Do you have a healing touch?

Health-care workers wash their hands only half as often as they should, according to estimates.

Last month, we advanced the premise that knowing when to wash your hands is an important step in reducing the risk of causing nosocomial infections, especially with resistant microbes often found in hospitals. At the end of the essay, a list of events that should prompt all personnel to wash their hands was provided.

Carl A. Osborne

Do you recall the events? Some are no-brainers, but others may be unfamiliar to you. Are all staff members in your hospital familiar with these events? At your next meeting, why not ask them to construct a similar list and provide the rationale for each?

This month's Diagnote focuses on how to wash your hands. In minimizing nosocomial infections, it is an evidence-based fact that how you wash your hands is equally important as when.

When you are at the hospital or clinic, are you using an acceptable protocol to wash your hands? Would you accept your hospital's hand-washing protocol if you were the patient? Have you prepared a standard operating protocol and periodically reviewed it with your staff in a timely fashion?

The main point is that to properly care for your patients, more is required than knowing the proper times to wash your hands. It is essential to know how to do so. So let me pose the question again:

How do you wash your hands?

What's the most effective procedure?

The technique chosen depends on its purpose; none is adequate for all circumstances. However, the traditional method of proper hygienic hand washing in veterinary hospitals requires three basic components (soap, running water and friction) and usually takes less than a minute. Here's how to do it:

1. Completely wet your hands and wrists in a running stream of warm water. Warm water is recommended because hot water is harsh on skin, while cold water may reduce the lathering action of cleaning agents.

2. Apply plain soap and distribute it to the front and back of your hands and between fingers (Figure 1). Use enough soap to create lots of lather. If liquid soap is used, apply about 3 to 5 milliliters to the palm (see manufacturer's recommendation).

Figure 1: Interlacing fingers and vigorous rubbing should be a routine part of hygienic hand-washing. Be sure to include the dorsal surface and the tips of your fingers (see Figure 2, p. 5S).

3. Away from running tap water, vigorously rub all surfaces of lathered hands to create friction. Be sure to inter-lace your fingers and vigorously rub them up and down. It is the abrasive action that loosens dirt and transient microbes. Because fingernail areas often harbor high numbers of microbes, pay special attention to them. One way to help clean under fingernails is to rub the fingertips of one hand across the palm of the other (Figure 2). If your fingernails are visibly soiled, clean under them with a disposable manicure stick. In addition to fingernails, areas frequently missed include thumbs and the dorsal surfaces of both fingers and hands.

Figure 2: To help clean under fingernails, rub the fingertips of one hand across the palm of the other.

4. Vigorously lather your hands for 15 seconds. The ideal duration varies, but numerous studies confirm that most people don't wash their hands long enough. The generally accepted minimum duration is 15 seconds. Washing at least that long has been found to be effective in removing most transient organisms. However, more time may be required if your hands are visibly soiled.

5. Thoroughly rinse hands in a stream of clear, running, warm tap water until all soap residue is removed. This facilitates suspension and removal of loosened microbes and also the residual hand-washing agent. To avoid recontamination, don't use a standing basin of water to rinse your hands. Remember that failure to remove soap residue from your hands can result in dermatitis.

6. Avoid recontamination of hands with water and soap from your wrists.

Figure 3: Wearing hand jewelry tends to increase the number of transient bacteria on your hands. Although these hands have an attractive manicure, the length of the nails appears to be more than recommended (approximately ¼ inch).

7. Gently dry hands with disposable paper towel(s). The towels should be conveniently placed to reduce the possibility of hand recontamination. Compared to properly dried hands, the number of bacteria found on hands with residual moisture after washing often is greater. And when hands are wet, the number of micro-organisms transferred after contact with other surfaces often is much greater (almost double in one study) than when hands are dry. Drying with disposable towels is preferred because it is quicker than hot-air dispensers. To avoid skin damage from frequent washing, pat your hands with the towel until they are dry, rather than rubbing them dry. Reusable towels should be avoided because of the high potential for microbial contamination. It is especially important not to use your clothing to remove residual moisture.

8. To keep clean hands free from recontamination, turn off the faucet with a paper towel. Do not use your bare hands because the faucet is always considered to be contaminated (Figure 4). Sinks with faucets that can be turned off by means other than your hands (e.g., foot or knee pedals) and sinks that minimize splash can minimize immediate recontamination.

Figure 4: Do not use your bare hands to turn off water faucets because faucets are likely to be contaminated. Use a disposable towel to protect your hands from recontamination.

9. Start over if either of your clean hands accidentally touches the faucet or outside of the sink.

10. Discard towels in a waste container of appropriate design without touching it. Remember to open the outer lavatory door with the towel before tossing it into the receptacle.

11. As needed, use hand lotion to prevent damage to your skin from frequent washing. Use of liquid soaps containing antiseptics and emollients will help minimize dermatitis. If an antiseptic hand-washing product is used instead of plain soap, check to see if it is compatible with the hand lotion you have chosen. Appropriate hand-care lotions should be supplied in small, non-refillable containers and placed in convenient locations.

What is the most effective procedure for antiseptic hand washing by hospital staff?

