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Hand hygiene

The control of Healthcare Associated Infections (HCAI) represents a major challenge to hospitals and healthcare providers.

Introduction

Transmission of pathogens on the hands of healthcare workers is the most common cause of cross infection (Damani 1997), occurring directly from patient contact or indirectly via contact with the environment (Epic2 Guidelines 2007).

Hand hygiene is therefore considered to be one of the most important procedures in the prevention of cross contamination and cross infection (Rationale 1).

Studies on hand hygiene compliance among healthcare workers suggest that the mean baseline rate ranges from five to 81 per cent, with an average of 40 per cent compliance (Boyce and Pittet 2002).

The Trust is committed to increasing compliance to hand washing and has reviewed hand washing agents, paper towel quality and gloves, and is actively promoting education programmes on hand hygiene (Rationale 2).

Parents and children should be taught the importance of good hand hygiene in the home environment as well as in hospital.

Types of hand wash procedure

1. Social hand wash

Why should a social hand wash be performed? 

Social hand wash is performed to render the hands physically clean and to remove transient micro-organisms. It is an infection control practice with a clearly demonstrated efficacy and remains the cornerstone of efforts to reduce the spread of infection (Larson 1989)(Rationale 3).

When should a social hand wash be performed?

The times that hand hygiene should be performed have been summarised into the 'Your 5 Moments for Hand Hygiene' document, as these are considered the most fundamental times for the levels of hand hygiene to be undertaken during care delivery and daily routines (National Patient Safety Agency (NPSA) 2009).

Download: Your 5 Moments for Hand Hygiene (PDF, 185 KB) 

Examples of when to perform a social hand wash

Before:

  • the beginning of the shift
  • preparing, handling and eating food
  • donning gloves
  • any patient contact
  • clean/aseptic procedures
  • entering/leaving clinical areas
  • entering/leaving isolation cubicles
  • preparing/giving medications
  • using a computer keyboard in a clinical area
After:
  • the end of a shift
  • any patient contact
  • bed making
  • contact with patient surroundings
  • visiting the toilet
  • the removal of gloves
  • hands become visibly soiled
  • handling laundry/waste
  • using a computer keyboard in a clinical area
  • the administration of medications
  • blood and/or body fluid exposure risk

What solution should be used for performing a social hand wash?

Liquid soap (plain or antimicrobial)

  • The soap comes in disposable cartridges and must not be re-used or 'topped-up' (Rationale 4).
  • Bar soap should not be used in clinical areas (Rationale 4).  

How should a social hand wash be performed?

Social hand washing should take at least 30 seconds:

  • Wet hands under running warm water.

  • Dispense one dose of soap into cupped hands.

  • Rub hands palm to palm.

  • Right palm over the back of the other hand with interlaced fingers and vice versa.

  • Palm to palm with fingers interlaced.

  • Back of fingers to opposing palms with fingers interlocked.

  • Rotational rubbing of left thumb clasped in right palm and vice versa.

  • Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.

  • Rinse hands with warm water.

  • Dry thoroughly with paper towel (Rationale 5). Cloth towels must not be used (Rationale 6). Warm air hand dryers may be used in non-clinical areas (Rationale 7).

  • Turn off taps using a ‘hands-free’ technique (eg elbows). Where this is not possible, the paper towel used to dry the hands can be used to turn off the tap (Rationale 8). 

  • Dispose of the paper towel without re-contaminating hands. Do not touch bin lid with hands (Rationale 9).

Alcohol gel/foam

This can be used on visibly clean hands as an alternative to a social hand wash. 

Alcohol gel/foam:

  • Will not remove dirt and organic matter and can only be used when hands are not visibly soiled.
  • Should not be used prior to handling medical gas cylinders because of the risk of ignition.
  • Is NOT effective against Clostridium difficile and Norovirus. When caring for a patient with either of these organisms, hands must be washed with soap and water.
  • Soap and alcohol-based handrub should not be used concomitantly (World Health Organisation (WHO) 2009).
  • When applying alcohol handrub leave to dry naturally on the skin.
  • Hands should be washed with soap and water after several consecutive applications of handrub (Epic2 Guidelines 2007)(Rationale 10).

Download: A poster with the correct hand cleaning techniques 

2. Hygienic hand wash

Why should a hygienic hand wash be performed?

To remove or destroy transient micro-organisms and to substantially reduce resident micro-organisms during times when surgical procedures are performed.

When should a hygienic hand wash be performed?

Before all aseptic procedures on the ward.

What should be used for performing a hygienic hand wash?

An approved antiseptic detergent (eg 4% Chlorhexidine gluconate or 7.5% Povidone iodine).

How should a hygienic hand wash be performed?

See above instructions on ‘How should a social hand wash be performed?’

