‫ﻛﻠﻴﯿﺔ ﺍاﻟﻄﺐ ﻗﺴﻢ ﻁطﺐ ﺍاﻻﺳﺮﺓة ﻭوﺍاﻟﻤﺠﺘﻤﻊ‬ ‫ﺟﺎﻣﻌﺔ ﻁطﺮﺍاﺑﻠﺲ‬

ABSTRACT  
1. To review scientific data regarding hand
hygiene (H.H)
2.To know the recommended guidelines
and the different techniques for H.H
3. To study H.H practices among health
care workers (HCWs)
Dr  Ezzadin  Franka  
Infection  Control  

HAND  HYGIENE  
INFECTION CONTROL
 Hand Hygiene

Learning objectives
1. To review scientific data regarding hand hygiene(H.H) including:
• Introduction and historical perspectives
• Normal bacterial skin flora
• Evidence of transmission of pathogens on hands
• Important definitions
• Comparison of different preparations used for hand hygiene
• Factors to consider when selecting hand-hygiene products
• Irritant contact dermatitis and proposed methods to reduce the adverse
effects

2. To know the recommended guidelines and the different techniques for

H.H

3. To study H.H practices among health care workers (HCWs) including:

• Low compliance and barriers to H.H
• Key Factors for hand hygiene compliance improvement
• Some strategies for successful promotion of H.H.
• Performance indicators
• Success stories

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Scientific Data Regarding Hand Hygiene

Introduction
Hand hygiene is the single most important procedure for preventing the transmission
of nosocomial infections. Studies have shown that an average of only 40% of HCWs
adheres to hand hygiene practices in their institutions. The challenge, however, is to
improve adherence with appropriate Hand hygiene.

Historical Perspective
• Handwashing with soap and water has been considered a measure of
personal hygiene.
• Our Islamic
• The concept of cleansing hands with an antiseptic agent probably emerged
in the early 19th century.
• In a paper published in 1825, a French pharmacist stated that physicians
and other persons attending patients with contagious diseases would
benefit from moistening their hands with a liquid chloride solution.
• In 1846, Ignaz Semmelweis insisted that students and physicians clean
their hands with a chlorine solution between each patient in the clinic.
• In 1843, Oliver Wendell Holmes concluded independently that puerperal
fever was spread by the hands of health personnel.
• Handwashing gradually became accepted as one of the most important
measures for preventing transmission of pathogens in health-care facilities.
• In 1961, the U. S. Public Health Service produced a training film that
demonstrated hand washing techniques recommended for use by health-
care workers.
• In 1975 and 1985, formal written guidelines on hand washing practices in
hospitals were published by CDC.
• In 1988 and 1995, guidelines for hand washing and hand antisepsis were
published by the Association for Professionals in Infection Control
(APIC).
• In 1995 and 1996, the Healthcare Infection Control Practices Advisory
Committee (HICPAC) recommended that either antimicrobial soap or a
waterless antiseptic agent be used for cleaning hands upon leaving the
rooms of patients with multidrug-resistant pathogens (e.g. MRSA& VRE).
• In 2002: recommendations have been prepared by a Hand Hygiene Task
Force, comprising representatives from HICPAC, the Society for
Healthcare Epidemiology of America (SHEA), APIC, and the Infectious
Diseases Society of America (IDSA).
• In 2005/2006 : World alliance for patient safety is focusing part of its
attention on improving hand hygiene standards and practice to be
implemented worldwide with a sense of equity and solidarity through the
campaign "Clean Hands are Safer Hands"

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Normal Bacterial Skin Flora
• Total bacterial counts on the hands of medical personnel have ranged from 3.9
x 104 to 4.6 x 106.

Bacteria recovered from the hands were divided into two

categories: transient and resident
Transient flora
• They colonize the superficial layers of the skin.
• They are more amenable to removal by routine handwashing.
• They are often acquired by HCWs during direct contact with patients or
contact with contaminated environmental surfaces within close proximity
of the patient.
• They are the organisms most frequently associated with health-care–
associated infections.
Resident flora
• They are attached to deeper layers of the skin (e.g., coagulase-negative
staphylococci and diphtheroids).
• They are more resistant to removal.
• They are less likely to be associated with health-care–associated
infections.
• The hands of HCWs may become persistently colonized with pathogenic
flora (e.g., S. aureus), Gram negative bacilli, or yeast.

