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COURSE OBJECTIVE: The purpose of this course is to enable healthcare professionals to understand the rationale for hand hygiene, recognize current hand hygiene products, and enhance adherence to recommended handwashing guidelines.
Upon completion of this course, you will be able to:
- State the relationship between hand hygiene and the prevention of healthcare-associated infections.
- Discuss the antiseptic effectiveness and safety of common hand hygiene products.
- Explain the steps involved in effective handwashing.
- Identify factors that affect adherence to handwashing protocols.
TABLE OF CONTENTS
Good hand hygiene is one of the most important actions healthcare workers can take to reduce the spread of infection and protect the lives of their patients (Aziz, 2013). The Association of periOperative Registered Nurses (AORN) cites proper hand hygiene practices as the most effective and least expensive means of preventing healthcare-associated infections (HAIs) (Spruce, 2013). Such infections are the most frequent adverse events in healthcare, affecting hundreds of millions of patients globally (WHO, 2014). This creates a tremendous economic burden on both developed and developing countries.
The term hand hygiene includes two primary actions: 1) washing the hands with soap and water to decrease colonization of transient flora by removing dirt, soil, and loose flora and 2) rubbing hands with a small amount of highly effective, fast-acting antiseptic agent, termed a hand sanitizer.
A HISTORY OF HANDWASHING
For generations, handwashing with soap and water has been considered a measure of personal hygiene. Only in the last two centuries has the link between handwashing and the spread of disease been clearly established.
As early as 1822, a French pharmacist demonstrated that solutions containing chloride of lime or soda could eradicate the foul odor associated with human corpses and be used as disinfectants and antiseptics. In a paper published in 1825, the pharmacist said that those who attend patients with contagious diseases would benefit by moistening their hands with a liquid chloride solution (CDC, 2002).
DISINFECTANT VERSUS ANTISEPTIC
- Usually a chemical agent (but sometimes a physical agent) that destroys disease-causing pathogens or other harmful microorganisms but might not kill bacterial spores. Refers to substances applied to inanimate objects. The Environmental Protection Agency (EPA) groups disinfectants by product label claims of “limited,” “general,” or “hospital” disinfection.
- Substance that prevents or arrests the growth or action of microorganisms by inhibiting their activity or by destroying them. The term is used especially for preparations applied topically to living tissue.
Source: CDC, 2008.
In 1846, Ignaz Semmelweis observed that women whose babies were delivered by physicians in the First Clinic at the General Hospital of Vienna consistently had a higher mortality rate than those delivered by midwives in the Second Clinic. He noted that physicians who went directly from the autopsy suite to the obstetric ward had a disagreeable odor on their hands, and he postulated that puerperal fever was caused by “cadaverous particles” transmitted from the autopsy suite to the obstetrics ward by way of the hands of physicians. As a result, in May 1847, Semmelweis insisted that physicians cleanse their hands with chlorine solution between patients. Thereafter, the maternal mortality rate in the First Clinic dropped dramatically (CDC, 2002).
In 1961 the U.S. Public Health Service recommendations directed personnel to wash their hands with soap and water for 1–2 minutes before and after patient contact. Rinsing hands with an antiseptic agent was believed to be less effective than handwashing with plain soap and was recommended only in emergencies or in areas where sinks were not available.
In 1975 and 1985 guidelines on handwashing practices in hospitals were published by the Centers for Disease Control (CDC). They recommended handwashing with plain soap between patients and washing with antimicrobial products before and after performing invasive procedures. Waterless antiseptic agents such as alcohol-based solutions were again recommended only in situations where sinks were not available.
In 1988 and 1995, the Association for Professionals in Infection Control published guidelines similar to those of the CDC (APIC, 2011). The 1995 APIC guidelines included discussion of alcohol-based hand sanitizers 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 upon leaving the rooms of patients with multi-drug resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA), caregivers use either antimicrobial soap or a waterless antiseptic agent to cleanse their hands. These guidelines also recommended handwashing and hand antisepsis for routine patient care.
In 2002, the Guideline for Hand Hygiene in Health-Care Settings was published as the recommendation of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. In 2014, the 2002 Guideline continued to be available on the CDC website (CDC, 2002).
In 2012, the World Health Organization (WHO) reaffirmed the recommendation to wash hands with soap and water when visibly dirty, soiled with blood or other body fluids, or exposed to potential spore-forming pathogens, such as Clostridium difficile. While neither soap and water nor hand sanitizers kill such spores, soap and water removes the spores from the hands when conducted properly (APIC, 2013). When hands are not visibly soiled, the WHO recommends the use of alcohol-based hand rubs as the preferred means for routine hand antisepsis (WHO, 2012).
