LEARNING OBJECTIVES

Upon completion of this course, you will be able to:

• State the relationship between hand hygiene and the acquisition of healthcare-associated pathogens.
• Describe hand cleansing techniques and the accepted principles of surgical hand antisepsis.
• Summarize the categories of hand cleansers and their applications.
• Identify factors affecting adherence to hand hygiene guidelines among healthcare workers.

Good hand hygiene just may be the single most important thing that healthcare workers can do every day to help protect the lives of their patients.

For generations, handwashing with soap and water has been considered a measure of personal hygiene, but only in the last two centuries has the link between handwashing and the spread of disease been established (WHO, 2005). In 1961 the U.S. Public Health Service recommendations directed that personnel wash their hands with soap and water for 1 to 2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing and was recommended only in emergencies or in areas where sinks were unavailable.

In 1975 and 1985 guidelines on handwashing practices in hospitals were published by the Centers for Disease Control (CDC), which recommended handwashing with non-antimicrobial soap between patient contacts and washing with antimicrobial soap before and after performing invasive procedures or caring for patients at high risk. Use of waterless antiseptic agents (eg, alcohol-based solutions) was recommended only in situations where sinks were not available.

In 1988 and 1995 guidelines for handwashing and hand antisepsis were published by the Association for Professionals in Infection Control (APIC) that were similar to those listed in the CDC guidelines. The 1995 APIC guideline included discussion of alcohol-based hand rubs and supported their use in more clinical settings than had been recommended earlier.

In 1995 and 1996 the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommended that either antimicrobial soap or a waterless antiseptic agent be used for cleansing hands upon leaving the rooms of patients with multidrug-resistant pathogens such as vancomycin-resistant enterococci (VRE) and methicillin-resistant Staphylococcus aureus (MRSA). These guidelines also provided recommendations for handwashing and hand antisepsis in other clinical settings, including routine patient care.

In 2002, Guideline for Hand Hygiene in Health-Care Settings was published as the recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC / SHEA / APIC / IDSA Hand Hygiene Task Force. This document is available in multiple locations, including the CDC website, and is the main source for this course. It was in this guideline that alcohol-based hand rubs were defined as the standard for hand hygiene in most healthcare settings (WHO 2005).

Although the APIC and HICPAC guidelines have been adopted by the majority of hospitals, adherence of healthcare workers to recommended handwashing practices has often been demonstrated to be low. A number of factors have been identified as impacting adherence to hand hygiene programs, so individuals and institutions must remain proactive. Many organizations, agencies, and professional groups are undertaking research and consensus meetings, so healthcare workers and institutions should stay abreast of the news.

SKIN PHYSIOLOGY AND NORMAL SKIN FLORA

The primary function of the skin is to reduce water loss, provide protection against abrasive action and microorganisms, and act as a permeability barrier to the environment. The basic structure of skin includes, from outer to innermost layer, the superficial region (ie, the stratum corneum or horny layer, which is 10 to 20 μm thick), the viable epidermis (50 to 100 μm thick), the dermis (1 to 2 mm thick), and the hypodermis (1 to 2 mm thick). The barrier to percutaneous absorption lies within the stratum corneum, the thinnest and smallest compartment of the skin.

Traditionally, bacteria recovered from the hands are divided into two categories: transient and resident. Transient flora, which colonize the superficial layers of the skin, are more amenable to removal by routine handwashing. Transient flora are the organisms most frequently found in healthcare-associated infections. Resident flora, which are attached to deeper layers of the skin, are more resistant to removal.

The hands of some healthcare workers may become persistently colonized with pathogenic flora (eg, S. aureus), gram-negative bacilli, or yeast). Investigators have documented that, although the number of transient and resident flora varies considerably from person to person, it is often relatively constant for any specific person.

Skin irritation caused by chemicals, removal of tape, and other physical disruptions leads to a decrease in skin-barrier function. Detergents and acetones remove glycerolipids and sterols from the skin, which are necessary for barrier function. It takes time for normal barrier function to return: 50% to 60% of barrier recovery typically occurs within 6 hours, but complete normalization of barrier function requires 5 to 6 days.

TRANSMISSION OF PATHOGENS VIA HANDS

Pathogens can be transmitted from one patient to another via the hands of healthcare workers; such transmission requires a sequence of five steps:

• Organisms present on patients' skin or in the inanimate environment
• Organisms transferred to healthcare workers' hands
• Organisms capable of surviving on hands
• Defective hand cleansing resulting in hands remaining contaminated
• Cross-transmission of organisms by contaminated hands (WHO, 2005)

Healthcare-associated pathogens can be recovered not only from infected or draining wounds but also from frequently colonized areas of normal intact skin. The perineal or inguinal areas are usually most heavily colonized, but the axillae, trunk, and upper extremities (including the hands) are also frequently colonized.

