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Update on Hand Hygiene
Proposed CDC guidelines are aimed at making scrubbing safer and more effective.
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Publish Date: October 10, 2007   |  Tags:   Infection Prevention

This year, the Centers for Disease Control (CDC), working with several other recognized authorities, is expected to release "Guideline for Hand Hygiene in Healthcare Settings." This comprehensive update of a 15-year-old guideline may signal a new era in hand antisepsis.

Released in draft form last year by the CDC's Healthcare Infection Control Practices Advisory Committee, the guideline was reviewed by patient care and infection control experts. It's possible and even probable that revisions will occur prior to the final release of the document. However, the following recommendations in the draft guideline bear watching:

  • The agency seems to support the practice of using waterless alcohol-based handrubs for all handwashing, including surgical scrubbing. The agency praises the efficacy, fast action and convenience of these rubs and their gentleness on the hands. It suggests that health-care workers are more likely to comply with proper use of these scrubs than with others. The guidelines do indicate that surgical scrubs should contain ingredients which contribute to a persistent effect, however, which is not alcohol's strong point;
  • The guidelines suggest avoiding the use of a brush or harsh sponge when scrubbing (a soft sponge is acceptable). These devices can cause a significant increase in microorganism shedding and skin damage-damaged skin harbors more and/or altered microbial flora.
  • Surgical team members should keep fingernails short and not wear artificial nails. Most hand flora are found under and around the fingernails, plus long nails have the potential to puncture surgical gloves. There has been documented transmission of infections from nurse to patient caused by artificial nails.
  • The document suggests that facilities need to monitor hand care practices and use skin protectants as a matter of policy and practice.

Scrubbing Tips

Here are a few tips to improve your OR personnel's compliance with effective scrubbing technique.

  • Place brightly colored signs at each scrubbing area detailing the Center for Disease Control's scrubbing guidelines.
  • Monitor scrubbing technique for all staff, but particularly for surgeons and nursing assistants. They are typically the poorest compliers.
  • Train new employees on proper scrubbing. One idea is to cover staff members' hands with finger-paint prior to scrubbing. Areas where paint remains help pinpoint breaks in aseptic technique.
  • Prohibit artificial nails, and remind staff to keep nails short.
  • Make scrubbing easy. Two-minute scrubs with any capable agent are as effective as the traditional 10-minute variety.
  • Select scrubbing agents that are easy on the hands. Look for emollients or conditioners.
  • Require a full scrub at the case's beginning, including a thorough cleaning underneath fingernails with a brush. Use waterless antiseptic agents between cases.
  • At the initial scrub, rinse all soap off the hands to reduce drying.
  • Eliminate unnecessary requirements, such as scrubbing above the elbows.
  • Use brushes just for cleaning under fingernails, but avoid them for scrubbing hands.

Hand washing practices
The proposed guideline closely examines research on hand washing as it actually occurs in healthcare facilities, and states that "adherence of healthcare personnel to recommended handwashing practices is poor."

The guideline cites studies that have noted a wide variance in the number of times that healthcare workers wash their hands, and the duration of hand washing. Overall, adherence to hand hygiene procedures averages about 40 percent.

The document comments that nurses are better compliers than physicians and nursing assistants. But it cites other factors as risk factors for poor compliance including:

  • High workload and understaffing
  • Not enough time to wash hands
  • Skin irritation caused by hand hygiene products
  • Inaccessibility of hand washing supplies
  • The perception of patient needs perceived as a priority
  • Glove wearing
  • Forgetfulness
  • Lack of scientific information about the importance and impact of hand hygiene

The document notes that no randomized controlled studies prove absolutely that surgical site infection rates are lowered by hand washing with antiseptics rather than soap and water. However, there is "compelling evidence" to indicate that the surgical team should scrub with antiseptics:

  • Skin bacteria multiply rapidly under surgical gloves on hands washed with plain soap, and more slowly when washed with an antiseptic.
  • Reducing hand flora on the surgical team reduces the risk of transmission if gloves are punctured during surgery.
  • At least one documented outbreak of surgical site infections occurred when surgeons switched from an antiseptic scrub to plain soap and water.

Overview of Agents

The proposed "Guideline for Hand Hygiene in Healthcare Settings" offers specific information about antimicrobial agents used in hand hygiene products. Following is a brief overview of the strengths and weaknesses of each, as noted by the guideline:

Plain (antimicrobial) soap. This effectively removes dirt, soil and various organic substances, but has "little if any antimicrobial activity." Plain soap can become contaminated, which may lead to colonization of gram-negative bacilli on the hands of health care workers. Plain soap can irritate hands, although emollients may reduce irritation.

