Effect of hand hygiene regimens on skin condition in health care workers
2006; Elsevier BV; Volume: 34; Issue: 10 Linguagem: Inglês
10.1016/j.ajic.2006.05.217
ISSN1527-3296
AutoresMarty O. Visscher, Jennifer Canning, Dina Said, Randy Wickett, Pattie Bondurant,
Tópico(s)Infection Control and Ventilation
ResumoFrequent, repetitive exposure to hand cleansers can negatively impact the skin, particularly the protective stratum corneum (SC). We investigated the effects of synergistic test products (TP) and current products (CP) among health care workers (HCWs) during spring and winter. TP and CP were significantly different in quantitative measures of skin condition. TP resulted in improved condition versus CP at times during both trials. Compared with non-HCW control subjects, HCW hand skin was appreciably compromised. The skin was damaged at the start of a work cycle, suggesting that the SC damage did not recover during time off. In general, the skin was in poorer condition (higher grades) for CP at the end of a cycle than the start during both trials. The dryness scores were often lower for TP at the end of the cycle, suggesting an improvement in skin condition. During some winter cycles, the skin remained unchanged for TP and worsened for CP. For others, the skin improved with TP and was unchanged with CP. Dryness tended to decrease (improve) and erythema increased for TP. Overall, the use of TP consistently resulted in higher skin hydration compared with CP, indicating that product composition can significantly influence HCW skin condition. Regimens that minimize skin damage can improve condition while achieving skin disinfection. The findings emphasize the importance of providing hand hygiene products to minimize irritant dermatitis and maintain an effective skin barrier. Use of such products is expected to substantially impact and increase hand hygiene compliance. Frequent, repetitive exposure to hand cleansers can negatively impact the skin, particularly the protective stratum corneum (SC). We investigated the effects of synergistic test products (TP) and current products (CP) among health care workers (HCWs) during spring and winter. TP and CP were significantly different in quantitative measures of skin condition. TP resulted in improved condition versus CP at times during both trials. Compared with non-HCW control subjects, HCW hand skin was appreciably compromised. The skin was damaged at the start of a work cycle, suggesting that the SC damage did not recover during time off. In general, the skin was in poorer condition (higher grades) for CP at the end of a cycle than the start during both trials. The dryness scores were often lower for TP at the end of the cycle, suggesting an improvement in skin condition. During some winter cycles, the skin remained unchanged for TP and worsened for CP. For others, the skin improved with TP and was unchanged with CP. Dryness tended to decrease (improve) and erythema increased for TP. Overall, the use of TP consistently resulted in higher skin hydration compared with CP, indicating that product composition can significantly influence HCW skin condition. Regimens that minimize skin damage can improve condition while achieving skin disinfection. The findings emphasize the importance of providing hand hygiene products to minimize irritant dermatitis and maintain an effective skin barrier. Use of such products is expected to substantially impact and increase hand hygiene compliance. Control of hospital-acquired infections is a high priority for health care institutions world wide, particularly since approximately one third may be preventable.1Aiello A.E. Larson E.L. Causal inference: the case of hygiene and health.Am J Infect Control. 2002; 30: 503-511Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar, 2Lam B.C. Lee J. Lau Y.L. Hand hygiene practices in a neonatal intensive care unit: a multimodal intervention and impact on nosocomial infection.Pediatrics. 2004; 114: e565-e571Crossref PubMed Scopus (226) Google Scholar, 3Hilburn J. Hammond B.S. Fendler E.J. Groziak P.A. 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Differences in skin flora between inpatients and chronically ill outpatients.Heart Lung. 2000; 29: 298-305Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar The primary reason for hand hygiene compliance failure is skin irritation and the deleterious effects of repetitive use of products and procedures.11Pessoa-Silva C.L. Posfay-Barbe K. Pfister R. Touveneau S. Perneger T.V. Pittet D. Attitudes and perceptions toward hand hygiene among healthcare workers caring for critically ill neonates.Infect Control Hosp Epidemiol. 