Hand Hygiene and Hand Washing

>>How to perform a hygienic hand wash | >>Surgical hand preparation

SUMMARY

Hand hygiene reduces bacteria on the hands as well as those objects that hands come into contact with; Resident bacterial flora on hands help protect skin; Transient bacteria are acquired via contamination and easier to remove from hands; Hand hygiene antisepsis increases by levels; There are six steps to a staged hand wash protocol; Alcoholic hand rubs should not be an alternative to hand wash; Use of gloves do not provide complete protection against contamination; Ensure senior staff offer a good role model in hand hygiene methods; Ensure all staff have suitable instruction, education, and constant reinforcement to hand hygiene


Hand hygiene, whilst generally acknowledged by health workers, including those in the veterinary field, as a vital part in the prevention of transmission of bacteria and other pathogens, nevertheless remains an area of poor performance in real life. It is almost impossible to find any health professional who will admit ignorance of good hand hygiene procedure, but research continues to show that health staff consistently fail to wash their hands frequently enough or in the correct way. Not only does this failure increase the risk of transmission of disease, it also has a profoundly negative effect on the confidence of the public when they see poor hand hygiene among health staff.

The term ‘hand hygiene’ not only refers to the process of keeping the hands clean; it includes the attitudes that arise from a deep understanding of the importance of preventing the transmission of bacteria. On a practical level, hand hygiene is aimed at reducing the bacterial contamination of the hands and, by extension, that of the objects into which they come in contact. This includes hand washing with soap or cleanser and the use of antimicrobials.

The micro-organisms that can be found on the skin fall into two main groups: ‘Resident’ (or ‘Colonising’) flora and ‘Transient’ (or ‘Contaminating’) flora. Resident flora normally occurs on a particular individual and helps to protect the skin from contamination or invasion by other pathogens. They are difficult to remove completely and are, essentially, the body’s first line of defence. They mostly consist of staphylococci and micrococci, and are generally harmless to the body unless they are introduced to the tissues below the surface through surgery or other invasive procedures.

Transient flora presents the greater danger to patients. They are generally acquired through contact with a contaminated area either on the individual, other people or animals, or the environment. They are relatively easy to remove from the skin through hand washing.

Hand hygiene can be achieved in three ways: through a plain hand wash, an antiseptic hand wash or a surgical scrub; each achieves a different level of freedom from bacteria.

Plain hand washing is a process that uses water and soap to remove debris from the surface of the skin along with some of the naturally produced oil that keeps the skin supple and which also traps microorganisms. The soap effectively breaks up this layer of oil which is then removed, along with debris and bacteria, by the rinse, but does not, in itself, aim to kill bacteria.

An antiseptic hand wash is the same but with the inclusion of an antiseptic solution that may be included in the soap itself or added as a separate element. This method will actively kill both resident and transient microorganisms and, if the antiseptic is residual, will tend to slow the rate at which bacteria re-colonises the skin.

The surgical scrub procedure is used when a very high level of antisepsis is required, such as for surgical procedures. It takes much longer than the other types of hand wash and involves a more thorough process in order to remove all possible microorganisms from the skin.

The antiseptic solutions most commonly used in veterinary practice for hand hygiene are chlorhexidine, triclosan and iodophors. The characteristics of the three most commonly used antiseptic solutions in the UK are summarised below.

Clorhexidine Iodophors Triclosan
Intermediate range of microbial activity Wide range of microbial activity Intermediate rance of microbial activity
Persistent chemical activity (up to 6 hours) Persistent chemical activity Persisten chemical activity
Minimally affected by organic matter Neutralised in presence of organic material Minimally affected by organic matter
Less irritating than iodophors Most frequently used for surgical scrubbing Commonly used in commercial hygiene products

How to perform a hygienic hand wash

To be effective all surfaces of the hand and wrist should be washed and if an antiseptic hand wash is being performed the product should be in contact with the skin according to the manufacturer's instructions. For example the manufacturers of Hibiscrub TM1 recommend a contact time of 1 minute for a hygienic hand wash. The most effective way to ensure all parts of the hand are cleaned is to follow a staged hand wash protocol. This involves 6 basic steps:

1. Palm to palm

2. Right palm over left dorsum and left palm over right dorsum
3. Palm to palm fingers interlaced

4. Backs of fingers to opposing palms with fingers interlocked
5. Rotational rubbing of right thumb & hand in left palm and vice versa

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

If the proper process is not followed, hand washing will be inadequate and areas of the hands will not be cleaned properly. The results of a hand washing protocol can be tested using hand creams that fluoresce under UV light if not properly washed off. These products are useful training aids.

Effective hygienic hand wash can be achieved by:

  • Washing the hands under warm freely flowing water
  • Thoroughly rinsing the hands to remove soap and dried with disposable paper wipes
  • Applying antiseptic solution after the rinse while the hands are still wet
  • Turning off the taps using arms or the paper towel adopting a No-Touch-Touchtechnique
  • Disposing of the towel in a foot-operated bin.

