Using Effective Hand Hygiene Practice to Prevent and Control Infection

| PEER-REVIEWED | infection prevention and& control / evidence practice

Why you should read this article: ● To learn methods of improving compliance with hand hygiene measures ● To understand when it is appropriate to use soap or alcohol for hand hygiene ● To be reminded of the correct technique for undertaking hand hygiene Using effective hand hygiene practice to prevent and control infection

Mark Dexter Hillier

Citation Abstract Hillier MD (2020) Using effective hand hygiene Decontamination using hand hygiene remains one of the most important and effective0 methods for practice to prevent and control reducing healthcare-associated infections and cross-infection between patients. In 186 , Florence Nightingale wrote that nurses should wash their hands frequently throughout the day, demonstrating an infection. Nursing Standard. early awareness of the effectiveness of this simple procedure. The COVID-19 pandemic has demonstrated doi: 10.7748/ns.2020.e11552 that effectively applied hand hygiene is a vital intervention that can be used to prevent the spread of disease. This article details the correct procedure required for effective hand hygiene and emphasises Peer review the need for nurses to keep up to date with evidence-based guidelines. The article also outlines the This article has been subject differences between hand decontamination using alcohol-based hand gels and soap and water, and to external double-blind the complex factors that can interfere with effective hand hygiene compliance. peer review and checked for plagiarism using Author details automated software Mark Dexter Hillier, course leader, adult nursing, Nursing and Health Care, School of Health and Community Studies, Leeds Beckett University, Leeds, England Correspondence [email protected] Keywords

Conflict of interest clinical, environment, hand hygiene, health promotion, infection, infection control, pandemic, None declared public health

Accepted 6 April 2020 The COVID-19 pandemic has emphasised the of antimicrobial resistance has been common importance of optimal hand hygiene practice to practice for many years (Pires and Pittet 2017). Published online reduce cross-contamination and the spread of Nightingale (1860) called on nurses to wash April 2020 the SARS-CoV-2 virus that causes the disease their hands and faces frequently throughout the (World Health Organization (WHO) 2020a). day, reflecting a long-standing recognition of the During circumstances that present a threat to effectiveness of hand hygiene. Compliance with public health, it is important that nurses across hand hygiene practices has improved in recent the globe adhere to their professional codes years due, in part, to effective role modelling and of conduct. This involves nurses acting as role peer pressure, with increased research into the models for their peers and the public with regard technique’s effectiveness (Pires and Pittet 2017). to clinical behaviours such as hand hygiene and There are several important issues which, when demonstrating how to consider clinical evidence understood, will enable nurses to undertake and and deliver best practice, rather than following promote effective hand hygiene. For example, the anecdotal information. In the UK, the ‘promote importance of hand hygiene in reducing cross- professionalism and trust’ standard in The Code: infection; the technique itself, which includes Professional Standards of Practice and Behaviour the choice of the optimal hand hygiene solution, for Nurses, Midwives and Nursing Associates such as soap and water, or alcohol-based hand (Nursing and Midwifery Council (NMC) 2018) gel; and the factors that can limit compliance states that nurses should ‘act as a role model of with hand hygiene, for example, allergies to professional behaviour for students and newly soap products. qualified nurses, midwives and nursing associates to aspire to’. Permission Improving compliance To reuse this article or for In healthcare, the use of effective hand In nursing, so-called ‘slips’ and ‘lapses’ are linked information about reprints hygiene practice to prevent healthcare-associated to skill-based errors and take place, for example, and permissions, contact infections, cross-infection and reduce the spread when a piece of equipment or a medicine is [email protected] nursingstandard.com © RCN Publishing Company Limited 2020 | PEER-REVIEWED | infection prevention& and control / evidence practice

