Hand Hygiene and Infection Control

Skill 28.1: Hand Hygiene Fundamentals

• Delegation and Collaboration: Hand hygiene is a non-optional skill performed by all caregivers. Health care team members serve as role models and should provide reminders if the technique is missed or incomplete.

• Necessary Equipment:

  • Antiseptic hand rub (alcohol-based waterless antiseptic containing emollients).

  • Sink with warm running water.

  • Antimicrobial or regular soap.

  • Paper towels.

  • Optional disposable nail cleaner.

Assessment and Preparation for Hand Hygiene

• Skin Integrity: Inspect the surface of the hands for breaks, cuts, or lesions in the skin or cuticles. Any skin lesions must be covered with a dressing before providing care. Large lesions may lead to restrictions from direct patient care because open wounds can harbor high concentrations of microorganisms.

• Visible Soil: Inspect for visible dirt or organic material, which necessitates handwashing with soap and water.

• Nail Condition: Natural nail tips should be no longer than $0.625\,cm$ ($1/4\,inch$). Fingernails must be kept short, filed, and smooth. Subungual areas (under the nails) harbor high bacterial concentrations; long nails or chipped polish increase these levels.

• Artificial Nails: The CDC recommends that artificial fingernails and extenders should not be worn by personnel in contact with high-risk patients, as they increase the microbial load on the hands.

• Jewelry and Clothing: Wristwatches and long uniform sleeves should be pushed above the wrists. Rings should be avoided or removed, as the skin underneath carries higher bacterial counts, including gram-negative bacilli, enterobacteria, and Staphylococcus aureus.

Procedural Implementation for Hand Hygiene

• Antiseptic Hand Rub (Preferred Method for Non-Soiled Hands):

  • Dispense an ample amount of product into the palm of one dry hand.

  • Rub hands together to cover all surfaces, including fingers.

  • Continue rubbing until the alcohol is completely dry. Hands must be dry before applying gloves.

• Handwashing with Soap and Water:

  • Stand in front of the sink without touching the sink surface with hands or uniform. If contact occurs, the sequence must be repeated.

  • Turn on water using hand faucets, knee pedals, or foot pedals. Faucet handles are considered contaminated with organic debris and microorganisms.

  • Regulate water to a warm temperature. Warm water removes fewer protective oils than hot water.

  • Thoroughly wet hands and wrists, keeping hands and forearms lower than the elbows so water flows from the least to most contaminated area.

  • Apply manufacturer-recommended soap amount and rub hands together. Soap emulsifies fat and oil while friction mechanically removes transient bacteria.

  • Perform hygiene for at least $20\,seconds$. This duration is required when hands are visibly soiled, before eating, and after using the restroom.

  • Interlace fingers and rub palms and backs of hands with a circular motion at least $5$ times each.

  • Clean under fingernails using the fingernails of the other hand or a disposable nail cleaner.

  • Rinse hands and wrists thoroughly while maintaining the hands-down, elbows-up position.

  • Dry thoroughly from fingers (cleanest) to wrists (least clean) using a paper towel to avoid chapping.

  • Turn off hand faucets using a clean, dry paper towel to prevent the transfer of pathogens from the faucet by capillary action.

Clinical Judgment and Evaluation of Hand Hygiene

• Product Selection: The choice between antiseptic soap and alcohol-based rub is determined by the presence of visible soil, the specific infectious microorganism (e.g., C-diff or norovirus), the procedure being performed, and the patient's immune status.

• Evaluation Measures:

  • Inspect hands for remaining dirt or contaminants; if soil remains, repeat the soap and water wash.

  • Routinely inspect for dermatitis or cracked skin, which increases the risk for microorganism transmission.

• Unexpected Outcomes Interventions:

  • If repeated soap use causes dermatitis, rinse and dry hands thoroughly, avoid excessive amounts of product, and use agency-approved hand lotions or barrier creams that do not interfere with sanitizing products.

• Reporting: While the procedure does not require documentation, nurses must report dermatitis, psoriasis, or cuts to the agency's employee health or infection control department.

Home Care and Surgical Hand Antisepsis

• Home Care Factors: Evaluate the availability of warm running water, soap, and proximity of facilities to the patient. Anticipate the need for alternative products like alcohol-based rubs or detergent-containing towels. Use teach-back to confirm learning for patients and caregivers.

• Surgical Planning: Use surgical shoe covers, caps/hoods, face masks, and protective eyewear. Specialized eyewear is required for laser surgery.

• Prescrub Wash: Perform a $15\,second$ wash/rinse at the beginning of the shift to remove gross debris.

• Surgical Hand Scrub (Sponge Method):

  • Clean under nails with a disposable pick.

  • Scrub each finger, hand, and arm, visualizing each as having $4$ sides. Keep hands elevated above elbows during the scrub and rinse to prevent microorganisms from flowing back onto the hands.

  • Fingernails have higher bacterial loads than fingertips.

  • Do not use a brush, as it may damage the skin and increase bacteria.

• Spongeless Surgical Scrub: Use approved brushless, alcohol-based products with added emollients. Apply to hands and forearms for the specified time and rub until completely dry before donning gloves.

• Post-Surgical Evaluation: Monitor the patient for surgical site infection (SSI), which typically manifests $2$ to $3$ days after surgery with symptoms like redness, heat, swelling, pain, or purulent drainage.

Impact and Rationale for Hand Hygiene

• Infectious Statistics: Approximately $1.7$ million Hospital Acquired Infections (HAIs) occur annually in U.S. hospitals, leading to $99,000$ deaths and $20$ billion in healthcare costs.

• Core Purpose: Hand hygiene is the most important technique for preventing and controlling the transmission of infection, a claim supported by evidence-based practice.

• High-Contamination Areas: Pathogens are prevalent on bedside equipment, including bed siderails, IV poles, wheelchairs, bedside tables, urinals, and bedpans.

• Specific Microorganisms:

  • Alcohol-based sanitizers must be at least $60\%$ alcohol but are ineffective against certain germs.

  • Handwashing with soap and water is mandatory for contamination with proteinaceous material, blood, body fluids, and specifically when dealing with Clostridium difficile (C-Diff) or Norovirus.

• Hygiene Situations: Soap and water must be used before/during/after food preparation, before eating, before/after caring for someone with vomiting/diarrhea, before/after treating wounds, after using the toilet, after changing diapers, after touching animals/waste, and after touching garbage.