Hand Hygiene: Handwashing (AUS and NZ)

ALERT

Elsevier Clinical Skills covers the principles of this procedure. Follow local policies and procedures regarding equipment, resources and documentation.

LEARNING OBJECTIVES

After completing all elements of the skill, the learner should be able to:

1. Confidently identify situations in the healthcare context requiring handwashing.
2. Demonstrate the standard hand washing technique.

National Safety and Quality Health Service Standards (AUS)

Standard and Criterion

Standard 1: 1.1, 1.2, 1.3, 1.7, 1.12
Standard 3: 3.1, 3.5, 3.7, 3.10, 3.11, 3.19

RN Standards of Practice (AUS)

Standard and Indicator

Standard 1: 1.1, 1.2, 1.3, 1.4
Standard 2: 2.1, 2.5

EN Standards of Practice (AUS)

Domain, Standard and Indicator

Professional and Collaborative Practice:
Standard 1: 1.2, 1.3, 1.4
Standard 3: 3.1, 3.9
Reflective and Analytical Practice:
Standard 8: 8.3
Standard 9: 9.4

Competencies for Registered Nurses (NZ)

Domain and Competency

Domain 1 Professional Responsibility: 1.1, 1.4
Domain 2 Management of Nursing Care: 2.1, 2.9
Domain 4 Interprofessional Health Care and Quality Improvements: 4.3

INTRODUCTION

The skill Hand Hygiene: Handwashing refers to the cleansing of hands with water and a suitable handwashing solution (either non-antiseptic or antiseptic). This skill is performed in the healthcare context by all staff, patients and visitors who come in contact with people or potentially contaminated inanimate objects. Hand hygiene is the single most effective method to prevent healthcare-acquired infections (HAIs).

In order to perform the skill safely and to provide optimal care, the worker performing the skill must understand the chain of infection and adhere to infection prevention and control standards outlined in local, national and international guidelines.

THEORY AND EVIDENCE BASE

Healthcare workers' hands are considered to be the most common way in which microorganisms are transported (undefined#ref5">Osborne, 2017). Hand hygiene covers both washing with water and handwashing solution and the use of an alcohol-based hand rub (ABHR) (NHMRC, 2010). Handwashing is the procedure of cleansing the hands through the mechanical action of rubbing and rinsing with water, a method that is capable of detaching, suspending and removing organic material. The use of ABHR is considered a more efficient way of hand hygiene, but used alone it is sufficient only if hands are socially clean and no evidence of spore-forming microbes is present. Use of ABHR is insufficient on hands contaminated with body fluids or excreta, as it does not mechanically remove organic material (Loveday et al., 2014). ABHR can be used in addition to, but not instead of, handwashing if Clostridium difficile is present (NHMRC, 2010).

The ‘5 moments of hand hygiene’

The ‘5 moments of hand hygiene’ indicate the times when nurses should perform hand hygiene in the context of a healthcare environment. Hand Hygiene Australia's web page (www.hha.org.au/home/5-moments-for-hand-hygiene.aspx) links to explanations and rationales for all five moments and provides specific examples of indications to conduct hand hygiene. In general, indications for performing hand hygiene (WHO, 2009) are:

• before and after touching a patient
• before handling an invasive device for patient care, regardless of whether or not gloves are used
• after contact with body fluids or excretions, mucous membranes, non-intact skin or wound dressings
• if moving from a contaminated body site to another body site during care of the same patient
• after removing sterile or non-sterile gloves.

Hand hygiene enablers

In order to effectively perform hand hygiene in general, and handwashing in particular, healthcare professionals should avoid wearing any hand jewellery or a wristwatch during clinical patient care (WHO, 2009). Staff who do not work in direct patient care should consider how their hand jewellery will affect handwashing effectiveness and either remove their jewellery and watch, or employ acceptable adjustments (e.g. moving a ring to clean the area under the ring) when washing hands (Loveday et al., 2014; NHMRC, 2010).

