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Compliance with guidelines on effective hand hygiene.

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The National Audit Office (2000) estimated that if all staff followed guidelines already in place, healthcare-assoc…


VOL: 103, ISSUE: 19, PAGE NO: 28

Linda Bissett, BN, SPQ infection control, RN, Dip Food Hygiene, is infection control nurse, NHS Tayside primary care division, Murray Royal Hospital, Perth

The National Audit Office (2000) estimated that if all staff followed guidelines already in place, healthcare-associated infections (HCAIs) could be reduced by 15-30%. It estimated that 5,000 people die each year from HCAIs and that they contribute to a further 15,000 deaths. Taking these figures into account, a possible 6,500 lives could be saved each year if staff took the time to follow standard infection control guidelines including hand hygiene guidance.

Hands are the principal route by which HCAI occurs. A thorough handwash (not a surgical scrub) takes approximately one minute and yet research indicates that conformity to hand hygiene guidelines rarely exceeds 40% (Widmer, 2000). It is extremely important that all healthcare professionals are aware that they are responsible for their own practice and can be held accountable for any act or omission on their part that endangers the well-being of their patients or colleagues (NMC, 2002). This includes failure to comply with the hand hygiene guidelines adopted by their employer.

Hand-hygiene activities

Hand-hygiene activities can be broken down into four parts: the washing and rinsing of hands; thorough drying; use of alcohol-based handrubs/gels; and hand care.

Washing hands

Handwashing using liquid soap and water removes the transient micro-organisms found on the hands (Damani, 2003). Transient organisms are those picked up by staff when handling people, surfaces or objects and are easily transferred to the next person or surface touched.

Washing with an antimicrobial cleanser is recommended before any aseptic technique, before caring for an immuno-compromised patient or after caring for an infected patient (Infection Control Nurses Association, 1997). Antimicrobial cleansers remove transient flora and also reduce the counts of colonising resident bacteria (micro-organisms that live on the skin and are part of the individual’s normal flora). Antimicrobial cleansers have a residual action that provides continuous antimicrobial activity for a period.

Care should be taken to rinse hands carefully before drying.

Drying hands

The ICNA (1997) recommended drying hands thoroughly using good-quality paper towels. It stated that staff should pat their hands dry to reduce damage to the skin surface. Cloth towels are not advised within a clinical area as they can become contaminated. If they must be used then they are for single use only and should be laundered after each use (Damani, 2003).

Handrubs and gels

Alcohol handrubs are less harmful to skin than constant washing and drying (Heeg, 2001). Rubbing the hands vigorously with an alcohol-based gel/liquid for 30 seconds is an alternative to handwashing if contact has been of a social nature (Pratt et al, 2001). This would include, for example, after using the telephone or returning to the ward from another area.

Between patient contacts, alcohol-based rubs and gels can be used up to three times if hands are not visibly dirty or contaminated (ICNA, 1997). Hands should then be thoroughly washed. Rubs and gels can also be used as a substitute for handwashing if the facilities available are inadequate, such as in the community. Small individual dispensers of alcohol gel/rub are available for use in these circumstances. Alcohol-based preparations are not cleansers; therefore any visible contaminants must be removed using soap and water or cleansing wipes before using alcohol rubs.

Bissett (2002) stated that the need for hands to be washed before and after each patient contact must be emphasised and the proper use of alcohol-based handgels/rubs (where appropriate) should be encouraged to reduce the risk of spreading antimicrobial-resistant bacteria. During handwashing any cleansing agent must be applied to all surfaces of the hands and rubbed vigorously. This can be achieved by following the six-step technique used for handwashing (RCN, 2000). 

The same technique can be adopted for applying alcohol-based rubs to ensure that the entire surface area of the hands is rubbed when using these products. Rinsing and drying of the hands is not necessary after applying alcohol-based rubs/gels but the alcohol product must be allowed to dry before any task is undertaken. 

Hand care

Skin care is an often neglected area of hand hygiene despite the fact that bacterial counts are known to increase on dry or damaged skin. Healthcare professionals cite the effect on the skin of constant handwashing/disinfecting as a reason for non-compliance with hand hygiene guidance. All staff should use a good-quality, aqueous-based handcream to protect their skin from damage. This should be applied when it will have time to be effective (such as at lunch breaks, at the end of shifts and before going to bed). 

Reasons for non-compliance

Some of the reasons given for non-compliance with hand hygiene guidelines include: heavy workload; lack of awareness of contamination levels; the lack of availability of cleansing agents; the lack of or inappropriate placement of wash facilities; and lack of awareness of hand hygiene policies/guidelines.

It has also been suggested that staff may be confused by the over-abundance of terms used to describe the activities covered by the term ‘hand hygiene’. Clear and concise definitions of terminology may improve understanding and lead to informed decisions by staff on the product to be used for different tasks. Educating practitioners on the chain of infection and the actions needed to break the chain may also improve understanding of how infection spreads, which in turn may highlight the importance of compliance with guidance.

Staff responsibilities

Each staff member is her or his own health and safety representative and, as infection control issues are a health and safety risk, infection control measures must be risk-assessed. If there is a lack of facilities or a lack of materials to maintain a safe environment for both staff and patients then this must be brought to the attention of the infection control team and managers. If members of staff are not complying with handwashing standards then it is the responsibility of their peers to encourage them to follow guidelines or to bring this to the attention of a senior member of staff so that appropriate action can be taken. 

Education and audit

To ensure adherence to guidelines and protocols, surveillance and audit of practice must be carried out and the results fed back to ward managers and employers to facilitate improved infection control practice.

Infection control measures, particularly hand hygiene, must be included in all induction programmes for new staff. Hand hygiene must be part of an ongoing programme of infection control education for all staff members. Patients, relatives and carers would also benefit from receiving information on the issue. This could take the form of booklets, posters and information stands.

Visitors to healthcare settings should be invited to wash their hands on entering and leaving. Creating and displaying posters aimed at visitors asking them to wash their hands to help reduce the risk of infection could contribute to this.

In the author’s place of work the infection control team carries out hand hygiene awareness sessions on a regular basis. These have proved popular with both staff and visitors and have helped to raise awareness of the need for good hand hygiene practice. The team also audits handwashing skills and handwashing facilities in all areas on an annual basis to ensure standards remain high and that facilities are appropriate.


Practitioners must be made aware of their responsibility to patients and colleagues alike. Failure to wash hands before and after patient contact could lead to cross-infection, increased hospital stays, increased antibiotic therapy and in some cases the death of a patient. Nurses must take care to avoid any act or omission that could reasonably be foreseen as likely to cause injury or harm. It is no longer acceptable to blame lack of time, equipment or materials.

Next week’s NT Clinical Development article is on adopting marketing techniques to improve hand hygiene compliance.

Learning objectives

- Understand nurses’ responsibilities in infection control and hand hygiene

 - Be aware of the different hand hygiene activities and understand when and how to carry them out

- Know the actions nurses should take when hand hygiene protocols are not followed

- Know some measures to take to improve awareness of hand hygiene

Guided learning

- Outline nurses’ responsibilities in infection control and hand hygiene

- Explain the four parts of hand hygiene activities

- Outline the actions nurses should take when faced with a lack of facilities or colleagues’ failure to comply with local guidelines

- List some measures that could improve staff and patient awareness of the importance of hand hygiene

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