Infectious Disease Prevention: Handwashing
Handwashing is the single most important measure in preventing the spread of infection. Handwashing involves the mechanical action of washing the hands with unmedicated detergent and water, or just water alone. The objective is to remove dirt and transient flora.
Hygienic handwashing involves the addition of an antiseptic agent to the detergent, such as medicated soap or alcohol.
The hand is colonized by many bacteria. These bacteria can be divided into two groups – transient flora and resident flora. Transient flora are those that are picked up by everyday contact. They lie in the superficial layers of the skin and are the one’s usually responsible for transmissible diseases. Resident flora are those that lie in the deeper layers of the skin. They are much more difficult to remove with basic handwashing but, fortunately, are less likely to be associated with healthcare-related infections.
Transmission of healthcare-associated pathogens occurs when a healthcare worker picks up organisms from a patient, or from objects in the immediate area of a patient, and then transfers them to another patient, person, or inanimate object. Even if handwashing is an intermediate step in this sequence, transmission can still occur if handwashing is inadequate.
Hand Hygiene Preparations:
Numerous studies have documented the efficacy of handwashing with antiseptic solutions in reducing healthcare-related disease transmission. The efficacy of hand-hygiene products is evaluated using test subjects that wash their hands for 30 seconds to 1 minute. Unfortunately, healthcare workers most frequently are observed to spend less than 15 seconds washing their hands. The following is a brief list of agents used for hand-hygiene.8
Antiseptic agents reduce the number of microbial flora and include: alcohols, chlorhexidine, chlorine, iodine, chloroxylenol, hexachlorophene, and triclosan.
-Alcohol-Based Hand Rubs: These preparations typically contain 60% to 95% ethanol or isopropanol. They have good antimicrobial activity, but are ineffective against spores and certain enveloped viruses. Furthermore, they have no residual germicidal activity. Use of an alcohol-based hand rub requires removal of any dirt present on the hands to be effective. These preparations are rapid acting, more convenient (as in they are easy to spread and evaporate rapidly), and they irritate the hands less often than other preparations. Therefore, they are widely used in the healthcare community.
-Chlorhexidine Gluconate: Chlorhexidine works less rapidly than alcohol, has minimal activity against tuberculosis, and is not effective against spores. However, unlike alcohol, this preparation has good residual activity.
-Chloroxylenol (also called PCMX): PCMX is not as rapidly active as chlorhexidine and has less residual activity.
-Hexachlorophene: This preparation is bacteriostatic, meaning it does not kill bacteria. It has modest efficacy after a single hand wash and has good residual activity. Hexachlorophene is weak against tuberculosis and fungi, as well as gram-negative bacteria. It has not been recognized by the FDA as safe or effective.
-Iodine: Iodine is effective against bacteria, viruses, and fungi. However, it is not sporicidal in typical concentrations. It has poor residual activity and commonly irritates the skin.
-Quaternary Ammonium Compounds: These agents are bacteriostatic and fungistatic, but are seldom used.
-Triclosan: Triclosan is a seldom used bacteriostatic agent.
Detergents are substances that possess cleaning action. These substances are mainly soaps.
-Plain Soaps: Plain soaps are detergents that effectively remove dirt and various organic products from the hands, but have minimal antimicrobial activity. The mechanical action of rubbing the hands with soap and water can remove loose flora present on the skin.
-Antimicrobial Soaps: Antimicrobial soaps are detergents that contain an antiseptic agent, which can kill microbes.
Hand Hygiene Products and Adverse Effects:
As you may have gathered, alcohol-based products are some of the most effective agents available. Fortunately, they are also one of the safest antiseptics available. Although alcohol can cause dryness and irritation, the rate of allergic contact dermatitis with alcohol is low. Irritant contact dermatitis is more common with iodine and similar compounds, as well as with fragrances and preservatives that are present in some soaps. Regular use of hand lotions and creams can help prevent or treat irritant contact dermatitis caused by hand hygiene products.8
Proper handwashing should last at least 15 seconds. Begin by washing distally and then proceed proximally. In other words, if your hands were only exposed up to the wrists, begin scrubbing at your fingertips, and proceed toward the wrist. Work your way around each finger, including underneath finger nails. It is important to use a device, such as a scrub brush, to get underneath your fingernails, where pathogens can go uncleansed. Vigorously lather and scrub each area with soap. Carefully cleanse the hard to reach crevices and areas between your fingers. Finally, rinse thoroughly. While rinsing, attempt to keep the most proximal part of your body that you scrubbed lower than your fingertips. This maneuver serves to prevent any contaminants that you may have missed from being carried by water back towards your hands. Repeat this washing procedure as many times as necessary to remove all dirt and contaminants. Dry yourself well, preferably with a disposable towel. Use the towel to turn off the faucet, as the faucet handle may contain bacteria.
Sometimes soap and water are not available. In these instances, you will hopefully have access to antipathogenic foam or liquid that you can rub over your hands until handwashing becomes available. Apply the agent to the palm of your hand in the amount indicated by the particular manufacturer. Rub your hands together, covering all surfaces, until your hands are dry.
One final note to remember is that you should wash your hands even if you were wearing gloves.
Healthcare workers often fail to wash their hands as recommended. In fact, compliance with hand hygiene recommendations is estimated to be less than 50%. Risk factors for poor adherence include:9
1) Male sex.
2) Wearing gowns/gloves.
3) Working during the week.
4) Lack of protocol knowledge and risks.
5) Lack of a role model.
6) Lack of agency priority for hand hygiene.
7) Lack of active participation in hand hygiene promotion at the individual and institutional levels.
8) Lack of easy access to hand-hygiene supplies.
Multimodal strategies are the most effective in improving hand hygiene adherence.8,9
At the core of every strategy should be employee education. Personnel should be taught that hand hygiene works. It should be emphasized that adequate hand hygiene reduces the risk of infection to one’s self, one’s patients, and one’s family. Employees should be taught to recognize the low adherence rate of themselves and others. Active observation of one’s self and others will help to increase compliance.
Personnel should receive information on the appropriateness, efficacy, and use of cleaning agents and skin care products. Many employees fear skin irritation that may result from frequent handwashing. However, many newer agents are less irritative and incorporate emollients to soothe the skin. Furthermore, most people do not realize that handwashing is not required after applying alcohol. Therefore, alcohol disinfectants can be used to reduce the amount of handwashing. Finally, personnel should be instructed to use lotions frequently to ensure adequate hydration and reduce irritation.
-Role Model Provision:
Role model provision is an additional effective measure in improving hand hygiene adherence. Frequently, personnel will follow the “herd mentality” and if one person is not washing his or her hands then others will find it more acceptable not to do so as well. This is especially important in the initial training of healthcare personnel, as they are most impressionable during their education. Role models should be provided for both initial and continuing education of hand hygiene, so as to serve as a constant reminder of proper hand hygiene technique.
-Ready Access to Hygiene Supplies:
Hand hygiene standards are much easier to comply with if the supplies and equipment are readily accessible. Furthermore, agencies should purchase hand hygiene products that employees will want to use and should make decisions based on the preferences of the employees.
-Involvement of Administrative Personnel:
The administrative personnel’s role should also be mentioned. They are responsible for setting guidelines and enforcing them, whether with penalties for poor adherence or rewards for adequate adherence.