Hand hygiene is the single most important procedure for preventing cross infection. Body secretions, excretions, environmental surfaces and hands of all healthcare workers can carry microorganisms (bacteria, viruses and fungi) that are potentially infectious to them and others.

Hand washing is known to reduce patient morbidity and mortality from hospital-acquired infection.

Hand washing technique
Courtesy of the Ontario ministry of health and long-term care.

Indications for Hand Hygiene

The decsion to decontaminate hands should be based on an assessment of the risk that microorganisms have been acquired on the hands and transiently carried to another person or location.

Hand hygiene must be carried out in the following situations:

• At the beginning of every shift Before contact with any patient
• In between contact with each and every patient
• After contact with a patient on Additional Precautions or one who is colonized with microorganisms of special clinical significance, e.g. resistant to a number of antibiotics
• Before performing mouth care
• Before and after contact with susceptible sites, e.g. wounds, burns, IV sites
• Before performing invasive procedures, e.g. where natural defences against infection are breached
• After hands have been contaminated, e.g. contact with body fluids, soiled linen, equipment or garbage
• After gloves have been removed
• Before handling food or medicines
• Before handling clean linen After using the toilet or after toileting others
• Before and after eating
• Prior to entering and leaving a nursing station
• Prior to using computers and other electronic devices

Hand hygiene may also be desirable at other times. The Infection Prevention and Control Team may request additional requirements for hand hygiene, e.g. during an outbreak of infection.

Nail and Skin Care

The nails are the area of greatest contamination. Short nails are easier to clean and are less likely to tear gloves. Please refer to VIHA‘s Policy 15.1 – Hand Hygiene Policy.

Nail varnish (polish) is prohibited, regardless of colour, for staff with direct patient contact, or who work in areas where direct patient contact takes place

Nail extensions/nail art and acrylic nails are prohibited for staff with direct patient contact, or who work in areas where direct patient contact takes place

Ensure the skin on your hands does not become dry or damaged. In these conditions the hands show a higher bacterial load, which is more difficult to remove than with healthy, intact skin.

Hand lotion may be used to prevent skin damage from frequent hand washing.

Skin lotions for patient and/or staff use have been reported sources of outbreaks, so pump dispensers are preferable over tubes or jars. If a pump dispenser is not available, individualized containers must be used.

Compatibility between lotions and antiseptic products, and lotion’s potential effect on glove integrity should be checked (i.e. lotions should not be petroleum based). Please check with Infection Prevention and Control or Occupational Health and Safety to ensure lotion is approved for use.

Creams that have been taken into a patient’s room should be dedicated to that patient and either disposed of or sent home with the patient on discharge.

Type of Cleansing Agents

Alcohol Based Hand Rub

Use routinely when hands are not physically soiled.

Alcohol based hand rubs (ABHR) can be used in place of soap and water, except where hands are visibly soiled (e.g. feces, blood, etc.). They are especially useful in situations where hand washing and drying facilities are inadequate or where there is a frequent need for hands to be decontaminated (such as in client‘s homes). Every effort should be made to install these products as close to point of care as possible.

Alcohol based surgical scrubs are used in situations where a reduction in the resident microbial flora is considered desirable, such as in an operating theatre or similar department, and before performing an invasive procedure, especially the placement of an indwelling medical device.

The optimal concentration of ABHR is 70-90% with added emollients; a minimum of 70% ethanol will protect against Norovirus. If the ABHR is a gel, a minimum of 80% ethanol is recommended. ABHR dispensers should read volume per volume, not weight per volume.

Reference: WHO, World alliance for Patient Safety (2006) WHO guidelines on hand hygiene in healthcare (advanced draft). April 2006. Report No: WHO/WPI/QPS/05.2

Soap and Water

Indications:

• When hands are physically soiled
• When hands look or feel dirty
• Following contact with blood or body fluids
• Following contact with any patient with diarrhea/vomiting, and their environment, including bathroom facilities

In clinical areas, soap is supplied as liquid or foam, in sealed containers, where the dispensing nozzle is integral to the container, and changed when the unit is empty. Soap dispenser pumps are never to be reused, refilled or ―topped up‖ and must be disposed of once empty.

It is recommended that hands are washed with soap and water if in contact with spores (e.g. Clostridium difficile), because the physical action of washing, rinsing and drying hands has been proven to be more effective than alcohols, chlorhexidine, iodophors and other antiseptic agents.

Handwashing Technique

A brief wash will remove the majority of transient microorganisms, but the technique should aim to cover all surfaces of the hands. Where soap or a surgical scrub has been used, hands should be rinsed under running water and thoroughly dried with a disposable towel. The soap and hand towels should be of a quality acceptable to users, so as not to deter hand washing. The skin should be maintained in good condition to discourage the accumulation of bacteria.

The optimal concentration of ABHR is 70-90% with added emollients; a minimum of 70% ethanol will protect against Norovirus. If the ABHR is a gel, a minimum of 80% ethanol is recommended. ABHR dispensers should read volume per volume, not weight per volume.