The number of organisms present on intact areas of the skin varies with patients. Individuals with diabetes, those undergoing dialysis for chronic renal failure, and those with chronic dermatitis are likely to have areas of intact skin colonized with S. aureus.

Patient gowns, bed linen, bedside furniture, and other objects in the patient's immediate environment can easily become contaminated with patient flora. Such contamination is particularly likely to be caused by staphylococci or enterococci, which are resistant to desiccation (drying). Contamination has also been noted on hand washing stations, including on taps and faucets.

Healthcare workers can contaminate their hands with gram-negative bacilli, S. aureus, enterococci, or Clostridium difficile by performing "clean procedures" or touching intact areas of the skin of hospitalized patients. Hospital staff caring for infants with respiratory syncytial virus (RSV) infections have acquired RSV by performing certain activities (e.g., feeding or playing with infants, changing diapers).

Even those who had contact only with surfaces contaminated with infant secretions acquired RSV by contaminating their hands and inoculating their oral or conjunctival mucosa. Other studies have documented that healthcare workers may contaminate their hands (or gloves) merely by touching inanimate objects in patient rooms.

Hand antisepsis reduces the incidence of healthcare-associated infections. Trials have studied the effects on infection rates of handwashing with plain soap and water versus some form of hand antisepsis. The rates were lower when antiseptic handwashing was performed. However, if handwashing is done incorrectly or not done when indicated, the result could be contaminated hands and transmission of organisms to another patient.

Increased handwashing frequency among hospital staff has been associated with decreased transmission of Klebsiella spp. among patients. Outbreak investigations have indicated an association between infections and understaffing or overcrowding; the association was consistently linked with poor adherence to hand hygiene.

While studies have shown the ability of microorganisms to survive on hands for differing amounts of time and that contaminated hands could be vehicles for the spread of certain viruses, there are few studies that prove inadequate hand cleansing (WHO, 2005). Studies do highlight the role of many factors, including the staffing issues mentioned above, ring wearing, the use of artificial nails, the specifics of products and techniques for handwashing, contaminated soaps and lotions, and even the transmission of pathogens from out-of-hospital sources (WHO, 2005). More research is clearly needed and is underway.

HAND HYGIENE PRODUCTS

Evaluation

In the United States, antiseptic handwash products intended for use by healthcare workers are regulated by FDA's Division of Over-the-Counter Drug Products. Accepted methods of evaluating hand hygiene products require that test volunteers wash their hands with a plain or antimicrobial soap for 30 seconds or 1 minute, despite the observation in the majority of studies that the average duration of handwashing by hospital personnel is less than 15 seconds.

Only a few investigators have used 15-second handwashing or hygienic hand-wash protocols. Therefore, almost no data exist regarding the efficacy of plain or antimicrobial soaps under conditions in which they are actually used. Similarly, certain accepted methods for evaluating waterless antiseptic agents for use as antiseptic hand rubs require that 3 mL of alcohol be rubbed into the hands for 30 seconds, followed by a repeat application for the same duration. Clearly the 15-second average handwashing falls short of that standard.

As with transmission studies, there are multiple factors affecting the study of handwashing products. Not all evaluation methods currently employed are equally useful and relevant. In its Guidelines on Hand Hygiene in Health Care (Advanced Draft 2005) the World Health Organization (WHO) presents an extensive discussion of current methods, shortcomings, and standards, as well as new methods they suggest for future studies.

Cleansing Products and Antiseptic Agents

EFFICACY OF HAND HYGIENE ANTISEPTIC AGENTS*

* Hexachlorophene is not included because it is no longer an accepted ingredient of hand disinfection. Source: CDC, 2007.
Alcohols
Gram-positive bacteria	excellent
Gram-negative bacteria	excellent
Mycobacteria	excellent
Fungi	excellent
Viruses	excellent
Speed of action	fast
Comments	optimum concentration 60%–95%; no persistent activity
Chlorhexidine (2% and 4% aqueous)
Gram-positive bacteria	excellent
Gram-negative bacteria	good, but does not include the entire bacterial spectrum
Mycobacteria	fair
Fungi	fair
Viruses	excellent
Speed of action	intermediate
Comments	persistent activity; rare allergic reactions
Iodine Compounds
Gram-positive bacteria	excellent
Gram-negative bacteria	excellent
Mycobacteria	excellent
Fungi	good, but does not include the entire bacterial spectrum
Viruses	excellent
Speed of action	intermediate
Comments	causes skin burns; usually too irritating for hand hygiene
Iodophors
Gram-positive bacteria	excellent
Gram-negative bacteria	excellent
Mycobacteria	fair
Fungi	good, but does not include the entire bacterial spectrum
Viruses	good, but does not include the entire bacterial spectrum
Speed of action	intermediate
Comments	less irritating than iodine; acceptance varies
Phenol Derivatives
Gram-positive bacteria	excellent
Gram-negative bacteria	fair
Mycobacteria	fair
Fungi	fair
Viruses	fair
Speed of action	intermediate
Comments	activity neutralized by nonionic surfactants
Tricolsan
Gram-positive bacteria	excellent
Gram-negative bacteria	good, but does not include the entire bacterial spectrum
Mycobacteria	fair
Fungi	no activity or not sufficient
Viruses	excellent
Speed of action	intermediate
Comments	acceptability on hands varies
Quaternary Ammonium Compounds
Gram-positive bacteria	fair
Gram-negative bacteria	good, but does not include the entire bacterial spectrum
Mycobacteria	no activity or not sufficient
Fungi	no activity or not sufficient
Viruses	fair
Speed of action	slow
Comments	used only in combination with alcohols; ecologic concerns

