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CONTINUING EDUCATION
Back to Basics: HandHygiene and Surgical HandAntisepsis
LISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR 1.2www.aorn.org/CE
Continuing Education Contact Hoursindicates that continuing education (CE) contact hours
are available for this activity. Earn the CE contact hours by
reading this article, reviewing the purpose/goal and objectives,
and completing the online Examination and Learner Evalua-
tion at http://www.aorn.org/CE. A score of 70% correct on the
examination is required for credit. Participants receive feed-
back on incorrect answers. Each applicant who successfully
completes this program can immediately print a certificate of
completion.
Event: #13533
Session: #0001
Fee: Members $7.20, Nonmembers $14.40
The CE contact hours for this article expire November 30,
2016. Pricing is subject to change.
Purpose/GoalTo provide the learner with knowledge of best practices related
to hand hygiene and performing surgical hand antisepsis.
Objectives
1. Discuss common areas of concern that relate to peri-
operative best practices.
2. Discuss best practices that could enhance safety in the
perioperative area.
3. Describe implementation of evidence-based practice in
relation to perioperative nursing care.
AccreditationAORN is accredited as a provider of continuing nursing edu-
cation by the American Nurses Credentialing Center’s Com-
mission on Accreditation.
http://dx.doi.org/10.1016/j.aorn.2013.08.017
� AORN, Inc, 2013
ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-
cation, as well as other CE requirements.
AORN is provider-approved by the California Board of
Registered Nursing, Provider Number CEP 13019. Check with
your state board of nursing for acceptance of this activity for
relicensure.
Conflict of Interest DisclosuresDr Spruce has no declared affiliation that could be perceived as
posing a potential conflict of interest in the publication of this
article.
The behavioral objectives for this program were created by
Kimberly Retzlaff, managing editor, with consultation from
Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan
Bakewell, MS, RN-BC, director, Perioperative Education. Ms
Retzlaff, Ms Holm, and Ms Bakewell have no declared affili-
ations that could be perceived as posing potential conflicts of
interest in the publication of this article.
Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this
article.
DisclaimerAORN recognizes these activities as CE for RNs. This rec-
ognition does not imply that AORN or the American Nurses
Credentialing Center approves or endorses products mentioned
in the activity.
November 2013 Vol 98 No 5 � AORN Journal j 449
I
Back to Basics: H
and Hygiene andSurgical Hand AntisepsisLISA SPRUCE, DNP, RN, ACNS, ACNP, ANP, CNOR 1.2www.aorn.org/CE
ABSTRACT
Health careeassociated infections (HAIs) are a significant issue in the United
States and throughout the world, but following proper hand hygiene practices is the
most effective and least expensive way to prevent HAIs. Hand hygiene is inex-
pensive and protects patients and health care personnel alike. The four general
types of hand hygiene that should be performed in the perioperative environment
are washing hands that are visibly soiled, hand hygiene using alcohol-based
products, surgical hand scrubs, and surgical hand scrubs using an alcohol-based
surgical hand rub product. Barriers to proper hand hygiene may include not
thinking about it, forgetting, skin irritation, a lack of role models, or a lack of a
safety culture. One strategy for improving hand hygiene practices is monitoring
hand hygiene as part of a quality improvement project, but the most important
aspect for perioperative team members is to set an example for other team members
by following proper hand hygiene practices and reminding each other to perform
hand hygiene. AORN J 98 (November 2013) 450-457. � AORN, Inc, 2013. http://
dx.doi.org/10.1016/j.aorn.2013.08.017
Key words: hand hygiene, surgical hand rub, surgical hand scrub, health caree
associated infection.
t is appropriate to begin this “Back to Basics”
series with hand hygiene and surgical hand
antisepsis, because these activities are the foun-
dation of infection prevention for all perioperative
personnel. It is probably safe to say that anyone in
health care today has heard of the importance of
hand hygiene. Hand hygiene is the most effective
and least expensive way to prevent health caree
associated infections (HAIs).1 All health care
workers can prevent HAIs by washing their hands.
