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Hand Hygiene

Find answers to clinical questions related to hand hygiene and surgical hand antisepsis.

  • What is the difference between artificial nails and enhanced nail lacquer?

    Artificial nails are substances or devices designed to sculpt, shape, or lengthen the natural nail bed (ie, increase surface area) and as such are sometimes referred to as nail enhancements. Some examples are plastic prosthetic nails; bonding; extensions; tips; gel and acrylic overlays; and fiberglass, resin, silk, or paper wraps.

    Enhanced nail lacquers are products that improve nail bed attractiveness (ie, color) or strength without extending the nail bed. The term “enhanced” indicates that these products are formulated to increase adhesion and duration (ie, wear) when applied to the nail bed. Examples include ultraviolet-cured nail lacquer (ie, gel polish), self-adherent colored plastic films, and dipped nail coatings. More research is needed to determine whether enhanced nail lacquer carries the same risk as artificial nails for reduced hand hygiene performance and increased bacterial counts on the hands of health care personnel.

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Bryson PH, Sirdesai SJ. Chapter 27: Colored nail cosmetics and hardeners. In: Cosmetic Dermatology: Products and Procedures. Hoboken, NJ: Wiley-Blackwell Pub; 2010:206-214.
    • Schoon D, Baran R. Chapter 10: Cosmetics: the care and adornment of the nail. In: Baran & Dawber’s Diseases of the Nails and Their Management. 4th ed. Hoboken, NJ: John Wiley & Sons, Ltd; 2012:471-483.

    Updated: June 1, 2022

  • Can nail lacquer be worn by personnel in the operating room?

    Nail lacquer or enhanced nail lacquer should not be worn by personnel performing the scrub role. However, an interdisciplinary team that includes perioperative RNs, anesthesia professionals, physicians, and infection preventionists should determine whether nail lacquer or enhanced nail lacquer may be worn by non-scrubbed personnel in the perioperative setting. The collective evidence is inconclusive regarding the effect of nail lacquer or enhanced nail lacquer on hand hygiene, and professional organizations provide differing opinions on the wearing of either type of nail lacquer based on the inconclusive evidence.

    Although evidence is lacking to determine any harms of wearing nail lacquer or enhanced nail lacquer, the potential harms could include obscuring a nail infection, hindering the effectiveness of hand hygiene, transmission to a patient of pathogens harbored in chipped or old lacquer, or chipped lacquer becoming deposited in the sterile field or wound.

    Resource:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated: June 1, 2022

  • What is the ideal fingernail length for members of the perioperative team?
    Ideal Fingernail Length in a Perioperative Setting

    Fingernail tips should be no longer than 2 mm (0.08 inch). Studies have found that fingernails at a length shorter than 2 mm are less likely to harbor bacteria compared to nails longer than 2 mm. One suggested method of determining whether nails are longer than 2 mm is if the nails do not extend beyond the tips of the fingers when the hands are held vertically and viewed from the palmar side.

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Fagernes M, Lingaas E. Factors interfering with the microflora on hands: a regression analysis of samples from 465 healthcare workers. J Adv Nurs. 2011;67(2):297-307.
    • Hautemaniere A, Cunat L, Diguio N, et al. Factors determining poor practice in alcoholic gel hand rub technique in hospital workers. J Infect Public Health. 2010;3(1):25-34.
    • Hardy JM, Owen TJ, Martinez SA, Jones LP, Davis MA. The effect of nail characteristics on surface bacterial counts of surgical personnel before and after scrubbing. Vet Surg. 2017;46:952-961.
    • Rupp ME, Fitzgerald T, Puumala S, et al. Prospective, controlled, cross-over trial of alcohol-based hand gel in critical care units. Infect Control Hosp Epidemiol. 2008;29(1):8-15.

    Updated: June 1, 2022

  • What type of alcohol should be the active ingredient in alcohol-based hand hygiene products used in the health care setting?

    According to the US Food and Drug Administration and the Centers for Disease Control and Prevention, alcohols approved for use in alcohol-based hand hygiene products in the health care setting are ethanol (also referred to as ethyl alcohol) and isopropyl alcohol (also referred to as isopropanol or 2-propanol).

    Resources:

    • Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(12 Suppl):S3-S40.
    • US Food and Drug Administration. Safety and Effectiveness of Health Care Antiseptics; Topical Antimicrobial Drug Products for Over-the-Counter Human Use. Final rule. Fed Regist. 2017;82(242):60474-60503.

    Updated: June 1, 2022

  • What does “v/v” indicate on the alcohol-based hand rub label?