The institution should support handwashing compliance by providing well-stocked, suitable handwashing facilities. These should include (1) non-antiseptic handwashing solution, such as liquid soap or foam for routine handwashing, and (2) an antiseptic handwashing solution containing chlorhexidine or iodine, for example, for use before aseptic procedures, as well as skin moisturiser. Adverse effects related to handwashing procedures such as allergies or the development of dermatitis should be reported through the appropriate work health and safety channels within the facility (NHMRC, 2010).

Handwashing solutions and skin-care products are best supplied from a pump bottle or automatic dispenser. Bars of soap should not be used in clinical areas, as soap left sitting in a pool of water provides the ideal environment for growth of microorganisms and is an infection risk (WHO, 2009).

Using automated taps or elbow- or foot-operated mixer taps, or turning taps off using a paper towel, prevents hands from becoming re-contaminated after washing. Paper towel should be disposed of immediately in an appropriate waste container with a foot-operated lid. This avoids re-contamination when disposing of the paper towel. In some institutions, hand towels are considered to be clinical waste and so should be discarded in the clinical waste bag; while in others, they are deemed to be household waste and so should be discarded in the black non-clinical waste bag. Check local policy.

A lack of supplies, such as an empty soap container, empty towel dispenser, missing moisturiser or an overflowing waste bin, can affect handwashing compliance (WHO, 2009). Staff are responsible for reporting any deficits through the appropriate channels in their facility.

The chain of infection

(Adapted from Prieto & Kilpatrick, 2011)

The terms ‘chain of infection’, ‘cycle of infection’ and ‘infection process’ are often used to describe the circumstances that can lead to patients or others developing a healthcare-acquired infection (HAI). The rationale for applying infection prevention measures is based on this chain of events. It is crucial to understand how microorganisms spread and infection occurs.

Transmission of infectious agents within a healthcare setting requires the following elements (Figure 1):

1. A source of infectious agents: This includes people (i.e. patients, staff or visitors) and also the environment (e.g. bedding, curtains, equipment, furniture, sinks or surfaces) (NHMRC, 2010).
2. A mode of transmission: In order for transmission to occur, the infectious agent must be expelled from the source via exhalation, aerosolisation, secretion or excretion. Then, the infectious agent must be transmitted via a specific route, such as contact (including blood-borne), droplets or airborne. Transmission of infection can also occur indirectly via contaminated food, water, medication, devices or equipment (vector-borne) (NHMRC, 2010).
3. A susceptible host: The host must provide microorganisms with an entry point. In many cases the portal of entry is a breach of skin integrity, such as a wound, an invasive device, ingestion, inhalation or direct contact with mucous membranes. The infectious agent must present in overwhelming numbers, or encounter a weakened immune system, in order to finally cause an infection. The susceptible host then becomes the source of the infectious agent and the cycle closes (NHMRC, 2010).

The principles relating to all infection prevention measures are based on interrupting this cyclical process. If these measures are not taken, the cycle will continue and patients, and possibly staff and visitors, may be exposed to potentially pathogenic (disease-causing) microorganisms that can cause harm (ACSQHC, 2017; NHMRC, 2010).

Body fluids are a major source of microorganisms associated with HAIs. Meticulous hand hygiene helps to protect healthcare workers and patients from the risks of cross-infection.

Hands must be decontaminated by performing the appropriate type of hand hygiene after removal of gloves as gloves do not eliminate contamination entirely, and the warm, moist environment under gloves allows microorganisms to multiply rapidly (HHA, 2016).

Hand hygiene procedures are not usually documented in the clinical patient record, but facility-specific compliance audits should be in place.

Hand hygiene compliance audit tools are available online from: www.hha.org.au/ForHealthcareWorkers/auditing.aspx

PROCEDURE

1. Identify the indication/rationale for hand hygiene.

Rationale: To reduce the risk of cross-contamination and cross-infection and to comply with infection control principles. Perform hand hygiene before and after every episode of patient contact and after any activity or contact that potentially results in hands becoming contaminated in line with the ‘5 moments for hand hygiene’ ( ACSQHC, 2017; HHA, 2016; NHMRC, 2010, pp. 55–56). Hand hygiene is the single most effective action to reduce healthcare-associated infections ( ACSQHC, 2017; HHA, 2016). Everyone working in a healthcare facility has a duty of care to adhere to meticulous hand hygiene.

