The 5 Stages Of Hand Hygiene

So, with more information than ever available on the positive impact of proper hand hygiene within healthcare environments, understanding the correct procedures for washing and cleaning your hands at every stage of patient care is vital. A Michigan based study found the hands of healthcare workers were regularly contaminated with Gram-negative bacteria (66%), Candida spp. (41%), Staphylococcus aureus (20%), and cancomycin-resistant enterococci (9%). With such a high level of infection spreading throughout healthcare facilities such as care homes, it is important to understand what is meant by proper hand hygiene and how best to implement it within your workplace.

Hand hygiene is recognised as the process of cleaning one's hands with either soap and water or an alcohol-based handrub (ABHR). These rubs have been recommended worldwide for use since 2006 and vastly reduce the amount of time needed to eliminate the risk of cross infection. The European Standard EN1500 states that the efficacy of hand antisepsis (an extension of hand washing using an antiseptic product) is achieved by rubbing hands with an ABHS for 20-30 seconds as opposed to the 40-60 seconds required for soap and water. This information can also be found in Pier C, Soule H. Bellissimo-Rodrigues E, at al.Hand hygiene with alcohol-based handrubs: how long is long enough? ICHE (in press), which states that 30 seconds of rubbing is usually sufficient.

The most popular diagram for illustrating proper hand hygiene methods has been produced by the World Health Organisation in 2009 and is entitled 'Guidelines on Hand Hygiene in Health Care” - see image below. This image sets out the 7 individual stages required to successfully bring your hands back to optimal cleanliness when working in a patient care environment.

The image below has been published by the World Health Organization to visually show the correct procedure for appropriate hand rubbing:

Download the pdf here - Image reposted from WHO Guidelines on Hand Hygiene in Health Care, 2009 http://www.who.int/gpsc/5may/resources/posters/en/

Put simply, the following instructions apply when using the hand rubbing technique:

1. Apply a palmful of product in a cupped hand and cover all surfaces
2. Rub hands palm to palm
3. Place your right palm over your left dorsum with interlaced fingers, curl fingers and then repeat on the other side
4. Place both palms together and interlace your fingers
5. Place the back of your fingers to opposing palms with fingers interlocked
6. Perform a rotation rubbing using your left thumb while clasping your right thumb in your left hand. Repeat on the other side.
7. Perform a rotational rubbing on the inside of your left palm with the clasped fingers of your right hand. Repeat on the other side
8. Allow your hands to dry for best results.

The image below has been published by the World Health Organization to visually show the correct procedure for appropriate hand washing:

Download the pdf here - Image reposted from WHO Guidelines on Hand Hygiene in Health Care, 2009 http://www.who.int/gpsc/5may/resources/posters/en/

The following instructions apply when using water and soap (when hands are soiled or this is the main method available):

1. Wet your hands with sterile water
2. Apply enough soap to cover all surfaces
3. Rub your hands' palm to palm
4. Place your right palm over your left dorsum with interlaced fingers, curl fingers and then repeat on the other side
5. Place both palms together and interlace your fingers
6. Place the back of your fingers to opposing palms with fingers interlocked
7. Perform a rotation rubbing using your left thumb while clasping your right thumb in your left hand. Repeat on the other side.
8. Perform a rotational rubbing on the inside of your left palm with the clasped fingers of your right hand. Repeat on the other side
9. Rinse your hand with sterile water
10. Dry each hand thoroughly with a single use towel
11. Use said towel to turn off the faucet or tap

It is important to note that 'enough product to cover all surfaces' has been defined by the WHO as a palmful or more specifically, between 2 and 3ml of product.

Which products to use?

The choice between alcohol-based hand rubs or soap and water is one that can be defined according to each individual scenario. Should your hands become visibly soiled in any way, soap and water is the most efficient tool for removing and sanitising your hands appropriately during patient care. Where infection and cross-contamination are involved, alcohol-based hand rubs have been proven more popular for their ability to reduce the risk of irritation, taking less time to dry into the skin and being more conveniently placed than traditional sinks. Therefore, it is worth taking note of the dispenser locations within each patient’s room upon arrival and ensuring you have direct access at every point of care.

While we discuss best practices, we must also look at the optimal times to perform hand hygiene procedures. Where it was once considered common practice to simply ensure your hands were cleaned after each patient visit, research such as the 'Systematic review of studies on compliance with hand hygiene guidelines in hospital care<' published in 2010 by Erasmus V, Daha TJ, Brug H et al. has found that hand hygiene was found to be poorer before patient contact than after. Remembering that your hands are the main transportation for infection, keep in mind that cross-contamination can also occur before and during care from contaminated surfaces as well as from your patient.

the World Health Organisation to highlight each of the five moments where hand hygiene should occur during the care of a patient:

download the pdf here - Image reposted from WHO Guidelines on Hand Hygiene in Health Care, 2009 http://www.who.int/gpsc/5may/resources/posters/en/

This research states that the five moments for hand hygiene are as follows:

1. Before touching a patient

2. Before clean/aseptic procedures

3. After body fluid exposure risk

4. After touching a patient

5. After touching a patient's surroundings

Take a moment to consider the common steps you take to keep your hands sanitised and sterile during a normal day at work. Do they correlate with the information provided here that would ensure your care is at its peak? Remember, that hand hygiene is defined as 20-30 seconds of accurate hand rubbing (when hands are not soiled) and 40-60 seconds of hand washing with water and soap (when hands are visibly soiled).

Simply introducing these steps in your everyday care could see a significant reduction in the spread of infection throughout your care home as well as providing your patients with the confidence that their care is at the height of importance.

In our next blog post, we take a look at the products available on the market that contribute to the maintenance of good hand hygiene in your work environment including alcohol-based hand rubs, dispensers and antibacterial hand soaps.