Skill List > Hand Washing
Clinical Alert
Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Based on Nicol: Essential Nursing Skills 4E
Adapted by: Professor Maggie Nicol BSc(Hons) MSc(Nursing) PGDipEd RN
Updated by: Janet Hunter MA BSc(Hons) PGCE RN; Karen Rawlings-Anderson BA(Hons) MSc DipNEd RN
Last updated: August 2017
Figure 1 Hand-washing techniques. (From Brooker C, Nicol M (eds) Alexander’s Nursing Practice, 4th edn. Churchill Livingstone Elsevier, Edinburgh.)
Learning Objective
After reading the skill overview, watching the video, following up some of the references/web sites and completing the self-test quiz you should be ready to be assessed in practice in the skill of hand washing to prevent infection.

Introduction

People’s hands are considered to be the most common way in which micro-organisms are transported. Two important principles in infection prevention and control are standard precautions and aseptic non-touch technique (ANTT) (see below). Hand hygiene is fundamental to both, even if gloves have been worn.

The infection process

The terms ‘infection process’, ‘cycle of infection’, and ‘chain of infection’ are often used to describe the circumstances that can lead to patients or others developing a healthcare associated infection (HCAI) or any infectious disease. The rationale for applying infection prevention measures is based on this chain of events. It is crucial to understand how micro-organisms spread and infection occurs (Prieto & Kilpatrick 2011).

The infection process involves (Prieto & Kilpatrick 2011):

  • The presence of an infectious agent, i.e., micro-organisms that are capable of causing infection.
  • A reservoir or source where micro-organisms can be found. Within healthcare settings, this includes people (i.e., patients, staff, visitors) and also the environment (e.g., dust, bedding, equipment, furniture, sinks, washbowls, bedpans, surfaces).
  • The potential for micro-organisms to be transmitted from sources. This is often called a ‘portal of exit’ and is the means by which micro-organisms are expelled from the body, such as exhalation, aerosolisation (when liquid droplets are dispersed into the air, e.g., when coughing or sneezing), secretion, and excretion.
  • A means or route of transmission of micro-organisms, categorised as contact, droplet, airborne, blood borne, food and water borne (a common vehicle), and vector borne.
  • The potential for micro-organisms to enter the body through a susceptible site. This is often called a ‘portal of entry’ and includes a breach in skin integrity such as a wound or open skin lesion, mucous membranes, ingestion, and any breach in normal immune defences, commonly through a variety of invasive devices (e.g., vascular access devices, urinary catheters, respiratory devices).
  • A susceptible host: anyone who, for whatever reason, is at risk of infection by micro-organisms, including those that would not normally cause them harm. Factors that affect the body’s natural ability to fight infection include:
  • the presence of underlying disease (e.g., diabetes mellitus)
  • being immunocompromised (e.g., HIV, chemotherapy treatment)
  • poor nutritional status
  • extremes of age, i.e., the very young and the very old.

(Prieto & Kilpatrick 2011)


The principles relating to all infection prevention measures are based on the interruption of this process. If these measures are not taken, a cycle will continue whereby patients, and possibly staff and others, may be exposed to potentially pathogenic (disease-causing) micro-organisms that can cause harm.

Standard precautions

Standard precautions are the standard infection control precautions that are essential in preventing cross-infection (Loveday et al. 2014). These standard precautions must be applied by all healthcare professionals when caring for all patients, irrespective of age, condition or setting. Loveday et al. (2014) stipulate that these can be divided into 5 key principles which are:
  
  • Hand hygiene (Box 1).
  • Use of personal protective equipment (PPE)
  • Safe use and disposal of sharps.
  • Principles of asepsis (e.g. management of invasive devices; wound care; administration of medication).
  • Hospital environmental hygiene ( e.g. safe disposal of waste; safe handling of contaminated linen; appropriate decontamination of equipment and a clean safe environment).

Box 1 Indications for hand hygiene. (Loveday et al. 2014)

  • Immediately before each episode of direct patient contact or care, including clean/aseptic procedures 
  • Immediately after each episode of direct patient contact or care
  • Immediately after contact with body fluids, mucous membranes and non-intact skin
  • Immediately after other activities or contact with objects and equipment in the immediate patient environment that may result in the hands becoming contaminated
  • Immediately after the removal of gloves

Aseptic non-touch technique (ANTT)

ANTT is based on the principles of maintaining asepsis and identifying key parts and key sites that must be protected from contamination. This aims to reduce the risk of micro-organisms entering the body. 

Asepsis refers to the absence of potentially pathogenic microorganisms. Aseptic technique is a precisely controlled method which aims to prevent contamination by microorganisms when carrying out any invasive procedure when the body’s natural defenses have been bypassed, for example, wound care, cannulation, or venepuncture (Loveday et al. 2014).

