Back to Basics: Hand Hygiene and Surgical Hand Antisepsis · PDF fileBack to Basics: Hand Hygiene and Surgical Hand ... Discuss best practices that could enhance safety ... Hand Hygiene

CONTINUING EDUCATION

Back to Basics: HandHygiene and Surgical HandAntisepsis

www.aorn.org/CE

Continuing Education Contact Hoursindicates that continuing education (CE) contact hours

are available for this activity. Earn the CE contact hours by

reading this article, reviewing the purpose/goal and objectives,

and completing the online Examination and Learner Evalua-

tion at http://www.aorn.org/CE. A score of 70% correct on the

examination is required for credit. Participants receive feed-

back on incorrect answers. Each applicant who successfully

completes this program can immediately print a certificate of

completion.

Event: #13533

Session: #0001

Fee: Members $7.20, Nonmembers $14.40

The CE contact hours for this article expire November 30,

2016. Pricing is subject to change.

Purpose/GoalTo provide the learner with knowledge of best practices related

to hand hygiene and performing surgical hand antisepsis.

Objectives

1. Discuss common areas of concern that relate to peri-

operative best practices.

2. Discuss best practices that could enhance safety in the

perioperative area.

3. Describe implementation of evidence-based practice in

relation to perioperative nursing care.

AccreditationAORN is accredited as a provider of continuing nursing edu-

cation by the American Nurses Credentialing Center’s Com-

mission on Accreditation.

http://dx.doi.org/10.1016/j.aorn.2013.08.017

� AORN, Inc, 2013

ApprovalsThis program meets criteria for CNOR and CRNFA recertifi-

cation, as well as other CE requirements.

AORN is provider-approved by the California Board of

Registered Nursing, Provider Number CEP 13019. Check with

your state board of nursing for acceptance of this activity for

relicensure.

Conflict of Interest DisclosuresDr Spruce has no declared affiliation that could be perceived as

posing a potential conflict of interest in the publication of this

article.

The behavioral objectives for this program were created by

Kimberly Retzlaff, managing editor, with consultation from

Rebecca Holm, MSN, RN, CNOR, clinical editor, and Susan

Bakewell, MS, RN-BC, director, Perioperative Education. Ms

Retzlaff, Ms Holm, and Ms Bakewell have no declared affili-

ations that could be perceived as posing potential conflicts of

interest in the publication of this article.

Sponsorship or Commercial SupportNo sponsorship or commercial support was received for this

article.

DisclaimerAORN recognizes these activities as CE for RNs. This rec-

ognition does not imply that AORN or the American Nurses

Credentialing Center approves or endorses products mentioned

in the activity.

November 2013 Vol 98 No 5 � AORN Journal j 449

I

Back to Basics: H

www.aorn.org/CE

ABSTRACT

Health careeassociated infections (HAIs) are a significant issue in the United

States and throughout the world, but following proper hand hygiene practices is the

most effective and least expensive way to prevent HAIs. Hand hygiene is inex-

pensive and protects patients and health care personnel alike. The four general

types of hand hygiene that should be performed in the perioperative environment

are washing hands that are visibly soiled, hand hygiene using alcohol-based

products, surgical hand scrubs, and surgical hand scrubs using an alcohol-based

surgical hand rub product. Barriers to proper hand hygiene may include not

thinking about it, forgetting, skin irritation, a lack of role models, or a lack of a

safety culture. One strategy for improving hand hygiene practices is monitoring

hand hygiene as part of a quality improvement project, but the most important

aspect for perioperative team members is to set an example for other team members

by following proper hand hygiene practices and reminding each other to perform

hand hygiene. AORN J 98 (November 2013) 450-457. � AORN, Inc, 2013. http://

dx.doi.org/10.1016/j.aorn.2013.08.017

Key words: hand hygiene, surgical hand rub, surgical hand scrub, health caree

associated infection.

t is appropriate to begin this “Back to Basics”

series with hand hygiene and surgical hand

antisepsis, because these activities are the foun-

dation of infection prevention for all perioperative

personnel. It is probably safe to say that anyone in

health care today has heard of the importance of

hand hygiene. Hand hygiene is the most effective

and least expensive way to prevent health caree

associated infections (HAIs).1 All health care

workers can prevent HAIs by washing their hands.