Evidence of Transmission of Pathogens on Hands

Transmission of health-care–associated pathogens from one patient to another via the
hands of HCWs requires the following sequence of events:
• Organisms present on the patient’s skin, or those have been shed onto
inanimate objects in close proximity to the patient, must be transferred to the
hands of HCWs.
• These organisms must then be capable of surviving for at least several minutes
on the hands of personnel.
• Next, handwashing or hand antisepsis by the worker must be inadequate or
omitted entirely, or the agent used for hand hygiene must be inappropriate.
• Finally, the contaminated hands of the caregiver must come in direct contact
with another patient, or with an inanimate object that will come into direct
contact with the patient.

Health-care–associated pathogens can be recovered not only from infected or draining

wounds, but also from frequently colonized areas of normal, intact patient skin. The
perineal or inguinal areas are usually most heavily colonized,
but the axillae, trunk, and upper extremities (including the hands) also are frequently
colonized.

Contamination of HCWs’ hands occur during activities that involved direct patient-
contact wound care, intravascular catheter care, respiratory tract care, and the
handling of patient secretions.

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Nurses can contaminate their hands during “clean” activities (e.g., lifting a patient;
taking a patient’s pulse, blood pressure, or oral temperature; or touching a patient’s
hand, shoulder, or groin)

Studies also have documented that HCWs may contaminate their hands (or gloves)
merely by touching inanimate objects in patient rooms.

Definition of Terms
Handwashing: Washing hands with plain (i.e., non-antimicrobial) soap and water.
Antiseptic hand wash: Washing hands with detergents containing an antiseptic agent.
Antiseptic hand rub: Applying an antiseptic hand-rub product to all surfaces of the
hands to reduce the number of microorganisms present.
Alcohol-based hand rub: An alcohol-containing preparation designed for application
to the hands for reducing the number of viable microorganisms on the hands.
Hand antisepsis: Refers to either antiseptic hand wash or antiseptic hand rub.
Surgical hand antisepsis: Antiseptic hand wash or antiseptic hand rub performed
preoperatively by surgical personnel to eliminate transient and reduce resident hand
flora.
Hand hygiene: A general term that applies to hand washing, antiseptic hand wash,
antiseptic hand rub, or surgical hand antisepsis.
Visibly soiled hands: Hands showing visible dirt or those visibly contaminated with
proteinaceous material, blood, or other body fluids (e.g. fecal material or urine).
Plain soap: refers to detergents that do not contain antimicrobial agents or contain
low concentrations of antimicrobial agents that are effective solely as preservatives.
Antimicrobial soap: detergent containing an antiseptic agent.
Detergent: Detergents (i.e., surfactants) are compounds that possess a cleaning action.
Antiseptic agent: Antimicrobial substances that are applied to the skin to reduce the
number of microbial flora.
Waterless antiseptic agent: An antiseptic agent that does not require use of exogenous
water. After applying such an agent, the hands are rubbed together until the agent has
dried.
Persistent activity: is defined as the prolonged or extended antimicrobial activity that
prevents or inhibits the proliferation or survival of microorganisms after application
of the product. This property also has been referred to as “residual activity.”
Substantivity; Substantivity is an attribute of certain active ingredients that adhere to
the stratum corneum (i.e., remain on the skin after rinsing or drying) to provide an
inhibitory effect on the growth of bacteria remaining on the skin.
Cumulative effect: A progressive decrease in the numbers of microorganisms
recovered after repeated applications of a test material.

Preparations Used for Hand Hygiene

Plain (Non-Antimicrobial) Soap
• Soaps are detergent-based products that contain esterified fatty acids and
sodium or potassium hydroxide.
• They are available in various forms including bar soap, and liquid
preparations.

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 • Their cleaning activity can be attributed to their detergent properties,
which result in removal of dirt, soil, and various organic substances from
the hands.
• Soaps may be associated with considerable skin irritation and dryness,
although adding emollients to soap preparations may reduce their
propensity to cause irritation.
• Handwashing with plain soap can result in paradoxical increases in
bacterial counts on the skin, which is probably caused by increased
shedding of viable bacteria in desquamating epithelium (resident flora) as
a result of the trauma of frequent washing.
• Occasionally, plain soaps have become contaminated, which may lead to
colonization of hands of personnel with Gram-negative bacilli.