Health careeassociated infections are a major
problem in the United States and throughout the
world. In US hospitals, the most frequently occur-
ring HAIs are urinary tract infections (36%),
450 j AORN Journal � November 2013 Vol 98 No 5
surgical site infections (20%), and blood stream
infections and pneumonia (11%).2 The economic
effect of these infections was $6.5 billion in 20042
and reached $33.8 billion in 2009.3 Hand hygiene
practices can jeopardize safety in the perioperative
area if not performed as recommended; if perfor-
med correctly, hand hygiene can significantly im-
prove the burden on the global health care system
by decreasing microorganism transmission to pa-
tients and health care workers.
HOW-TO GUIDE
The World Health Organization (WHO) Guidelines
on Hand Hygiene in Health Care state,
http://dx.doi.org/10.1016/j.aorn.2013.08.017
� AORN, Inc, 2013
BACK TO BASICS: HAND HYGIENE www.aornjournal.org
Guidelines in the [United States] recommend
that agents used for surgical hand preparation
should significantly reduce microorganisms on
intact skin, contain a non-irritating antimicro-
bial preparation, have broad-spectrum activity,
and be fast-acting and persistent.2(p55)
A complete guide to products is included in the
WHO guidelines. However, there are basic types
of products that should be used in perioperative
settings. Alcohol-based hand rubs are the pre-
ferred type of product for hand hygiene, while
the recommended formulation for surgical hand
antisepsis products is more complex and there
are multiple antiseptic agents that fit this
category.2
The AORN “Recommended practices for hand
hygiene”1 recommends that hand hygiene should
be performed at numerous times:
n on arrival at the facility,
n before and after every patient contact,
n before putting on gloves,
n after removing gloves,
n after removing personal protective equipment,
n after possible contact with blood or other po-
Resources for Hand Hygiene
Videos
n Hygi�ene des mains Hopitaux Universitaires de Gen�eve Vigi
Germe. http://youtu.be/0at_jtzJCDM.
n WHO hand hygiene video. http://youtu.be/s08yiZBSGOw.
Online resources
n Clean care is safer care. World Health Organization. http://
www.who.int/gpsc/5may/background/5moments/en.
n Hand hygiene in healthcare settings. Centers for Disease Control
and Prevention. http://www.cdc.gov/handhygiene/Resources
.html#HCP.
n How to wash your hands e hand washing techniques from the
NHS. NHS. http://www.wash-hands.com/resources.
Web site access verified August 12, 2013.
tentially infectious
materials,
n before and after eating,
n before and after using the
restroom,
n before leaving the
facility, and
n when hands are visibly
soiled.
Perioperative personnel
should review and be mindful
of these recommended prac-
tices and keep reminders of
them visible in a prominent
place to help ensure that
good practices become habit.
There are four general
types of hand hygiene that
should be performed in the perioperative environ-
ment: washing hands that are visibly soiled, hand
hygiene using alcohol-based products, surgical
hand scrubs, and surgical hand scrubs using an
alcohol-based surgical hand rub product. There
are specific techniques for each of these types of
hand hygiene.
Washing Hands That Are Visibly Soiled
This type of hand hygiene should take 40 to 60
seconds to perform. According to WHO,2 health
care personnel should use the following 11-step
hand-washing process to ensure their hands are
properly cleaned (Figure 1). After wetting hands
with water, the following steps should be taken:
1. Apply enough soap to cover all hand surfaces;
2. Rub hands palm to palm;
3. Right palm over left dorsum with interlaced
fingers and vice versa;
4. Palm to palm with fingers interlaced;
5. Backs of fingers to opposing palms with fingers
interlocked;
6. Rotational rubbing of left thumb clasped in
right palm and vice versa;
AORN Journal j 451
Figure 1. How to Handwash. http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf ª World HealthOrganization 2009. All rights reserved. Reprinted with permission.
