Hand Hygiene (Home Health Care) - CE/NCPD

ALERT

Carry alcohol-based hand rubbing solutions, small containers of liquid soap, and disposable paper towels to every home visit. Never use the patient’s personal bar or liquid soap or cloth towels because these may be contaminated.

Avoid using water in homes with potentially contaminated water sources.

Wearing gloves does not replace the need to perform hand hygiene.

OVERVIEW

Hand hygiene is the most important and most basic component in the prevention and control of the transmission of infection. When properly performed at the appropriate point of care, hand hygiene is the most effective way to prevent the spread of infection. Hand hygiene is the primary method used by health care team members to reduce the spread of germs or infection between patients and health care team members.^{undefined#ref3">3,7} Proper hand hygiene has been shown to significantly reduce infection and colonization rates for multidrug-resistant organisms.⁸

Hand hygiene is a general term that refers to handwashing (with plain soap and water), antiseptic handwashing (with soap containing an antiseptic agent and water), antiseptic hand rubbing (rubbing an antiseptic agent, usually alcohol, on all surfaces of the hand), or surgical hand antisepsis (washing or rubbing with an antiseptic agent preoperatively). The purpose of hand hygiene is to remove dirt, materials, and microbial organisms picked up by contact with other people or the environment.

Proper hand hygiene requires using the right agent for the circumstances (soap, water, and a disposable towel, or an alcohol-based rub) and mechanical rubbing of all surfaces for a sufficient length of time. Washing the hands with soap and water is the only effective way to prevent the spread of spore-forming pathogens.² Antimicrobial agents or plain soap and water should be used in the following situations:

When hands are visibly dirty
When hands are visibly soiled with blood or other bodily fluids
After using the bathroom
After exposure or suspected exposure to spore-forming pathogens (e.g., Clostridioides difficile)²

When not contraindicated, alcohol-based products are effective at reducing the presence of microorganisms on the hands.⁵ Hand sanitizer products do not eliminate all germs.⁵ Alcohol-based hand rubs may not be performed with maximum effectiveness if the health care team member is wearing a ring or wristwatch.¹ Alcohol-based sanitizers should have at least 60% isopropyl alcohol for maximum effectiveness.⁴ Alcohol-based hand rubs are included in the World Health Organization’s list of essential medicines.⁹

Natural nails should be kept trimmed to ¼ inch.³ When in direct contact with high-risk patients, artificial nails and nail extenders should not be worn.³ Long fingernails, artificial nails, and chipped nail polish may harbor bacteria. The skin underneath rings harbors more germs than skin without rings.³ More data are needed to make specific recommendations pertaining to jewelry in the healthcare setting. Organization infection control policies may vary and should be reviewed for details regarding the wearing of jewelry.

Regardless of the health care setting or the method used, hand hygiene is a requisite skill that every health care professional must perform at key times. In the home setting, the patient, family, and caregivers need to perform hand hygiene and ensure that health care team members do the same.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
Teach the patient, family, and caregivers proper hand hygiene techniques.
Teach the patient, family, and caregivers the reason for hand hygiene.
Teach the patient, family, and caregivers situations in which hand hygiene is required.
Educate the patient, family, and caregivers about the risks for infection with improper hand hygiene.
Explain that the patient, family, and caregivers can play an important role in improving hand hygiene compliance by reminding the health care team member to perform hand hygiene.
Encourage questions and answer them as they arise.

PROCEDURE

Remove hand hygiene supplies from the outer pocket of the nursing bag.
Remove jewelry during hand hygiene per the organization’s practice. Do not leave jewelry on the patient’s sink, counters, or tables.
Inspect all surfaces of the hands for breaks or cuts in the skin or cuticles.
Cover any skin lesions before providing patient care.
Push long sleeves up above the wrists.
Rationale: Pushing the sleeves up provides complete access to the fingers, hands, and wrists.

Hand Hygiene Using a Waterless Alcohol-Based Antiseptic Rub

Dispense an ample amount of alcohol-based product into the palm of one hand.
Rationale: An adequate amount of product is needed to thoroughly cover the hands. For maximum effectiveness, enough product is needed to thoroughly cover all skin on the hands and fingers.
Rub the hands together, covering all surfaces of hands and fingers with antiseptic rub. Rub the palms of the hands together.
Rub the fingers of one hand over the dorsum of the other hand and interlace the fingers. Repeat with the other hand.
Rub the fingers of each hand over the palmer surface of the other hand and interlace the fingers.
Rub the backs of fingers across the palms of each hand alternately.
Decontaminate the fingertips by rubbing them in the palm of the other hand. Repeat with the other hand.
Rationale: Many microorganisms on the hands come from the subungual region (beneath the fingernails).
Clasp each thumb in the palm of the opposite hand and twist.
Rub the hands together until the alcohol is dry. Allow the hands to completely dry before donning gloves.
Rationale: Rubbing hands until they are dry helps ensure maximum efficacy.

Hand Hygiene Using Plain or Antimicrobial Soap, Water, and Disposable Paper Towel

If using soap and water, ask the patient, a family member, or a caregiver where the sink or water source for sanitizing hands is located; take the hand hygiene supplies to this location.
Stand in front of the sink, keeping the hands and clothing away from the sink surfaces.
Rationale: Sink surfaces may be contaminated; contact with surfaces may transfer contaminates to the skin or clothing.