1. If hands are not visibly soiled, the Centers for Disease Control and Prevention (CDC) recommends routine use of an alcohol-based hand rub (or antimicrobial soap and water) to decontaminate hands in these instances:

• Before direct contact with patients

• Before donning sterile gloves to insert intravascular catheters, urinary catheters or other invasive devices that do not require a surgical procedure

• After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings.

2. When decontaminating hands with an alcohol-based hand rub, apply product to the palm of one hand and then rub hands together, covering all surfaces of hands, fingers and thumbs until hands are dry. Follow the manufacturer's recommendations regarding the amount to use.

More hand-washing caveats

• Hand washing may be indicated more than once in the care of an individual patient, such as after touching septic secretions in one body site and before proceeding to provide care for another body site in the same patient.

• Subungual areas of hands harbor high concentrations of microbes. Even after hands are properly washed, substantial numbers of potential pathogens have been found in subungual spaces. To minimize contamination, avoid long fingernails (keep natural nail tips less than ¼-inch long; Figure 3), artificial nails and chipped or old (more than four days) nail polish because they further increase the number of transient bacteria.

• A greater number of potentially pathogenic bacteria have been cultured from skin under rings than comparable areas of skin without rings. Therefore, remove excessive hand jewelry before washing your hands, especially when working with patients at high risk for nosocomial infections. Although hand-washing may reduce the number of microbes, wearing rings tends to increase transient bacteria on hands (Figure 3).

Ordinary soap or antiseptic products?

Hand-washing products for use in hospitals are available in several forms. Factors to be considered include the degree of microbial killing desired and the acceptability, cost and ease of using them. Cost should not be the primary factor. If hands are not visibly soiled, the CDC recommends routine use of an alcohol-based hand rub (or antimicrobial soap and water) to decontaminate hands.

Hand-cleaning agents must be effective in removing transient micro-organisms, but must be mild to the skin after many applications. It is important that the product be acceptable to the personnel who will use it. To maximize acceptance by hospital staff, solicit their input, their preference of fragrance, feel and skin tolerance.

Plain soaps and detergents

Following CDC guidelines, we define plain soaps as detergents that do not contain antimicrobial agents, or that contain low concentrations of antimicrobial agents that serve as preservatives. Hydrophilic and lipophilic components are contained in plain soaps and can be divided into four groups of detergents:

1) anionic, b) cationic, 3) amphoteric and 4) nonionic. The cleansing activity of plain soaps is due to their detergent properties which, when properly used, results in removal of dirt, soil and various organic substances. Hand washing with plain unmedicated soaps (in bar, granule, soap-impregnated tissue or liquid form) and friction created by rubbing the hands together are sufficient to remove most dirt, organic material and transient microorganisms. They contribute to hygiene primarily by aiding mechanical removal of microbes during washing.

Liquid soap generally is easier to use than bar soap. In addition, when applied via an appropriate dispenser, liquid soap minimizes the possibility of transfer of microbes by direct contact with a contaminated bar of soap. However, since liquid soap containers can become contaminated and might serve as reservoirs of microbes, reusable liquid containers should be used until empty and cleaned before refilling with fresh soap. Liquid soaps should not be used to refill a partially full dispenser. Completely disposable containers obviate the need to empty and clean dispensers. Topping off dispensers can contaminate soap.

If bar soap is used, it should be kept in a self-draining holder that is cleaned thoroughly after use of each bar. Why? Because bacteria generally multiply quickly in moisture. Use of small bars of soap is also recommended.

Antiseptic soaps

Antiseptic hand-washing agents contain relatively nontoxic and nonirritant antimicrobial materials that are sufficiently bland to be safely applied to the skin. Most antimicrobial-containing hand-washing products are available as liquids and often contain alcohols, chlorine, chlorhexidine gluconate, hexachlorophene povidone-iodine, quaternary ammonium compounds or triclosan.

These agents may kill microbes (microbicidal effect) or inhibit their growth (micobistatic effect), a process often referred to as the chemical removal of microorganisms. Since their introduction, use of antimicrobial hand-washing agents has been shown to be more effective in reducing the number of microbes on the skin than plain soaps.

Alcohols

Most of the alcohol-based antibacterial hand soaps contain isopropanol, ethanol, n-propanol or a combination of two of them. The antimicrobial activity of alcohol has been attributed to its ability to denature proteins. Solutions containing 60 percent to 90 percent alcohol are most effective; higher concentrations are less potent because proteins are not easily denatured in absence of water.

The alcohol content of solutions may be expressed as a percentage by weight (w/w), which is not affected by temperature or other variables; it may also be expressed as a percentage by volume (vol/vol), which can be affected by temperature, specific gravity and/or reaction concentration.

For example, 70 percent alcohol by weight is equivalent to 76.8 percent by volume if prepared at 15 degrees Centigrade, or 80.5 percent if prepared at 25 degrees Centigrade. Alcohol concentrations in antiseptic hand rubs often are expressed as a percentage by volume.

Alcohols have excellent in-vitro germicidal activity against gram-positive and gram-negative bacteria, Mycobacterium tuberculosis, various fungi and some enveloped (lipophilic) viruses. Alcohols have poor germicidal activity against bacterial spores, protozoan oocysts and some non-enveloped (non-lipophilic) viruses.

