Hand Hygiene

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By Persis Mary Hamilton, RN, CNS, MS, EdD

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.

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 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 and washing 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 and the HICPAC/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-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.

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 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.

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 nail polish often harbor high concentrations of bacteria, most frequently coagulase-negative Staphylococci, gram-negative rods (including Pseudomonas spp.), Corynebacteria, and yeasts. Whether artificial nails contribute to transmission of pathogens is unknown.

Recently, 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. Personnel wearing artificial nails also have been epidemiologically implicated in several other outbreaks of infection caused by gram-negative bacilli and yeast. Although these studies provide evidence that wearing artificial nails poses an infection hazard, additional studies are needed to confirm the concern.

While the 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, 2009). Many hospitals and hospital systems have adopted policies in line with WHO recommendations.

Several studies have demonstrated that skin underneath rings is 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. Other studies showed that bacterial colony counts on hands after handwashing was similar for persons who wore rings and those who did not. Clearly, 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, the 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” (WHO, 2009). 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 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 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, 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

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 and can 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.

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.

EFFICACY OF HAND HYGIENE ANTISEPTIC AGENTS*

Gram- positive bacteria	Gram- negative bacteria	Myco- bacteria	Fungi	Viruses	Speed of action	Comments
Source: CDC, 2002.
ALCOHOLS
E	E	E	E	E	Fast	Optimum concentration 60%–95%; no persistent activity
CHLORHEXIDINE (2% and 4% aqueous)
E	G	F	F	E	Intermediate	Persistent activity; rare allergic reactions
IODINE COMPOUNDS
E	E	E	G	E	Intermediate	Causes skin burns; usually too irritating for hand hygiene
IODOPHORS
E	E	F	G	G	Intermediate	Less irritating than iodine; acceptance varies
PHENOL DERIVATIVES
E	F	F	F	F	Intermediate	Activity neutralized by nonionic surfactants
TRICLOSAN
E	G	F	N	E	Intermediate	Acceptability on hands varies
QUATERNARY AMMONIUM COMPOUNDS
F	G	N	N	F	Slow	Used only in combination with alcohols; ecologic concerns
KEY: E = excellent G = good, but does not include the entire bacterial spectrum F = fair N = no activity or not sufficient
* Hexachlorophene is not included because it is no longer an accepted ingredient of hand disinfection.

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 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

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.
• 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, however vinyl gloves have been found to have more defects after prolonged use than latex gloves. 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.

Although the 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.

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 (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 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.

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

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
• 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.