Alcoholic hand rubs are an alternative to hygienic hand washing provided the hands are not dirty i.e. hands that do not have visible dirt, blood or body fluids on them. These products usually contain a combination of alcohol (typically 60-95% ethanol or isopropanol), an antiseptic agent such as chlorhexidine, and an emollient and can be found either as a liquid or gel and can be delivered from wall dispensers or pocket bottles. The solution is rubbed into all parts of the hands (using the 6 step protocol) for 15-20 seconds and the hands allowed to air dry.

The advantages of alcohol based hand rubs are that:

  • They require less time than hand washing
  • They act more quickly
  • A sink isn't required
  • Hands don't need to be dried
  • They cause less skin irritation, although alcohol rubs without an emollient will tend to cause drying and sometimes breaking of the skin.

All of these factors have been demonstrated to improve hand hygiene compliance in human medicine.

Whatever technique is chosen for hand hygiene other important measures include:

  • Keeping finger nails short and clean
  • Covering cuts and abrasions with waterproof dressings
  • Avoiding nail polish, nail extensions/artificial nails
  • Avoiding jewellery (although a plain wedding ring is acceptable)
  • Keeping sleeves short
  • Using fob watches in place of wristwatches.

As well as acting as barrier protection, gloves can also reduce the bacterial contamination of hands; however gloves do not provide complete protection against contamination as this may occur via small defects in the glove or by contamination of the hands during glove application and removal. When used, gloves should be removed after each patient contact. Hands should always be washed after removing gloves, and glove use should not reduce the frequency of hand washing.

Surgical hand preparation

The surgical scrub aims to remove dirt, oils and bacteria from the hands and forearms of operating personnel. It should kill transient bacteria and have a prolonged depressant effect on the resident bacteria and should not irritate skin or be time consuming. Brushes and nail cleaners are commonly used with one of the antiseptics mentioned earlier. Brushes should be soft enough to not damage skin, but still achieve the expected result, and it should be remembered that excessive use of the surgical scrub process may result in skin damage and dermatitis. It is important that specific attention is paid to the fingernails as this area has the highest bacterial load. There are a variety of methods of scrubbing.

Two scrub procedures commonly used are a timed anatomic scrub, where all surfaces of the hand and arm are scrubbed for a specified length of time, and the counted strokes method where each part of the hand and arm receives a specific number of scrub strokes. For all techniques it is important that hands are held above elbows so that water flows away from the hands, and that the scrub solution is left on the skin for a suitable length of time (this will be dependent on the manufacturers’ recommendations). Provided a product with residual activity is being used subsequent scrubs may be shorter. Prolonged scrubbing in excess of the manufacturers’ recommendation has been shown to be no more effective, and can also lead to irritation of the skin and increase the risk of infection. Whatever technique is used, the hands are clean rather than sterile, so sterile surgical gloves and a sterile long sleeved surgical gown should be worn.

An alternative method that has been reported more recently in the literature is the use of alcoholic hand rubs for pre surgical preparation. The basis for their use is increased compliance; repeated surgical scrubbing can result in discomfort and allergies that reduce the duration and intensity of the surgical scrub so reducing its efficacy. Studies have shown that they are effective and that the addition of alcohol reduces the bacterial skin load.

As yet, the adoption of waterless pre-surgical skin preparations is not wide spread in veterinary medicine.

Hand hygiene should occur:

  • Before and after touching catheters, drains, wounds etc
  • After removing gloves
  • When hands are visibly soiled
  • On arrival to and before leaving work
  • Before and after eating/smoking
  • After using the toilet/wiping nose
  • After any clean up

A hand wash with soap and water is suitable for most basic care activities. However, before touching wounds or performing invasive procedures, and after dealing with infected/contaminated patients/tissues, an antiseptic hand wash or alcoholic hand rub should be performed.

Despite the fact that it is readily acknowledged that hand washing is the single most important means of preventing hospital acquired infections, there are major problems regarding compliance and many human hospital care workers fail to perform hand hygiene at appropriate times. The reasons for this have been the subject of much research and many reasons for poor compliance have been identified. These include:

  • Being too busy and not thinking about it
  • Skin irritation
  • Washing facilities not being readily available
  • Wearing gloves
  • Lack of guidance/protocols
  • Absence of an appropriate role-model from colleagues/superiors
  • Scepticism about the effectiveness of hand hygiene

Studies of poor compliance in human hospitals reveal that behaviours/working practices associated with poor hand hygiene include:

  • Being a physician or nursing assistant rather than a nurse
  • Being male
  • Working in critical care
  • Wearing gloves/gowns
  • Undertaking activities with a high risk of cross transmission
  • When the intensity of patient care is high

Methods to improve hand hygiene compliance include: education; instruction and constant reinforcement within the work place; modelling of good behaviour by senior staff; ensuring the staff patient ratio is favourable; introducing conveniently placed alcoholic hand rubs in order to remove the need to wash hands after every patient contact; and, allowing opportunities for hand hygiene remote from washing facilities. Good hand hygiene is fundamental to effective prevention of cross-infection and should be adopted by all those working in clinical veterinary medicine. It is easy to perform and good compliance will result in a reduction in hospital acquired and zoonotic infections. This will bring benefits to patients and clients as well as veterinary surgeons and their staff. Veterinary surgeons and nurses should be instrumental in educating staff, students and owners about the importance of hand hygiene.


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