Coming Clean on Hand Hygiene: How Much Do You Really Know?

Infection Prevention

By: Jerry Zuckerman

Published: 10/10/2007

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Hand hygiene is your first defense against SSIs and, increasingly, against preventing MRSA transmission.


With the increase in methicillin-resistant staphylococcus aureus infections in healthcare, we at Albert Einstein Medical Center have renewed our focus on hand hygiene (see "The Plexus MRSA Initiative at a Glance" on page 36). Along with active surveillance and barrier precautions, it's one of the most crucial factors in preventing this problem that you may be seeing more of in the outpatient setting.

You may be wondering what's left to learn about hand hygiene - you wash, you rub, you glove. And it's been four years since the CDC released its comprehensive hand hygiene guidelines. But attitudes change slowly in healthcare, and despite the available guidance, a paradigm shift has yet to occur, and misconceptions still abound.

Here's an 11-question quiz to test yourself and your staff in an effort to keep hand hygiene at the fore of their minds. Some of the answers may surprise you.

1. What is the No. 1 means of spread for nosocomial pathogens?
a. Central IV catheters
b. Peripheral IV catheters
c. Foley catheters
d. Endotracheal tubes
e. Hands of healthcare workers

Answer: e. Hands are the most common means of spread for pathogens. Studies have shown a lowered rate of spread when staff adhere to good hand hygiene, thereby preventing cross-contamination of both patients and personnel.

2. What are the barriers to good hand hygiene?
a. Lack of time/understaffing
b. Lack of access to a nearby sink
c. Misunderstanding of hand hygiene's importance
d. Irritation and drying of the skin by hand washing
e. All of the above

Answer: e. All of the above. But the biggest barrier to hand hygiene adherence is staff not understanding the importance of protecting themselves and their patients.

3. Which of the following is the true statement?
a. Plain soap and water has been shown to be as effective as antimicrobial soap.
b. Antimicrobial soap and plain soap and water should routinely be used, unless gloves are worn on a routine basis.
c. Compared to soap and water, alcohol-based hand rubs are more drying on the hands because of their 60 percent isopropanol content.
d. Alcohol-based hand rubs can be used after hands are visibly soiled.
e. The most effective means of hand hygiene is the alcohol-based hand rub, followed by antimicrobial soap, then plain soap and water.

Answer: e. Alcohol-based rubs are most effective, followed by antimicrobial soap, then plain soap and water. When hands are visibly soiled, use soap and water instead. Don't abandon hand hygiene practices when you use gloves, since small defects in gloves can still transmit pathogens, and hands may become contaminated during glove removal. Both before and after each patient contact, use alcohol-based hand rubs or soap and water, even if you wear gloves. Because most alcohol-based hand rubs contain emollients and moisturizers, they tend to be less drying on the hands than soap and water.

The Plexus MRSA Initiative at a Glance

Who? The Plexus Institute, a non-profit organization that seeks to foster "the health of individuals, families, communities and organizations and our natural environment by helping people use concepts emerging from the new science of complexity."

What? Plexus is undertaking a "positive deviance" initiative to uncover the most successful practices that can prevent the transmission of methicillin-resistant staphylococcus aureus infections in healthcare facilities.

"The individual units identify the problems that exist and determine their own interventions and plans," says Jerry Zuckerman, MD, the hospital epidemiologist and an attending physician in the division of infectious disease at Albert Einstein Medical Center. "Infection control has always worked top-down; with this approach, we aid them in carrying out the fixes they come up with."

Where? Five beta sites: Albert Einstein Medical Center (Philadelphia) the Billings Clinic (Billings, Mont.) Franklin Square Hospital (Baltimore) the Johns Hopkins Hospital (Baltimore) University of Louisville Hospital (Louisville, Ky.) and VA Pittsburgh Healthcare System (Pittsburgh).

How? The beta sites are taking three actions to prevent MRSA, says Dr. Zuckerman:

' active surveillance (patients admitted to certain units undergo nares cultures because "for every patient who presents with symptoms of MRSA, there are a couple more who are carrying it," says Dr. Zuckerman)

' contact precautions ("anyone who has a positive culture upon admission is immediately isolated," where gowns, gloves and designated equipment will be used, he says)

' and hand hygiene (proper washing and sanitizing of hands will be done before and after every patient contact).

Why? According to the CDC, healthcare-acquired infections "account for some two million infections, 90,000 deaths and an estimated $4.5 billion in excess healthcare costs every year," says the Plexus Institute. "Many of the infections are antibiotic resistant, and MRSA is the most common of those. MRSA deaths are increasing dramatically ' [and] scientists believe the figures are underreported."

- Stephanie Wasek

4. True or false:
Studies have shown that adherence to hand hygiene can terminate outbreaks in healthcare facilities and reduce overall infection rates, but not reduce transmission of such antimicrobial resistant organisms as MRSA.