3. Surgical hand wash

Why should a surgical hand wash be performed?

To remove or destroy transient micro-organisms and to substantially reduce resident micro-organisms during times when surgical procedures are performed. It is intended to decrease the risk of wound infections should surgical gloves become damaged.

When should a surgical hand wash be performed?

Before all surgical/invasive procedures.

What should be used for performing a surgical hand wash?

An approved antiseptic detergent (eg 4% Chlorhexidine gluconate or 7.5% Povidone iodine).

How should a surgical hand wash be performed?

  • When performing a surgical hand wash, the level of the hands should always remain above the elbows (Rationale 11).

  • Always use sensor or elbow operated taps (Rationale 8).

  • Apply antiseptic detergent to the hands and wrists and wash for at least one minute up to the elbow. 

  • A sterile brush may be used for the first application of the day, but continual use is inadvisable.

  • Using a pre-packed sterile brush, clean under the nails only of both hands.

  • Rinse thoroughly.

  • Apply a second application of antiseptic detergent and wash hands and two thirds of the forearms with either Povidone iodine for at least one minute, or Chlorhexidine gluconate for at least two minutes.

  • Rinse thoroughly. 

  • One sterile towel should be used to blot dry the first hand and arm and another sterile towel for the second hand and arm (Rationale 12).

The use of gloves

  • The use of gloves does not replace the need for hand hygiene by either hand rubbing or hand washing (WHO 2009).

  • Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin/mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments. Some procedures not normally requiring gloves may require gloves when infection is present eg eye care (Epic2 2007).

  • Gloves can have pores that may allow micro-organisms to pass through and hands should be cleaned before and after wearing gloves (Epic2 2007).

  • Gloves should be single-use and changed between dirty and clean procedures and between patients (Larson 1989)(Rationale 12).

  • Gloved hands should not be washed or cleaned with alcohol hand rubs, gels or wipes (Walsh 1987)(Rationale 13).

  • Sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented and alternatives to natural rubber latex gloves must be available (Epic2 2007).

Other aspects of hand hygiene

  • Artificial fingernails or extenders should not be worn when having direct contact with patients (Rationale 14).

  • Natural nails should be kept short (tips less than 0.5cm long) (Rationale 15).

  • The wearing of rings and wrist jewellery (including watches) during health care is strongly discouraged. If religious or cultural influences strongly condition the health care worker’s attitude, the wearing of a simple wedding ring (band) during routine care may be acceptable, but in high-risk settings, such as the operating theatre, all rings and other jewellery should be removed (WHO 2009).

  • Cuts and abrasions must be covered with waterproof dressings (Rationale 16).

  • Bare below the elbows - in order to ensure that hands can be easily decontaminated, only clothing that does not go past the elbow should be worn. Suit jackets, long sleeves, wrist watches, bracelets and rings (other than a plain wedding band) should not be worn.

  • Download the poster: Bare below the elbows

  • 'Bare below the elbows' applies to all clinical staff wearing a uniform, anyone entering a patient's bed space or room, when having clinical patient contact and anyone entering PICU, NICU or CICU.

  • 'Bare below the elbows' is not required for anyone visiting a ward (with the exception of PICU, NICU or CICU) that does not enter a patient's bed space or room.  

Hand care

Contact dermatitis caused by frequent exposure to soaps and cleaners is the most common form of work-related skin disease in nurses and other healthcare professionals (Health and Safety Exective (HSE) 2007).

Hand care advice:

  • Always wet hands thoroughly before washing (Rationale 17).

  • Ensure water is warm (neither hot nor cold).

  • Do not use more soap product than recommended by the manufacturer ('One squirt is enough').

  • During handwashing, thoroughly rinse off residual soap.

  • Dry hands completely by carefully patting rather than rubbing with a paper towel.

  • Donning gloves while hands are still wet from either washing or applying alcohol gel, increases the risk of skin irritation.

  • Use emollient creams regularly, especially before breaks and after finishing work. Ensure all parts of the hand are covered.

  • Check your skin for early signs of dermatitis and report concerns to Occupational Health (Rationale 18). Early detection can help prevent more serious dermatitis from developing.


Download: Hand Care Plan

Download: One squirt is enough hand care poster 

Rationale

Rationale 1: Hand washing causes a significant reduction in the carriage of potential pathogens on hands.

Rationale 2: This is in line with the requirements of the NHS Controls Assurance Standards 2000 and the Clinical Negligence Scheme for Trusts Criterion 5.1.6 in 2005.

Rationale 3: Transient microorganisms are located under the surface of the skin and beneath the superficial cells of the stratum corneum. They are termed 'transient' because direct contact with other people, equipment or body sites all result in the transfer of microorganisms to and from the hands.

