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The skin is your hands' and body's first defense against infection from pathogenic organisms. While it's intact, it's impermeable to the likes of human immunodeficiency virus (HIV) and hepatitis as well as countless other microbes, so its proper care and hygiene are crucial. Simply keeping your hands clean is arguably the single most important measure you can take to prevent the spread of communicable diseases, control infectious organisms and illnesses caused by them.
Handwashing, when done correctly, prevents diseases spread through fecal-oral transmission: Infections which may be transmitted through this route include salmonella, shigella, hepatitis A, giardia, entervirus, amebiasis, campylobacter, etc. Because these diseases are spread through the ingestion of even minute particles of fecal material, hand washing following defecation cannot be overemphasized.
Handwashing, when done correctly, prevents diseases spread through indirect transmission: Infections which may be transmitted through this route include influenza, strep, respiratory syncytial virus (RSV) and the common cold. Because these diseases may be spread indirectly by hands freshly soiled by respiratory discharges of infected people, illness may be avoided by washing hands after coughing or sneezing.
Handwashing, when done correctly, prevents diseases may also be spread when hands are contaminated with urine, saliva or other moist body substances. Infections which may be transmitted by one or more of these body substances include cytomegalovirus, schistosomiasis, typhoid, staphylococcal organisms, Epstein-Barr virus, etc. These germs may be transmitted from person to person or indirectly by contamination of food or of inanimate objects such as toys.
Handwashing Guide & Technique
Handwashing is so routine and basic that it's often taken for granted. The following is recommended as an effective washing technique with soap and running water. Steps 2, 4, 5 and 6 should be repeated with the other hand.
There is more to handwashing than you think! By rubbing your hands vigorously with soapy water, you pull the dirt plus the oily soils free from your skin. The soap lather suspends both the dirt and germs trapped inside and are then quickly washed away.
Wet your hands with warm running water.
Add soap, then rub your hands together, making a soapy lather.
Do this away from the running water for at least ten seconds, being careful not to wash the lather away. Wash the front and back of your hands, as well as between your fingers and under your nails.
(For midwives and other health care providers, handwashing should also include the forearms to the elbows when we are going to examine our clients or patients. Handwashing should be done prior to examination and again following the examination! Handwashing is essential whether you are doing an external or an internal exam or both. Always handwash before putting on exam gloves and then again after removing them.)
Rinse your hands well under warm running water. Let the water run back into the sink, not down to your elbows. Turn off the sink with a paper towel and dispose in a proper receptacle.
Dry hands thoroughly with a clean towel.
Any type of soap may be used. However, bar soap should be kept in a self draining holder that is cleaned thoroughly before new bars are put out and liquid soap containers (which must be used in day care centers) should be used until empty and cleaned before refilling.
To prevent chapping use a mild soap with warm water; pat rather than rub hands dry; and apply lotion liberally and frequently.
Soap
Choose a neutral pH soap with no added substances. Strong perfumes or alcoholic drying chemicals tend to dry out the skin, especially if you wash frequently. Use a good-quality moisturizing cream to help restore your hands if they get "washed out."
Skin Care
Your skin is impermeable to pathogenic organisms only while it's intact. Cuts, abrasions, lesions and dermatitis should be covered by a waterproof occlusive dressing for extra protection. To be safe, follow the Center for Disease Control and Prevention's (CDC) universal precautions - always wear gloves if you're in contact with body fluids.
When to wash your hands
- When arriving on the unit or in the client's home.
- Whenever hands are soiled.
- Before and after patient or client care.
- Before and after gloving.
- Before eating.
- Before leaving the building or client home.
- After wiping your nose.
- After using the bathroom.
- After any clean up activity.
What to Avoid
DON'T use a single damp cloth to wash a group of children's hands.
DON'T use a standing basin of water to rinse hands.
DON'T use a common hand towel. Always use disposable towels.
DON'T use sponges or non-disposable cleaning cloths unless you launder them on a regular basis, adding chlorine bleach to the wash water.
Remember that germs thrive on moist surfaces!
Teach Children Proper Handwashing Techniques
It is important to encourage and help children to wash hands before eating, after playing outdoors or playing with pets, after using the bathroom, and after blowing their noses.
Even though hands may appear clean, they may carry germs or microorganisms that are capable of causing disease. Don't assume that children know how to wash their hands properly. Supervision, especially in a day care setting, is an essential element in forming good handwashing habits in children.
Finally, children learn by example! Let them observe good handwashing technique from adults who care for them.
