Why Hand Hygiene is Crucial
In healthcare, hand hygiene is not just a routine; it’s a cornerstone of safety for both healthcare professionals and patients. Effective hand hygiene encompasses cleaning your hands thoroughly using various methods:
- Washing with soap and water (plain or antiseptic).
- Using antiseptic hand rubs (alcohol-based sanitizers in foam or gel form).
- Performing surgical hand antisepsis for sterile procedures.
The primary goal of diligent hand cleaning is to significantly reduce:
- The transmission of potentially deadly pathogens to vulnerable patients.
- The spread of germs, including antibiotic-resistant organisms that pose a growing global threat.
- The risk of healthcare personnel becoming carriers or developing infections from patient contact.
It’s not uncommon for healthcare workers to need to sanitize their hands up to 100 times within a single shift to uphold safety standards for themselves, their patients, and colleagues. Maintaining healthy and clean skin on hands is a continuous challenge in such demanding environments.
The Foundation: CDC Recommendations for Hand Hygiene
The Centers for Disease Control and Prevention (CDC) provides comprehensive guidelines for hand hygiene practices in healthcare settings, ensuring a standardized and effective approach to infection prevention.
Key Recommendations for Hand Hygiene Timing
Adhering to specific moments for hand hygiene is paramount. The CDC recommends cleaning your hands:
- Immediately before touching a patient, setting the stage for safe interaction.
- Prior to performing aseptic tasks, such as inserting catheters or handling invasive devices, to maintain sterility.
- Before moving from a contaminated area of a patient’s body to a clean site on the same patient, preventing cross-contamination.
- After touching a patient or their immediate surroundings, as environmental surfaces can harbor pathogens.
- After any contact with blood, bodily fluids, or potentially contaminated surfaces, regardless of glove use.
- Immediately after removing gloves, as gloves can have micro-perforations and can contaminate hands during removal.
Alcohol-Based Hand Sanitizer (ABHS): When to Choose It
In most clinical scenarios, unless hands are visibly soiled, an alcohol-based hand sanitizer (ABHS) is the preferred method over soap and water. This preference is based on several advantages [1, 2]:
- Superior Germ-Killing Efficacy: ABHS is demonstrably more effective at eliminating germs on hands compared to soap and water.
- Ease of Use and Accessibility: ABHS is quicker and more convenient, especially in busy healthcare settings, facilitating rapid transitions between tasks, patient interactions, and movement within shared spaces.
- Skin Health Benefits: ABHS typically causes less skin irritation and dryness than frequent handwashing with soap and water, promoting better skin integrity among healthcare workers.
- Improved Hand Hygiene Compliance: The convenience and skin-friendly nature of ABHS contribute to higher rates of adherence to hand hygiene protocols among healthcare personnel.
Soap and Water: When It’s Essential
Despite the advantages of ABHS, soap and water remain crucial in specific situations:
- Visibly Soiled Hands: When hands are visibly dirty, greasy, or contaminated with organic material, soap and water are necessary for effective cleaning.
- Before Eating: Washing hands with soap and water before meals is a fundamental hygiene practice in all settings, including healthcare.
- After Restroom Use: Handwashing after using the restroom is essential to prevent the spread of fecal-oral pathogens.
- During Outbreaks of C. difficile and Norovirus: In cases of suspected or confirmed infections with Clostridium difficile (C. difficile) or norovirus, soap and water are recommended due to their enhanced ability to remove spores and viruses compared to ABHS.
Proper Technique for Hand Sanitizer Application
To maximize the effectiveness of alcohol-based hand sanitizer, follow these steps:
- Apply the Correct Amount: Dispense the manufacturer-recommended volume of sanitizer onto your hands. The efficacy of ABHS is directly related to the volume used.
- Cover All Surfaces and Rub Thoroughly: Rub your hands together vigorously, ensuring complete coverage of all surfaces, including the backs of hands, palms, between fingers, and under fingernails, until your hands feel dry. This process should take approximately 20 seconds.
- Focus on Often-Missed Areas: Pay particular attention to areas frequently missed during hand sanitization [3], such as:
- Thumbs
- Fingertips
- Areas between fingers
Proper Technique for Handwashing with Soap and Water
Effective handwashing requires a systematic approach:
- Wet Hands: Wet your hands thoroughly with water. Avoid using hot water, as it can contribute to skin dryness.
- Apply Soap: Apply the manufacturer-recommended amount of soap to your hands.
- Lather and Scrub: Rub your hands together vigorously for at least 15-20 seconds, ensuring all surfaces of your hands and fingers are scrubbed.
- Rinse Thoroughly: Rinse your hands well under running water to remove soap and loosened germs.
- Dry Hands Properly: Use disposable towels to dry your hands completely. Use a towel to turn off the faucet to avoid recontamination.