PLAIN SOAP

Soaps are detergent-based products that possess a cleansing action. Their cleansing activity is due to their detergent properties, which remove dirt, soil, and various organic substances from the hands. Plain soaps have minimal, if any, antimicrobial activity (destroying or inhibiting the growth of microorganisms). However, handwashing with plain soap can remove loose transient flora. In several studies, handwashing with plain soap failed to remove pathogens from the hands of hospital personnel.

ALCOHOLS

The majority of alcohol-based hand antiseptics contain isopropanol, ethanol, n-propanol, or a combination of two of these products. Alcohol solutions containing 60% to 95% alcohol are most effective; higher concentrations are less potent. Alcohols have excellent germicidal activity in the laboratory against gram-positive and gram-negative vegetative bacteria, including multidrug-resistant pathogens (e.g., MRSA and VRE), Mycobacterium tuberculosis, and various fungi.

Certain viruses such as herpes simplex virus (HSV), human immunodeficiency virus (HIV), influenza virus, respiratory syncytial virus (RSV), and vaccinia virus are susceptible to alcohols when tested in vitro. Hepatitis B virus (HBV) is somewhat less susceptible but is killed by 60% to 70% alcohol; hepatitis C virus (HCV) also is likely killed by this percentage of alcohol. Despite its effectiveness against these organisms, alcohols have very poor activity against bacterial spores, protozoan oocysts, and certain nonenveloped (nonlipophilic) viruses.

Alcohols are rapidly germicidal when applied to the skin, but they have no appreciable persistent or residual activity (prolonged or extended antimicrobial activity that prevents or inhibits the proliferation or survival of microorganisms after application of the product). However, regrowth of bacteria on the skin occurs slowly after use of alcohol-based hand antiseptics, presumably because of the sublethal effect alcohols have on some skin bacteria.

Addition of chlorhexidine, quaternary ammonium compounds, octenidine, or triclosan to alcohol-based solutions can result in persistent activity. Alcohols, when used in concentrations present in alcohol-based hand rubs, also have in vitro activity against several nonenveloped viruses (eg, rotavirus, adenovirus, and rhinovirus, hepatitis A, poliovirus).

Alcohols are not appropriate for use when hands are visibly dirty or contaminated with proteinaceous materials. However, when relatively small amounts of proteinaceous material (eg, blood) are present, ethanol and isopropanol may reduce viable bacterial counts on hands more than plain soap or antimicrobial soap.

Alcohol can prevent the transfer of healthcare-associated pathogens. When the hands of healthcare workers are heavily contaminated, an antiseptic hand rub using an alcohol-based rinse can prevent pathogen transmission more effectively than handwashing with plain soap and water.

Alcohol-based products are more effective for standard handwashing or hand antisepsis than soap or antimicrobial soaps. Alcohols are effective for pre-operative cleansing of the hands of surgical personnel. The efficacy of alcohol-based hand hygiene products is affected by several factors, including the type of alcohol, concentration of alcohol, contact time, volume of alcohol, and whether the hands are wet when the alcohol is applied.

Alcohol-Based Rubs and Fire Safety

Alcohols are flammable. Flashpoints of alcohol-based hand rubs range from 21°C to 24°C, depending on the type and concentration of alcohol present. As a result, alcohol-based hand rubs should be stored away from high temperatures or flames, in accordance with National Fire Protection Agency (NFPA) recommendations. In Europe, where alcohol-based hand rubs have been used extensively for years, the incidence of fires associated with such products has been low.

When using alcohol-based hand-rubs, the CDC recommends that:

• Healthcare personnel rub their hands until the alcohol has evaporated (hands are dry).
• Alcohol-based hand rubs be stored away from high temperatures or flames, in accordance with CDC and National Fire Protection Agency recommendations.
• Supplies of alcohol-based hand rubs be stored in cabinets or areas approved for flammable materials.

