Handwashing: a key to infection control

Handwashing undoubtedly is an important element of personal hygiene. For health-care workers, however, it is a primary disease-prevention measure. The simple act of handwashing significantly reduces the number of microorganisms that reside on a host, thus limiting the spread of infection from provider to patient and co-workers.

A simple handwashing routine can reduce the threat of microorganisms in the dental office.

Karen Gomolka

Handwashing undoubtedly is an important element of personal hygiene. For health-care workers, however, it is a primary disease-prevention measure. The simple act of handwashing significantly reduces the number of microorganisms that reside on a host, thus limiting the spread of infection from provider to patient and co-workers.

The skin harbors resident and transient bacterial flora. Resident flora (also referred to as "colonizing flora") are likely to become permanent residents of the skin and can exist several layers beneath the skin`s surface. They never can be completely removed, even with a thorough surgical scrub.

Resident dermal microflora can cause infection when directly or indirectly spread to others. But they are considered less important in disease transmission than transient skin flora. Also referred to as "contaminating flora," transient organisms contaminate the hands through contact with environmental surfaces and instruments They typically do not colonize and survive on the hands for very long. They can, however, be a source for disease transmission, because they remain on the outer layers of the skin. Routine handwashing can remove or greatly reduce transient microflora on the hands.

Pathogens in blood, saliva, and dental plaque cause infection by entering the body through dermal defects (minute openings in the skin). They also can be transferred to mucous membranes by the hands and, subsequently, enter the bloodstream.

The fingernails have been common sites for blood impaction in ungloved personnel. Studies suggest that blood is not easily removed by handwashing techniques. In fact, blood from patient contact can remain under a practitioner`s fingernails for five days or longer.

Gloving does not replace handwashing - the two protective measures work "hand-in-glove." Hands must be washed both before gloving and after gloves are removed. When the skin is occluded with gloves, resident and, to a lesser extent, transient flora thrive, with microbial numbers climbing as high as 4,000-fold per hour. Microbial overgrowth in the warm, moist environment that gloves generate can cause skin irritation. Handwashing before gloving minimizes the level of skin bacteria at the onset. After removing gloves, handwashing reduces the buildup of skin bacteria that have multiplied under the gloves and removes transient bacteria that may have entered through pinholes and tears.

Both mechanical friction and rinsing are critical to effective handwashing. The mechanical action suspends dirt and microbes from the skin surface, allowing them to be rinsed away. Plain soap and water is effective in removing dirt and some transient microbes from the hands. Using a handwashing detergent with an antimicrobial agent destroys most of the transient microbes and reduces the number of viable resident flora.

Antimicrobial soaps contain an ingredient with in vitro and in vivo activity against skin flora. Formulations classified as health-care handwashes contain low to medium levels of broad-spectrum antimicrobial agents to reduce the number of transient flora on intact skin to a baseline level. These products are fast-acting, nonirritating, and designed for frequent use. Their routine use in 10- to 30-second routine handwashing not only minimizes the number of transient microbes on the hands, but also aids in reducing the levels of resident bacteria through its bactericidal chemical activity.

For maximum reduction of both transient and resident flora, nonirritating surgical hand scrubs contain the highest levels of antimicrobial agents. They incorporate fast-acting, persistent agents with broad-spectrum antimicrobial activity.

Although routine handwashing provides protection from cross-contamination, it can make hands dry and chapped. At the office, avoid lotions or creams with a petroleum or mineral oil base. These products can degrade glove material, making the individual more susceptible to infection as well as sensitive to components in gloves.

Studies show that antimicrobial hand gels can reduce soap-induced irritation when used as a supplement to frequent handwashing. A study of 60 percent ethonal gel plus emollients revealed that gel-treated hands exhibited significantly lower photographic scores for cracking, scaling, and erythema.

For overnight hand treatment, some contend that applying a rich cream and sleeping with cotton gloves can help restore dermal integrity.

Handwashing is the most basic part of a practice`s overall infection-control program. Combined with other aseptic techniques and recommended infection-control protocols, this simple practice can reduce the potential for direct and indirect transmission of microorganisms in the dental office.

This resource was reprinted with the permission of OSAP. OSAP is a nonprofit organization providing information and education on dental infection control and office safety. For more information, please call (800) 298-6727.

Suggested handwashing procedures

At the beginning of the workday:

1. Remove all jewelry; check the surfaces of the hands for hangnails, small cuts/abrasions, and sores.

2. Gently clean fingernails with a plastic or wood stick.

3. Scrub hands, nails, and forearms with a liquid germicidal handwashing agent and a soft, sterile brush or sponge for one to two minutes. Rinse with cool to lukewarm tap water for 10 seconds.

4. Vigorously lather hands and forearms with the liquid cleaning agent by rubbing for 10 to 20 seconds. Rinse with cool to lukewarm tap water for 10 seconds.

5. Repeat lathering and rinsing procedures.

6. With clean paper towels, dry hands first, then forearms. Use the paper towels to turn off hand-controlled sink faucets.

Between nonsurgical patients:

1. Vigorously lather hands and forearms with a liquid antimicrobial handwashing soap and water by rubbing for 10 to 20 seconds. Rinse with cool to lukewarm tap water for 10 seconds.

2. Repeat lathering and rinsing procedures .

3. With clean paper towels, dry hands first, then forearms. Use the paper towels to turn off hand-controlled sink faucets.

Before surgery:

1. Remove all jewelry and gently clean fingernails with a plastic or wood stick.

2. Scrub nails, hands, and forearms with a germicidal surgical scrub product and soft, sterile brush or sponge for a total of five to seven minutes, using multiple scrub and rinse cycles.

3. Rinse hands and forearms with cool to lukewarm tap water, starting with the fingers and keeping the hands above the level of the elbows. Let runoff rinse water drip from the elbows, not the hands.

4. Dry with sterile towels.

5. With a sterile-gloved assistant holding new, sterile gloves around the wrists, insert the hands into the gloves.

6. Check the gloves for defects.

7. Do not touch contaminated items or surfaces before patient care.

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