Student Nurse

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    Hand Washing

    Infection control is a contentious issue in the modern healthcare setting. One of the areas in contention, especially in the media is the hygiene practices in hospital and by staff. One of the main areas is the staffs' hand hygiene practices and how they contribute to the problem of Hospital Acquired Infections (Storr & Clayton-Kent, 2004). Nurses' actions account for roughly 80 percent of the direct care patients' receive and usually involves personal and intimate care activities (Storr & Clayton-Kent, 2004). As such, the chance of infecting a patient with an avoidable HAI is as high as ten percent and some of the infections will be caused by microbes present on the hands of those providing care (DoH, 2003). Hand hygiene is a simple procedure and the rates of compliance should be high although the evidence points to the contrary (Clark, 2001). There are significant advantages and disadvantages to hand hygiene but the importance of it as a method of infection control should not be overlooked. The reality of clinical areas also means there are some barriers to practising hand hygiene; personal experience has shown this. There are implications for nursing practice both presently and in the future in regards to hand hygiene, these will be discussed.

    The act of hand hygiene is simple but effective against the possibility of cross-contamination between patient-patient or indeed another part of the patient's body. Hands should be washed before and after each patient contact and when moving from one part of the same patient to another (Jamieson et al, 2002). This may be a full hand wash, using liquid antibacterial soap (those containing chlorhexidine or povidone-iodine) and water or alcohol rubs (Nicol et al, 2003). A full hand wash should be carried out before placing gloves on the hands; when the hands are visibly soiled; after contact with contaminated materials, e.g. linen; when performing an aseptic technique; before handling food; after using the toilet and before leaving the ward (Parker, 2002). Hand washing, to be reliable, should take about 20 seconds and should follow the standardised hand washing techniques (NHS Quality Improvement Scotland, 2003). Both surfaces of the hands should be washed thoroughly, taking particular care of areas that are usually missed, for example, nail beds, back of thumbs and in-between fingers. The hands should be wetted first, the soap applied and used to wash the hands, then with the hands bring rinsed in clean water and thoroughly dried with disposable paper towels (Stewart, 2002). Hot air dryers or re-usable towels should not be used in the clinical setting as studies have shown the increased contamination after drying, or with the hand dryers, the lack of drying (Parker, 2002). The taps should be turned off with elbow or wrist or in the case of normal taps, a paper towel (Clark, 2004). Part of modern day hand hygiene procedures now include alcohol rubs which are in widespread use as they are easily used and are effective destroying the transient microbes found on the hands. They are usually used between hand washes and require no water or paper towels as the alcohol evaporates very quickly. Most contain an emollient to ensure that constant use of the alcohol does not cause skin problems (Myers & Parini, 2003). Alcohol rubs are very useful in the community setting where access to appropriate hand washing facilities is near impossible (Lawton et al, 2001). Although, an alcohol gel rub is not a substitute for hand washing as it is ineffective if used on hands contaminated with body fluids or excreta (Nicol et al, 2003). It also has been shown that without washing the hands regularly when using alcohol rubs causes a build-up of emollient on the hands, which means that the alcohol becomes less effective at killing the transient bacteria (Girou et al, 2002). Paulson et al (1999) showed the use of antimicrobial soap and water along with an alcohol gel sanitizer was the most effective at reducing the number of transient microbes, over 99.99 percent, compared with just fewer than 99.0 percent for antimicrobial soap and water alone, and 99.46 percent for just alcohol gel sanitizer. This highlights the fact that the use of only alcohol gel or hand washing alone still leaves a risk of contamination, albeit a negligible one.

    The importance of hand hygiene in reducing the rate of Hospital Acquired Infections is apparent. However, there are advantages and disadvantages associated with the practise of hand hygiene. Obviously, the main advantage is the fact that hand hygiene reduces the risk of a professional contaminating a patient or indeed themselves with potentially harmful microbes (Parker, 2002). The increasing use of alcohol gel as the primary means of hand hygiene also has advantages, as the use of soap and water damages the epidermis, as soap is a drying agent and also then mechanical force used when washing and especially drying (Stewart, 2002). This will lead to less staff affected by occupational skin conditions. Modern alcohol gels have emollients added to ensure that the alcohol does not damage the skin. Alcohol cleansing products were previously thought to 'dry and toughen' the skin, but research has shown the converse to be true. The emollients protect the water content of the skin layers and as they are moisturisers, actually soften the hands; therefore using these less irritating products will decrease the risk of skin problems (Myers & Parini, 2003). The time that it now takes to effectively make the hands as microbe-free as possible also is a positive factor in hand hygiene. It was shown that by the time a nurse left a patient, found a sink, washed and dried her hands and then returned to the bedside would take on average more than a minute. Whereas, alcohol gel use would take roughly 15 seconds, and also the nurse would not have to leave the bedside (Voss & Widmer, 1997). As with all procedures, there are disadvantages associated with them, with hand hygiene, the main problem is the compliance of staff to properly wash their hands (Rumbau et al, 2001). They usually fall at the first step; wetting the hands. Most staff washing their hands were found to put the soap on first, this reduces the lather produced if wet hands are used and putting the soap onto dry skin may also cause problems (Kampf & Loffler, 2003). Staff also have problems complying with hand washing techniques, it is understandable that they might be busy, but this important component of infection control should not be missed. The recommended time for actually washing the hands should be about 20 seconds (NHS Quality Improvement Scotland, 2004). However, staff have difficulty in judging what 20 seconds is and as a result do not perform a proper hand wash. Also their technique is not adequate enough to cover all surfaces and effectively remove the microbial contamination (Reynolds & Edmonds, 2000). Staff should also realise not to use hot water when washing their hands, as repeated use of hot water may increase the risk of dermatitis. As a result staff should use tepid water rather than hot or cold (Boyce et al, 2000). Studies have shown dermatitis and skin dryness to be major barriers to good hand hygiene because they discourage staff from washing their hands or using alcohol gel rubs (Duffin, 2004). Along with poor technique, there are practical difficulties to hand hygiene. The access to sinks is particularly important as well as the supply of soaps and paper towels (Scottish Executive, 1998).

