta Allegranzi

Dr. Hugo Sax

Julie Storr

, .

Dr. Nizam Damani

Marie-Noelle Chraitie

,

Dr. Amjad Raja

Dr. Allah Yar Malik

A Manual for WHO “My Five Moments for Hand Hygiene” Concept

Objective of Manual

This manual has been created to help the HCWs to perform hand hygieneactions in correct and timely manner according to WHO “My FiveMoments for Hand Hygiene” concept.

Manual is helpful for HCWs especially in developing countries whereinternet and audiovisual education aids are limited. We have givenscenarios according to each indication for hand hygiene. We hope thatafter reading the manual you will more able to perform hand hygiene incorrectly and timely manner.

Any suggestion will be welcomed

Thanks

Dr. Hammad ur Rehman MalikMultanPakistanContact: +92-333-7637918Email: [email protected]

1A Manual for WHO “My Five Moments for Hand Hygiene” Concept

Important

All informations presented in this manual are mainly derived from twosources

1. “My five moments for hand hygiene” a user- centred design approachto understand, train, monitor and report hand hygieneD. Pittet, B. Allegranzi, E. Larson et al, Journal of hospital infection 2007

2. Clean Care is Safer Care WHO (http://www.who.int/gpsc)


My Five Moments for Hand Hygiene Concept

Hand hygiene is a core element of patient safety for the prevention ofhealthcare-associated infections and spread of antimicrobial resistance.Its promotion represents a challenge that requires a multi-modal strategyusing a clear, robust and simple conceptual framework. 'My fivemoments for hand hygiene' describes the fundamental reference pointsfor healthcare workers (HCWs) in a time-space framework anddesignates the moments when hand hygiene is required to effectivelyinterrupt microbial transmission during the care sequence. The conceptapplies to a wide range of patient care activities and healthcare settings. Itproposes a unified vision for trainers, observers and HCWs that shouldfacilitate education, minimize inter-individual variation and resourceuse, and increase adherence. 'My five moments for hand hygiene'bridges the gap between scientific evidence and daily health practiceand provides a solid basis to understand, teach, monitor and report handhygiene practices. To know the concept clear and better you should firstread below two topics.

A) The negatives outcomes of microorganisms' transmission pathways:Health care associated colonization and infectionB) Conceptualisation of the risk: Two Zones, Two Critical Sites

For conceptual clarity, it is useful to know two important outcomes oftransmission pathways. Colonisation denotes the presence of micro-organisms on body sites without invading the tissue and withouttriggering a symptomatic host defence reaction; infection denotes tissueinvasion of micro-organisms triggering an inflammatory host response.

Transmission of micro-organisms from the health-care environment (e.g.furniture, equipment, walls, doors, documents, neighbouring patients,etc.) to a patient most often results in cross-colonisation and not ininfection. Cross-colonisation with multi-resistant micro-organismsrepresents an important target for prevention because it contributes to in-creasing antimicrobial resistance and the reservoir of potentialpathogens. With respect to cross-colonisation, it is important to

A) The negatives outcomes of microorganisms' transmissionpathways: Health care associated colonization and infection


recognise three facts: first, colonised or infected patients represent themain reservoir for healthcare-associated micro-organisms; second, theenvironment in the healthcare facility contains a wide variety of differenthealthcare-associated micro-organisms and represents a secondarysource for transmission; and third, the immediate patient environmentbecomes colonised by the patient flora.

Cross-transmission can result in exogenous HCAI, in particular if thepatient s defence against the implicated micro-organism is low or if it isdirectly introduced into a vulnerable body site, or mucous membrane.Most HCAIs, however, are of an endogenous nature, and due to micro-organisms already colonising the patient before the onset of infection.This implies that hands may play a role in this process by transferringmicro-organisms from a colonised body site to a site to be protected fromgerms in the same patient, e.g. from the perineum to a tracheal tube, orfrom the leg skin to a catheter hub. Care-induced breaks of physical and

Figure 1: Distribution of S aureus on body sites of the colonized patient fromgeneral population ( Vol 8 February 2008)http://infection.thelancet.com

'

Nose 27%

Neck 10%

Axilla 8%

Forearm 20%

Hand 27%

Pharynx 10–20%

Skin chest 15%

Skin

abdomen 15%

Perineum 22%

Vaginal 5%

Ankle 10%


biological defence mechanisms by invasive procedures and devices. Inaddition to patient colonisation and/or infection, two additional negativeoutcomes are targeted by hand hygiene: infection in HCWs withpathogens contained in body fluids and cross-colonisation of inanimateobjects in the healthcare environment and colonisation of HCWs bypatient flora.

