Hand Hygiene

Original Editor -Rachael Lowe Top Contributors - Rachael Lowe, Tony Lowe, Candace Goh, Wanda van Niekerk and Kim Jackson  

Introduction

Hand hygeine.jpg

Hand Hygiene is a general term that applies to either handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis.[1] 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 others from infection transmission. It is one of the most effective ways to prevent hospital care-associated infection rates.[1][2] 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)[3] and has been recognised as a substantial contributor to outbreaks[1].

Washing hands with soap and water are recommended for visibly soiled hands[4] 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 sanitisers 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).[4]

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.[5]

Importance of Hand Hygiene

Normal human skin is colonized with microorganisms which, although varying considerably from person to person, are often relatively constant for any specific person. On the hands it is described in two categories of flora[4]:

  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%[6][7][8]
  • Reduces diarrheal illness in people with weakened immune systems by 58%[9]  
  • Reduces respiratory illnesses, like colds, in the general population by 16-21% [7]
  • Reduces absenteeism due to gastrointestinal illness in schoolchildren by 29-57%[10]

Indications for Hand Hygiene

The CDC[11] 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 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 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, 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 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

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Washing with Soap

There are 5 steps to proper handwashing[12]:

  • 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 the water does not influence microbe removal. A report[13] 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. Instead, friction, thorough rinsing and contact time are considered the most essential factors for effective handwashing.

What You Need To Know About Handwashing from the CDC:

[14]

Handwashing video from the WHO:

[15]

Alcohol-based hand sanitiser

When using alcohol-based hand sanitiser:

  • Apply the product to the palm of one hand and rub hands together
  • Cover all surfaces of hands and fingers until they feel dry
  • This should take around 20 seconds
[16]

Surgical Hand Antisepsis

This is performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora:

  • Remove rings, watches, and bracelets before beginning the surgical hand scrub
  • Remove debris from underneath fingernails using a nail cleaner under running water
  • Prewash hands and forearms with a non-antimicrobial soap for 40-60 seconds and dry hands and forearms with a single-use towel.
  • Apply the alcohol-based product according to manufacturer's instructions, allow hands and forearms to dry thoroughly before donning sterile gloves.

Skin Care

If skin health is suffering it is recommended that lotions and creams be used to prevent irritation.

Factors affecting adherence

There are many factors that affect healthcare professionals' adherence to hand hygiene practices. The CDC adapted findings from Pittet[17] to come up with the following reasons.

Observed risk factors for poor adherence to recommended hand-hygiene practices:

  • Physician status (rather than a nurse)
  • Nursing assistant status (rather than a nurse)
  • Male sex
  • Working in an intensive-care unit
  • Working during the week (versus the weekend)
  • Wearing gowns/gloves
  • Automated sink
  • Activities with a high risk of cross-transmission
  • A high number of opportunities for hand hygiene per hour of patient care

Self-reported factors for poor adherence with hand hygiene :

  • Handwashing agents cause irritation and dryness
  • Sinks are inconveniently located/shortage of sinks
  • Lack of soap and paper towels
  • Often too busy/insufficient time
  • Understaffing/overcrowding
  • Patient needs take priority
  • Hand hygiene interferes with health-care worker relationships with patients
  • Low risk of acquiring infection from patients
  • Wearing of gloves/beliefs that glove use obviates the need for hand hygiene
  • Lack of knowledge of guidelines/protocols
  • Not thinking about it/forgetfulness
  • No role model from colleagues or superiors
  • Skepticism regarding the value of hand hygiene
  • Disagreement with the recommendations
  • Lack of scientific information of definitive impact of improved hand hygiene on health-care-associated infection rates

Additional perceived barriers to appropriate hand hygiene:

  • Lack of active participation in hand-hygiene promotion at individual or institutional level
  • Lack of role model for hand hygiene
  • Lack of institutional priority for hand hygiene
  • Lack of administrative sanction of non-compliers/rewarding compliers
  • Lack of institutional safety climate

Addressing these predictors of poor adherence in your health care setting can promote good hand hygiene practices among your staff. Easy wins would be to:

  1. Provide education and a culture of adherence, with feedback on performance.
  2. Give easy access to hand hygiene materials. For example, place alcohol-based hand products at every bedside or in every clinic room.

