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.
WhileIgnaz Semmelweis is credited with being the father of handwashing,1the most predominant teacher was our mothers. Those familiar words, "Gowash your hands," ring loud and clear, filled with the ultimate authorityof "I know what is best for you." Much later in our education did thefundamental knowledge crystallize with increasing facts, rationale and emphasis.This article focuses on the best practices for handwashing, using the infectioncontrol principle of separating dirty from clean with appropriate cleansing anddisinfecting agents to reduce transmission risk of microbes.
Reservoir and Transmission
Known as the 10 dirty digits, our hands are valuable assets to dailyfunctioning as healthcare workers (HCWs) and in our ability to care for a myriadof patients. However, these helpful hands have gained some notoriety as culpritsin serious infections. Hands, especially under the fingernails, are reservoirsfor microorganisms. Unless cleaning under the nails occurs daily with a nailfile or other similarly effective device, debris accumulates and can be easilytransferred to other animate or inanimate sources.
Fingernail length is worthy of a mention. Short is a frequent descriptor inhealthcare guidance, but leaves the interpretation open to each person. As arule of thumb, a fingernail that extends beyond the fingertip is considered toolong. In healthcare delivery where gloves are routinely worn, tears occur in thefingertips due to long nails; thus, the barrier protection is compromised butpreventable 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, withjagged nail tips smoothed away and with surrounding skin intact. Paronychia-freefingernails are evidence that HCWs are conscious of the danger their fingershave for being implicated in outbreaks.2 Well-manicured nails excludethe adornment of artificial nails, assorted nail applications and piercingjewelry. Microbes have an affinity for moist, dark areas to establish theirhabitat 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 extensionto a major Pseudomonas aeruginosa outbreak was published by the Centersfor Disease Control and Prevention (CDC) in February 2000, where the causallinks to 16 neonate deaths were a nurse with long natural nails and a nurse withlong artificial nails.3
In the healthcare arena, dress codes require conformity for hygiene, safetyand identification reasons; yet individuality is obvious in noncompliantpersonnel 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 patientswith their assorted sharp edges, dangling and height. And a word about nailpolish: although it has been written in healthcare guidance that clear nailpolish is acceptable,4 has anyone informed microbes to avoid it? Nailpolish deteriorates, chips and breaks off the nail surface. The time it takesvaries based on the age of the polish, its adherence characteristics, health ofthe nail and the wearer's activity. Polish fragments are foreign bodies that canpotentially cause reaction when deposited in wounds through glove tears.Dermatologists report reactions to nail hardeners and lacquers cause onycholysisand secondary pseudomonas and Candida infections.5 In the healthcarevocation, conformity serves a higher purpose -- to care for patients withoutadding preventable adverse occurrences. The best preparation for handwashing isshort, healthy, natural, clean fingernails free of polish and adornments.
Infection control principles are fundamental to personnel who make themviable and effective in daily routines. The workflow principle is basic to handcleansing activities and is the separation of dirty, clean, cleaner andcleanest. The workflow pattern is often the guiding premise in reprocessingfomites and maintaining sterile fields. For hand cleansing, the removal of dirtand debris, transient and resident bioburden and natural skin substances isbasic. This is frequently referred to as routine handwashing. Requirementsinclude the physical equipment of a draining sink with warm running water, aliquid non-antimicrobial soap, paper towels and wastebasket. Ideally,operational sensor activated water and soap distribution limit the person'sspread of contamination. The non-antimicrobial soap products are adequate forroutine handwashing; however, their availability is limited in the marketplace.The use of antimicrobial over-the-counter products may be aiding the germs morethan man.