PATIENT ENVIRONMENT

HEALTH CARE ENVIRONMENT


Endogenous infection

PATIENT ENVIRONMENT

Exogenous infection (Figure 2)


In summary, four negative outcomes constitute the prevention target forhand hygiene:(1) Cross-colonisation of patients

(2) Endogenous and exogenous infection in patients

(Figure 3)

(Figure 4)


PATIENT ENVIRONMENT

PATIENT ENVIRONMENT



endogenous infectionPATIENT ENVIRONMENT

exogenous infection

Cololnisation Infection


(3) Infection in HCWs

(4) Cross-colonisation of the healthcare environment including HCWs

(Figure 5)

(Figure 6)


PATIENT ENVIRONMENT

HCW


PATIENT ENVIRONMENTHCW

HCWHCW


B) Conceptualisation of the risk: Two Zones, Two Critical Sites

To understand better my five moments for hand hygiene, you must knowterms zone & critical sites. The terms zone and critical sites wereintroduced to allow a geographical visualisation of key moments forhand hygiene. Focusing on a single patient, the healthcare setting isdivided into two virtual geographical areas, the patient zone and thehealthcare zone (Figure 7).

The patient zone contains the patient X and his/ her immediatesurroundings. This typically includes the intact skin of the patient and allinanimate surfaces that are touched by or in direct physical contact withthe patient such as the bed rails, bedside table, bed linen and infusiontubing and other medical equipment. It further contains surfacesfrequently touched by HCWs while caring for the patient such as

' ' ' '

' '

KEY POINTS: You should know after reading topic A

1) …The presence of microorganisms on body siteswithout invading the tissue and without triggering a symptomatichost defence reaction2)i) of patients…transmission of micro-organisms from the health-careenvironment (e.g. furniture, equipment, walls, doors, documents,neighbouring patients, etc.) to a patientii) of health care environment…transmission of micro-organismsfrom the already colonised patients to health care environment (e.g.furniture, equipment, walls, doors, documents, neighbouringpatients, etc including HCWs).3) …denotes tissue invasion of micro-organisms triggeringan inflammatory host response.I) Exogenous infection… introduction of the infection to patient fromhealth care environment.II) Endogenous infection…. introduction of infection due to micro-organisms already colonising the patient before the onset ofinfection.4) Four negative outcomes that should be targeted to prevent thetransfer of germs by hand hygiene actions.

Colonisation

Cross- colonisation

Infection


monitors, knobs and buttons, and other high frequency touch surfaceswithin the patient zone. It has been assumed that the patient flora rapidlycontaminates the entire patient zone, but that it is being cleaned betweenpatient admissions.

The healthcare zone contains all surfaces outside the patient zone ofpatient X, i.e. all other patients and their patient zones and the healthcarefacility environment. Conceptually, the healthcare zone is contaminatedwith microorganisms that might be foreign and potentially harmful topatient X, either because they are multi-resistant or because theirtransmission might result in exogenous infection.

Within the patient zone, two critical sites should be distinguished (Figure7): sites to be protected from germs corresponding to body sites ormedical devices that have to be protected against micro-organismspotentially leading to HCAIs, and body fluid sites leading to handexposure to body fluids and blood-borne pathogens. Critical sites mayco-exist: drawing blood for example would result in a

o and a body fluid site at the same time at the site of needleperforation of the skin.

' '

site to be protectedfr m germs

(Figure 7)

PATIENT ZONE

HEALTH CARE ZONE

Body Fluid Site


Site to be Protectedfrom Germs

The geographical representation of the two zones and the two criticalsites (Figure 7) is useful to introduce the five moments for hand hygiene.The correlation between these five moments and the indications for handhygiene according to WHO Guidelines on Hand Hygiene in Healthcareis given in Table I. To further facilitate ease of recall and expand theergonomic dimension, the five moments for hand hygiene are numberedaccording to the habitual care workflow.

(Figure 8) My Five Moments for Hand Hygiene

KEY POINTS: You should know after reading topic B

1) … The patient zone contains the patient X and his/her immediate surroundings2) …contains all surfaces outside the patientzone of patient X, i.e. all other patients and their patient zones andthe healthcare facility environment including HCWs.3) … corresponding to bodysites or medical devices that have to be protected against micro-organisms potentially leading to HCAIs.4) …. sites that leads to hand exposure to body fluidsand blood-borne pathogens5) Critical sites may co-exist at same.

