G.8.5 Personal Hand Hygiene

PURPOSE

To ensure the continuous high standard of personal hygiene with respect to all aspects of patient care and employment. Hand hygiene is the responsibility of all individuals involved in health care.  

Hand hygiene refers to removing or killing microorganisms on the hands as well as maintaining good skin integrity. There are two methods of removing/killing microorganisms on hands: washing with soap and running water or using an alcohol-based hand rub. Generally, the focus is on microorganisms that have been picked up by contact with patients/health care provider, contaminated equipment, or the environment (transient or contaminating bacteria). 

Effective hand hygiene kills or removes microorganisms on the skin and maintains hand health.
 

APPLICATION

• Paramedics
• Paramedic Superintendents
• Senior Managers
   

PROCEDURE

Alcohol-Based Hand Rub

Alcohol-based hand rub (ABHR) is the preferred method for decontaminating hands. Using alcohol-based hand rub (70-90% alcohol) is better than washing hands (even with an antibacterial soap) when hands are not visibly soiled.

However, hand washing with soap and running water must be performed when hands are visibly soiled. If running water is not available, use moistened towelettes to remove the visible soil, followed by alcohol­ based hand rub. 

* Hands must be fully dry before touching the patient or patient's environment/equipment for the hand rub to be effective and to eliminate the extremely rare risk of flammability in the presence of an oxygen-enriched environment. 
 

Hand Washing

Most transient bacteria present on the hands are removed during the mechanical action of washing, rinsing and drying hands. Hand washing with soap and running water must be performed when hands are visibly soiled. 
 

When Should Hand Hygiene Be Performed?

• Hand hygiene must be performed: Before and after contact with a patient
• Before performing invasive procedures
• Before preparing, handling, serving or eating food
• After care involving the body fluids of a patient (e.g. assisting patient to blow nose, toileting the patient or doing wound care) and before moving to another activity
• Before putting on and after taking off gloves
• After personal body functions, such as using the toilet or blowing one's nose
• Whenever a health care provider is in doubt about the necessity for doing so
• When hands accidentally come into contact with secretions, excretions, blood and body fluids, cleaning, sanitizing vehicle/equipment. (hands must be washed with soap and running water)
• After contact with items in the patient's environment 
   

Factors That Influence Hand Hygiene

The following factors influence the effectiveness of hand hygiene: 

• Condition of the skin: intact skin vs. presence of dermatitis, cracks, cuts or abrasions. EMAs/Paramedics with lesions or weeping dermatitis should refrain from direct patient care and handling patient care equipment until the skin condition is resolved. 
   
• Nails: natural nails more than 3-4 mm (1/4-inch) long are difficult to clean, can pierce gloves and harbor more microorganisms than short nails. Only nail polish in good condition is acceptable. Artificial nails or nail enhancements are not to be worn by those giving patient care as they have been implicated in the transfer of microorganisms.
   
• Jewelry: rings and bracelets hinder effective hand hygiene and should not be worn for patient contact; rings increase the number of microorganisms present on hands and increase the risk of tears in gloves.
   

Hand Hygiene Agents

Alcohol-based hand rubs:

• Are recommended to routinely decontaminate hands in clinical situations when hands are not visibly soiled.
• Provide for a rapid kill of most transient microorganisms.
• Contain a variety of alcohols in concentrations from 60 - 90%.
• Are not used with water.
• Contain emollients to reduce skin irritation.

Liquid or Foam Soap:

• Soap must be dispensed in a disposable pump dispenser.
• Soap containers are not to be topped up, as there is a risk of contamination.
• Bar soaps are not acceptable in health care settings except for individual client/patient/resident personal use.
• Antibacterial soaps may be used in critical care areas such as ICU, or in other areas where invasive procedures are performed. 
   

Techniques

Alcohol-based Hand Rub:

• Remove hand and arm jewelry. Jewelry is very hard to clean, and hides bacteria and viruses from the antiseptic action of the alcohol.
• Ensure hands are visibly clean (if soiled, follow hand washing steps).
• Apply between 1 to 2 full pumps of product, or squirt a Lonnie-sized amount, onto one palm.
• Spread product over all surfaces of hands, concentrating on fingertips, between fingers, back of hands, and base of thumbs. These are the most commonly missed areas.
• Rub hands until product is dry*. This will take a minimum of 15 to 20 seconds if enough product is used. 
   

Hand Washing:

• Remove hand and arm jewelry. Jewelry is very hard to clean, and hides bacteria and viruses from the mechanical action of the washing.
• Wet hands with warm (not hot) water. Hot water is hard on the skin and will lead to dryness.
• Apply liquid or foam soap. Do not use bar soap in health care settings as it may harbor bacteria that can then be spread to other users.
• Vigorously lather all surfaces of hands for a minimum of 15 seconds. Removal of transient or acquired bacteria requires a minimum of 15 seconds mechanical action. Pay attention to fingertips, between fingers, backs of hands and base of the thumbs. These are the most commonly missed areas.
• Using a rubbing motion, thoroughly rinse soap from hands. Residual soap can lead to dryness and cracking of skin.
• Dry hands thoroughly by blotting hands gently with a paper towel. Rubbing vigorously with paper towels can damage the skin.
• Turn off taps with paper towel, to avoid recontamination of your hands 

(NOTE: If hand air dryers are used, hands-free taps are necessary).  
 

Other Issues 

Intact skin is the first line of defense; therefore, careful attention to skin care is an essential part of the hand hygiene program. If using hand lotion, ensure that it does not interfere with glove integrity.

Note:  It is reassuring to the patient to see that the health care provider performs hand hygiene, as patients have an increased awareness of the importance of hand hygiene.
 

REFERENCE

Emergency Health Services Branch, 2007 Infection Prevention and Control Best Practices Manual for Land Ambulance Paramedics, Ministry of Health and Long-Term Care. 

PIDAC - Best Practices for Hand Hygiene in all Health Care Settings- January 2009 

Manitoulin-Sudbury District Services Board, Care and Transportation of Communicable Disease Cases, Policy