The culture of hand hygiene

We all know that hand hygiene substantially reduces potential pathogens on the hands and is considered a primary measure for reducing the risk of transmitting organisms to patients and staff. Hospital-based studies have shown that noncompliance with hand hygiene practices is associated with health care-associated infections, the spread of multiresistant organisms, and has been a major contributor to outbreaks.

Studies also have shown that the prevalence of health care-associated infections decreased as hand hygiene measures improved. Yet the statistics are dismal. A survey from the World Health Organization (WHO) shows that almost 50% of health-care workers around the globe are not washing their hands before providing care to patients. What needs to change? The very culture we work in and the social actions need to change. You have the power to help make that change happen.

Each setting we work and live in has culture. Culture is the total of the inherited ideas, beliefs, values, and knowledge that constitute the shared bases of social action. Those social actions can include everything from the way we dress to the way we embrace hand hygiene. Some of those ideas, beliefs, and values may help us take the right social action. Some may be incorrect and lead to detrimental actions.

The hand hygiene culture in your office

In your office as you perform your daily tasks, the culture of hand hygiene has built-in ideas, beliefs, values, and knowledge. What is acceptable are the tasks that will be adhered to. Sometimes these can be outdated or inaccurate. Dispelling myths is the first step toward cultural change. As everyone in the office gains knowledge, the staff can embrace new cultural traditions of hand hygiene that promote health and well-being. The following may be a starting point for the changes in your office.

1. Hand hygiene and gloves — Gloves should not be considered a substitute for effective hand hygiene practices before and after patient contact. Although gloves can reduce the number of germs transmitted to the hands, they do not eliminate the possibility of transmission, as germs can still get through latex. Gloved hands can become contaminated due to tiny punctures in the glove material or during glove removal; therefore, hand hygiene must be performed immediately after glove removal. Consequently, gloves are an important adjunct to, but not a replacement for proper hand hygiene practice. Hands can also be contaminated by “back spray” when gloves are removed after contact with body fluids.
2. Dry your hands — After performing hand hygiene procedures, it is vital to dry your hands. Hands must be completely dry from either hand sanitizers or water before gloving. These agents can affect the strength and durability of the glove.
3. Bar soap — Bar soap should not be used in the medical setting. Pathogenic organisms have been found on or around bar soap during and after use. Using liquid soap with hands-free controls for dispensing is preferable for reducing the risks of cross contamination.
4. Liquid soap and gel handling — Most antibacterial liquid soaps and gels have expiration dates. The Centers for Disease Control gives the following recommendation for handling — hand care products, including plain (non-antimicrobial) soap and antiseptic products, can become contaminated or support the growth of microorganisms. Liquid products should be stored in closed containers and dispensed from disposable containers or containers that are washed and dried thoroughly before refilling. Soap should not be added to a partially empty dispenser, because this practice of “topping off” might lead to bacterial contamination of soap and negate the beneficial effect of hand cleaning and disinfection. Store and dispense products according to manufacturer’s instructions.
5. Hand sanitizers — Directions can vary from product to product and it is important to read the label. The volume needed to reduce the number of bacteria on hands varies by product. There are current studies that show efficacy also depends on contact time, volume of product used, and whether or not the hands are wet when applied. There are bacteria and spores that have been shown to be resistant to the chemicals in some products. When washing your hands, those resistant bacteria are rinsed down the sink during washing. With hand sanitizers, they remain on the hand.
6. Debris — Anytime the hands are visibly soiled, the hands must be washed. Hand sanitizer does not penetrate debris or remove debris.
7. Evaluate — Each time you perform hand hygiene, you must evaluate what hand hygiene practice you’re going to perform based on a variety of factors. The preferred method for hand hygiene depends on the type of procedure, the degree of contamination, and the desired persistence of antimicrobial action on the skin.

Indications for hand hygiene include the following:

• Before and after treating each patient (i.e., before glove placement and after glove removal).
• After barehanded touching of inanimate objects likely to be contaminated by blood, saliva, or respiratory secretions.
• Before leaving the dental operatory.
• When hands are visibly soiled.
• Before regloving, after removing gloves that are torn, cut, or punctured.
• For oral surgical procedures, perform surgical hand antisepsis before donning sterile surgical gloves.

The steps involved in hand hygiene are very specific for each method. The CDC recommendations are as follows:

Hand hygiene technique —

• 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. Follow the manufacturer’s recommendations regarding the volume of product to use.
• When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings.

Surgical hand antisepsis —

• Remove rings, watches, and bracelets before beginning the surgical hand scrub.
• Remove debris from underneath fingernails using a nail cleaner under running water.
• 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.
• When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually two to six minutes. Long scrub times (e.g., 10 minutes) are not necessary.
• When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions. Before applying the alcohol solution, prewash hands and forearms with a nonantimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves. RDH

Noel Brandon Kelsch, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists’ Association.

References

1. http://www.ke.undp.org/index.php/the-s
2. Tenorio AR, Badri SM, Sahgal NB, et al. Effectiveness of gloves in the prevention of hand carriage of vancomycin-resistant Enterococcus species by health care workers after patient care. Clin Infect Dis. 2001;32:826-829.
3. Pittet D. et al. Bacterial contamination of the hands of hospital staff during routine patient care. Arch Intern Med. 1999;159:821-826.
4. Fuller C, Savage J, Besser B, et al. The Dirty Hand in the Latex Glove: A Study of Hand-Hygiene Compliance When Gloves Are Worn. Infection Control and Hospital Epidemiology 32:12 (December 2011).
5. Boyce JM, Pittet D. (2002) Guideline for Hand Hygiene in Healthcare Settings: Recommendations of the Healthcare Infection Control Practice Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infection Control and Hospital Epidemiology.
6. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf accessed 2.1.2012
7. Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force Centers for Disease Control and Prevention (CDC).

Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control. MMWR2002; 51: (No. RR-16).

8. http://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf accessed 2.2.2012
9. Larson E, Bobo L. Effective hand degerming in the presence of blood. J. Emerg. Med.(1992) 10:7.