Patient zone

The healthcare zone

The sites to be protected from germs

Body fluid sites


Tab

leI‘M

yfive

mom

ents

for

handhygie

ne

’ :expla

nations

and

link

toevid

ence-b

ased

recom

mendations

Mom

ent

En

dp

ints

of

ha

nd

tran

smis

sion

Pre

ven

ted

neg

ativ

eout c

om

eE

xam

ple

sW

HO

reco

mm

endat

ion

(ran

kin

gfo

r

scie

nti

fic

evid

ence

)a

Com

men

ts

Bef

ore

pat

ient

conta

ct

Do

no

rsu

rface:

an

ys

ur

fa

ce

in

th

eh

ea

l th

ca

re

zo

ne

.R

ecep

tor

surf

ace:

any

surf

ace

inth

epat

ient

zone

Pa

tie

nt

cr

os

s-

colo

nis

atio

n;

rare

lye

xo

ge

no

us

infe

ctio

n

Shak

ing

han

ds,

hel

pin

ga

pat

ient

tom

ove

around,get

ting

was

hed

,ta

kin

gp

uls

e,b

loo

dp

ress

ure

,ch

est

ausc

ult

atio

n,

abd

om

inal

pal

pat

ion

Bef

ore

and

afte

rto

uch

ing

pat

ients

(IB

)T

he

two

mom

ents

bef

ore

and

afte

rto

uch

ing

apat

ient

wer

ese

par

ated

bec

ause

of

thei

rsp

ecif

icse

quen

tial

occ

urr

ence

inro

uti

ne

care

and

uneq

ual

neg

ativ

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om

ein

case

of

fail

ure

toad

her

e,an

dusu

alad

her

ence

level

.

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ore

asep

tic

task

Do

no

rsu

rface:

an

yoth

ersu

rfac

eR

ecep

torsu

rfac

e:si

teto

be

pro

tec

ted

f ro

mger

ms

Pat

ient

endogen

ous

infe

cti

on

;ra

rely

exogen

ous

infe

ctio

n

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l/d

en

tal

ca

re,

sec

reti

on

asp

irati

on

,sk

inle

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ncare

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ound

dre

ssin

g,

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taneo

us

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cti

on

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ete

rin

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pe

nin

ga

va

scu

lar

ac

ce

sssy

stem

;p

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arat

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of

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d,

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icat

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sets

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ore

han

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ng

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ice

for

pat

ientc

are,

regar

dle

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whet

her

or

not

glo

ves

are

use

d(I

B)

This

conce

pt

was

enla

rged

toco

ver

all

tran

sfer

of

mic

ro-o

rgan

ism

sto

vuln

erab

lebody

site

spote

nti

ally

resu

ltin

gin

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ctio

n.

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ovin

gfr

om

aco

nta

min

ated

body

site

toa

duri

ng

pat

ientc

are

(IB

)

site

tobe

prot

ecte

dfr

omge

rms

Sin

ceit

isnot

poss

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todet

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ine

thes

ebody

site

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ctiv

ely,

this

indic

atio

nw

asnot

reta

ined

asa

separ

ate

item

,but

cover

edby

wit

hin

-pat

ient-

zone

mom

ents

.

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erbody

fluid

exposu

reri

sk

Do

no

rsu

rface:

bo

dy

fluid

site

Rec

epto

rsu

rfac

e:an

yoth

ersu

rfac

e

Healt

hcare

wo

rker

infe

ctio

nO

ral/

de

nta

lc

are

,se

cre

tio

nasp

irati

on

;sk

inle

sio

ncare

,w

ound

dre

ssin

g,

subcu

taneo

us

inje

cti

on

;d

ra

win

ga

nd

man

ipula

ting

any

fluid

sam

ple

,o

pe

nin

gd

rain

ing

sy

ste

m,

endotr

achea

ltu

be

inse

rtio

nan

dre

mo

val;

cle

ari

ng

up

uri

nes,

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es,

vom

it,

han

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ng

was

te(b

andag

es,

nap

kin

,in

conti

nen

cepad

s),

clea

nin

gof

conta

min

ated

and

vis

ibly

soil

edm

ater

ial

or

are

as

(la

va

tori

es,

me

dic

al

inst

rum

ents

)

Aft

erre

movin

gglo

ves

(IB

)‘A

fter

body

fluid

exposu

reri

sk’

cover

sth

isre

co

mm

en

dati

on

;se

ete

xt

for

furt

her

com

men

ts.

Aft

erco

nta

ctw

ith

bo

dy

flu

ids

or

ex

cre

tio

ns,

mu

co

us

me

mb

ran

es,

nonin

tact

skin

,orw

ound

dre

ssin

gs

(IA

)

Ifm

ovin

gfr

om

aco

nta

min

ated

body

site

toa

duri

ng

pat

ientc

are

(IB

)

site

tobe

prot

ecte

dfr

omge

rms

This

risk

was

gen

eral

ised

toin

clude

allta

sks

that

can

pote

nti

ally

resu

ltin

han

dex

posu

reto

body

fluid

s.A

par

adox

of

body

fluid

exposu

rew

asre

solv

edby

incl

udin

gth

enoti

on

of

exposu

reri

skin

stea

dof

actu

alex

posu

re.

