Focusing on hand hygiene to prevent HAIs
By Matt Phillion
Five medical organizations have teamed up to recommend best practices for hand hygiene in healthcare settings to protect patients and providers from infection. In particular, the recommendations focus on alcohol-based hand sanitizers and the importance of healthy skin and nails.
The report, Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene: 2022 Update, was published in the journal Infection Control & Hospital Epidemiology. The Society of Healthcare Epidemiologists of America gathered the subject matter experts who performed and managed the report’s literature review.
The good news: While hand hygiene needs to remain part of the discussion at all times, the industry is doing well, says lead author Janet Glowicz, PhD, RN, CIC, with the Centers for Disease Control and Prevention (CDC).
“I don’t think we’re struggling. I think hand hygiene and keeping hands clean is one of the most important things we can do to prevent infections and is one of the foundations of infection prevention,” she says. “It has to remain top of mind.”
There are so many opportunities to clean one’s hands in the course of a shift, Glowicz notes, that trying to do it as often as is indicated can be a challenge. “I think they’re doing a great job. [But] it’s about really helping personnel notice those times when their hands might become contaminated and having access to supplies to clean them appropriately,” says Glowicz.
The report notes that only 7% of healthcare personnel effectively clean the entire surface of their hands, but it also observes that 86% of personnel clean their hands at the appropriate moment, Glowicz points out. “I think we’re improving and refining practices,” she says.
The importance of alcohol-based sanitizers
Highlights in the report include two newer practices. One highlight is a refinement to existing recommendations, urging organizations to ensure access to appropriate supplies and make sure hand sanitizer dispensers are unambiguously accessible.
“This is the first time we’ve set a minimum benchmark for accessibility,” explains Glowicz. “We consider one dispenser in the hallway and one in the patient’s room a minimum benchmark for accessibility.”
The very first recommendation in the report, though, is to promote the healthy maintenance of hands, skin, and fingernails, and to urge the use of alcohol-based hand sanitizers. “The preferential use of alcohol-based hand sanitizer comes from thinking about how frequently personnel need to clean their hands—the only way to do this effectively is with alcohol-based sanitizers,” says Glowicz.
While there may be exceptions to the rule, alcohol-based sanitizers are the most efficient option for the vast majority of hand washing situations, so the report promotes putting their use into the workflow and making it easy for staff to comply.
Glove use highlighted as well
High on the list of recommendations is ensuring staff maintain appropriate glove use.
“We want to educate them about appropriate use. What we recognize with gloves is when healthcare personnel use them, it [reduces] hand contamination, such as C. diff, but we want them to use gloves appropriately,” says Glowicz. “And that they remove them at appropriate times and clean their hands immediately when gloves are removed.”
Inappropriate glove use risks more environmental contamination, she says. “There’s a nice study about all the things healthcare personnel touch once gloves are on: disinfectant wipes, antiseptic dispensers,” says Glowicz. Building awareness of all the things those gloves come into contact with can help staff remember when to wear them and when to discard them—as well as to disinfect their hands after removing the gloves.
The report talks about monitoring hand hygiene in different ways, but the most important element is ensuring that the monitoring provides good data, says Glowicz. “I think that’s the key to improving hand hygiene,” she says. “I wouldn’t say it’s surprising, but some studies show that without good data, healthcare personnel may not engage as fully with hand hygiene.”
Building awareness about environmental contamination
Additionally, the report takes a look at environmental contamination related to sinks and sink drains.
“Over the past five years or so, we’ve seen more outbreaks caused by water-associated pathogens,” says Glowicz. “We felt it was important to include measures that included areas around sinks and how to keep sinks free from splashing.” The report recommends keeping patient care supplies more than three feet away from sinks, for example.
The CDC has long encouraged water infection control assessments along with hand washing assessments, and their website includes a report on how to better address this issue. “When infection control does a risk assessment, they should be looking specifically at the areas around hand washing sinks,” says Glowicz.
Glowicz mentions another recent study looking at the ICU and hand washing sinks in that environment. Often, many other tasks arise in the immediate vicinity of the sinks, including draining liquids from feeding tubes or IV fluids. “Those things can help contamination grow in the drain,” says Glowicz. “If feasible, sinks should be dedicated to hand washing, and those other tasks should be [conducted] in soiled utility locations.”
There’s a new EPA registration process for disinfectants that are effective against biofilms in sink drains, Glowicz notes, but those products are very new to the market. “We list those as an additional practice. Those are going to become important as we battle these kinds of outbreaks,” she says.
Continued perseverance and improvement
Infection preventionists have made hand hygiene a goal, Glowicz notes, while The Joint Commission has done significant work in helping healthcare personnel keep hands clean.
“There’s a lot of awareness and recognition that it is a foundational measure of infection prevention,” says Glowicz. “If anything, nurses, nursing technicians, [and] physicians all have a tremendous awareness of how important this is.”
Healthcare providers are also broadly aware of antibiotic resistance and the role hand hygiene plays in preventing it. “Any time we prevent an infection, we also prevent the rise of antibiotic resistance,” says Glowicz.
What should be next for hand hygiene and infection prevention? “Keep an eye on those water-associated pathogens, especially around vulnerable patients—such as neonatal, burn units, critical care units—all locations where the patients are especially vulnerable,” says Glowicz. “It’s something we have a lot to learn about, with how to keep sink drains free from biofilm.”
Another area to keep on the radar is automated monitoring systems. “How can we make it even easier to collect actionable data that can help healthcare personnel, and how can we potentially provide even real-time feedback that helps them in the moment to get their hands clean?” Glowicz says.
The report sees accessibility of alcohol-based hand sanitizer as the most immediate actionable goal. “When I walk into a facility, I want to see alcohol hand sanitizer front and center,” says Glowicz. “Staff shouldn’t have to look for it; it should be obvious and ready to use.” Ensuring dispensers give enough of a dose to cover a person’s entire hand needs to be a priority, too, so staff don’t have to wonder if they’re reaching every spot.
And, of course, awareness needs to be ongoing and constant. Hand washing isn’t “something you train about once and you’re done,” says Glowicz. “You need to remain constantly aware of it, and healthcare personnel need to have the ability to recognize when their hands are contaminated and have those supplies immediately available for their use. Those are the most important things.”
Empowering staff and making compliance easy is the future of continuous improvement in this area. “The number of opportunities healthcare personnel have during the course of a single shift to clean their hands is huge. The more we can make it easy for them, the better our adherence will be,” says Glowicz. “Being able to refine that and have the right products available at the right time so they can do the right thing is the crux of our message.”