452 j AORN Journal
November 2013 Vol 98 No 5 SPRUCE
BACK TO BASICS: HAND HYGIENE www.aornjournal.org
7. Rotational rubbing, backwards and forwards
with clasped fingers of right hand in left palm
and vice versa;
8. Rinse hands with water;
9. Dry hands thoroughly with a single use towel;
10. Use towel to turn off faucet;
11. Your hands are now safe.4
Hand Hygiene Using Alcohol-BasedProducts
During situations in which hands are not visibly
soiled, such as after removing gloves or touching
a doorknob, perioperative team members should
use an alcohol-based hand rub for hand hygiene.
This type of hand hygiene process should take 20 to
30 seconds to complete. According to WHO,2
perioperative team members should use an eight-
step hand-rub process to ensure their hands are
properly cleaned (Figure 2). If visibly soiled,
hands and forearms should be prewashed with
plain soap and water or an antimicrobial agent,
and then the following steps should be taken:
1. Apply a palmful of the product in a cupped
hand, covering all surfaces;
2. Rub hands palm to palm;
3. Right palm over left dorsum with interlaced
fingers and vice versa;
4. Palm to palm with fingers interlaced;
5. Backs of fingers to opposing palms with fingers
interlocked;
6. Rotational rubbing of left thumb clasped in
right palm and vice versa;
7. Rotational rubbing, backwards and forwards
with clasped fingers of right hand in left palm
and vice versa;
8. Once dry, your hands are safe.5
Surgical Hand Scrub
According to AORN,1 a surgical hand scrub should
be performed before donning sterile gloves for
surgical or other invasive procedures. This pro-
cess is effective at a duration of three to five min-
utes. Perioperative team members should use the
following steps to ensure their hands are prop-
erly cleaned:
1. Remove jewelry including rings, watches, and
bracelets.
2. Don a surgical mask. If others are at the scrub
sink, a surgical mask should be worn in the
presence of hand scrub activity.
3. Wash hands and forearms if visibly soiled with
soap and running water immediately before
beginning the surgical scrub.
4. Clean the subungual areas of both hands under
running water using a disposable nail cleaner.
Discard the nail cleaner in the appropriate
container.
5. Rinse hands and forearms under running water.
6. Dispense the approved antimicrobial scrub
agent according to the manufacturer’s written
directions.
7. Apply the antimicrobial agent to wet hands and
forearms using a soft, nonabrasive sponge.
8. A three- or five-minute scrub should be timed
to allow adequate product contact with skin,
according to the manufacturer’s written
directions.
9. Visualize each finger, hand, and arm as having
four sides. Wash all four sides and the web
space, keeping the hand elevated. Repeat this
process for opposite fingers, hand, and arm.
10. For water conservation, turn water off when it
is not directly in use, if possible.
11. Avoid splashing surgical attire.
12. Discard sponges, if used, in appropriate
containers.
13. Hands and arms should be rinsed under run-
ning water in one direction from fingertips to
elbows as often as needed.
14. Hold hands higher than elbows and away from
surgical attire.
15. In the OR, beginning at the fingertips of one
hand and working up to the elbow with one end
of the towel and repeating the process with the
clean end of the towel on the other hand and
arm before discarding the towel and donning
a sterile surgical gown and gloves.1(p67)
AORN Journal j 453
Figure 2. How to Handrub. http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf ª World HealthOrganization 2009. All rights reserved. Reprinted with permission.
454 j AORN Journal
November 2013 Vol 98 No 5 SPRUCE
During proper hand hygiene, perioperative personnelshould a) don a surgical mask, b) rinse the handsfrom fingertips to elbows, and c) keep surgical attiredry. What’s Wrong With This Picture? reprinted withpermission from AORN, Inc, Denver, CO. All rightsreserved.
