AHBS 3256 HOSPITAL SAFETY

SEM 2 2019/2020
DEPARTMENT OF BIOMEDICAL SCIENCE

HOSPITAL VISIT REPORT

“HAND HYGIENE, PPE AND
GLOVE DERMATITIS”

NO NAME MATRIC NO
1 Nur Rifqah Alia binti Ismail 1717324
2 Nur Saiyidah binti Zainal 1716880
3 Nuradhiya Nabiha binti Jantraz 1714382
4 Nurul ‘Aina Aqilah binti Rosli 1716384
5 Nurul Ezzah Syazana binti Abd Manap 1616896
6 Nurul Jasmeen binti Baseer Ahmad 1710954

Date of Submission: 12th June 2020

Lecturer: Asst. Prof. Dr. Norul Hernani binti Abd Latif

HAND HYGIENE

Hands are the most common vehicle to transmit pathogenic microorganisms. As these
microorganisms cannot be seen with naked eyes, people often overlook their existence by
assuming the hands are fully clean without dirt. Health care workers (HCWs) who have the
highest exposure to this biological hazard must take safety precaution by practicing good
hand hygiene so that it will not be pass to the patients. As mentioned by Richard P. Wenzel, a
professor of internal medicine at Virginia Commonwealth University, “The most advanced
medical care will not work if clinicians do not prevent infections through basic things such as
regular hand hygiene. Health care workers want the best for their patients; following standard
infection control practices every time will help ensure their patients’ safety” (Anderson,
2014). Thus, hand hygiene should be part of HCW’s personal hygiene and they need to
practice consistently to prevent further risk to the public health.

According to World Health Organization (WHO) (2009), the term hand hygiene
literally means the action of hand cleansing. In other words, it refers to the act of removing
dirt, organic material and microorganisms. Hand hygiene is the most basic and easiest step in
preventing and controlling infection from being transmitted to one another. It can be done
through proper hand wash or hand rub technique as outlines by WHO. Basically, antiseptic
hand washing and hand rubbing are the most prominent ways to eliminate germs that reside
on the hands of HCWs as they usually involve with patient-care activities. This will
eventually reduce the risk of nosocomial infection among HCWs as well as the patients.

The concept of hand hygiene was once introduced few decades ago. In July 1881, the
former USA President, James Abram Garfield was shot and he was brought to the hospital for
medical treatment. However, due to improper hand hygiene practices of the physicians when
removing the bullet, led to an overwhelming infection known as sepsis and he was eventually
died (Markel, 2016). On the other hand, in the mid of 1800s, Oliver Wendell Holmes and
Ignaz Phillips Semmelweis had long discovered the potential of getting healthcare-associated
disease were through HCWs’ unhygienic hands (World Health Organization, 2009).
Nevertheless, because of the ignorance of many HCWs during that time had led to the loss of
people’s live. The records in WHO has stated that Semmelweis had undergone an
investigation in a clinic which was reported to have a significantly high maternal mortality
rate due to puerperal fever. Later, it is revealed that the disease was transmitted via the
doctors and nurses’ hands. Semmelweis then suggested them to practice a proper hand
washing technique using an antiseptic agent. Surprisingly, the mortality rate became decline
and remained low. Hence, a good hand hygiene practice has been provenly effective to
prevent healthcare-associated infections (HAIs).

Basically, microorganisms that inhabiting at human’s body are known as flora. This
microflora which are also known as microbiota can reside at any part of human’s body. In
fact, after the gut, skin has the highest microflora present on the body especially at the hands
(Lee, August 2014). There are two types of microflora that exist on the skin; resident flora
(normal flora) and transient flora. Resident flora are microorganisms that stay on the skin
silently and usually do not cause any harm to its owner. Remarkably, some of the resident
flora are beneficial by acting as the the barrier of the skin and protect it from any new
pathogenic microorganism. Meanwhile, transient flora was totally the opposite of resident
flora. Transient flora are the microorganisms that deposited on the skin temporarily and can
be washed out by performing proper hand hygiene technique (Lilly & Lawbury,1978). They
are the organisms that most likely to cause HAI. Therefore, HCWs must adhere to the
hospital policy by practicing good hand hygiene regularly which has been guided by WHO.

