Happy Hands - the Picture Says it All
An Illustrative Practice Guideline on Hand Hygiene
WHY Hand Hygiene is Important:
- Health care-associated infections (HCAI), also known as nosocomial infections are a major problem for patient safety and their surveillance and prevention must be a first priority for settings and institutions committed to making health care safer.
- The impact of HCAI implies prolonged hospital stay, long-term disability, increased resistance of microorganisms to antimicrobials, massive additional financial burden, high costs for patients and their families, and excess deaths.
- Microorganisms like viruses, fungi, parasites and, more frequently- bacteria are responsible for HCAI and hands are the main pathways of the transmission of these microorganisms during health care.
- Transmission of health care-associated pathogens from one patient to another via health care workers' (HCWs) hands occurs in five sequential steps:
- Organism present on the patient skin, or on inanimate objects in immediate environment
- Organism transferred to the hands of HCWs
- Organism capable of surviving for at least several minutes on HCWs' hands
- Defective / incorrect / inadequate / entirely omitted hand cleansing or inappropriate agent used for hand hygiene, result in hands remaining contaminated
- Failure to cleanse hands (contaminated hands) results in between-patient cross transmission
- Good hand hygiene, the simple task of cleaning hands at the right time and in the right way, is therefore the most important measure to avoid the transmission of harmful microorganisms and to prevent health care-associated infections (nosocomial infections).
WHO Should Practise Hand Hygiene:
Any health-care worker, care giver or person involved in direct or indirect patient care needs to be concerned about hand hygiene and should be able to perform it correctly and at the right time.
Patient zone: Defined as the patient's intact skin and his/her immediate surroundings colonized by the patient flora.
Healthcare area: Defined as containing all other surfaces.
Symbols for critical sites with infectious risk for the patient and critical sites with body fluid exposure risk, two critical sites for hand hygiene within the patient zone.
1. Before Touching a Patient
To protect the patient against colonization and, in some cases, against exogenous infection, by harmful germs carried on your hands
Clean your hands before touching a patient when approaching him/her*
Situation when Moment 1 applies:
- Before shaking hands, before stroking a child's forehead
- Before assisting a patient in personal care activities: to move, to take a bath, to eat, to get dressed, etc.
- Before delivering care and other non-invasive treatment: applying oxygen mask, giving a massage
- Before performing a physical non-invasive examination: taking pulse, blood pressure, chest auscultation, recording ECG
2. Before Clean/Aseptic Procedure
To protect the patient against interaction with harmful germs, including his/her own germs, entering his/her body
Clean your hands immediately before accessing a critical site with infectious risk for the patient (e.g. a mucous membrane, non-intact skin, an invasive medical device*
Situation when Moment 2 applies:
- Before brushing the patient teeth, instilling eye drops, performing a digital vaginal or rectal examination, examining mouth, nose, ear with or without an instrument, inserting a suppository/ pessary, suctioning mucous
- Before dressing a wound with or without instrument, applying ointment on vesicle, making a percutanous injection / puncture
- Before inserting an invasive medical device (nasal cannula, nasogastric tube, endotracheal tube, urinary probe, percurianecus catheter, drainage), disrupting / opening any circuit of an invasive medical device (for food, medication, draining, suctioning, monitoring purposes)
- Before preparing food, medications, pharmaceutical products, sterile material
3. After Body Fluid Exposure Risk
To protect you from colonization or infection with patient's harmful germs and to protect the healthcare environment from germ spread
Clean your hands as soon as the task involving an exposure risk to body fluids has ended (and after glove removal)*
Situation when Moment 3 applies:
- When the contact with a mucous membrane and with non-intact skin ends
- After a percutaneous injection or puncture; after inserting an invasive medical device (vascular access, catheter, tube, drain, etc); after disrupting and opening an invasive circuit
- After removing an invasive medical device
- After removing any form of material offering protection (napkin, dressing, gauzes, sanitary towel, etc.)
- After handing a sample containing organic matter, after clearing excreta and any other body fluid, after cleaning any contaminated surface and soiled material (soiled, bed linen, dentures, instruments, urinal, bedpan, lavatories, etc.)
