hand hygiene with guidelines.docx
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Hand Hygiene
Copyright © 2011 Wild Iris Medical Education, Inc. All Rights Reserved.
By Persis Mary Hamilton, RN, CNS, MS, EdD
Much of the material in this course is based on the report “Guideline for Hand Hygiene in Health-Care
Settings” (2002), by the Centers for Disease Control and Prevention. In 2010, the 2002 Guideline
continued to be the most recent report on hand hygiene recommendations available on the CDC website.
COURSE OBJECTIVE: The purpose of this course is to provide a rationale for hand hygiene, directions for
carrying out hand hygiene, information about hand hygiene products, and recommendations for improving
adherence to hand-cleansing practice.
LEARNING OBJECTIVES
Upon completion of this course, you will be able to:
State the relationship between hand hygiene and the acquisition of pathogens.
Demonstrate effective hand-cleansing techniques.
Discuss the antiseptic effectiveness and safety of common hand hygiene products.
Identify factors that improve adherence to handwashing protocols by caregivers.
Good hand hygiene may be the single most important thing healthcare workers can do to protect
the lives of their patients.
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).
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
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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 to 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 andwashing with antimicrobial products before and after performing invasive procedures. Waterless
antiseptic agents such as alcohol-based solutions were recommended only in situations where sinks
were not available.
In 1988 and 1995, guidelines similar to those of the CDC were published by the Association for
Professionals in Infection Control (APIC, 2010). The 1995 APIC guidelines 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 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
recommendations of the Healthcare Infection Control Practices Advisory Committee andtheHICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. In 2010, the 2002 Guideline continued to be
available on the CDC website (CDC, 2002).
In 2009, 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-
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forming pathogens, such as Clostridium difficile. When hands are not visibly soiled, the WHO
recommended the use of alcohol-based hand rubs as the preferred means for routine hand antisepsis
(WHO, 2009).
In 2011, although the guidelines of all these healthcare organizations have been adopted by the
majority of hospitals, adherence by healthcare providers to recommended handwashing protocols
remains low. For this reason, various professional groups have undertaken studies to identify factors
that improve adherence to hand hygiene protocols.
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.
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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, however, 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
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for just half of the normal barrier function of these protective secretions to return, and 5 to 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 (WHO, 2009)
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.
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HAND HYGIENE PRODUCTS
With contamination by infectious organisms everywhere, it is heartening to know that hand hygiene
antisepsis 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 infections rates. These include such things as the handwashing
technique, wearing artificial nails or rings, contaminated soaps or cleansers, and out-of-hospital
sources of pathogens (WHO, 2009).
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 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.
Antiseptic Agents
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.
ALCOHOLS
The majority of alcohol-based hand antiseptics contain isopropanol, ethanol, n-propanol, or a
combination 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
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against gram-positive and gram-negative vegetative bacteria, including fungi and multi-drug resistant
pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-
resistantEnterococci (VRE).
Certain viruses such as herpes simplex virus, human immunodeficiency virus, influenza virus,
respiratory syncytial virus, and vaccinia virus are susceptible to alcohols when tested in vitro. Hepatitis
B virus is somewhat less susceptible but is killed by 60% to 70% alcohol; hepatitis C virus 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 rinses 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 caregiver first should be
cleansed with soap and water. Then, an antiseptic hand rub, using an alcohol-based rinse, 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.
When using alcohol-based hand rubs, the CDC recommends healthcare personnel rub their hands
until the alcohol evaporates and the hands are dry.
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.
CHLORHEXIDINE
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The immediate antimicrobial activity of chlorhexidine 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. 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% 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.
PHENOL DERIVATIVES
Phenol was discovered in 1834 when it was extracted from coal tar. Its antiseptic properties were used
by Sir Joseph Lister in his pioneering work of antiseptic surgery. Commonly called carbolic acid ,
phenol not only kills pathogens, but its vapor is corrosive to the eyes, skin, and respiratory tract andcan harm the central nervous system, heart, kidneys, and liver. During World War II the Nazis used
phenol to exterminate untold thousands of people, first in gas chambers and then by injection,
especially at the Auschwitz extermination camp.
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Today, phenols are use in the production of plastics and related materials, herbicides,
pharmaceuticals, and a large collection of drugs, most notably aspirin. Phenols are also a precursor to
non-ionic detergents, used in dish and handwashing liquids (Virtual Chembook, 2010).
TRICLOSAN
Triclosan is a non-ionic, colorless substance that was developed in the 1960s. It has been
incorporated into detergents and other consumer products. Concentrations of 0.2% to 2% have
antimicrobial activity as well as a broad range of antimicrobial activity. 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 antiseptic activity in hand-care
products is affected by the acidity of the product; the presence of surfactants, emollients, or
moisturizers; and 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 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 recent 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.
