Resource Packages: Hand Washing
Historical Overview
In 1847 Ignaz Semmelweiss became the first doctor to give specific orders to all students to scrub their hands in chlorinated lime believing that disinfection of hands could break the transmission of disease from cadaver to pregnant women.
Florence Nightingales' triumphs in the Crimea have been well documented. She convincingly showed that safe food, water and a clean environment could result in a major decrease in death rates in a military hospital. Her interest in hospital hygiene never waned and throughout her long career she proved to be a very able lobbyist.
Recent Developments
Handwashing has been proven to be the single most important technique in the prevention and minimisation of the spread of infection within the hospital environment. The role of unwashed hands in the transmission of infection has long been established – hands that are used to care, treat and comfort can potentially become instruments of harm (Gould 1997b.)
Transient Flora
Transient organisms are picked up by contact with other people, objects or the environment and do not survive indefinitely on the hands (Maurer, 1991). These organisms have the potential to do harm as they have the ability to survive long enough to be transferred to others.
Resident Flora
These tend to be persistently present as part of the individuals own flora. They cannot be permanently removed and are the reason a no touch technique is required for aseptic procedures (Stucke, 1993).
Types of handwashing (Lowbury, 1991) categorizes handwashing as follows:
- Social handwash – This renders the hands socially clean and removes transient microorganisms. The hands are washed for 5-10 seconds with soap liquid and water and this type of handwash is suitable for all routine procedures
- Hygienic hand disinfection – This removes or destroys transient microorganisms, reduces resident microorganisms and confers a residual effect. The hands are washed with an anti-septic for 15-30 seconds and this procedure would be used during an outbreak situation, before aseptic procedures and following contact with blood and body fluids
- Surgical scrub – This removes or destroys transient micro-organisms and confers a prolonged effect. The hands and forearms are washed with an antiseptic soap for a minimum of two minutes. The hands are dried using a sterile towel. This should be carried out before all invasive procedures
It is essential that handwashing is followed by thorough rinsing to remove soap residue and harsh chemicals in the antiseptic agents, to both protect the skin and prevent chapping.
Hand drying – A variety of methods are available for hand drying but it is imperative that hands are properly dried as it is known that microorganisms transfer more effectively from wet surfaces. Cloth towels should not be used in patient treatment areas as they have the potential to be a source of infection. Paper towels for use in the home setting, can be carried by community nurses along with small bottles of antiseptic handwash and alcohol rub. Hand dryers have the potential to spread air borne pathogens and therefore should be avoided.
Indications for Handwashing
Hands should be washed according to the type, intensity, duration and sequence of events.
The following are examples of significant patient contacts, which should be proceeded by handwashing:
- Examination of a patient or similar prolonged contact
- Contact with wounds
- Contact with catheters or other invasive devices
- Administration of an intramuscular or intravenous injection
Hands must be cleaned immediately before and after any direct patient care.
The following are recommendations by the Centers for Disease Control and Prevention (1986) when hands should be washed:- After prolonged and intense contact with any patient
- After removal of gloves
- After contact with blood/body fluids
- Before and after entering or leaving source isolation rooms
- Before handling food
- Before all clean procedures
- Before aseptic procedures
- Before contact with any immunosuppressed patients
Hands should also be washed after toileting and smoking.
As an adjunct to handwashing, disposable gloves should be worn when contamination of the hands with blood or body substances is anticipated. Gloves should also be worn when the skin integrity of the staff member’s hands is incomplete. In these cases cuts and abrasions on exposed skin must be covered by a waterproof dressing. It is important that gloves are changed and hands washed between patients.
Handwashing procedure
- To ensure hands are washed thoroughly use the following technique:
- Ensure all skin surfaces are accessible
- Ensure nails are short and clean
- Wet hands thoroughly
- Use 3-5mls of soap and rub together five times
- Lather and do this technique for 15-30 seconds (suitable for social and hygienic hand disinfection)
For a surgical scrub, including the forearms, 3-5mls of antiseptic soap should be applied. The wrists should be similarly rubbed and hands thoroughly rinsed and dried.
The primary problem with effective handwashing is not the lack of good handwashing agents but feckless practice (Larson, 1995).
Mayone-Ziomek (1998) suggests that using educational intervention and performance feedback should increase the effectiveness and compliance with handwashing.
References
Ayliffe SA et al (1978) A Test for Hygienic Hand Disinfection. Journal of Clinical Pathology. Vol 31, p 923.
Taylor LJ (1978) An Evaluation of Handwashing Techniques. Nursing Times. Vol 74, P108-110.
Lowbury EJ (1991) Special problems in hospital antisepsis.
In Russell AD et al (Eds) Principles and practices of disinfection,
sterilization. Oxford, Blackwell
Science.
Maurer IM (1991) Hospital hygiene. Third edition. London. Edward Arnold.
Bennet JV, Brachman PS, Sanford JP, eds, 1992 3rd edition. Hospital Infections, Little, Brown and Company, Boston.
Infection Control Association. NSW Inc 1992, Standards for Practice, Sydney.
Stucke VA (1993) Microbiology for nurses: Application To Patient Care. Seventh edition, London. Balliere Tindall.
Larson EL (1995) APIC Guidelines for Infection Control Practice- APIC Guidelines for Handwashing and Hand Antisepsis in Health Care Settings. American Journal of Infection Control. Vol 23, P 4251.
Gold DJ (1997) Giving Infection Control a Big Hand. Community Nursing Notes, Vol 15, P 3-6.
Mayone-ziomek: Dermatological nursing, Vol 10(3). June 1998 pp183-188
NSW Health Department, 1999 Infection Control Policy 99/87. AIDS/Infectious Diseases branch.
Video - available from the video library: Breaking the Chain: Module 3, Hands Up and Be Counted
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