Hand hygiene is one of the most effective ways to minimize personal exposure by
applying hand wash or hand rubs. Washing hand with good detergent removes external
bacteria and chemicals before they can be ingested or absorbed. Hand should be washed
frequently throughout the day especially before eating, leaving the laboratory, before and
after touching patients and using hospital facilities. Hand should be thoroughly lathered with
soap, using friction for 20 seconds, rinsed in clean water and dried using a clean paper or
cloth towel. Alcohol- based hand sanitizers are recommended to decontaminate lightly soiled
hands when proper hand washing is not available or convenient. Hand rubs can be done by
using an alcohol-based hand sanitizer that contains at least 60% alcohol for 20 seconds until
hands feel dry. For good, use hand sanitizer after hand wash give a prefect personnel hygiene
in restricting the transfer of bacteria, viruses and germs from sources of contamination. It is
important to practise hand hygiene because hands are measured as the dominant medium of
pathogen transfer. It happens when we hold contaminated sources and forget to wash hands.
The germs not only will make us infected but we are also spreading the germs to others.
Hence, proper hand hygiene must be performed correctly at the right time to avoid
transmission of infectious disease. This transmission can be ranged from HCWs to caregivers
or person that involved in direct or indirect with patients.
 Next, removing the dirt, dust and harmful germ carried on hand. According to a study,
one of Detroit hospital has found a way to improve hand hygiene as many HCWs do not
wash their hands nearly as often as they should. The infection team at the Henry Ford Health
System aimed to evoke the feeling of disgust among HCWs after inspired by a study in 2014
shown emotional motivators more effective than traditional messaging. The infection team
presented millions of images of bacterial growth to motivate HCWs to comply with hand
hygiene guidelines. The images captured bacterial growth on common surfaces like unused
gloves, doorknobs, a nurse station mouse, health-care workers' hands, a mobile phone and an
ultrasound machine. After the images shared and tested for two months, the infection team
found that hand-washing rates improved among HCWs[ CITATION Cab20 \l 17417 ]. Thus,
hand hygiene is one of the most important ways to prevent and control the spread of
infectious diseases which can lead to HAIs to hospitalized patients.

Good hand hygiene can minimize the risk of healthcare associated infections being
passed from person to person. HAIs can be transmitted via HCWs’ hands by five sequential
ways. Firstly, thorough the microorganisms present on the patient’s skin or have been shed
onto inanimate objects surrounding the patient. Secondly, microorganisms transfer from
patients to the hands of HCWs can lead cross-transmission of nosocomial pathogens. Third,
survival of microorganisms for at least several minutes on HCWs’ hands. Forth, inadequate
hand washing or hand sanitize by the HCWs. Inappropriate hand hygiene can result in hands
remaining contaminated. Fifth, the contaminated hands during patient care result in within-
patient cross transmission [ CITATION Nat16 \l 17417 ].

Therefore, the HCWs should perform 5 Moments of Hand Hygiene which are
designed to reduce the risk of transmission of nosocomial pathogens between other HCWs,
the patients, and in healthcare environment. First, cleaning hands before touching a patient.
HCWs must wash their hands to remove any potential germs before entering a patient’s room
even though they do not touch the previous patient directly or they only touch inanimate
objects surrounding patients. Second, cleaning hands before a procedure. HCWs must clean
their hands to reduce the spread of infection especially accessing critical site with infectious
risk for patients like mucous membrane, non- intact skin and an invasive medical devise.
Third, cleaning hands after a procedure or exposure to bodily fluids. This will protect HCWs
from harmful germs and also protect the healthcare environment from germ spread. The
HCWs must wash their hands appropriately after contact with blood, urine and other bodily
fluids of patients. Forth, cleaning hands after touching a patient. After touching a patient,
HCWs should wash their hands thoroughly even though they have a little contact with
patients. Therefore, the chances of spreading infection from one patient to other patients can
be reduced. Fifth, cleaning hands after touching patients’ environment. After an activity
involving physical contact with the patient’s immediate surroundings like changing bed linen,
holding a bed trail, clearing a bedside table and monitoring alarm, the HCWs should wash
their hands (World Health Organization, 2020) . Thus, performing hand hygiene is essential
for HCWs and should be performed correctly when handling patients are highly susceptible
to infection.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Every occupation is this world have its very own risk of hazards. These occupational
hazards exist in various forms which are physical hazards, biological hazards, chemical
hazards, mechanical hazards and many other potentially dangerous situations. These hazards
are contributing to work injuries and these injuries could be reduced when there is a proper
assessment being conduct and at the same time applying standards preventive measures.
Personal protective equipment (PPE) is one of the important steps in applying preventive
measures in working environment.

