Handwashing: Breaking the Chain of Infection

July 1, 2000

Handwashing: Breaking the Chain of Infection

By Amy Walker Barrs

Many people consider handwashing to be a matter of common sense when it comes toremoving dirt and germs from the hands. In fact, handwashing is more than simple commonsense. According to the US Centers for Disease Control (CDC), "handwashing is thesingle most important procedure for preventing the spread of infection."

The Association for Professionals in Infection Control and Epidemiology (APIC) concurs,stating that "handwashing causes a significant reduction in the carriage of potentialpathogens on the hands," and [in healthcare settings it] "can result inreductions in patient morbidity and mortality from nosocomial infection."

APIC Guidelines

The "APIC Guideline for Handwashing and Hand Antisepsis in Health CareSettings" was published in 1995 and supplements guides published by the Associationof Operating Room Nurses (AORN), the CDC, and the Food and Drug Administration (FDA). Itprovides information on skin flora of hands, characteristics of selected antimicrobialagents used on hands, handwashing and surgical scrub techniques, and related aspects ofhand care and protection. In addition, recommendations are made regarding healthcarepersonnel handwashing, personnel hand preparation for operative procedures, and otheraspects of hand care and protection.1

While the purpose of this article is not to review the entire Guideline exhaustively,there are several areas that bear repeating, including recommendations on when and how towash hands and how to choose the best soap for the job.

The decision regarding when handwashing should occur depends on:

  • The intensity of contact with patients.

  • The degree of contamination that is likely to occur with that contact.

  • The susceptibility of patients to infection.

  • The procedure to be performed.

Healthcare workers come into frequent hand-contact with body secretions that can carrybacteria, viruses, and fungi, which may be potentially infectious. That's one of thereasons APIC recommends handwashing when there is prolonged and intense contact with anypatient. APIC further recommends that handwashing be considered necessary beforeand after situations in which hands are likely to become contaminated, especiallywhen hands have had contact with mucous membranes, blood and body fluids, and secretionsor excretions, and after touching contaminated items such as urine-measuringdevices.

According to APIC, the choice of plain or antiseptic soap, or of alcohol-based handrinses, should depend on whether it is important to reduce and maintain minimal counts ofcolonizing flora (those microorganisms that are considered permanent residents of the skinand are not readily removed by mechanical friction) as well as to remove the contaminatingflora mechanically (microorganisms that can be transmitted via skin-to-skin contact unlessremoved by mechanical friction and soap and water washing or destroyed by the applicationof an antiseptic handrub).

For general patient care, APIC and the CDC recommend the use of plain,non-antimicrobial soap. However, APIC goes on to note that antiseptic agents are necessaryto kill or inhibit microorganisms and reduce the level of microbes still further.Moreover, APIC adds that certain antiseptic agents have the ability to bind to the stratumcorneum, resulting in a persistent activity on the skin, which may be desirable to enhancecontinued antimicrobial activity when it is not possible to wash the hands duringprolonged surgical procedures or when continued chemical activity on the skin isadvantageous in other settings.

The choice of plain soap, antiseptic soap, or antiseptic handrubs should therefore bebased on the degree of hand contamination and whether it is important to reduce andmaintain minimal counts of resident flora as well as to remove the transient floramechanically from the hands of healthcare personnel, according to APIC.

Handwashing Techniques

APIC offers the following handwashing techniques for healthcare workers:

  • Wet hands with warm running water.

  • Apply handwashing agent (soap) and thoroughly distribute over hands.

  • Vigorously rub hands together for 10 to 15 seconds, generating friction on all surfaces of the hands and fingers, including thumbs, backs of fingers, backs of the hands, and beneath the fingernails.

  • Rinse hands thoroughly to remove residual soap then dry using paper towels dispensed from holders that require the user to remove them one at a time.

  • If the sink does not have foot controls or an automatic shutoff, a paper towel may be used to shut off the faucet to avoid recontaminating the hands.

While there is little evidence to recommend a specific ideal water temperature foreffective handwashing, it seems logical to use warm water. Excessively hot water is harderon the skin, dries the skin, and is too uncomfortable to wash for the recommended amountof time. In addition, cold water inhibits the proper lathering of soap.