If the hands touch the sink during handwashing, repeat handwashing.
Turn on the faucets to begin the flow of water.
Avoid splashing water on clothing.
Rationale: Microorganisms travel and grow in moist environments.
Regulate the flow of water so that the temperature is warm.
Rationale: Warm water removes less of the protective oils on hands than hot water.
Wet the hands and wrists thoroughly under the running water. Keep the hands and forearms lower than the elbows during washing.
Rationale: Hands are the most contaminated parts to wash. Water should flow from the least to the most contaminated area, rinsing microorganisms into the sink.
Apply an adequate amount of soap in the palm of one hand and rub the hands together to work up a lather.
Use a rotating frictional motion, applying friction to all surfaces of the hands and wrists, including the palms of the hands, between fingers, and around and under the nails. Interlace the fingers and rub up and down. Continue washing for at least 15 seconds.⁶
Rationale: Soap cleanses by emulsifying fat and oil and lowering surface tension. Friction and rubbing mechanically loosen and remove dirt and transient bacteria. Interlacing the fingers and thumbs ensures that all surfaces are cleansed.
Rinse the hands and wrists thoroughly, keeping the hands down and elbows up.
Rationale: Rinsing mechanically washes away dirt and microorganisms.
Dry the hands thoroughly with a paper towel.
Discard the paper towel in a trash can.
Turn off the faucet with a clean, dry paper towel. Avoid touching the handles with the hands.
Apply lotion to the hands if needed at the end of the visit. Avoid petroleum-based lotions.
Rationale: Lotion helps minimize skin dryness.

EXPECTED OUTCOMES

Complete cleansing of hands, including under fingernails, achieved
No skin irritation from use of soap or an alcohol-based product
No transmission of organisms

UNEXPECTED OUTCOMES

Skin irritation or dermatitis due to repeated use of harsh soaps or alcohol-based products
Incomplete decontamination of hands or areas under fingernails, leading to transmission of organisms

DOCUMENTATION

Patient’s, family’s, and caregivers’ learning and ability to verbalize or demonstrate topics taught
Education
Unexpected outcomes and related interventions

OLDER ADULT CONSIDERATIONS

Older adult patients may have an increased susceptibility to infections.
Older adult patients may have an increased incidence of dry skin and skin breakdown.

REFERENCES

Association of periOperative Registered Nurses (AORN). (2023). Hand hygiene. In Guidelines for perioperative practice (pp. 267-308). Denver: Author. (Level I)
Centers for Disease Control and Prevention (CDC). (2021a). C. diff (Clostridioides difficile): Prevent the spread of C. diff. Retrieved May 1, 2023, from https://www.cdc.gov/cdiff/prevent.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2021b). Hand hygiene in healthcare settings: Healthcare providers. Retrieved May 1, 2023, from https://www.cdc.gov/handhygiene/providers/index.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2021c). Handwashing in communities: Clean hands save lives: Hand sanitizer use out and about. Retrieved May 1, 2023, from https://www.cdc.gov/handwashing/hand-sanitizer-use.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2021d). Handwashing in communities: Clean hands save lives: Show me the science-how to wash your hands. Retrieved May 1, 2023, from https://www.cdc.gov/handwashing/show-me-the-science-handwashing.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2022a). Handwashing in communities: Clean hands save lives: When and how to wash your hands. Retrieved May 1, 2023, from https://www.cdc.gov/handwashing/when-how-handwashing.html (Level VII)
Centers for Disease Control and Prevention (CDC). (2022b). Infection control: CDC’s core infection prevention and control practices for safe healthcare delivery in all settings. Retrieved May 1, 2023, from https://www.cdc.gov/hicpac/recommendations/core-practices.html (Level VII)
Gall, E., Long, A., Hall, K.K. (2020). Chapter 5: Infections due to other multidrug-resistant organisms. In K.K. Hall and others (Eds.), Making healthcare safer III: A critical analysis of existing and emerging patient safety practices (pp. 5-1-5-89). Rockville, MD: Agency for Healthcare Research and Quality. Retrieved May 1, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK555533/ (Level VII)
World Health Organization (WHO). (2021). WHO model list of essential medicines – 22nd list, 2021. Retrieved May 1, 2023, from https://www.who.int/publications/i/item/WHO-MHP-HPS-EML-2021.02 (Level VII)

ADDITIONAL READINGS

Conway, J., Wu, A.G., Lipner, S.R. (2020). Guidance on hand jewelry for the prevention of COVID-19 transmission in healthcare settings. Dermatologic Therapy, 33(6), e14178. doi:10.1111/dth.14178 Retrieved May 1, 2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436558/

World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in health care. Retrieved May 1, 2023, from https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequence=1 (classic reference)*

*In these skills, a "classic" reference is a widely cited, standard work of established excellence that significantly affects current practice and may also represent the foundational research for practice.

Elsevier Skills Levels of Evidence

Level I - Systematic review of all relevant randomized controlled trials
Level II - At least one well-designed randomized controlled trial
Level III - Well-designed controlled trials without randomization
Level IV - Well-designed case-controlled or cohort studies
Level V - Descriptive or qualitative studies
Level VI - Single descriptive or qualitative study
Level VII - Authority opinion or expert committee reports

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