Hand Hygiene

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Introduction

Hand Hygiene is a general term that applies to either handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis. The Centers for Disease Control and Prevention (CDC) define these activities as the following:

• Handwashing - Washing hands with plain (i.e. non-antimicrobial) soap and water.
• Hand antisepsis - Refers to either antiseptic handwash or antiseptic hand rub.
• Surgical hand antisepsis - Antiseptic handwash or antiseptic hand rub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora.

Good hand hygiene is an important aspect of protecting yourself and your others from infection transmission. It is one of the most effective ways to prevent hospital care associated infection rates.  Failure to perform appropriate hand hygiene is considered the leading cause of healthcare-associated infections and spread of multi-resistant organisms such as Methicilin Resistant Staphylococcus Aureus (MRSA) and has been recognised as a substantial contributor to outbreaks.

Washing hands with soap and water is recommended for visibly soiled hands and is the best way to get rid of germs in most situations. If soap and water are not readily available, you can use an alcohol-based hand sanitiser that contains at least 60% alcohol. These are the most efficacious agents for reducing the number of bacteria and viruses on hands and are recommended for routine decontamination of hands for all clinical indications (except when hands are visibly soiled)

Clean hands are a simple effective approach to reducing the spread of infections from one person to another and throughout an entire community - from your home and workplace to childcare facilities and hospitals.

Importance of Hand Hygiene

Normal human skin is colonized with microorganisms which although vary considerably from person to person are often relatively constant for any specific person.  On the hands it is described in two categories of flora:

1. Transient flora - often acquired during direct contact with patients or contaminated surfaces and colonises superficial layers of the skin.  Most frequently associated with healthcare associated infections and are amenable to removal by hand washing.
2. Resident flora - attached to deeper layers of the skin, more resistant to removal and less likely to be associated with healthcare associated infections.

These microorganisms when pathogenic can cause potential risks to patients and health care facilities by:

• transmission of microorganisms to patients
• health-care worker colonization or infection caused by organisms acquired from the patient
• morbidity, mortality, and costs associated with healthcare-associated infections

Transmission of pathogens from one patient to another requires the following sequence of events:

1. Organisms present on the patient’s skin, or that have been shed onto inanimate objects in close proximity to the patient, are transferred to the hands of the caregiver.
2. These organisms must then be capable of surviving for at least several minutes on the hands of personnel.
3. Next, handwashing or hand antisepsis by the caregiver must be inadequate or omitted entirely, or the agent used for hand hygiene is ineffective.
4. Finally, the contaminated hands of the caregiver must come in direct contact with another patient, or with an inanimate object that will come into direct contact with the patient.

Teaching people about handwashing helps them and their communities stay healthy. Handwashing education in the community:

• Reduces the number of people who get sick with diarrhea by 23-40%
• Reduces diarrheal illness in people with weakened immune systems by 58%  
• Reduces respiratory illnesses, like colds, in the general population by 16-21%
• Reduces absenteeism due to gastrointestinal illness in schoolchildren by 29-57%

Indications for Hand Hygiene

The CDC describes the following indications for handwashing and hand antisepsis:

• 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 nonantimicrobial 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 all other clinical situations described in items
• 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, nonintact 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 HCWs, 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

Methods of Hand Hygiene

Washing with Soap

There are 5 steps to proper handwashing:

• Wet your hands with clean, running water (warm or cold), turn off the tap, and apply soap.
• Lather your hands by rubbing them together with the soap. Lather the backs of your hands, between your fingers, and under your nails.
• Scrub your hands for at least 20 seconds. Need a timer? Hum the “Happy Birthday” song from beginning to end twice.
• Rinse your hands well under clean, running water.
• Dry your hands using a clean towel or air dry them. Use a towel to turn off the faucet!

The temperature of water does not influence microbe removal. A report9 studying the effect of temperature ranging from 5°C to 50°C on the removal of different types of bacteria showed that heat did not influence the transient or residual flora. In fact, friction and thorough rinsing and contact time are considered the most essential factors for handwashing.

Resources

• Centers for Disease Control and Prevention. Handwashing: Clean hands save lives.
• Downloadable posters to promote handwashing from the CDC
• Downloadable tools for 5 moments hand hygiene from WHO