Alcohols
• The majority of alcohol-based hand antiseptics contain isopropanol,
ethanol, or a combination of two of these products.
• Although ethyl alcohol and isopropyl alcohol are both effective against
bacteria, fungi, and viruses, isopropyl alcohol has slightly greater activity
against bacteria and ethyl alcohol has greater activity against viruses.
• Alcohols have very poor activity against bacterial spores, protozoan
oocysts, and certain nonenveloped (nonlipophilic) viruses.
• Alcohols are rapidly germicidal when applied to the skin, but they have no
appreciable persistent (i.e., residual) activity. Addition of chlorhexidine to
alcohol-based solutions can result in persistent activity. This characteristic
of persistence may be desirable to enhance continued antimicrobial
activity when it is not possible to wash the hands during prolonged
surgical procedures.
• Alcohols are not appropriate for use when hands are visibly dirty or
contaminated with proteinaceous materials.
• Frequent use of alcohol-based formulations for hand antisepsis can cause
drying of the skin unless emollients are added to the formulations. The
drying effect of alcohol can be reduced or eliminated by adding 1%–3%
glycerol or other skin conditioning agents.
• Even well tolerated alcohol hand rubs containing emollients may cause a
transient stinging sensation at the site of any broken skin (e.g., cuts and
abrasions).
• Alcohol-based hand-rub preparations with strong fragrances may be poorly
tolerated by HCWs with respiratory allergies. Allergic contact dermatitis
or contact urticaria syndrome caused by hypersensitivity to alcohol or to
various additives present in certain alcohol hand rubs occurs only rarely.
• Because alcohols are volatile, containers should be designed to minimize
evaporation.
• Alcohols are flammable, as a result, alcohol based hand rubs should be
stored away from high temperatures or flames.

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In mid-2004, the Fire Protection Association, USA, announced the Life Safety Code
to specifically recognize and permit the use of alcohol-based hand rub solutions in
patient rooms, corridors, and suites of healthcare facilities. Adoption of this allows the
installation of dispensers in corridors, provided that the following conditions are met:
• The corridor width is 6 ft or greater, and dispensers are separated by at least 4
ft
• The maximum individual dispenser fluid capacity is 1.2 L for dispensers in
rooms, corridors, and areas open to corridors and 2.0 L for dispensers in suites
of rooms
• The dispensers are not installed over or directly adjacent to electrical outlets
and switches

Chlorhexidine
Chlorhexidine gluconate (2-4%), a cationic bisguanide, was developed in England in
the early 1950s.
• The antimicrobial activity of chlorhexidine is likely attributable to
attachment to, and subsequent disruption of, cytoplasmic membranes,
resulting in precipitation of cellular contents.
• Chlorhexidine immediate antimicrobial activity occurs more slowly than
that of alcohols.
• Chlorhexidine has good activity against Gram-positive bacteria, somewhat
less activity against Gram-negative bacteria and fungi, and only minimal
activity against tubercle bacilli. Chlorhexidine is not sporicidal. It has in
vitro activity against enveloped viruses and less activity against
nonenveloped viruses.
• The antimicrobial activity of chlorhexidine is only minimally affected by
the presence of organic material, including blood.
• Because chlorhexidine is a cationic molecule, its activity can be reduced by
natural soaps and hand creams containing anionic emulsifying agents.
• Chlorhexidine has substantial residual activity. Addition of low
concentrations (0.5%–1.0%) of chlorhexidine to alcohol-based preparations
results in greater residual activity than alcohol alone.
• Minimal, if any, absorption of the compound occurs through the skin. The
frequency of skin irritation is concentration-dependent, with products
containing 4% most likely to cause dermatitis when used frequently for
antiseptic handwashing.
• Care must be taken to avoid contact with the eyes, because the agent can
cause conjunctivitis and severe corneal damage. Ototoxicity precludes its
use in surgery involving the inner or middle ear. Direct contact with brain
tissue and the meninges should be avoided.

