Chapter 4: Infection prevention and control
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Related theory
Hand hygiene is generally accepted as a cornerstone of good infection prevention and so it is essential that wherever care is provided, there are accessible and appropriate facilities for hand hygiene (WHO [124]). The hands of healthcare workers are a common cause of transmission of micro‐organisms between patients and are frequently implicated as the route of transmission in HCAIs (Moolenaar et al. [80], Mortimer et al. [81], Pittet et al. [101], Sax et al. [108]). Transient micro‐organisms (bacteria, fungi and viruses) are organisms located on the surface of the skin and beneath the superficial cell of the stratum corneum. The subungual regions of the nails harbour the majority of the micro‐organisms found on the hands (AORN [3], Hedderwick et al. [56], McNeil et al. [76]). They are acquired from and transfer easily to the animate (patient) and inanimate environments during contact activities. Damaged skin, moisture, false nails and jewellery increase the possibility of colonization with transient micro‐organisms (McNeil et al. [76]). Both microbial load and type depend upon the prevalence of micro‐organisms in the environment and on the activities being undertaken by healthcare workers. Hands have been found to be contaminated after general ward‐based activities including bed making, handling curtains and patients’ clothing, and washing materials, and after sluice room activities. Transient micro‐organisms, unlike resident bacteria, can easily be removed from the hand surface via effective hand hygiene (Boyce et al. [9]).
There are three main levels of hand hygiene:
- Hand washing is the process for the physical removal of soil (dirt, blood, body fluids and transient micro‐organisms) from the hands (e.g. after using the lavatory or before preparing a meal) using ordinary liquid soap and water. In the clinical setting it should be performed as per the ‘5 Moments’ (discussed below) (Sax et al. [108], WHO [124]).
- Aseptic hand decontamination or hand antisepsis is the destruction of micro‐organisms on the hands (e.g. prior to a dressing procedure). If carrying out an aseptic procedure, an antiseptic soap may be used as an alternative to ordinary soap (but it is not essential). This will contain a disinfectant such as chlorhexidine or povidone‐iodine. Alternatively, it is very acceptable to wash with ordinary soap and water, dry hands and then apply alcohol‐based handrub.
- Surgical scrub aims to remove dirt and organic matter, kill transient micro‐organisms, and reduce the numbers of resident and transient bacteria on the skin prior to surgery. Surgical scrub technique may be carried out using antiseptic soap or approved alcohol‐based handrubs. Antiseptic handwash solutions such as chlorhexidine gluconate or povidone‐iodine solution should be used with an appropriate technique and for a minimum of 3 minutes as part of surgical preparation. Approved alcohol‐based products may be used on physically clean hands for a 90‐second scrub.
Taylor ([112]) noted that some nurses could wash their hands for a long time but not cover all the surfaces, whereas others could cover all the surfaces within 30 seconds (Figure 4.7). A six‐step hand hygiene technique to cover all areas of the skin was first described by Ayliffe et al. ([5]) to test the efficacy of different hand disinfectants. The technique has been adopted by the World Health Organization (WHO) ([124]) as standard and is used worldwide; however, more recently some have queryied whether a three‐stage technique would be more practical, especially for the use of alcohol‐based handrub (Tschudin‐Sutter et al. [114]).
Figure 4.7 Taylor's work in 1978 showed the areas most commonly missed following hand washing – in particular, the thumbs, especially on the dominant hand and in between the fingers.
Source: Reproduced from Taylor ([112]) with permission of EMAP Publishing Ltd.
