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Hand Hygiene

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

  • What is the difference between hand hygiene, hand washing, and surgical hand antisepsis?

    Hand Hygiene: Any activities related to hand condition and cleansing.

    Hand Washing: Using soap and water to perform hand hygiene.

    Surgical Hand Antisepsis: Hand wash or handrub using a surgical hand antiseptic, performed preoperatively by the surgical team to remove transient flora and reduce resident skin flora.

    Surgical Hand Antiseptic: A product that is a broad-spectrum, fast-acting, and nonirritating preparation containing an antimicrobial ingredient designed to significantly reduce the number of microorganisms on intact skin. Surgical hand antiseptic agents demonstrate both persistent and cumulative activity.

    Resources:

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

    Updated July 6, 2016

  • When should we perform hand hygiene in the perioperative setting?

    Your hands should be washed:

    • Before and after patient contact (eg, transferring or positioning the patient)
    • Before performing a clean or sterile task (eg, inserting an invasive device such as a vascular or urinary catheter)
    • After risk for blood or body fluid exposure (eg, after removing PPE)
    • After contact with patient surroundings (eg, patient bed and linens)
    • When hands are visibly soiled
    • Before and after eating
    • After using the restroom
    • When hands are visibly soiled

    Resources:

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

    Updated July 6, 2016

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

    A multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists should determine whether fingernail polish may be worn in the perioperative setting. The collective evidence is inconclusive regarding the effect of fingernail polish on hand hygiene and professional organizations provide differing opinions on the wearing of nail polish based on the inconclusive evidence.

    Further research is needed to determine whether wearing nail polish affects hand contamination or patient outcomes, including the rate of surgical site infections. The quality of the existing research is low. Although evidence is lacking to determine any harms of wearing nail polish, the potential harms could include nail polish hindering the effectiveness of hand hygiene, transmission of pathogens harbored in chipped or old nail polish to a patient, or chipped polish becoming deposited in the sterile field or wound.

    Resources:

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

    Updated July 6, 2016

  • Can health care personnel wear gel or shellac nail polish in the perioperative setting?

    A multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists should determine whether ultraviolet (UV)-cured nail polish (eg, gel, Shellac®) may be worn in the perioperative setting.

    An evidence review in the AORN Guideline for Hand Hygiene found no research to support or refute wearing UV-cured nail polish. The Society for Healthcare Epidemiology of America (SHEA)/Infectious Diseases Society of America (IDSA) hand hygiene practice recommendations also cite a lack of evidence-based guidance on wearing UV-cured nails and nail enhancements in the patient care setting. A conservative approach recommended by SHEA/IDSA is for the health care organization to consider UV-cured nails as artificial and to not allow health care personnel to wear this type of polish in high-risk areas, such as the operating room (OR).

    Research is needed to determine whether UV-cured nail polish affects the performance of hand hygiene and the microflora on the hands of health care personnel. Whether UV-cured nail polish carries the same risk of harboring pathogens or transmission of infection to patients as artificial nails is unknown. The harms of wearing UV-cured nail polish may include damage to the natural fingernail and harboring of pathogens in the gaps created as the nail and cuticle grow.

    Resources:

    • Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
    • Ellingson K, Haas JP, Aiello AE, et al. Strategies to prevent healthcare-associated infections through hand hygiene. Infection Control and Hospital Epidemiology. 2014;35(8): 937-960.
    • Wood, A, & Van Wicklin, S. Ultraviolet (UV)-cured nail polish. [Clinical Issues]. AORN Journal. 2015;101(6):701-708.

    Updated July 6, 2016

  • Can artificial nails be worn by personnel in the operating room?

    Artificial nails should not be worn in the perioperative environment. Any nail other than a natural nail is considered artificial. Artificial nails are defined as any substance or device applied or added to the natural nails to augment or enhance the nail, including bonding, extensions, tips, wraps, gel and acrylic overlays, and tapes. Artificial nails have been associated with hand contamination and epidemiologically implicated in outbreaks caused by gram-negative bacteria and yeasts.

    Resources:

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

    Updated July 6, 2016

  • What is the ideal fingernail length?
    Ideal Fingernail Length in a Perioperative Setting

    Fingernail tips should be no longer than 2mm (0.08 inch). Studies found that fingernails at a length shorter than 2mm were less likely to harbor bacteria when compared to nails longer than 2mm.

    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.
    • 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. doi:10.1086/524333
    • Hautemaniere A, Cunat L, Diguio N, et al. Factors determining poor practice in alcoholic gel hand rub technique in hospital workers. Journal of Infection and Public Health. 2010;3(1): 25-34.

    Updated July 6, 2016

  • Does the first surgical hand scrub of the day have to be soap and water before using surgical hand rub products?

    A standardized surgical hand scrub with a soap (antimicrobial agent), nonabrasive sponge, and water does not have to be the first surgical hand scrub of the day before an alcohol-based surgical hand rub product is used, unless it is recommended in the manufacturer's instructions for use. The surgical hand scrub reduces the transient and resident flora of the hands, which also may reduce health care-associated infections. A standardized surgical hand scrub using an alcohol-based hand rub product will decrease transient and resident flora on the hands. Hand washing does however need to be performed before the first surgical hand scrub of the day.

    Resources:

    • Ogg, MJ. First surgical hand scrub of the day. [Clinical Issues]. AORN Journal. 2011;93(3):397-398.

    Updated July 6, 2016

  • 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 be in compliance with 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
    • 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; 2015.

    Updated July 6, 2016

  • 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.

    Resources:

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

    Updated July 6, 2016

  • 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's safety 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. Ask your health care organization if personal dispensers are allowed and use a hand antiseptic product that is approved by your facility.

    Resources:

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

    Updated July 6, 2016