Health careeassociated infections are a major

problem in the United States and throughout the

world. In US hospitals, the most frequently occur-

ring HAIs are urinary tract infections (36%),

450 j AORN Journal � November 2013 Vol 98 No 5

surgical site infections (20%), and blood stream

infections and pneumonia (11%).2 The economic

effect of these infections was $6.5 billion in 20042

and reached $33.8 billion in 2009.3 Hand hygiene

practices can jeopardize safety in the perioperative

area if not performed as recommended; if perfor-

med correctly, hand hygiene can significantly im-

prove the burden on the global health care system

by decreasing microorganism transmission to pa-

tients and health care workers.

HOW-TO GUIDE

The World Health Organization (WHO) Guidelines

on Hand Hygiene in Health Care state,

http://dx.doi.org/10.1016/j.aorn.2013.08.017

� AORN, Inc, 2013

BACK TO BASICS: HAND HYGIENE www.aornjournal.org

Guidelines in the [United States] recommend

that agents used for surgical hand preparation

should significantly reduce microorganisms on

intact skin, contain a non-irritating antimicro-

bial preparation, have broad-spectrum activity,

and be fast-acting and persistent.2(p55)

A complete guide to products is included in the

WHO guidelines. However, there are basic types

of products that should be used in perioperative

settings. Alcohol-based hand rubs are the pre-

ferred type of product for hand hygiene, while

the recommended formulation for surgical hand

antisepsis products is more complex and there

are multiple antiseptic agents that fit this

category.2

The AORN “Recommended practices for hand

hygiene”1 recommends that hand hygiene should

be performed at numerous times:

n on arrival at the facility,

n before and after every patient contact,

n before putting on gloves,

n after removing gloves,

n after removing personal protective equipment,

n after possible contact with blood or other po-

Resources for Hand Hygiene

Videos

n Hygi�ene des mains Hopitaux Universitaires de Gen�eve Vigi

Germe. http://youtu.be/0at_jtzJCDM.

n WHO hand hygiene video. http://youtu.be/s08yiZBSGOw.

Online resources

n Clean care is safer care. World Health Organization. http://

www.who.int/gpsc/5may/background/5moments/en.

n Hand hygiene in healthcare settings. Centers for Disease Control

and Prevention. http://www.cdc.gov/handhygiene/Resources

.html#HCP.

n How to wash your hands e hand washing techniques from the

NHS. NHS. http://www.wash-hands.com/resources.

Web site access verified August 12, 2013.

tentially infectious

materials,

n before and after eating,

n before and after using the

restroom,

n before leaving the

facility, and

n when hands are visibly

soiled.

Perioperative personnel

should review and be mindful

of these recommended prac-

tices and keep reminders of

them visible in a prominent

place to help ensure that

good practices become habit.

There are four general

types of hand hygiene that

should be performed in the perioperative environ-

ment: washing hands that are visibly soiled, hand

hygiene using alcohol-based products, surgical

hand scrubs, and surgical hand scrubs using an

alcohol-based surgical hand rub product. There

are specific techniques for each of these types of

hand hygiene.

Washing Hands That Are Visibly Soiled

This type of hand hygiene should take 40 to 60

seconds to perform. According to WHO,2 health

care personnel should use the following 11-step

hand-washing process to ensure their hands are

properly cleaned (Figure 1). After wetting hands

with water, the following steps should be taken:

1. Apply enough soap to cover all hand surfaces;

2. Rub hands palm to palm;

3. Right palm over left dorsum with interlaced

fingers and vice versa;

4. Palm to palm with fingers interlaced;

5. Backs of fingers to opposing palms with fingers

interlocked;

6. Rotational rubbing of left thumb clasped in

right palm and vice versa;

AORN Journal j 451

Figure 1. How to Handwash. http://www.who.int/gpsc/5may/How_To_HandWash_Poster.pdf ª World HealthOrganization 2009. All rights reserved. Reprinted with permission.

