WHO的手卫生5个重要时刻改为4个更为合理，您的意见呢？

楚楚

前不久SIFIC会员们一起翻译了WHO的〈Hand Hygiene Technical Reference Manual〉https://bbs.sific.com.cn/thread-133266-1-1.html
通过学习该手册内容，结合加拿大卫生署的训练PPT提出的4个手卫生指征https://bbs.sific.com.cn/thread-126469-1-1.html
1.Before：initial patient or patient environment contact
2.Before：aseptic or clean procedure
3.After:body fluid exposure risk
4.After：patient or patient environment contact
个人认为，加拿大提出的手卫生4个指征，比WHO的手卫生5个指征，更全面，更容易理解！！
在该WHO手册中，为了说明做手卫生的必要性，WHO以患者的角度，将医疗环境分为二部分，即患者区域和医疗区域。所谓患者区域，即以患者为中心，及其提供给患者临时使用的周围设备及物品，而医疗区域，则包括其他患者区域以及公共医疗区域。做手卫生的目的在于预防病原区在患者区域与医疗区域之间传播，以及病原菌传播患者（进行清洁无菌操作前）和病原菌传播给医务人员或环境（接触血液体液后）。结合二个资料，个人认为加拿大的手卫生4个指征更为合理。而WHO的手卫生5个重要时刻的提法，虽然表面上来说还多了一个指征，但实际上没有加拿法的提法全面。WHO没有包括接触患者环境前这个指征，而实际上这个指征也是很重要的。试想一下，一位医务人员，如果没有做手卫生，接触患者前先接触了患者周围环境，即便接触患者前做了手卫生，但病原菌同样污染了患者的周围环境。那么病原菌就会通过患者周围的环境传播给患者。大家认为呢？

江边一碗水

楼主说的很有道理！我觉得这个可以深入讨论一下，如果可以的话，楼主可以将您的思考反馈给WHO方面。

safihu

1.Before：initial patient or patient environment contact
2.Before：aseptic or clean procedure
3.After:body fluid exposure risk
4.After：patient or patient environment contact
不是4个或5个的差别，只是把WHO的接触环境后和患者和在一个指征内了。只是明确增加了 接触环境前这一提法。
但是按WHO的五个指征都做到的话，就不应该存在楼主的假设那种情况了的，也可以认为WHO的5个指征是全面的。

kuailegongzhu

同意楼主观点。其实任何措施的制定都必须以实际工作出发，在细节、人性、秩序上加以考量，制度的建立一定有人性的理念，才能提高执行的力度，体现“依从性”。

蓝鱼o_0

坦率点说，还是很有道理。不过换个思考方式，抛开观念不说，其实在一段时间内稳定的传递信息更重要，费劲千辛万苦，好不容易接受了5个时刻。然后又进化为四个时刻。有点不严谨。会不会造成一个影响，感控很随意。
所以才会有这样一个笑话，当评审员问一个临床医务人员洗手的步骤，反馈说”4-7步“。

鬼才

我赞成3楼S管的观点。然而要指出的是，我们对待感控的一些规范、指南，在执行过程中要学会辩证法，而不能死搬教条，要学会具体问题具体分析。不要唯规范是从。同时目前的一些规范、指南，真的还值得推敲。

mars

其实加拿大的只是更简洁一点，和世卫的内容都是一样的。融合创新！

sliver71

蓝鱼o_0 发表于 2014-9-9 08:51
坦率点说，还是很有道理。不过换个思考方式，抛开观念不说，其实在一段时间内稳定的传递信息更重要，费劲千 ...

蓝鱼老师很幽默。。。不过确实很重要。。。标准很重要，依从性更更更重要。。。朝令夕改，只能呵呵。。。在全体医务人员中落实手卫生的5个时刻，肯定大家都花了不少力气。。。准备下次培训时候将接触患者周围环境前这个时机植入5个时机，要大家注意，但不一定要改变大家已经形成的观念

楚楚

蓝鱼o_0 发表于 2014-9-9 08:51
坦率点说，还是很有道理。不过换个思考方式，抛开观念不说，其实在一段时间内稳定的传递信息更重要，费劲千 ...

