May 6, 2009 — The World Health Organization (WHO) has issued Guidelines on Hand Hygiene in Health Care, offering a thorough review of evidence on hand hygiene in healthcare and specific recommendations to improve hygiene practices and reduce transmission of pathogenic microorganisms to patients and healthcare workers (HCWs).
The guidelines target hospital administrators and public health officials as well as HCWs, and they are designed to be used in any setting in which healthcare is delivered either to a patient or to a specific group, including all settings where healthcare is permanently or occasionally performed, such as home care by birth attendants. Individual adaptation of the recommendations is encouraged, based on local regulations, settings, needs, and resources.
Hand Hygiene Indications
Indications for hand hygiene are as follows:
• Wash hands with soap and water when visibly dirty, when soiled with blood or other body fluids, or after using the toilet.
• Handwashing with soap and water is preferred when exposure to potential spore-forming pathogens, such as Clostridium difficile, is strongly suspected or proven.
• In all other clinical situations, use an alcohol-based handrub as the preferred means for routine hand antisepsis, if hands are not visibly soiled. Wash hands with soap and water if alcohol-based handrub is not available.
• Hand hygiene is needed before and after touching the patient; before touching an invasive device used for patient care, whether gloves are used; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; if moving from a contaminated body site to another body site on the same patient; after touching inanimate surfaces and objects in the immediate vicinity; and after removing gloves.
• Hand hygiene is needed before handling medication or preparing food using an alcohol-based handrub or handwashing with water and either plain or antimicrobial soap.
• Soap and alcohol-based handrub should not be used together.
Hand Hygiene Techniques
Specific recommendations for hand hygiene technique are as follows:
• Rub a palmful of alcohol-based handrub over all hand surfaces until dry.
• When washing hands, wet hands with water and apply enough soap to cover all surfaces; rinse hands with water and dry thoroughly with a single-use towel. Whenever possible, use clean, running water. Avoid hot water, which may increase the risk for dermatitis.
• Use the towel to turn off the tap or faucet, and do not reuse the towel.
• Liquid, bar, leaf, or powdered soap is acceptable; bars should be small and placed in racks that allow drainage.
Surgical Hand Preparation
Specific recommendations for surgical hand preparation are as follows:
• Before beginning surgical hand preparation, remove jewelry. Artificial nails are prohibited.
• Sinks should be designed to reduce the risk for splashes.
• Visibly soiled hands should be washed with plain soap before surgical hand preparation, and a nail cleaner should be used to remove debris from underneath the fingernails, preferably under running water.
• Brushes are not recommended.
• Before donning sterile gloves, surgical hand antisepsis should be performed with a suitable antimicrobial soap or alcohol-based handrub, preferably one that ensures sustained activity. Alcohol-based handrub should be used when quality of water is not assured.
• When using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the maker, usually 2 to 5 minutes.
• When using an alcohol-based surgical handrub, follow the maker's instructions; apply to dry hands only; do not combine with alcohol-based products sequentially; use enough product to keep hands and forearms wet throughout surgical hand preparation; and allow hands and forearms to dry thoroughly before donning sterile gloves.
Selecting Hand Hygiene Agents
Some specific recommendations for selection and handling of hand hygiene agents are as follows:
• Provide effective hand hygiene products with low potential to cause irritation.
• Ask for HCW input regarding skin tolerance, feel, and fragrance of any products being considered.
• Determine any known interaction between products used for cleaning hands, skin care products, and gloves used in the institution.
• Provide appropriate, accessible, well-functioning, clean dispensers at the point of care, and do not add soap or alcohol-based formulations to a partially empty dispenser.
Skin Care Recommendations
Some specific recommendations for skin care are as follows:
• Educate HCWs about hand-care practices designed to reduce the risk for irritant contact dermatitis and other skin damage.
• Provide alternative hand hygiene products for HCWs with confirmed allergies to standard products.
• Provide HCWs with hand lotions or creams to reduce the risk for irritant contact dermatitis.
• Use of antimicrobial soap is not recommended when alcohol-based handrub is available. Soap and alcohol-based handrub should not be used together.
Recommendations for Glove Use
Some specific recommendations for use of gloves are as follows:
• Glove use does not replace the need for hand hygiene.
• Gloves are recommended in situations in which contact with blood or other potentially infectious materials is likely.
• Remove gloves after caring for a patient, and do not reuse.
• Change or remove gloves if moving from a contaminated body site to either another body site within the same patient or the environment.
"In hand hygiene promotion programmes for HCWs, focus specifically on factors currently found to have a significant influence on behaviour, and not solely on the type of hand hygiene products," the guidelines authors write. "The strategy should be multifaceted and multimodal and include education and senior executive support for implementation. Educate HCWs about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean their hands."