See

com

men

t(2)‘B

efore

asep

tic

task

’

(conti

nued

on

nex

tpag

e)

Lin

kto

WH

OG

uid

elin

es

for

Hand

Hygie

ne

inH

ealth

Care

27

1 2 3


Tab

leI‘M

yfive

mom

ents

for

handhygie

ne

’ :expla

nations

and

link

toevid

ence-b

ased

recom

mendations

Mom

ent

En

dp

ints

of

ha

nd

tran

smis

sion

Pre

ven

ted

neg

ativ

eout c

om

eE

xam

ple

sW

HO

reco

mm

endat

ion

(ran

kin

gfo

r

scie

nti

fic

evid

ence

)a

Com

men

ts

Af

te

rpat

ient

conta

ct

Healt

hcare

wo

rker

cro

ssc

olo

nis

ati

on

;e

nv

ir

on

me

nt

conta

min

atio

n

Bef

ore

and

afte

rto

uch

ing

pat

ients

(IB

)S

eeco

mm

ent(

1)‘B

efore

pat

ient

conta

ct’

The

two

mom

ents

bef

ore

and

afte

rto

uch

ing

apat

ient

wer

ese

par

ated

bec

ause

of

thei

rsp

ecif

icse

quen

tial

occ

urr

ence

inro

uti

ne

care

and

uneq

ual

neg

ativ

eoutc

om

ein

case

of

fail

ure

toad

her

e,an

dusu

alad

her

ence

level

.

Af

te

rco

nta

ctw

it

hpat

ient

surr

ou

nd

ings

Do

no

rsu

rface:

an

ysu

rfac

ein

the

pat

ient

zone

wit

hto

uch

ing

apat

ient.

Rec

epto

rsu

rfac

e:an

ys

ur

fa

ce

in

th

ehea

lthca

rezo

ne

Healt

hcare

wo

rker

cross

colo

nis

atio

n;

en

vi

ro

nm

en

tco

nta

min

atio

n

Chan

gin

gbed

linen

,per

fusi

on

spee

dad

just

men

t,m

on

ito

rin

gal

arm

,hold

ing

abed

rail

, cle

arin

gth

ebed

side

table

Aft

erco

nta

ctw

ith

inan

imat

eobje

cts

(incl

udin

gm

edic

aleq

uip

men

t)in

the

imm

edia

tevic

init

yofth

epat

ient (

IB)

Ret

ained

toco

ver

all

situ

atio

ns

wher

eth

ep

ati

en

t’s

imm

ed

iate

an

dp

ote

nti

all

yco

nta

min

ated

envir

onm

ent

isto

uch

edbut

not t

he

pat

ient

Do

no

rsu

rface:

an

ysu

rfac

ein

the

pat

ient

zone

wit

hout

touch

ing

the

pat

ient.

Rec

epto

rsu

rfac

e:an

ys

ur

fa

ce

in

th

ehea

lthca

rezo

ne

Lin

kto

WH

OG

uid

elin

es

for

Hand

Hygie

ne

inH

ealth

Care

27

aR

ankin

gsy

stem

forev

iden

ceac

cord

ing

toW

HO

guid

elin

es27:c

ateg

ory

IA,s

trongly

reco

mm

ended

forim

ple

men

tati

on

and

stro

ngly

support

edby

wel

l-des

igned

exper

imen

tal,

clin

ical

,orep

idem

iolo

gic

alst

udie

s;ca

tegory

IB,s

trongly

reco

mm

ended

forim

ple

men

tati

on

and

support

edby

som

eex

per

imen

tal,

clin

ical

,orep

idem

iolo

gic

alst

udie

san

da

stro

ng

theo

reti

cal

rati

onal

e.

4 5


Concept “My Five Moments for Hand Hygiene” Explained WithHelp of ScenariosTo perform hand hygiene opportunities in timely and correct manner, wehave given scenarios of each indication according to my five momentsfor hand hygiene. We hope that after reading these scenarios you will bemore able to know the concept. In each scenario HCW should supposedto be female and patient is male. Hand hygiene action performed is handrubbing with alcohol based formulations. Also read examples of eachindication carefully because some tasks look simple and apparentlypresent no risk but they may cause contamination of germs.

From the two-zone concept, a major moment 1 for hand hygiene isnaturally deduced. It occurs between the last hand-to-surface contactwith an object belonging to the healthcare zone and the first within the

Moment 1: Before Patient Contact

denotes hand hygiene action at place.