有点一石激起千层浪的感觉这么多高手参与讨论着实令人激动和开心！
很赞同蓝鱼斑斑的担忧，习惯成自然，一旦习惯养成，要改掉着实困难，为此常常让我们望而却步！！
但就因为此，我们就该放弃吗？相反，我们更应该对勇于持续改进而肃然起敬！
大家不妨思考一下，为什么WHO要将手卫生指征简化为5个重要时刻，而不是将一些常见的和不常见的需要进行手卫生的医疗行为罗列出来？对手卫生的依从性进行观察，并且在观察后进行反馈和沟通，指出什么时征没有落实，以及为什么要落实，这种基于科学性、可操作性的坦诚而相互信任的沟通，对促进手卫生无疑是非常重要的。因此建立基于科学性、可操作性、容易理解，监督指导者（手卫生依从性观察者）和被监督者（广大医务人员）达成共识，没有疑义的手卫生指征，无疑是非常重要的。

一室花香

以前是七步洗手，现在六步洗手，搞来搞去头好晕呀！！专家们到底是6步，还是7步？

一室花香

建议已经贯彻执行的就不必轻易改哈。
再说了，接触病人周围物品后是手消毒指征，那就不会说接触病人周围物品前能有多污染吧？卫生手和外科手还是不同，卫生手是允许带菌的

一室花香

卫生手是允许10个菌落，它不是无菌操作

小叶子

蓝鱼o_0 发表于 2014-9-9 08:51
坦率点说，还是很有道理。不过换个思考方式，抛开观念不说，其实在一段时间内稳定的传递信息更重要，费劲千 ...

同意您的观点！有些说法做法如果没有明显的缺陷，建议不要总是改来改去，反倒让大家无所适从！

江边一碗水

这个时点本省就有很大的研究价值，并非说大家都接受了就不可以探讨了。我觉得接触患者周围物品前，确实一个WHO遗漏了的重要手卫生时点。
至于洗手七步还是六步，这个应该不是问题的，关键是要去做手卫生。

江边一碗水

今天早上6点钟被冻醒了，于是打开手机看邮箱，哇，一个好消息！我和楚楚合作的关于这个话题的letter被Infection Control & Hospital Epidemiology接受啦！刚查了查这本杂志的IF，已经升到4.02，不错不错！
在这里，我来回顾一下我们合作写该文的历程。
当楚楚抛出这个话题的时候——这的确是她深思熟虑后的一个很闪亮的点子——我们大家都看到了。我之前查阅过一些相关论文，也写过类似文章发表，我一下觉得她的提法非常好，很适合写一篇letter投到国际杂志上去，也反映一下中国感控学者的思考嘛！于是我和楚楚一说，她也正有此意，于是我们一拍即合！我们大致花了十来天的时间，从进一步捋思路、凝练观点、确定论文的表达、进一步查文献，分头撰稿，合成，多次交叉修改，再请朋友修改润色英文。初稿完成！在选择投稿杂志的时候，我们想还是先投一个IF最高的——私下里，因为之前有人说美国的杂志对中国学者有偏见，我也想去验证一下下——，于是就选择了Infection Control & Hospital Epidemiology。
在国庆节前的9月30日投出去，第二天国庆节，我在回老家的高速路上接收到邮件，论文已经编号了，编辑已经在处理了，楚楚感叹：投国际杂志就是效率高呀！然后就是等待，越等我们的预感越好！——一般letter是不需要外审的，编辑和主编就可以确定是否刊发——越久不退稿，越可能被编辑传阅后给主编定夺——终于，在半个月后，传来了接受的好消息！
我们觉得，我们的论坛的讨论的话题，与国际接轨不是空话的！这真的给我和楚楚都带来了莫大的信心和动力，所以我们很乐意在这里传递这种信心和力量！
另外，合作，双方或者多方的合作精神、相互之间的关照和理解，等等，都是很重要的。意气相投的人在一起合作很愉快的！希望论坛中的朋友能够更多的合作共赢！
虽然只是篇小letter，但她的诞生有些特别，再此分享过程，供论坛的各位同道参考！

江边一碗水

Is it necessary to perform hand hygiene for healthcare workers before initial patient environment contact?