While some guidelines suggest 15 seconds and others 20 seconds for handwashing, the key is to focus on consistent hand cleaning at the right times and thorough scrubbing with soap and water.
Dispenser Management: Refilling and Safety
ABHS Dispenser Refilling: Safety Considerations
ABHS is regulated by the FDA as an over-the-counter product, and its storage and dispensing must adhere to safety standards. Refilling ABHS dispensers, especially pump bottles, pocket-sized containers, and wall-mounted units, is a practice that raises safety concerns due to limited research. Potential risks associated with refilling ABHS dispensers include:
- Contamination: Accidental introduction of contaminants during the refilling process.
- Reduced Effectiveness: Evaporation of alcohol can reduce the sanitizer’s efficacy.
- Irritation: Mixing different formulations can lead to irritant reactions.
Therefore, refilling or “topping off” ABHS dispensers should only be considered in strict accordance with manufacturer guidelines and FDA regulations.
Soap Dispenser Refilling: Avoid Topping Off
Unlike ABHS, refilling liquid soap dispensers by adding soap to partially empty containers is discouraged. This practice has been linked to outbreaks of pathogenic bacteria [2]. Soap dispensers should be properly emptied and cleaned before refilling to prevent bacterial contamination.
Gloves: An Adjunct, Not a Substitute for Hand Hygiene
Gloves are a critical component of infection control, but they are not a replacement for hand hygiene.
- Hand Hygiene Before Gloving: Always perform hand hygiene before putting on gloves when tasks require glove use.
- Hand Hygiene After Glove Removal: Hand hygiene is mandatory after removing gloves.
- Careful Glove Removal: Remove gloves carefully to avoid contaminating your hands with pathogens that may be present on the outer surface of the gloves.
When to Wear Gloves
Gloves should be worn in specific situations based on Standard and Transmission-Based Precautions:
- Standard Precautions: Wear gloves when anticipating contact with blood, infectious materials, mucous membranes, non-intact skin, potentially contaminated skin, or contaminated equipment.
- Transmission-Based Precautions: Adhere to glove use guidelines as part of Transmission-Based Precautions for specific infections.
Glove Changing and Hand Hygiene Practices
Appropriate glove changing and hand hygiene are essential during patient care:
- Damaged Gloves: Change gloves immediately if they become damaged (torn, punctured).
- Soiled Gloves: Replace gloves if they become soiled with blood or body fluids during a task.
- Transitioning Between Body Sites: When moving from working on a soiled area to a clean area on the same patient, change gloves and perform hand hygiene.
- Between Patients: Change gloves and perform hand hygiene when moving from one patient to another.
- Visibly Dirty Gloves: If gloves appear dirty or have blood or body fluids on them after completing a task [4], change them and perform hand hygiene.
- Exiting Patient Rooms: Remove gloves and perform hand hygiene before leaving a patient room.
Special Considerations: C. difficile and Hand Hygiene
Clostridium difficile (C. difficile) is a spore-forming bacterium causing severe diarrhea and is a common healthcare-associated infection. C. difficile spores are highly resilient and can survive on surfaces for extended periods. Transmission often occurs via the hands of healthcare providers who have touched contaminated surfaces.
- ABHS Preference (Unless Visibly Soiled): For routine hand hygiene in C. difficile care, ABHS remains the preferred method over soap and water unless hands are visibly soiled [1, 5]. This recommendation is consistent even when caring for patients with C. difficile infection (CDI).
- Limited Benefit of Soap and Water: While soap and water theoretically offer a slight advantage in removing C. difficile spores, studies haven’t demonstrated a clear clinical benefit over ABHS. Emphasizing soap and water might inadvertently reduce overall hand hygiene compliance.
- Glove Use Priority: When entering the room of a patient with C. difficile, prioritize consistent glove use (along with gowns) and meticulous glove removal technique to minimize self-contamination [6]. Evidence suggests that C. difficile spores may not be completely removed from hands by either hand hygiene method, highlighting the critical role of glove use.
Additional Precautions During C. difficile Outbreaks
As an added precaution during C. difficile outbreaks, the CDC recommends handwashing with soap and water after caring for patients with known or suspected C. difficile infections [1]. This is a supplementary measure due to the theoretical benefit of soap and water in spore removal, although supporting evidence is limited. Maintaining consistent glove use and proper glove removal remains paramount. Access to ABHS should not be restricted.
Surgical Hand Antisepsis: Ensuring a Sterile Field
In surgical settings, bacteria on surgeons’ hands can lead to surgical site infections. Surgical hand antisepsis is a critical procedure to minimize bacterial presence.
Before donning sterile gloves and performing surgery, perform surgical hand antisepsis using these steps:
- Remove Jewelry: Before starting, remove rings, watches, and bracelets.