452 j AORN Journal

November 2013 Vol 98 No 5 SPRUCE

BACK TO BASICS: HAND HYGIENE www.aornjournal.org

7. Rotational rubbing, backwards and forwards

with clasped fingers of right hand in left palm

and vice versa;

8. Rinse hands with water;

9. Dry hands thoroughly with a single use towel;

10. Use towel to turn off faucet;

11. Your hands are now safe.4

Hand Hygiene Using Alcohol-BasedProducts

During situations in which hands are not visibly

soiled, such as after removing gloves or touching

a doorknob, perioperative team members should

use an alcohol-based hand rub for hand hygiene.

This type of hand hygiene process should take 20 to

30 seconds to complete. According to WHO,2

perioperative team members should use an eight-

step hand-rub process to ensure their hands are

properly cleaned (Figure 2). If visibly soiled,

hands and forearms should be prewashed with

plain soap and water or an antimicrobial agent,

and then the following steps should be taken:

1. Apply a palmful of the product in a cupped

hand, covering all surfaces;

2. Rub hands palm to palm;

3. Right palm over left dorsum with interlaced

fingers and vice versa;

4. Palm to palm with fingers interlaced;

5. Backs of fingers to opposing palms with fingers

interlocked;

6. Rotational rubbing of left thumb clasped in

right palm and vice versa;

7. Rotational rubbing, backwards and forwards

with clasped fingers of right hand in left palm

and vice versa;

8. Once dry, your hands are safe.5

Surgical Hand Scrub

According to AORN,1 a surgical hand scrub should

be performed before donning sterile gloves for

surgical or other invasive procedures. This pro-

cess is effective at a duration of three to five min-

utes. Perioperative team members should use the

following steps to ensure their hands are prop-

erly cleaned:

1. Remove jewelry including rings, watches, and

bracelets.

2. Don a surgical mask. If others are at the scrub

sink, a surgical mask should be worn in the

presence of hand scrub activity.

3. Wash hands and forearms if visibly soiled with

soap and running water immediately before

beginning the surgical scrub.

4. Clean the subungual areas of both hands under

running water using a disposable nail cleaner.

Discard the nail cleaner in the appropriate

container.

5. Rinse hands and forearms under running water.

6. Dispense the approved antimicrobial scrub

agent according to the manufacturer’s written

directions.

7. Apply the antimicrobial agent to wet hands and

forearms using a soft, nonabrasive sponge.

8. A three- or five-minute scrub should be timed

to allow adequate product contact with skin,

according to the manufacturer’s written

directions.

9. Visualize each finger, hand, and arm as having

four sides. Wash all four sides and the web

space, keeping the hand elevated. Repeat this

process for opposite fingers, hand, and arm.

10. For water conservation, turn water off when it

is not directly in use, if possible.

11. Avoid splashing surgical attire.

12. Discard sponges, if used, in appropriate

containers.

13. Hands and arms should be rinsed under run-

ning water in one direction from fingertips to

elbows as often as needed.

14. Hold hands higher than elbows and away from

surgical attire.

15. In the OR, beginning at the fingertips of one

hand and working up to the elbow with one end

of the towel and repeating the process with the

clean end of the towel on the other hand and

arm before discarding the towel and donning

a sterile surgical gown and gloves.1(p67)

AORN Journal j 453

Figure 2. How to Handrub. http://www.who.int/gpsc/5may/How_To_HandRub_Poster.pdf ª World HealthOrganization 2009. All rights reserved. Reprinted with permission.

454 j AORN Journal

November 2013 Vol 98 No 5 SPRUCE

During proper hand hygiene, perioperative personnelshould a) don a surgical mask, b) rinse the handsfrom fingertips to elbows, and c) keep surgical attiredry. What’s Wrong With This Picture? reprinted withpermission from AORN, Inc, Denver, CO. All rightsreserved.