Four of the guidelines authors have disclosed various financial relationships with GOJO, Clorox, and GlaxoSmithKline, and other companies and institutions. A complete description of their disclosures is available in the original article. The other guidelines authors have disclosed no relevant financial relationships.
WHO Guidelines on Hand Hygiene in Health Care. May 2009.
Clinical Context
In 2004, WHO convened a group of international experts in infection control to prepare guidelines for hand hygiene in healthcare. In 2002, the Centers for Disease Control and Prevention Guideline for Hand Hygiene in Health-Care Settings was adopted. Following a systematic review of the literature and task force meetings, the Advanced Draft of the WHO Guidelines on Hand Hygiene in Health Care was published in 2006. An Executive Summary of the Advanced Draft of the Guidelines is available separately (http://www.who.int/gpsc/tools/en/). Pilot testing of the advanced draft occurred, with subsequent updating and finalization of the guidelines.
The WHO Guidelines on Hand Hygiene in Health Care includes a review of scientific data, consensus recommendations, process and outcome measurements, proposals for large scale promotion of hand hygiene, patient participation in promotion of hand hygiene, and a review of national and subnational guidelines. The recommendations are expected to be valid until 2011 and will be updated every 2 to 3 years.
Study Highlights
- Indications for washing hands with soap and water include visibly dirty hands, hands visibly soiled with body fluids, or after using the toilet.
- Handwashing with soap and water is preferred after exposure to potential spore-forming pathogens, including Clostridium difficile outbreaks.
- Alcohol-based handrub is preferred in the following situations if hands are not visibly soiled: before and after touching a patient; before handling an invasive device for patient care; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between contact with a contaminated body site to another site on the same patient; after contact with inanimate surfaces and objects; and after removing sterile or nonsterile gloves.
- Handwashing with soap and water is recommended when alcohol-based handrub is unavailable.
- Alcohol-based handrub or soap and water can be used before handling medication or preparing food.
- Concomitant alcohol-based handrub and soap use is not recommended.
- Soap and water hand-washing technique includes using a towel to turn off the faucet, thorough drying of hands, and single towel use.
- Acceptable forms of soap are liquid, bar, leaf, or powdered.
- Bar soap racks should allow drainage to ensure that the soap dries.
- Alcohol-based handrub technique includes applying palmful amount of handrub, covering all surfaces, and rubbing hands until dry.
- Surgical hand hygiene recommendations include removal of jewelry, no brushes, and use of either antimicrobial soap or alcohol-based handrub according to the maker's recommendations.
- Selection of hand hygiene agents should consider input from HCWs, interaction with other products or gloves, risk for contamination, accessibility and proper functioning of dispensers, approval of dispensers for flammable materials, and cost comparisons.
- Soap or alcohol-based handrub should not be added to partially empty soap dispensers.
- Skin care irritation in HCWs can be avoided by providing educational programs, alternative hand hygiene products for those with allergies or adverse reactions to standard products, and hand moisturizers to reduce irritant contact dermatitis.
- Glove use does not replace the need for handrub or handwashing.
- Gloves should be used if contact with potentially infectious body fluids, mucous membranes, or nonintact skin is anticipated.
- Gloves should be removed or changed after each patient or after contact with a contaminated body site.
- Artificial nails or extenders should not be used, and the length of natural nail tips should be less than 0.5 cm.
- Educational and motivational programs for HCWs should focus on behavior; be multimodal; include senior executive support; educate about the advantages and disadvantages of various hand hygiene methods; monitor adherence and provide performance feedback; and encourage partnership between patients, families, and HCWs.
- Healthcare administrators should provide and monitor safe, continuous water supply; provide alcohol-based handrub at the point of patient care; prioritize compliance; provide leadership, administrative support, and financial resources; ensure training; implement a multidisciplinary, multifaceted, and multimodal program to improve adherence; and adhere to national safety guidelines and local legal requirements.
- National governments should prioritize adherence; consider funded, coordinated implementation and monitoring; support strengthening of infection control in healthcare settings; promote community hand hygiene; and encourage use of hand hygiene as a quality indicator in healthcare settings.
Clinical Implications
- The WHO guidelines recommend handwashing with soap and water for visibly dirty hands, hands visibly soiled with body fluids, after toilet use, exposure to potential spore-forming pathogens, and if alcohol-based handrub is not available in other situations.
- The WHO guidelines recommend alcohol-based handrub before and after touching patients; before handling invasive devices; after contact with body fluids or excretions, mucous membranes, nonintact skin, or wound dressings; between touching contaminated body site and another body site; after contact with inanimate surfaces and objects; and after removing gloves.
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