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The recently published CDC document Guideline
for Hand Hygiene in the Healthcare Setting addresses issues that
can result in higher incidence of nosocomial infections among patients.
The guidelines note that a key reason clinicians do not adhere to
recommended hand-hygiene guidelines is skin irritation and specifically
recommend that health-care workers select products that contain emollients
in order to reduce the potential for contact irritant dermatitis.
In addition to being able to transfer infection to
patients, employees with compromised skin are at an
increased risk of occupational exposure to potentially
infectious organisms such as hepatitis B or C or even
HIV. Broken skin provides a more direct route for an
organism to enter the individual's blood stream.
Dermatic hands may also result in lost productivity
and lower job satisfaction and morale.
By undertaking a consistent, effective hand-care
regimen, health-care professionals will maintain the
integrity of their skin as their first line of defense against
the spread of bloodborne pathogens and other potentially
infectious microorganisms. Primary protection
of uncompromised skin is the optimal strategy for
prevention of occupational irritant contact dermatitis. However, despite persistent promotion of hand-hygiene
protocols over many years, a significant number of
facilities and clinicians do not follow best practices for
maintaining healthy skin while preventing cross
contamination between health-care workers and their
patients. Providing products that promote and maintain
healthy skin will result in increased compliance and
frequency of hand washing and hand hygiene among
health-care workers.
Measuring the delivery of skin health benefits
Contact irritant dermatitis is ranked as one of the top concerns
of health-care practitioners, with skin diseases ranked as the number
one cause of occupational illness across all professions.i According
to a National Institute for Safety and Health (NIOSH) study, combined
irritant and Type IV or chemical-induced dermatitis account for 15%
to 20% of all occupational diseases and incur costs of more than one
billion dollars annually. Of these contact dermatitis cases, 75% can
be classified as irritations. A study by Elaine Larson, et al in Heart
and Lung journal showed that of 410 nurses, almost 86% reported that
they had problems with their hands at some time, and the clinical
assessment revealed that many of those had "significant skin damage.ii
Contact dermatitis is an inflammation of the skin evidenced by itching, redness
and various skin lesions due to contact with an irritating substance. The frequent
hand washing and gloving required in health-care occupations can have detrimental
effects on skin, including dryness, cracking and increased sensitivity to hand-washing
products. Clinicians' frequent occupational exposure to various soaps, detergents,
disinfectants and other caustic chemicals are known to cause changes to the skin,
which can be aggravated
further by seasonal low humidity.
Because of these issues and their link to infections, there has been a great
deal of interest in new glove products and other products that contain additives
known to moisturize or otherwise benefit the skin. However, quantitative measures
detailing whether these additives actually have a beneficial effect on skin have
been lacking.
A key consideration when assessing gloves and other products designed to improve
skin health is to examine the available test data that specifically demonstrate
the benefit of the product in actual or simulated clinical use using recognized
tests developed by dermatologists.
Hand dermatitis: a significant
health-care issue
Irritation or contact dermatitis is a non-allergic reaction. Though clinicians
frequently describe their reactions as allergic in nature, irritations are not
an immunological response, but simply an irritant response to any number of substances
or factors. There are two types of irritations,
acute and chronic.
| Acute dermatitis |
 |
Chronic dermatitis |
 |
Rapid onset |
|
Severe in nature |
|
Manifests for a short
period of time |
|
Redness, itching
and possibly
burning sensation |
|
|
|
Gradual onset |
|
Localized to the
area in contact with
the irritant |
|
Longer duration |
|
Cracks, fissures, hard
bumps and sores |
|
How skin health can affect hand hygiene
Damaged hands become a deterrent to hand washing because washing
can worsen skin problems. Studies published in the American Journal
of Infection Control report that skin breakdown is "a major occupational
health problem among health-care workers, not only nurses and others
with direct patient contact, but also laboratory personnel and persons
working in housekeeping and building maintenance."iv
These and other studies published in the American Journal of Infection
Control have demonstrated that, with skin trauma, there is increased
shedding of damaged skin cells. Also, chronic dermatitis has been
associated with heavier colonization of bacteria, yeast, staphylococci
and other potential pathogens and outbreaks of health-care-acquired
infection.v Clearly, improving hand condition of clinicians is greatly
needed.