SKIN PHYSIOLOGY AND NORMAL SKIN FLORA
Function and Structure of the Skin
The primary function of the skin is to reduce water loss, provide protection to the body against abrasive action and microorganisms, and act as a permeable barrier to the environment. The skin helps maintain body temperature and transmits awareness of external stimuli. In addition, it serves a barrier function for the body by secreting glycerolipids and sterols to protect and nourish skin cells.
Considered a bodily organ, the skin varies in thickness from less than one millimeter in the eyelids to greater than four millimeters on the soles of the feet. It is composed of two layers, the epidermis and dermis, and is underlain by subcutaneous tissue called the hypodermis (Habif, 2004).
- The epidermis has five layers of cells—the stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale—though it is relatively thin when compared to the dermis.
- The dermis has two layers of cells—the papillary and reticular—and contains hair follicles, sebaceous and sudoriferous glands, blood vessels, and nerve cells.
- The hypodermis lies below the dermis. It cushions and supports the skin with fat cells and connective tissue.
The skin has two layers, the epidermis and the dermis, below which lies subcutaneous tissue. (Source: National Cancer Institute.)
Flora of the Skin
If we could see bacteria on our skin, we might be surprised to find that it is covered with colonies of microorganisms. Generally speaking, there are two categories of flora on the skin: transient and resident.
- Transient flora colonize the superficial layers of the skin and are more amenable to removal by routine handwashing. They are the organisms most frequently found in healthcare-associated infections.
- Resident flora are attached to deeper layers of the skin and are more resistant to removal.
The hands of some caregivers may become persistently colonized with resident pathogenic flora such as yeast and Staphylococcus aureus, a gram-negative bacillus. Investigators have found that although the number of transient and resident flora varies from person to person, the number of resident flora is relatively constant.
Skin irritation caused by chemicals, removal of tape, and other physical disruptions leads to a decrease in the skin’s barrier function provided by glycerolipids and sterols in the skin. Detergents and acetones remove these protective secretions. When they are removed, it takes the skin about 6 hours for just half of the normal barrier function of these protective secretions to return, and 5–6 days for their barrier function to completely return. Thus, caregivers need to nourish the skin of their own hands with protective creams or lotions.
TRANSMISSION OF PATHOGENS BY WAY OF THE HANDS
Pathogens are transmitted from patient to patient by way of the hands of caregivers because:
- Pathogenic organisms are present on patients’ skin and objects in the environment.
- Some of these organisms are transferred to healthcare workers’ hands.
- Pathogenic organisms may become resident flora on some caregivers’ hands.
- Inadequate hand cleansing allows organisms to contaminate workers’ hands.
- Cross-transmission of organisms occurs by contaminated hands.
Healthcare-associated pathogens can be spread not only from infected or draining wounds but also from frequently colonized areas of normal intact skin. Commonly, the perineal or inguinal areas of the body are the most heavily colonized, but the axillae, trunk, upper extremities, hands, and fingernails also may be contaminated.
The number of organisms present on intact areas of the skin varies from individual to individual. For instance, those with chronic dermatitis, diabetes, and chronic renal failure are more likely to have intact skin areas colonized by Staphylococcus aureus.
Environmental Sources of Pathogens
Common contaminants in the healthcare setting are gram-negative bacilli, Staphylococcus aureus, Enterococci, and Clostridium difficile.
Caregivers may contaminate their hands or gloves merely by touching inanimate objects. Patient gowns, bed linen, bedside furniture, and other objects in the patient's immediate environment can easily become contaminated with pathogenic organisms. Other objects in patient rooms—such as the side-rails of beds, handles of bedside table drawers, and intact areas of patients’ skin—can also be contaminated. Pathogens are often found at handwashing stations, on the handles of faucets, and on other fixtures.
Of course, patients themselves may be a source of infection. Caregivers of infants infected with respiratory syncytial virus (RSV) have been known to acquire the virus simply by touching an infant and then touching their own nose or mouth.
Healthcare Worker Sources of Pathogens
Studies have documented that the area under the fingernails or in chipped or cracked nail polish often harbor high concentrations of bacteria, most frequently coagulase-negative Staphylococci, gram-negative rods (including Pseudomonas spp.), Corynebacteria, and yeasts (Jefferies et al., 2012). AORN (2012) recommendations include healthcare workers keeping their nails no longer than 1/4-inch. Artificial nails and chipped nail polish should be avoided, as they may harbor microorganisms. The use of intact nail polish does not appear to harbor pathogenic microorganisms (Fagernes & Lingaas, 2011), but AORN recommends that nail polish not be worn for longer than four days due to the risk of chips not visible to the naked eye (AORN, 2013b).
Healthcare personnel wearing artificial nails have been epidemiologically implicated in several other outbreaks of infection. In one instance, an outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit was attributed to two nurses, one with long natural nails and one with long artificial nails. They both carried the strains of Pseudomonas on their hands and were believed to be the likely source of the pathogens. Although some studies provide evidence that wearing artificial nails poses an infection hazard, additional studies are needed to confirm the concern.