2005; 26: 305-311Crossref PubMed Scopus (97) Google Scholar The CDC guideline details the frequency and product types to reduce skin microflora. Visibly soiled hands are washed with soap (with or without antibacterial ingredients) and water. Antibacterial handrubs are indicated when visible soils are absent. Decontamination is to occur after contact with patient skin, fluids, equipment, and others. Health care institutions are to provide agents with low irritancy potential and products to minimize irritant dermatitis.5Boyce J. Pittet D. Guideline for hand hygiene in health-care settings.MMWR. 2002; 51: 1-44Google Scholar The skin, particularly the stratum corneum (SC; the outermost layer of the epidermis), provides a physical, mechanical, and immunologic barrier to protect against environmental insults. The SC shields the Langerhans cells (immune function) from direct environmental exposure and, thereby, serves an essential function in infection control. However, frequent repetitive exposure of the skin to soap/surfactant cleansers and water has significant effects on the structure and function of the stratum corneum (SC) barrier, including disruption of the SC lipid bilayer architecture and increased permeability, penetration, and epidermal inflammation. 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Increased stratum corneum turnover induced by subclinical irritant dermatitis.Br J Dermatol. 1990; 122: 793-798Crossref PubMed Scopus (55) Google Scholar A damaged barrier is more susceptible to penetration by environmental insults, including microorganisms. The relationship between skin damage and bacteria counts was investigated, and, as damage increased, total bacteria counts were higher.28Winnefeld M. Richard M.A. Drancourt M. Grob J.J. Skin tolerance and effectiveness of two hand decontamination procedures in everyday hospital use.Br J Dermatol. 2000; 143: 546-550Crossref PubMed Google Scholar In the strictest sense, compliance with the hand hygiene guideline results in damaged skin and increased bacterial load. The challenge is to provide appropriate skin disinfection while maintaining an adequate and functional SC barrier. Therefore, the use of systems formulated to minimize the deleterious effects of repeated hand cleansing is necessary. We hypothesized that the use of a hand hygiene regimen (ie, a “synergistic” set of products), referred to as the test products (TP), based on (1) mild (minimally disruptive) cleansers, (2) an alcohol handrub with emollient, and (3) a protective lotion would minimize the damage from hand hygiene procedures and maintain an effective SC barrier. The specific aims were as follows: (1) evaluate the effects of the synergistic regimen (TP) and the current products (CP) in health care workers (HCWs) using quantitative measures of skin condition (integrity and function) and (2) compare the changes in skin condition of HCWs using the “synergistic” regimen with the changes for HCWs using current products. Nurses and respiratory therapists from the Regional Center for Newborn Intensive Care (RCNIC) at Cincinnati Children's Hospital Medical Center (CCHMC) took part in the spring (n = 54) and winter (n = 61) trials. The RCNIC is a comprehensive level III intensive care unit (ICU) with approximately 190 full- and part-time staff. The ICU was selected because of the high frequency of hand hygiene procedures. Eligible subjects had (1) visible skin damage or irritation (ie, dryness, scaling, erythema) at enrollment or a verified history of damage, (2) hand hygiene frequency of at least 20 procedures per 8 hours, and (3) a schedule of at least 2 consecutive 8-hour shifts once every 2 weeks to ensure sufficient exposure to hand hygiene procedures on a regular basis. Subjects were excluded if they had a history of allergic contact dermatitis from the specific study products. The Institutional Review Board of CCHMC approved the research protocol, and all subjects provided written informed consent. The control group (n = 26) was composed of subjects whose jobs did not involve repeated exposure to water, solvents, hand hygiene procedures, chemicals, cleaning solutions, and others. Subjects were excluded if they (1) had visible skin damage or irritation (ie, skin grades of 0.5 or higher for dryness; erythema; or fissuring at the knuckles, fingers, and dorsum), (2) had a history of skin irritation because of normal (non-HCW) handwashing, ie, 10 times in 8 hours, (3) routinely wore gloves, or (4) were outside the age range of the HCW population. High-resolution digital photographs were taken using a Fuji S2-Pro Camera 6.1 Megapixel (Fuji Corporation, Hyogo, Japan), SLR, an AF Micro-Nikkor 60mm f/2.8 Macro Lens (Nikon Corporation, Tokyo, Japan), and a Nikkon SB-29s Macro Speedlight Flash (Nikon Corporation), for a resolution of 2848 × 4256 pixels (2.8 pixels/mm). The hands were placed in a metal “repositioning” device to allow comparison of images from different times. Lighting conditions were controlled and standardized for white balance and color. Optical imaging methods and software (Adobe Photoshop, ImageJ; Adobe Systems, San Jose, CA) were used to evaluate and compare images for skin damage and to quantify erythema. Separate grades were