Despite a choice of agents and techniques, adherence is challenging
I’ll never forget my first simulated clinical patient exam in medical school. After entering the exam room, I introduced myself to the patient and shook his hand. The proctor immediately interjected and told me that I had failed the first test. She made the point that we, as healthcare providers, should cleanse our hands before as well as after every patient contact.
Hand hygiene is the simplest and most common step we, as orthopaedic surgeons, can take to protect our patients and ourselves from healthcare-associated infections. Although thoroughly cleaning one’s hands seems obvious, most—if not all—of us have lapsed at some point during an interaction with a patient.
Ever since 1847, when Ignaz Semmelweis demonstrated that the mortality rate for mothers delivering babies was lower when hospital staff cleaned their hands with an antiseptic agent versus just plain soap and water, efforts have been made to try to reduce transmission of healthcare-associated pathogens. According to the World Health Organization (WHO) campaign, “Clean Care is Safer Care,” at any given time, more than 1.4 million people worldwide become seriously ill from healthcare-associated infections. The percentage of hospitalized patients in high-income countries who acquire at least one of these infections ranges from 3.5 percent to 12 percent.
When healthcare personnel fail to clean their hands between patient contacts or during the sequence of patient care, they transfer microbes—especially when hands move from a microbiologically contaminated body site to a cleaner site in the same patient. Several methods of hand hygiene are available, however, that can help prevent the spread of infection.
Several studies have shown that hand washing with plain, nonantimicrobial soap fails to remove pathogens from the hands of healthcare workers and decreases only loosely adherent, transient flora. Water temperature does not appear to be a critical factor in microbial removal, although warmer temperatures are significantly associated with skin irritation. As a result, several types of hand rubs have been developed and tested during the past few decades.
Alcohol-based solutions containing isopropranol, ethanol, or a combination of the two have been shown to be most effective in solutions with at least a 60 percent concentration. The volume of alcohol-based product applied affects its efficacy; in one study, using 1 mL of alcohol was found to be substantially less effective in removing pathogens than using 3 mL. Alcohols are rapidly germicidal when applied to the skin, but have limited persistent activity. Combining alcohol-based formulations with other antiseptic agents can prolong the germicidal activity and increase effectiveness.
Chlorhexidine has a good safety record when used as recommended. It is strongly active against Gram-positive bacteria, somewhat less active against Gram-negative bacteria and fungi, and minimally active against mycobacteria. Although its immediate antimicrobial activity is slower than that of alcohols, chlorhexidine has significant persistent activity. When used as an antiseptic in hand washing, chlorhexidine preparations should have at least a 4 percent concentration of chlorhexidine. One study found that a scrub agent with 4 percent chlorhexidine was more effective than a povidone-iodine (7.5 percent) scrub agent in reducing bacterial count.
Adding chlorhexidine (in low concentrations of 0.5 percent to 1 percent) to alcohol-based preparations prolongs the residual antibacterial activity of the alcohol. Therefore, a highly concentrated alcohol rub to which a low concentration chlorhexidine has been added can have both immediate and prolonged activity.
Iodine has been used as an effective antiseptic since the 1800s. Iodophors have largely replaced iodine as the active ingredient in antiseptic solutions because iodine often irritates and discolors the skin. Iodophors are combined with a polymer to produce iodine molecules that create the antimicrobial activity. The typical 10 percent povidone-iodine formulations contain 1 percent available iodine.
Iodophors cause less skin irritation and fewer allergic reactions than iodine, but their use also results in more irritant contact dermatitis than other antiseptics commonly used for hand hygiene. Preparations with 7.5 percent to 10 percent povidone-iodine are typically used as effective hand washes.
Other agents have less data to support their use and remain under study. For example, results of parachlorometaxylenol (PCMX) use have been mixed. Some studies have suggested that it has the weakest immediate and residual activity of any of the agents included, while others demonstrated activity comparable to other agents. The difference may be due to the concentration of PCMX used in the individual studies.
Triclosan is another agent that has been incorporated into detergents and alcohols. It has a broad range of antimicrobial activity, but is often bacteriostatic; factors such as pH, emollients, and other substances may diminish its activity. The Food and Drug Administration (FDA) has classified PCMX and triclosan as agents with insufficient data, and further evaluation of these compounds is ongoing.
To rub or to wash?
In all studies conducted to date, using hand rubs with alcohol-based preparations has been more effective than washing hands with plain soap. In most cases, alcohol-based solutions reduced bacterial counts on hands more than antimicrobial soaps and detergents. Among the alcohols, a clear positive correlation with concentration is seen. When tested at the same concentration, the order of efficacy is as follows: n-propanol is more active than isopropanol, which is more efficacious than ethanol.