Iodine and Iodophors

• Iodine has been recognized as an effective antiseptic since the 1800s.
However, because iodine often causes irritation and discoloring of skin,
iodophors have largely replaced iodine as the active ingredient in
antiseptics.
• Iodine molecules rapidly penetrate the cell wall of microorganisms and
inactivate cells by forming complexes with amino acids and unsaturated

6
 fatty acids, resulting in impaired protein synthesis and alteration of cell
membranes.
• Iodophors are composed of elemental iodine, iodide or triiodide, and a
polymer carrier (i.e., the complexing agent) of high molecular weight. The
amount of molecular iodine present (so-called “free” iodine) determines the
level of antimicrobial activity of iodophors.
• Combining iodine with various polymers increases the solubility of iodine,
promotes sustained release of iodine, and reduces skin irritation. The most
common polymers incorporated into iodophors are polyvinyl pyrrolidone
(i.e., povidone).
• Iodine and iodophors have bactericidal activity against Gram-positive,
Gram-negative, and certain spore-forming bacteria (e.g., clostridia and
Bacillus spp.) and are active against mycobacteria, viruses, and fungi.
However, in concentrations used in antiseptics, iodophors are not usually
sporicidal.
• Povidone-iodine 5%–10% has been classified by FDA as a Category I
agent (i.e., a safe and effective agent for use as an antiseptic hand wash and
an HCW hand wash).
• The in vivo antimicrobial activity of iodophors is substantially reduced in
the presence of organic substances (e.g., blood or sputum).
• Iodophors cause less skin irritation and fewer allergic reactions than iodine,
but more irritant contact dermatitis than other antiseptics commonly used
for hand hygiene.
• Occasionally, iodophor antiseptics have become contaminated with Gram
negative bacilli as a result of poor manufacturing processes and have
caused outbreaks of infection.

Chloroxylenol
• Chloroxylenol, also known as parachlorometaxylenol (PCMX), is a
halogen-substituted phenolic compound that has been used as a
preservative in cosmetics and other products and as an active agent in
antimicrobial soaps. It was developed in Europe in the late 1920s.
• The antimicrobial activity of PCMX likely is attributable to inactivation of
bacterial enzymes and alteration of cell walls.
• It has good in vitro activity against Gram-positive organisms and fair
activity against Gram-negative bacteria, mycobacteria, and certain viruses.
PCMX is less active against P. aeruginosa, but addition of
ethylenediaminetetraacetic acid (EDTA) increases its activity against
Pseudomonas spp. and other pathogens.
• PCMX is not as rapidly active as chlorhexidine gluconate or iodophors, and
its residual activity is less pronounced than that observed with
chlorhexidine gluconate.
• In 1994, FDA classified PCMX as a Category IIISE active agent (i.e.,
insufficient data are available to classify this agent as safe and effective).
Further evaluation of this agent by the FDA is ongoing.

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Hexachlorophene

• Hexachlorophene is a bisphenol composed of two phenolic groups and

three chlorine moieties. In the 1950s and early 1960s, emulsions containing
3% hexachlorophene were widely used for hygienic hand washing, as
surgical scrubs, and for routine bathing of infants in hospital nurseries.
• The antimicrobial activity of hexachlorophene results from its ability to
inactivate essential enzyme systems in microorganisms. Hexachlorophene
is bacteriostatic, with good activity against S. aureus and relatively weak
activity against Gram-negative bacteria, fungi, and mycobacteria.
• Hexachlorophene has residual activity for several hours after use and
gradually reduces bacterial counts on hands after multiple uses (i.e., it has a
cumulative effect).
• In the early 1970s, certain infants bathed with hexachlorophene developed
neurotoxicity. As a result, in 1972, the FDA warned that hexachlorophene
should no longer be used routinely for bathing infants.
• The agent is classified by FDA as not generally recognized as safe and
effective for use as an antiseptic hand wash.

Triclosan
• Triclosan (chemical name: 2, 4, 4' –trichloro-2'-hydroxydiphenyl ether) is a
nonionic, colorless substance that was developed in the 1960s.
• Triclosan activity against Gram-positive organisms (including MRSA) is
greater than against Gram-negative bacilli, particularly P. aeruginosa. The
agent possesses reasonable activity against mycobacteria and Candida spp.,
but it has limited activity against filamentous fungi.
• In 1994, FDA classified Triclosan as a Category IIISE active agent (i.e.,
insufficient data exist to classify this agent as safe and effective for use as
an antiseptic hand wash).

