There are two levels of hand treatment for medical personnel:

Hand hygiene:

1. hygienic hand washing with soap,

   hand hygiene skin antiseptic(without washing them first).

Treatment of surgeons' hands.

Hand hygiene.

Target: removing contaminants and reducing the number of microorganisms to a safe level (prevention of HAIs).

Indications:

before direct contact with the patient;

after contact with the patient's intact skin;

before performing various patient care procedures;

after contact with biological media of the body, mucous membranes, dressings;

after contact with medical equipment and other objects located in close proximity to the patient;

after treating a patient with purulent inflammatory processes;

after each contact with contaminated surfaces and equipment.

Contraindications: individual intolerance to the soap or skin antiseptic used.

Effectiveness conditions:

short-cut nails;

lack of nail polish;

no artificial nails;

lack of jewelry on hands (rings, rings, etc.);

provision of sufficient quantities of effective means for washing and disinfecting hands, as well as products for hand skin care (creams, lotions, balms).

Hygienic hand washing with soap.

Equipment: a sink equipped with a faucet with an elbow (touchless) valve; liquid soap; dispenser for liquid soap (elbow or other non-contact); paper towels(or an individual cloth towel); paper towel holder; pedal bin with class A waste bag.

Manipulation algorithm:

Rice. 2. Hygienic hand washing with soap.

Hygienic treatment of hands with skin antiseptic.

Equipment: skin antiseptic approved for use in an elbow dispenser (or other non-contact) or in an individual container.

Resolution of the Chief State Sanitary Doctor of the Russian Federation dated May 18, 2010 N 58 (as amended on June 10, 2016) “On approval of SanPiN 2.1.3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities” (together with...

12. Hand treatment rules medical personnel and skin

patients' covers

12.1. In order to prevent nosocomial infections, the hands of medical workers are subject to disinfection (hygienic treatment of hands, treatment of surgeons’ hands) and the skin of patients (treatment of surgical and injection fields, elbow bends of donors, sanitization skin).

Depending on the medical procedure being performed and the required level of reduction in microbial contamination of the skin of the hands, medical personnel perform hygienic treatment of hands or treatment of the hands of surgeons. The administration organizes training and monitoring of compliance with hand hygiene requirements by medical personnel.

12.2. To achieve effective hand washing and disinfection, the following conditions must be observed: short-cut nails, no nail polish, no artificial nails, no hands of rings, rings and other jewelry. Before treating surgeons' hands, it is also necessary to remove watches, bracelets, etc. To dry hands, use clean cloth towels or disposable paper napkins; when treating surgeons' hands, use only sterile cloth ones.

12.3. Medical personnel must be provided in sufficient numbers effective means for washing and disinfecting hands, as well as hand skin care products (creams, lotions, balms, etc.) to reduce the risk of contact dermatitis. When choosing skin antiseptics, detergents and hand skin care products, individual tolerance should be taken into account.

Target household level hand treatment - mechanical removal from the skin of most of the transient microflora (antiseptics are not used).

A similar hand treatment is carried out:

• after visiting the toilet;
• before eating or working with food;
• before and after physical contact with the patient;
• for any contamination of hands.

Required equipment:

1. Liquid dosed neutral soap or individual disposable soap in pieces. It is desirable that the soap does not have a strong odor. Opened liquid or bar reusable non-individual soap quickly becomes infected with germs.
2. Napkins measuring 15x15 cm are disposable, clean for blotting hands. Using a towel (even an individual one) is not advisable, because it does not have time to dry and, moreover, is easily contaminated with germs.

Hand treatment rules:

All jewelry and watches are removed from hands, as they make it difficult to remove microorganisms. Hands are soaped, then rinsed with warm running water and everything is repeated all over again. It is believed that during the first soaping and rinsing warm water germs are washed off from the skin of the hands. Under the influence of warm water and self-massage, the pores of the skin open, so when repeated soaping and rinsing, germs are washed away from the opened pores.

Warm water promotes a more effective effect of antiseptic or soap, while hot water removes the protective fat layer from the surface of the hands. In this regard, you should avoid consuming too much hot water for washing hands.