Health Care Providers
Hand hygiene is widely acknowledged to be the single most important activity for reducing the spread of disease, yet evidence suggests that many health care professionals do not decontaminate their hands as often as they need to or use the correct technique which means that areas of the hands can be missed.
Hands should be decontaminated before direct contact with patients and after any activity or contact that contaminates the hands, including following the removal of gloves. While alcohol hand gels and rubs are a practical alternative to soap and water, alcohol is not a cleaning agent.
Hands that are visibly dirty or potentially grossly contaminated must be washed with soap and water and dried thoroughly. Hand preparation increases the effectiveness of decontamination. You should:
- Keep nails short, clean and polish free.
- Avoid wearing wrist watches and jewelry, especially rings with ridges or stones.
- Artificial nails must not be worn.
- Any cuts and abrasions should be covered with a waterproof dressing.
- Remove your wristwatch and any bracelets and roll up long sleeves before washing your hands (and wrists) and dry them thoroughly.
In addition, bear in mind the following points:
Facilities: Adequate hand washing facilities must be available and easily accessible in all patient areas, treatment rooms, sluices and kitchens. Basins in clinical areas should have elbow or wrist lever operated mixer taps or automated controls and be provided with liquid soap dispensers, paper hand towels and foot-operated waste bins (NHS Estates, 2002). Alcohol hand gel must also be available at "point of care" in all primary and secondary care settings (National Patient Safety Agency (2004).
All health care workers should bring any lack of, or inappropriately placed facilities to the notice of their managers (or matron). They also have a duty of care to patients and themselves and must use facilities provided to prevent cross infection.
Hand drying:Improper drying can re-contaminate hands that have been washed. Wet surfaces transfer organisms more effectively than dry ones and inadequately dried hands are prone to skin damage. Disposable paper hand towels of good quality should be used to ensure hands are dried thoroughly. Hand towels should be conveniently placed in wall mounted dispensers close to hand washing facilities.
Handwashing History
by Christine L. Case, Ed.D
During the 19th century, women in childbirth were dying at alarming rates in Europe and the United States. Up to 25% of women who delivered their babies in hospitals died from childbed fever (puerperal sepsis), later found to be caused by Streptococcus pyogenes bacteria.
As early as 1843, Dr. Oliver Wendell Holmes advocated handwashing to prevent childbed fever. Holmes was horrified by the prevalence in American hospitals of the fever, which he believed to be an infectious disease passed to pregnant women by the hands of doctors. He recommended that a physician finding two cases of the disease in his practice within a short time should remove himself from obstetrical duty for a month. Holmes's ideas were greeted with disdain by many physicians of his time.
In the late 1840's, Dr. Ignaz Semmelweis was an assistant in the maternity wards of a Vienna hospital. There he observed that the mortality rate in a delivery room staffed by medical students was up to three times higher than in a second delivery room staffed by midwives. In fact, women were terrified of the room staffed by the medical students. Semmelweis observed that the students were coming straight from their lessons in the autopsy room to the delivery room. He postulated that the students might be carrying the infection from their dissections to birthing mothers. He ordered doctors and medical students to wash their hands with a chlorinated solution before examining women in labor. The mortality rate in his maternity wards eventually dropped to less than one percent.
Despite the remarkable results, Semmelweis's colleagues greeted his findings with hostility. He eventually resigned his position. Later, he had similar dramatic results with handwashing in another maternity clinic, but to no avail. Ironically Semmelweis died in 1865 of puerperal sepsis, with his views still largely ridiculed.
Perhaps handwashing seemed odd at the time. The lack of indoor plumbing made it difficult to get water. In order to make the water comfortably warm, it would have to be heated over a fire. Besides, contact with water was associated with diseases such as malaria and typhoid fever. It is difficult perhaps in our current day to imagine physicians being so resistant to what we now consider common practice. But the resistance continued.
In the 1870's in France, one hospital was called the House of Crime because of the alarming number of new mothers dying of childbed fever within its confines. In 1879, at a seminar at the Academy of Medicine in Paris, a noted speaker stood at the podium and cast doubt on the spread of disease through the hands. An outraged member of the audience felt compelled to protest. He shouted at the speaker: "The thing that kills women with [childbirth fever]... is you doctors that carry deadly microbes from sick women to healthy ones." That man was Louis Pasteur. Pasteur, of course, contributed to the germ theory of disease (whereas the founder to this theory was Robert Koch). He was a tireless advocate of hygiene, but his efforts too were initially met with skepticism. Skepticism, however, was not the only problem facing advocates of hygiene.