Not long after the 2002 CDC guideline was published, fire marshals in some areas prohibited the placement of dispensers for alcohol-based hand rubs in exit corridors due to concerns about fire safety (WHO, 2005). However, in March 2005, the Centers for Medicare and Medicaid Services (CMS) issued an interim final rule adopting an amendment by the NFPA allowing for the installation of alcohol hand-rub dispensers in egress corridors (CDC, 2005; WHO, 2005).

Healthcare organizations are encouraged to install dispensers in patient rooms, treatment rooms, suites and all other appropriate locations. Healthcare facilities should work with local fire marshals to ensure that these installations are consistent with local fire codes, which may differ from the national codes.

CHLORHEXIDINE

Chlorhexidine's immediate antimicrobial activity occurs more slowly than that of alcohols. Chlorhexidine has good activity against gram-positive bacteria, somewhat less activity against gram-negative bacteria and fungi, and only minimal activity against tubercle bacilli. Chlorhexidine is not sporicidal.

Chlorhexidine has in vitro activity against enveloped viruses (eg, HSV, HIV, cytomegalovirus, influenza, RSV) but substantially less activity against nonenveloped viruses. It has substantial residual activity. Addition of low concentrations (0.5%—1.0%) of chlorhexidine to alcohol-based preparations results in greater residual activity than alcohol alone. Note: Healthcare workers may be familiar with a chlorhexidine-containing product made by Skinvisible, Inc.

CHLOROXYLENOL

Chloroxylenol, also known as parachlorometaxylenol (PCMX), is a compound that has been used as a preservative in cosmetics and other products and as an active agent in antimicrobial soaps. The antimicrobial activity of PCMX likely is attributable to inactivation of bacterial enzymes and alteration of bacterial cell walls. (Chloroxylenol is a phenol derivative, see table above.)

It has good in vitro activity against gram-positive organisms and activity against gram-negative bacteria, mycobacteria (leprosy, TB), and certain viruses. PCMX is less active against P. aeruginosa, but addition of ethylene-diaminetetraacetic acid (EDTA) increases its activity against Pseudomonas spp. and other pathogens.

HEXACHLOROPHENE

In the 1950s and early 1960s, emulsions containing 3% hexachlorophene were widely used for hygienic handwashing, as surgical scrubs, and for routine bathing of infants in hospital nurseries. Studies of hexachlorophene as a hygienic handwash and surgical scrub demonstrated only modest efficacy after a single handwash.

Current guidelines recommend against the routine bathing of neonates with hexachlorophene because of its potential neurotoxic effects. The agent is classified by FDA as not generally recognized as safe and effective for use as an antiseptic handwash.

IODINE AND IODOPHORS

Iodine has been recognized as an effective antiseptic since the 1800s. However, because iodine often causes irritation and discoloring of skin, iodophors have largely replaced iodine as the active ingredient in antiseptics.

Iodine and iodophors have bactericidal activity against gram-positive, gram-negative, and certain spore-forming bacteria (eg, clostridia, Bacillus spp.)and are active against mycobacteria, viruses, and fungi. However, in concentrations used in antiseptics, iodophors are not usually sporicidal.

The majority of iodophor preparations used for hand hygiene contain 7.5% to 10% povidone-iodine. Formulations with lower concentrations also have good antimicrobial activity because dilution can increase free iodine concentrations. However, as the amount of free iodine increases, the degree of skin irritation also may increase. Iodophors cause less skin irritation and fewer allergic reactions than iodine, but more irritant contact dermatitis than other antiseptics commonly used for hand hygiene.

TRICLOSAN

Triclosan is a nonionic, colorless substance that was developed in the 1960s. It has been incorporated into soaps for use by HCWs and the public and into other consumer products. Concentrations of 0.2% to 2% have antimicrobial activity.

Triclosan has a broad range of antimicrobial activity, but it is often bacteriostatic. The agent possesses reasonable activity against mycobacteria and Candida spp., but it has limited activity against filamentous fungi. Like chlorhexidine, triclosan has persistent activity on the skin. Its activity in hand-care products is affected by pH, the presence of surfactants, emollients, or humectants and by the ionic nature of the particular formulation.

Some reports indicate that providing hospital personnel with a triclosan-containing preparation for hand antisepsis has led to decreased MRSA infections. Triclosan's lack of potent activity against gram-negative bacilli has resulted in occasional reports of contamination.

QUATERNARY AMMONIUM COMPOUNDS

Of this large group of compounds, alkyl benzalkonium chlorides are the most widely used as antiseptics. Other compounds that have been used as antiseptics include benzethonium chloride, cetrimide, and cetyl Pyridium chloride.