* Hand hygiene must be performed regardless of the fact that gloves are used or not.

1BeforePatientContact

EXAMPLES:

Courtesy and comfort gestures: shaking hands, stroking an armDirect physical contact: helping a patient to move around, to get washed, giving amassageClinical examination: taking pulse, blood pressure, chest auscultation, abdominalpalpation

When:

Why:

Action:

This indication applies when the health care worker enters thepatient surroundings to make contact with patient. You should clean yourshands before touching either the patient or his / her surroundings and afterlast hand contact with care environment.

This indication is justified by the risk of germ transmission from thecare environment to the patient. Hand hygiene action is performed toprotect the patient from harmful germs carried on yours hands.

Hand hygiene must be performed before touching the patient. Thehealth care worker must not touch any surface in the care environment afterhaving performed hand hygiene; the patient is thus protected.Note: Contacts of the same kind of following an “initial” contact with patient do notconstitute indications for hand hygiene unless the health care worker leaves thepatient zone.


patient zone best visualized by crossing the virtual line between the twozones. Hand hygiene at this moment will mainly prevent cross-colonization of the patient and, occasionally, exogenous infection. Aconcrete example would be the temporal period between touching thedoor handle and shaking the patient's hand: the door handle belongs tothe healthcare zone and the patient's hand to the patient zone.

You may understand better by reading following different scenarios.From which you can easily conclude that when indication for beforepatient contact applies.

Situation:

Indication 1: before patient contact

PATIENT ZONE

HEALTH CARE ZONE

Shaking hands Taking blood pressure Helping patient to get up

ACTIVITIES


Scenario A: Hand hygiene action before direct physical contact

Discussion:

Scenario B: Hand hygiene action before contact with patientsurroundings

HCW enters the room by opening the door (last contact with health carezone). She performs hand hygiene (hand rubbing) while approaching tothe patient. She helps the patient to bring out his arm from under the sheet(first contact with patient).

In the above scenario HCW performs the hand hygiene before directphysical contact. This is simple example of indication for hand hygienebefore patient contact. From above scenario you can easily understandthat you have to perform hand hygiene before direct contact with patientskin. So HCW performed hand hygiene action correctly at right moment.

HCW enters the room by opening the door (last contact with health carezone). She performs hand hygiene (hand rubbing). She moves the nighttable (contact with patient surroundings). She shakes hand with patient(first direct contact with patient) and palpates the pulse.

(Figure 9) Hand hygiene action before direct physical contact

HEALTH CARE ZONEPATIENT ZONE


(Figure 10) Hand hygiene action before contact with patient surroundings

In above scenario, HCW perform hand hygiene while entering thepatient zone. After hand hygiene action, first she has contact with patientsurroundings and then direct contact with patient by shaking hand. Youmay think that she has touched patient surroundings and not performedhand hygiene before direct physical contact. Night table belongs to thepatient zone; there is no need to perform hand hygiene again beforedirect physical contact with patient after touching the patientsurroundings. We hope that from above discussion you can easilyunderstand that while entering the patient zone if you have alreadyperformed hand hygiene; there is no need of again performing handhygiene after touching the patient surroundings. So, HCW performedhand hygiene action at right moment to prevent the germs.

HCW enters the room by opening the door (last contact with health carezone). She moves the night table (first contact with patient surroundings).She performs hand hygiene (hand rubbing) while approaching to thepatient. She helps the patient to bring his arm from under the sheet (firstdirect physical contact).

Discussion:

Scenario C: Hand hygiene action after touching the patientsurroundings and before the direct physical contact



(Figure 11) Hand hygiene action after touching the patient surroundings andbefore the direct physical contact

Discussion:

Scenario D: Hand hygiene action at wrong movement

In above scenario, HCW has first contact with patient surroundings andperformed hand hygiene before direct contact with patient. Contact withpatient surroundings does not strictly need for hand hygiene. As long asyou stay in the patient zone but you have not direct contact with patientand touched the patient's objects like night table, furniture, there is noneed for performing hand hygiene before contact with patientsurroundings. But as move to direct patient contact then it becomes amust condition to perform hand hygiene. So action performed correctly.

HCW while in the corridor performs hand hygiene and opens the door(last contact with health care environment) and goes to patient andshakes hand with patient (first contact with patient).



(Figure 12) Hand hygiene action at wrong movement

Discussion:

Scenario E: Multiple contacts with in the paint zone

In above scenario HCW hand hygiene action is missed because whileentering the patient zone she had contaminates her hand by touching thedoor handle. She has to perform hand hygiene again before patientcontact. While you are in the health care zone and perform hand hygieneand then touched any surface like door handle in health care zone. Youhave again contaminates yours hand because these surfaces like doorhandle are potential source of pathogens. You have to perform handhygiene again.