    The symbol “v/v” is a measurement of the alcohol content in the alcohol-based hand rub. The symbol most often appears after the type of alcohol that is listed as the active ingredient on the label (eg, ethyl alcohol 70% v/v).

    The amount of alcohol contained in a solution can be expressed as percent by weight (w/w) or percent by volume (v/v). The difference is that the percent by weight is not affected by temperature or other variables, whereas the percent by volume can be affected by temperature, specific gravity, and reaction concentration. For example, if the solution was prepared at 15° C (59° F), 70% alcohol by weight would be equivalent to 76.8% by volume, but if prepared at 25° C (75° F), it would be equivalent to 80.5% by volume. The alcohol concentration of antiseptic hand rubs is most often expressed as percent by volume.

    Resources:

    • Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(12 Suppl): S3-S40.
    • WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization; 2009.

    Updated: June 1, 2022

  • Do alcohol-based hand hygiene products have an expiration date? If so, are they still effective after the expiration date?

    Alcohol-based hand hygiene products are regulated by the US Food and Drug Administration (FDA) as over-the-counter drug products. To ensure the product meets applicable standards at the time of use, appropriate stability testing, as outlined by the FDA, must be performed to establish an expiration date. The only exception is if the manufacturer can provide data indicating product stability for more than 3 years and the labeling does not carry dosage limitations. The expiration date must appear on the container and on any outer packaging. The stability or effectiveness of the drug products beyond their expiration date is not provided to the FDA; therefore, it is important for perioperative team members to check expiration dates on these products before using them.

    Resources:

    Updated: June 1, 2022

  • Is a traditional hand scrub required for initial surgical hand antisepsis?

    Initial surgical hand antisepsis using a standardized surgical hand scrub with soap (ie, an antimicrobial agent), a nonabrasive sponge, and water does not have to be completed before an alcohol-based surgical hand rub product is used, unless it is recommended in the manufacturer’s instructions for use. Evidence comparing a surgical hand rub with an alcohol-based product to a surgical hand scrub with an antimicrobial agent found both methods to be effective in reducing the microflora on scrub persons’ hands and in reducing the probability of a patient developing a surgical site infection.

    However, during performance of either method of surgical hand antisepsis, if hands are visibly soiled or dirty, they must be washed with soap and water for at least 15 seconds, rinsed, and dried thoroughly before the surgical hand scrub or hand rub is performed.

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • López Martin MB, Erice Calvo-Sotelo A. Comparative study of presurgical hand hygiene with hydroalcoholic solution versus traditional presurgical hand hygiene. Enferm Clin. 2017;27(4):222-226.
    • Gaspar GG, Menegueti MG, Lopes AER, et al. Alcohol-based surgical hand preparation: translating scientific evidence into clinical practice. Antimicrob Resist Infect Control. 2018;7(80):1-7.
    • Kashkoush A, Agarwal N, Ayres A, Novak V, Chang YF, Friedlander RM. Scrubbing technique and surgical site infections: an analysis of 14,200 neurosurgical cases. J Neurosurg. 2020;133:580-587.

    Updated: June 1, 2022

  • Can alcohol-based surgical hand rub dispensers be placed in the OR?

    Consult with your infection preventionist before placing dispensers in the OR. Alcohol-based surgical hand rub dispensers may be placed in the OR, although the placement of these flammable products must follow local, state, and federal regulations. According to the National Fire Protection Association (NFPA), alcohol-based hand hygiene product dispensers should

    • be at least 4 ft apart;
    • hold a maximum of 1.2 L in rooms, corridors, and areas open to corridors;
    • not be placed above an ignition source (eg, electrical outlet, switch) or within 1 inch of the ignition source; and
    • not total more than 10 gallons (37.8 L) outside of a storage cabinet in a single smoke compartment.

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc. 
    • NFPA 101: Life Safety Code. Quincy, MA: National Fire Protection Association; 2021.

    Updated: June 1, 2022

  • What frequency of hand moisturizer application is necessary as a preventive measure for hand dermatitis?

    Although several controlled trials have demonstrated that regular, frequent use of hand moisturizers can help prevent and treat contact irritant dermatitis caused by hand hygiene products, consensus on the frequency of application has not been established. However, what is known is that the frequency of moisturizer application can vary based on geographical location, corresponding climate, and an individual’s predisposition to skin dryness.  Additionally, frequent use of gloves may increase the need for moisturizing hand care products.

    Resources:

    • Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(12 Suppl):S3-S40.
    • WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization; 2009.
    • van der Meer EW, Boot CR, van der Gulden JW, et al. Hands4U: the effects of a multifaceted implementation strategy on hand eczema prevalence in a healthcare setting. Results of a randomized controlled trial. Contact Dermatitis. 2015;72:312-314.