Authors:
Rong-hui Liu MD Ph.Da, Duo-shuang Xie MD Ph.Db*

Affiliations:
a Department of Infection Control, the First College of Clinical Medical Science, China Three Gorges University & Yichang Central People’s Hospital, Yichang, Hubei, China
b Department of Infection Control, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei, China

* Corresponding author. Address: Department of Infection Control, Taihe Hospital, Hubei University of Medicine, No 32 Renmin Road, Shiyan, Hubei 430030, P.R. China. Tel.: +86 719 8801606. Fax: +86 719 8801379. E-mail address: xieds8@163.com.

To the Editor− Hand hygiene (HH) is considered to be a simple, but the most effective way of preventing healthcare-associated infections and cutting off the spread of pathogens.1 In recent years, more and more attentions has been paid to hand hygiene, meanwhile a plenty of guidelines have been developed already to improve hand hygiene practices among healthcare settings.2,3
According to the WHO Guideline on Hand Hygiene in Health Care 2009, the indications for hand hygiene were divided into 5 groups: (1) before touching a patient, (2) before clean/aseptic procedure, (3) after body fluid exposure risk, (4) after touching a patient, and (5) after touching patient surroundings.4 It’s noted specially that hand hygiene is not required before touching items of the patient zone but before contact with the patient.5
According to the Guideline for Hand Hygiene in Healthcare Settings, which was issued by the healthcare infection control practices advisory committee and the HICPAC/ SHEA/ APIC/ IDSA hand hygiene task force in 2002, the indications for hand-rubbing with an alcohol-based handrub or handwashing with soap and water were consistent with those of WHO.
Meanwhile, in ‘Best Practices for Hand Hygiene in All Health Care Settings’6, Which was developed by the Provincial Infectious Diseases Advisory Committee (PIDAC) of Canada, there are 4 moments when hand hygiene is performed, which are: (1) before initial patient or patient environment contact, (2) before aseptic or clean procedure, (3) after body fluid exposure risk, and (4) after patient or patient environment contact.
So, is it necessary to perform hand hygiene for healthcare workers before initial patient environment contact? There is significant difference between the above guidelines about hand hygiene.
During the process of health-care delivery, a patient’ hands often touch his/her immediate surfaces and substances directly. With each patient-to-surrounding exposure a bidirectional exchange of micro-organisms occurs between the patient and the touched surroundings.1 Therefore, the patient and his/her surroundings, also knows as the patient zone, form an organic whole. The so-called his/her surroundings includes some surfaces and items that are temporarily and exclusively dedicated to him or her. The surroundings includes all inanimate surfaces that are contacted by or in direct physical contact with the patient such as the call button, remote control, bed rail, bedside table, bed linen, infusion tubing and other medical equipment, as well as personal items. It further contains surfaces frequently touched by healthcare workers while caring for the patient, such as knobs, buttons and monitors, and other touchable surfaces.5
Healthcare workers’ hands can become increasingly colonized by germs and potential pathogens during daily practice. 7,8 If healthcare workers don’t perform hand hygiene before touching patients, the germs and potential pathogens on their hands could be transmitted to the patients. While performance without hand hygiene before touching patients’ surroundings, those surfaces and items can be also contaminated by germs and potential pathogens colonized on health-care workers’ hands, and then they could be transmitted to the patients through health-care workers’ hands and the patients themselves.9 Potential pathogens which have been presented on the surrounding environment can be eliminated by cleaning and disinfection, 10 however, those surfaces which are frequently touched by health-care workers’ hands may be quickly contaminated again.
In conclusion, health-care workers should perform hand hygiene right before entering the patient zone, either initial touching a patient or his/her surroundings.