2. Inspect the surface of the hands for breaks or cuts and ensure that the arms are bare to the elbow.

Rationale: To reduce barriers to optimal hand hygiene and minimise the risk of bacterial growth. Wearing artificial fingernails, hand jewellery or a wristwatch can encourage and harbour high concentrations of bacterial growth ( WHO, 2009). Long sleeves and wristwatches or jewellery worn during handwashing prevent thorough cleansing of all hand surfaces. All cuts or abrasions should be covered with a waterproof dressing ( Loveday et al., 2014; NHMRC, 2010).

3. Turn on and adjust the taps so that the water temperature is comfortable and the water flow is steady.

Rationale: To increase comfort and lift organic material more effectively. Water that is too hot can promote skin irritation ( Osborne, 2017). Do not touch the taps after commencing handwashing: instead, use the elbow technique, foot-operated taps or automatic taps.

4. Wet both hands without splashing the surrounding area.

Rationale: To create a better lather and minimise the risk of skin irritation. Splashing creates droplets and can contaminate the area around the sink, such as the handwashing solution dispenser, hand towel dispenser and taps.

5. Apply sufficient handwashing solution to create a good lather.

Rationale: To ensure that cleanser has contact with all areas of the hands. A good lather aides the suspension of organic material.

6. Rub the hands together briskly. Wash 15–20 seconds in total by rubbing:
   • palm to palm
   • palm to dorsum of the hand with interlacing fingers; switch hands
   • palm to palm with interlacing fingers
   • backs of fingers and knuckles
   • fingertips rotating in the palm of the hand; switch hands
   • thumbs; switch hands
   • wrists; switch hands.

   Rationale: To ensure effective hand washing of all hand surfaces. Friction helps to lift organic material from the hands. Commonly missed areas are the thumbs, fingernails, fingertips, palms, backs of the hands and wrists. Scrubbing the skin with a brush is not recommended, as it causes micro abrasions. If dirty, clean underneath the fingernails with a disposable plastic nail pick ( Osborne, 2017).

7. Rinse hands and wrists thoroughly until all traces of the handwashing solution are removed.

Rationale: To remove the suspended organic material together with the lather and reduce the risk of skin irritation, especially when using antiseptic handwashing solutions ( NHMRC, 2010).

8. Turn off the taps using the elbow technique and allow the water to run off the hands with the fingertips pointing upwards.

Rationale: To avoid touching the ‘dirty’ taps with clean hands. Keeping the fingertips pointing upwards means that water from the unwashed arms will not run down over the clean hands.

9. Dry the hands, using disposable paper towel, working from the fingertips towards the wrists.

Rationale: To further reduce bacterial burden. A dry environment discourages rapid re-growth of microorganisms. Thorough drying also prevents skin maceration and irritation ( NHMRC, 2010). Drying from fingertips towards forearms prevents re-contamination from the unwashed arms.

10. Discard the used paper towel into a bin with a foot-operated lid according to local policy.

Rationale: To avoid re-contamination by touching the bin with clean hands and ensure effective hand hygiene. Some organisations treat used hand towels as clinical waste, whereas others require them to be discarded in the household waste. Check your local policy.

11. Moisturise hands with appropriate cream or lotion to maintain skin integrity.

Rationale: To maintain skin integrity. Frequent exposure to handwashing solutions and ABHR can affect the healthcare worker’s skin. Antiseptic handwashing solutions especially deplete skin lipids and damage the skin barrier and dryness, irritation or loss of skin integrity may result. Regular use of compatible moisturising products is recommended. The facility should provide a moisturiser compatible with the hand hygiene agents in use. Incompatible products may affect the chemistry and adversely interact with antiseptics contained in hand hygiene products ( NHMRC, 2010).