- Clean Under Nails: Use a nail cleaner under running water to remove debris from under fingernails.
- Antimicrobial Soap Scrub: If using antimicrobial soap, scrub hands and forearms for the duration recommended by the manufacturer, typically 2-6 minutes. Longer scrub times (e.g., 10 minutes) are not necessary.
- ABHS with Persistent Activity: If using ABHS with persistent activity:
- Follow manufacturer’s instructions.
- Prewash hands and forearms with non-antimicrobial soap and dry thoroughly.
- Apply the ABHS product as directed and allow hands and forearms to air dry completely before donning sterile gloves.
Additional recommended practices in surgical settings include:
- Antimicrobial Soap Importance: Using antimicrobial soap is crucial as bacterial growth is more rapid under surgical gloves when hands are washed with non-antimicrobial soap.
- Double Gloving: Consider double gloving during invasive procedures with a higher risk of blood exposure.
- Reducing Skin Flora: Reducing resident skin flora on the surgical team’s hands throughout a procedure minimizes the risk of bacterial release into the surgical field from glove punctures or tears.
Skin Care and Hand Health
Maintaining healthy skin is essential for consistent hand hygiene compliance.
- ABHS Benefits for Skin: ABHS is generally less irritating and drying to the skin compared to soap and water, making it preferable for routine use.
- Lotions and Creams: Regular use of hand lotions and creams can prevent and alleviate skin dryness caused by frequent hand cleaning. Use facility-approved lotions that do not interfere with hand sanitizers.
- Gentle Handwashing Techniques: When washing with soap and water, use techniques to protect skin health:
- Avoid hot water.
- Pat hands dry gently instead of rubbing vigorously.
- Managing Hand Irritation: Healthcare personnel with hand irritation should use cotton glove liners and follow facility guidelines for laundering or discarding liners.
Nail Hygiene and Jewelry
Nail and jewelry hygiene are important aspects of hand hygiene.
- Natural Nail Length: Natural nails should be kept short, not extending past the fingertip.
- Artificial Nails: Avoid wearing artificial fingernails or extensions, especially when in direct contact with high-risk patients in areas like intensive care units or operating rooms. Artificial nails can harbor germs even after hand hygiene.
- Rings: Studies suggest that skin under rings can harbor more germs than fingers without rings. While further research is needed, minimizing jewelry in healthcare settings is a prudent approach.
Administrative Measures to Support Hand Hygiene
Healthcare facility administrations play a vital role in promoting hand hygiene:
- Require Adherence: Mandate hand hygiene practices based on CDC recommendations.
- Ensure Soap and Water Availability: Ensure soap and water are readily available for situations requiring their use, such as visibly soiled hands.
- Provide Accessible Supplies: Make hand hygiene supplies (ABHS, soap, towels) easily accessible wherever patient care is delivered.
Special Issues: Fire Safety and ABHS – The 6-Inch Rule
Fire Safety with Alcohol-Based Hand Sanitizer
ABHS contains ethyl alcohol, a flammable liquid that evaporates into ignitable vapor at room temperature. While ABHS-related fires are rare, safe storage and proper dispenser installation and maintenance are critical.
Adhering to Fire Safety Regulations
Building officials and fire marshals enforce fire safety regulations to protect patients and residents. Fire safety measures aim to:
- Minimize ignition sources.
- Ensure safe storage of flammable liquids.
- Establish clear emergency exits.
These officials also ensure ABHS dispensers are placed in locations that do not increase fire risks.
Life Safety Code Compliance and the 6-Inch Distance
Compliance with the National Fire Protection Association (NFPA) Life Safety Code 101 is mandatory for healthcare facilities receiving Medicaid or Medicare reimbursement. This code sets minimum fire safety standards, including guidelines for ABHS storage and dispenser placement.
Crucially, the Life Safety Code specifies a minimum distance of one inch between ABHS dispensers and ignition sources. However, a more conservative and highly recommended approach is to maintain a distance of no less than 6 inches (152 millimeters) horizontally or vertically from the center of the dispenser to any ignition source. Ignition sources include electrical outlets, thermostats, and appliances. This 6-inch buffer, when compared to the hand reaching for sanitizer, ensures a safer margin and minimizes the risk of accidental ignition.
Collaborating with Local Fire Officials
Healthcare facilities should proactively engage with local fire officials to ensure compliance with all ABHS installation requirements. Fire official tours can:
- Verify code compliance.
- Refresh facility staff’s understanding of fire safety infrastructure.
- Identify potential vulnerabilities.
Benefits of these tours include:
- Building positive relationships with fire safety authorities.
- Demonstrating a strong commitment to safety.
Table 1. NFPA 101 Life Safety Code Requirements for ABHS Dispensers
| Criteria | Requirement
