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Handwashing - are you doing it properly?

Alison Fuller
RGN BSc(Hons)
Clinical Nurse Specialist
Infection Control
Bradford North Primary Care Trust

The changes in healthcare, particularly within the community setting, have seen an increase in the number of referred patients not only to the home environment but also to healthcare centres and clinics. Consequently, there is an expanding delivery of clinical interventions such as intravenous therapy in the home environment and minor surgery in general practice. To support clinical practice it is essential that handwashing facilities are reviewed and that structured programmes of education are in place to increase the compliance of all healthcare workers.

Hand microbiology
The types of organisms located on the hands are resident microorganisms and transient microorganisms.
Resident organisms refer to those that form part of the normal flora and live deep within the epidermis of the skin, hair follicles and sebaceous glands, and beneath fingernails. They live and multiply on the skin and are generally regarded as of low virulence and do not readily cause infections and are not easily removed. They take the form of coagulase-negative staphylococci and diphtheroids. However, during surgery or other invasive procedures they may enter the deep tissues and potentially cause infection.(4)
Transient organisms are those located on the surface of the skin and beneath the superficial cells of the stratum corneum. Transient infers that they are transferred directly from contact with another person, object, contaminated surface or through contact with colonised or infected patients. Any damaged skin, moisture or the wearing of stoned rings will increase the possibility of colonisation.(5,6) Nails are required to be kept short, as debris may collect under them.(7)
Organisms identified by hand carriage may include Staphylococcus aureus Gram-positive and various Gram-negative organisms as a result of everyday clinical practice.(8) The antibacterial properties of skin prevent the survival of these transient organisms after a few hours,(9)  but within this time period they have the ability to transfer themselves to and from hands with ease. They are, however, easily removed by handwashing, unlike resident flora, and therefore routine handwashing removes most transient microorganisms from contaminated hands before they have contact with any susceptible site.

Handwashing - when and how?
As defined by Ayliffe et al, social handwashing is the precursor to all routine tasks.(10) There is no set frequency for handwashing: it is determined by actions - those that are completed and those about to be performed.(11) The Epic guidelines identify four key factors to be considered when deciding on the necessity to decontaminate hands.(12) These include:

  • The level of the expected contact.
  • The extent of contamination that may occur with that contact.
  • The patient care activities being performed.
  • The susceptibility of the patient.

Within the clinical setting the type of handwashing is categorised as social/routine or hygienic hand disinfection. It is rare that a surgical scrub will be used within a community setting. The choice of agent, length of wash and technique is very dependent upon the procedure and susceptibility of the patient.
Preparations with a residual effect are often unnecessary in general practice but do have use where invasive procedures are taking place, such as minor surgery and secondary-primary care shift procedures. Antiseptic agents should be made available at sinks within the designated clinical area. Using liquid soap and water is adequate for most care settings and routine procedures.(13,14)
The wearing of gloves is an important protective measure, and one that does not preclude the process of handwashing. Gloves are not always a complete impermeable barrier but do offer a means to reduce the transfer of microorganisms to and from wearers' hands.(11)

Technique
Investigations into the technique of hand decontamination are limited.(12) However, it has long been established that there are essential elements necessary to ensure a good handwash technique is conducted. These include:

  • The duration of hand decontamination.
  • The exposure of all aspects of the hands and wrists to the preparation in use.
  • Vigorous rubbing to create friction through rinsing and drying.

Mallet and Bailey postulate that where sleeves are long they should be rolled up exposing the forearm, and that wristwatches and rings be removed to expose all aspects of the hand and wrist.(15) The wearing of rings has long been debated, and the general consensus via anecdotal evidence directs us to their removal.
One handwashing technique recommends that hands should be wet first before the application of soap or antibacterial preparation, as illustrated in Figure 1.(13,16,17) The procedure should take at least 10-15 seconds, although preferably 30 seconds.(18)

[[NIP23_fig1_54]]

Hands should be washed under running water,(13) preferably using taps that are elbow/wrist-operated. This prevents recontamination of the hands while turning the taps off. Wherever possible within the clinical area, elbow/wrist-operated taps should be fitted and supplied by water that is temperature-controlled. The water temperature should be suitable to facilitate thorough removal of residual soap, which may irritate the skin.
Hand drying is essential, as wet surfaces facilitate the transference of microorganisms more effectively than dry ones.(19) Therefore what is used to dry the hands is important, and the use of a good-quality paper towel is the method of choice. The friction produced removes transient organisms and dead skin scales and penetrates to remove bacteria, which lie within the deeper layers of the skin. The use of cloth towels should be discouraged within GP practices as they become damp and contaminated and act as a reservoir for bacteria.(20,21) Despite this, many district nurses may use a towel provided by the client within the home environment. This needs to be carefully monitored,(22) and alternatives introduced where possible, such as alcohol hand rubs or disposable paper towels.
Once dried, paper towels can be disposed of effectively into foot-operated pedal bins situated by the sink. Using this method ensures that hands are not recontaminated when opening the bin.(23)
The use of nailbrushes should be discouraged unless single-use disposable brushes are available. Clear access to the handwash basin is essential to ensure compliance with the procedure. Hands should not be washed within a sink that is used for the decontamination of equipment and instruments. Using the same sink can significantly increase the risk of hand and environmental contamination.(24) Providing a separate sink establishes good practice and ensures a safe working environment. Handwashing instructions outlining the correct technique to facilitate compliance should be located as near to the sink as possible.(16)
The value of alcohol hand rubs within the community setting has long been noted,(25) primarily where there is little or no readily available water or towels. When using these preparations it must be remembered that alcohol is not a cleaning agent and is not recommended in the presence of physical dirt.(13) For maximum effect and to decrease any possible irritation, it is essential that the alcohol is allowed to thoroughly evaporate from the skin.