Personal Protective Equipment or PPE is being defined as equipment worn to minimize

exposure to variety of hazards and examples of PPE are gloves, foot and eye protection,
protective hearing devices (earplugs or muffs), hard hats, respirators or full body suit
(Personal Protective Equipment, 2004). The requirement of PPE is much needed in order to
ensure the greatest possible protection for employees in the working environment. However,
it is the employer’s responsibility to decide on the appropriate use of PPE depending on the
type of hazards the employees are dealing with.

Next, the selection of PPE is based on hazard assessments at the workplace and also the
proper training provided by the employer. The proper training on the correct technique of
wearing PPE is really important, to ensure all of the workers really understand on the correct
technique of wearing PPE. inadequate understanding on the usage of PPE would be such a
waste of PPE and not serving its sole function which is to reduce hazards. Then, hazard
assessment will determine on which type of PPE that is needed for the workers. For example,
eye and face personal protective equipment, this protection is crucial for workers that are
very much expose to biological or chemical hazards such as bodily fluids and harmful
chemicals.

As employees can be exposed to a large number of hazards that pose danger to their eyes
and face, it is suggested by OSHA that “eye protection be routinely considered for use by
carpenters, electricians, machinists, mechanics, millwrights, plumbers and pipefitters, sheet
metal employees and tinsmiths, assemblers, sanders, grinding machine operators, sawyers,
welders, laborers, chemical pro-cess operators and handlers, and timber cutting and logging
workers. Employers of employees in other job categories should decide whether there is a
need for eye and face PPE through a hazard assessment” (Personal Protective Equipment,
2004).

The standard of PPE is also crucial in order to publish standards for the manufacture,
testing and the functionality of the PPE. There are several standards of care for PPE exists,
The American National Standard Institute (ANSI), American Society for Testing and
Material (ASTM), and National Fire Protection Association (NFPA). According to OSHA,
“Existing PPE stocks must meet the ANSI standard in effect at the time of its manufacture or
provide protection equivalent to PPE manufactured to the ANSI criteria. Employers should
inform employees who provide their own PPE of the employer’s selection decisions and
ensure that any employee-owned PPE used in the workplace conforms to the employer’s
criteria, based on the hazard assessment, OSHA requirements and ANSI standards”
(Personal Protective Equipment, 2004).

Failure of practising fully PPE will causes the workers to be liable of their own injuries
instead of their employer, in which will make it hard for the responsible organizations to
issue compensation or employment injury benefits for the respective workers. Being found
partially responsible in a court of law for your own workplace injuries from a failure to
practise PPE is a worst-case scenario.

There are many types of PPE being used in hospitals and healthcare system. Firstly,
gloves. Gloves are part of the PPE that helps to protect the hands and it should be worn when
handling patient as healthcare workers are often exposed to blood, bodily fluids, secretions or
excretions. It is also used when handling contaminated equipment to protect healthcare
workers against the pathogens (Mathieson, 2015). Hospitals often use disposable gloves to
reduce cross-contaminations between patients. Healthcare workers should be aware that
gloves are for single patient use and should be discarded appropriately before handling
another patient. Next, sterile gloves are also used in healthcare settings especially surgeons or
personnel that perform invasive patient procedure such as surgeries. Healthcare workers
should avoid touching unnecessary environmental surface when wearing gloves as it might
cause “touch contamination” (CDC, n.d.). When removing the gloves, one should avoid
touching the outer surface of the gloves. Instead, one should remove one glove and remove
another by hooking a finger into the end of the glove and remove it from the inside.

