Despite acknowledgement of the critically important role of hand hygiene in reducing the transmission of pathogenic microorganisms, overall compliance with hand hygiene is less than optimal in healthcare settings. This article addresses hand hygiene best practices, measuring compliance and considerations for improvement strategies. In this context, the term hand hygiene refers to handwashing, antiseptic handwashing, antiseptic hand rub or surgical hand antisepsis.1
Opportunities for Transmission
Although they are a healthcare professional’s most relied-upon tools, the hands are also among the most common conduits for infection. Hand hygiene is recognized as the single-most important practice to reduce the transmission of infectious agents in healthcare settings.2
Opportunities for the transfer of microorganisms fall into three primary categories.3-4
1. Animate transmission. The healthcare worker comes into contact with an infected patient, does not perform appropriate hand hygiene and transfers the pathogen through touching another patient.
2. Inanimate transmission. An object, such as a stethoscope, is contaminated through contact with an infected patient, is not properly disinfected and is then used on another patient.
3. Animate and inanimate interaction. The hands of an infected patient touch and contaminate an object, which is then touched by a healthcare worker who does not perform hand hygiene before touching another patient.
Protective garments provide another opportunity for transfer of microbes. One study found that 65 percent of healthcare workers’ gowns or uniforms were contaminated following routine morning care nursing activities. When caring for patients who have methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) patients, 69 percent of lab coats were contaminated. Additionally, 27 percent of these healthcare workers contaminated their hands after touching their coats.5-6
Hand Hygiene Best Practices
Primary sources of guidance on hand hygiene are those published by the Centers for Disease Control and Prevention (CDC)7and the World Health Organization (WHO).8
Although both reflect widely accepted best practices, a healthcare organization is best served by adopting one set of guidelines and doing so consistently. Hand hygiene best practices as recommended by the CDC’s Guideline for Hand Hygiene in Health-Care Setting follow.7
The guideline maintains that hand hygiene should be performed when hands are contaminated with proteinaceous material, or are visibly soiled with blood or other body fluids. In such cases, hands should be washed with a non-antimicrobial soap and water, or with an antimicrobial soap and water. In all other clinical situations, routine decontamination should be performed on hands that are not visibly soiled by using an alcohol-based handrub.
Hands should be decontaminated before:
• Direct patient contact
• Inserting urinary catheters, peripheral vascular catheters or other invasive devices not requiring surgery
• Eating
• Donning sterile gloves when inserting a central intravascular catheter
• Hands should be decontaminated after:
• Contact with a patient’s intact skin
• Contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings
• Contact with inanimate objects in a patient’s immediate vicinity
• Removing gloves
• Using the toilet
As well, personnel should decontaminate hands during patient care when moving from a contaminated body site to a clean body site. Gloving is not a substitute for hand hygiene; healthcare workers should be trained on, and frequently reminded of, this distinction.
The prevalence of healthcare-associated diarrhea caused by Clostridium difficile has raised significant concerns regarding the capability of antiseptic agents to combat spore-forming bacteria. Unfortunately, none of the agents used in antiseptic handwash or hand-rub preparations (alcohols, chlorohexidine and iodophors) is reliably sporicidal, and is thus ineffective against Clostridium or Bacillus species. Washing with soap (non-antimicrobial or antimicrobial) can physically remove spores from the surface of contaminated hands. Healthcare workers should be encouraged to wear gloves when caring for patients with C. difficile-associated diarrhea. As always, hands should be washed or disinfected after gloves are removed.
Other general recommendations:
• Artificial fingernails or extenders should not be worn while in direct contact with patients at high risk for infection.
• Gloves should be worn if there is a possibility of contact with blood or other potentially infectious materials, mucous membranes and other non-intact skin.
• Hand hygiene should always be performed following patient care and subsequent glove removal.