Hand Hygiene

Hand Hygiene

Proper hand hygiene is the single most important and least expensive means of
reducing the prevalence of HAIs and the spread of antimicrobial resistance.
 Normal flora of hand
There are two types of microbes colonizing hands:
Resident flora-consists of micro organism residing under the superficial cells of the
stratum corneum

Transient flora-colonizes the superficial layers of the skin and is more amenable
to removal by routine hand hygiene

Transient microbes survive but do not usually multiply on the skin. They are often
acquired by HCWs during direct contact with patients or their nearby contaminated
environmental surfaces

Transient microbes are the organisms most frequently associated with HAIs
 Transmission of pathogens through hand
• The hand of HCWs are commonly colonized with pathogens like MRSA
VRE,MDR gram negative bacteria (GNB), Candida spp. and C.difficile
which can survive for as long as 150 hours
• Colonization of HCWs hand with S.aureus may range between 10.5 to
78.3%, whereas those for GNB have been described to range from 21 to
86.1%
• Approximately 106 skin squames containing viable micro organisms are
shed daily from the normal skin. These can contaminate the gowns, bed
linen, bedside furniture and other objects in the patients immediate
environment
• The hands may become contaminated by merely touching the patients
intact skin or inanimate objects in patient’s room or during performance
of apparently ‘clean’ procedures like recording blood pressure
 Terms related to hand hygiene
Hand hygiene-a general term that applies to either handwashing,antiseptic
hand wash, antiseptic hand rub or surgical hand antisepsis
Handwashing/social handwashing- Washing hands with plain soap and
water (removes dirt,soil,and various organic substances)
Antimicrobial soap-Soap (i.e., detergent) containing an antiseptic agent
Antiseptic agent- Antimicrobial substances that are applied to the skin to
reduce the number of microbial flora like alcohols,chlorhexidine,iodine etc.
Waterless antiseptic agent- An antiseptic agent that does not require use
of exogenous water. After applying such agent, the hands are rubbed
together until the agent has dried
Alcohol based hand rub- An alcohol containing preparation designed for
application to the hands for reducing the number of viable organisms on
the hands
 Terms related to hand hygiene
Antiseptic hand wash-Washing hands with water and soap or other detergents
containing an antiseptic agent

Antiseptic hand rub- Applying an antiseptic hand rub product to all surface of
the hands to reduce the number of microorganisms present

Surgical hand antisepsis- Antiseptic hand wash or antiseptic hand rub

performed preoperatively by surgical personnel to eliminate flora and reduce
resident hand flora. Antiseptic detergents preparations often have persistent
antimicrobial activity

Surgical hand wash/surgical hand scrub- The cleaning of hands with

anti-microbial soap and water preoperatively by surgical team
 Indications for hand hygiene during patient care
Wash hands with soap and water when:
• Visibly dirty or contaminated with proteinaceous materials, blood or
other body fluids
• After using a rest room, wash hands with a non antimicrobial soap and
water or with an antimicrobial soap and water
• Before and after having food

Use an alcohol based hand rub routinely for decontaminating hands

when hands are not visibly soiled
• Before having direct contact with patients
• Before donning sterile gloves when inserting central IV catheter
 Indications for hand hygiene during patient care
Use an alcohol based hand rub routinely for decontaminating hands
when hands are not visibly soiled
• Before inserting indwelling urinary catheter, peripheral vascular
catheter or other invasive devices that do not require surgical procedure
• After contact with a patient’s intact skin (e.g., when taking pulse or blood
pressure or lifting a patient
• After contact with inanimate objects (including medical equipments)
in the immediate vicinity of the patients
• After removing gloves
• If moving from a contaminated body site to a clean body site during
patient care
 Five moments for Hand Hygiene
• Before touching a patient

• Before clean / aseptic procedures

• After body fluid exposure / risk

• After touching a patient

• After touching patient surrounding

Avoid unnecessary touching of surfaces in close proximity to the patient

Source: WHO Guidelines on Hand Hygiene in Health

Care
 Steps of
Method ofHand
Handhygiene
Washing
• Remove the jewellery and rinse hands under running water
• Lather with soap an using friction, cover all surfaces of hands and
fingers
• Wash thoroughly under running water
• Turn off tap with wrist / elbow or use towel to turn off the tap /faucet
• Dry hands thoroughly using a method that does not re-contaminate
hands. Make sure towels are not used multiple times or by multiple
people
• If using antiseptic rub take an adequate amount and rub on all
surfaces for the recommended time. Let the antiseptic dry on its own
 Steps of Hand
Hand hygiene technique hygiene
with alcohol based foundation