4. After Touching a Patient
To protect you from colonization with patient germs and to protect the healthcare environment from germ spread
Clean your hands when leaving the patient's side, after having touched the patient*
Situation when Moment 4 applies, if they correspond to the last contact with the patient before leaving him/her:
- After shaking hands, stroking a child's forehead
- After you have assisted the patient in personal care activities: to move, to bathe, to eat, to dress, etc.
- After delivering care and other non-invasive treatment:
changing bed linen as the patient is in, applying oxygen mask, giving a massage
- After performing a physical non-invasive examination:
taking pulse, blood pressure, chest auscuttation, recording ECG
5. After Touching Patient Surroundings
To protect you from colonization with patient germs that may be present on surfaces / objects in patient surroundings and to protect the health-care environment against germ spread
Clean your hands after touching any object or furniture when leaving the patient surroundings, without having touched the patient*
The Moment 5 applies in the following situation if they correspond to the last contact with the patient surroundings, without having touched the patient:
- After an activity involving physical contact with the patient's immediate environment: changing bed linen with the patient out of the bed, holding a bed trail, clearing a bedside table
- After a care activity: adjusting perfusion speed, clearing a monitoring alarm
- After other contacts with surfaces or inanimate objects (note - ideally try to avoid these unnecessary activities like leaning against a bed, leaning against a night table / bedside table
Hand Hygiene Technique with Alcohol-Based Formulation
Rub hands for hand hygiene, when not visibly soiled. Wash hands when visibly soiled.
Duration of the Entire Procedure: 20-30 Seconds
Hand Hygiene Technique with Soap (Plain/Antimicrobial) and Water
Wash hands when visibly soiled / dirty with blood / other body fluids or after using toilet. Otherwise, use handrub
Duration of the Entire Procedure: 40-60 Seconds
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 and available in the market.
Protocol for Surgical Scrub with a Medicated Soap
- Start timing. Scrub each side of each finger, between the fingers, and the back and front of the hand for 2 minutes.
- Proceed to scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water from the elbows and prevents bacteria-laden soap and water from contaminating the hands.
- Wash each side of the arm from wrist to the elbow for 1 minute.
- Repeat the process on the other hand and arm, keeping hands above elbows at all times. If the hand touches anything at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated.
- Rinse hands and arms by passing them through the water in one direction only, from fingertips to elbow. Do not move the arm back and forth through the water.
- Proceed to the operating theatre holding hands above elbows.
- At all times during the scrub procedure, care should be taken not to splash water onto surgical attire.
- Once in the operating theatre, hands and arms should be dried using a sterile towel and aseptic technique before donning gown and gloves.
Surgical Hand Preparation Technique with an Alcohol-Based Handrub Formulation
The handrubbing technique for surgical hand preparation must be performed on perfectly clean, dry hands. On arrival in the operating theatre and after having donned theatre clothing (cap/hat/bonnet and mask], hands must be washed with soap and water.
After the operation when removing gloves, hands must be rubbed with an alcohol-based formulation or washed with soap and water if any residual talc or biological fluids are present (e.g. the glove is punctured).
Surgical Procedures May be Carried Out One After the Other Without the Need for Handwashing, Provided that the Handrubbing Technique for Surgical Hand Preparation is Followed (Images 1 to 17).
Technique for Donning (Wearing) and Removing Non-Sterile Examination Gloves
When the hand hygiene indication occurs before a contact requiring glove use, perform hand hygiene by rubbing with an alcohol-based handrub or by washing with soap and water.
How to Don Gloves
How to Remove Gloves
Then, perform hand hygiene by rubbing with an alcohol-based handrub or by washing with soap and water.
Technique for Donning and Removing Sterile Examination Gloves (Including Surgical)
The purpose of the technique is to ensure maximum asepsis for the patient and protect the health-care worker from the patient's body fluid(s). To achieve this goal, the skin of the health-care worker remains exclusively in contact with the inner surface of the glove and has no contact with the other surface. Any error in the performance of this technique leads to a lack of asepsis requiring a change of gloves.