Hand treatment - the necessary sequence of movements

1. Rub one palm against the other palm in a back-and-forth motion.

1. Rub the back of your left hand with your right palm and switch hands.
2. Connect the fingers of one hand in the interdigital spaces of the other, rub internal surfaces fingers up and down.
3. Place your fingers in a “lock” and rub the palm of your other hand with the back of your bent fingers.
4. Cover the base thumb left hand between the thumb and index fingers right hand, rotational friction. Repeat on the wrist. Change hands.
5. Rub the palm of your left hand in a circular motion with your fingertips right hand, change hands.

Each movement is repeated at least 5 times. Hand treatment is carried out for 30 seconds - 1 minute.

It is very important to follow the described hand washing technique, since special studies have shown that during routine hand washing, certain areas of the skin (fingertips and their inner surfaces) remain contaminated.

After the last rinse, wipe your hands dry with a napkin (15x15 cm). The same napkin is used to close the water taps. The napkin is dumped into a container with a disinfectant solution for disposal.

In the absence of disposable napkins, it is possible to use pieces of clean cloth, which after each use are thrown into special containers and, after disinfection, sent to the laundry. Replacing disposable napkins with electric dryers is impractical, because... with them there is no rubbing of the skin, which means there is no removal of residues detergent and desquamation of the epithelium.

In order to prevent nosocomial infections, the hands of medical workers (hygienic treatment of hands, disinfection of surgeons’ hands) and the skin of patients (treatment of surgical and injection fields, elbow bends of donors, sanitary treatment of the skin) are subject to disinfection. Depending on the medical procedure being performed and the required level of reduction in microbial contamination of the skin of the hands, medical personnel perform hygienic treatment of hands or treatment of the hands of surgeons. The administration organizes training and monitoring of compliance with hand hygiene requirements by medical personnel.

To achieve effective washing and disinfection of hands, the following conditions must be observed: short-cut nails, no nail polish, no artificial nails, no rings, rings or other jewelry on the hands. Before treating surgeons' hands, it is also necessary to remove watches, bracelets, etc. To dry hands, use clean cloth towels or disposable paper napkins; when treating surgeons' hands, use only sterile cloth ones.

Medical personnel should be provided with sufficient quantities of effective means for washing and disinfecting hands, as well as hand skin care products (creams, lotions, balms, etc.) to reduce the risk of contact dermatitis. When choosing skin antiseptics, detergents and hand care products, individual tolerance should be taken into account.

Hand hygiene.

Hand hygiene should be carried out in the following cases:

before direct contact with the patient;

after contact with the patient's intact skin (for example, when measuring pulse or blood pressure);

after contact with body secretions or excreta, mucous membranes, dressings;

before performing various patient care procedures;

after contact with medical equipment and other objects located in close proximity to the patient;

after treating patients with purulent inflammatory processes, after each contact with contaminated surfaces and equipment.

Hand hygiene is carried out in two ways:

hygienic hand washing with soap and water to remove contaminants and reduce the number of microorganisms;

treating hands with a skin antiseptic to reduce the number of microorganisms to a safe level.

To wash your hands, use liquid soap using a dispenser. Dry your hands with an individual towel (napkin), preferably disposable.

Hygienic treatment of hands with alcohol-containing or other approved antiseptic (without prior washing) is carried out by rubbing it into the skin of the hands in the amount recommended in the instructions for use, turning Special attention for treating fingertips, skin around nails, between fingers. An indispensable condition for effective hand disinfection is keeping them moist for the recommended treatment time.

When using a dispenser, a new portion of antiseptic (or soap) is poured into the dispenser after it has been disinfected, washed with water and dried. Preference should be given to elbow dispensers and photocell dispensers.

Skin antiseptics for hand treatment should be readily available at all stages of the diagnostic and treatment process. In departments with a high intensity of patient care and with a high workload on staff (resuscitation and intensive care units, etc.), dispensers with skin antiseptics for hand treatment should be placed in places convenient for use by staff (at the entrance to the ward, at the patient’s bedside and etc.). It should also be possible to provide medical workers with individual containers (bottles) of small volumes (up to 200 ml) with skin antiseptic.