Washing is indicated when the hands are visibly contaminated with blood or body fluids or have been exposed to spore-forming organisms. With the exception of very high concentrations of iodine, antiseptics are not reliably sporicidal against Clostridium or Bacillus species.
The mechanical friction of washing with soap and water may help physically remove spores from the surface of contaminated hands. Hand washing should entail wetting, applying soap, and rubbing hands vigorously together to cover all surfaces, followed by rinsing and drying. Reusable towels should be avoided, and the faucet should be turned off using a paper towel to prevent recontamination. The procedure should take 40 to 60 seconds to complete.
The chosen hand rub should meet ASTM International or European Committee for Standardization guidelines and be well tolerated and accepted by healthcare workers. A general rule is that the hands should be rubbed until dry to ensure maximal efficacy and that the technique should focus on all aspects of the hand including interdigital areas, subungual regions, and the thumb. This should take 20 to 30 seconds to complete. Complete drying of the hand in less than 20 seconds usually signifies insufficient application of the product.
Gloves help prevent the transmission of microorganisms between the healthcare worker and the patient, but do not replace the use of antiseptics for hand hygiene. Hand rubbing or washing needs to be performed after the gloves are removed because gloves may have defects and hand contamination may occur when gloves are removed.
Thus, hand hygiene must be performed regardless of glove use. WHO describes five moments of hand hygiene: (1) before touching a patient, (2) before performing clean/aseptic procedures, (3) after being exposed to body fluids, (4) after touching a patient, and (5) after touching a patient’s surroundings. The type of antiseptic is not as important as having sufficient concentration and volume, as well as rubbing or washing for an adequate amount of time.
The challenge remains
Adherence remains the biggest challenge for effective hand hygiene. Studies analyzing factors leading to poor adherence cite the following: physician status (rather than a nurse), lack of hand washing agents, irritation or dryness, and perceived lack of guidelines or role modeling. The following actions can increase adherence among healthcare workers: more convenient sink locations, the availability of widely accessible hand rub products at the point of care, education, training, feedback, and administrative support.
That day in medical school remains a distinct memory for me whenever I am about to shake a patient’s hand. With readily available hand rub dispensers outside patient rooms throughout the hospitals where I now work—as well as signs and reminders from infectious control leaders—I am much better at cleaning my hands both before and after seeing a patient.
As orthopaedists, we have high visibility with both patients and other healthcare workers in our practice settings. If we model excellent hand hygiene practices, we can set an example for others to follow in the prevention of microbial transmission. By simply washing or using a hand rub with each encounter, we will protect our patients and ourselves from infections. We painstakingly aim to prevent infections during and immediately surrounding the time of an operation; why should any other patient encounter be different?
Calvin C. Kuo, MD, a PGY-4 resident at the San Francisco Orthopaedic Residency Program, is the resident member of the AAOS Patient Safety Committee. He can be reached at firstname.lastname@example.org
- WHO guidelines on hand hygiene in health care. Geneva: World Health Organization, 2009. http://whqlibdoc.who.int/publications/2009/9789241597906_eng.pdf
- Larson EL, Eke PI, Wilder MP, Laughon BE: Quantity of soap as a variable in handwashing. Infect Control 1987;8(9):371-375.
- Furukawa K, Tajiri T, Suzuki H, Norose Y. Are sterile water and brushes necessary for hand washing before surgery in Japan? J Nihon Med Sch 2005;72(3):149-154.
- Aly R, Maibach HI: Comparative antibacterial efficacy of a 2-minute surgical scrub with chlorhexidine gluconate, povidone-iodine, and chloroxylenol sponge-brushes. Am J Infect Control 1988;16(4):173-177.
- Davies J, Babb JR, Ayliffe GA, Wilkins MD: Disinfection of the skin of the abdomen. Br J Surg 1978;65(12):855-858.
- Hugonnet S, Perneger TV, Pittet D: Alcohol-based handrub improves compliance with hand hygiene in intensive care units. Arch Intern Med 2002;162(9):1037-1043.
- Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force: Guideline for Hand Hygiene in Health-Care Settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Am J Infect Control 2002;30(8):S1-S46.
- Longtin Y, Sax H, Allegranzi B, Schneider F, Pittet D: Videos in clinical medicine: Hand hygiene. N Engl J Med 2011;364(13):e24.