The efficacy of various hand hygiene antiseptics is listed in the following table.
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antiseptic hand wash or antiseptic hand rub preparations are reliably sporicidal against Clostridium
spp. or Bacillus spp.
ASEPTIC HAND CLEANSING
General Hand Cleansing Technique
The following steps constitute the technique outlined in the CDC Guideline for Hand Hygiene in Health-
Care Settings (2002) and the WHO Guidelines (2009). Caregivers are advised to follow the
manufacturer’s recommendations about the product they are using.
When washing hands with soap and water, wet hands first with water, apply the amount of
product to hands, and rub hands together vigorously for at least 15 seconds, covering all
surfaces of hands and fingers. Rinse hands with water and dry thoroughly with a disposable
towel. Use towel to turn off the faucet. Avoid using hot water in order to decrease the risk of
dermatitis.
Liquid, bar, leaflet, or powdered forms of plain soap are acceptable when washing hands
with soap and water. When bar soap is used, soap racks that facilitate drainage and small
bars of soap should be used.
When decontaminating hands with an alcohol-based hand rub, apply product to palm of one
hand and rub hands together, covering all surfaces of hand and fingers until hands are dry.
Multiple-use cloth towels of the hanging or roll type are not recommended for use in
healthcare settings.
Surgical Hand Cleansing
ANTISEPTIC PREPARATIONS
Antiseptic preparations intended for use as surgical hand scrubs are evaluated for their ability to
reduce the number of bacteria released from the hands at different times. Immediate and persistent
activity is considered the most important issue in determining the efficacy of the product. CDC
Guidelines recommend that agents used for surgical hand scrubs should:
Substantially reduce microorganisms on intact skin
Contain a non-irritating antimicrobial preparation
Have broad-spectrum activity
Be fast-acting and persistent
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When antiseptic preparations were evaluated for bacterial growth-activity after surgical hand scrubs
with various chemicals, researchers ranked them from best to least effective, as follows:
Formulations containing 60% to 95% alcohol alone (most effective, least bacterial growth)
Formulations of 50% to 95% alcohol plus limited amounts of hexachlorophene chlorhexidine
gluconate, or quaternary ammonium compound
Chlorhexidine gluconate alone
Iodophors alone
Triclosan alone
Plain soap (least effective, most bacterial growth)
SCRUBBING TECHNIQUE
Traditionally, surgical personnel have been required to scrub their hands preoperatively for 10 minutes
before donning gloves. This practice leads to skin damage and does not significantly reduce bacterial
counts. Several studies show that scrubbing for 5 minutes reduces bacterial counts as effectively as 10
minutes, and some studies indicate that scrubbing for 2 or 3 minutes reduces bacterial counts to
acceptable levels. Other studies show that a two-stage surgical scrub with an antiseptic detergent,
followed by an alcohol-containing preparation, effectively reduces bacterial count.
Scrubbing with a disposable sponge reduces bacterial counts on the hands as effectively as scrubbing
with a bristle brush. Furthermore, scrubbing with a brush can damage the skin. Several studies
indicate that when alcohol-based products are used, neither a brush nor a sponge is necessary to
reduce bacterial counts to acceptable levels (CDC, 2002).
WHO RECOMMENDATIONS
In 2009, WHO recommended:
Before beginning surgical hand preparation, remove jewelry. Artificial nails are prohibited.
Sinks should be designed to reduce the risk for splashes.
Visibly soiled hands should be washed with plain soap and water before surgical hand
preparation, and a nail cleanser should be used to remove debris from under fingernails,
preferably under running water.
Brushes are not recommended.
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Before donning sterile gloves, surgical hand antisepsis should be performed with suitable
antimicrobial soap or alcohol-based hand rub, preferably one that ensures sustained
activity. Alcohol-based hand rub should be used when quality of the water is not assured.
When using an antimicrobial soap, scrub hands and forearms for the length of time
recommended by the maker, usually 2 to 5 minutes.
When using an alcohol-based surgical hand rub, follow the maker’s instructions; apply to
dry hands only; do not combine with alcohol-based products sequentially; use enough
product to keep hands and forearms wet throughout surgical hand preparations; and allow
hands and forearms to dry thoroughly before donning sterile gloves (Barclay, 2010).
Glove Use
In addition to their recommendations for surgical scrub, WHO (2009) recommendations for glove use
by caregivers state:
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.
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 leakage through damaged gloves. Gloves should be discarded
after use and not reused. 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,
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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 (WHO, 2009). When reactions
occur, they may be caused by additives or impurities in the product, but rarely to the alcohol itself.
Healthcare institutions need to provide alternative compounds for workers who have allergic reactions
to standard products.
By selecting alcohol-based hand rubs 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 (WHO, 2009).