While WHO guidelines urge each healthcare facility to create policies regarding artificial nails and nail polish, the consensus 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, 2012). Many hospitals and hospital systems have adopted policies in line with the WHO recommendations.
Similar findings show the presence of pathogenic bacteria such as Staphylococcus aureus and Enterobacteriaceae under rings, wristwatches, and fingernails >2 mm in length (Fagernes & Lingaas, 2011). Skin underneath rings has been found to be more heavily colonized with pathogens than comparable areas of skin on fingers without rings. One study found that 40% of the caregivers tested harbored gram-negative bacilli on skin under rings and some carried the organism for several months. However, other studies showed that bacterial colony counts on hands after handwashing were similar for persons who wore rings and those who did not. Further study is needed to establish whether wearing rings results in greater transmission of pathogens in healthcare facilities.
While acknowledging the need for more studies, WHO guidelines state: “The consensus recommendation is to discourage the wearing of rings or other jewelry during healthcare; 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.” Many hospitals and hospital systems have adopted policies in line with the WHO recommendations.
HAND HYGIENE PRODUCTS
With contamination by infectious organisms everywhere, it is heartening to know that properly practiced hand hygiene reduces the incidence of healthcare-associated infections.
Studies have compared the rates of infection of handwashing with plain soap and water versus some form of chemical antiseptic hand-cleansing products. When hand cleansing was performed correctly, the infection rates were lower with chemical antiseptic products than with plain soap and water. However, many factors increase infection rates, including handwashing technique, wearing artificial nails or rings, contaminated soaps or cleansers, and out-of-hospital sources of pathogens (WHO, 2012).
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 that will destroy or inhibit the growth of microorganisms. Handwashing with plain soap removes loose transient flora even though it does not remove pathogens from the hands of healthcare workers.
A great many antiseptic agents have been introduced to the healthcare market, the most common of which are alcohols. However, in choosing an agent, decision makers must consider two primary issues:
- Effectiveness of the agent against pathogens
- Potential damage to human skin by the agent
The following section describes some of the most commonly used antiseptics. Caregivers are instructed to read labels carefully and diligently follow recommended hand hygiene procedures.
The majority of alcohol-based hand antiseptics contain isopropanol, ethanol, n-propanol, or a combination of these products. Alcohol solutions containing 60%–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 fungi and multi-drug resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE).
Certain viruses such as herpes simplex virus (HSV), human immunodeficiency virus (HIV), influenza virus, respiratory syncytial virus, and vaccinia virus are susceptible to alcohols when tested in vitro. Hepatitis B virus (HBV) is somewhat less susceptible but is killed by 60%–70% alcohol; hepatitis C virus (HCV) also is likely killed by this percentage of alcohol. Despite their 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 that will prolong antimicrobial activity or inhibit the survival of microorganisms after application. Regrowth of bacteria on the skin occurs slowly after use of alcohol-based hand antiseptics.
Alcohol-based hand sanitizers are not appropriate for use when hands are visibly dirty or contaminated with proteinaceous materials such as blood. In these situations, the hands of the healthcare worker first should be cleansed with soap and water. Then, an antiseptic hand rub, using an alcohol-based hand sanitizer, can be applied to prevent pathogen transmission.
Alcohols are effective for pre-operative cleansing of the hands of surgical personnel. The efficacy of alcohol-based hand hygiene products varies according to concentration, type, volume used, time of contact, and whether the hands are wet when the alcohol is applied.
Alcohols are flammable. Flashpoints of alcohol-based hand rubs range from 21 °C to 24 °C, depending on the type and concentration of alcohol. For this reason, the National Fire Protection Agency recommends that alcohol-based hand rubs should be stored away from high temperatures or flames in accordance with local fire codes. In Europe, where alcohol-based hand rubs have been used for many years, the incidence of fires associated with such products has been low.
Cedar Medical Center initiated a new hand hygiene compliance program based on the most current WHO guidelines to improve healthcare workers’ handwashing practices. This followed a sentinel event in which a patient died from a hospital-acquired Clostridium difficile infection. As part of the compliance program, alcohol-based hand rub dispensers were installed outside of every room in the hospital and an extra sink installed in the hallway of each unit. The expectation is that personnel will “sanitize” before entering a patient room and “sanitize” when leaving.
As a nurse educator in the facility, it is Dorothy’s responsibility to share hand hygiene guidelines and the new hand hygiene policies with the staff. She displays hand hygiene posters throughout the facility, conducts a series of in-services, and recruits assistant nurse managers on each unit to reinforce the new policies as “secret shoppers” through anonymous visual audits. Emphasis is placed on when it is most appropriate to wash hands with soap and water (visibly soiled, proteinaceous materials such as blood, or contact precautions with C. difficile). Dorothy also instructs personnel to sanitize hands with an alcohol-based rub frequently in other instances to prevent the transmission of pathogens.