assigned to the knuckle, finger, and dorsal regions of each hand because the areas could respond differently to hand hygiene procedures. At each visit, a trained judge evaluated the skin using 0 to 5 scales for dryness and fissuring and a 0 to 4 scale for erythema. Dryness scores were as follows: 0, none; 1, patches of slight powderiness and occasional patches of small scales with generalized distribution; 2, generalized slight powderiness, early cracking or occasional small lifting scales; 3, generalized moderate powderiness and/or moderate cracking and lifting scales; 4, generalized heavy powderiness and/or heavy cracking and lifting scales; and 5, generalized high cracking and lifting scales.29Lukacovic Dunlap F.E.M.S. Visscher M.O. Watson D.D. Forearm wash test to evaluate the clinical mildness of cleansing products.J Soc Cosmet Chem. 1988; 39: 355-366Google Scholar Erythema scores: 0, none; 0.5, barely perceptible redness, weak, or spotty; 1, slight redness (spotty or diffuse); 2, moderate redness; 3, intense redness; 4, fiery redness with edema.29Lukacovic Dunlap F.E.M.S. Visscher M.O. Watson D.D. Forearm wash test to evaluate the clinical mildness of cleansing products.J Soc Cosmet Chem. 1988; 39: 355-366Google Scholar The investigators were blinded with respect to treatment (product set) at the times of visual grading, image evaluation, and instrumental data collection. The SC barrier integrity was evaluated by measuring the rate of transepidermal water loss (TEWL) through the skin (g/m2/hr) with a DermaLab Evaporimeter (Cortex Technology, Denmark). SC barrier function was assessed by measuring the rate of transepidermal moisture accumulation (MAT) during 20 seconds of continuous probe occlusion with the Corneometer (Courage and Khazaka, Koln, Germany). Water moves through the upper epidermis and builds up under the probe. The instrument measures skin hydration by determination of skin capacitance in arbitrary units (AU). MAT is the regression line slope in AU/sec. SC hydration was the first reading of the capacitance measurement (Corneometer), reported as capacitance in AU. Skin hydration is due to residual surface moisture, evaporative moisture from the dermis, and water bound to corneocyte proteins. HCWs completed a self-rating scale (each hand) for moisture content (dry-normal), appearance (red, blotchy, rash), intactness (abrasions, fissures), and sensation (itching, burning, stinging) on a 7-point scale, on which 0 indicated the best skin condition and 6 was the worst condition.30Cimiotti J.P. Marmur E.S. Nesin M. Hamlin-Cook P. Larson E.L. Adverse reactions associated with an alcohol-based hand antiseptic among nurses in a neonatal intensive care unit.Am J Infect Control. 2003; 31: 43-48Abstract Full Text Full Text PDF PubMed Scopus (41) Google Scholar Ambient RNCIC conditions (temperature, relative humidity) were recorded twice a day, and outdoor daily conditions were obtained from meteorologic records. The spring trial was conducted among 2 parallel HCW groups, beginning in April 2004. The final visits were in early August 2004. One group was assigned to the test regimen (TP, liquid handwash [Kindest Kare Bodywash and Shampoo, containing amphoteric surfactants sodium lauroamphoacetate and disodium soyamphodiacetate, anionic surfactants disodium oleamido sulfosuccinate, and emollients], antimicrobial liquid handwash [CV Medicated Soap, containing Triclosan potassium; and sodium salts of fatty acids, disodium cocoamphodiacetate, and others], alcohol rub [Alcare Plus, containing ethyl alcohol, emulsifying wax, and emollients], skin lotion [Lotion Soft Skin Conditioner, containing glycerin, cyclomethicone, emulsifying wax, and emollients], STERIS Corporation, Mentor, OH) and the other group continued using the current product set (CP, liquid handwash [Endure 50, containing potassium cocoate, SD alcohol 40-B, potassium stearate, cocoamidopropyl PG-dimonium chloride phosphate], antimicrobial liquid handwash [Endure 200, containing Triclosan, potassium cocoate, propylene glycol, glycerin, potassium stearate], alcohol rub [Endure 320, containing ethyl alcohol, cetyl alcohol, PEG-32, glycerin], and skin lotion [Endure 500, containing stearic acid, glycol stearate, isopropyl palmitate, mineral oil], Ecolab Inc, St. Paul, MN). The treatment set (TP or CP) was randomly assigned to subjects at the time of their first visit (baseline measurement session) because all subjects had been using set CP prior to the start of the study. Products were supplied to all work areas. The subjects were reminded of the guidelines for hand hygiene and lotion use and used only the assigned product set throughout both trials. All subjects continued their current products and procedures for washing and skin care at home. The winter trial took place among parallel groups from early December 2004 through early March 2005. Most subjects took part in both trials, and the initial CP or TP