Quaternary ammonium compounds are primarily bacteriostatic and fungistatic, although they are microbicidal against certain organisms at high concentrations; they are more active against gram-positive than against gram-negative bacilli. Quaternary ammonium compounds have relatively weak activity against mycobacteria and fungi and have greater activity against lipophilic viruses.

A recent study of surgical ICU personnel found that cleansing hands with antimicrobial wipes containing a quaternary ammonium compound was about as effective as using plain soap and water for handwashing; both were less effective than decontaminating hands with an alcohol-based hand rub.

Activity of Antiseptic Agents Against Spore-Forming Bacteria

The widespread prevalence of healthcare-associated diarrhea caused by Clostridium difficile and the recent occurrence in the United States of human Bacillus anthracis infections associated with contaminated items sent through the postal system has raised concern regarding the activity of antiseptic agents against spore-forming bacteria. None of the agents (including alcohols, chlorhexidine, hexachlorophene, iodophors, PCMX, and triclosan) used in antiseptic handwash or antiseptic hand-rub preparations are reliably sporicidal against Clostridium spp. or Bacillus spp.

During outbreaks of C. difficile-related infections, washing hands with a non-antimicrobial or antimicrobial soap and water after removing gloves is prudent. Healthcare workers with suspected or documented exposure to B. anthracis-contaminated items also should be encouraged to wash their hands with a non-antimicrobial or antimicrobial soap and water.

HAND CLEANSING TECHNIQUE

The following steps constitute the technique outlined in the WHO Guidelines on Hand Hygiene in Health Care (Advanced Draft 2005). Be sure to follow the manufacturer's recommendations regarding the volume of product to use.

• Apply a palmful of the [hand cleansing] product and cover all surfaces of the hands. Rub hands until hands are dry.
• When washing hands with soap and water, wet hands with water and apply the amount of product necessary to cover all surfaces. Vigorously perform rotational hand rubbing on both hand palms and backs, interlace and interlock fingers to cover all surfaces. Rinse hands with water and dry thoroughly with a single-use towel. Use running and clean water whenever possible. Use towel to turn off tap/faucet.
• Make sure hands are dry. Use a method that does not recontaminate hands. Make sure towels are not used multiple times or by multiple people. Avoid using hot water, as repeated exposure to hot water may increase the risk of dermatitis.
• Liquid, bar, leaf, or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, small bars of soap in racks that facilitate drainage should be used (WHO, 2005).

SURGICAL HAND ANTISEPSIS

Antiseptic preparations intended for use as surgical hand scrubs are evaluated for their ability to reduce the number of bacteria released from hands at different times. Immediate and persistent activity is considered the most important in determining the efficacy of the product. Guidelines recommend that agents used for surgical hand scrubs should substantially reduce microorganisms on intact skin, contain a nonirritating antimicrobial preparation, have broad-spectrum activity, and be fast-acting and persistent.

Formulations containing 60% to 95% alcohol alone or 50% to 95% when combined with limited amounts of a quaternary ammonium compound, hexachlorophene, or chlorhexidine gluconate, lower bacterial counts on the skin immediately post scrub more effectively than do other agents. The next most active agents (in order of decreasing activity) are chlorhexidine gluconate, iodophors, triclosan, and plain soap.

Surgical staff have been traditionally required to scrub their hands for 10 minutes preoperatively, which frequently leads to skin damage. Several studies have demonstrated that scrubbing for 5 minutes reduces bacterial counts as effectively as a 10-minute scrub. In other studies, scrubbing for 2 or 3 minutes reduced bacterial counts to acceptable levels. Studies have indicated that a two-stage surgical scrub using an antiseptic detergent, followed by application of an alcohol-containing preparation, is effective.

Scrubbing with a brush can damage the skin and result in increased shedding of bacteria from the hands. Scrubbing with a disposable sponge or combination sponge-brush has reduced bacterial counts on the hands as effectively as scrubbing with a brush. However, several studies indicate that neither a brush nor a sponge is necessary to reduce bacterial counts on the hands of surgical personnel to acceptable levels, especially when alcohol-based products are used.

SKIN REACTIONS RELATED TO HAND HYGIENE

Two major types of skin reactions are associated with hand hygiene. Irritant contact dermatitis is the most common and symptoms may include dryness, irritation, itching, and sometimes cracking and bleeding. Symptoms may range from mild to debilitating. Allergic contact dermatitis, on the other hand, is rare and is an allergy to an ingredient in the hand hygiene product being used (WHO, 2005).