omitted, or a step in a procedure, Gluyas (2015) further suggested hygiene, nurses should follow local such as part of a medicine equation, that sustained improvement in policy and keep up to date with is missed. Errors are more likely to hand hygiene practices have been best practice guidelines. There are happen when tasks become familiar inconsistent but, where they have five main moments when healthcare and require little conscious thought. been successful, a combination workers, such as nurses, should Mistakes occur when the nurse is of approaches has been involved. undertake hand hygiene during not consciously paying attention These approaches include: clinical care (WHO 2009b): to the task and are more likely to effective role modelling of optimal » Before touching a patient. be related to a lack of knowledge practice; peer pressure where non- » Before undertaking (knowledge-based errors), compliance has become routine; aseptic procedures. application of an incorrect rule, and an emphasis on the importance » After exposure or risk of or incorrect application of a rule of leadership, commitment and exposure to bodily fluids. (rule-based errors) (Carayon 2012, provision of resources. The » After touching a patient. Gluyas 2015). availability of equipment such as » After touching a patient’s Gluyas (2015) examined hand running water, soap and alcohol- surroundings. hygiene compliance from the based hand gel at the point of care These factors support other perspective of human factors, which and a clear space to store healthcare guidelines such as those by include interactions between people’s staff’s belongings such as lockers Loveday et al (2014), who defined cognitive processes and their actions, for nurses to put their non-uniform touching a patient as ‘each episode the environment they are working clothes and bags are also crucial of direct patient contact or care’. in, and the tools they are using. This to sustained improvement in hand In addition, Loveday et al (2014) knowledge can provide an improved hygiene practices. stipulated that hand hygiene must understanding of errors, as well as In any healthcare organisation, occur after the removal of clinical identifying strategies that will reduce Burnett (2018) stated that gloves, although wearing gloves them (Gluyas 2015). Suboptimal leadership is crucial when should never replace optimal hand hand hygiene compliance can also developing, implementing and hygiene. Gloves are reserved for occur through violations of accepted evaluating effective infection specific activities such as invasive practice, where a healthcare prevention and control measures. procedures, contact with sterile worker deliberately decides not to The purpose of effective leadership sites or non-intact skin and follow procedures or requirements in infection prevention and control mucous membranes, handling (Seo et al 2019). This differs from is to reduce the risks of healthcare- contaminated devices, and for slips, lapses and mistakes in that associated infection, particularly activities assessed as carrying a risk departures from procedures and those caused by antimicrobial of exposure to blood or bodily protocols are deliberate choices. resistant organisms, and to achieve fluids (Loveday et al 2014). Gloves Gluyas (2015) suggested that continuous quality improvement are therefore generally not worn for the decision to violate rules or (Gould et al 2016, Burnett 2018). administering injections; rather, the protocols is primarily associated Burnett (2018) raised two nurse should follow optimal hand with an intention to complete important points in relation to hygiene practice. tasks in the most efficient manner infection control, which can be and that resulting errors and any related to hand hygiene. One is subsequent harm are not intended. the need for an effective leader Hand hygiene in Time pressures and the environment to improve competence where Duringclinical clinical practice practice and when may have a role in infection control necessary by developing a non- in contact with patients, healthcare violations, for example where punitive culture. Encouraging staff should ensure their clothing the lack of a nearby sink means an open learning culture where does not extend below the elbow a healthcare worker may not wash staff feel comfortable to raise any and many local guidelines suggest their hands before attending to challenges involved in undertaking that jewellery should be limited a patient in an emergency. effective hand hygiene – particularly to one plain single-band wedding Gluyas (2015) noted that there is related to human factors such as ring. Any cuts or breaks in the skin a risk that nurses can begin to focus errors and omissions – can prevent should be covered with a water- on clinical activities and forget to issues being hidden and suboptimal resistant dressing. Nails should be undertake hand hygiene practice, practice being maintained. Second, short and clean, with no varnish even when there is time available. the effectiveness of any infection or artificial additions. Some However, when hand hygiene is prevention control and prevention small-scale observational studies considered using human factors strategy depends on the efforts of have demonstrated that wearing rather than a punitive approach that the whole multidisciplinary team rings and false nails is associated regards nurses’ mistakes as aberrant and should not rely solely on the with increased carriage of or negligent, the environment can leader (Burnett 2018). microorganisms and, in some cases, be adapted to reduce the effect linked to the carriage of outbreak of those factors. Adapting the strains (Loveday et al 2014). environment includes the provision When to undertake Healthcare staff should have of education regarding when hand Inhand attempting hygiene to understand when ready access to a sink with warm hygiene practice must be applied. it is necessary to undertake hand water for washing hands using