HCW enters the room by opening the door and performing the handhygiene while approaching the patient. She helps the patient to bring hisarm from under the sheet (first direct physical contact) and measureblood pressure. She moves the night table (contact with patientsurroundings). She takes the patient right arm (direct physical contact)and assesses the finger mobility. She bends to examine urine bag andtouch the patient bed (contact with patient surroundings). She pours aglass of water for the patient and also helps to drink it by holding his head(direct physical contact).



(Figure 13) Multiple contacts with in the patient zone

Discussion:In above scenario, you can understand that HCW has several contactswith patient and patient surroundings but no aseptic task indicationapplies nor after body fluid exposure risk indication. First she has contactwith patient, then patient surroundings and vice versa. HCW performedhand hygiene only once before first patient contact. There is no need forfurther hand hygiene as long as she stays in the patient zone. So youconclude that if no before aseptic task nor after body fluid exposure riskindication occurs during patient care activity, single hand hygiene actionis sufficient to cover all activities in the patient zone.

KEY POINTS: You should know for indication before patientcontact

Always do hand hygiene before direct physical contact withpatient.It is not mandatory to perform hand hygiene before touchingpatient surroundings.If you have performed hand hygiene action in health care zonethen don't touch any surface like door handle in the health carezone because these surfaces are potential sites of pathogens andcontaminate yours hands. If touched any surface in the healthcare zone then you should perform hand hygiene again.Single action hand hygiene performed is sufficient to cover all theactivities as long as you stay in the patient zone during patientcare unless a before aseptic task or after body fluid exposure riskindication applies.



Moment 2: Before Aseptic Task

Once within the patient zone, usually after a hand exposure to thepatient's intact skin, clothes or any other object, the HCW might engagein an aseptic task on a site to be protected from germs such as opening avenous access line, giving an injection, or performing wound care.Importantly, hand hygiene required at this moment aims at preventingcolonisation and HCAI. In line with the predominantly endogenousaetiology of these infections, hand hygiene is taking place between thelast exposure to a surface, even within the patient zone and immediatelybefore access to a site to be protected from germs. This is importantbecause HCWs customarily touch another surface within the patientzone before contact with a site to be protected from germs. For sometasks on sites to be protected from germs, e.g. lumbar puncture, surgicalprocedures, tracheal suctioning, etc., the use of gloves is standardprocedure. In this case, hand hygiene is required before donning gloves


2BeforeAsepticTask

EXAMPLES:

When:

Why:

Action:

This indication applies before any task involving direct or indirect*contact with mucous, damaged skin, an invasive medical device (catheter,probe), or health care equipments and products. You should clean yourshands before any aseptic task.

This indication is justified by the risk of germ transmission to thepatient via inoculation. These germs may come from the care environmentor from the patient himself. Hand hygiene action is performed to protect thepatient from harmful germs including the patient own germs, entering thepatient body.

Hand hygiene must be performed immediately before the task i.e.after having performed hand hygiene, the health care worker must touchonly surface required by the task. This is prerequisite for asepsis, the patientis thus protected.* Any health care worker operating “upstream” from actual direct care and involvedin preparing the equipment (i.e. a sterilization worker), substance (i.e. a pharmacist),and food (i.e. a cook) is concerned by this indication.

Contact with mucous membrane: oral/dental care, giving eye drops, secretionaspirationContact with non-intact skin: skin lesion care, wound dressing, any type ofinjectionContact with medical devices: catheter insertion, opening a vascular accesssystem or a draining systemPreparation of food, medications, dressing sets

Taking blood pressure Injection in a catheter Replacing a dressing

because gloves alone may not prevent contamination entirely.

Below we are given some scenarios for the indication of hand hygienebefore aseptic task. We hope after reading you will be more able tounderstand.

Situation:Indication 2: before aseptic task. Indication 2: before aseptic task.


PATIENT ZONE

HEALTH CARE ZONE

Scenario A: Hand hygiene action before direct aseptic taskHCW enters the room and places the instrument tray with the items readyfor injection on the night table (last contact with care environment). Thepatient is lying in bed asleep with a peripheral venous catheter on his armdirectly accessible to her. She pours the antiseptic onto the swabs. Sheperforms hand hygiene by hand rubbing. She opens the tap on theperipheral venous catheter, gives the injection and closes the tap again.

In the above scenario, indication for aseptic task is unique in thisscenario. HCW has no direct contact with the patient. She has directlyperformed aseptic task without touching any surface in the patient zone,not the patient and patient surroundings. She performs hand hygienecorrectly at right moment.

(Figure 14) Hand hygiene action before direct aseptic task.