REFERENCES

1. Australian Commission on Safety and Quality in Health Care (ACSQHC). (2017). National Safety and Quality Health Service Standards (2nd ed.). Retrieved from: www.safetyandquality.gov.au/wp-content/uploads/2017/12/National-Safety-and-Quality-Health-Service-Standards-second-edition.pdf
2. Hand Hygiene Australia (HHA). (2018). The 5 moments of hand hygiene. Retrieved from: www.hha.org.au/home/5-moments-for-hand-hygiene.aspx
3. Loveday, H., Wilson, J., Pratt, R. et al. (2014). Epic 3: National evidence-based guidelines for preventing healthcare-associated infections in NHS Hospitals in England. Journal of Hospital Infection, 86(Suppl), S1–S70.
4. National Health and Medical Research Council (NHMRC). (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare. Commonwealth of Australia. Retrieved from: www.nhmrc.gov.au/guidelines-publications/cd33
5. Osborne, S. (2017). Understanding infection control. In J. Crisp, C. Douglas, G. Rebeiro, & D. Waters (Eds.). Potter and Perry's Fundamentals of Nursing – ANZ Version (5th ed., pp 622–680). Chatswood, NSW: Elsevier.
6. Prieto, J., & Kilpatrick, C. (2011). Infection prevention and control. In C. Brooker & M. Nicol (Eds), Alexander’s nursing practice (4th ed.). Edinburgh: Churchill Livingstone.
7. World Health Organization (WHO). (2009). WHO Guidelines on Hand Hygiene in Healthcare. Geneva: WHO. Retrieved from: apps.who.int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf

ADDITIONAL RESOURCES

Australian College for Infection Prevention and Control (ACIPC). (2013). Position statement: Compulsory hand hygiene training. Retrieved from: www.acipc.org.au/PDFs/HH%20Position%20Statement%20Final.pdf

Australian Commission on Safety and Quality in Healthcare (ACSQHC). (2015). National hand hygiene initiative. Retrieved from: www.safetyandquality.gov.au/our-work/healthcare-associated-infection/hand-hygiene

Brooker, C., & Nicol, M. (eds) (2011). Alexander’s nursing practice (4th edn). Edinburgh: Churchill Livingstone Elsevier.

Dougherty, L., & Lister, S. (2011). Manual of clinical nursing procedures. The Royal Marsden Hospital (8th ed.). Oxford: Wiley-Blackwell.

Hand Hygiene Australia (HHA) online learning packages. Available from: www.hha.org.au/home.aspx

Hui, S., Ng, J., Santiano, N., Schmidt, H-M., Caldwell, J., Ryan, E., & Malley, M. (2014). Improving hand hygiene compliance: harnessing the effects of advertised auditing. Healthcare Infection, 19(3), 108–113.

Nicol, M., Bavin, C., Cronin, P., Rawlings-Anderson, K., Cole, E. & Hunter, J. (2012). Essential nursing skills (4th ed.). Edinburgh: Mosby Elsevier.

Nursing and Midwifery Board of Australia (NMBA). Code of Professional Conduct for Nurses in Australia. Conduct statement 2: Nurses practise in accordance with the standards of the profession and broader health system. Retrieved from: www.nursingmidwiferyboard.gov.au/Codes-Guidelines-Statements/Professional-standards.aspx

Rebeiro, G., Jack, L., Scully, N., & Wilson, D. (2013). Fundamentals of nursing: clinical skills workbook (2nd ed.). Sydney. Elsevier.

ACKNOWLEDGEMENTS

Elsevier Australia would like to thank the following people who contributed to this skill: Elfi Ashcroft (Author and Editorial consultant) and Damian Wilson (Section editor).

SOURCE

Elsevier Clinical Skills UK
Based on: Nicol et al., Essential Nursing Skills 4e
Adapted by: Professor Maggie Nicol RN BSc (Hons) MSc (Nursing) PGDipEd