Infections associated with the provision of medical care(HAIs) are the main problem in ensuring patient safety, which is why preventing their occurrence should be a priority for medical organizations of any profile. According to the World Health Organization, out of 100 hospitalized patients, at least 7 become infected with HAIs. Among seriously ill patients treated in intensive care units, this rate increases to approximately 30 HAIs per 100 people.

HAIs often occur in situations where the source of pathogenic microorganisms for the patient is the hands of healthcare workers. Today, hand washing by medical personnel or treating them with skin antiseptics are the most important infection control measures, which can significantly reduce the spread of infections that arise during the diagnostic and treatment process in organizations engaged in medical activities.

Background

The history of hand hygiene among medical personnel dates back to the mid-19th century, when the highest mortality rate due to “puerperal fever” was observed in obstetric clinics in European countries. Septic complications claimed the lives of about 30% of women in labor.
IN medical practice At that time, doctors' passion for dissecting corpses was widespread. Moreover, after visiting the anatomical theater, the doctors went to the patients without treating their hands, but simply wiping them with a handkerchief.
There were many different theories about the origin of puerperal fever, but discover real reasons Only the Viennese doctor Ignaz Philipp Semmelweis succeeded in spreading it. The 29-year-old doctor suggested that the main cause of postpartum complications is contamination of the hands of medical personnel with cadaveric material. Semmelweis noticed that a solution of bleach eliminates the smell of rotting, which means it can also destroy the infectious principle present in corpses. An observant doctor suggested treating obstetricians' hands with a chlorine solution, which led to a 10-fold reduction in mortality in the clinic. Despite this, Ignaz Semmelweis's discovery was rejected by his contemporaries and received recognition only after his death.

Hand hygiene is a priority measure that has proven high efficiency in preventing HAIs and the spread of antimicrobial resistance of pathogenic microorganisms. However, even today the problem of cleaning the hands of medical personnel cannot be considered completely resolved. Research conducted by WHO has shown that poor hand hygiene compliance among health care workers occurs in both developed and developing countries.

According to modern concepts, the transmission of HCAI pathogens occurs in various ways, but the most common transmission factor is the contaminated hands of medical workers. Wherein infection through the hands of personnel occurs in the presence of a number of the following: conditions :

1) the presence of microorganisms on the patient’s skin or objects in his immediate environment;

2) contamination of the hands of medical workers with pathogens through direct contact with the patient’s skin or surrounding objects;

3) the ability of microorganisms to survive on the hands of medical personnel for at least several minutes;

4) incorrect implementation of the hand disinfection procedure or ignoring this procedure after contact with the patient or objects in his immediate environment;

5) direct contact of the contaminated hands of a medical worker with another patient or an object that will come into direct contact with this patient.

Microorganisms associated with medical care can often be found not only on the surface of infected wounds, but also on areas of completely healthy skin. Every day, about 10 6 skin flakes with viable microbes peel off, contaminating patients' underwear and bed linen, bedside furniture and other objects. After direct contact with a patient or environmental objects, microorganisms can survive on the hands of healthcare workers for quite a long time, most often from 2 to 60 minutes.

The hands of medical personnel can be colonized by representatives of their own, resident microflora, and can also be contaminated with potential pathogens (transient microflora) during various manipulations, which is of great epidemiological significance. In many cases, pathogens of purulent-septic infections released from patients are not found anywhere except on the hands of medical workers.

Rules for hand treatment of medical personnel

IN Russian Federation the rules for treating the hands of medical personnel are regulated by SanPiN 2.1.3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities.” Depending on the nature of the medical procedure being performed and the required level of reduction in microbial contamination of the skin, medical personnel must perform hand hygiene or the so-called surgical hand treatment.

To achieve an effective level of hand skin disinfection medical workers must comply with the following requirements :

1. Have short-cut natural nails without varnish.

It should be understood that the use of nail polish itself does not lead to increased contamination of the hands, but cracked polish makes it difficult to remove microorganisms. Varnish dark colors may hide the condition of the subungual space, which leads to insufficient high-quality processing. In addition, the use of nail polish can cause unwanted dermatological reactions, which often result in secondary infection. The procedure for performing a manicure is quite often accompanied by the appearance of microtraumas, which can easily become infected. For the same reasons, medical workers should not wear artificial nails.