How to Don Sterile Gloves
1. Perform hand hygiene before an 'aseptic procedure' by handrubbing or hand washing.
2. Check the package for integrity. Open the first non-sterile packaging by peeling it completely of the heat seal to expose the second sterile wrapper, but without touching it.
3. Place the second sterile package on a clean, dry surface without touching the surface. Open the package and fold it towards the bottom so as to unfold the paper and keep it open.
4. Using the thumb and index finger of one hand, carefully grasp the folded cuff edge of the glove.
5. Slip the other hand into the glove in a single movement, keeping the folded cuff at the wrist level.
6-7. Pick up the second glove by sliding the fingers of the gloved hand underneath the cuff of the glove.
8-10. In a single movement, slip the second glove on to the ungloved hand while avoiding any contact/resting of the gloved hand on surfaces other than the glove to be donned (contact/resting constitutes a lack of asepsis and requires a change of glove).
11. If necessary, after donning both gloves, adjust the fingers and interdigital spaces until the gloves fit comfortably.
12-13. Unfold the cuff of the first gloved hand by gently slipping the fingers of the other hand inside the fold, making sure to avoid any contact with a surface other than the outer surface of the glove (lack of asepsis requiring a change of gloves).
14. The hands are gloved and must touch exclusively sterile devices or the previously-disinfected patient's body area.
How to Remove Sterile Gloves
15-17. Remove the first glove by peeling it back with the fingers of the opposite hand. Remove the glove by rolling it inside out to the second finger joints (do not remove completely).
18. Remove the other glove by turning its outer edge on the fingers of the partially ungloved hand.
19. Remove the other glove by turning it inside out entirely to ensure that the skin of the health-care worker is always and exclusively in contact with the inner surface of the glove.
20. Discard gloves.
21. Perform hand hygiene after glove removal according to the recommended indication.
- It is proceeded by a surgical hand preparation;
- Donning gloves is performed after putting on the sterile surgical gown;
- The opening of the first packaging (non-sterile) is done by an assistant;
- The second packaging (sterile) is placed on a sterile surface other than used for the intervention;
- Gloves should cover the wrists of the sterile gown.
Summary of the Indications for Gloving and for Glove Removal
- Take care of your hands by regularly using a protective hand cream or lotion of good quality, at least daily to prevent skin damage.
- Do not routinely wash hands with soap and water immediately before or after using an alcohol-based handrub as it is not only unnecessary but also may lead to dermatitis.
- Washing with soap and water is harsher on the skin than handrubbing with an alcohol-based handrub containing a humectant.
- Certain detergent and antiseptic soaps cause more irritation than others - a skin tolerability test is recommended before their introduction.
- Do not use hot water to rinse your hands.
- Rub hands until the alcohol-based product has completely evaporated.
- Dry hands carefully after washing with soap and water.
- After handrubbing or handwashing, let your hands dry completely before putting on gloves or else it may increase the risk of skin irritation.
- Powdered gloves can cause irritation when used concurrently with alcohol based products.
- Using a protective hand cream helps to improve skin condition provided it is compatible with the hand hygiene products and gloves used.
- Avoid performing hand hygiene outside the framework of indications.
- Avoid wearing gloves outside the framework of indications.
- Do not wear finger rings; keep hands and forearms free of jewellery (bracelets, wrist watches, etc.) during health care as wearing jewellery encourages the presence and survival of transient flora.
- Keep natural nails, short and unvarnished, as the areas above and below nails attract germs, particularly if nails are long, varnished.
- Do not wear artificial fingernails or extenders when in direct contact with patients as they may contribute to the transmission of certain healthcare associated pathogens.
- Hand hygiene actions are more effective when hand skin is free of cuts. Any changes in the superficial layer of the epidermis and deeper damage also encourage colonization by non-commensal skin flora (e.g.. Staphylococcus aureus and Gram negative bacteria).
2. Hand Hygiene Technical Reference Manual, 2009. World Health Organization