Secondly, disposable aprons or gowns which are used to protect the uniforms/clothing
from being contaminated by blood or body fluids during the handling of patient. Usually,
isolation gowns are mainly used as PPE, but aprons are occasionally used when limited
contamination anticipated during a procedure. Clean or sterile gowns can both be used as
PPE depending on the procedures. For example, clean gowns are generally used for isolation
while sterile gowns are mainly used during invasive procedure like inserting a central line
(CDC, n.d.). Aprons or gowns should not be worn routinely in ward and must be changed
between patients. In some cases, the gowns or aprons may need to be changed between
different procedures on the same patient. When removing the gowns, the outer surface must
not be touched and must be taken off inside out. The apron or gown should be folded or
rolled into a ball before being discarded into appropriate bin (Mathieson, 2015).

Third, face protection that comprises of few types. The selection of face protection
depends on the isolation precautions required and the nature of the patient contact. Mainly, it
helps to protect mouth and nose during procedures that might involve splashes of blood and
body fluids. It also prevents transmission of infectious disease that transmitted through
droplets and airborne.

1) Masks
It helps to protect nose and mouth and it prevent fluid penetration. When
wearing a mask, one should ensure that it fit and fully cover the nose and
mouth. Usually, mask that have a flexible nose piece and have string ties or
elastic are much preferable as it can fit for almost everyone (CDC, n.d.). Mask
should be used only once and be discarded when soiled or after used. Next,
when discarding the mask one should be careful not to touch the outer surface
of the mask as it has been contaminated (Mathieson, 2015).
2) Goggles
 It helps to provide barrier for the eyes. Goggles should fit snuggly over and
around the eyes or over the glasses (for people wearing prescribed glasses).
Antifog feature for the goggles should be considered as it helps to maintain the
clarity of the vision. After wearing the goggles, it should be disposed properly
if single-used. If it is reusable, it should be placed in a labelled container
where it will be collected, disinfected, washed and then reused (CDC, n.d.;
Mathieson, 2015; NIOSH, 2013).

3) Face shield
It can also be used to protect the face, nose, mouth, and eyes. It should cover
the forehead, extend below the chin, and wrap around the side of the face
(CDC, n.d.).

Donning (putting on) and doffing (putting off) of PPE

When donning the PPE, hand hygiene should be performed. Then, it is followed with
wearing the disposable cap and disposable gowns or aprons. The gown should cover from the
neck to knees, arms to end wrists, and wrap around the back. Ensure to fasten the tie in the
back of the neck and waist. Next, put on the mask or respirator. Secure ties or elastic band at
middle of head and neck. Fit the flexible nose piece accordingly to the nose bridge. Ensure
that the mask snug to the face and below the chin. A simple fit-check test can be done by
exhaling and inhaling into the mask. If it fits, the mask will inflate during exhalation and
deflate during inhalation. Then, put on the goggles or face shield over the face and the eyes
and adjust it to fit. Lastly, put on the gloves. Extend the gloves to cover the wrist of isolation
gown.

Meanwhile, doffing of the PPE is started with removing the gloves. Using a gloved
hand, grasp the palm area of the other gloved hand and peel it off. Hold the removed glove in
gloved hand. Then, slide fingers of ungloves hand under the gloved hand at the wrist and peel
off the second glove. Discard the gloves in the appropriate bin to prevent further
contamination. Secondly, goggles and face shield are removed by lifting the head band at the
back of the head or the earpieces. If reusable, place it at the receptable area for reprocessing.
Otherwise, discard it appropriately. Thirdly, remove the gowns. Unfasten the gown ties, pull
it away from neck and shoulders then turn the gown inside out. Fold or roll the gown into a
bundle before discarding in the appropriate bin. Ensure to not touch the outer surface of the
gown as it is contaminated. Fourth, take of the mask or respirator by unfastening the ties at
the bottom followed by the ties at the top. Ensure to touch the tie only and not the front of the
mask when discarding the mask. Lastly, perform hand hygiene such as hand washing or hand
rub using an alcohol-based hand sanitizer after removing the PPE. Healthcare workers should
be alert in donning and doffing of PPE as there are risk of contamination. When removing the
PPE, if the hands got contaminated in any steps of doffing the PPE, immediately wash your
hands or use hand rub. It is advisable to perform hand hygiene after every step of doffing the
PPE to minimise the contamination to healthcare workers (Goodwin Veenema, 2018).

