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.
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
- 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.
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:
- If hands are visibly soiled with blood or other bodily fluids, wash hands as soon as possible with soap (plain or antimicrobial) and water.
- If hands are not visibly soiled, it is preferable to use an alcohol-based handrub for routinely decontaminating hands in all other clinical situations.
- As part of a multi-disciplinary program to improve hand hygiene, provide healthcare workers with a readily accessible alcohol-based handrub product.
- 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.
- Remove all jewelry before beginning a surgical scrub.
- 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.
- 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.
- Provide healthcare workers with lotions or creams to minimize irritant contact dermatitis.
- Do not wear artificial fingernails or extenders.
- Monitor hand hygiene practices, and provide your staff members with information regarding their performance.