CDC guideline for hand hygiene in health care
The recently published CDC document Guideline for Hand Hygiene in
Health-Care Settings addresses the issues that can result in a higher
incidence of nosocomial infections among patients and notes that
a key reason clinicians do not adhere to recommended hygiene guidelines
is skin irritation. The guidelines specifically recommend that health-care
workers select products that contain emollients in order to reduce
the potential for contact irritant dermatitis.
Patient outcomes
The Institute of Medicine recently reported that as many as 98,000
patients a year contract a hospital-related infection that was preventable.
It is also believed that many of these infectious agent transmissions
could have been prevented by simple hand hygiene. The hands of clinicians
with compromised skin (a skin barrier that is breached by open lesions
or cracks) may harbor an increased amount of infectious organisms
compared to individuals with healthy, intact skin. Dry skin may
shed or flake more than healthy skin. Since organisms can be shed
along with skin flakes, this may increase the likelihood that organisms
can be transmitted to patients. Patients may acquire a nosocomial
infection by simple contact of a gloved or non-gloved hand.
Employee outcomes
Employees with compromised skin are at an increased risk of
occupational exposure to potentially infectious organisms such as
hepatitis B or C or even HIV. Broken skin provides a more direct
route for an organism to enter an individual's blood stream. Employees
are also at increased risk for exposure to contact organisms such
as Staphylococcus aureus and Escherichia coli. Dermatic hands may
also result in lost productivity and impact job satisfaction and
employee morale.
The impact on clinical practice
Products that promote and maintain healthy skin will result in increased
compliance and frequency of hand washing and hand hygiene in health-care
providers. It is specifically stated in the CDC guidelines that
employers should "provide personnel with efficacious hand hygiene
products that have low irritancy potential, particularly when these
products are used multiple times per shift."vii
In light of these new guidelines, clinicians, especially infection
control professionals, have a renewed interest in products that
promote and maintain healthy skin. They are using these guidelines
to support their rationale and justification to purchase products.
Products that reduce trans-epidermal water loss, increase skin hydration
(moisturize), have low irritancy potential and improve skin tolerance
can increase adherence to hand washing and hand hygiene and will
be integral to an overall hand-care and skin wellness program.
The link between nosocomial infections and skin health
Health-care workers are not fully adhering to recommended hand-washing
procedures. While lack of time and poor technique play some role
in this issue, infection control professionals are recognizing the
direct link between skin health and nosocomial (health-care-associated)
infections. Repeated use of hand scrubs and hand-washing products
has been cited as one of the contributing factors to dermatitis.
Commonly reported irritants include iodophors, chlorhexidine, PCMX,
triclosan and alcohol-based products. Numerous articles note that
failure to use supplemental hand lotions or creams is one of the
factors contributing to dermatitis associated with frequent hand-washing
activity.viii Several controlled trials have demonstrated that regular
use of hand lotions or creams helps prevent and treat irritant contact
dermatitis.ix
References
i NIOSH and Project Nora.(1996).Latex Allergy News . 11(5),1084-1121.
ii Prevalence and Correlates of Skin Damage on the Hands of Nurses.(1997
September/October). Heart & Lung. (Vol.26, No.5), 404-412.
iii Boyce, J.M., Pittet, D.(2002). Guideline for Hand Hygiene in
Healthcare Settings: Recommendations of the Healthcare Infection
Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA
Hand
Hygiene Task Force.Infection Control and Hospital Epidemiology.
(Vol.23, No.12).
iv Larson, E., et al.(1998).Changes in bacterial flora associated
with skin damage on hands of health-care personnel.Am J Infection
Control. (Vol.26),513-521.
v Ibid.
vi Boyce, J.M., Pittet, D.(2002).Guideline for Hand Hygiene in Health-Care
Settings: Recommendations of the Healthcare Infection Control Practices
Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand
Hygiene Task Force.Infection Control and Hospital Epidemiology.
(Vol.23, No.12).
vii Ibid.
viii Ibid.
ix Grove, G.L.,et al .(2001). Methods for Evaluating Changes in
Skin Condition Due to the Effects of Antimicrobial Hand Cleansers:
Two Studies Comparing a New Waterless Chlorhexidine Gluconate/Ethanol
Emollient Antiseptic Preparation with a Conventional Water-Applied
Product. Am J Infection Control. (Vol.29,No.6),361-369.
x Menne,T. and Maibach, H.(2002).Hand Eczema (2nd ed.).CRC Press.Boca
Raton,FL.
xi Ibid.
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