    Updated: June 1, 2022

  • What actions can be implemented to prevent water dispersal and the potential spread of waterborne pathogens from sinks?

    Actions to limit water dispersal from perioperative hand and scrub sinks should be incorporated into a facility’s water management plan. Measures can include

    • installing sinks with basins deep enough to minimize splashing;
    • providing sufficient space between sinks and patients, sterile items, and medication preparation;
    • installing splash guards;
    • locating faucets so that they do not discharge directly above the drain;
    • adjusting water pressure to reduce forceful discharge into the sink at maximum flow; and
    • implementing regular cleaning of sinks and surrounding areas.

    Resources:

    Updated: June 1, 2022

  • Why are electronic faucets considered high-risk hardware?

    The complex design of electronic faucets (eg, sensor controls) can contribute to biofilm formation and bacterial growth. Design elements of electronic faucets that may contribute to biofilm and bacterial growth include the water flow rate, holding water temperature, location of the mixing chamber, and volume of the mixing chamber. These factors along with the electronic faucet’s internal component complexity and composition should be evaluated by a facility’s interdisciplinary water management team when contemplating installation of electronic faucets. Additionally, standard procedures for removal of biofilm and water disinfection in these faucets have been minimally successful and have contributed to health care–associated infections in vulnerable populations. Although prevention of hand contact with faucet handles is recommended for reducing the risk of hand contamination after hand hygiene is performed, consideration of alternative hands-free faucets (ie, knee- or foot-operated controls) may lessen the chance for biofilm formation and bacterial growth, as well as enable faucet operation in the event of electricity loss.

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization; 2009.
    • Bédard E, Prévost M, Déziel E. Pseudomonas aeruginosa in premise plumbing of large buildings. 2016;5(6):937-956.
    • Charron D, Bédard E, Lalancette C, Laferrière C, Prévost M. Impact of electronic faucets and water quality on the occurrence of Pseudomonas aeruginosa in water: a multi-hospital study. Infect Control Hosp Epidemiol. 2015;36(3):311-319.
    • Yapicioglu H, Gokmen TG, Yildizdas D, et al. Pseudomonas aeruginosa infections due to electronic faucets in a neonatal intensive care unit. J Paediatr Child Health. 2012;48(5):430-434.

    Updated: June 1, 2022

  • What should I do if I cannot leave the patient to perform hand hygiene?

    In the event that performing hand hygiene would put the patient at risk, the perioperative team member should weigh the risks and benefits of delaying hand hygiene. Work with your infection preventionist to make hand hygiene products available at the point of use, so that you do not have to leave the patient’s bedside.

    Wearing personal dispensers of alcohol-based hand hygiene products may be another way to maintain hand hygiene protocols and patient safety. Follow your organization’s policy on the use of personal dispensers and facility-approved hand antiseptic products.

    Resource:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated: June 1, 2022

  • Do I have to stop and perform hand hygiene between clean tasks?

    Depending on the situation and nature of the tasks, this may not be necessary. Multiple indications for hand hygiene may arise simultaneously that create a single opportunity to perform hand hygiene. Performing a single act of hand hygiene may fulfill multiple indications (eg, opening multiple sterile items sequentially). Consult with your infection preventionist on the exact tasks and hand hygiene indications when considering grouping tasks to optimize workflow.

    Resource:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.

    Updated June 1, 2022

  • Is wearing hand and wrist jewelry (ie, rings, bracelets, watches) an acceptable practice for personnel working in the perioperative environment?

    Jewelry worn on the hands and wrists can impede removal of microorganisms during hand hygiene performance. Perioperative personnel wearing jewelry can transmit microorganisms to patients, which may result in the patient acquiring a health care–associated infection. Therefore, organizations should establish and implement policies for the wearing of hand and wrist jewelry by both scrubbed and non-scrubbed team members.

    For personnel performing the scrub role, no jewelry should be worn on the hands and wrists. For non-scrubbed team members, after weighing the benefits and harms, an organization may determine that wearing a ring, wristwatch, or personal fitness tracker constructed of smooth materials without stones or adornments may be permissible when personnel are not performing tasks that require sterile technique (eg, inserting a urinary catheter).

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee. Society for Healthcare Epidemiology of America. Association for Professionals in Infection Control. Infectious Diseases Society of America. Hand Hygiene Task Force. Guideline for Hand Hygiene in Health-Care Settings: Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Infect Control Hosp Epidemiol. 2002;23(12 Suppl):S3-S40.
    • WHO Guidelines on Hand Hygiene in Health Care. Geneva, Switzerland: World Health Organization; 2009.

    Updated: June 1, 2022