Quaternary Ammonium Compounds

• Quaternary ammonium compounds are composed of a nitrogen atom linked
directly to four alkyl groups, which was used as early as 1935.
• The antimicrobial activity of this group of compounds likely is attributable
to adsorption to the cytoplasmic membrane, with subsequent leakage of
low molecular weight cytoplasmic constituents.
• Quaternary ammonium compounds are primarily bacteriostatic and
fungistatic, although they are microbicidal against certain organisms at high
concentrations; they are more active against Gram-positive bacteria than
against Gram-negative bacilli. Quaternary ammonium compounds have
relatively weak activity against mycobacteria and fungi and have greater
activity against lipophilic viruses.
• Their antimicrobial activity is adversely affected by the presence of organic
material, and they are not compatible with anionic detergents.
• Because of weak activity against Gram-negative bacteria, they are prone to
contamination by these organisms.

8
 • In 1994, FDA classified them as Category IIISE active agents (i.e.,
insufficient data exists to classify them as safe and effective for use as an
antiseptic hand wash).
Activity of Antiseptic Agents Against Spore-Forming
Bacteria
The widespread prevalence of health-care–associated diarrhea caused by Clostridium
difficile and the recent occurrence in the United States of human Bacillus anthracis
infections associated with contaminated items sent through the postal system has
raised concern regarding the activity of antiseptic agents against spore-forming
bacteria. None of the agents (including alcohols, chlorhexidine, hexachlorophene,
iodophors, PCMX, and triclosan) used in antiseptic hand wash or antiseptic hand-rub
preparations are reliably sporicidal against Clostridium spp. or Bacillus spp. Washing
hands with non-antimicrobial or antimicrobial soap and water may help to physically
remove spores from the surface of contaminated hands. HCWs should be encouraged
to wear gloves when caring for patients with C. difficile associated diarrhea. After
gloves are removed, hands should be washed with a non-antimicrobial or an
antimicrobial soap and water.

Table (1) Antimicrobial spectrum and characteristics of hand-hygiene agents

Gram- Gram-
Group positive negative Mycobacteria Fungi Virus Speed of action comments
bacteria bacteria
Alcohols +++ +++ +++ +++ +++ Fast Optimum
conc.60-
95%;no
persistent
activity
Chlorhexidine: +++ ++ + + +++ Intermediate persistent
2- 4% aqueous activity
rare allergic
reactions
Iodophors +++ +++ + ++ ++ Intermediate Less irritating
than iodine
Phenol +++ + + + + Intermediate Activity
derivatives neutralized by
nonionic
surfactants
Triclosan +++ ++ + - +++ Intermediate Acceptability
on hands
varies
Quaternary + ++ - - + Slow Used only in
ammonium combination
compounds with alcohols

Note: +++=excellent, ++=good, but doesn’t include the entire bacterium spectrum; +=fair;
-=no activity or not sufficient

9
Factors To Consider When Selecting Hand-Hygiene
Products
• The relative efficacy of antiseptic agents against various pathogens (Table
1).
• The acceptance of hand-hygiene products by personnel( Characteristics of
a product that can affect acceptance by personnel include its smell,
consistency, color and ease of lathering for soaps ,also the tendency of
products to cause skin irritation and dryness. With alcohol-based
products, the time required for drying may also affect user acceptance. )
• The accessibility of hand-hygiene facilities.
• The cost of hand-hygiene products.

The ideal one should be :

• Quick,
• Reduce hand contamination to the lowest possible level ,and
• Be free from notable side effects on HCWs’ skin.

Examples:
Aqueous:
• Povidone-iodine/ detergent solution.
• Chlorhexidine gluconate/ detergent solution.

Alcoholic:
• 70% ethanol or 60% isopropanol.
• 0.5% chlorhexidine or Povidone-iodine in 70% ethanol or isopropanol.