BACK TO BASICS: HAND HYGIENE www.aornjournal.org
Surgical Hand Scrub Using an Alcohol-Based Surgical Hand Rub Product
According to AORN,1 an alcohol-based antiseptic
surgical hand rub with documented persistent and
cumulative activity that has met US Food and Drug
Administration regulatory requirements is accept-
able. The WHO does not recommend a standard-
ized process for the surgical hand scrub with an
alcohol-based product; however, the organization
does stress the importance of keeping the hands wet
with the product throughout the process.2 The
volume of product that should be used depends on
the size of the team member’s hands and forearms.
After the product is dispensed, the forearms should
be the focus of the rub for the first minute and then
the hands should be the focus, following the same
procedure outlined in the hand scrub technique. To
ensure their hands are properly cleaned, perioper-
ative team members should use the following steps
during a surgical hand scrub using an alcohol-based
surgical hand rub product:
1. Remove jewelry including rings, watches, and
bracelets.
2. Don a surgical mask. If others are at the scrub
sink, a surgical mask should be worn in the
presence of hand scrub activity.
3. If visibly soiled, prewash hands and forearms
with plain soap and water or antimicrobial
agent.
4. Clean the subungual areas of both hands under
running water using a disposable nail cleaner.
5. Rinse hands and forearms under running
water.
6. Dry hands and forearms thoroughly with a
disposable paper towel.
7. Dispense the manufacturer-recommended
amount of the surgical hand rub product.
8. Apply the product to the hands and forearms
according to the manufacturer’s written
instructions.
9. Repeat the product application process as
directed.
10. Rub hands thoroughly until completely dry.
11. In the OR or other invasive procedure room,
don a sterile surgical gown and gloves.1(p66-67)
BENEFITS
Using the four techniques described in the pre-
ceding text is the most effective way to prevent and
control infections among patients and health care
workers. Hand hygiene is inexpensive and achieves
a benefit for both populations.1 Hand hygiene re-
duces the transmission of microorganisms and de-
creases the incidence of HAIs.3 Evidence supports
that a failure to wash hands appropriately is the
AORN Journal j 455
November 2013 Vol 98 No 5 SPRUCE
leading cause of the spread of multidrug-resistant
organisms among patients.3 Surgical hand anti-
sepsis takes hand hygiene a step beyond hand
washingdit eliminates transient flora from the
hands and reduces resident skin flora.2 Transient
flora are colonized on the superficial layers of the
skin of the hands and are easily removed with
washing, whereas resident skin flora are not only
on the superficial layers but also in the deeper
layers of the skin and are not as easy to remove.2
TIPS & TRICKS
Since 1847, when Ignaz Semmelweis insisted that
students and physicians wash their hands, hand
hygiene has been a challenge to enforce; today is
no different.3 To improve hand hygiene practices,
perioperative nurses first need to understand the
reasons for poor compliance.
Reasons for poor compliance include self-
reported factors such as not thinking about it,
forgetting, or skin irritation, as well as aspects such
as a shortage of role models or lack of a safety
culture. Recommended hand hygiene practices may
not always be intuitive. Everyone washes their
hands when they are visibly soiled, bloody, sticky,
or perceived to be dirty. In social situations, people
may touch each other by shaking hands, patting
each other on the back, hugging, or using touch as
affirmation. Hands are not generally washed after
these types of contact. These same types of social
contact can occur in the health care setting among
colleagues and during patient care. Washing the
hands after these types of situations may be over-
looked, so what can be done to improve compliance
with hand hygiene by health care workers?
