Key Takeaways: Hand Hygiene - Nails


Revised Guideline for Hand Hygiene

The recently revised Guideline for Hand Hygiene recommends that healthy, short, natural fingernails should be maintained.


Moderate-quality evidence and guidance from health agencies and professional societies support that health care personnel should maintain healthy, natural fingernails at a short length. Unhealthy, or long fingernails may impede the removal of microorganisms from the nails during hand hygiene. Transmission to the patient of microorganisms harbored in unhealthy or long fingernails may result in the patient developing a health care–associated infection.

The Evidence

In a case report, McNeil et al15 described an outbreak of 16 postoperative Pseudomonas aeruginosa wound infections in a thoracic surgical setting. The outbreak source was traced to a scrub person with severe chronic (ie, > 2 years) onycholysis of her right thumbnail. The person kept the lesion covered by continuously concealing it with flesh-colored nail lacquer, which prevented her colleagues from noticing it. P aeruginosa was cultured from the nail’s subungual region and the nurse’s home manicure products. After the individual abstained from participating in surgical procedures until after the previously infected thumbnail was totally removed, no additional postoperative P aeruginosa wound infections were reported.

In a prospective observational study with an educational intervention, Hautemaniere et al14 evaluated factors associated with hand hygiene effectiveness for 3,067 hospital personnel in France. The researchers evaluated hand hygiene before and after an educational intervention, which consisted of a 30-minute session to teach best practices for using an alcohol-based hand rub. Hand hygiene effectiveness was determined using a validated observation technique for rubbing time (limit 30 seconds), adherence to the application method protocol, and evaluation by visual criteria. The researchers visually assessed hand hygiene effectiveness by having personnel apply a fluorescent alcohol-based hand rub and using ultraviolet light to evaluate the percentage of hand coverage. In this study, the evaluation criteria showed an association between long nails and ineffective hand rub use. However, the researchers did not describe the nail length used to classify nails as long in this study.

In a literature review conducted to assess the efficacy of rectal screening of health care workers to determine the source of gram-negative pathogen outbreaks, Ulrich et al6 found that examining health care workers’ hands and fingernails was more beneficial, lower in cost, and more efficient than rectal screening for intestinal colonization. In six of the 10 case reports reviewed, the hands of health care workers were identified as reservoirs because of onychomycosis, nail length, and artificial nails.

The benefits of maintaining healthy, short nails include a reduced risk of harboring potential pathogens under fingernails. The harms of having long nails may include puncturing gloves,1,7,12 limiting the effectiveness of hand hygiene,7,14 or injuring patients during patient care.

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