When using an alcohol-based antimicrobial cleaner, APIC recommends that a vigorous,one-minute rubbing with enough alcohol (3-5ml is generally recommended) to wet the handscompletely is the most effective method for hand antisepsis. Failure to cover all surfacesof the hands because of poor technique or use of insufficient amounts of alcohol handrubsolution can leave surfaces contaminated. Also, keep in mind that these alcohol handrubsare not designed to remove physical dirt, and therefore should be used with anothercleaning agent in the presence of physical dirt.

The Role of Gloves

Protective gloves are routinely worn in healthcare settings as a safety barrier betweenskin-borne microorganisms and patients. The Occupational Safety & HealthAdministration (OSHA) in standards published in 1991, requires that gloves be wornwhenever there is a reasonable likelihood that hands will be in contact with blood orother potentially infectious material, mucous membranes, or non-intact skin; whenperforming any vascular access procedure; or when handling contaminated items or surfaces.

Microbial contamination of hands and possible transmission of infection have beenreported even when gloves are worn, and studies have shown that handwashing is animportant complement to glove use. In fact, APIC and the CDC recommend a soap and waterhandwash or an antiseptic handrub after gloves are removed.

While gloves offer important protection, constant use of gloves may cause irritantdermatitis due to mechanical irritation from the glove or glove powder, or from chemicalagents such as residual soap trapped between the glove and the skin. (The problem ofdermatitis is discussed in more detail below.) Some healthcare workers choose powder-freegloves to decrease irritation and the risk of allergies.2 It is important tokeep in mind that no glove is 100% resistant to all pathogens.

Barriers to Proper Handwashing

According to APIC, handwashing associated with general patient care occurs inapproximately half of the instances in which it is indicated and usually is of shorterduration than recommended. A recent study supports that figure, finding that averagehandwashing compliance was 48% in a teaching hospital.3 The study concludedthat the primary problem with handwashing is laxity of practice and that high workloadamong healthcare workers was associated with low compliance.

Other factors influencing handwashing behavior include placement of sinks, unacceptablehandwashing products, the effect of handwashing on skin condition, and awareness of theimportance of handwashing in preventing infection.

The convenient placement of sinks, handwashing products, and paper towels is oftensuggested as a means of encouraging frequent and appropriate handwashing. Sinks withfaucets that can be turned off by means other than the hands (e.g., foot pedals)and sinks that minimize splash can help personnel avoid immediate recontamination ofwashed hands (Table 1).4

The Dermatitis Dilemma

Dry skin and dermatitis are two conditions linked to frequent handwashing that mayaffect handwashing compliance among healthcare personnel. In fact, the National Institutefor Occupational Safety & Health (NIOSH) states that skin injuries and diseasesaccount for a large proportion of all occupational injuries and diseases. In 1998,dermatological diseases accounted for approximately 19% of all chronic occupationaldiseases in the US, according to NIOSH. And, that of workers who developed adermatological disease in 1997, more than 28% lost three to five working days, accordingto the Bureau of Labor Statistics. In the service industries, which include the healthservice industry, nearly 18,000 cases of dermatological diseases were reported to theBureau of Labor Statistics in 1998. Dermatitis is such an important (and until recently,overlooked) issue that NIOSH has made it a top priority in the National OccupationalResearch Agenda (NORA).

Dermatitis is an inflammation that occurs when an irritating substance comes intocontact with the skin, causing an abnormal reaction. Areas of irritated skin may be red,swollen, tender, hot, painful or itchy. In addition, there may be some scaling as the skinheals. Skin affected for several weeks by dermatitis tends to thicken and change to adeeper color. As well as causing pain or discomfort, dermatitis in severe cases can resultin long periods away from work.

The APIC Guideline notes that dermatitis in healthcare personnel may place patients atrisk because handwashing will not decrease bacterial counts on dermatitic skin, anddermatitic skin contains high numbers of microorganisms. Moreover, the Guideline statesthat healthcare personnel with dermatitis may be at increased risk of exposure tobloodborne pathogens during skin contact with blood or body fluids because the integrityof the skin is compromised.

Dermatitis may be considered the "Catch-22" of handwashing compliance as itcan be caused by the excessive handwashing that healthcare personnel must comply with on adaily basis. The problem is that many skin cleansers do not discriminate between the dirton the skin surface and the essential oils that protect the skin.

Even given the problems associated with dermatitis, the simple act of handwashing hasbeen an important and enduring element of most infection control programs. And now, morethan ever, it is recognized that an effective handwashing program can greatly reduce therisks of cross-contamination.