In conclusion, PPE is important to be used in any procedure that may risk healthcare
worker towards infectious disease that might be transmitted during patient contact. Each of
healthcare workers should be responsible for their own PPEs as it could harm others if
discarded inappropriately. Hence, awareness towards proper steps and hygiene during
removing the PPE is very important and should be monitored regularly. It will not only
protect the healthcare worker itself, but also the patient and the environment.

GLOVE DERMATITIS

Proper Handling of Gloves

Gloves are part and parcel of the medical and laboratory settings when handling all
sorts of hazardous chemicals and materials as they provide protection of the hands from
possible contamination and infections. Healthcare workers should be equipped with the
knowledge of the proper way to put on gloves and the disposal of gloves. Before donning any
gloves, they should first inspected cuts and tears, or discolouration as that may be an
indication of degradation, and should be disposed. If the gloves are in acceptable condition,
the staff must know of the proper way to don them and minimising skin contact as much as
possible. It is of the importance to take precautions in avoiding touching materials not
involved in the procedure such as cell phones, clothes, face or eyes to avoid the incidence of
cross contamination. Once finished with the procedure, the staff must also properly remove
them and minimising contact with skin exposure. A recommended method to perform this is
by grasping the cuff and peeling the glove off the hand so that the glove is inside out before
crumpling it and repeating the process with the other glove. This ensures that the gloves are a
unit during disposal. An additional but no less important step to the glove handling process is
the correct hand hygiene to ensure that the hands are free from contamination. This is because
skin contamination can go unnoticed by the staff and if this 7-step hand-washing technique,
which is the most effective one as endorsed by World Health Organisation (WHO) and
Ministry of Health Malaysia (MOH), is not practised stringently, touching other objects with
bare hands may lead to more contaminations that can lead the objects towards being sources
of infections.

Types of Gloves

Medical gloves are also a part of personal protective equipment with the main
function to protect the hands of the wearer from danger such as infection of diseases.
According to World Health Organization (2009), the medical gloves used by the healthcare
workers help them to reduce the transmission of pathogens. However, pathogens may invade
the body when there is defect to the medical gloves and it is suggested to ensure the practice
of hand hygiene by hand washing (WHO, 2009).

(a) (b)

Figure 1: Two Types of Medical Gloves (a) Latex Gloves and (b) Nitrile Gloves.

The most common types of medical gloves are latex and nitrile gloves. Latex gloves
are the natural rubber gloves that is manufactured by milky fluid produced by rubber trees,
Hevea brasiliensis. It is not very chemical resistant and less expensive compared to the nitrile
gloves. It is mainly used in the occupational settings such as food handlings and medical
industry as it can protect the wearer from the transmission of blood-borne pathogens.
However, the usage of the latex gloves can cause allergic reaction to the powder coating in
the gloves.

Next, another type of medical gloves that is commonly used in the medical industry is
nitrile gloves. This glove is made of synthetic rubber that has a good chemical resistance and
an ideal alternative to the users with latex allergies reaction. This is because nitrile gloves are
resistant to oils and fats in the body. Other than that, this glove also resist to gasoline,
kerosene and other petroleum solvents which shows that it can resist many chemical with
high level sensitivity. Nitrile gloves usually come up with two colours; blue or black in
colour. Compared to latex, this gloves is much more superior when it comes to puncture
resistance. Thus, it has a long shelf-life and recommended by the World Health Organization
to be used within the healthcare workers to avoid reaction with the alcohol-based solution
(WHO, 2009).