Discussion:




Scenario B: Hand hygiene action before aseptic task within a caresequence

Note:

HCW enters the room and places the instrument tray with the items readyfor injection on the night table (last contact with care environment). Sheperforms hand hygiene by hand rubbing (indication: before patientcontact). She helps the patient to bring his arm out from under the sheets(first patient contact). She moves the night table (contact with patientsurroundings). She pours antiseptic onto the swabs. She performs handhygiene by hand rubbing. She opens the tap on the peripheral venouscatheter, gives the injection and closes the tap again (aseptic task).

Below are illustrations of above scenario with different versions. Aftertouching the patient and patient surroundings, after touching patient and aftertouching patient surroundings.

(Figure 15) Hand hygiene action before aseptic task within care sequence.



HEALTH CARE ZONE PATIENT ZONEPATIENT ZONE


Site to beProtected

fromGerms

Discussion:In above the scenario, hand hygiene action has been performed aftertouching the patient and patient surroundings and before access to a siteto be protected from germs for the indication before aseptic task. Handhygiene action needed immediately before doing the aseptic task. If youare in the patient zone and you have already performed hand hygiene butyou have to again perform hand hygiene action before access to a site tobe protected from germs (doing aseptic task) after touching the patient orpatient surroundings to prevents the patient from his own germs thatcomes from the patient itself or from patient surroundings (endogenousinfection). In above scenario, hand hygiene action has been performedcorrectly and in timely manner.


KEY POINTS: You should know for indication before aseptictask

Always perform hand hygiene action before every aseptic task.Hand hygiene action is needed immediately before aseptic task. Ifyou have touch patient or the patient surroundings in the patientzone after hand hygiene action, you should perform handhygiene again before aseptic task (recall endogenous infection).

Moment 3: After Body Fluid Exposure Risk

After a care task associated with a risk to expose hands to body fluids, e.g.after accessing a body fluid site, hand hygiene is required instantly andmust take place before any hand-to-surface exposure, even within thesame patient zone. This has a double objective. First and mostimportantly, it reduces the risk of colonisation or infection of HCWs withinfectious agents which can occur even in the absence of visible soiling.Second, it reduces the risk of a transmission of micro-organisms from abody site of which flora may be source of contamination to another body


3AfterBody FluidExposureRisk

EXAMPLES:

When:

Why:

Action:

This indication applies after any task which actually or potentiallyinvolves exposure of the hands to a body fluid. Clean yours handsimmediately after an exposure to body fluid risk (and after glove removal).

This indication is justified by risk of germ transmission from the patientto the health care worker and of their dissemination into care environment.Hand hygiene action is performed to protect yourself and health careenvironment from harmful pathogens.

Hand hygiene must performed immediately after task i.e., thehealth care worker must not touch any surface until HCW has performedhand hygiene; the health care worker and the care environment are thusprotected.

in handling the body fluids (i.e., laboratory technician, pathologist),contaminated and soiled equipment (i.e., sterilization worker) ,contaminated and soiled waste (i.e., maintenance or utility worker) isconcerned by this indication.

Note1:

Note 2:

Note3:

The action may be postponed until health care worker has left the patientsurroundings if the health care worker has to remove and process equipment on theappropriate premises. The health care worker must restrict him or herself exclusivelyto be removed and processed.

If health care worker wears gloves to perform the task involving a risk, thesemust be removed after task has been performed in order to practice hand hygiene atappropriate moment.

Any health care worker operating “downstream” from actual care andinvolved

Contact with mucous membrane and with non-intact skin, as detailed in theindication “before aseptic task”Contact with medical devices or clinical samples: drawing and manipulating anyfluid sample, opening a draining system, endotracheal tube insertion and removalClearing up urine, faeces, vomitHandling waste (bandages, napkin, incontinence pads), cleaning of contaminatedand visibly-soiled material or areas (lavatories, medical instruments)

site (including non-intact skin, mucous membrane or medical device)within the same patient. This routine moment for hand hygiene concernsall care actions associated with a risk of body fluid exposure and is notidentical to the hopefully very rare case of accidental visible soilingcalling for immediate hand washing. In some occasion, both criticalsites, site to be protected from germs and the critical body fluid site mayco-incide (Table I). Disposable gloves are meant to be used as a 'secondskin' to prevent exposure of hands to body fluids. However, hands are notsufficiently protected by gloves and hand hygiene is stronglyrecommended after glove removal. Even if glove removal represents astrong cue to hand hygiene action, the concept chooses to identify thismoment for hand hygiene with the associated risk (e.g. exposure to bodyfluids) rather than with the additional protective action (e.g. glove use).This has the double advantage of being more consistent with the risk-driven logic of the overall concept and to cover all times when gloves arenot worn.