Rationale 4: This increases the risk of contamination.

Rationale 5: These are quicker seven to nine seconds compared to 25.4 seconds with dryers (Taylor 1978). They rub away transient microorganisms and old, dead skin cells loosely attached to the surface of the hands.

Rationale 6: To avoid cross-contamination.

Rationale 7: There is conflicting evidence as to their efficacy in reducing infection (Infection Control Nurses Association 1997).

Rationale 8: To avoid re-contaminating the hands.

Rationale 9: To prevent re-contamination of hands if the lid is touched.

Rationale 10: Some alcohol-based handrubs become less effective following ten consecutive hand hygiene episodes (Sickbert-Bennett et al 2005).

Rationale 11: To prevent contaminated water from the arms running onto the hands.

Rationale 12: To avoid cross-contamination.

Rationale 13: This may spoil the integrity of the glove material (National Association of Theatre Nurses 1998) and organisms may adhere to the material.

Rationale 14: HCWs who wear artificial nails are more likely to harbour Gram-negative pathogens on their fingertips than those who have natural nails, both before and after handwashing or the use of alcohol gel. (WHO 2009).

Rationale 15: Long sharp fingernails, either natural or artificial, can puncture gloves easily. They may also limit the HCWs performance in hand hygiene practices (WHO 2009).

Rationale 16: To prevent micro-organisms from entering or leaving the wound.

Rationale 17: To minimise irritation.

Rationale 18: To monitor possible side effects of hospital antiseptics/detergents. To provide the individual with alternative cleansing agents.

References

Reference 1:
Ayliffe GAJ, Lowbury EJL, Geddes AM, Williams JD (1992) Control of Hospital Infection - A Practical Handbook 3rd Edition. London, Chapman and Hall Medical

Reference 2:
Boyce JM, Pittet D (2002) Guidelines for Hand Hygiene in Health-Care Settings: Recommendations of CDC and the Healthcare Infection Control Practices Advisory Committee . MMWR Recommendations and Reports 51: RR-16.

Reference 3:
Damani NN (1997) Manual of Infection Control Procedures. London, Greenwich Medical Media Ltd

Reference 4:
Pratt RJ; Pellowe CM; Wilson JA; Loveday HP; Harper P; Jones SRLJ; McDougall C; Wilcox MH (2007) EPIC2: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. J Hosp Infect 65S: 1-64.

Reference 5:
Health and Safety Executive (2007) Preventing contact dermatitis at work. London, HSE

Reference 6:
Infection Control Nurses Association (1997) Guidelines for Hand Hygiene. ICNA (e-pub) www.icna.co.uk .

Reference 7:
Larson E (1995) APIC guideline for handwashing and hand antisepsis in health care settings. Am J Infect Control 23 (4): 251-69.

Reference 8:
Larson E (1989) Hand washing is essential - even when you use gloves. Am J Nursing 89: 934-939.

Reference 9:
Walsh B, Blakemore PH, Drabu YJ (1987) The effect of handcream on the antibacterial activity of chlorhexidine gluconate. J Hosp Infect 9 (1): 30-3.

Reference 10:
World Health Organisation (2009) WHO guidelines in hand hygiene in health care. France, World Health Organisation

Reference 11:
National Association of Theatre Nurses (1998) Principles of safe practice in the peri-operative environment. Harrogate, National Association of Theatre Nurses

Reference 12:
National Patient Safety Agency (2009) Your 5 Moments for Hand Hygiene . www.npsa.nhs.uk/cleanyourhands . Viewed on: 02/02/2010

Reference 13:
Niffeneger JP (1999) Proper Hand washing Promotes Wellness in Child Care. Journal of Pediatric Healthcare January/February: 26-31.

Reference 14:
Paulssen J, Eidem T, Kristiansen R (1988) Perforations in surgeons' gloves. J Hosp Infect 11 (1): 82-5.

Reference 15:
Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, Sobsey MD, Samsa GP, Rutala WA (2005) Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control 33 (2): 67-77.

Reference 16:
Taylor LJ (1978) An evaluation of handwashing techniques-2. Nurs Times 74 (3): 108-10.

Reference 17:
Wilson J (2006) Infection Control in Clinical Practice Third edition. London, Bailliere Tindall

Document control information

Lead author(s)
Barbara Brekle, Deputy Lead Nurse, Infection Prevention and Control


Additional authors
Deirdre Malone, Lead Nurse Infection Prevention and Prevention and Control

Document owner
Dr John Hartley, DIPC, Infection Control and Microbiology

Approved by
Guideline Approval Group

First introduced: 1 January 2002
Date approved:
17 January 2014
Review schedule:
Two years
Next review:
17 January 2016
Document version: 5.0
Replaces version:
4.0