GUIDELINE FIRST LOOK
Guideline for hand hygiene Carina Stanton, Contributing Editor
he updated AORN “Guideline for hand hygiene” will provide guidance for perioperative RNs and other team members on hand hygiene and surgical hand antisepsis.1 “Protecting our patients from health care-associated infections, including surgical site infection, is a priority for all perioperative providers,” said Amber Wood, MSN, RN, CNOR, CIC, AORN senior perioperative practice specialist and author of the guideline. “We know hand hygiene and surgical hand antisepsis, when practiced correctly and consistently, are effective and cost-efficient ways to prevent and control infections in the perioperative setting.” Last revised in 2009, the updated guideline offers new and revised recommendations for evidencebased practices for skin and fingernail maintenance, hand hygiene, skin antisepsis, and patient education. To prevent the transmission of transient and resident microorganisms from the hands of perioperative team members to the patient and the environment, team members must know the appropriate indications and processes for hand hygiene. The guideline includes new, detailed examples of effective hand hygiene and skin antisepsis practices to support implementation.
Fingernail and skin maintenance All perioperative team members should maintain healthy fingernail and skin condition to perform hand hygiene.1 Fingernail tip length should be no more than 0.08 inch (two millimeters)— shorter than the 0.25-inch length previously recommended—to reduce the risk of harboring potential pathogens under fingernails, puncturing gloves, or injuring patients during patient handling. In a 2011 observational study, researchers found that fingernails longer than two millimeters were significantly associated with the prevalence of Staphylococcus aureus.2 Regarding nail polish, a multidisciplinary perioperative team at each facility should determine whether fingernail polish, including ultraviolet-cured polish, may be worn in the perioperative setting. http://dx.doi.org/10.1016/S0001-2092(16)30302-7
P10 | Periop Briefing
Perioperative team members should also take measures to prevent hand dermatitis and eczema. Personnel with these skin conditions are less likely to perform hand hygiene, and damage to the skin may change skin flora, resulting in more frequent colonization by disease-causing bacteria.3 Hot water for hand washing can irritate the skin and may lead to dermatitis or bacterial colonization.3,4 Water temperature for hand hygiene should be controlled between 70° F and 80° F (21.1° C and 26.6° C).5
Hand hygiene and surgical antisepsis indications Perioperative team members should perform hand hygiene before and after specific tasks to limit the spread of infection-causing agents.1 Perioperative personnel should perform hand hygiene • before and after patient contact (e.g., performing a physical examination, marking the surgical site, transferring or positioning the patient); • before performing a clean or sterile task, such as inserting an invasive device or moving from a contaminated body site (e.g., perineum) to a clean body site (e.g., face) on the same patient; • after risk for blood or body fluid exposure, which may occur while counting used sponges, handling specimens or drains, or removing surgical drapes; • after contact with patient surroundings (e.g., patient bed and linens, OR bed controls, the floor, items that touched the floor); • before and after assembling items for sterilization; and • when hands are visibly dirty or soiled.1 Perioperative team members can perform a single act of hand hygiene to fulfill multiple indications sequentially. “Try to organize your tasks from clean to dirty, such as performing hand hygiene and then opening all sterile items and preparing sterile medications to the sterile field, then your hands are still clean for performing skin antisepsis,” Wood said. Surgical hand antisepsis should be performed before donning sterile gowns and gloves for
operative and other invasive procedures.1 Surgical hand antisepsis using a surgical hand rub should be performed according to the manufacturer’s instructions for use. According to the guideline, having alcohol-based hand rub available at the patient’s bedside and other convenient locations, including individual containers carried by health care workers, can promote hand hygiene adherence among personnel who care for a high volume of patients.3 Dispenser placement and storage of flammable alcohol-based hand hygiene products must be in compliance with local, state, and federal regulations. Alcohol-based hand hygiene product dispensers should • be at least four feet apart; • hold a maximum of 1.2 liters in rooms, corridors, and areas open to corridors; • not be placed above an ignition source (e.g., electrical outlet, switch) or within one inch of the ignition source; and • not total more than 37.8 liters (10 gallons) outside of a storage cabinet in a single smoke compartment (i.e., an area separated by smoke barriers).5