Duration of the entire procedure: 20-30 seconds

1a/1b-Apply a palmful of the product in a cupped hand,
covering all surfaces

2-Rub hands palm to palm

3-Right palm over left dorsum with interlaced fingers
and vice versa
4-Palm to palm with fingers interlaced
5-Backs of fingers to opposing palms with fingers
interlocked
6-Rotational rubbing of left thumb clasped in right palm
and vice versa
7-Rotational rubbing, backwards and forwards with
clasped fingers of right hand in left palm and vice versa
8-Once dry, your hands are safe
Hand hygiene technique with soap and water
Duration of the entire procedure: 40-60 seconds
0-Wet hands with water
1-Apply enough soap to cover all the surfaces
2-Rub hands palm to palm
3-Right palm over left dorsum with interlaced fingers
and vice versa
4-Palm to palm with fingers interlaced
5-Backs of fingers to opposing palms with fingers
interlocked
6-Rotational rubbing of left thumb clasped in right palm
and vice versa
7-Rotational rubbing, backwards and forwards with
clasped fingers of right hand in left palm and vice versa
8-Rinse hands with water
9-Dry hands thoroughly with a single use towel
10-Use towel to turn off faucet
11-Your hands are now safe
 Surgical Hand Preparation
Steps before starting surgical hand preparation
• Keep nails short and pay attention to them when washing your hands –
most microbes on hands come from beneath the fingernails
• Do not wear artificial nails or nail polish
• Remove all jewellery (rings, watches, bracelets) before entering the
operating theatre.
• Wash hands and arms with a non-medicated soap before entering the
operating theatre area or if hands are visibly soiled.
• Clean subungual areas with a nail file. Nailbrushes should not be used
as they may damage the skin and encourage shedding of cells. If used,
nailbrushes must be sterile, once only (single use). Reusable
autoclavable nail brushes are on the market.
 Surgical Hand antisepsis steps
Steps of Surgical Hand Wash
• Step 1 & 2
Remove all jewelry
Wet your hands and forearms thoroughly

• Step 3
Clean under each fingernail with a stick
or sterile brush

• Step 4
Hold your hands up above elbow level
and apply antiseptic in a circular
motion fingertip to elbow.

Repeat for second hand

 Surgical
Steps Hand antisepsis
of Surgical steps
Hand Wash
• Step 5
Hold your hands above elbow and rinse
the finger tips first and each arm
separately
• Step 6
Use sterile towel, dry your arms--from
fingertips to elbow.
Use different side of the towel on each
arm
• Step 7
Keep hands above the wrist level.
Do not touch anything.
Put on sterile gloves.

Duration of entire process is 3-5 minutes

 Reasons for poor hand hygiene compliance
In most healthcare institutions, adherence to recommended hand
washing practices remain unacceptably low ,rarely exceeding 50%.
Some of the reasons of poor hand hygiene compliance are following:
- Wearing gowns/gloves (belief that glove use obviates the need for
hand hygiene)
- Lack of role model among colleagues or superiors
- Understaffing, patient overcrowding and insufficient time
- Handwashing agents causing irritation and dryness
- Sore hands/abrasions of hand
 Reasons for poor hand hygiene compliance
Some of the reason of poor hand hygiene compliance are following:
- Inconvenient location/shortage of sinks
- Lack of soap and paper towel
- Belief of low risk of acquiring infection from patients
- Lack of knowledge of guidelines/protocol
- Lack of active participation in hand hygiene promotion at
individual or institutional level
- Lack of institutional safety climate
- Skepticism regarding the value of hand hygiene
 Selection of hand hygiene product
• Selection of hand hygiene product is a key component of hand hygiene
promotion
• The major determinant for product selection are antimicrobial profile,
user acceptance and cost
• One of the key element in improving hand hygiene practice is the use
of an alcohol based hand rub instead of washing with water and soap
• An alcohol based hand rub requires less time, is microbiologically
more effective and less irritating to the skin
• In ICU switching to hand rub would decrease the time necessary for
hand hygiene from 1.3 hour to 0.3 hour.
• The physical, chemical and microbiological characteristics of water to
be used for handwashing in healthcare institution must meet local
regulation
 Monitoring of hand hygiene compliance
Monitoring hand hygiene by direct methods- As per WHO recommendation
detection of hand hygiene compliance by a validated observer (direct observation) is
currently considered the gold standard in hand hygiene compliance monitoring

Indirect monitoring of hand hygiene performance-In this method consumption of

hand hygiene products such as paper towels, alcohol-based hand rub or liquid soap are
calculated to estimate the number of hand hygiene actions performed.

Methods based on product consumption cannot determine if hand hygiene actions are
Performed at the right moment during care or if the technique is correct. The advantages,
however, are that they are simple, can be continuous, and provide a global picture that
remains unaffected by selection or observer bias

The amount of alcohol-based hand rub used by health-care settings has been selected
as one of the indicators.

Reference: WHO Guidelines on Hand Hygiene in Health Care