The immediate antimicrobial activity of chlorhexidine occurs more slowly than that of alcohols. When used as an antiseptic in hand washing, chlorhexidine preparations should have at least a 4% concentration. One study showed that a scrub agent with 4% chlorhexidine was more effective than a 7.5% povidone-iodine scrub preparation in reducing bacterial count (Kuo, 2014).
Chlorhexidine has good activity against gram-positive bacteria, somewhat less activity against gram-negative bacteria and fungi, and only minimal activity against tubercle bacilli. It does not kill spores. Chlorhexidine has in vitro activity against enveloped viruses such as herpes simplex virus (HSV), human immunodeficiency virus (HIV), cytomegalovirus, and influenza, 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.
IODINE AND IODOPHORS
Iodine has been recognized as an effective antiseptic since the 1800s. However, because iodine may cause 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 (e.g., 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%–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.
QUATERNARY AMMONIUM COMPOUNDS
Of this large group of compounds, alkyl benzalkonium chlorides are the most widely used antiseptics. The group also includes cetrimide and acetyl pyridium chloride.
Quaternary ammonium compounds are primarily bacteriostatic and fungistatic, although at high concentrations they are microbicidal against certain organisms; they are more active against gram-positive bacilli than gram-negative bacilli. Quaternary ammonium compounds have relatively weak activity against mycobacteria and fungi and have greater activity against lipophilic viruses.
A study of surgical intensive care unit personnel found that cleansing hands with quaternary ammonium compound wipes was about as effective as using plain soap and water for handwashing; both were less effective than alcohol-based hand rubs for decontaminating hands (WHO, 2009).
EFFICACY OF HAND HYGIENE ANTISEPTIC AGENTS
- Excellent efficacy for gram-positive bacteria, gram-negative bacteria, mycobacteria, fungi, viruses
- Fast speed of action
- Optimum concentration 60%–95%; no persistent activity
Chlorhexidine (2% and 4% aqueous)
- Excellent efficacy for gram-positive bacteria, viruses
- Good efficacy* for gram-negative bacteria
- Fair efficacy for mycobacteria, fungi
- Intermediate speed of action
- Persistent activity; rare allergic reactions
- Excellent efficacy for gram-positive bacteria, gram-negative bacteria, mycobacteria, viruses
- Good efficacy* for fungi
- Intermediate speed of action
- Causes skin burns; usually too irritating for hand hygiene
- Excellent efficacy for gram-positive bacteria, gram-negative bacteria
- Good efficacy* for fungi, viruses
- Fair efficacy for mycobacteria
- Intermediate speed of action
- Less irritating than iodine; acceptance varies
- Excellent efficacy for gram-positive bacteria
- Fair efficacy for gram-negative bacteria, mycobacteria, fungi, viruses
- Intermediate speed of action
- Activity neutralized by nonionic surfactants
- Excellent efficacy for gram-positive bacteria, viruses
- Good efficacy* for gram-negative bacteria
- Fair efficacy for mycobacteria
- No efficacy or not sufficient for fungi
- Intermediate speed of action
- Acceptability on hands varies
Quaternary Ammonium Compounds
- Good efficacy* for gram-negative bacteria
- Fair efficacy for gram-positive bacteria, viruses
- No efficacy or not sufficient for mycobacteria, fungi
- Slow speed of action
- Used only in combination with alcohols; ecologic concerns
* Good efficacy does not include the entire bacterial spectrum.
Source: CDC, 2002.
Antiseptic Agents and 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 have raised concern regarding the activity of antiseptic agents against spore-forming bacteria. None of the agents (including alcohols, chlorhexidine, hexachlorophene, iodophors, parachlorometaxylenol [PCMX], and triclosan) used in antiseptic hand wash or rub preparations are reliably sporicidal against Clostridium spp. or Bacillus spp (APIC, 2013).
ASEPTIC HAND CLEANSING
Hand Cleansing Technique
The following steps constitute the techniques outlined in the WHO guidelines for hand hygiene with soap and water. Caregivers are advised to follow the manufacturer’s recommendations about the product they are using.
Duration of the entire procedure: 40–60 seconds.
- Wet hands with water.
- Apply the amount of soap product necessary to cover all hand surfaces.
- Rub hands palm to palm.
- Rub right palm over left dorsum with interlaced fingers, and vice versa.
- Rub palm to palm with fingers interlaced.
- Rub backs of fingers to opposing palms with fingers interlocked.
- Rub left thumb rotationally while clasped in right palm, and vice versa.
- Rub clasped fingers of right hand rotationally in left palm, backwards and forwards, and vice versa.
- Rinse hands with water. Avoid using hot water in order to decrease the risk of dermatitis.
- Dry hands thoroughly with a single-use towel.
- Use towel to turn off faucet.
