Having read this chapter, the reader should be able to:
This chapter focuses on the principles of hand hygiene, an important means of infection control. Hand hygiene encompasses both hand care and hand decontamination; hand decontamination includes both handwashing and the use of alcohol handrub (NICE 2014). Hand hygiene is the most effective, least expensive way to prevent healthcare-associated infections (HCAIs) and one of the most important approaches to patient care (Kilpatrick et al 2013, Spruce 2013).
Transient microorganisms colonize the superficial layers of the skin; usually they do not multiply, although they occasionally survive and multiply but can be removed by hand decontamination. Colony forming units (CFUs) of bacteria on the hands range from 3.9 × 104 − 4.6 × 106 CFU/cm2 but can be much higher in the perineal and inguinal areas (WHO 2009). Up to 106 skin squames containing viable microorganisms can be shed each day from normal skin causing contamination of clothes, bedding, furniture, etc.; thus it can be easy to contaminate hands during ‘clean’ procedures such as taking vital signs, assisting with changing clothes. Microorganisms survive for differing time periods on the hands in the absence of hand decontamination, e.g. only 50% of Escherichia coli are killed in 6 minutes (WHO 2009). WHO (2009) advise that microorganisms such as staphylococci, enterococci, and Clostridium difficile are more resistant to desiccation and thus more likely to be the cause of contamination. Resident flora are attached to the deeper layers of the skin and are more resistant to removal but are also less likely to be a cause of a HCAI. Cross-contamination can also occur from hands to paper, including medical records (Hübner et al 2011).
Approximately 30% of the population is colonized with Staphylococcus aureus on their skin or in their nose with no ill effects. However 3% of the population has the methicillin-resistant Staphylococcus aureus (MRSA) strain of this microorganism which is difficult to treat because of its antibiotic resistance. MRSA is spread by direct contact with a contaminated surface/material or skin-to-skin and its spread is reduced with handwashing and the use of alcohol handrub (AHR). Clostridium difficile, another bacterial source of HCAIs, lives in the intestine of approximately 3% of the population. Usually the normal gut bacteria prevent C. difficile from affecting the person. However, if these are destroyed by antibiotics, C. difficile multiplies, producing toxins that can cause diarrhoea. Their spores are not killed by AHR use. MRSA and C. difficile were the underlying cause or contributory factor in approximately 9000 deaths in hospitals in England during 2007 (NICE 2012).
Healthcare-associated infections are infections acquired as a result of healthcare intervention; they are caused by a wide variety of microorganisms, many of which are commensals. HCAIs are troublesome to those affected because they are likely to have to stay in hospital three times longer than those who are unaffected and require longer-term follow-up and care (Gould et al 2007). Up to 300 000 patients per year in England, 1 : 10 according to Moore et al (2013), develop a HCAI as a result of receiving care in the NHS (NICE 2012), costing the NHS approximately one billion pounds each year. In the USA, there are approximately 1.7 million HCAIs per year, with 99 000 deaths and costing an additional $33.8 billion each year (Patrick & Van Wicklin 2012, Spruce 2013). Hand hygiene can reduce the incidence of HCAI.
General hand care
• Nails should be kept short and filed smoothly as long or ragged nails can scratch women and babies or tear gloves. Dirt and secretions, which can harbour microorganisms, may be found under fingernails. The ideal length of nails is under debate – Loveday et al (2014) advise ‘short’, Fagernes and Lingaas (2010) advise <2 mm, WHO (2009) <5 mm, and the CDC (2002) <6.3 mm. Regardless of which of these are correct, when looking at the palmar side of hands, the nails should not be visible (Patrick & Van Wicklin 2012).
• Apply an emollient hand cream/moisturizer, which is compatible with the antiseptics and barrier products used, to the hands on a regular basis to prevent them from drying out and cracking. The product should list water as its first ingredient and contain no anionic-based chemicals or petroleum.
• Be bare from the elbows down when providing direct patient care (Loveday et al 2014, NICE 2012). Long sleeves can be easily contaminated and make handwashing less effective (Martirani & Weaving 2011, NICE 2012). If exposure of the forearms is unacceptable for religious reasons, the sleeve should not be loose or dangling and must be rolled/pulled back securely during handwashing and direct patient care (NICE 2012).
• Rings, bracelets, and watches should not be worn (Loveday et al 2014). Rings (particularly stoned rings) increase the number of microorganisms found on the hand; jewellery and watches also make it difficult to clean the hands thoroughly, apply AHR and put gloves on (Hautemaniere et al 2010, Khodavaisy et al 2011). Hautemaniere et al (2010) suggest that wearing a flat band wedding ring does not interfere with hand decontamination, a view supported by Al-Allah et al (2008) who found that the wearing of a flat band wedding ring did not provide a source of increased bacterial load following a surgical scrub and suggest they may be kept on for this form of hand decontamination.
• False nails or nail extensions should not be worn as microorganisms can flourish in the ridge that appears as the nail grows. Additionally, Ward (2007) suggests the percentage of Gram-negative bacteria found on false nails is higher than on natural nails.
• Patrick & Van Wicklin (2012) suggest that nail polish can be worn as long as it is not cracked, crazed, or chipped. However the majority of hand hygiene and uniform policies exclude the wearing of nail polish, recognizing that it can chip easily.
Handwashing refers to both social and clinical situations where hands are washed. Social handwashing is generally ineffective in removing/killing microorganisms due to incorrect washing technique or inappropriate cleansing agents used. Hand decontamination is a more accurate term that refers to the removal of blood, body fluids, microorganisms and their debris by mechanical means or their destruction (Loveday et al 2014).
The use of soap and water removes almost all transient microorganisms but does not significantly reduce the number of resident microorganisms. While this is acceptable in non-invasive situations with a low-risk population, there are many situations where the resident microorganisms also need to be reduced (e.g. aseptic procedures). Antiseptics (e.g. chlorhexidine) reduce the transient and resident microorganisms at the time of application, with some residual activity keeping bacterial counts low over several days as the chlorhexidine binds to the stratum corneum (the top layer of the superficial skin layer) (Gould et al 2007). Loveday et al (2014) reviewed the effectiveness of different handwashing preparations and concluded that soap was as effective as antiseptic agents.
Both soap and antiseptics usually involve the use of running water following one of two procedures: the ‘medical/social’ or the ‘surgical’ scrub. The former is used for normal handwashing and prior to aseptic techniques, whereas the latter is used when scrubbing for an operative procedure; this is a lengthier procedure involving the hands and arms.