BACK TO BASICS: HAND HYGIENE www.aornjournal.org

Surgical Hand Scrub Using an Alcohol-Based Surgical Hand Rub Product

According to AORN,1 an alcohol-based antiseptic

surgical hand rub with documented persistent and

cumulative activity that has met US Food and Drug

Administration regulatory requirements is accept-

able. The WHO does not recommend a standard-

ized process for the surgical hand scrub with an

alcohol-based product; however, the organization

does stress the importance of keeping the hands wet

with the product throughout the process.2 The

volume of product that should be used depends on

the size of the team member’s hands and forearms.

After the product is dispensed, the forearms should

be the focus of the rub for the first minute and then

the hands should be the focus, following the same

procedure outlined in the hand scrub technique. To

ensure their hands are properly cleaned, perioper-

ative team members should use the following steps

during a surgical hand scrub using an alcohol-based

surgical hand rub product:

1. Remove jewelry including rings, watches, and

bracelets.

2. Don a surgical mask. If others are at the scrub

sink, a surgical mask should be worn in the

presence of hand scrub activity.

3. If visibly soiled, prewash hands and forearms

with plain soap and water or antimicrobial

agent.

4. Clean the subungual areas of both hands under

running water using a disposable nail cleaner.

5. Rinse hands and forearms under running

water.

6. Dry hands and forearms thoroughly with a

disposable paper towel.

7. Dispense the manufacturer-recommended

amount of the surgical hand rub product.

8. Apply the product to the hands and forearms

according to the manufacturer’s written

instructions.

9. Repeat the product application process as

directed.

10. Rub hands thoroughly until completely dry.

11. In the OR or other invasive procedure room,

don a sterile surgical gown and gloves.1(p66-67)

BENEFITS

Using the four techniques described in the pre-

ceding text is the most effective way to prevent and

control infections among patients and health care

workers. Hand hygiene is inexpensive and achieves

a benefit for both populations.1 Hand hygiene re-

duces the transmission of microorganisms and de-

creases the incidence of HAIs.3 Evidence supports

that a failure to wash hands appropriately is the

AORN Journal j 455

November 2013 Vol 98 No 5 SPRUCE

leading cause of the spread of multidrug-resistant

organisms among patients.3 Surgical hand anti-

sepsis takes hand hygiene a step beyond hand

washingdit eliminates transient flora from the

hands and reduces resident skin flora.2 Transient

flora are colonized on the superficial layers of the

skin of the hands and are easily removed with

washing, whereas resident skin flora are not only

on the superficial layers but also in the deeper

layers of the skin and are not as easy to remove.2

TIPS & TRICKS

Since 1847, when Ignaz Semmelweis insisted that

students and physicians wash their hands, hand

hygiene has been a challenge to enforce; today is

no different.3 To improve hand hygiene practices,

perioperative nurses first need to understand the

reasons for poor compliance.

Reasons for poor compliance include self-

reported factors such as not thinking about it,

forgetting, or skin irritation, as well as aspects such

as a shortage of role models or lack of a safety

culture. Recommended hand hygiene practices may

not always be intuitive. Everyone washes their

hands when they are visibly soiled, bloody, sticky,

or perceived to be dirty. In social situations, people

may touch each other by shaking hands, patting

each other on the back, hugging, or using touch as

affirmation. Hands are not generally washed after

these types of contact. These same types of social

contact can occur in the health care setting among

colleagues and during patient care. Washing the

hands after these types of situations may be over-

looked, so what can be done to improve compliance

with hand hygiene by health care workers?