ACKNOWLEDGMENTS
Financial support. This study was no funded.
Potential conflicts of interest. All authors report no conflicts of interest relevant to this article.
REFERENCE
1.        Pittet D, Allegranzi B, Sax H, et al. Evidence-based model for hand transmission during patient care and the role of improved practices. Lancet Infect Dis 2006; 6: 641-52.
2.        Higgins A, Hannan MM. Improved hand hygiene technique and compliance in healthcare workers using gaming technology. J Hosp Infect 2013; 84:32-37.
3.        Scheithauer S, Oude-Aost J, Heimann K, et al. Hand hygiene in pediatric and neonatal intensive care unit patients: daily opportunities and indication- and profession-specific analyses of compliance. Am J Infect Control 2011; 39: 732-7.
4.        Pittet D, Allegranzi B, Boyce J, for the World Health Organization World Alliance for Patient Safety First Global Patient Safety Challenge Core Group of Experts. The World Health Organization Guidelines on Hand Hygiene in Health Care and Their Consensus Recommendations. Infect Control Hosp Epidemiol 2009; 30:611-622.
5.        World Health Organization &WHO Patient Safety. Hand hygiene technical reference manual: to be used by health-care workers, trainers and observers of hand hygiene practices, Geneva : World Health Organization 2009. Available at: http:// www. who.int/ iris/ handle/ 10665/44196.
6.        Ontario. Provincial Infectious Diseases Advisory Committee. Best Practices for Hand Hygiene in All Health Care Settings. December 2010. Available at: http://www.health.gov.on.ca/english/providers/ program/ infectious/ diseases/ ic.hh.html.
7.        Sanderson PJ, Weissler S. Recovery of coliforms from the hands of nurses and patients: activities leading to contamination. J Hosp Infect 1992; 21: 85-93.
8.        Landelle C, Verachten M, Legrand P, et al.Contamination of healthcare workers' hands with Clostridium difficile spores after caring for patients with C. difficile infection. Infect Control Hosp Epidemiol 2014;35: 10-5.
9.        Boyce JM.Environmental contamination makes an important contribution to hospital infection. J Hosp Infect 2007;65: 50-4.
10.        Weber DJ, Anderson D, Rutala WA.The role of the surface environment in healthcare-associated infections. Curr Opin Infect Dis 2013;26:338-44.

江边一碗水

接收函

CC: mschreiber@cambridge.org

Ref.:  Ms. No. 35038
Is it necessary to perform hand hygiene for healthcare workers before initial patient environment contact?
Infection Control and Hospital Epidemiology

Dear Dr. Xie,

I am pleased to inform you that your manuscript, "Is it necessary to perform hand hygiene for healthcare workers before initial patient environment contact?," has been accepted for publication in Infection Control & Hospital Epidemiology.

The corresponding author must sign a copyright transfer form and email it to Cambridge University Press, the publisher of the journal. You can download the copyright form directly from this link: http://journals.cambridge.org/im ... uments/ICE_ctf.pdf.  We cannot publish your article until we have this signed form in hand. Please fill out and sign both sections A and B (you can sign on behalf of your co-authors).

Before publication, you will receive page proofs, along with a form to order reprints, from Cambridge University Press, who is the publisher of the journal. Your manuscript will be edited for consistency, clarity, and style; the manuscript editor may contact you by e-mail with questions.  You will be notified by e-mail when the proofs are ready for you to check, approximately four weeks after we receive your copyright form.  

We look forward to working with you during the remainder of the publication process. Thank you for your interest in Infection Control & Hospital Epidemiology.

Sincerely,
Suzanne F. Bradley, MD
Editor-in-Chief

楚楚

江边一碗水 发表于 2014-10-15 08:41
今天早上6点钟被冻醒了，于是打开手机看邮箱，哇，一个好消息！我和楚楚合作的关于这个话题的letter被Infec ...

一次非常开心的合作之旅！从观点提出得到江边一碗水斑斑认可之时起，我就特别有久旱遇干露，人海遇知音的赶脚接着江边一碗水斑斑又提议写成letter，我觉得更是一拍即合。其实用心写，也就3个晚上的时间，整个过程一气呵成，毫不费力，这个让我一直只敢望其项背的SCI就这样实现了零的突破。在此，非常感谢江边一碗水斑斑的引路和鼓励，没有你，就没有这篇实现零的突破的SCI，感谢你！当然，还要感谢icchina提供了SIFIC这么好的一个合作平台！我行，你们会更行的，广大的SIFIC会员们，加油！期待你们也与大家分享你们的收获和惊喜哦！

江边一碗水

楚楚 发表于 2014-10-15 09:22
一次非常开心的合作之旅！从观点提出得到江边一碗水斑斑认可之时起，我就特别有久旱遇干露，人海遇知音的 ...

楚楚谬赞了！你提出的点子，我们合作完成的！
论坛的确是交流思想的好地方！

江边一碗水

2015年ICHE第一期刊出了，见附件