Irritant Contact Dermatitis Resulting from Hand-Hygiene

Measures
Frequent and repeated use of hand-hygiene products, particularly soaps and other
detergents, is a primary cause of chronic irritant contact dermatitis among HCWs.
Affected persons often complain of a feeling of dryness or burning; skin that feels
“rough;” and erythema, scaling, or fissures. Irritant contact dermatitis is more
commonly reported with iodophors. Other antiseptic agents that can cause irritant
contact dermatitis (in order of decreasing frequency) include chlorhexidine, PCMX,
triclosan, and alcohol-based products. Other factors that can contribute to dermatitis
associated with frequent handwashing include using hot water for handwashing, low
relative humidity (most common in winter months), failure to use supplementary
hand lotion or cream, and the quality of paper towels. Shear forces associated
with wearing or removing gloves and allergy to latex proteins may also contribute to
dermatitis of the hands of HCWs.

Proposed Methods for Reducing Adverse Effects of Agents

• Replacing products with high irritation potential with preparations that
cause less damage to the skin.
• Educating personnel regarding the risks of irritant contact dermatitis.
• Providing caregivers with moisturizing skin-care products or barrier
creams.

10
WHO Recommended Guidelines for Hand Washing and
Hand Antisepsis
A. Wash hands with soap and water in the following situations:
• when visibly dirty or contaminated with proteinaceous material, or
• visibly soiled with blood or other body fluids, or
• if exposure to potential spore-forming organisms is strongly suspected or proven or
• after using the restroom

B. Preferably use an alcohol-based hand rub for routine hand antisepsis in the following clinical
situations, listed below, if hands are not visibly soiled
• before and after having direct contact with patients
• after removing gloves
• before handling an invasive device for patient
• after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound
dressings
• if moving from a contaminated body site to a clean body site during patient care
• after contact with inanimate objects (including medical equipment) in the immediate vicinity
of the patient.

C. Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol- based
formulation before handling medication or preparing food.

E. When alcohol-based hand rub is already used, do not use antimicrobial soap concomitantly.

Surgical hand antisepsis

• Before all surgical procedures

Hand-hygiene technique

When washing hands with soap and water:

• Remove Jewelry
• Wet hands first with water.
• Avoid hot water, because it may increase the risk of dermatitis.
• Apply a suitable amount of the product, recommended by the manufacturer.
• Rub hands vigorously for at least 15 seconds (as in the diagram below).
• Rinse hands with water and dry thoroughly with a disposable towel.
• Use the towel to turn off the faucet, if not turned off by elbow or foot control.
Important tips
• When bar soap is used, soap racks that facilitate drainage and small bars of soap
should be used.
• When liquid form is used evaluate the dispenser systems to ensure that dispensers
function adequately and deliver an appropriate volume of product.

• If disposable containers cannot be used, reusable containers should be recycled

appropriately.
• Do not add soap to a partially empty soap dispenser. This practice of “topping off”
dispensers can lead to bacterial contamination of soap Disposable containers should
be used.

When decontaminating hands with an alcohol-based hand rub:

• Apply product to palm of one-hand and rub hands together, covering all surfaces of
hands and fingers until hands are dry (as in the diagram below).

11
 • Follow the manufacturer’s recommendations regarding the volume of product to use
(usually 3-5 ml).

Important Tips
• If after cleaning your hands 5 to 10 times with an alcohol-based hand rub, you feel a
“build-up” of emollients on your hands, wash your hands with soap and water.
• If you clean your hands with an alcohol- based hand rub before putting on gloves,
make sure the alcohol has dried completely before putting on gloves.

Other Policies Related to Hand Hygiene

Fingernails and Artificial Nails
Studies have documented that subungual areas of the hand harbor high concentrations
of bacteria, most frequently coagulase-negative staphylococci, Gram-negative rods
(including Pseudomonas spp.), Corynebacteria, and yeasts, so it is recommended to
keep nail tips short.
HCWs who wear artificial nails are more likely to harbor Gram-negative pathogens
on their fingertips than are those who have natural nails, both before and after
handwashing, so it is recommended not to wear artificial fingernails when having
direct contact with patients.
Jewelry
Several studies have demonstrated that skin underneath rings is more heavily
colonized than comparable areas of skin on fingers without rings, however further
studies are needed to establish if wearing rings results in greater transmission of
pathogens in healthcare settings.
Gloving
Gloves should be used as an adjunct to, not a substitute for, hand hygiene
• Gloves do not provide complete protection against hand contamination.
Bacterial flora colonizing patients may be recovered from the hands of
<30% of HCWs who wear gloves during patient contact.
• Further, wearing gloves does not provide complete protection against
acquisition of infections caused by hepatitis B virus and herpes simplex
virus. In such instances, pathogens presumably gain access to the
caregiver’s hands via small defects in gloves or by contamination of the
hands during glove removal.

