In order to comply with these safety standards, a hierarchy of controls is utilized. The hierarchy of safety and health controls include (CDC, 2004a):

• Legal and regulatory controls.
• Administrative and Training controls.
• Engineering controls.
• Work practice controls.
• Personal protective equipment (this will be covered in Element IV of this training).

The Occupational Safety and Health Administration (OSHA) Occupational Safety and Health Act of 1970, General Duty Clause requires that each employer:

1. Shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to employees;
   
   
2. Shall comply with occupational safety and health standards promulgated under this Act.

These guidelines include the following indications for handwashing and hand antisepsis (CDC, 2002):

• When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water.
  
  
• If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in clinical situations. Alternatively, wash hands with an antimicrobial soap and water in clinical situations.
  
  
• Decontaminate hands before having direct contact with patients.
  
  
• Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter.
  
  
• Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure.
  
  
• Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient).
  
  
• Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled.
  
  
• Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care.
  
  
• Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient.
  
  
• Decontaminate hands after removing gloves.
  
  
• Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water.
  
  
• Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of healthcare workers, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap.
  
  
• Wash hands with non-antimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores.

Hand-hygiene technique recommendations of the guidelines include:

• When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's recommendations regarding the volume of product to use.
  
  
• When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis.
  
  
• Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used.
  
  
• Multiple-use cloth towels of the hanging or roll type are not recommended for use in healthcare settings.

Surgical hand antisepsis recommendations of the guidelines include:

• Remove rings, watches, and bracelets before beginning the surgical hand scrub.
  
  
• Remove debris from underneath fingernails using a nail cleaner under running water.
  
  
• Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures.
  
  
• When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2--6 minutes. Long scrub times (e.g., 10 minutes) are not necessary.
  
  
• When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer's instructions. Before applying the alcohol solution, prewash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.

Recommendations for the selection of hand-hygiene agents include:

• Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift. This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel.
  
  
• To maximize acceptance of hand-hygiene products by healthcare workers, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-hygiene products should not be the primary factor influencing product selection.
  
  
• When selecting non-antimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution.
  
  
• Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product.
  
  
• Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap.

Recommendations for skin care in the guidelines include:

• Provide healthcare workers with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing.
  
  
• Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution.

Recommendations for other aspects of hand hygiene in the Guidelines include:

• Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms).
  
  
• Keep natural nails tips less than 1/4-inch long.
  
  
• Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur.
  
  
• Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients.
  
  
• Change gloves during patient care if moving from a contaminated body site to a clean body site.
  
  
• No recommendations were made regarding wearing rings in healthcare settings; this remains an unresolved issue.

Recommendations for healthcare worker educational and motivational programs include (this is a training control):

• As part of an overall program to improve hand-hygiene practices of healthcare workers, educate personnel regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their hands.
  
  
• Monitor healthcare workers' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance.
  
  
• Encourage patients and their families to remind healthcare workers to decontaminate their hands.

Recommendations for administrative measures included in the Guideline (this is an administrative control):

• Make improved hand-hygiene adherence an institutional priority and provide appropriate administrative support and financial resources.
  
  
• Implement a multidisciplinary program designed to improve adherence of health personnel to recommended hand-hygiene practices.
  
  
• As part of a multidisciplinary program to improve hand-hygiene adherence, provide healthcare workers with a readily accessible alcohol-based hand-rub product.
  
  
• To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based hand rub available at the entrance to the patient's room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by healthcare workers.
  
  
• Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials.

Others have also recommended controls to manage the spread of infections. In 2003, JCAHO issued a Sentinel Event Alert related to infection control (JCAHO, 2003). They had two recommendations:

1. Comply with the CDC's 2002 Hand Hygiene Guidelines (covered earlier in this course); and
   
   
2. Manage as sentinel events all identified cases of death and major permanent loss of function attributed to a nosocomial infection (i.e. except for the infection, the patient would probably not have died or suffered loss of function).

As a result of the sentinel events arising from infections and in response to the identified root causes, healthcare organizations implemented various risk reduction strategies, including the implementation of relevant clinical pathways for MRSA, endometritis and urinary tract infection. These strategies include (JCAHO, 2003):

• Revising orientation and training processes and competency assessments.
• Revising equipment cleaning processes.
• Revising handwashing procedures.
• Switching to the use of single-use IV flush vials.
• Adding waterless handrubs.
• Defining supervisory expectations.
• Revising critical care privileging and ICU admission criteria.
• Conducting in-service and team trainings.
• Instituting tracking systems.