Irritant Contact Dermatitis

In certain surveys, approximately 25% of nurses report symptoms or signs of dermatitis involving their hands, and as many as 85% give a history of having skin problems. The potential for detergents to cause skin irritation varies considerably and can be ameliorated by the addition of emollients and humectants. Damage to the skin also changes skin flora, resulting in more frequent colonization by staphylococci and gram-negative bacilli.

Although alcohols are among the safest antiseptics available, they can cause dryness and irritation of the skin. Irritant contact dermatitis is more commonly reported with iodophors. Other antiseptic agents that can cause irritant contact dermatitis include chlorhexidine, PCMX, triclosan, and alcohol-based products. Skin that is damaged by repeated exposure to detergents may be more susceptible to irritation by all types of hand antisepsis formulas, including alcohol-based preparations.

Other factors that can contribute to dermatitis associated with frequent handwashing include using hot water for handwashing, low relative humidity (most common in winter months), failure to use supplementary hand lotion or cream, and perhaps the quality of paper towels. Shear forces associated with wearing or removing gloves and allergy to latex proteins may also contribute to dermatitis.

Allergic Contact Dermatitis

Allergic reactions to products applied to the skin (contact allergies) may present as delayed type reactions (allergic contact dermatitis) or less commonly as immediate reactions (contact urticaria). The most common causes of contact allergies are fragrances and preservatives; emulsifiers are less common causes. Liquid soaps, hand lotions or creams, and "udder" ointments may contain ingredients that cause contact allergies among HCWs.

Allergic reactions to alcohol-based products are very uncommon (WHO, 2005). Such reactions may represent true allergy to the alcohol, allergy to an impurity or aldehyde metabolite, or allergy to another constituent of the product. Allergic contact dermatitis or immediate contact urticarial reactions may be caused by ethanol or isopropanol. In addition, allergic reactions can be caused by compounds that may be present as inactive ingredients in alcohol-based hand rubs, including fragrances, benzyl alcohol, stearyl or isostearyl alcohol, phenoxyethanol, myristyl alcohol, propylene glycol, parabens, and benzalkonium chloride.

It is important for healthcare institutions to provide alternative compounds for HCWs who experience allergic reactions to the products normally provided.

Reducing Adverse Effects

There are two primary strategies for minimizing hand hygiene–related irritant contact dermatitis among healthcare workers

• Selecting less irritating hand hygiene products
• Using moisturizing skin care products following hand cleansing (WHO, 2005)

When providing hand cleaning products, institutions need to choose ones that are both efficacious and as safe as possible for skin. Workers must clean their hands frequently so concerns about skin irritation and dryness can influence their acceptance and ultimate use of hand cleaners (WHO, 2005).

One strategy for reducing the exposure of personnel to irritating soaps and detergents is to promote the use of alcohol-based hand rubs containing various emollients. Hand lotions and creams often contain humectants and various fats and oils that can increase skin hydration and replace altered or depleted skin lipids that contribute to the barrier function of normal skin. Care should be taken with moisturizing products, because most are not sterile and the containers can become contaminated (WHO, 2005).

Certain collateral practices may also help to reduce adverse effects. Workers should not routinely wash with soap and water just before or after using an alcohol-based rub. Also, care should be taken to dry hands thoroughly before putting on gloves, regardless of the product used to clean the hands (WHO, 2005).

HAND HYGIENE PRACTICES

Studies indicate that the frequency of handwashing or antiseptic handwashing by personnel is affected by the accessibility of hand hygiene facilities. In certain healthcare facilities, only one sink is available in rooms housing several patients, or sinks are located far away from the door of the room, which may discourage handwashing by personnel leaving the room.

In intensive-care units, access to sinks may be blocked by bedside equipment. In contrast to sinks used for handwashing or antiseptic handwash, dispensers for alcohol-based hand rubs do not require plumbing and can be made available adjacent to each patient's bed and at many other locations in patient-care areas.

Pocket carriage of alcohol-based hand-rub solutions—including flat containers designed to fit into a scrub pocket—combined with availability of bedside dispensers has been associated with substantial improvement in adherence to hand hygiene protocols. To avoid any confusion between soap and alcohol hand rubs, alcohol hand-rub dispensers should not be placed adjacent to sinks.

Healthcare workers should be informed that washing the hands with soap and water after each use of an alcohol hand rub is neither necessary nor recommended, because it may lead to dermatitis. However, because personnel feel a "build-up" of emollients on their hands after repeated use of alcohol hand gels, washing hands with soap and water after 5 to 10 applications of a gel has been recommended by certain manufacturers.

Hospital administrators must consider that by purchasing more effective or more acceptable hand hygiene products to improve hand hygiene practices, they will avoid the occurrence of nosocomial infections; preventing only a limited number of additional healthcare-associated infections per year will lead to savings that exceed any incremental costs of improved hand hygiene products.