Patient education Patients and visitors should be encouraged to remind health care personnel to perform hand hygiene before care.1 The guideline encourages this patient and provider interaction, citing a global survey of patient experiences with hand hygiene.3 In this survey, 29 percent of respondents (i.e., patients) asked health care personnel to wash their hands, and 25 percent of these patients reported receiving a negative response to the request.3 According to the survey, patients were more comfortable reminding personnel to wash their hands when encouraged to provide reminders. This patient engagement should be structured within a health care facility’s hand hygiene strategy to encourage ownership and shared responsibility of practices that support positive patient outcomes.3
Quality improvement Team members should identify barriers for performing hand hygiene in the perioperative setting and implement interventions to improve hand hygiene compliance.1 “These barriers could include deficiencies in staff education, cultural factors negatively impacting accountability and speaking up, as well as environment-of-care factors such as the placement and function of hand washing stations or access to alcohol-based hand rubs,” Wood said. “Evaluate unit-specific and more widespread cultural barriers before any new policies
The guideline also supports recommended steps from the American Association of Nurse Anesthetists for the anesthesia professional to wear two pairs of gloves (a sterile glove beneath an outer exam glove), so they may remove the contaminated outer gloves after airway manipulation and continue patient care until the patient’s status allows for removal of the inner gloves and performance of hand hygiene.6 Wood said this twoglove approach is different from perioperative nurses donning two sterile gloves (i.e., double gloving) during intraoperative care; however, wearing gloves does not replace the need to perform hand hygiene because of the risk of glove failure. Wood said perioperative leaders should collaborate with anesthesia professionals to shape policies and When performing hand hygiene, perioperative personnel procedures that set clear parameters should wash or apply sanitizer between all fingers and around the base of for practices such as donning sterile the thumb. gloves beneath outer exam gloves.
© AORN, Inc, 2016
July 2016 Vol 104 No 1 • Periop Briefing | P11
are implemented in order to develop relevant interventions to improve hand hygiene compliance.”
Conclusion Perioperative RNs and other team members need to follow safe personal practices to reduce the risk of transmitting infectious microorganisms to patients. “Hand hygiene compliance can be a challenge because it’s largely a matter of behavior,” Wood said. “Perioperative RNs need to ask themselves if they are modeling correct hand hygiene behaviors and holding every colleague, including leaders, accountable to model good behavior.” Frontline staff members can provide valuable insights into cultural barriers to guide quality improvement efforts. Successful implementation of evidencebased practices for hand hygiene and surgical hand antisepsis promote patient and personnel safety and reduce the risk of infections. References 1. Guideline for hand hygiene. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017. In press.
P12 | Periop Briefing
2. Fagernes M, Lingaas E. Factors interfering with the microflora on hands: a regression analysis of samples from 465 healthcare workers. J Adv Nurs. 2011;67(2):297-307. 3. WHO guidelines on hand hygiene in health care. World Health Organization. http://apps.who.int/ iris/bitstream/10665/44102/1/9789241597906_ eng.pdf. Published 2009. Accessed June 6, 2016. 4. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/ APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Recomm Rep. 2002;51(RR-16):1-45. 5. Facility Guidelines Institute. Guidelines for design and construction of hospitals and outpatient facilities. Chicago, IL: American Society for Healthcare Engineering; 2014. 6. Infection Prevention and Control Guidelines for Anesthesia Care. American Association of Nurse Anesthetists. http://www.aana.com/resources2/ professionalpractice/Pages/Infection-Preventionand-Control-Guidelines-for-Anesthesia-Care. aspx. Published February 2015. Accessed June 6, 2016.