soap and water. This is not required sometimes be unclear initially when using alcohol-based hand whether patients with a diarrhoeal gel. Soap should be obtained from illness have a C. difficile infection, it Key points a liquid dispenser – not from is prudent to use soap and water for ● The COVID-19 pandemic has emphasised the a bar of soap, which can harbour hand hygiene practice at the outset in importance of optimal hand hygiene practice germs – or alcohol-based hand these patients. gel should be used. Moisturiser, Although alcohol-based hand gel ● With regards to optimal hand hygiene, nurses which is not required when using is effective in reducing the spread should follow local policy and keep up to date alcohol-based hand gel, and paper of infection of Gram-negative towels, which can be disposed of, and Gram-positive bacteria, it is with best practice guidelines should be available when using less effective against some non- soap and water. enveloped viruses such as rotavirus ● There is a risk that nurses may focus on Where access to appropriate and norovirus and is dependent on clinical activities and forget to decontaminate equipment is limited, such as when the alcohol concentration of the gel their hands the nearest sink is located some (Kampf 2018). In cases of actual distance away or there is a lack of or suspected norovirus, healthcare ● Nurses should decontaminate their hands readily available alcohol-based hand staff should follow local policy and before touching a patient, after touching gel, it could be argued that there is washing the hands with soap and a patient, after touching a patient’s a risk that compliance with hand water is generally recommended, hygiene will be omitted, particularly with alcohol-based hand gel used as surroundings, before undertaking aseptic in a time-pressured environment. an additional safety measure. The procedures and after exposure to bodily fluids WHO (2020b) noted that the efficacy of alcohol-based hand gel availability of alcohol-based hand against norovirus varies according gel increases the likelihood of to the type and concentration of follow local hand hygiene protocols, compliance with hand hygiene. alcohol in the formulation, with although the principles will Healthcare staff now frequently a minimum 60% concentration of reflect those listed below. Before carry a small hand gel dispenser ethanol required for effectiveness commencing handwashing, the with them for this reason. (Kampf 2018, WHO 2020b). hands and wrists need to be fully Research on the use of alcohol- exposed and should be free from based hand gel in the management jewellery and any long-sleeved Soap and water or alcohol- of COVID-19 is increasing, clothing (Loveday et al 2014). The Thebased use hand of soap gel and water and with guidance recommending procedure for handwashing with alcohol-based hand gel are both a concentration of at least 60% soap and water is as follows: effective hand hygiene methods, ethanol (Centers for Disease » Turn on the taps at the sink although each has limitations. It Control and Prevention 2020). using the elbows, or foot pedals is important for nurses to follow When the hands are visibly if provided. Check that the local and national best-practice clean and nurses have not been water is at a comfortable warm guidelines so they are aware of the exposed to patients presenting temperature and soak the hands circumstances in which each method with C. difficile or diarrhoea of thoroughly from the tips of is effective. unknown origin, alcohol-based fingers to the lower forearms. Loveday et al (2014) noted that hand gel with 70% ethanol content » Dispense one to two applications alcohol-based hand gel can be used is more effective at cleansing the of liquid soap into the palm for decontamination of the hands hands and reducing the spread of of the hand. before and after direct patient infection compared with soap and » Rub the hands together to contact and clinical care, except water alone (Turner et al 2010). create a lather – this should take in some situations when soap and approximately ten seconds. water must be used. These situations » Follow handwashing stages 2-7 include when the hands are visibly WhenHandwashing the hands with are soap washed and using water of the WHO (2009a) guidance, as soiled or potentially contaminated soap and water, it is not the soap outlined in Figure 1. with body fluids and when caring for and/or water alone that disrupts the » Rinse the hands thoroughly using patients with vomiting or diarrhoeal microorganisms. It is also important water only, ensuring that all soap illnesses, regardless of whether or that healthcare staff understand is removed from the hands and not gloves have been worn. One that the mechanical process of lower arms. reason that it is important to use handwashing assists in the removal » Turn off the taps using the soap and water when caring for of contaminants from the hands. elbows, or foot pedals if provided. patients with a diarrhoeal illness This effect combined with that Alternatively, use a clean paper is that alcohol-based hand gel is of the warm water, promotes the towel to turn off the taps. Do not ineffective against Clostridium opening of the pores in the skin of use the hands. difficile spores. Therefore, the use of the hands and lower arms, aiding » Dry the hands and lower arms soap and water is a vital component microorganism removal (Wilkinson using a clean paper towel, and of hand hygiene interventions in and Treas 2010). dispose of the used towel in C. difficile infection (Barker et al When handwashing with soap accordance with local policy. 2017, Loftus et al 2019). As it can and water, healthcare staff should » If the skin on the hands is nursingstandard.com © RCN Publishing Company Limited 2020 | PEER-REVIEWED | infection prevention& and control / evidence practice

noticeably dry, a hand moisturiser » Apply a palmful of alcohol-based from a wall-mounted dispenser Hand cleansing using alcohol- hand gel to the hands. can be applied sparingly Alcohol-basedbased hand gel hand gel works by » Rub hands together, ensuring that until absorbed. lysing (the process of breaking the gel is spread all over hands, The whole procedure should take down the cell membrane) fingers and lower arms. 40-60 seconds (WHO 2009a). and denaturing the cells of » Follow hand-cleansing stages 2-7 After handwashing using soap microorganisms, reducing microbial of the WHO (2009a) guidance, as and water, nurses should dry their contamination on the hands to outlined in Figure 2. hands thoroughly. This is because low levels. » Ensure hands are dry and that the spread of microorganisms is Before commencing hand hygiene no gel residue remains on the more likely when the nurse’s hands with alcohol-based hand gel, the hands or lower arms. If there is are warm and moist, creating ideal hands and wrists need to be fully residue, repeat the stages shown conditions for microbial growth exposed and therefore should be in Figure 2 until the hands and (Huang et al 2012). Evidence also free from jewellery and any long- lower arms are dry. suggests that the use of soap and sleeved clothing (Loveday et al » Moisturiser should not be water together is more effective 2014). The procedure for hand required after using alcohol- compared with using water alone cleansing using alcohol-based hand based hand gel, because these (Burton et al 2011). gel is as follows: preparations often contain