2. Do not wear rings, rings or other jewelry on your hands while working. Before surgical treatment of the hands, it is also necessary to remove wrist watch, bracelets and other accessories.

Jewelry on the hands can lead to increased contamination of the skin and difficulty in removing microorganisms, jewelry and Jewelry complicate the process of putting on gloves and also increase the likelihood of damage.

According to SanPiN 2.1.3.2630-10, there are two types of disinfection of the hands of medical workers - hygienic hand treatment and disinfection of the hands of surgeons.

Hand hygiene must be carried out in the following cases:

Before direct contact with the patient;

After contact with the patient's intact skin (for example, when measuring pulse or blood pressure);

After contact with body secretions or excreta, mucous membranes, dressings;

Before performing various patient care procedures;

After contact with medical equipment and other objects located in close proximity to the patient;

After treating patients with purulent inflammatory processes, as well as after each contact with contaminated surfaces and equipment.

Exist two ways hand hygiene: washing with soap and water to remove contaminants and reduce the number of microorganisms, and using a skin antiseptic to reduce the number of microorganisms to a safe level.

For hand washing, liquid soap is used, dispensed using a dispenser. Avoid using hot water as it may increase the risk of dermatitis. If the faucet is not equipped with an elbow drive, you must use a towel to close it. To dry your hands, use individual clean cloth or paper towels, preferably single-use ones.

Hygienic treatment of hands (without prior washing) with a skin antiseptic is carried out by rubbing it into the skin of the hands in the amount recommended in the instructions for use, paying special attention to the fingertips, the skin around the nails and between the fingers. An important condition effective hand hygiene is to keep them moist for the recommended exposure time. You should not wipe your hands after handling.

For your information

Alcohol-based skin antiseptics show b O greater effectiveness compared to antiseptics on water based, and therefore their use is preferable in the absence of conditions necessary for hand washing, or in conditions of shortage of working time.

Treatment of surgeons' hands performed by all medical workers involved in surgical interventions, childbirth and catheterization of great vessels. Surgical hand antisepsis includes two mandatory stages:

1. Wash hands with soap and water for 2 minutes, then dry with a sterile cloth towel or napkin.

On at this stage It is recommended to use sanitary devices and elbow dispensers, which can be operated without the use of hands. If brushes are used, which is not a requirement, the choice should be either sterile, soft, disposable brushes or brushes that can withstand autoclaving. Brushes should only be used to treat periungual areas when disinfecting hands for the first time during a work shift.

2. Treatment of hands, wrists and forearms with a skin antiseptic.

Hands must be kept moist throughout the recommended treatment time. After exposure to a skin antiseptic, it is prohibited to wipe your hands. The amount of a particular product required for treatment, the time of its exposure and the frequency of application are determined by the recommendations set out in the instructions attached to it. Sterile gloves are put on immediately after completely dry antiseptic on the skin of the hands.

For surgical hand treatment, the same preparations can be used as for hygienic treatment. However, it is very important to use skin antiseptics that have a pronounced residual effect.

Fill dispensers for soap or skin antiseptic only after they have been disinfected, washed with water and dried. Preference should be given to elbow dispensers and dispensers powered by photocells.

Skin antiseptics for hand treatment should be readily available at all stages of the diagnostic and treatment process. In departments with a high intensity of patient care and a high workload for staff, dispensers with skin antiseptics should be placed in places convenient for use by medical workers (at the entrance to the ward, at the patient’s bedside, etc.). It should also be possible to provide medical workers with small-volume individual bottles of skin antiseptic (up to 200 ml).

Prevention of occupational dermatitis

Repeated hand cleaning during execution labor responsibilities by medical personnel can lead to skin irritation, as well as the occurrence of dermatitis - one of the most widespread occupational diseases of medical workers. The most common skin reaction is irritative contact dermatitis, which is manifested by symptoms such as dryness, irritation, itching, and in some cases, cracking of the skin. The second type of skin reaction is allergic contact dermatitis, which is much less common and is an allergy to certain ingredients in a hand sanitizer. The manifestations and symptoms of allergic contact dermatitis can be varied and range from mild and localized to severe and generalized. In the most severe cases allergic contact dermatitis may be accompanied by difficulty breathing and some other symptoms of anaphylaxis.