[[NIP23_box1_55]]

Conclusion
The first step towards reducing healthcare-associated infections and their associated costs is to increase compliance with hand hygiene. Handwashing needs to be viewed as a priority and must be continually challenged by both the individual and their colleagues.(11)
Within primary care, the utilising of clinical governance and quality assurance standards is key to ensuring that suitable facilities are made available to all clinical areas and that education programmes are an integral part of professional development.
 
References

  1. Semmelweiss I. The aetiology concept and prophylaxis of child birth fever (transl. K Codell Carter). London: University of Wisconsin Press; 1983.
  2. Horton R, Parker LJ. Informed ­infection control practice. New York: Churchill Livingstone; 1997.
  3. Harding N. Time to freshen up handwashing nosocomial infection. Nurs Times 1996;92(19):62-3.
  4. Garner JS, Favero MS. CDC ­guidelines for the prevention and control of nosocominal infections: guidelines for handwashing and ­hospital environmental control 1985. Am J Infect Control 1986;14(3):110-29.
  5. Hoffman PN, Cooke EM, McCarville MR, Emmerson AM. Micro-organisms isolated from skin under wedding rings worn by hospital staff. BMJ 1985;290:260-7.
  6. Salisbury DM, Hutfilz P, Treen LM, Bollin GE, Gautam S. The effect of rings on microbial load of healthcare workers hands. Am J Infect Control 1997;25(1):24-7.
  7. McGinley KJ, Larson EL, Leyden JJ. Composition and density of micro-flora in the subungual space of the hand.J Clin Microbiol 1988;26:950-3.
  8. Sanderson PJ, Weissler S. Recovery of coliforms from the hands of nurses and patient activitiesleading to contamination. J Hosp Infect 1992;21:85-93.
  9. Reybrouk G. Role of the hands in the spread of nosocominal infections.J Hosp Infect 1983;4:103-10.
  10. Ayliffe G, Babb J, Taylor L. Hospital acquired infection principles and ­prevention. 3rd edn. Oxford: Butterworth-Heinemann; 1999.
  11. ICNA, in association with Department of Health. Guidelines for hand hygiene. London: ICNA; 1999.
  12. The Epic Project. Developing national evidence based guidelines for preventing healthcare associated ­infections. J Hosp Infect 2001;47(Suppl):21-8.
  13. Ward V. Auditing infection.Nurs Times 1997;93:71-4.
  14. Larson EL. APIC guidelines for ­handwashing and hand antisepsis in health-care settings. Washington: APIC Inc; 1995. p. 1-17.
  15. Mallet J, Dougherty L, editors.The Royal Marsden NHS Trust manual of clinical procedures. 4th ed. Oxford: Blackwell Science; 1998.
  16. Ayliffe GA, Babb JR, Quoraishi AH. A test for hygiene hand ­disinfection. J Clin Pathol 1978;31:923.
  17. Gould D. Making sense of hand hygiene. Nurs Times 1994;90:63-4.
  18. Gould D. The significance of hand drying in the prevention of infection. Nurs Times 1994;90:33-5.
  19. Hoffman PN, Wilson J. Hands, hygiene and hospitals. Microbiol Digest 1994;11(4):211-61.
  20. Horton R. Handwashing: the ­fundamental infection control ­principle. Br J Nurs 1995;4(16):926-33.
  21. Lyle H. The situation in hand.Nurs Times 1997;93(37):76.
  22. Kerr J. Handwashing.Nurs Standard 1998;12:35-42.
  23. Gould D. Hygienic hand ­decontamination. Nurs Standard 1992;6(32):33-6.
  24. Finn L, Crook S. Minor surgery in general practice - setting the standards. J Publ Health Med 1998;2(2):169-74.
  25. McFarlane A. Why do we forget to remember handwashing? Prof Nurse 1990;5:250-2.

Resources
Infection Control Nurses Association
W:www.icna.co.uk

Public Health Laboratory Service
W:www.phls.co.uk

Association for Professionals in Infection Control and Epidemiology
W:www.apic.org

Further reading
Guidelines for hand hygiene.  ICNA, in ­association with Department of Health. London: ICNA; 1999

Developing national evidence based guidelines for preventing healthcare ­associated ­infections.
The Epic Project.  J Hosp Infect 2001;47(Suppl):
21-8