Hand hygiene should include the cleaning of arms to the elbow, especially when wearing a sleeveless apron.

Levels of Hand Disinfection

Social
Used routinely. Soap and water or Alcohol-based hand rub are both acceptable.

Hygienic hand disinfection
Used prior to invasive procedures performed on the units.
Soap and Water FOLLOWED by alcohol-based hand rub.

Aseptic (Surgical scrub)
Used prior to surgical procedures in the operating room or similar.
A 2 minute antiseptic wash (i.e. chlorhexidine CHG 4%) and dry on sterile towels or Soap and water hand wash followed by surgical alcohol based hand rub.

Hand Hygiene Procedure

The areas of the hands that are often missed are the wrist creases, thumbs, fingertips, under the fingernails and under jewelry. For this reason, only a plain wedding band with no stones is acceptable (please refer to VIHA‘s Policy 15.1 – Hand Hygiene Policy).

Alcohol based hand rub technique

• Soap and water hand wash must be performed if hands look or feel dirty
• Apply an application to fill cupped palm of one hand
• Rub into all surfaces of hands (finger tips and nails, wrists, palms, backs of hands and between fingers)
• There must be sufficient wetness on all skin surfaces that it takes 15 or more seconds to dry
• Rub hands together until rub has evaporated prior to gloving or touching the patient

Soap and Water hand washing technique

• Wet your hands up to the wrists ensuring all surfaces of the hands are covered by water
• Apply the cleanser/soap
• Smooth it evenly all over your hands, including the thumbs and in between fingers, lather well rubbing vigorously. Place fingertips and nails into the lathered palm and rub. Repeat with opposite hand
• Rinse off every trace of lather under running water, to prevent skin irritation
• Dry thoroughly, taking special care between the fingers. More than one paper towel may be necessary

Surgical asepsis (scrub) technique with an alcohol based hand rub

• Use sufficient product to keep hands and forearms wet with the alcohol based surgical scrub (ABSS) throughout the procedure (usually at least a cupped hand filled with ABSS).
• Apply ABSS to clean, dry hands and nails:
• Cup hand and hold 1–2 inches from the nozzle

PUMP 1

• Dispense first full pump into the cupped palm of one hand (fill cupped hand)
• Dip fingertips of the opposite hand into the ABSS and work in under the nails and wipe the excess solution from the fingertips back onto the palm of the same hand
• Spread the remaining amount from the palm from wrist to elbow of the opposite arm, covering all surfaces

PUMP 2

• Place another full pump into the opposite, dry palm and repeat the above procedure with the other hand

PUMP 3

• Dispense a final full pump into either palm and reapply to all aspects of both hands up to the wrist
• Proceed to the operating room suite holding hands above elbows After applying ABSS allow hands and forearms to dry thoroughly before donning sterile gloves and gown.

Surgical asepsis technique with a medicated soap

Wash hands and arms up to elbows with a non-medicated soap before entering the Operating Room area or if hands are visibly soiled

Start timing

• Scrub each side of each finger, between the fingers and the back and front of the hands for 2 minutes
• Scrub the arms, keeping the hand higher than the arm at all times. This helps to avoid recontamination of the hands by water running from the elbows, and prevents bacteria laden soap and water from contaminating the hands
• Wash each side of the arm from wrist to elbow for 1 minute
• Repeat this process on the other hand and arm, keeping the hands above the elbows at all times. If the hand touches anything except the brush at any time, the scrub must be lengthened by 1 minute for the area that has been contaminated
• Rinse hands and arms by passing them through the water in one direction only; from fingertips to elbow
• Proceed to the operating room suite, holding hands above elbows

At all times during the scrub procedure, care should be taken not to splash water onto surgical attire

Once in the operating room suite, hands and arms should be dried using a sterile towel before putting on gown and gloves.

Aseptic technique must be maintained at all times

A standardized means of describing the form of stool.

A reproduction of the classic observation of a fungus (Penicillium notatum) secreting a substance (penicillin) that inhibits the growth of a bacterium (Staphylococcus aureus) made by Sir Alexander Fleming.

This started the antibiotic era. It is worth reflecting upon the fact that Penicillium notatum had been producing penicillin for millions of years before this observation was made!

Spherules – the typical form seen in pathology specimens from patients with coccidioidomycosis as in this lung biopsy.

The general geographic distribution of the dimorphic fungus Coccidioides immitis.

Typical fuzzy colonies of Aspergillus sp. growing on an agar plate. The appearance is very different to the other common group of fungi that infect humans – yeasts. See Candida plate

Candida albicans, the most common yeast that infects humans, growing on a blood agar plate. The colonies are very similar to bacterial colonies.

Typical vaginitis caused by Candida albicans. Note the white “curdy” discharge. Most women recognize this condition and self-diagnosis and therapy is common.