Irritative contact dermatitis is usually associated with the use of iodophors as skin antiseptics. Other antiseptic components that can cause contact dermatitis, with decreasing incidence, include chlorhexidine, chloroxylenol, triclosan and alcohols.

Allergic contact dermatitis occurs when using hand products containing quaternary ammonium compounds, iodine or iodophors, chlorhexidine, triclosan, chloroxylenol and alcohols.

Available a large number of data received in various studies, about the best skin tolerance of alcohol-containing antiseptics.

Allergic reactions and irritation of the skin of the hands of medical personnel cause a feeling of discomfort, thereby worsening the quality of medical care, and also increase the risk of transmitting HAI pathogens to patients due to the following: reasons:

Due to skin damage, a change in its resident microflora, colonization with staphylococci or gram-negative microorganisms is possible;

During the procedure, hygienic or surgical hand treatment is not achieved required level reducing the number of microorganisms;

As a result of discomfort and other unpleasant subjective feelings There is a tendency for a health care worker who experiences skin reactions to avoid hand sanitizing.

Adviсe

In order to prevent the development of dermatitis, medical personnel must observe a number of the following additional recommendations:
1) do not resort to frequent hand washing with soap immediately before or after using alcohol-containing products. Washing your hands before using an antiseptic is necessary only if there are visible contaminants on the skin;
2) when washing your hands, you should avoid using very hot water, as this can lead to skin injury;
3) when using disposable towels, it is very important to blot the skin rather than rub it to avoid the formation of cracks;
4) you should not wear gloves after treating your hands until they are completely dry in order to reduce the risk of developing skin irritation;
5) it is necessary to regularly use creams, lotions, balms and other hand skin care products.

One of basic preventive measures The development of occupational dermatitis in medical workers is to reduce the frequency of exposure of the skin to soap and other irritating detergents through the widespread introduction into practice of alcohol-based antiseptics containing various emollient additives. According to WHO recommendations, use in medical organization alcohol-based hand hygiene products are preferable when available, as this type antiseptics have a number of advantages, such as a wide spectrum of antimicrobial activity, including against viruses, short exposure time, and good skin tolerance.

The problem of medical personnel compliance with hand hygiene rules

Numerous epidemiological studies of the adherence (compliance) of medical personnel to the recommended rules of hand hygiene show unsatisfactory results. On average, medical staff compliance with hand sanitizing requirements is only 40%, and in some cases much lower. Interesting fact is that doctors and junior medical staff are much more likely than nurses to not follow recommendations for hand antiseptics. Most high level compliance is observed on weekends, which is apparently associated with a significant reduction in workload. More low level hand hygiene is recorded in intensive care units and also during periods of intense nursing care, while the highest levels are observed in children's wards.

Obvious barriers to proper implementation of recommendations hand treatment by medical personnel are skin allergic reactions, low availability of hand antisepsis and conditions for its implementation, priority of measures to care for the patient and provide medical assistance to him, the use of gloves, shortage of working time and high professional workload, forgetfulness of medical workers, lack of basic knowledge of existing requirements, misunderstanding of the role of hand treatment in the prevention of HCAI.

Activities to improve hand hygiene practices in a medical organization, there should be extensive educational programs among personnel on hand hygiene issues, monitoring the application of acquired knowledge in professional activity, development of written recommendations on the issues of antiseptic treatment when performing various manipulations, reducing the workload on medical workers, creating appropriate conditions for hand hygiene, providing staff not only with antiseptics, but also skin care products, various administrative measures, sanctions, support and encouragement of employees , performing high-quality hand treatment.

Introduction of modern antiseptics, skin care products and hand hygiene equipment, as well as broad educational programs for medical personnel it is absolutely justified. Data from numerous studies show that the economic costs associated with treating 4-5 cases of HCAI medium degree severity, exceed the annual budget required to purchase hand hygiene products for the entire health care organization (HPO).