    It is clear that there are many advantages and disadvantages to the process of hand hygiene, and procedures and protocols should be in place to minimize the disadvantages but in practice these are not always implemented or are hindered in some way. Personal experience has shown that there are barriers to hand hygiene. I was in a surgical ward within a medium general hospital serving a large population. As this ward was surgical, the importance of hand hygiene needed emphasis due to the number of recently operated on patients and also the high prevalence of Methicillin Resistant Stapylococcus Aureus (MRSA) that was already on the ward and in fact throughout the hospital. From the moment of starting it was iterated the importance of ensuring that the MRSA did not spread especially to the patients that had recently had surgery. This ward was a mix of vascular and colorectal surgery and as such had patients that were somewhat vulnerable to MRSA. The ward was well managed and had a skilled and knowledgeable team, from the auxiliary nurses up to the ward manager. However, it was noted on numerous occasions when infection control procedures, especially hand hygiene were either forgotten or totally disregarded. This was not only by the nursing staff, but the medics, physiotherapists, visitors and patients themselves. To effectively combat the spread of MRSA and other Hospital Acquired Infections it is important that the hand hygiene protocols and procedures laid down are followed. On one occasion during the morning 'background', I witnessed one of the auxiliary staff entering a MRSA 'contact' room. This was a four-bedded room where all four patients had come into close contact with a patient who eventually tested positive for MRSA, although these patients were not MRSA positive (yet!) they were isolated together to reduce the risk to the other patients until three swabs came back as clear. They each had their own coloured aprons and gloves by their bedside and these were to be strictly used for that patient only. The auxiliary entered the room and went to the first patient and placed on the appropriate apron and gloves, and dealt with that patient. Once she was finished, she removed her apron and gloves, put them in a black domestic waste bag and then left the room without washing her hands. Not only did she not wash her hands after removing the protective clothing, she discarded them into a normal household waste bag. This was not usual practice in any way but was an avoidable oversight that occasionally occurred. Another occasion was when after changing a dressing, going to perform hand hygiene at the sink in the clean area. Once the hands were washed and I was ready to dry them, there were no paper towels in the dispenser. With wet hands, some had to be taken from the kitchen dispenser and unfortunately on this ward and others in the hospital, this was a regular occurrence. It is hard to follow procedure if the materials are not available to carry it out to the best of the staffs' ability, although not all can be attributed to these problems. Some staff were not aware of the importance of infection control procedures, as indeed neither was I, who had to be reminded on numerous occasions to put an apron on when entering a MRSA room. It is very easy to forget especially in such a busy ward about hand hygiene but everyone must be vigilant in ensuring that it is not a regular occurrence.

    The barriers to adequate hand hygiene are apparent, these must be overcome to ensure that Hospital Acquired Infections do not reach epidemic proportions, and as a result there are implications to nursing practice that must be met (Simpson, 1997). This may be in the form of education and training on the aspects of infection control, with constant up-dates on the current issues that are supported through evidenced-based practice (RCN, 2004). This will not only improve practice and assist in the appropriate use of resources but will also contribute towards nurses' professional profiles for PREP requirements (NMC, 2004). Infection control departments have a clear responsibility to provide staff in clinical areas with information on infection control policies and procedures. It is imperative that clinical staff are made aware of the existence of such policies and procedures (NHS Quality Improvement Scotland, 2004). Registered nurses must be aware that they may be in breach of the NMC's Code of Professional Conduct (2004) specifically clause 1.4: "You have a duty of care to your patients and clients, who are entitled to receive safe and competent care." Meaning should they fail to take appropriate precautions when dealing with a patient, for instance disregard for hand hygiene procedures they may be liable for disciplinary procedures by the NMC. This may make nurses more aware of their responsibility with regards to infection control. Staff must take a pro-active rather than a reactive approach to the barriers that they face with hand hygiene. They must ensure that the materials needed are readily available and others can be sourced if the need arises and that their training on infection control is up-to-date. (Scottish Executive, 1998).

    In conclusion, the importance of hand hygiene cannot be emphasised enough. Ten percent of all patients entering a National Health Service hospital will contract a Hospital Acquired Infection, some of which are fatal. As nurses account for 80 percent of a patient's contact with a healthcare professional, it is imperative that proper hand hygiene techniques are carried out. The use of antimicrobial soap and water along with an alcohol gel decreases the numbers of microbes that can potentially result in the contamination of a patient. Following standard hand hygiene and infection control procedures properly will reduce this chance of cross-contamination. There are advantages and disadvantages associated with the practise of hand hygiene, the advantages of hand hygiene are exceptionally important and some of the disadvantages can be reduced in severity with appropriate remedial actions. Personal experience has shown that the correct procedures with regards to hand hygiene are not always followed in the clinical setting. With continued education and training in the area of infection control in general these instances of 'oversights' can be reduced to an acceptable level. This reiterates the fact that hand hygiene is everyones' responsibility and must face the consequences when they fail to perform this simple yet vital procedure.

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    last updated 18/06/05

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