Surgical hand antisepsis

Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand
rub with persistent activity is recommended before donning sterile gloves when
performing surgical procedures.
Surgical scrub:
• Keep nails short and pay attention to them when washing your
hands.
• Do not wear artificial nails or nail polish.
• Remove all jewelry (rings, watches, bracelets) before entering
the operating room suite.
• Wash hands and arms up to elbows with a non-medicated soap
before entering the operating room area or if hands are visibly
soiled.

12
 • Clean subungual areas with a nail file. Nailbrushes, if used,
must be sterile and used only once.
Steps:
• Start timing.
• Scrub each side of each finger, between the fingers, and the back and front of
the hand for two minutes.
• Proceed to scrub the arms, keeping the hand higher than the arm at all times.
• Wash each side of the arm from wrist to the elbow for one minute.
• Repeat the process on the other hand and arm, keeping hands above elbows at
all times. If the hand touches anything except the brush at any time, the scrub
must be lengthened by one minute for the area that has been contaminated.
• Rinse hands and arms by passing them through the water in one direction only,
from fingertips to elbow. Do not move the arm back and forth through the
water.
• Proceed to the operating room suite holding hands above elbows.
• At all times during the scrub procedure, care should be taken not to splash
water onto surgical attire.
• Once in the operating room suite, hands and arms should be dried using a
sterile towel and aseptic technique before putting on gown and gloves.
•

When using an alcohol-based surgical hand-rub:

Ø In the first time of the day before applying the alcohol solution,
pre wash hands and forearms thoroughly with a mild soap.
Ø Dry hands and forearms completely.
Ø Start timing. Use sufficient product to keep hands and forearms
wet with the handrub throughout the procedure.
Ø Allow hands and forearms to dry thoroughly before donning
sterile gloves.
Ø Proceed to the operating room suite holding hands above
elbows.
Ø For the rest of the day, between patients rub with alcohol alone.

Hand-Hygiene Practices among HCWs

Appropriate H.H. is considered the leading measure to reduce the transmission of
nosocomial pathogens in health care settings. Nevertheless, the importance of this
simple procedure is not sufficiently recognized by HCWs and compliance with
recommended H.H. practices remains unacceptably low (overall average: 40%).
Both the frequency and the quality are considerably suboptimal.

Low compliance and barriers to Hand-Hygiene

Identification of risk factors associated with poor compliance is of utmost importance

to the design of an effective promotion campaign.
Parameters associated with non-compliance are related not only to the individual
HCW, but also to the group he/ she is working in and, to the institution to which that
group belongs.

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Interventions to promote H.H. should consider variables at all these levels.

Distribution of factors associated with poor adherence to H.H

Individual level
Lack of education/ experience
Lack of knowledge of guidelines
Being a refractory non-complier
Group level
Under staffing/ high workload
Lack of performance feedback
Lack of encouragement/role model from key staff
Institutional level
Lack of existing guidelines (written)
Lack of H.H. facilities
Lack of suitable H.H. agents
Lack of skin care agents
Lack of culture of compliance
Lack of administrative leadership/sanction/rewarding/support

The challenge of H.H. promotion could be summarized in one single question: “How
can we change HCWs behavior?” Tools for change are known, but need to be
implemented. The dynamic of behavioral change is complex. It involves education,
motivation, and system change.
The factors necessary for change include
• Dissatisfaction with the current situation
• Perception of alternatives
• Recognition, both at the individual and institutional level, of the
ability and potential to change.