The WHO guideline includes multiple tools to
help with improving hand hygiene practices (eg, the
Global Patient Safety Challenge document, Pilot
Implementation Pack, Hand Hygiene Brochure,
Clean Hands Poster, Hand Hygiene Observation
Survey).2 Additionally, WHO has a hand hygiene
tool kit that provides strategies and tools to those
who are interested in improving compliance with
456 j AORN Journal
hand hygiene practices at their facilities.6 Some
examples include a facility action plan, protocols
for hand hygiene, and educational materials and
posters. Education is the critical component to im-
prove hand hygiene practices according to WHO.2
The power to inform, along with using other tools,
has been proven to increase compliance.2
Another barrier to following hand hygiene
practices is skin irritation, which can occur with
the use of hand hygiene products. Perioperative
team members should remember to let their hands
dry completely before donning gloves, and in
some cases, alternate products should be pro-
vided to personnel who have sensitive or reac-
tive skin.
To determine compliance with hand hygiene
practices, WHO recommends that individual facil-
ities observe health care workers performing hand
hygiene.2 However, no ideal observation method
exists currently.2 Facilities have used direct obser-
vations by educated observers as well as automated
observations, such as video cameras to monitor
personnel, with some success; however, direct
observation can be biased, as can the interpretation
of videos. Furthermore, these methods can be
costly and hard to monitor during complex activi-
ties.2 It is important for perioperative team mem-
bers to be examples for each other and remind each
other to perform hand hygiene. For a complete
discussion on observations and other tools, see the
WHO guideline.2
WRAP-UP
The effect of HAIs on patient health and safety and
the economy is significant. The foundation of in-
fection prevention is hand hygiene; therefore,
health care facilities need to make hand hygiene
a number one priority in the prevention of HAIs.
The goals are to refresh perioperative personnel’s
knowledge of hand hygiene and instill a new sense
of urgency to protect patients and health care
workers from the potential of developing an
infection and spreading it to others.
BACK TO BASICS: HAND HYGIENE www.aornjournal.org
References1. Recommended practices for hand hygiene. In: Perioper-
ative Standards and Recommended Practices. Denver,
CO: AORN, Inc; 2013:63-74.
2. WHO Guidelines on Hand Hygiene in Health Care.
Geneva, Switzerland: World Health Organization; 2009.
http://whqlibdoc.who.int/publications/2009/9789241597906_
eng.pdf. Accessed September 9, 2013.
3. Guideline for hand hygiene in health-care settings. Re-
commendations of the Healthcare Infection Control Prac-
tices Advisory Committee and the HICPAC/SHEA/APIC/
IDSA Hand Hygiene Task Force. MMWR Recomm Rep.
2002;51(RR-16):1-45.
4. How to Handwash? [poster]. Geneva, Switzerland: World
Health Organization; 2009. http://www.who.int/gpsc/5may/
How_To_HandWash_Poster.pdf. Accessed September 13,
2013.
5. How to Handrub? [poster]. Geneva, Switzerland: World
Health Organization; 2009. http://www.who.int/gpsc/5may/
How_To_HandRub_Poster.pdf. Accessed September 13,
2013.
6. Guide to Implementation: A Guide to the Implementation
of the WHO Multimodal Hand Hygiene Improvement
Strategy. Geneva, Switzerland: World Health Organiza-
tion; 2009. http://whqlibdoc.who.int/hq/2009/WHO_IER_
PSP_2009.02_eng.pdf. Accessed September 9, 2013.
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,
CNOR, is the director, Evidence-Based Periop-
erative Practice, AORN, Inc, Denver, CO. Dr
Spruce has no declared affiliation that could be
perceived as posing a potential conflict of in-
terest in the publication of this article.
Check back in January 2014 for the next “Back to Basics” topic: Hygiene and Cleanliness.
AORN Journal j 457
EXAMINATION
CONTINUING EDUCATION PROGRAM1.2
www.aorn.org/CEBack to Basics: Hand Hygiene andSurgical Hand Antisepsis
PURPOSE/GOAL
45
To provide the learner with knowledge of best practices related to hand hygiene
and performing surgical hand antisepsis.