The same technique is used when decontaminating hands with an alcohol-based hand rub, however no water is used. Similarly, towels are not used for drying, as hands will quickly dry on their own. When using alcohol-based hand rubs, the CDC recommends healthcare personnel rub their hands until the alcohol evaporates and the hands are dry (CDC, 2012).
(See the WHO Guidelines on Hand Hygiene in Health Care, pages 155–156, for illustrations of this recommended hand hygiene technique [WHO, 2009].)
Jorge is the assistant nurse manager on a busy medical-surgical unit. During a hospital-wide campaign to improve caregivers’ hand hygiene compliance, he and the nurse manager brainstorm ways to educate their staff on the impact of good and poor hand hygiene. Jorge suggests that the med-surg unit make use of the hospital’s infection control training equipment, which includes a UV light and disclosing solution that simulates the presence of contamination.
Later that week, Jorge, the nurse manager, and several charge nurses get trained on the use of the solution and UV light. They select a vacant room on the unit, and over the course of the next several days, every member of the nursing staff practices applying the disclosing solution on their hands, cleaning their hands as they usually do before entering a patient room, and then moving around the room randomly touching furniture and other items. The UV light is then used to illuminate areas “contaminated” by the disclosing solution, which shows how even supposedly clean hands can still spread infectious material. The touched areas are then cleaned, and each staff member is individually coached on how to improve their hand hygiene. Staff members then repeat the solution-clean-touch-view process.
Word spreads, and several of the physicians ask to be included. To a person, everyone who participates in the training comes away with a renewed commitment to practicing proper hand hygiene. Because of the success on Jorge’s unit and the championing of several of the physicians, the hospital’s infection preventionist requests and receives funding for additional kits in order to train personnel throughout the hospital.
|Source: WHO, 2012.|
|1. Before patient contact: Clean your hands before touching a patient when approaching him or her.||To protect the patient against harmful germs carried on your hands|
|2. Before an aseptic task: Clean your hands immediately before any aseptic task.||To protect the patient against harmful germs, including the patient’s own germs, from entering his or her body|
|3. After a body fluid exposure risk: Clean your hands immediately after an exposure risk to body fluids (and after glove removal).||To protect yourself and the healthcare environment from harmful patient germs|
|4. After patient contact: Clean your hands after touching a patient and his or her immediate surroundings when leaving.||To protect yourself and the healthcare environment from harmful patient germs|
|5. After contact with patient surroundings: Clean your hands after touching any object or furniture in the patient’s immediate surroundings when leaving, even if you haven’t contacted the patient.||To protect yourself and the healthcare environment from harmful patient germs|
AORN recommendations for the use of gloves in the clinical setting state:
- Wash hands before putting on or after removing gloves or any other personal protective equipment (PPE).
- Glove use does not replace the need for hand hygiene.
- Gloves are recommended in situations in which contact with blood or other potentially infectious material is likely.
- Remove gloves after caring for a patient and do not reuse.
- Change or remove gloves if moving from a contaminated body site to either another body site within the same patient or the environment.
- When gloves are removed, hands must be washed or an alcohol-based hand sanitizer used.
(Patrick & Van Wicklin, 2012)
The CDC further recommends that healthcare workers wear gloves in order to reduce the risk that:
- Caregivers will acquire infections from patients
- Pathogens of caregivers will be transmitted to patients
- Caregiver hands will transmit pathogens from one patient to another
When there is a risk that hands may become heavily contaminated, caregivers should wear clean gloves as compared to sterile gloves. This is recommended because hand-cleansing asepsis does not remove all organisms. After removing gloves, caregivers should cleanse their hands with antiseptics or soap and water as a precaution against any contamination of the hands that may have occurred during glove removal. Gloves should be discarded after use and not reused (Van Wicklin, 2014). Fresh gloves should be used for each patient to prevent transmission of organisms from patient to patient.
The integrity of gloves varies according to type and quality of glove material, intensity of use, and the length of time gloves are used. Intact vinyl gloves provide comparable protection to latex gloves, however vinyl or nitrile gloves have been found to have more defects after prolonged use than latex gloves (Phalen & Wong, 2011). Petroleum-based hand creams may weaken the integrity of latex gloves. To accommodate caregiver preferences, institutions usually provide more than one type of glove.
SKIN REACTIONS RELATED TO HAND HYGIENE
Two major types of skin reactions are associated with hand hygiene: irritant contact dermatitis and allergic contact dermatitis.
- Irritant contact dermatitis is the most common skin reaction. It causes dryness, irritation, itching, and sometimes cracking and bleeding. Its symptoms range from mild to debilitating.
- Allergic contact dermatitis, though rare, is an allergic response to an ingredient in the hand hygiene product or to the gloves being used. Common symptoms include swelling, redness, and itching.
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 skin problems. The potential for detergents to cause skin irritation varies considerably and can be ameliorated by the addition of emollients and moisture-retaining products called humectants. Damaged skin may change skin flora, resulting in more frequent colonization by Staphylococci and gram-negative bacilli (Vissher & Wickett, 2012).
