GUIDELINES FOR THE SUCCESFUL DECONTAMINATION OF HANDS

GUIDELINES FOR THE SUCCESSFUL DECONTAMINATION OF HANDS

Hand decontamination is the single most important measure in reducing the spread of disease. Hands are a recognised principle route of cross infection. Hand washing is an infection control practice with a clearly demonstrated efficacy, and remains the cornerstone of efforts to reduce the spread of infection, but studies have shown that it is rarely carried out in a satisfactory manner. This reluctance to wash hands has become a major concern. The ability of transient micro organisms to transfer to, and from, hands with ease results in hands being extremely efficient vectors of infection. Thorough hand washing will reduce the risk of cross infection immediately.

Effective hand decontamination is essential in the prevention of infection and this can only be achieved when hands are washed following the GPCT 6 stages as illustrated (in appendix 3).

Micro organisms on the hand are either resident or transient flora.
Resident flora is usually of a low virulence and rarely cause infections except when introduced into the body through exposure prone procedures such as surgery or the introduction of an invasive device i.e. a urinary catheter, peripheral cannula etc.
Transient flora may consist of many different pathogenic micro organisms. They are not firmly attached to the skin and are removed quickly and effectively with routine hand washing using soap and water or an alcohol based hand rub.

Hand decontamination can take place with a number of different decontamination agents;

Liquid soap should be non-perfumed and non-coloured and dispensed from a clean wall mounted or free standing pump action dispenser.
Anti-microbial action hand wash solutions i.e. Hibiscrub are not required for social hand washing and are only required prior to a minor surgery procedure.
Alcohol hand rubs can only be used if there is no visible soiling on the hands and that the potential organism involved with the action prior to hand decontamination is not a spore forming pathogen.
Biocide hand wipes can be used on soiled hands, as there is a detergent ingredient that will remove soiling and still disinfect the hands due to biocidal action.

When to wash hands

There is no set frequency for washing hands; it is determined by actions - those completed and those about to be performed. Examples of some of the reasons are outlined below.

Prior to and on completion of duty.
Between any patient contact.
Before and after all aseptic/invasive procedures.
After removal of gloves.
Before handling food.
After any contact with blood/body fluids.
Before entering and after leaving any source isolation facility.
Before leaving work place, office, ward, clinic or patients home.
After removal of personal protective clothing/equipment.

Routine washing

Before preparing, eating, drinking or handling food
Before and after smoking..
After visiting the toilet.
Before starting work (remove jewellery e.g. rings) and after leaving
Before and after physical contact with each client in clinical situations e.g. bathing, assisting to move, toileting.
After handling contaminated items such as dressings, bedpans, urinals, urine drainage bags and nappies etc.
Before putting on sterile gloves.
Before and after removing any protective clothing this includes sterile and non-sterile gloves
After blowing your nose, covering a sneeze
Whenever hands become visibly soiled
After handling contaminated laundry and waste

Routine (Social) hand wash for all patient contact:-

Wet hands and wrists, apply sufficient liquid soap to create a lather and wash hands for a minimum of 15 seconds using the recommended procedure, clean, rinse and dry hands thoroughly with soft white paper towels - correct hand drying is as effective as hand washing.

Hygienic or Disinfection Hand Wash

Prior to undertaking invasive procedures, or when caring for patients with known infections:-

Wash and dry hands as described above, then apply alcohol hand rub to the cupped hands and rub until dry using the procedure described for hand washing to insure the hands are covered with the alcohol hand rub.

Antiseptic Hand Wash (Chlorhexidine/Iodine)

Prior to undertaking invasive procedures or when caring for patients with known infections:-

Wet hands and wrists; apply 3-5mls of solution into cupped hands and wash for 15-30 seconds using procedure described (see Appendix 1). Rinse hands and dry thoroughly with paper towels.

