The hands of healthcare workers (HCWs) are known to be a primary source of transmission of hospital-acquired infections (HAIs). Thus, both practising hand hygiene (HH) and adhering to HH guidelines are expected to decrease the risk of transmission.Handwashing practices in the patient care setting began in the early 19th century. 

The practice evolved over the years with evidential proof of its vast importance and coupled with other hand-hygienic practices, decreased pathogens responsible for nosocomial or hospital-acquired infections (HAI). Contaminated hands of healthcare providers are a primary source of pathogenic spread. 

Proper hand hygiene decreases the proliferation of microorganisms, thus reducing infection risk and overall healthcare costs, length of stays, and ultimately, reimbursement. According to the Centers for Disease Control and Prevention (CDC), hand hygiene is the single most important practice in the reduction of the transmission of infection in healthcare settings. 

This illustrates the importance of handwashing and highlights the importance of the interprofessional team in educating patients about preventing infections and improving outcomes by remembering to wash hands frequently. Improving hand hygiene from high to very high compliance has not been documented to decrease healthcare-associated infections.The association between hand hygiene and infection prevention has long been known (if not always fully accepted) since the time of Semmelweis. The challenge in healthcare settings is to achieve and sustain high compliance among many disciplines of personnel who interact with patients and their environment.

Identifying the problem

Most germs that cause serious infections in healthcare are spread by people’s actions. Hand hygiene is a great way to prevent infections. However, studies show that on average, healthcare providers clean their hands less than half of the times they should. This contributes to the spread of healthcare-associated infections that affect 1 in 31 hospital patients on any given day. Every patient is at risk of getting an infection while they are being treated for something else. Even healthcare providers are at risk of getting an infection while they are treating patients. Preventing the spread of germs is especially important in hospitals and other facilities such as dialysis centres, nursing homes and Care homes.

Understanding the indications

According to the CDC, understanding the importance of hand hygiene and its impact on the pathogenic spread of microorganisms is best understood when one understands the anatomy of the skin. The skin serves as a protective barrier against water loss, heat loss, microorganisms, and other environmental hazards.

Structurally, the skin is made up of an outer, superficial layer known as the stratum corneum, the epidermis, dermis, and the hypodermis. Healthy skin is colonised with resident flora that are microorganisms that reside below the stratum corneum and the skin's surface. This flora has two main functions: microbial antagonism and competing for nutrients within the ecosystem. Generally, these bacteria are not pathogenic on intact skin but may cause infections in other areas of the body such as non intact skin, the eyes, or sterile body cavities. 

Transient microorganisms are often acquired by healthcare workers through direct, close contact with patients or contaminated inanimate objects or environmental surfaces. Transient flora colonises the superficial skin layers. It can be removed by routine hand washing more easily than resident flora. These organisms vary in number depending upon body location. Healthcare-associated infections are a result of these transient organisms.

According to the CDC, hand hygiene encompasses the cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels, or surgical hand antisepsis. Indications for handwashing include when hands are visibly soiled, contaminated with blood or other bodily fluids, before eating, and after restroom use. Hands should be washed if there was potential exposure to Clostridium difficile, Norovirus, Bacillus anthracis or any other common infectious Organisms.

In 2009, the World Health Organization (WHO) highlighted preset guidelines known as the "Five Moments for Hand Hygiene." 

1. Before touching or coming into contact with a patient
2. Before performing a clean or aseptic procedure
3. After an exposure risk to bodily fluids and glove removal
4. After contact with a patient and their immediate surroundings
5. After touching an inanimate object in the patient's immediate surroundings even if no direct patient contact

Alcohol-based hand sanitizers are the recommended product for hand hygiene when hands are not visibly soiled. Apply alcohol-based products per manufacturer guidelines on dispensing of the product. Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all surfaces on both hands get covered, about 20 seconds is required for all surfaces to dry completely.

Patient and facility healthcare professionals are monitored for hand-washing practices, and they are conforming to hand-hygiene practices. This practice is becoming increasingly popular as healthcare professionals strive for a safer environment.

Contradictions

Artificial nails and nail extensions contain pathogens in the subungual spaces; thus posing a threat to microorganism transmission in the healthcare arena. Therefore, it is recommended that healthcare professionals do not use them. Well-manicured nails and adherence to artificial nail policies outlined in facility-specific guidelines are vital to hand hygiene practices. The WHO guidelines recommend that nails should be kept less than 0.5cm long.

Hand rubbing with an alcohol-based rub should not be performed when the hands are visibly soiled. In this case, the CDC and WHO guidelines recommend handwashing with soap and water.

Hand hygiene practices are paramount in reducing cross-transmission of microorganisms, hospital-acquired infections and the risk of occupational exposure to infectious diseases. Mortality and morbidity increase in the presence of hospital-acquired infections, thus diligent hand hygiene is essential to providing safe, cost-efficient, quality care to our patients. Educational programs for patients and healthcare providers, ergonomics, and staffing ratios all play a role in hand hygiene compliance.

About the author:
Jibi Thankachan is a Senior Specialist Of Infection Prevention And Control. He is a Former IC specialist at KSMC & Rapid Response Team Lead at MOH, KSA.