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So Why All the Fuss About Hand Hygiene?



  • Clean hands are the single most important factor in preventing the spread of pathogens and antibiotic resistance in healthcare settings.
  • Hand hygiene reduces the incidence of healthcare associated infections.
  • CDC estimates that each year nearly 2 million patients in the United States get an infection in hospitals, and about 90,000 of these patients die as a result of their infection.
  • More widespread use of hand hygiene products that improve adherence to recommended hand hygiene practices will promote patient safety and prevent infections.


  • There is substantial evidence that hand hygiene reduces the incidence of infections.
  • Semmelweis demonstrated that the mortality rate among mothers who delivered in the First Obstetrics Clinic at the General Hospital of Vienna was significantly lower when hospital staff cleaned their hands with an antiseptic agent than when they washed their hands with plain soap and water.
  • In more recent studies healthcare-associated infection rates were lower when antiseptic handwashing was performed by personnel and went down when adherence to recommended hand hygiene practices improved.

  • In general, adherence of healthcare workers to recommended hand hygiene procedures has been poor.
  • Studies shown here are representative of the overall adherence rates which averaged about 40%.
  • Adherence rates do vary by occupation.

  • Healthcare workers have reported several factors that may negatively impact their adherence with recommended practices including; handwashing agents cause irritation and dryness, sinks are inconveniently located, lack of soap and paper towels, not enough time, understaffing or overcrowding, and patient needs taking priority.
  • Lack of knowledge of guidelines/protocols, forgetfulness, and disagreement with the recommendations were also self reported factors for poor adherence with hand hygiene.
  • Perceived barriers to hand hygiene are linked to the institution and HCWs colleagues.
  • Therefore, both institutional and small-group dynamics need to be considered when implementing a system change to secure and improve HCWs hand hygiene practice.

  • Hand hygiene is a general term that applies to either handwashing, antiseptic handwash, alcohol-based handrub, or surgical hand hygiene/antisepsis.
  • Handwashing refers to washing hands with plain soap and water.
  • Handwashing with soap and water remains a sensible strategy for hand hygiene in non-healthcare settings and is recommended by CDC and other experts.
  • Antiseptic handwash refers to washing hands with water and soap or other detergents containing an antiseptic agent.
  • Alcohol-based handrub refers to the alcohol-containing preparation applied to the hands to reduce the number of viable microorganisms.
  • Surgical hand hygiene/antisepsis refers to an antiseptic handwash or antiseptic handrub performed preoperatively by surgical personnel to eliminate transient and reduce resident hand flora. Antiseptic detergent preparations often have persistent antimicrobial activity.

  • Healthcare workers should wash hands with soap and water when hands are visibly dirty, contaminated or soiled and use an alcohol-based handrub when hands are not visibly soiled to reduce bacterial counts.

  • Hand hygiene is indicated before: patient contact, donning gloves when inserting a central venous catheter (CVC), and inserting urinary catheters, peripheral vascular catheters, or other invasive devices that don't require surgery.
  • Hand hygiene is also indicated after contact with a patient's intact skin, contact with body fluids or excretions, non-intact skin, or wound dressings, and after removing gloves.
  • Gloves should be used when a HCW has contact with blood or other body fluids in accordance with universal precautions.

  • Plain soap is good at reducing bacterial counts but antimicrobial soap is better, and alcohol-based handrubs are the best.

  • This graph shows that alcohol-based handrub is better than handwashing at killing bacteria.
  • Shown across the top of this graph is the amount of time after disinfection with the hand hygiene agent.
  • The left axis shows the percent reduction in bacterial counts.
  • The three lines represent alcohol-based handrub, antimicrobial soap, and plain soap.

  • Alcohol-based handrubs are less damaging to the skin than soap and water.
  • In the graph on the left the blue bar shows self-reported skin health scores for persons using soap and water, and persons using alcohol-based handrubs are depicted by the orange bar. Self-reported studies indicate participants using soap and water reported a significant increase in dryness, cracking, and irritation after 2 weeks, whereas those that used the alcohol-based handrub reported improvement in skin dryness.
  • Epidermal water content shows the same results as the self reported scores, after 2 weeks of use, the skin water content decreased for those that used soap and water (resulting in dryer skin) as compared with those who used an alcohol-based handrub.

  • The time required for nurses to leave a patient's bedside, go to a sink, and wash and dry their hands before attending the next patient is a deterrent to frequent handwashing or hand antisepsis.
  • More rapid access to hand hygiene materials could help improve adherence.
  • Alcohol-based handrubs may be a better option than traditional handwashing with plain soap and water or antiseptic handwash because they require less time, act faster, and irritate hands less often.

  • These recommendations will improve hand hygiene practices of HCWs and reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings.
  • When decontaminating hands with an alcohol-based handrub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry.
  • When washing hands with soap and water, wet hands first with water, apply the amount of soap recommended by the manufacturer, and rub hands together for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water, dry thoroughly with a disposable towel, and use the towel to turn off the faucet.

  • Nail length is important because even after careful handwashing, HCWs often harbor substantial numbers of potential pathogens in the subungual spaces.
  • Numerous studies have documented that subungual areas of the hand harbor high concentrations of bacteria, most frequently coagulase-negative staphylococci, gram-negative rods (including Pseudomonas spp.), corynebacteria, and yeasts.
  • Natural nail tips should be kept to ¼ inch in length.
  • A growing body of evidence suggests that wearing artificial nails may contribute to transmission of certain healthcareassociated pathogens. Healthcare workers who wear artificial nails are more likely to harbor gram-negative pathogens on their fingertips than are those who have natural nails, both before and after handwashing. Therefore, artificial nails should not be worn when having direct contact with high risk patients.

  • No recommendation can be made regarding the routine use of nonalcohol-based handrubs for hand hygiene in healthcare settings.
  • Whether the wearing of rings results in greater transmission of pathogens is unknown.

  • Wearing gloves reduces the risk of healthcare workers acquiring infections from patients, prevents flora from being transmitted from healthcare workers to patients, and reduces contamination of the hands of healthcare workers by flora that can be transmitted from one patient to another.
  • Gloves should be used when HCWs have contact with blood or other body fluids.
  • Gloves should be removed after caring for a patient.
  • The same pair of gloves should not be worn for the care of more than one patient.
  • Gloves should not be washed or reused.

  • Alcohol-based handrubs should be stored away from high temperatures or flames, in accordance with National Fire Protection Agency recommendations.
  • In Europe, where alcohol-based handrubs have been used extensively for many years, the reported incidence of fires related to such products has been extremely low.
  • In the U.
  • S., there has been a report of a flash fire that occurred as a result of an unusual series of events, which included a healthcare worker applying an alcohol gel to her hands, then immediately removing a polyester isolation gown, and touching a metal door before the alcohol had evaporated. Removing the polyester gown created a large amount of static electricity that generated an audible static spark when she touched the metal door, igniting the unevaporated alcohol on her hands.
  • Following application of alcohol-based handrubs, hands should be rubbed together until all the alcohol has evaporated.
  • In other words, Let It Dry!

  • In summary, alcohol-based handrubs provide several advantages compared with handwashing with soap and water, because they not only require less time, they also act faster.
  • In addition, alcohol-based handrubs are more effective for standard handwashing than soap, are more accessible than sinks, are the most efficacious agents for reducing the number of bacteria on the hands of healthcare workers, and can even provide improved skin condition.




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