Surgical hand washing

This type of hand washing is intended to remove or destroy the transient micro-organisms and reduce detachable resident organisms. This requires the use of an antiseptic hand wash solution. The process aims to decrease the resident organisms to prevent wound contamination should gloves become damaged. A defined washing technique is more important than the type of antiseptic solution that is being used. This process is essential before all surgical or any invasive procedure.

Surgical Hand Scrub/Disinfection - Prior to surgical procedures:-

Removal of transient & resident micro-organisms, using the technique described to include forearms, for a period of approximately 2 minutes with an antiseptic solution (Chlorhexidine recommended) with single use nail brush. All surfaces of the hands must be washed by the technique described.

Soap or antiseptic solution?

In reality, cosmetically pleasing and a `kind' to skin solution will be far more acceptable. Therefore, the supply of a cleansing agent that will improve compliance to the washing of hands will outweigh the benefits of small cost savings, when compared to the costs of cross infection and human suffering resulting from non-compliance. Rinsing the hands before and following the application of the cleansing agent will reduce the risk of sensitisation to the agent.

Liquid soap

Liquid soap is the preferred option, in the main, for most care settings. Emollients are now standard in the majority of hand wash detergents. Soap physically removes microorganisms from the skin. It is all that is necessary to remove the transient organisms acquired from contact with patients. Disposable cartridge type liquid soap dispensers are preferable to the refillable models. This is because refillable containers have a greater risk of contamination by Gram-negative bacteria; they can multiply in the liquid soap. Bar soap can become contaminated with skin bacteria and Gram-negative bacilli and should, therefore, be avoided when possible. It is definitely not recommended for staff.

Antiseptic solution

These are soap solutions with an antiseptic added. They will significantly reduce the microorganisms that normally live on the skin as well as completely remove the transient ones. Antiseptic soap is only necessary prior to invasive procedures or after handling infectious material. The user must make the decision on which variety to choose after taking all aspects of the procedure into consideration.

Surgical hand wash solution

Agents for surgical hand washing are essentially the same as for those with aqueous antiseptic solutions, some being more commonly used than others. The user, again, should make the choice of which should be supplied.

Nailbrushes

Nailbrushes should not be generally used because they become heavily contaminated. If they are required, they should be single use items that are disposed of post single use.

Hand Drying

Thorough hand drying is an essential part of successful hand decontamination. Good quality soft paper towels with effective drying properties will work well in this role and also improve compliance to the washing of hands. Communal towels must not be used; they are a cross infection hazard. Evidence about the use and efficacy of warm air hand dryers is conflicting but they are noisy, can only be used by one person at a time and it takes longer to dry hands.

Alcohol Rubs

Alcohol-based products contain emollients designed to help prevent the drying out of the hands. Alcohol is an effective alternative when water and towels are not available such as when in the community. It is also useful when there is a need for rapid hand disinfection. Alcohol is more effective than aqueous antiseptic solutions but a preliminary wash is always needed for physically soiled hands.

Limitations of alcohol hand rubs

Alcohol hand rubs are not effective when used against spore forming pathogens. This means that alcohol hand rub does not kill Clostridium difficile, a spore forming bacterium or Rota viruses, Noro, Norwalk or winter vomiting virus which are spore forming viruses. Alcohol solutions are not effective against some viruses as there is insufficient contact time. The method of application has been described in the `Guidelines for Hand Hygiene' published by the Infection Control Nurses Association (ICNA):

Dispense the required amount of solution onto the hands

Ensure solution covers all hand surfaces

Rub vigorously, using hand washing technique, until dry.

Biocidal Hand Wipes

A relatively new innovation in hand decontamination is the biocidal wipe. This wipe contains a detergent to cleanse the skin, emollients to moisturise the hands and a biocidal action to disinfect the skin. The wipe contains only a small amount of alcohol (approx. 5%) which acts as a drying agent so that the hands do not remain moist with the wipe fluid. Early indications are that these wipes are ideal for situations where there is concern that soiling of the hands has taken place and so the use of an alcohol hand rub is unsuitable. The wipes can be used when no satisfactory hand washing facilities are available. For further information on these wipes please contact the Infection Prevention & Control Team.