In 1910, Josephine Baker, M.D. started a program to teach hygiene to child care providers in New York. Thirty physicians sent a petition to the Mayor protesting that "it was ruining medical practice by...keeping babies well."
How Far Have We Come?
Despite its rocky beginnings, handwashing has become a part of our culture. Handwashing and other hygienic practices are taught at every level of school, advocated in the work place, and emphasized during medical training. According to the United States Centers of Disease Control and Prevention (CDC), "Handwashing is the single most important means of preventing the spread of infection." Yet, recent studies and reports indicate that lack of or improper handwashing still contributes significantly to disease transmission. While we are all potentially at risk of contracting hand-transmitted illnesses, one-third of our population is especially vulnerable, including pregnant women, children, old people, and those with weakened immune systems.
It seems reasonable to assume that hospitals have come closest to responding to this problem. Modern surgery, after all, has long since solved many of the early problems of infection. However, fundamental problems of hygiene still exist. In 1992, The New England Journal of Medicine reported on a handwashing study in an intensive-care unit. Despite special education and monitored observation, handwashing rates were as low as 30% and never went above 48%!
Nosocomial infections are infections acquired by patients while they are in the hospital, unrelated to the condition for which the patients were hospitalized. The Centers for Disease Control and Prevention estimates that from 5% to 15% of all hospital patients acquire some type of nosocomial infection. Hospital personnel can also become infected. In 1993, 11 health-care workers became ill with hepatitis A because they didn't wash their hands after treating one of two patients with hepatitis A.
The rate of nosocomial infections can be reduced by full-scale infection control programs whose expense would be recovered by the reduction of the cost involved in treating the nosocomial infections. But, as The New England Journal of Medicine report reminds us, one of the most effective, simple, and yet difficult to implement solutions would be for all hospital personnel to wash their hands between every patient!
Hospitals are not the only places in which handwashing is important. A recent study in Infectious Diseases in Children states: "In spite of all the studies about the benefits of handwashing, improper or infrequent handwashing continues to be a major factor in the spread of disease in day-care." Each year, children in daycare centers, elderly in convalescent homes, and contact lens wearers acquire infections transported on hands. Cleanliness in the food-service industry has long been of concern with regard to transmission of foodborne illness. During the last nine years, the popularity of iguanas and other reptiles has resulted in a startling increase in the incidence of salmonella infections.
Salmonella: A Case Study in the Need for Improvement
Salmonella sp. is a rod-shaped bacteria with over a thousand strains capable of causing infection (salmonellosis). Salmonella is easily transferred among humans and animals by both direct and indirect contact. The great increase in mass production of certain food products, including poultry and eggs, has resulted in a large increase in salmonella infections. In uncooked, room-temperature food, Salmonella multiplies at an alarming rate. In addition to other strict hygiene practices when handling uncooked poultry and raw eggs, scrupulous handwashing is necessary, using hot and soapy water. In the 1970s, many of us may remember having baby turtles. Researchers discovered a disturbing problem, however. A quarter million children contracted salmonellosis from their tiny pets. Legislation was quickly enacted regulating the sale of pet turtles. In recent years, the increasing popularity of reptile pets, particularly green iguanas, has brought the Salmonella issue back in the news.
The Centers for Disease Control and Prevention (CDC) has reported an alarming number of cases of unusual strains of Salmonella causing infections in both adults and children. These strains seem to be associated with reptiles. The infections have been contracted by both direct and indirect contact. Once again, pet owners are being precautioned to take adequate measures when handling their pets, including proper handwashing.
Conclusion
In 1996, the lack of handwashing is surprising. We have hot running water and the benefits of many antimicrobial soaps to prevent infections. In the food-service industry, studies indicate that inadequate handwashing and cross-contamination is responsible for as much as 40% of foodborne illnesses, including Salmonella. It is estimated that there are over 80 million cases of food poisoning in the United States each year, resulting in greatly increased health care costs, loss of job productivity, and as many as 10,000 deaths per year. About 20,000 people die from nosocomial infections each year, due primarily to the lack of infection control programs. $500 million would be saved if just 17% of the nosocomial infections were prevented. This money could be used for such things as cancer or AIDS research. What a simple act, handwashing, with such remarkable benefits if it were to be practiced properly.
Handwashing Links
Washing Hands Quiz
CDC: An ounce of Prevention Keeps the Germs Away
CDC: Why is Handwashing Important
MoonDragon's Standard Precautions- Infection Control
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