Answer: False. Improved adherence to hand hygiene, either hand washing or use of alcohol-based hand rubs, has been shown to reduce transmission of antimicrobial-resistant organisms as well as terminate outbreaks and lower overall infection rates in healthcare facilities. In addition to traditional hand washing with soap and water, the CDC released guidelines recommending the use of alcohol-based hand rubs by healthcare personnel. Com-pliance with those guidelines is one of the key actions for which the Joint Commission surveys.

5. Which of the following statements is true?
a. Using gloves doesn't eliminate the need for hand hygiene.
b. Hand hygiene can replace the need for gloves.
c. Gloves reduce hand contamination by 99 percent, prevent cross-contamination and protect patients and healthcare personnel from infection.

Answer: a. The use of gloves doesn't eliminate the need for hand hygiene. It reduces hand contamination by 70 to 80 percent, but disposable gloves and hand hygiene aren't interchangeable. Rather, they are complementary means of protecting staff and patients from infection. Change gloves after each patient contact and practice hand hygiene before and after each patient contact.

6. Which product kills the greatest number of microorganisms on the skin?
a. Soap and hot water
b. Antimicrobial soap and water
c. Alcohol-based hand rubs

Answer: c. Alcohol-based hand rubs. Alcohols have excellent in vitro germicidal activity against gram-positive and gram-negative vegetative bacteria, including multi-drug-resistant pathogens (such as MRSA and VRE), Mycobacterium tuberculosis and fungi. Herpes simplex virus, HIV, RSV, influenza virus and vaccinia virus are susceptible in vitro to alcohols. HBV is somewhat less susceptible, but is killed by 60 to 70 percent alcohol, as is hepatitis C virus. Alcohols have very poor activity against bacterial spores (such as clostridium difficile), protozoan oocysts and certain nonenveloped (nonlipophillic) viruses.

7. All of the following are known risk factors for poor adherence to hand hygiene practices, except
a. Physician status
b. Male gender
c. Working in the ICU
d. Weekend work
e. High number of opportunities for hand hygiene per hour of patient care
f. Wearing gowns and gloves

Answer: d. Weekend work. Observational studies have identified several risk factors for poor adherence to recommended hand hygiene practices. Among these, being a physician, a nursing assistant, working during the week, wearing gowns and gloves, ICU work, automated sinks, activities with a high risk of cross-contamination and a heavy patient load are all associated with worsening hand hygiene compliance. Unfortunately, studies have shown that the higher the demand for hand hygiene, the lower the adherence. Overall average rates of adherence were 40 percent, with the highest adherence in pediatric wards and the lowest in ICUs. There was an inverse relationship between the number of opportunities for hand hygiene and the actual performance of the act by the healthcare worker.

8. Which of the following is false?
a. Freshly applied nail polish doesn't increase the number of bacteria recovered from periungual skin.
b. Artificial nails haven't been associated with outbreaks of pseudomonas.

Answer: b. Artificial nails have, in fact, been associated with outbreaks of pseudomonas. Subungual areas of the hands harbor large numbers of bacteria, mostly coagulase-negative staphylococci, gram-negative rods, corynebacteria and yeast. Chipped nail polish may support the growth of large numbers of organisms on fingernails. Even after careful hand washing or the use of surgical scrubs, healthcare workers often harbor substantial numbers of potential pathogens under the nail space. Further, healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips before and after hand washing.

As a result, the CDC recommends that personnel who care for patients at high risk for infections not wear artificial nails and keep natural nails less than a quarter-inch long.

9. Which of the following is true?
a. Adherence to the CDC guidelines won't increase time spent practicing good hand hygiene.
b. An anticipated increase in allergic contact dermatitis will occur with greater adherence to hand hygiene practices.

Answer: a. Adherence to the CDC guidelines won't increase time spent practicing good hand hygiene. It takes an average of 60 seconds to find a sink, wash the hands with soap and water and dry them appropriately. On the other hand, the average time for use of alcohol-based hand rubs, as recommended by the CDC, is 20 seconds. One study documented that, on an eight-hour shift in the ICU, it took a nurse a total of 56 minutes to wash with soap and water based on seven 60-second hand washing episodes per hour. Use of alcohol-based hand rubs reduced this to 18 minutes, based on seven 20-second episodes per hour.

The second statement is only half true. Better compliance with soap and water cleaning may lead to an increase in allergic dermatitis, but the assumption that using alcohol-based rubs will cause dry, red, cracked skin is a myth. So far, the incidence of allergic contact dermatitis due to alcohol-based hand rubs has been uncommon.

10. Which of the following is true?
a. Healthcare workers who wear gloves during patient contact contaminated their hands with an average of 3 colony-forming units per minute of patient care versus 16 CFUs for those who didn't wear gloves.
b. Unlike with direct patient contact, gloves haven't been shown to reduce the risk of contaminating hands with pathogens from environmental surfaces.

