Disinfecting Those Digits is Critical to Good Handwashing
By Nancy B. Bjerke, BSN, RN, MPH, CIC
1. Differentiate handwashing strategies based on the workflow principle of dirty to cleanest.
2. Identify appropriate FDA-cleared antiseptics for use by healthcare personnel.
3. Discuss the alcohol phenomenon for hand hygiene.
While Ignaz Semmelweis is credited with being the father of handwashing,1 the most predominant teacher was our mothers. Those familiar words, "Go wash your hands," ring loud and clear, filled with the ultimate authority of "I know what is best for you." Much later in our education did the fundamental knowledge crystallize with increasing facts, rationale and emphasis. This article focuses on the best practices for handwashing, using the infection control principle of separating dirty from clean with appropriate cleansing and disinfecting agents to reduce transmission risk of microbes.
Reservoir and Transmission
Known as the 10 dirty digits, our hands are valuable assets to daily functioning as healthcare workers (HCWs) and in our ability to care for a myriad of patients. However, these helpful hands have gained some notoriety as culprits in serious infections. Hands, especially under the fingernails, are reservoirs for microorganisms. Unless cleaning under the nails occurs daily with a nail file or other similarly effective device, debris accumulates and can be easily transferred to other animate or inanimate sources.
Fingernail length is worthy of a mention. Short is a frequent descriptor in healthcare guidance, but leaves the interpretation open to each person. As a rule of thumb, a fingernail that extends beyond the fingertip is considered too long. In healthcare delivery where gloves are routinely worn, tears occur in the fingertips due to long nails; thus, the barrier protection is compromised but preventable with shorter nails. As patients are lifted, turned and cared for, the risk of harming the patient with long fingernails is also present.
A sign of healthy fingernails is well-manicured nails -- clean, short, with jagged nail tips smoothed away and with surrounding skin intact. Paronychia-free fingernails are evidence that HCWs are conscious of the danger their fingers have for being implicated in outbreaks.2 Well-manicured nails exclude the adornment of artificial nails, assorted nail applications and piercing jewelry. Microbes have an affinity for moist, dark areas to establish their habitat and artificial nail applications contribute to this reservoir. Proliferation is natural and rapid for transient organisms.
The most noted link of these adornments and their accompanying nail extension to a major Pseudomonas aeruginosa outbreak was published by the Centers for Disease Control and Prevention (CDC) in February 2000, where the causal links to 16 neonate deaths were a nurse with long natural nails and a nurse with long artificial nails.3
In the healthcare arena, dress codes require conformity for hygiene, safety and identification reasons; yet individuality is obvious in noncompliant personnel who add adornments. While the current style is a ring for each finger (10 or more), these germ trappers are difficult to clean and can harm patients with their assorted sharp edges, dangling and height. And a word about nail polish: although it has been written in healthcare guidance that clear nail polish is acceptable,4 has anyone informed microbes to avoid it? Nail polish deteriorates, chips and breaks off the nail surface. The time it takes varies based on the age of the polish, its adherence characteristics, health of the nail and the wearer's activity. Polish fragments are foreign bodies that can potentially cause reaction when deposited in wounds through glove tears. Dermatologists report reactions to nail hardeners and lacquers cause onycholysis and secondary pseudomonas and Candida infections.5 In the healthcare vocation, conformity serves a higher purpose -- to care for patients without adding preventable adverse occurrences. The best preparation for handwashing is short, healthy, natural, clean fingernails free of polish and adornments.
Infection control principles are fundamental to personnel who make them viable and effective in daily routines. The workflow principle is basic to hand cleansing activities and is the separation of dirty, clean, cleaner and cleanest. The workflow pattern is often the guiding premise in reprocessing fomites and maintaining sterile fields. For hand cleansing, the removal of dirt and debris, transient and resident bioburden and natural skin substances is basic. This is frequently referred to as routine handwashing. Requirements include the physical equipment of a draining sink with warm running water, a liquid non-antimicrobial soap, paper towels and wastebasket. Ideally, operational sensor activated water and soap distribution limit the person's spread of contamination. The non-antimicrobial soap products are adequate for routine handwashing; however, their availability is limited in the marketplace. The use of antimicrobial over-the-counter products may be aiding the germs more than man.