Figure 1. Handwashing steps using soap and water

Duration of the entire procedure: 40-60 seconds

0 1 2

Wet hands with water Apply enough soap to cover all hand Rub hands palm to palm surfaces

3 4 5

Right palm over left dorsum with Palm to palm with fingers interlaced Backs of fingers to opposing palms interlaced fingers and vice versa with fingers interlocked

6 7 8

Rotational rubbing of left thumb Rotational rubbing, backwards and Rinse hands with water clasped in right palm and vice versa forwards with clasped fingers of right hand in left palm and vice versa

9 10 11

Dry hands thoroughly with a single Use towel to turn off faucet Your hands are now safe use towel

(Adapted from World Health Organization 2009a)

emollients to prevent dry skin. could use a technique such as However, healthcare staff can singing the ‘happy birthday’ song ItCultural is important considerations to remember that check the ingredients of the to themselves while they undertake during the continued emphasis on gel to verify the presence of handwashing, which equates effective hand hygiene associated an emollient. to approximately 20 seconds. with the COVID-19 pandemic, Importantly, following the process people from some cultures and of decontamination with soap and religions may prefer not to use Evidence base water or alcohol-based hand gel alcohol-based products (Loftus et al WongDuration and Lee (2019) noted advocated in the WHO (2009a) 2019). While this preference needs that there is a lack of empirical guidance, healthcare staff should to be sensitively addressed by evidence concerning the optimal ensure that they pay attention healthcare staff, recent research duration of handwashing for the to areas of the hands that are has suggested that culturally- general public. For healthcare staff, commonly missed. While these specific interventions – such as a minimum handwashing duration areas vary across the literature, they involving religious groups in of 20 seconds is recommended include the finger tips, the palm of planning guidelines and careful use across the guidance (WHO 2009a, the hands, the back of the hands, of terminology related to alcohol 2020b). In the UK, the author the thumbs and the wrists (Wong (WHO 2009b) – could significantly recommends that healthcare staff and Lee 2019). improve compliance and beliefs

2 Figure . Hand decontamination steps using alcohol-based hand gel

Duration of the entire procedure: 20-30 seconds

1a 1b 2

Apply a palmful of the product in a cupped hand, covering all surfaces Rub hands palm to palm

3 4 5

Right palm over left dorsum with interlaced Palm to palm with fingers interlaced Backs of fingers to opposing palms with fingers fingers and vice versa interlocked

6 7 8

Rotational rubbing of left thumb clasped in right Rotational rubbing, backwards and forwards Once dry, your hands are safe palm and vice versa with clasped fingers of right hand in left palm and vice versa

(Adapted from World Health Organization 2009a) nursingstandard.com © RCN Publishing Company Limited 2020 | PEER-REVIEWED | infection prevention& and control / evidence practice

concerning the use of alcohol-based gels, accepting the importance of cross-infection and the spread of hand gel in people from countries optimal patient care (WHO 2009b). antimicrobial resistance. The subject such as the United Arab Emirates It would also be overly simplistic to of handwashing is a deceptively (Ng et al 2019). More research is conclude that religious and cultural complex issue and compliance required in this area. aspects of hand hygiene focus is affected by a range of factors, WHO (2009b) has noted that purely on alcohol. This is a wider including accurate knowledge, the there are various interpretations topic and incorporates other areas correct decontamination technique, concerning alcohol prohibition such as the concept of ‘dirty hands’, human factors, the environment among various religions, and among which may be linked to beliefs and effective leadership. people with the same religious around purity, and the inclusion of The COVID-19 pandemic has affiliation. According to some handwashing in religious practice. emphasised the importance of faiths, using alcohol-based hand effective hand hygiene practice. gels does not present an issue. In However, it is important to stress general, those religions that observe EffectiveConclusion hand hygiene practice that healthcare staff should alcohol prohibition in everyday life remains one of the most useful maintain hand hygiene standards demonstrate a pragmatic attitude tools in the prevention of at all times, not simply during to the use of alcohol-based hand healthcare-associated infections, challenging circumstances.

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