Adherence to Recommended Practices

Adherence to recommended hand hygiene procedures has been poor among healthcare workers, with an overall average of 40%. Risk factors for poor adherence to hand hygiene have been determined objectively in several observational studies or interventions to improve adherence.

In the largest hospital-wide survey of hand hygiene practices, predictors of poor adherence to hand hygiene measures were identified. Predictor variables included:

• Professional category
• Hospital ward
• Time of day/week
• Type and intensity of patient care

In 2,834 observed opportunities for hand hygiene, average adherence was 48%. Adherence was highest among nurses and during weekends. Nonadherence was higher in intensive-care units compared with internal medicine wards, during procedures that carried a high risk of bacterial contamination, and when intensity of patient care was high. The higher the demand for hand hygiene, the lower was the adherence.

The lowest adherence rate (36%) was found in intensive-care units, where indications for hand hygiene were typically more frequent. The highest adherence rate (59%) was observed in pediatrics wards, where the average intensity of patient care was lower than in other hospital areas. The results of this study indicate that full adherence to previous guidelines may be unrealistic, and that facilitated access to hand hygiene could help improve adherence.

BARRIERS TO ADHERENCE

Perceived barriers to adherence with hand hygiene practice recommendations include:

• Skin irritation caused by hand hygiene agents
• Inaccessible hand hygiene supplies
• Interference with HCW-patient relationships
• Priority of care (ie, the patients' needs are given priority over hand hygiene)
• Wearing of gloves
• Forgetfulness
• Lack of knowledge of the guidelines
• Insufficient time for hand hygiene
• High workload and understaffing
• Lack of scientific information about healthcare-associated infection rates

THE ROLE OF EDUCATION IN ADHERENCE

Education is a cornerstone for improvement of hand hygiene practices. Healthcare workers should receive scientific information related to hand hygiene and healthcare-associated infection and resistant organism transmission rates. They must also be educated about hand hygiene during daily patient care and the low average adherence rate to hand hygiene by the majority of workers. The appropriateness and efficacy of hand hygiene and skincare-protection agents also requires ongoing education.

Examples of possible targets for hand hygiene promotion at the group level include:

• Education and performance feedback on hand hygiene adherence
• Efforts to prevent high workload, downsizing, and understaffing
• Encouragement and provision of role models from key members in the work unit

At the institutional level, targets for improvement include:

• Written guidelines, hand hygiene agents, skincare promotions and agents, or hand hygiene facilities
• Culture or tradition of adherence
• Administrative leadership, sanction, support, and rewards

Related Issues

FINGERNAILS AND ARTIFICIAL NAILS

Studies have documented that subungual (under the fingernail) areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.), Corynebacteria, and yeasts. Freshly applied nail polish does not increase the number of bacteria recovered from periungual skin, but chipped nail polish may support the growth of larger numbers of organisms on fingernails.

Whether artificial nails contribute to transmission of healthcare-associated infections is unknown. However, HCWs who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing. Whether the length of natural or artificial nails is a substantial risk factor is unknown, because most bacterial growth occurs along the proximal 1 mm of the nail adjacent to subungual skin.

Recently, an outbreak of P. aeruginosa in a neonatal intensive care unit was attributed to two nurses (one with long natural nails and one with long artificial nails) who carried the strains of Pseudomonas spp. on their hands. Patients were substantially more likely than controls to have been cared for by the two nurses during the exposure period, indicating that colonization of long or artificial nails with Pseudomonas spp. may have contributed to causing the outbreak.

Personnel wearing artificial nails have also been epidemiologically implicated in several other outbreaks of infection caused by gram-negative bacilli and yeast. Although these studies provide evidence that wearing artificial nails poses an infection hazard, additional studies are warranted.

While the WHO Guidelines urge each healthcare facility to create policies regarding artificial nails and nail polish, the consensus in the Guidelines is that "[healthcare workers] should not wear artificial fingernails or extenders when having direct contact with patients and that natural nails should be kept short (≤ 0.5 cm long)" (WHO, 2005). Many hospitals and hospital systems have adopted policies in line with the WHO recommendations.

JEWELRY

Several studies have demonstrated that skin underneath rings is more heavily colonized than comparable areas of skin on fingers without rings. One study found that 40% of nurses harbored gram-negative bacilli on skin under rings and that certain nurses carried the same organism under their rings for several months.

In a more recent study involving more than sixty ICU nurses, multivariable analysis revealed that rings were the only substantial risk factor for carriage of gram-negative bacilli and S. aureus and that the concentration of organisms recovered correlated with the number of rings worn. Whether the wearing of rings results in greater transmission of pathogens is unknown. Two studies determined that mean bacterial colony counts on hands after handwashing were similar among persons wearing rings and those not wearing rings. Further studies are needed to establish if wearing rings results in greater transmission of pathogens in healthcare settings.