Although alcohols are among the safest antiseptics available, they can cause dryness and irritation of the skin. Iodophors are more commonly reported as causing irritant contact dermatitis. Other antiseptic agents that can cause irritant contact dermatitis include chlorhexidine, parachlorometaxylenol (PCMX), and triclosan. Skin that is damaged by repeated exposure to detergents may be more susceptible to irritation by all types of hand antiseptics, including alcohol-based preparations.
Other factors that can contribute to dermatitis associated with frequent handwashing include use of hot water, low atmospheric humidity (more common in winter months), failure to use supplementary hand lotion or cream, and mechanically rough paper towels. The shear force associated with donning and removing gloves may also contribute to dermatitis (Vissher & Wickett, 2012).
Allergic Contact Dermatitis
Allergic reactions to products applied to the skin may be immediate or delayed. The most common causes of allergic contact dermatitis are the preservatives and fragrances in these products. Fortunately, allergic reactions to alcohol-based products are uncommon. When reactions occur, they may be caused by additives or impurities in the product, but rarely to the alcohol itself.
Healthcare institutions should provide alternative compounds for workers who have allergic reactions to standard products. By selecting alcohol-based hand sanitizers containing emollients, institutions can help reduce skin irritation and promote consistent hand hygiene by their workers. However, when separate moisturizing skin products are available, staff members should remember that these products are not sterile and that the contents can become contaminated.
As a result of increasing incidents of allergic contact dermatitis, especially among surgical personnel, latex gloves have generally been replaced by those containing no rubber and are no longer powdered (Ponten, 2013).
ADHERENCE TO HAND HYGIENE PRACTICES
Although the guidelines of many healthcare organizations have been adopted by the majority of hospitals, adherence by healthcare providers to recommended handwashing protocols remains low. Hand hygiene is the simplest, most effective measure for preventing nosocomial (hospital-associated) infections, yet studies indicate that, on average, healthcare workers follow recommended hand hygiene procedures less than half of the time (Aziz, 2013).
In the largest hospital-wide survey of hand hygiene practices, predictors of poor adherence to hand hygiene measures were identified according to:
- Professional category (physicians, nurses, pharmacists, technicians, etc.)
- Hospital unit (emergency department, pediatrics, maternity, adult medical, etc.)
- Time of day/week (day, evening, night shifts, and Monday through Sunday)
- Type and intensity of patient care (intensive, moderate, minimal care)
In one study of 2,834 observed opportunities for hand hygiene, researchers found the average adherence rate was a shockingly low 48%. Adherence was highest among nurses during weekends and in pediatric units. Nonadherence was higher in intensive-care units, during procedures that carried a high risk of bacterial contamination, and when the intensity of patient care was high. In other words, the higher the need for hand hygiene, the lower 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. This study indicates that much needs to be done to improve adherence to hand hygiene practices (Vissher & Wickett, 2012).
Nurses often cite their own adherence as three times higher than what is observed. Adherence rates proved to be better after patient care activities than before (Harne-Britner et al., 2011).
Overcoming Barriers to Adherence
Various professional groups have undertaken studies to identify barriers to hand hygiene protocols and factors that improve adherence. Barriers were found to include:
- Inaccessible hand hygiene supplies
- Skin irritation caused by hand hygiene agents
- Handwashing and hygiene products thought to be harmful to the skin
- Priority of care (the patient’s need takes priority over hand hygiene)
- Lack of knowledge of the guidelines
- Lack of feedback to encourage compliance
- Insufficient time for hand hygiene
- High workload and understaffing
- Lack of scientific information about healthcare-related infection rates
To decrease hospital-associated (nosocomial) infections and increased adherence to hand hygiene protocols, barriers to their implementation must be addressed. Institutions need to:
- Place dispensers of skin cleansing and emollient agents in accessible locations
- Minimize hand hygiene dermatitis by providing emollient agents
- Educate caregivers about infection rates and hand hygiene protocols
- Increase nurse-patient ratios
- Create an institutional culture of care that includes antiseptic hand hygiene
ACCESSIBILITY OF HAND HYGIENE FACILITIES
Studies indicate that the frequency of handwashing or antiseptic hand rubs by personnel is affected by the accessibility of hand hygiene facilities. In some institutions, only one sink or hand hygiene product dispenser is available in rooms housing several patients. This discourages hand cleansing between patients and adds extra steps and effort for caregivers.
Fortunately, dispensers for alcohol-based sanitizers do not require plumbing. They can be located in every patient-care unit, lavatory, near doorways, and in other convenient locations. In addition, staff may use pocket dispensers of alcohol-based hand rub products. To avoid confusion between soap and alcohol-based sanitizers, both types of dispensers should be clearly marked. Soap dispensers should be placed beside sinks, and alcohol-based sanitizer dispensers should be placed some distance from sinks.