Below are the differences between both types of gloves in the simplest form;

Latex gloves Nitrile gloves

Made of natural rubber Made of synthetic rubber
Less expensive Quite expensive
Can cause allergy reaction Resistant to oils and fats in the body
Short shelf-life Long shelf-life
(not good at resisting puncture) (good at resisting puncture)
Table 1: The Differences between Latex Gloves and Nitrile Gloves

Prevalence of Latex Allergy

Through extensive research, however, latex has been proven to contain approximately
15 allergenic proteins which can trigger a hypersensitivity immune response in susceptible
individuals. According to a study by National Institute for Occupational Safety and Health
(NIOSH) and Centre for Disease Control (1998), there is about 1% to 6% of the general
population are sensitized to latex. Meanwhile, the rate of sensitization of latex among the
healthcare workers are about 8% to 12% and almost half of this population are having latex
asthma. Prevalence rates up to 11% among the non-healthcare workers with different
occupational settings (CDC, 1998).

Adverse Reactions to Latex

According to Binkley, Schroyer, & Catalfano (2003), there are 3 types of immune
response towards latex. The first type of reaction is known as Type I Hypersensitivity or
Immediate Hypersensitivity wherein susceptible individuals develop a reaction moderated by
the development of IgE antibodies to specific proteins in latex. This will subsequently cause
mast cells and basophils to release histamine, leukotrienes, prostaglandins, and kinins and
lead to symptoms that range from mild such as skin redness, rash, hives, or itching to severe
respiratory symptoms such as runny nose, sneezing, itchy eyes, scratchy throat, or asthma.
The second type of immune response is Type IV Hypersensitivity or Delayed
Hypersensitivity where it is only limited to the skin that triggers a T-cell dependent reaction
caused by chemicals used in latex production. This type of hypersensitivity is a chemical
contact inflammation that manifests as redness, itching, and various skin lesions and may
increase the likelihood of Type I Hypersensitivity with repeated exposures to latex. The last
common type of reaction towards latex is known as irritant contact dermatitis and allergic
contact dermatitis. Irritant contact dermatitis is defined as a non-allergic, localized
inflammation of the skin that does not involve the immune system and is caused by the
chemicals involved in the production of the latex gloves. Susceptible individuals usually
develop dry, itchy, irritated areas on the skin which allows for easier access of the allergens
once the skin barrier breaks. Meanwhile, individuals with allergic contact dermatitis may
notice a delay in appearance of symptoms ranging from 24 to 48 hours after exposure. This is
because allergic contact dermatitis involves a process called sensitisation where the immune
system stores the information after the first exposure to allergens and is only able to form an
immune response after subsequent exposures to the same allergens. Interestingly, the
symptoms of this reaction are likened to those caused by poison ivy.

Management and Prevention of Adverse Reactions to Latex

Despite all the adverse reactions associated with latex gloves, occupational hazards
due to latex among healthcare workers seem to have been effectively halted. This is
contributed by the introduction of screening tests for individuals susceptible to latex allergies,
using powder-free low-protein (PFLP) latex gloves and synthetic gloves (latex-free), and
overall avoidance of using latex products. Other effective preventive measures such as
frequently cleaning work areas contaminated with latex dust, changing the ventilation filters
and vacuum bags, and having the knowledge of latex allergy symptoms have also been
adopted in some parts of the world. However, the risk of exposure to latex still remains,
particularly in countries that are short of appropriate resources or with risk of possibly further
exposure to other latex-containing products (Wu et al., 2016). Therefore, various
management strategies are recommended that range from simple treatments to emergent-care
procedures. For less severe reactions, antihistamines can be administered to minimise
symptoms. The most important management of latex allergy is of anaphylactic shock. Prompt
treatment in the form of intramuscular or intravenous epinephrine should be administered
promptly to avoid life-threatening conditions. Other supportive treatments such as the
administration of oxygen and monitoring of vital signs should also be supplied as needed
(Accetta & Kelly, 2011).
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