In the surgical setting, every infection control measure is a link in a chain of defense against pathogenic organisms. Each time we break just one link, we create an opportunity for organisms to move in. Unfortunately, misconceptions about hand hygiene are common, and when improper hand hygiene procedures combine with other 'breaks in the chain' - such as improper instrument processing, environmental oversights or antibiotic overuse - we set the stage for post-op infection. This article reviews seven of the most common hand hygiene misconceptions.

1. It's OK to put soap on dry skin
During routine "soap-and-water" handwashing or surgical scrubbing, apply the soap or cleansing agent only after wetting hands.[1] When you apply soap to dry hands, the soap imbeds in the pores, blocking water from entering the pore and ultimately leaving a soapy residue even after a thorough rinse. The residue can cause the skin to break down, which, in turn, increases the potential for bacterial colonization and shedding. Detergents, in particular, break down the outermost layer of the skin (stratum corneum) by altering lipids and inhibiting the cells' ability to cohere and bind to water. By applying the soap or cleansing agent to wet hands, the water gets in the pores of the skin first, diluting the soap and allowing you to lather up faster and rinse off more thoroughly.

2. The warmer the water, the more effective the handwash
Manufacturers have different water-temperature recommendations for handwashing and scrubbing, but the general rule of thumb is that tepid water works with all types of soaps and cleansing agents. Repeated exposure to hot water removes the skin's protective oils, thereby increasing the risk of dermatitis, dryness and subsequent skin breakdown.[1] Hot water is also uncomfortable and can shorten wash time. And although cold water does not cause these same problems, water that is too cold can inhibit lathering and thus reduce the effectiveness of the cleansing agent.

3. The more soap, the better
More soap is not better. Manufacturers test set amounts of their products to maximize cleaning and antimicrobial efficacy and prevent waste.[2] Too much soap can also increase residue on the hands because it takes longer to rinse off. As mentioned earlier, this can promote skin irritation, which can increase bacterial colonization and shedding. When using an impregnated sponge during surgical scrubbing, don't add more soap.

4. Rub hands together for a good 25 seconds during routine handwash
The Association for Professionals in Infection Control and Epidemiology, Inc. (APIC) and the CDC recommend rubbing hands together vigorously for just 15 seconds, covering and generating friction on all surfaces of the hands and fingers.[1] This is about how long it takes to sing the "happy birthday" song. Dry hands thoroughly with a disposable towel, because leaving them partially wet can cause chapping and skin breakdown.

When using an alcohol-based hand rub for hand antisepsis, continue rubbing until hands are dry.[1] If hands dry in less than a minute, use more of the waterless rub.

5. Gloves obviate the need to clean hands between noninvasive patient encounters
Hand hygiene guidelines recommend 'washing' hands before every patient contact regardless of the nature of the encounter or whether you are donning gloves.[1,3] Since we can transfer bacteria from person to person or from surface to person via our hands, we must assume that every patient is colonized with a pathogen. This is particularly important given the rise of methicillin-resistant Staphylococcus aureus (MRSA) in healthcare settings and our inability to know who is and is not colonized with this community-acquired pathogen.[4] In addition, although gloves reduce hand contamination by 70 to 80 percent, they do not provide 100 percent protection against bacterial or viral transmission. FDA standards allow manufacturers to market gloves with some holes or other defects. As a result, pathogens can pass through both vinyl and latex gloves, even when they are intact.

When moving from patient to patient in the outpatient setting, waterless, alcohol-based hand rubs are often ideal to use between encounters. If, however, you contact a dressing or bodily fluid or suspect other physical contamination, it is best to wash your hands with an antibacterial agent and water. This is because alcohol rubs effectively kill bacteria, but do not remove organic material from the hands.[1]

6. Alcohol kills bugs and cleans hands
Alcohol kills microbes quickly. Research shows that formulations containing 60 to 95 percent alcohol alone - or as little as 50 percent alcohol combined with small amounts of a quaternary ammonium compound, hexachlorophene (HCP) or chlorhexidine gluconate (CHG) - have the quickest and most thorough antimicrobial action.[1]

However, alcohol alone does not remove organic debris from hands. This is an important distinction because an alcohol-based, waterless hand rub effectively kills bacteria but does not remove the dead bugs or other contaminants like bodily fluids or dirt. Therefore, it makes sense to use a soap-and-water antibacterial handwash (or a traditional soap-and-water handwash followed by an alcohol hand rub) if there is any reason to suspect that you have dirt, bodily fluids or other physical contaminants on your hands.[1] Some manufacturers of alcohol-based, waterless agents also recommend cleaning hands with a soap-and-water handwash after eight-to-10 consecutive applications of a waterless, alcohol-based hand rub to remove residue and organic contaminants.[1]

7. Clear nail polish is preferable to colored nail polish
There is no difference between colored and clear nail polish from an infection control viewpoint. The primary concern about fingernails is that the subungual space harbors the greatest concentration of microbes on the hand, and some research suggests that chipped polish (whether clear or colored) can act as a nidus for bacterial colonization on fingernails.[1] For this reason, AORN supports the wearing of only freshly applied polish,[5] although this is difficult if not impossible to enforce.

Research also shows that people with long, natural nails and especially artificial nails also tend to harbor more subungual bacteria than those with shorter, natural nails. Ideally, keep fingernails natural, trimmed, clean and polish-free.[1]

Good hand hygiene
Overall, good hand hygiene goes hand-in-hand with other infection control measures. By tackling these seven misconceptions in your facility, you'll be better equipped to keep the chain of defense against unwanted organisms intact.

References
1. HICPAC Guideline for Hand Hygiene in Health-Care Settings. MMWR. October 25, 2002. Vol. 51, No. RR-16.
2. Tentative Final Monograph for Healthcare Antiseptic Drug Products. Proposed Rule. Federal Register. 21 CFR; Parts 333 and 369. June 17, 1994. Vol. 59, No. 116, p. 31442.
3. Occupational Exposure to Bloodborne Pathogens: Final Rule. Occupational Safety and Health Administration. Federal Register. 29 CFR; Part 1910.1030. December 6, 1991. Vol. 56, No. 235, p. 64176.
4. Rampling A, Wiseman S, Davis L, et al. Evidence that hospital hygiene is important in the control of methicillin-resistant Staphylococcus aureus. J Hosp Infect. 2001 Oct;49(2):109-16.
5. Recommended Practices for Surgical Hand Scrubs. AORN 2003 Standards, Recommended Practices, and Guidelines. 2003;p. 277.