product assignment was maintained so that the effect of season could be determined effectively, ie, same product in both seasons. During the time between trials, all HCWs returned to using CP for hand hygiene procedures. Subjects were enrolled in the winter trial, assigned to use the same product set as they had in the spring, and instructed to use the product prior to the first visit of cycle 1 to ensure that the observed skin effects were attributable to product exposure. The subjects had been using the assigned products for at least 6 days (mean 21 days; range, 6-34 days) prior to the first measurement visit, ie, after transition to the new product. Subjects who were new to the research were randomly assigned to CP or TP at the start of the winter study. The HCWs typically work 12-hour shifts. Full-time personnel generally work 3 consecutive days with 3 or 4 days between cycles. Part-time personnel had to work at least 2 consecutive shifts on a regular basis to participate. The effects of the hand hygiene procedures and products were determined by measuring the skin condition during a set of shifts, ie, from beginning (prior to the initial scrub) to end (approximately an hour after the last procedure) of a work cycle. The start and end visits together constituted a cycle. The skin was evaluated for 6 cycles (12 visits) during spring and 3 cycles during winter, with visits arranged in accordance with subject schedules. In the winter trial, subjects were evaluated again when they returned to work following their time off after cycle 3 (visit 7). A volar forearm site outside the treatment area (between elbow crease and wrist) was evaluated as a within-subject control. This site was not an ideal control because of variations in product exposure and skin characteristics (hand vs forearm). However, repeated evaluation of a relatively unperturbed site provided information on the variability in skin condition. To avoid measurement order bias, the hands were randomized, eg, assessments began with left or right hand. The forearm was the same side as the starting hand (ie, left hand first, left forearm). The evaluations were performed in a designated area within the RCNIC. The subjects first completed the self-assessment of each hand. The sequence began with the control hand (left or right) as follows: control hand image, visual grading (knuckles, fingers, dorsum), other hand image, visual grading, hydration (dorsum, forearm, other dorsum), and TEWL (dorsum, forearm, other dorsum). The hydration and TEWL readings were made on adjacent sites to avoid carryover effects of the instrumental procedures. The order of evaluations was maintained at each visit. The control subjects (non-HCWs) were assessed once in late June-early July of 2005 for grades, imaging, hydration, and TEWL. The data were analyzed with Sigma Stat Software (SPSS, Inc., Chicago, IL) and a significance level of P ≤ .05. Results are reported as mean ± SD and mean ± SEM. Paired t test procedures were used to compare the skin condition at the beginning and end of each work cycle and the skin condition for spring versus winter (among the subjects who did both studies). Regional differences in skin condition (eg, dryness, erythema) were assessed by analysis of variance. Student t tests were used to compare the skin condition of the CP and TP groups at various time points. The effects of the treatment (CP set vs. TP set) were determined by computing the change in skin condition as final (end of cycle) minus start (beginning of cycle) and using Student t tests to compare the changes for CP versus TP. Fifty-six HCWs participated in the spring trial, and 60 were in the winter study. Twenty-three CP and 25 TP subjects took part in both trials. The demographics and the number of days of product exposure (ie, length of cycle) are shown in Table 1. The cycle times for CP and TP subjects were not significantly different for any of the 6 spring cycles or the 3 winter cycles, indicating that product comparisons are valid.Table 1Health care worker demographic characteristics∗Values are presented as mean ± SD.SpringWinterCharacteristicCurrent productTest productCurrent productTest productNumber of subjects25293130 Sex Female25293030 Male––1– Race White23263029 Black2311Total mean study duration (day)49.7 ± 12.058.3 ± 13.434.9 ± 12.234.9 ± 8.8 Mean cycle duration (day) Cycle 12.6 ± 1.22.1 ± 0.82.5 ± 1.22.2 ± 0.8 Cycle 22.5 ± 1.02.7 ± 1.12.5 ± 1.12.4 ± 1.0 Cycle 32.9 ± 1.22.7 ± 1.22.6 ± 1.22.6 ± 1.8 Cycle 42.7 ± 1.42.7 ± 1.2–– Cycle 52.8 ± 1.12.3 ± 1.6–– Cycle 63.0 ± 2.52.5 ± 0.9––∗ Values are presented as mean ± SD. Open table in a new tab The outdoor dew points were significantly different between the seasons, averaging 16.3°C ± 4.5°C for spring and −2.6°C ± 7.4°C for winter. The indoor RCNIC unit dew points were significantly different as well, with 6.1°C ± 1.5°C in spring and 2.3°C ± 2.3°C in winter (Table 2). Unit dew points in the