While acknowledging the need for more studies, the WHO Guidelines state: "The consensus recommendation is to discourage the wearing of rings or other jewelry during health care; the use of a wedding ring for routine care may be acceptable, but in high-risk settings, such as the operating theatre, all rings or other jewelry should be removed" (WHO, 2005). Many hospitals and hospital systems have adopted policies in line with the WHO recommendations.

GLOVING POLICIES

The CDC recommends that healthcare workers wear gloves to:

• Reduce the risk of personnel acquiring infections from patients
• Prevent flora from being transmitted from personnel to patients
• Reduce transient contamination of the hands of personnel by flora that can be transmitted from one patient to another

Preventing heavy contamination of the hands is considered important, because handwashing or hand antisepsis may not remove all potential pathogens when hands are heavily contaminated.

The following caveats regarding use of gloves by healthcare workers must be considered:

• Gloves do not provide complete protection against hand contamination.
• Bacterial flora colonizing patients may be recovered from the hands of approximately 30% of workers who wear gloves during patient contact.
• Wearing gloves does not provide complete protection against acquisition of infections caused by HBV and HSV.

The barrier integrity of gloves varies on the basis of type and quality of glove material, intensity of use, length of time used, manufacturer, whether gloves were tested before or after use, and method used to detect glove leaks. Vinyl gloves have had defects more frequently than latex gloves, the difference in defect frequency being greatest after use.

Intact vinyl gloves provide protection comparable to that of latex gloves. Limited studies indicate that nitrile gloves have leakage rates that approximate those of latex gloves. Having more than one type of glove available is desirable, because it allows personnel to select the type that best suits their patient-care activities.

Hands should be decontaminated or washed after removing gloves. Gloves should not be washed or reused. Use of petroleum-based hand lotions or creams may adversely affect the integrity of latex gloves. After use of powdered gloves, certain alcohol hand rubs may interact with residual powder on the hands of personnel, resulting in a gritty feeling on the hands. In facilities where powdered gloves are commonly used, various alcohol-based hand rubs should be tested after removal of powdered gloves to avoid selecting a product that causes this undesirable reaction.

Personnel should be reminded that failure to remove gloves between patients may contribute to transmission of organisms.

The Role of Healthcare Agencies

To ensure improvement in hand hygiene practices, an institution must measure improvements in hand hygiene adherence. It should:

• Periodically monitor and record adherence in terms of the number of hand hygiene episodes performed by personnel/number of hand hygiene opportunities, by ward or by service.
• Provide feedback to personnel regarding their performance.
• Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient-days.
• Monitor adherence to policies dealing with wearing of artificial nails.
• When outbreaks of infection occur, assess the adequacy of worker hand hygiene.

Evidence supports the belief that improved hand hygiene can reduce healthcare-associated infection rates. Failure to perform appropriate hand hygiene is considered the leading cause of healthcare-associated infections and spread of multiresistant organisms and has been recognized as a substantial contributor to outbreaks.

Promotional strategies involving multidisciplinary teams of healthcare workers, the use of wall posters, promotion of antiseptic hand rubs located at bedsides throughout the facility, and regular performance feedback to all personnel have had good results in some studies.

Hand hygiene is a critical issue and is being addressed on the national level by many agencies, organizations, and professional associations. In 2006 the Institute for Healthcare Improvement converted its highly successful 100,000 Lives Campaign into the 5 Million Lives Campaign in which it asked "hospitals to improve, more rapidly than before, the care they provide in order to protect patients from 5 million incidents of medical harm over a 24-month period, ending December 9, 2008" (IHI, 2006).

The 5 Million Lives Campaign focused on twelve interventions in order to reach this goal. Several of these interventions have hand hygiene as a critical element in their accomplishment. The IHI has created a how-to guide for improving hand hygiene that may be downloaded from their website (see Resources). This well-publicized campaign underscored a renewed interest and emphasis on saving lives through the simple act of washing the hands.

In March 2007, the Association for Professionals in Infection Control and Epidemiology (APIC) published the Guide to the Elimination of Methicillin-Resistant Staphylococcusaureus (MRSA) Transmission in Hospital Settings. Hand hygiene is addressed early on where the guide says "the importance of hand hygiene in the elimination of MRSA transmission cannot be overstated." The discussion that follows mentions the IHI online tool and a study led by the Joint Commission in an effort to identify methods institutions can use to monitor hand hygiene compliance.

Institutions are responsible for establishing good working systems and monitoring compliance with those systems, but in the end it takes every healthcare worker's positive participation to make those systems work for everyone's benefit.

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Photograph © 2008 Jon Klein