During handwashing the anatomical area to cleanse is fingertips to wrists. The method involves:
- Thoroughly wetting the skin surface to fill pores with water, dilute the soap and reduce irritation from harsh chemicals that remain concentrated in the pores when soap is placed on dry hands.
- Obtaining a dose of liquid agent to act as a surfactant to dislodge debris, remembering that more is not necessarily better. When hand cleansing is performed correctly and consistently, there will be less irritation from various products.
- Spreading the liquid agent over the entire hand to aid in removal of all contaminants.
- Applying friction for 10 to 15 seconds by rubbing the fingertips and nails, digits, front and back of hands and wrists to dislodge debris. Singing "Happy Birthday" to yourself is a good way to mark time.
- Completely rinsing all contaminants and residual soap from the washed surfaces to cleanse and prevent subsequent irritation.
- Blotting the cleansed surfaces with dry paper towels to absorb the excess water before gentle rubbing the skin dry.
- Tossing the used paper towels in the wastebasket before using a dry paper towel to turn off the faucets. The dry towel is a more effective barrier to touch the contaminated faucet than to re-contaminate clean hands; a used paper towel is a weak barrier and wicking can occur).
Lotion is more beneficial for skin reconditioning when it is applied before the longest period when hand cleansing is averted, usually when sleep occurs. If the person normally sleeps with the hands near the eyes, wear clean cotton gloves after the lotion application. This will contain the lotion yet still permit it to work at restoring skin integrity. If lotion is used in the healthcare arena, compatibility with soap, antiseptics and gloves is essential to avert negating its benefits. Lotion dispensed from a disposable container and disposed of when empty is recommended.6
Indications for routine hand cleansing include, but are not limited to: when visibly soiled; in between patient contact; after handling contaminated fomites; before glove placement; after glove removal as mandated by OSHA;7 after bodily functions (i.e., toileting, sneezing, coughing, handling body secretions, touching the face, etc.); after smoking; before and after eating. When in doubt, just do it!
The progression to cleaner hands connotes a further decline in surface organisms with a more potent agent, namely an antiseptic. The Food and Drug Administration (FDA) defines a healthcare antiseptic as a product applied topically to the skin to help prevent infection or cross contamination; being frequently used; reducing the number of transient microorganisms on intact skin; having a broad spectrum and being fast acting and persistent.8 These antiseptics must meet the testing requirements of FDA before being cleared for market distribution. The familiar comparative list from healthcare guidance includes alcohol, iodine/iodophors, chlorhexidine gluconate, triclosan and para-chloro-meta-xylenol (PCMX).9 The physical requirements for routine handwashing apply here with the upgrade from soap to an antiseptic detergent product, requiring a single dose amount specified by the manufacturer's label instructions to be effective.
The same steps and anatomical area mentioned in the previous bullet points, still apply for antiseptic handwash. Not only is cleansing accomplished, skin disinfection occurs, destroying microorganisms. Indications for using antiseptic handwash would be caring for different sites on the same patient and a multi-resistant colonized, infected or isolated patients. Additional indications are after handling contaminated items such as linen, dressings, bedpans and urinals. However, when the intended activity involves insertion of devices (i.e., Foley catheters, intravascular lines and respiratory tubes, dressing procedures or similar levels of intensified patient care) the anatomical area for skin cleansing and disinfecting extends from fingertips to forearms. This extension reduces the microbial flora of the skin that may be unprotected by personal protective equipment (PPE) beyond gloves and/or over the sterile field. The extra antisepsis effort is reasonable in light of the invasiveness of care and resources available.