Caregivers need to know that washing their hands with soap and water after use of an alcohol hand rub is neither necessary nor recommended. When personnel feel a “build-up” of emollients on their hands after repeated use of alcohol-based sanitizers, some manufacturers recommend handwashing with soap and water to remove any excessive build-up.
MINIMIZING HAND HYGIENE DERMITITIS
When choosing hand-cleansing products, institutions need to select those that are both efficacious and as nonirritating to skin as possible. Because caregivers must cleanse their hands frequently, skin irritation and dryness, or concerns about these conditions, may influence the acceptance and use of hand cleaners (Vissher & Wickett, 2012).
As a consequence, institutions can minimize hand hygiene dermatitis by:
- Selecting less-irritating hand hygiene products
- Encouraging healthcare workers to use moisturizing skin care products after hand cleansing
EDUCATING HEALTHCARE PROFESSIONALS
Education is the cornerstone of improved hand hygiene practices. Healthcare workers need scientific information about hand hygiene, healthcare-associated infections, and resistant organism transmission rates. They need to know how to cleanse their hands and use appropriate and efficacious antiseptic and protective agents (described earlier in this course).
Written guidelines should be available to everyone, including visitors. New employees should receive these guidelines during their initial orientation. Then, all caregivers should be observed and given feedback about how consistently they are adhering to established hand hygiene protocols.
Alicia is an RN working in an ICU in a large university medical center that is the trauma center for the region. Two hand hygiene issues were just communicated in the “huddle” at shift change on her unit. First, several ICU staff members complained about redness and swelling on their hands after working 3 or 4 shifts in a row, making them less likely to wash their hands as often as guidelines recommend. The second problem is the lack of adherence to the center’s hand hygiene and gloving policies, such as washing hands after removing gloves.
Because of a recent rise in the rate of patients testing positive for methicillin-resistant Staphylococcus aureus (MRSA) in the center, a new hand hygiene compliance program has just been initiated. As a charge nurse, Alicia is working with the education department to improve compliance data. Auditing revealed the ICU nurses to have the lowest compliance in the facility, with practices deteriorating during times of increased busyness and stress such as during “code blues.” The nurses cited busy work schedules and lack of supplies to interfere with their ability to wash their hands often enough.
As a response to these issues, Alicia organizes an in-service on the center’s hand hygiene policy, to be given during the next staff meeting. Alcohol-based hand rub dispensers are also installed outside of every room in the ICU, and Alicia posts hand hygiene flyers in front of each patient room by the alcohol rub dispensers to help educate and remind all the ICU staff of hand hygiene policies.
INCREASING CAREGIVER-TO-PATIENT RATIOS
When patient-care units are understaffed and healthcare providers are overworked, they tend to cut corners. Often, one of those corners is hand hygiene. As a result, infection rates rise; death rates mount; and the health of caregivers, visitors, and patients suffers. Multiple studies support a decrease in mortality in California hospitals with minimum nurse-patient staffing ratios (Wallis, 2013).
Traditionally, nurse-to-patient ratios have been decided by healthcare agencies, many of which are for-profit institutions seeking to cut costs. In recent years, nursing organizations have been pressing for laws to mandate minimum staffing ratios in patient-care units.
NURSE-PATIENT RATIO LAWS
In 2004, California became the first state to pass legislation mandating nurse-patient ratios, as follows:
- 1 nurse to 2 critical care patients in units such as intensive care, labor and delivery, neonatal intensive care, post-anesthesia recovery, and the emergency department
- 1 nurse to 3 patients in step-down units
- 1 nurse to 4 patients in specialty units such as antepartum, postpartum (4 couplets, mother and baby), pediatrics, telemetry, and non-critical patients in the emergency room
- 1 nurse to 5 patients in medical-surgical units
- 1 nurse to 6 patients in psychiatric units
(Serratt et al., 2011)
As of March 2011, fifteen states and the District of Columbia had enacted nurse staffing legislation and/or adopted regulations addressing nurse staffing, and other states are considering similar legislation (Miller, 2012). California Senator Barbara Boxer has introduced federal legislation similar to that practiced in California since 2004.
CREATING A CULTURE THAT SUPPORTS HAND HYGIENE
Adherence to hand hygiene increases when its practice is expected of everyone in the institution and it becomes part of its culture. To create such a culture of care, institutions need to:
- Provide written guidelines for all healthcare providers
- Introduce and demonstrate hand hygiene protocols to all caregivers
- Encourage leaders to model and support antiseptic hand hygiene practice
- Monitor and give feedback to all healthcare providers, including physicians, nursing care providers, food service personnel, laboratory technicians, pharmacists, and therapists
By fostering such a culture, healthcare institutions can decrease transmission of pathogenic organisms, reduce infection rates, and diminish death rates.