Alcohols effectively reduce bacterial counts on hands. The FDA has classified 60 percent to 90 percent ethanol as a Category 1 agent (i.e., generally safe and effective in health-care workers' antiseptic hand-wash products). Alcohols should not be used when hands are visibly dirty or contaminated with proteinaceous material.

Although alcohols are rapidly germicidal when applied to the skin, they do not have persistent residual activity. However, regrowth of bacteria on the skin occurs slowly after use of alcohol-based antiseptics, presumably because of the sub-lethal effects that alcohols have on some bacteria. Addition of chlorhexidine, quaternary ammonium compounds, octenidine or triclosan to alcohol-based solutions can result in persistent activity.

At this time, alcohol-based products have proven more effective for standard hand washing or hand antisepsis by health-care workers than plain soap or other types of antimicrobial soaps. Alcohol reduced bacterial counts on hands more than washing hands with soaps or detergents containing hexachlorophine, chlorhexidine, quaternary ammonium compounds, provodine-iodine or triclosan.

Frequent use of alcohol formulations for hand antisepsis can cause painful drying and cracking of skin. In my experience, painful cracking of skin adjacent to fingernails is especially bothersome. This can reduce compliance with standard operating protocols for hygienic or surgical hand cleansing. Addition of emollients, humectants, and/or other skin-conditioning agents to alcohol-based product formulations will reduce or eliminate this problem. Hospital staff should be educated about the value of frequent use of hand-care products.

Chlorohexidine gluconate

Chlorohexidine gluconate is a cationic bisbiguanide whose antimicrobic activity is attributable to attachment to, and subsequent disruption of, cyto-plasmic membranes, resulting in precipitation of cellular contents. The immediate antimicrobial activity of chlorohexidine occurs more slowly than that of alcohols.

Chlorohexidine has good activity against gram-positive bacteria, less activity against gram-negative bacteria and fungi and minimal activity against tubercle bacilli. It is not sporicidal, but has in-vitro activity against some enveloped viruses. The antimicrobial of chlorohexidine is minimally affected by the presence of organic material, including blood. However, because it is a cationic molecule, its activity can be reduced by natural soaps, inorganic ions, nonionic surfactants and hand creams containing anionic emulsifying agents.

Aqueous or detergent formulations containing 0.5 percent to 0.75 percent chlorohexidine are more effective than plain soap, but they are less effective than antiseptic detergent preparations containing 4 percent chlorohexidine gluconate. Addition of 0.5 percent to 1 percent chlorohexidine to alcohol-based preparations results in greater residual activity than alcohol alone.

Other antiseptic soaps

For specific information about other antiseptics in soaps, including chloroxylenol, hexachlorophene, iodine, iodo-phors, quaternary ammonium compounds and triclosan, please refer to an excellent review entitled Guidelines for hand hygiene in health-care settings, by John M Boyce, MD, and Didier Pittet, MD. It can be accessed on the CDC's Web site at www.cdc.gov/mmwr/preview/mmwrhtml/rr5116a1.htm>.

Hand washing with plain soaps vs. antiseptic soaps

The following discussion regarding hand washing with plain soaps vs. antiseptic soaps was developed from reproducible studies performed in a hospital environment with human patients. I could find few reports of evidence-based studies performed in veterinary hospitals.

Hand washing with an alcohol-based antiseptic agent is recommended between patient contacts. To reduce occurrence of dry skin and dermatitis associated with frequent use, select appropriate alcohol-based products that have been fortified with emollients, humectants and/or other skin conditioners.

There is a concern that unnecessary use of antiseptic soaps may foster development of resistant microbes. If microbes are exposed repeatedly to antiseptics that do not kill them, resistant microbes may develop. Therefore, when the sole purpose of hand washing is to remove soil and transient organisms at home or in an environment other than hospitals or clinics, soap is usually adequate. Antibacterial hand cleansers are not needed.

However, in a hospital environment, hand-washing with an antiseptic agent (alcohol-based hand-rub) is indicated:

• When there is heavy microbial contamination

• Before performing invasive procedures (biopsies, intravenous catheters, urinary catheters, etc.)

• Before contacting patients with wounds or immunosuppressed patients

• Before and after direct contact with patients with antimicrobial-resistant organisms

How can hand-washing compliance be improved?

Failure to wash hands is a complex problem that may be caused by a lack of motivation or lack of knowledge about the importance of the procedure. It may be caused by obstacles such as understaffing, inconveniently located sinks, absence of paper towels, unacceptable hand-washing products or dermatitis caused by previous hand washing.

The convenient placement of sinks maintained to provide proper water temperatures and pressure, and ready availability of hand-washing products, including nail brushes, disposable paper towels and waste containers, may help promote frequent and appropriate hand washing. In addition, busy hospital staff should understand and adhere to the concept that use of antiseptic cleansing agents does not provide an acceptable alternative to consistent use of proper hand-washing technique.

Dr. Osborne, a diplomate of the American College of Veterinary Internal Medicine, is professor of medicine in the Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Minnesota.