The WHO guideline includes multiple tools to

help with improving hand hygiene practices (eg, the

Global Patient Safety Challenge document, Pilot

Implementation Pack, Hand Hygiene Brochure,

Clean Hands Poster, Hand Hygiene Observation

Survey).2 Additionally, WHO has a hand hygiene

tool kit that provides strategies and tools to those

who are interested in improving compliance with

456 j AORN Journal

hand hygiene practices at their facilities.6 Some

examples include a facility action plan, protocols

for hand hygiene, and educational materials and

posters. Education is the critical component to im-

prove hand hygiene practices according to WHO.2

The power to inform, along with using other tools,

has been proven to increase compliance.2

Another barrier to following hand hygiene

practices is skin irritation, which can occur with

the use of hand hygiene products. Perioperative

team members should remember to let their hands

dry completely before donning gloves, and in

some cases, alternate products should be pro-

vided to personnel who have sensitive or reac-

tive skin.

To determine compliance with hand hygiene

practices, WHO recommends that individual facil-

ities observe health care workers performing hand

hygiene.2 However, no ideal observation method

exists currently.2 Facilities have used direct obser-

vations by educated observers as well as automated

observations, such as video cameras to monitor

personnel, with some success; however, direct

observation can be biased, as can the interpretation

of videos. Furthermore, these methods can be

costly and hard to monitor during complex activi-

ties.2 It is important for perioperative team mem-

bers to be examples for each other and remind each

other to perform hand hygiene. For a complete

discussion on observations and other tools, see the

WHO guideline.2

WRAP-UP

The effect of HAIs on patient health and safety and

the economy is significant. The foundation of in-

fection prevention is hand hygiene; therefore,

health care facilities need to make hand hygiene

a number one priority in the prevention of HAIs.

The goals are to refresh perioperative personnel’s

knowledge of hand hygiene and instill a new sense

of urgency to protect patients and health care

workers from the potential of developing an

infection and spreading it to others.

BACK TO BASICS: HAND HYGIENE www.aornjournal.org

References1. Recommended practices for hand hygiene. In: Perioper-

ative Standards and Recommended Practices. Denver,

CO: AORN, Inc; 2013:63-74.

2. WHO Guidelines on Hand Hygiene in Health Care.

Geneva, Switzerland: World Health Organization; 2009.

http://whqlibdoc.who.int/publications/2009/9789241597906_

eng.pdf. Accessed September 9, 2013.

3. Guideline for hand hygiene in health-care settings. Re-

commendations of the Healthcare Infection Control Prac-

tices Advisory Committee and the HICPAC/SHEA/APIC/

IDSA Hand Hygiene Task Force. MMWR Recomm Rep.

2002;51(RR-16):1-45.

4. How to Handwash? [poster]. Geneva, Switzerland: World

Health Organization; 2009. http://www.who.int/gpsc/5may/

How_To_HandWash_Poster.pdf. Accessed September 13,

2013.

5. How to Handrub? [poster]. Geneva, Switzerland: World

Health Organization; 2009. http://www.who.int/gpsc/5may/

How_To_HandRub_Poster.pdf. Accessed September 13,

2013.

6. Guide to Implementation: A Guide to the Implementation

of the WHO Multimodal Hand Hygiene Improvement

Strategy. Geneva, Switzerland: World Health Organiza-

tion; 2009. http://whqlibdoc.who.int/hq/2009/WHO_IER_

PSP_2009.02_eng.pdf. Accessed September 9, 2013.

Lisa Spruce, DNP, RN, ACNS, ACNP, ANP,

CNOR, is the director, Evidence-Based Periop-

erative Practice, AORN, Inc, Denver, CO. Dr

Spruce has no declared affiliation that could be

perceived as posing a potential conflict of in-

terest in the publication of this article.

Check back in January 2014 for the next “Back to Basics” topic: Hygiene and Cleanliness.

AORN Journal j 457

EXAMINATION

1.2

Surgical Hand Antisepsis

PURPOSE/GOAL

45

To provide the learner with knowledge of best practices related to hand hygiene

and performing surgical hand antisepsis.

OBJECTIVES

1. Discuss common areas of concern that relate to perioperative best practices.

2. Discuss best practices that could enhance safety in the perioperative area.

3. Describe implementation of evidence-based practice in relation to perioperative

nursing care.