Alcohols. Alcohols have excellent germicidal activity against gram-positive and gram-negative vegetative bacteria, Mycobacterium tuberculosis, and fungi, but have poor activity against bacterial spores. Alcohols are active against most viruses. Hands cleaned with alcohol are less likely to transfer pathogens to supplies and equipment than hands washed with plain soap. Studies show that alcohol inhibits the regrowth of bacteria better than plain soaps, and possibly antimicrobial soaps as well. Frequent use of alcohol-based products can cause drying of hands, but the addition of emollients reduces dryness and irritations. The main drawback to alcohol is that it is flammable, requiring precautions when storing it.

Chlorhexidine. This agent, incorporated into hand hygiene products as chlorhexidine gluconate, has good activity against gram-positive bacteria, less activity against gram-negative bacteria, and minimal activity against tubercule bacilli. It's active against some viruses, such as herpes simplex, HIV and influenza. Chlorhexidine is antimicrobial even in the presence of blood or other organic materials. It has significant residual activity. Chlorhexidine generally should not be used in eye, ear, or brain surgery.

Chloroxylenol. This agent, also known as para-chloro-meta-xylenol or PMX, is widely used in antimicrobial soaps. It has good activity against gram-positive organisms and fair activity against gram-negative organisms, mycobacteria and some viruses. Studies of this product have been few and contradictory, with one study finding it comparable to chlorhexidine gluconate, while two others found it inferior.

Iodophor. This agent is active against gram-positive, gram-negative, some spore-forming bacteria, mycobacteria, viruses and fungi. Its antimicrobial activity can be affected by pH, temperature, exposure time, concentration, and the presence of blood, sputum, alcohols and detergents. One study shows persistent activity for six hours, while others indicate persistent activity of 30 to 60 minutes. Hand hygiene preparations often contain 7.5% to 10% povidone-iodine, but formulations with lower concentrations also have good antimicrobial activity because dilution increases free iodine concentrations. However, as the concentration increases, it may cause more skin irritations. Iodophors cause more contact dermatitis than other products.

Quaternary ammonium compounds. These compounds, used in antiseptics, include alkyl benzalkonium chlorides, benzethonium chloride, cetrimide and cetylpyridium chloride. They are more active against gram-positive than gram-negative bacilii, and are relatively weak against mycobacteria and fungi. They are adversely affected by blood and detergents. These compounds are well-tolerated, but are prone to contamination by gram-negative organisms. However, newer hand-washing products containing these compounds have been introduced and may be appropriate for health care workers. One study showed the products to be about as effective as washing with plain soap and water, while another showed that it was more effective.

Triclosan. This bacteriostatic agent has a broad range of antimicrobial activity. It's more effective against gram-positive than gram-negative organisms, is active against mycobacteria, but has little activity against fungi. Studies show it reduces bacterial counts on hands, but less so than chlorhexidine, iodophors, or alcohol-based products. Triclosan has persistent activity on the skin. Its activity is not affected by the presence of blood, but surfactants present in some formulations may affect it. Formulations with less than 2% triclosan are well-tolerated and do not cause allergic reactions.

That said, the proposed guideline indicates that significant uncertainty exists regarding the efficacy of hand hygiene products currently on the market. In at least some cases, test subjects were not actual health care workers, so the flora on their hands may not have been the same as those on healthcare workers' hands.

The document notes that surgical scrubs need to be easy on the skin. A number of studies show that previously accepted practices of scrubbing for 10 minutes prior to surgery or scrubbing with a brush damages the skin over time- and damaged skin can harbor microorganisms. Irritant contact dermatitis, which can be caused by detergents found in some antiseptic products, is another contributor to poor skin condition.

The agancy's overall handwashing recommendations include:

  1. If hands are visibly soiled with blood or other bodily fluids, wash hands as soon as possible with soap (plain or antimicrobial) and water.
  2. If hands are not visibly soiled, it is preferable to use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations.
  3. As part of a multi-disciplinary program to improve hand hygiene, provide healthcare workers with a readily accessible alcohol-based handrub product.
  4. In areas of high workloads and high intensity of patient care, make an alcohol-based handrub available in prominent, convenient locations, and in individual, pocket-sized containers to be carried by healthcare workers.
  5. Remove all jewelry before beginning a surgical scrub.
  6. Immediately before putting on surgical gloves, scrub with an alcohol-based product or antimicrobial soap, avoiding lengthy duration hand scrub times (10 minutes) and the use of a brush.
  7. When choosing hand hygiene products, solicit input from health care workers regarding the feel, fragrance and skin tolerance. Cost should not be the primary selection factor.
  8. Provide healthcare workers with lotions or creams to minimize irritant contact dermatitis.
  9. Do not wear artificial fingernails or extenders.
  10. Monitor hand hygiene practices, and provide your staff members with information regarding their performance.