PATIENT ZONE

HEALTH CARE ZONE

ACTIONPOSTPONED

Changing the a soiled bed Discarded soiled sheets Tidying bed side table

Lung auscultation Tracheal aspiration



Body Fluid Site



Body Fluid Site


KEY POINTS: You should know about indication after bodyfluid exposure

Always perform hand hygiene immediately after body fluidexposure. You should not touch any surface in patient zone orcare zone until you have performed hand hygiene.If yours hands are visibly soiled after body fluid exposure then youshould use water and soap for hand hygiene.You can postponed yours hand hygiene action but you shouldrestrict yourself exclusively to contact with equipment to beremoved and processed and hand hygiene should be atappropriate premises.

4AfterPatientContact

EXAMPLES:

When:

Why:

Action:

Note:

This indication applies when the health care worker leaves thepatient surroundings after touching the patient and his / her surroundingsand before having the first contact with the health care environment .

This indication is justified by the risks of germs transmission to healthcare worker and their dissemination into care environment. You shouldperform hand hygiene action to protect yourself and health careenvironment from harmful germs.

Hand hygiene must be performed after having touched the patientand patient surroundings i.e., the health care worker must not touch anysurface in the health care environment until hand hygiene has beenperformed. The health care worker and care environment are protected.


Courtesy and comfort gestures: shaking hands, stroking an armDirect physical contact: helping a patient to move around, to get washed,giving a massageClinical examination: taking pulse, blood pressure, chest auscultation,abdominal palpation


PATIENT ZONE

HEALTH CARE ZONE

ACTIONPOSTPONED

Making up the bed (bed-bound patient) Discarding sheets Tidying a bedside table

Shaking hands Taking blood pressure Returning to the office




KEY POINTS: You should know for indication after patientcontact.

Always perform hand hygiene action after patient contactYou should perform hand hygiene before touching any surface inhealth care environment after patient contact. If some belongingsto care environment like trolley in the patient zone, you shouldperform hand hygiene before touching them because these areparts of the care zone not the patient zone.You can postponed yours hand hygiene action but you shouldrestrict yourself exclusively to contact with equipment to beremoved and processed and hand hygiene should be atappropriate premises


5AfterContactwith PatientSurroundings

EXAMPLES:

When:

Why:

Action:

Note:

This indication applies when health care worker leaves the patientsurroundings after having touched the equipments, furniture, medicaldevices, personal belongings, or other inanimate surfaces, without havingbeen in contact with the patient. You must clean yours hand after touchingthe patient surroundings and before having the first contact with health careenvironment.

This indication is justified by the risk of germ transmission to the healthcare worker and of the dissemination into health care environment.

Hand hygiene must be performed after contact with patientsurroundings i.e., the hands must touch no surface in the care environmentuntil hand hygiene has been performed. The health care environment is thusprotected.


Changing bed linen, perfusion speed adjustment, monitoring alarm, holding abed rail, cleaning the night table

Adjusting perfusion speed Tidying the bed side table Leaving the room


PATIENT ZONE

HEALTH CARE ZONE

ACTIONPOSTPONED

Tidying the bedside table Removing dirty dishes Returning to the offices



KEY POINTS: You should know for the indication aftercontact with patient surroundings.

Always perform hand hygiene action after patient contact withpatient surroundings.You should perform hand hygiene before touching any surface inhealth care environment.If some belongings to care environment like trolley in the patientzone, you should perform hand hygiene before touching themafter contact with patient surroundings because these are parts ofthe care zone not the patient zone.You can postponed yours hand hygiene action but you shouldrestrict yourself exclusively to contact with equipment to beremoved and processed and hand hygiene should be atappropriate premises

Taking blood pressure Injection in a catheter Replacing a dressing

Taking the patient Xs vital signs Putting the patient Y to bed Helping the patient Z to drink something


Indication 4 :After patient contact Indication 4 Indication 4

Indication 3: After body fluid exposure


HEALTH CARE ZONEPATIENT ZONEPATIENT ZONE

HEALTH CARE ZONEPATIENT ZONEPATIENT ZONE


KEY POINTS: You should know for coincidence of twomoments for hand hygiene

Single hand hygiene action is sufficient to cover two indicationsfor two patients if you have not touch any surface in the patientzone or health care zone.



KEY POINTS: You should know for hand hygiene actionduring sequence Break

For any reason, you want to leave the patient zone, perform handhygiene before touching any surface in care zone and performhand hygiene before returning to patient.If you are not intended to or not touch any surface in health carezone. This does not apply.

Clean Care is Safer Care

This manual is adopted from WHO

2008

who “my five moments for hand hygiene” concept who “my five

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