spring were substantially lower than outdoor conditions. These relatively dry ambient work conditions contributed to the stress on skin from hand hygiene procedures. No significant differences were observed in either outdoor or unit dew points for CP compared with TP at any cycle during spring and winter. The outdoor dew point was significantly higher for spring cycle 5 compared with cycle 2 (ANOVA, P < .05). This finding indicates an increase in dew point during the study, as expected from the historical weather conditions. The dew points did not vary significantly throughout the winter cycles.Table 2Environmental conditions∗Values are presented as mean ± SD.Mean dew point (°C)SpringWinterOutdoor conditions16.3°C ± 4.5°C−2.6°C ± 7.4°CIndoor conditions (RCNIC)6.1°C ± 1.5°C2.3°C ± 2.3°C∗ Values are presented as mean ± SD. Open table in a new tab The skin condition at the start of a cycle (cycle 6, spring) was compared with that of the non-HCW controls. Visual dryness/scaling and erythema scores in all regions (knuckle, finger, and dorsum) were significantly higher for the HCWs (Table 3). This finding is not surprising, given that the basis for selection for controls was the lack of visible dryness and erythema. However, it verifies the increased skin damage experienced by HCWs. Skin hydration (knuckle, dorsum, and forearm sites) was significantly lower for the HCWs than for the control subjects, indicating drier skin. For the non-HCW controls, TEWL values were significantly higher on the dorsum (10.0 ± 1.6 g/m2/hr) than the volar forearm (7.2 ± 1.2 g/m2/hr) because of, at least in part, to structural and physiologic differences between sites. TEWL (dorsum and forearm) was significantly higher for the HCWs than for the control group, indicating a poorer SC barrier.Table 3Skin condition of HCWs versus control subjects∗Values are presented as mean ± SEM.AttributeHCW (n = 24)Control (Non-HCW) (n = 26)t Test P valueVisual dryness/scaling score Knuckle0.73 ± 0.140.00<.001 Fingers1.1 ± 0.120.00<.001 Dorsum0.67 ± 0.110.00<.001Visual erythema score Knuckles1.3 ± 0.110.00<.001 Fingers0.79 ± 0.070.00<.001 Dorsum0.85 ± 0.080.00<.001Skin hydration (baseline, AU) Knuckle26.4 ± 1.638.2 ± 1.8<.001 Dorsum38.7 ± 2.152.4 ± 2.1<.001 Forearm37.2 ± 2.158.8 ± 1.9<.001Transepidermal Water Loss (g/m2/hr) Dorsum13.6 ± 1.78.1 ± 0.48<.001 Forearm7.0 ± 0.45.6 ± 0.37.01∗ Values are presented as mean ± SEM. Open table in a new tab At the start of the spring trial, all subjects (n = 54) had been using the CP. Significant regional differences (P < .001, ANOVA) were found in visual dryness in the order: finger > knuckle > dorsum (Fig 1A). The right hand regions were significantly drier than the left. All HCWs were right handed with one exception. Significant regional differences were observed for erythema (knuckle > finger > dorsum), with the knuckle having the highest score (most damage) (Fig 1B). The mean self-assessment scores (0-6 scale, on which 0 is best and 6 is worst) at baseline for the right hand were as follows: appearance = 1.8 ± 0.2, intactness = 1.6 ± 0.2, moisture content = 3.2 ± 0.2, and sensation = 2.0 ± 0.2, indicating that the HCWs perceived their skin to be compromised at the start of a work cycle. The left and right hands were not different by self-assessment. Significant regional differences in skin condition were also found at the beginning of the winter trial. The visual dryness scores for the knuckle and finger were significantly higher than for the dorsum (Fig 2A). Baseline hydration measurements revealed no significant differences among the left dorsum, right dorsum, and volar forearm sites (ANOVA). The moisture accumulation rate was significantly higher for the left dorsum (0.54 ± 0.04 AU/s) compared with the volar forearm (0.36 ± 0.03 AU/s) (ANOVA). Baseline TEWL values indicated significant differences between the dorsal and volar forearm sites, with mean values of 12.0 ± 0.9 g/m2/hr for the left dorsum, 12.3 ± 0.7 g/m2/hr for the right dorsum, and 6.4 ± 0.5 g/m2/hr for the forearm. The nearly 2-fold difference between dorsum and forearm is attributed in part to structural and physiologic differences in these regions and due not only to differences in SC barrier function.Fig 2Effect of season on skin condition. The effect of season was determined in the HCWs who used the current products (CP) in both trials (n = 23). Spring (third cycle, visit 5) and winter (third cycle, visit 5) measurements were analyzed using paired t tests. Dryness grades were significantly higher during the winter for the knuckles (P < .001) and dorsum (P = .05) regions (A; right hand), indicating poorer skin condition. Visual erythema scores were comparable between the seasons for the finger and dorsum areas and directionally higher (P = .10, poorer skin condition) during the winter for the knuckles (B).View Large Image Figure ViewerDownload (PPT) For
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