Answer: a. Healthcare workers who wear gloves during patient contact contaminated their hands with an average of 3 CFUs per minute of patient care versus 16 CFUs for those who didn't wear gloves. Wearing gloves will reduce the risk of acquiring pathogens on the hands from both direct patient contact and from the environment around the patient, such as bed rails, sheets and tables. This translates into a reduced risk of transmitting pathogens to other patients and staff.

Change gloves and decontaminate hands when moving from a contaminated to a clean body site on a patient and when moving between patients. The CDC says to wear gloves when contact with blood, mucous membranes, non-intact skin or other potentially infectious materials could occur.

11. Gowning is indicated in patient care in all of the following situations except
a. When clothing may have contact with the patient.
b. When clothing may have contact with environmental surfaces.
c. When handling patients with diarrhea and incontinence.
d. When handling patients with draining wounds contained by a dressing.
e. When handling patients on contact precautions.

Answer: d. When handling patients with draining wounds contained by a dressing. Gowning is an essential contact precautions and must be done for every patient colonized with antimicrobial-resistant organisms. Gowning must also be practiced when dealing with potential splashes of blood or body fluids, including draining wounds not contained by dressings and ostomies.

First defense
To encourage full compliance, trial products to find a rub your staff and physicians like (see "Rub Trial: 5 Factors to Investigate" on page 38). Also talk to the unit managers in your facility to determine standard and customized dispenser locations. Next to phones, between patient rooms and outside conference rooms are convenient places. A tip: Don't place alcohol-based rubs near sinks. If staff are near a sink, they likely need to wash their hands or scrub for surgery, not perform a spot-cleaning.

Rub Trial: 5 Factors to Investigate

Every alcohol-based rub trial starts with selecting several products that meet guidelines for efficacy - 60 to 95 percent ethanol, plus ingredients to extend the life of the kill. But there's more to picking the right rub than buying the first one you see that meets your budgetary needs and FDA guidelines for safety and efficacy. Here are five such factors to look at during your hand hygiene trial.

  • Spread the responsibility. Because our facility is so large, we used a limited number of representatives from several departments as our testers. While we got less feedback, we were able to get more quality feedback on the rubs. In a smaller facility, it's easy to have all 30 or 50 staff trial the hand hygiene products you're considering; but a sample will do, especially if you find that there's a clear majority as you progress.
  • Scrutinize the dispenser. Judge this as closely as you would the formulation, as it could pose a safety hazard or deter usage. Be sure that the dispensing method is easy to control (so users don't get too little or too much), and doesn't allow the product to drip onto the floor or to build up and clog the nozzle. Dripping could lead to residue - and a possible fall hazard - on the floor. We also consulted with housekeeping on this factor to determine ease of restocking and to standardize dispensers.
  • Consider all the consistencies. Alcohol-based rubs come in liquids, gels and foams. The consistency of the product should be considered in conjunction with the dispenser because those two factors can encourage either dripping or excess build-up. The former can lead to wasted product and increased costs, while the latter can deter physicians and staff from complying with hand hygiene protocols; no one wants the have rub squirting out the sides of a clogged nozzle or to have it not come out at all. After we'd winnowed our hand sanitizer choices to two, the ease of product dispensing (based on the method and product consistency) was really a deciding factor.
  • Avoid fragrance. A lot of people are bothered by strong perfumes, but male physicians and staff have especially negative reactions - and I'm not talking about the allergic variety - to something that smells like flowers. One of the formulations in our trial had a soft baby powder scent, but even that wasn't well-received. A little bit of fragrance is nice in some respects, because it masks the alcohol, but when you consider that it tends to decrease usage, it's a good idea to ask about the scent on the evaluation form.
  • Feel the finish. Emollients are added to all formulations, and actually keep hands better hydrated than washing with soap and water between patient contacts. However, some staff may feel that these emollients make their hands feel sticky after several applications. If physicians and staff feel that using the product "too often" means difficulty donning gloves or leads them to more hand washing, it may discourage compliance. Ask whether, after dozens of uses per day, users feel that the rub tends to build up; this will indicate whether there are too many emollients in the product for users' tastes.

It helps if the product that wins your trial comes from a manufacturer you already have a good relationship with. That was the case for us, and it's a relief knowing that, if there's a problem with the product or getting it in stock, we'll be taken care of. Remember, once the dispensers are installed all over your facility, it would be a major undertaking to replace them. So it's important to make the right decision the first time.

We're sure we did: We phased in the dispensers and the alcohol-based rubs by placing them only in select locations to start, such as near elevators, in the ICU and in the surgery unit. It wasn't long before we in infection control noticed that dispensers would mysteriously go missing ' only to reappear in departments that didn't yet have the rubs. We took the hint and sped up the rollout - and the rubs stopped walking around the facility. - Dottie Borton, RN, BSN, CIC

Ms. Borton ("[email protected]")) is an infection control practitioner at Albert Einstein Medical Center in Philadelphia.

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