The first hand hygiene protocols for health-care professionals were instituted in hospitals by Dr. Ignaz Semmelweis in 1847. His early observations led him to conclude that physicians' and medical students' hands contaminated during patient care were a major source of infection among mothers in hospital maternity wards. His handwashing program's success led the way for a well-documented body of literature strongly supporting a connection between improved hand hygiene practices and reduced patient infections.
The 2002 CDC "Guidelines for Hand Hygiene in Health-Care Settings" provides an excellent literature review, as well as reinforcement of the concept that considers hand hygiene the most important measure in preventing the spread of health-care infections. Yet, despite all documented evidence, compliance by health-care professionals remains an ongoing problem area.
Many people assume that health-care professionals routinely wash their hands and use waterless alcohol-based hand rub in accordance with evidence-based recommendations before and after contact with patients. However, clinical research has shown that high numbers of health care-associated infections, in addition to the spread of drug-resistant microorganisms, continue to occur from poor hand hygiene compliance. Adherence to recommended procedures has historically been shown to be poor, with overall reported rates of only about 40%–60% in hospital settings. A variety of factors contribute to the problem; a few of the more common reasons are listed in Table 1. When these and other perceived barriers are evaluated, it is apparent that quality assurance of hand hygiene practices continues to be a major challenge in health care. The following will briefly discuss two of these factors.
Table 1: Representative reasons for lack of hand hygiene compliance
Lack of knowledge regarding hand hygiene principles, guidelines, and protocols
Gloves worn as substitute for hand hygiene
Inappropriate procedures and agent exposure times used
Too busy or insufficient time
Skin irritation and dermatitis from frequent handwashing procedures
Inconvenient location or lack of sinks
Lack of soap and paper towels
Hands did not look dirty
Perceived low risk of cross-infection
Not thinking about hand hygiene/forgetfulness
Gloves as hand hygiene substitutes
Gloves are a very important element of any infection prevention program, but they are not a substitute for hand hygiene procedures. While there have been published reports demonstrating that gloves do not maintain their protective function as well after washing and reuse, the principle given above can also be explained using basic microbiology. Hands contact a variety of surfaces, both animate and inanimate, many times an hour when gloves are not being worn. These include the epithelial tissues of others and environmental surfaces. Certain bacteria and viruses can survive for days or even weeks on these external surfaces. As an example, Staphylococcus aureus is a common component of one's normal skin microflora and can remain viable on inanimate surfaces for weeks to months. These and another virulent type of staphylococcus, methicillin-resistant S. aureus (MRSA), can attach to hand tissues after a person touches a surface harboring these bacteria. In this instance these organisms are considered "transient flora" and can be readily eliminated using appropriate hand hygiene. However, if handwashing or waterless antiseptics are not used before gloving, these organisms can reproduce and thrive on the skin. Why? Think about it—hands typically perspire when gloves are worn. That moisture plus the warm temperature created under the gloves causes a perfect humid environment for microbial growth. Think of it as a "mini-incubator" under the gloves. They can be passed onto others via direct skin contact when the organisms are not removed and killed by hand hygiene procedures. In fact, cross-infection of MRSA from colonized health-care professionals to hospitalized patients was shown to occur in this manner in studies performed in the early 1980s. Clinical infections with other pathogenic bacteria and viruses also have been described. In summary, glove use in place of hand hygiene should be discouraged—period.
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Skin irritation and dermatitis
Damage to healthy skin from frequent hand hygiene procedures is one of the most frequent problems reported by all health-care professionals, who commonly perform 30–40 hand hygiene procedures a day. Soaps and antimicrobial hand wash agents can dry and damage skin when applied on a regular basis by removing protective oils and lipids. Keratinized epithelium can become red and sore, with the local acute inflammation leading to irritation dermatitis. These lesions are often found in those health-care professionals who have sensitive skin, a history of skin problems, or both. Symptoms of irritation dermatitis usually develop gradually (over days to weeks) and are localized. The discomfort, bleeding, and pain from the irritated hand surfaces has caused many affected health-care professionals to compromise their normal hand hygiene practices.
Addressing and preventing dermatitis involves evaluating the causes, taking steps to resolve irritation, and also using appropriate medical-grade hand hygiene products developed for frequent use. Actions one can take include the following:
- Health-care professionals suffering from nonspecific dermatitis can use a mild, nonantimicrobial soap to wash hands. The basic principle is to clean hands, and this can be accomplished without using antimicrobial antiseptics, which can cause further drying.
- All water-based soaps and antimicrobial antiseptics should be rinsed off completely before drying hands. This is especially applicable for those health-care professionals with any degree of dermatitis. Damaged epithelium tends to cause soaps to adhere more tightly, thus making it more difficult to remove the agent.
- The use of waterless, alcohol-based hand rubs containing emollients on unsoiled hands can help increase compliance. Alcohol is a rapidly effective, broad-spectrum antimicrobial on skin, but its denaturing and dehydrating actions on proteins can dry tissues. Emollients in the products counteract those destructive effects by lubricating the skin. Cool or tepid water should be used for routine handwashing procedures. Hot water can leave epithelial pores open and accelerate leaching of skin oils and lipids.
- Periodic use of water-based lotions can be included in a regimen to further promote skin integrity.
We are only born with two hands and they serve us very well in life and when treating patients. They deserve the best of care and maintenance.
John A. Molinari, PhD, is director of infection control for the Dental Advisor. Previously, he was professor and chair of the department of biomedical sciences at the University of Detroit Mercy School of Dentistry. Contact him at firstname.lastname@example.org.