The Examination and Learner Evaluation are printed here for your conven-

ience. To receive continuing education credit, you must complete the Exami-

nation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS

1. Hand hygiene practices can

1. decrease microorganism transmission to pa-

tients and health care workers.

2. jeopardize safety in the perioperative area if

not performed correctly.

3. significantly improve the burden on the

global health care system if performed as

recommended.

a. 1 and 3 b. 1 and 2

8 j AORN Journal

c. 2 and 3 d. 1, 2, and 3

2. According to the World Health Organization,

agents used for surgical hand preparation should

1. be fast-acting and persistent.

2. contain a nonirritating antimicrobial prep-

aration.

3. be chlorine based to kill spores.

4. have broad-spectrum activity.

� November 2013 Vol 98 No 5

5. significantly reduce microorganisms on intact

skin.

a. 1 and 2 b. 1 and 3

c. 1, 2, 4, and 5 d. 1, 2, 3, 4, and 5

3. According to AORN, hand hygiene should be

performed

1. after removing personal protective equipment.

2. before and after every patient contact.

3. on arrival and before leaving the facility.

4. when hands are visibly soiled.

a. 1 and 3 b. 2 and 4

c. 2, 3, and 4 d. 1, 2, 3, and 4

4. Evidence shows that a failure to wash hands ap-

propriately is the leading cause of the spread of

multidrug-resistant organisms among patients.

a. true b. false

� AORN, Inc, 2013

CE EXAMINATION www.aornjournal.org

5. Strategies that can be used to improve compliance

with hand hygiene protocols include

1. creating and implementing a facility action plan.

2. establishing protocols for hand hygiene.

3. mandating one brand of hand hygiene products

for all personnel to use.

4. monitoring hand hygiene practices and re-

porting on findings to personnel.

5. providing personnel with educational ma-

terials.

a. 2 and 4 b. 1, 2, 4, and 5

c. 1, 3, 4, and 5 d. 1, 2, 3, 4, and 5

AORN Journal j 459

LEARNER EVALUATION

1.2

Surgical Hand Antisepsis

This evaluation is used to determine the extent

to which this continuing education program

met your learning needs. Rate the items as

described below.

OBJECTIVES

To what extent were the following objectives of this

continuing education program achieved?

1. Discuss common areas of concern that relate to

perioperative best practices.

Low 1. 2. 3. 4. 5. High

2. Discuss best practices that could enhance safety in

the perioperative area.

Low 1. 2. 3. 4. 5. High

3. Describe implementation of evidence-based practice

in relation to perioperative nursing care.

Low 1. 2. 3. 4. 5. High

CONTENT

4. To what extent did this article increase your

knowledge of the subject matter?

Low 1. 2. 3. 4. 5. High

5. To what extent were your individual objectives

met? Low 1. 2. 3. 4. 5. High

6. Will you be able to use the information from this

article in your work setting? 1. Yes 2. No

7. Will you change your practice as a result of reading

this article? (If yes, answer question #7A. If no,

answer question #7B.)

460 j AORN Journal � November 2013 Vol 98 No 5

7A. How will you change your practice? (Select all

that apply)

1. I will provide education to my team regarding

why change is needed.

2. I will work with management to change/

implement a policy and procedure.

3. I will plan an informational meeting with

physicians to seek their input and acceptance

of the need for change.

4. I will implement change and evaluate the

effect of the change at regular intervals until

the change is incorporated as best practice.

5. Other: _______________________________

7B. If you will not change your practice as a result

of reading this article, why? (Select all that

apply)

1. The content of the article is not relevant to my

practice.

2. I do not have enough time to teach others

about the purpose of the needed change.

3. I do not have management support to make

a change.

4. Other: ________________________________

8. Our accrediting body requires that we verify

the time you needed to complete the 1.2 con-

tinuing education contact hour (72-minute)

program: _________________________________

� AORN, Inc, 2013