ADHERENCE TO HAND HYGIENE PRACTICES
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 (Pittet, 2001; Erasmus et al., 2010).
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 hygienic hand rub.
Adherence Rates
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
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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 (Pittet, 2001).
Overcoming Barriers to Adherence
Why, you may ask, is the rate of adherence to hand hygiene so low, especially among healthcare
providers, who should be the most diligent. The reasons these same workers gave to researchers
(Pittet, 2001) were:
Inaccessible hand hygiene supplies
Skin irritation caused by hand hygiene agents
Priority of care (the patient’s need takes priority over hand hygiene)
Lack of knowledge of the guidelines
Insufficient time for hand hygiene and forgetfulness
High workload and understaffing
Lack of scientific information about healthcare-related infection rates
To decrease nosocomial (hospital-associated) 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 HYGIENCE FACILITIES
Studies indicate that the frequency of handwashing or antiseptic hand scrubs 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.
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Fortunately, dispensers for alcohol-based hand rubs 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 hand rubs, both dispensers should be clearly marked. Soap dispensers should be placed
beside sinks. Alcohol-based cleanser 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 hand gels, some manufacturers recommend hand washing with
soap and water to remove excessive gel.
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 (WHO, 2009).
As a consequence, institutions can minimize hand hygiene dermatitis by:
Selecting less-irritating hand hygiene products
Encouraging healthcare providers to use moisturizing skin care products after hand
cleansing
EDUCATING HEALTHCARE PROVIDERS
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.
INCREASING CAREGIVER-TO-PATIENT RATIOS
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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.
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. In 2004, California became the first state
to pass legislation mandating nurse-patient ratios, as follows:
1 nurse to 2 patients in intensive care units such as critical care, labor and delivery,
neonatal intensive care, post-anesthesia recovery, and emergency room intensive care
units
1 nurse to 3 patients in intensive care step-down units
1 nurse to 4 patients in specialty units such as antepartum, postpartum, pediatrics,
emergency room, telemetry, and specialty care
1 nurse to 5 patients in medical-surgical units
1 nurse to 6 patients in psychiatric units.
As of September 2009, fourteen states and the District of Columbia had enacted nurse staffing
legislation and/or adopted regulations addressing nurse staffing and another seventeen states had
introduced legislation.
In 2010, a study compared nurse-to-patient ratios in surgical units in New Jersey (NJ) and
Pennsylvania (PA) hospitals. Using death rates in all three states, researchers found that if the
average patient-to-nurse ratios in NJ and PA hospitals had been what it is in California, NJ would have
had 14% fewer patient deaths and PA would have had 11% fewer deaths. Over a 2-year period, 468
lives might have been saved (Aitken et al., 2010).
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
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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.
RESOURCES
Hand Hygiene
http://www.cdc.gov/handhygiene/
Handwashing
http://www.cdc.gov/handwashing/
Healthcare-Associated Infections (HAI)
http://www.cdc.gov/hai/
REFERENCES
Aikin LH, et al. (2010). Implications of the California nurse staffing mandate for other states. Health Services
Research, 45 (4), 904 –921.
Association for Professionals in Infection Control and Epidemiology (APIC). (2010). Guide to the Elimination of
Methicillin-Resistant Staphylococcusaureus (MRSA) Transmission in Hospital Settings (2nd ed.). Retrieved
March 16, 2011, from http://www.apic.org/downloads/MRSA_elimination_guide_27030.pdf.
Barclay L. (2010). World Health Organization issues Guidelines on Hand Hygiene in Healthcare. Medscape
Medical News. Retrieved June 17, 2010, from http://www.medscape.com/viewarticle/702406.
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(No. RR-16). Retrieved March 2011 from
http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf.
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Erasmus V, Daha TJ, Brug H, Richardus JH, Behrendt MD, Vos MC, & van Beeck EF. (2010). Systematic review of
studies on compliance with hand hygiene guidelines in hospital care. Infection Control and Hospital
Epidemiology, 31(3), 283 –294.
Habif P. (2009). Clinical Dermatology: A Color Guide to Diagnosis & Therapy (4th ed.). St. Louis: C.V. Mosby.
Pittet D. (2001). Improving adherence to hand hygiene practice: A multidisciplinary approach. Emerging Infectious
Diseases, 7 (2), 234 –240. Retrieved June 2010 from http://www.cdc.gov/ncidod/eid/vol7no2/pittet.htm.
Virtual Chembook. (2010). Detergents and surfactants.Retrieved June 12, 2010, from
http://www.elmhurst.edu/~chm/vchembook/558detergent.html.
World Health Organization (WHO). (2009). WHO Guidelines on Hand Hygiene in Health Care. Retrieved May 17,
2010, from http://www.who.int/rpc/guidelines/9789241597906/en/.