Key Factors for hand hygiene compliance improvement

Predisposing, enabling, and reinforcing factors should be taken into account for
successful promotion and prevention of nosocomial infections.
Predisposing Factors
Knowledge
Attitudes
Beliefs

Enabling Factors Prevention of

H.H.
Skills Compliance Nosocomial
Equipment Improvement Infections

Reinforcing factors
Feedback
Supervisor support
Patient participation
Link to changes in infection rates

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Some strategies for successful promotion of H.H.
• Educating personnel regarding the types of patient-care activities that can
result in hand contamination and the advantages and disadvantages of
various methods used to clean their hands.
• Easy access to hand-hygiene supplies, whether sink, soap, medicated
detergent, or alcohol-based hand-rub solution.
• Monitoring HCWs’ adherence to recommended hand-hygiene practices
and providing personnel with information regarding their performance.
• Encouraging patients and their families to remind HCWs to decontaminate
their hands.
• Making improved hand-hygiene adherence an institutional priority and
providing appropriate administrative support and financial resources.
• Making an alcohol-based hand rub available at the entrance to the patient’s
room or at the bedside, in other convenient locations, and in individual
pocket-sized containers to be carried by HCWs who work in areas in
which high workloads and high intensity of patient care are anticipated,.
Performance Indicators
The following performance indicators are recommended for measuring improvements
in HCWs’ hand-hygiene adherence:
• Periodical monitoring and recording adherence as the number of hand-hygiene
episodes performed by personnel/number of hand-hygiene opportunities, by
ward or by service together with providing feedback to personnel regarding
their performance.
• Monitoring the volume of alcohol-based hand rub (or detergent used for hand
washing or hand antisepsis) used per 1,000 patient-days.
• When outbreaks occur, assess the adequacy of healthcare worker hand
hygiene.

Success stories:
Implementation of an effective H.H. promotion campaign In some
hospitals include the following:
• Color posters that emphasized the importance of H.H. were displayed in
strategic areas within the hospital called “ Talking Walls”.
• Bottles of hand rub solutions were distributed in large amounts to all words
and holders were mounted on all beds to facilitate access to H.H.
• HCWs were encouraged to carry a bottle in their pocket and a newly
designed flat (instead of round) bottle was made available to facilitate
pocket carriage.
• Constant reminders were always available at work environment.
• Active participation and feed back at both individual and organizational
levels.

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In conclusion:
• Hands contaminated with transient bacteria are a primary means for
transmission of infection.
• Hands without healthy skin are more susceptible to becoming colonized with
transient bacteria, including multidrug- resistant organisms (MDROs).
• Healthcare workers need to clearly understand when and how to perform hand
hygiene.
• Healthcare worker adherence to hand hygiene recommendations depends on
clearly understood policies, targeted education, healthy hand skin, convenient
hand hygiene products, and monitoring of performance with feedback.
• Use of alcohol-based hand rubs has increased adherence of healthcare workers
to recommended hand hygiene policies.
• Improved hand hygiene practices have been associated with reduced
healthcare-associated infection rates.
• Implementation of waterless hand antiseptics does not negate the need for
hand washing sinks for staff.
• Patients should be offered the opportunity to clean their hands during the day.

The   most   common   areas   that   missed   during   hand   washing   among  
HCWs.  

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 H.H check List

Steps Possible Points

points earned

1-Removes all jewelry, watches, and places in secure 2

area or pocket. Pushes long sleeves to the level of elbow.
2-Selects appropriate soap, paper towels, and waste 6
basket.
3-Assembles equipment at work station. 1
4-Allows water to flow freely. 1
5-Regulates water temperature until it feels warm. 1
6-Allow warm water to flow over each hand. 2
7-Points fingers down. 1
8-Wets hands. 1
9-Selects liquid soap. 1
10-Dispenses appropriate amount into palm of one hand. 1
11-Places palms one upon the other. 1
12-Creates soapy lather and rub palms together using 5
friction and circular movement.
13-Rubs back of each hand 3-5 times 6
14- Interlaces fingers of both hands and rub back and 5
forth many times.
15-Washes tips of fingers, thumbs, palms and wrists 10
thoroughly.
16-Rinses hands, wrists and nails under running water 1
with fingertips pointed down.
17-Chooses dry and clean paper towel. 1
18-Starts at fingers and move up to wrists to dry. 1
19-Uses a paper towel to turn off faucet and place used 1
towels into waste can.
20-Selects appropriate hand lotion. 1
21-Apply about one half-teaspoon hand lotion to one 1
palm and rub onto both hands until absorbed.
Total points 50

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Reference:

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