During handwashing the anatomical area to cleanse is fingertips to wrists.The method involves:
Lotion is more beneficial for skin reconditioning when it is applied beforethe longest period when hand cleansing is averted, usually when sleep occurs. Ifthe person normally sleeps with the hands near the eyes, wear clean cottongloves after the lotion application. This will contain the lotion yet stillpermit it to work at restoring skin integrity. If lotion is used in thehealthcare arena, compatibility with soap, antiseptics and gloves is essentialto avert negating its benefits. Lotion dispensed from a disposable container anddisposed of when empty is recommended.6
Indications for routine hand cleansing include, but are not limited to: whenvisibly soiled; in between patient contact; after handling contaminated fomites;before glove placement; after glove removal as mandated by OSHA;7after bodily functions (i.e., toileting, sneezing, coughing, handling bodysecretions, 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 surfaceorganisms with a more potent agent, namely an antiseptic. The Food and DrugAdministration (FDA) defines a healthcare antiseptic as a product appliedtopically to the skin to help prevent infection or cross contamination; beingfrequently used; reducing the number of transient microorganisms on intact skin;having a broad spectrum and being fast acting and persistent.8 Theseantiseptics must meet the testing requirements of FDA before being cleared formarket distribution. The familiar comparative list from healthcare guidanceincludes alcohol, iodine/iodophors, chlorhexidine gluconate, triclosan andpara-chloro-meta-xylenol (PCMX).9 The physical requirements forroutine handwashing apply here with the upgrade from soap to an antisepticdetergent product, requiring a single dose amount specified by themanufacturer'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, skindisinfection occurs, destroying microorganisms. Indications for using antiseptichandwash would be caring for different sites on the same patient and amulti-resistant colonized, infected or isolated patients. Additional indicationsare after handling contaminated items such as linen, dressings, bedpans andurinals. However, when the intended activity involves insertion of devices(i.e., Foley catheters, intravascular lines and respiratory tubes, dressingprocedures or similar levels of intensified patient care) the anatomical areafor skin cleansing and disinfecting extends from fingertips to forearms. Thisextension reduces the microbial flora of the skin that may be unprotected bypersonal protective equipment (PPE) beyond gloves and/or over the sterile field.The extra antisepsis effort is reasonable in light of the invasiveness of careand resources available.
When the spectrum of care elevates to surgical invasion, handwashing is evenmore stringent. Known as the surgical hand scrub, the physical requirementsgenerally include some type of hands-free mechanism to initiate a warm stream ofwater. The FDA-cleared surgical hand scrub is dispensed in an impregnateddisposable sponge-brush or is triggered by a no-hands system. The commonsurgical scrub agents are iodophors, chlorhexidine gluconate, triclosan, andPCMX formulations.10 Once again, dosage is product dependent;however, more is not necessarily better or more effective. The sequential stepsto scrubbing commence by washing hands and forearms before cleaning under thesublingual areas under running water with a nail pick or file to remove debrisaccumulation. The steps for the scrub include a count or a timed method which isa local written policy in surgical suites. The anatomical area is expanded fromfingertips to two inches above the elbow. The sequent steps for cleansing theskin surface remain the same to maintain skin integrity. The time duration hasnarrowed from 10 minutes to two minutes based on published research.11Although this surface is protected with sterile attire, body fluids can stillseep through the barrier and contact the skin. Cross transmission can occurbetween patient and surgical team member and vice versa. The newest tendency isto eliminate the scrub brush due to research indicating this amount of frictionincreases skin shedding.
Indications for the surgical hand scrub are preparation for invasiveoperations usually performed in the operating room, surgicenters, cardiaccatheterization laboratories and for some invasive radiographic procedures. Theanticipated level of care can be a decisive factor for the "cleanest"cleansing category. The decision is patient centered and based on infectionprevention.
The Alcohol Phenomenon
Alcohol is a quick killer of microbes and a means to increase compliance ofHCWs to cleanse their hands. In the early 1980s, alcohol liquid products wereoffered to counter the lack of handwashing sinks in healthcare arenas. Theformulations were adjunct to inventory and specific for degerming betweenpatients when hands were not soiled. The intent was to reduce microbes untilhand cleansing occurred. These preparations contained emollients that preventedskin drying. Alcohol products received the typical novel response and were usedappropriately in institutions that chose to use them.
Since the American Institute of Architects (AIA) construction guidelines12incorporate more sinks to address handwashing demands and modern facilities arebeing constructed, the pressing need for alcohol agents has declined. Recently,however, these products have re-emerged in gel and foam media with advocacy byexperts as the sole means to increase personnel compliance in hand hygiene inall practice settings.13 Healthcare institutions and personnel areclassic in their initial reactions to the guidance while manufacturers providethe expected competitive agents and advertising. The staying power of thesealcohol handrubs as they are referred to is yet to be determined. The handrubprocedural steps are vendor driven to meet FDA label requirements andprofessional organizations are still in developmental stages of publishedprocedures for alcohol handrubs in all practice settings. Alcohol does killmicrobes quickly; however, it lacks cleansing capabilities. Removing thebioburden is key for disinfection.
Handwashing to hand antisepsis to surgical hand scrub are naturalapplications for the infection control principle: separate dirty from clean fromcleanest. Hand cleansing choice is based on the activity to be performed or justcompleted. The options are numerous, but the sequence remains steadfast. Tomaintain skin integrity and to promote recovery and health in patients, keep the10 digits clean and disinfect when necessary. Realize that you are responsibleto 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 forInfection Control Associates in San Antonio.