OBJECTIVES
1. Discuss common areas of concern that relate to perioperative best practices.
2. Discuss best practices that could enhance safety in the perioperative area.
3. Describe implementation of evidence-based practice in relation to perioperative
nursing care.
The Examination and Learner Evaluation are printed here for your conven-
ience. To receive continuing education credit, you must complete the Exami-
nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Hand hygiene practices can
1. decrease microorganism transmission to pa-
tients and health care workers.
2. jeopardize safety in the perioperative area if
not performed correctly.
3. significantly improve the burden on the
global health care system if performed as
recommended.
a. 1 and 3 b. 1 and 2
8 j AORN Journal
c. 2 and 3 d. 1, 2, and 3
2. According to the World Health Organization,
agents used for surgical hand preparation should
1. be fast-acting and persistent.
2. contain a nonirritating antimicrobial prep-
aration.
3. be chlorine based to kill spores.
4. have broad-spectrum activity.
� November 2013 Vol 98 No 5
5. significantly reduce microorganisms on intact
skin.
a. 1 and 2 b. 1 and 3
c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5
3. According to AORN, hand hygiene should be
performed
1. after removing personal protective equipment.
2. before and after every patient contact.
3. on arrival and before leaving the facility.
4. when hands are visibly soiled.
a. 1 and 3 b. 2 and 4
c. 2, 3, and 4 d. 1, 2, 3, and 4
4. Evidence shows that a failure to wash hands ap-
propriately is the leading cause of the spread of
multidrug-resistant organisms among patients.
a. true b. false
� AORN, Inc, 2013
CE EXAMINATION www.aornjournal.org
5. Strategies that can be used to improve compliance
with hand hygiene protocols include
1. creating and implementing a facility action plan.
2. establishing protocols for hand hygiene.
3. mandating one brand of hand hygiene products
for all personnel to use.
4. monitoring hand hygiene practices and re-
porting on findings to personnel.
5. providing personnel with educational ma-
terials.
a. 2 and 4 b. 1, 2, 4, and 5
c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5
AORN Journal j 459
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM1.2
www.aorn.org/CEBack to Basics: Hand Hygiene andSurgical Hand Antisepsis
This evaluation is used to determine the extent
to which this continuing education program
met your learning needs. Rate the items as
described below.
OBJECTIVES
To what extent were the following objectives of this
continuing education program achieved?
1. Discuss common areas of concern that relate to
perioperative best practices.
Low 1. 2. 3. 4. 5. High
2. Discuss best practices that could enhance safety in
the perioperative area.
Low 1. 2. 3. 4. 5. High
3. Describe implementation of evidence-based practice
in relation to perioperative nursing care.
Low 1. 2. 3. 4. 5. High
CONTENT
4. To what extent did this article increase your
knowledge of the subject matter?
Low 1. 2. 3. 4. 5. High
5. To what extent were your individual objectives
met? Low 1. 2. 3. 4. 5. High
6. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No
7. Will you change your practice as a result of reading
this article? (If yes, answer question #7A. If no,
answer question #7B.)
460 j AORN Journal � November 2013 Vol 98 No 5
7A. How will you change your practice? (Select all
that apply)
1. I will provide education to my team regarding
why change is needed.
2. I will work with management to change/
implement a policy and procedure.
3. I will plan an informational meeting with
physicians to seek their input and acceptance
of the need for change.
4. I will implement change and evaluate the
effect of the change at regular intervals until
the change is incorporated as best practice.
5. Other: _______________________________
7B. If you will not change your practice as a result
of reading this article, why? (Select all that
apply)
1. The content of the article is not relevant to my
practice.
2. I do not have enough time to teach others
about the purpose of the needed change.
3. I do not have management support to make
a change.
4. Other: ________________________________
8. Our accrediting body requires that we verify
the time you needed to complete the 1.2 con-
tinuing education contact hour (72-minute)
program: _________________________________
� AORN, Inc, 2013