Medical gloves

Another aspect related to hand hygiene for medical personnel is use of medical gloves. Gloves significantly reduce the likelihood of occupational infection when in contact with patients or their secretions, reduce the risk of contamination of the hands of medical personnel with transient microflora and its subsequent transmission to patients, and prevent infection of patients with microorganisms that are part of the resident flora of the hands of medical workers. By creating an additional barrier to potentially pathogenic agents, gloves simultaneously protect both the healthcare worker and the patient.

The use of gloves is an important component of the system universal measures precautions and infection control in healthcare facilities. However, medical personnel often neglect to use or change gloves even in cases where there are clear indications for this, which significantly increases the risk of transmission of infection both to the medical worker himself and from one patient to another through the hands of staff.

According to existing requirements sanitary legislation gloves must be worn in all of the following situations :

There is a possibility of contact with blood or other biological substrates potentially or obviously contaminated with microorganisms;

There is a possibility of contact with mucous membranes or damaged skin of the patient.

If gloves are contaminated with blood or other biological fluids, in order to avoid contamination of hands during the process of removing gloves, remove visible contamination with a swab or napkin moistened with a solution disinfectant or skin antiseptic. Used gloves are disinfected and disposed of along with other medical waste of the appropriate class.

The significant effectiveness of gloves in preventing contamination of the hands of medical personnel and reducing the risk of transmission of microorganisms during the provision of medical care has been confirmed in clinical studies. However, healthcare workers must be aware that gloves cannot provide complete protection against microbial contamination of the hands. Microorganisms are able to penetrate through the smallest defects, pores and holes in the material, and also fall on the hands of personnel during the procedure for removing gloves. Penetration of liquids into gloves is most often observed in the area of ​​the fingertips, especially the thumb. However, only 30% of medical personnel notice such situations. In connection with these circumstances, before putting on gloves and immediately after removing them, it is necessary to carry out antiseptic treatment of hands.

Gloves are single-use medical devices and therefore decontamination and reprocessing are not recommended. This practice should be avoided, including in organizations engaged in medical activities, where the level of material resources is low and the supply of gloves is limited.

The following main ones are distinguished types of medical gloves:

Examination (diagnostic) gloves;

Surgical gloves with an anatomical shape, providing high-quality wrist girth;

Special purpose (for use in various branches of medicine): orthopedic, ophthalmological, etc.

To make it easier to put on gloves, manufacturers use various substances. Most often, talc, starch-containing powder, magnesium oxide, etc. are used. It should not be forgotten that the use of powdered gloves can lead to a decrease in tactile sensitivity. It is undesirable for glove powder to get into the wound area, since cases of postoperative complications due to hypersensitivity reactions in patients have been described. The use of powdered gloves in dental practice is not recommended, as this can cause discomfort in the patient’s oral cavity.

The following requirements apply to medical gloves: :

Should fit snugly to the hand throughout the entire time of use;

Should not cause hand fatigue and correspond to the size of the healthcare worker’s hand;

Must maintain good tactile sensitivity;

The material from which the gloves are made, as well as the substances used to powder them, must be hypoallergenic.

Compliance modern requirements to hand hygiene of medical personnel can significantly improve the quality of medical care in healthcare facilities by significantly reducing the risk of patients becoming infected with HAIs.

Literature

1. Afinogenov G. E., Afinogenova A. G. Modern approaches to hand hygiene of medical personnel // Clinical microbiology and antimicrobial chemotherapy. 2004. T. 6. No. 1. P. 65−91.
2. Hand hygiene and the use of gloves in health care facilities / Ed. Academician of the Russian Academy of Natural SciencesL. P. Zuevoy. St. Petersburg, 2006. 33 p.
2. Opimakh I. V.The history of antiseptics is a struggle of ideas, ambitions... // Medical technologies. Evaluation and selection. 2010. No. 2. P. 74−80.
3. WHO guidelines on hand hygiene in health care: summary, 2013. Access mode:http:// www. who. int/ gpsc/5 may/ tools/9789241597906/ ru/ . Date of access: 11/01/2014.
4. SanPiN 2.1.3.2630-10 “Sanitary and epidemiological requirements for organizations engaged in medical activities.”

Dubel E.V., head epidemiological department, epidemiologist of the Vologda City Hospital No. 1; Gulakova L. Yu., chief nurse of the Vologda City Hospital No. 1