Many sources cite hand hygiene practices in hospitals as the foremost method of reducing infection and transmission of microorganisms from person to person. It is crucial for healthcare workers to understand and comply with their facility’s hand hygiene policies. Traditional soap-and-water handwashing and the application of alcohol-based sanitizers both prove effective and may be used following different practice criteria. Healthcare providers must be aware of barriers to staff compliance, including antiseptic product-induced dermatitis, lack of supplies, a knowledge deficit, or understaffing. Organizations such as the CDC, WHO, APIC, and AORN have all addressed such barriers and formulated recommendations to encourage compliance with hand hygiene policies.
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
Association for Professionals in Infection Control and Epidemiology (APIC). (2013). Guide to preventing Clostridium difficile infections. APIC implementation guide. Retrieved from http://www.apic.org
Association for Professionals in Infection Control and Epidemiology (APIC). (2011). APIC text of infection control and epidemiology, chapter 19. Retrieved from http://text.apic.org
Association of periOperative Registered Nurses (AORN). (2013a). Hand antisepsis. Retrieved from http://www.aorn.org
Association of periOperative Registered Nurses (AORN). (2013b). Recommended practices for hand hygiene in the perioperative setting. Perioperative Standards and Recommended Practices, 63–74.
Association of periOperative Registered Nurses (AORN). (2012). Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc.
Aziz AM. (2013). How better availability of materials improved hand hygiene compliance. British Journal of Nursing, 22(8), 458–63.
Centers for Disease Control and Prevention (CDC). (2012). Hand hygiene basics. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (2008). Guideline for disinfection and sterilization in healthcare facilities. Retrieved from http://www.cdc.gov
Centers for Disease Control and Prevention (CDC). (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. MMWR 51,(RR-16). Retrieved from http://www.cdc.gov
Encyclopaedia Britannica. (2014). Phenols. Retrieved from http://www.britannica.com
Fagernes M. & Lingaas E. (2011) Factors interfering with the microflora on hands: a regression analysis of samples from 465 healthcare workers. Journal of Advanced Nursing 67(2), 297–307. doi:10.1111/j.1365-2648.2010.05462.x.
Habif P. (2009). Clinical dermatology: a color guide to diagnosis & therapy (4th ed.). St. Louis: C.V. Mosby.
Harne-Britner S, Allen M, & Fowler KA. (2011). Improving hand hygiene adherence among nursing staff. Journal of Nursing Care Quality, 26(1), 39–48.
Jefferies JMC, Cooper T, Yam T, & Clarke SC. (2012). Pseudomonas aeruginosa outbreaks in the neonatal intensive care unit—a systematic review of risk factors and environmental sources. Journal of Medical Microbiology, 61(8), 1052–61. doi:10.1099/jmm.0.044818-0.
Kuo CC. (2014). What’s your hand hygiene? American Academy of Orthopedic Surgeons Now, 8(4), 1.
Miller LA. (2012). Nurse staffing legislation: an overview. Journal of Perinatal & Neonatal Nursing, 26(1), 10–2. doi:10.1097/JPN.0b013e3182432cdc.
Patrick M & Van Wicklin SA. (2012). Implementing AORN recommended practices for hand hygiene. AORN Journal, 95(4), 492–507. Retrieved from http://dx.doi.org
Phalen RN & Wong WK. (2011). Integrity of disposable nitrile exam gloves exposed to simulated movement. Journal of Occupational and Environmental Hygiene, 8, 289–329. doi:10.1080/15459624.2011.569285.
Ponten A. (2013). Occupational allergic contact dermatitis caused by sterile non-latex protective gloves: clinical investigation and chemical analyses. Contact Dermatitis, 68(2), 103–10.
Serratt T, Harrington C, Spetz J, & Blegen M. (2011). Staffing changes before and after mandated nurse-to-patient ratios in California's hospitals. Policy Politics Nursing Practice, 12, 133. doi:10.1177/1527154411417881.
Spruce L. (2013). Back to basics: hand hygiene and surgical hand antisepsis. AORN Journal, 98(40), 249–60.
Van Wicklin SA. (2014). Clinical issues. AORN Journal, 99(2), 320–34. Retrieved from http://dx.doi.org
Vissher MO & Wickett RR. (2012). Hand hygiene compliance and irritant dermatitis: a juxtaposition of healthcare issues. International Journal of Cosmetic Science, 34, 402–15. doi:10.1111/j.1468-2494.2012.00733.x.
Wallis L. (2013). Nurse-patient staffing ratios. American Journal of Nursing, 113(8), 21–2.
World Health Organization (WHO). (2014). The evidence for clean hands. Retrieved from http://www.who.int
World Health Organization (WHO). (2012). Hand hygiene in outpatient and home-based care and long-term care facilities. Retrieved from http://apps.who.int
World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in health care. Retrieved from http://whqlibdoc.who.int