Glove Use

  • Hand contamination may occur as a result of small, undetected holes in examination gloves
  • Contamination may occur during glove removal
  • Wearing gloves does not replace the need for hand hygiene
  • Failure to remove gloves after caring for a patient may lead to transmission of micro organisations from one patient to another

Handwashing After a Disaster or Emergency

Hygiene is especially important in an emergency such as a flood, hurricane, or earthquake, but finding clean, safe running water can sometimes be difficult. If your tap water is not safe to use, wash your hands with soap and water that has been boiled or disinfected. A temporary hand washing station can be created by using a large water jug that contains clean water (for example, boiled or disinfected).

Resources

References

  1. 1.0 1.1 1.2 Centers for Disease Control and Prevention. Handwashing: Clean hands save lives. Available from:https://www.cdc.gov/handwashing/index.html (accessed 13 March 2020)
  2. World Health Organization. Evidence of hand hygiene to reduce transmission and infections by multi-drug resistant organisms in health-care settings. WHO. 2014.
  3. Centers for Disease Control and Prevention. MRSA. Available from:https://www.cdc.gov/mrsa/index.html (accessed 14 March 2020)
  4. 4.0 4.1 4.2 Boyce, J.M. and 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 & Hospital Epidemiology, 23(S12), pp.S3-S40.
  5. Jefferson T, Del Mar C, Dooley L, Ferroni E, Al-Ansary LA, Bawazeer GA, Van Driel ML, Foxlee R, Rivetti A. Physical interventions to interrupt or reduce the spread of respiratory viruses: systematic review. Bmj. 2009 Sep 22;339:b3675.
  6. Ejemot‐Nwadiaro RI, Ehiri JE, Meremikwu MM, Critchley JA. Hand washing for preventing diarrhoea. Cochrane database of systematic reviews. 2008(1).
  7. 7.0 7.1 Aiello AE, Coulborn RM, Perez V, Larson EL. Effect of hand hygiene on infectious disease risk in the community setting: a meta-analysis. American journal of public health. 2008 Aug;98(8):1372-81.
  8. Freeman MC, Stocks ME, Cumming O, Jeandron A, Higgins JP, Wolf J, Prüss‐Ustün A, Bonjour S, Hunter PR, Fewtrell L, Curtis V. Systematic review: hygiene and health: systematic review of handwashing practices worldwide and update of health effects. Tropical Medicine & International Health. 2014 Aug;19(8):906-16.
  9. Huang DB, Zhou J. Effect of intensive handwashing in the prevention of diarrhoeal illness among patients with AIDS: a randomized controlled study. Journal of medical microbiology. 2007 May 1;56(5):659-63.
  10. Wang Z, Lapinski M, Quilliam E, Jaykus LA, Fraser A. The effect of hand-hygiene interventions on infectious disease-associated absenteeism in elementary schools: A systematic literature review. American journal of infection control. 2017 Jun 1;45(6):682-9.
  11. Recommendations from the CDC Guideline for Hand Hygiene in Healthcare Settings, by the Healthcare Infection Control Practices Advisory Committee, 3MHealthCarehttps://multimedia.3m.com/mws/media/309799O/cdc-guidelines-reprint.pdf
  12. "Handwashing - Clean Hands Save Lives | CDC." https://www.cdc.gov/handwashing/index.html. Accessed 13 Mar. 2020.
  13. The WHO Guidelines on Hand Hygiene in Healthcare (Advanced Draft)https://www.who.int/patientsafety/information_centre/Last_April_versionHH_Guidelines%5B3%5D.pdf Accessed on 13/March/2020.
  14. Centers for Disease Control and and Prevention.What You Need To Know About Handwashing. Published on 16 December 2019. Available from https://www.youtube.com/watch?v=d914EnpU4Fo&feature=emb_logo. [last accessed 17 March 2020]
  15. World Health Organisation. WHO: How to handwash? With soap and water. Published on 20 October 2015. Available fromhttps://www.youtube.com/watch?time_continue=1&v=3PmVJQUCm4E&feature=emb_logo. [last accessed 17 March 2020]
  16. WHO: How to handrub? With alcohol-based formulation, World Health Organisation, Oct 2015, https://www.youtube.com/watch?v=ZnSjFr6J9HI
  17. Pittet D. Improving compliance with hand hygiene in hospitals. Infection Control & Hospital Epidemiology. 2000 Jun;21(6):381-6.