When the spectrum of care elevates to surgical invasion, handwashing is even more stringent. Known as the surgical hand scrub, the physical requirements generally include some type of hands-free mechanism to initiate a warm stream of water. The FDA-cleared surgical hand scrub is dispensed in an impregnated disposable sponge-brush or is triggered by a no-hands system. The common surgical scrub agents are iodophors, chlorhexidine gluconate, triclosan, and PCMX formulations.10 Once again, dosage is product dependent; however, more is not necessarily better or more effective. The sequential steps to scrubbing commence by washing hands and forearms before cleaning under the sublingual areas under running water with a nail pick or file to remove debris accumulation. The steps for the scrub include a count or a timed method which is a local written policy in surgical suites. The anatomical area is expanded from fingertips to two inches above the elbow. The sequent steps for cleansing the skin surface remain the same to maintain skin integrity. The time duration has narrowed from 10 minutes to two minutes based on published research.11 Although this surface is protected with sterile attire, body fluids can still seep through the barrier and contact the skin. Cross transmission can occur between patient and surgical team member and vice versa. The newest tendency is to eliminate the scrub brush due to research indicating this amount of friction increases skin shedding.
Indications for the surgical hand scrub are preparation for invasive operations usually performed in the operating room, surgicenters, cardiac catheterization laboratories and for some invasive radiographic procedures. The anticipated level of care can be a decisive factor for the "cleanest" cleansing category. The decision is patient centered and based on infection prevention.
The Alcohol Phenomenon
Alcohol is a quick killer of microbes and a means to increase compliance of HCWs to cleanse their hands. In the early 1980s, alcohol liquid products were offered to counter the lack of handwashing sinks in healthcare arenas. The formulations were adjunct to inventory and specific for degerming between patients when hands were not soiled. The intent was to reduce microbes until hand cleansing occurred. These preparations contained emollients that prevented skin drying. Alcohol products received the typical novel response and were used appropriately in institutions that chose to use them.
Since the American Institute of Architects (AIA) construction guidelines12 incorporate more sinks to address handwashing demands and modern facilities are being constructed, the pressing need for alcohol agents has declined. Recently, however, these products have re-emerged in gel and foam media with advocacy by experts as the sole means to increase personnel compliance in hand hygiene in all practice settings.13 Healthcare institutions and personnel are classic in their initial reactions to the guidance while manufacturers provide the expected competitive agents and advertising. The staying power of these alcohol handrubs as they are referred to is yet to be determined. The handrub procedural steps are vendor driven to meet FDA label requirements and professional organizations are still in developmental stages of published procedures for alcohol handrubs in all practice settings. Alcohol does kill microbes quickly; however, it lacks cleansing capabilities. Removing the bioburden is key for disinfection.
Handwashing to hand antisepsis to surgical hand scrub are natural applications for the infection control principle: separate dirty from clean from cleanest. Hand cleansing choice is based on the activity to be performed or just completed. The options are numerous, but the sequence remains steadfast. To maintain skin integrity and to promote recovery and health in patients, keep the 10 digits clean and disinfect when necessary. Realize that you are responsible to break the chain of infection and handwashing is the most effective, economical, reliable and timely method.
Nancy B. Bjerke, BSN, RN, MPH, CIC, is an infection control consultant for Infection Control Associates in San Antonio.
|Test Questions: True or False||T||F|
|1. Applying detergent to the dry palm reduces irritation from hand cleansing.|
|2. The duration of cleansing for surgical hand scrub is the same as for routine handwashing.|
|3. Antimicrobial products are recommended for simple hand cleansing after toileting.|
|4. Hand antisepsis encompasses cleansing and disinfecting with an antiseptic.|
|5. Alcohol is an antiseptic that kills microbes, persists on the skin and cleans.|
|6. Hand lotion is applied after each handwashing episode.|
|7. False nail applications are acceptable in healthcare, as they present no risk to the wearer.|
|8. Sublingual areas are cleaned daily to decrease microbial load and debris.|
|9. Cleansing the hands with Betadine is adequate for Foley insertion.|
|10. Shut off the water faucet after hand washing before drying hands to save water.|