Amy Walker Barrs is the executive director of the Kimberly-Clark Skin WellnessInstitute (Roswell, Ga).

1 Larson E. APIC guideline for handwashing and hand antisepsis in health care settings. AJIC. 1995;4:251-269.

2 Hutchisson B. Gloves: Practical information for healthcare workers. Infect Control Sterlization Technol. March 1999:12-16.

3 Pittet D, Mourouga P, Perneger T. Compliance with handwashing in a teaching hospital. Ann Intern Med. 1999;130:126-130.

4 Garner J, Favero S. Guideline for handwashing and hospital environmental control. US Department of Health & Human Services 1985; Section 1.

Table 1: Make It Easy to Wash up Right

  • A sink should be located in or just outside every patient room. More than one sink per room may be necessary if a large room is used for several patients.

  • If bar soap is used, it should be kept on racks that allow water to drain. Small bars of soap that can be changed frequently should be used.

  • If liquid soap is used, it should be stored in closed containers, and the dispenser should be replaced or cleaned and filled with fresh product when empty. Liquids should not be added to a partially full dispenser.

  • Paper towels should be within easy reach of the sink but beyond splash contamination. A "no-touch" dispenser lets users touch only the towels they need and reduces the possibility of hand contamination via soiled levers.

  • Antimicrobial-containing products that do not require water for use can be used in areas where no sinks are available or in small containers for portability.

  • Lotions supplied in small, non-refillable containers can be used to help prevent skin dryness and dermatitis. Lotion formulations should be checked for compatibility with antiseptic products and their effect on glove integrity.

Handwashing Protocol

Often handwashing technique leaves much to be desired. It was found, for example, thatmany anesthesiologists washed only the palms and the backs of their hands, whereas themain contact points are the fingers and the finger tips. Instruction was required to teachthem to wash their hands from the fingers to the wrist whereupon the reduction inbacterial counts improved.1 It may be worth thinking about a technique forcleansing damaged hands. The skin on the backs of the hands is often more sensitive todamage than the palmar surface and can become readily chapped. In this condition, it maybe better to wash the main contact surfaces of the hands by rubbing together only thepalms and fingers including finger pads rather than avoid the handwash because of sorehands.

Chamberlain, et. al.2, based on data with inoculated as well asnaturally-occurring bacteria, have questioned the value of typically recommended handwashprocedures and of the "perfunctory handwashes frequently adopted by nursing staff inbusy wards." They suggest that experimental evidence should be obtained to supportthe recommended procedures and to identify the circumstances where they are valuable.

Little attention has been paid to drying as part of the handwashing protocol. Manytransient bacteria will not survive drying, and drying is an important component ofreducing bacterial numbers during handwashing whether cloth, paper, or warm air was used.Residual moisture on hands after washing has been found to be an important determinant ofbacterial transfer.3 We also have observed this for viruses.4 Thedata presented by Patrick et. al demonstrate that cloth towels dry hands morequickly than warm air when both methods were applied for various periods up to 45 seconds.The longer the time spent drying hands, the fewer bacteria were transferred torepresentative surfaces. However, even after 45 seconds, bacterial transfer remained abovepreset levels. Observation of drying times routinely used for cloth towels were 3.5 and5.2 seconds for males and females, respectively. The corresponding figures for air dryingwere 17 and 13.3 seconds. Paper towels, often the preferred drying mode in North America,were not included in this study. Although this work was initiated as a result of anobservation of an increased touch contamination level of peritoneal dialysis equipmentafter handwashing, there are widespread implications for many healthcare procedures andinfection.

Another study5, which looked at the transfer of bacteria from unwashed andwashed hands to contact lenses, demonstrated higher transfer after washing. Bacterialtransfer could only be reduced to prewash levels by the application of an alcohol wipeafter washing and drying. However, because the study design was different, it is notpossible to tell what proportion of the transfer was due to residual moisture.

Careful hand-drying is therefore an important factor, not only in possible transfer ofmicroorganisms to patients but also in their acquisition by hands from patients and fromcontaminated objects in the patient environment. The contribution of environmentalmicroorganisms to nosocomial infections has been controversial for many years, but we haveargued that hand hygiene and sensible environment decontamination should go hand-in-hand.For example, a recent study of environmental contamination in the vicinity of patientscolonized or infected with methicillin-resistant Staphylococcus aureus6 suggestedready contamination of gloves and possibly hands as well as gowns and uniforms ofattendant personnel.

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