Aseptic non-touch technique (ANTT) requires healthcare professionals to maintain asepsis by identifying the ‘key parts’ of  devices or equipment that come into contact with a susceptible site on the patient’s body during clinical procedures. Key parts are the parts of equipment (e.g., the tip of a needle, or the sterile inside surface of a dressing) that if contaminated by pathogenic organisms increase the risk of infection. ANTT means avoiding (either directly or indirectly) touching the key parts of the equipment used (Loveday et al. 2014).

A ‘key site’ is any wound or insertion site where the body’s defenses are bypassed. 

It is important to assess the risk of contamination before carrying out the aseptic technique, as the measures taken will depend on the procedure being undertaken. For example, some procedures will require sterile gloves, sterile dressing pack, sterile towel and dressing (e.g., wound care); others may only need sterile equipment and nonsterile gloves (e.g. venepuncture); both will require non-touch methods.
There are a number of considerations for the use of ANTT in general , but you must follow appropriate guidelines for specific skills such as aseptic dressing technique and intramuscular injection. General considerations are:

  • Explain all procedures to the patient to gain cooperation and consent.
  • Always use sterile equipment when carrying out procedures where there is a risk of contamination (e.g., sterile dressing pack, intravenous cannula, syringe, needle). 
  • Only handle the part of the equipment that is not in contact with the patient or other medical equipment (e.g. only touch the barrel and plunger of a syringe, do not touch the nozzle.).
  • Provide an aseptic field for sterile equipment e.g. dressing towel or sheet. Never place sterile equipment onto a non-sterile surface e.g. an opened sterile dressing should not be placed on a patient’s locker.
  • Contamination will occur if you touch the outside of a sterile glove with a non-gloved hand.
  • Appropriate choice of hand hygiene to include hand washing and the use of alcohol hand rub must be undertaken prior to any direct patient contact.
  • The environment should be clean.

Preparation and safety

  • Hand hygiene should be performed before and after all patient contact (Box 1). The use of alcohol hand rub does not mechanically remove organic material and so is unsuitable for cleansing visibly soiled hands (Loveday et al. 2014).
  • Standard precautions are the standard infection control precautions that are essential in preventing cross-infection (Loveday et al. 2014). They include the precautions required when contact with body fluids is likely. These precautions are (Loveday et al. 2014):
  • cover all cuts, abrasions and lesions, especially those on the hands and forearms, with a waterproof dressing
  • maintain hand hygiene (hand washing or use of alcohol-based hand rub) before and after each patient contact
  • maintain cleanliness of the environment
  • use disposable gloves and aprons when handling body fluids
  • use disposable aprons for direct patient care, bed making, and aseptic techniques
  • dispose of waste safely
  • avoid overcrowding patients
  • avoid unnecessary transfer of patients between wards
  • isolate patients with a known or suspected infection.
  • A sink with elbow- or foot-operated mixer taps is best. If this type is not available, leave the water running until after drying your hands and then use a paper towel to turn off the taps.
  • Hand cleansing agent. Liquid/foam soap is usually sufficient for hand washing in most situations, but an antiseptic detergent hand-washing solution containing chlorhexidine or iodine may be required before procedures. Local infection control policies will indicate when this is necessary.
  • Bars of soap should never be used in clinical areas as they provide the ideal environment for growth of micro-organisms when left sitting on the sink in a pool of water.
  • Disposable paper hand towels.
  • Foot-operated waste bins. In some institutions, hand towels are considered to be clinical waste and so should be discarded in the clinical waste bag. In others, they are deemed to be household waste and so should be discarded in the black non-clinical waste bag. Check your local policy.
  • Remove rings, jewellery, and wristwatches. Local policy may permit the wearing of a wedding ring. This should be a plain band and loose enough to allow washing and drying underneath it. Wrist watches and bracelets/wristbands must not be worn, as they prevent effective washing of the wrist area, and arms should be uncovered below the elbow.
  • Cover cuts or abrasions on the hands with a waterproof, occlusive dressing.
  • The fingernails should be short and no nail polish or artificial nails should be worn (Health Protection Scotland 2015).
  • Alcohol hand rub may be used instead of washing when the hands are socially clean. The alcohol must be applied to all areas and the hands then rubbed vigorously until dry. Alcohol effectively reduces microbial counts in clean hands, but it is ineffective if used on hands contaminated with body fluids or excreta as it does not mechanically remove organic material (Loveday et al. 2014).
  • Alcohol hand rub alone is not effective against Clostridium difficile spores and should be used in addition to, not instead of, hand washing if Clostridium difficile is present (Health Protection Scotland 2015, Loveday et al. 2014).

Procedure

  1. Adjust the taps so that the water temperature is comfortable and the water flow is steady and you do not splash the surrounding area. Wet both hands.
    Rationale – Set the water temperature so that you do not have to touch the taps after commencing hand washing. Wetting the hands before applying hand cleansing agent creates a better lather and minimises the risk of skin irritation.
  2. Apply sufficient hand cleansing agent to create a good lather.
    Rationale – A good lather is required to ensure contact with all areas of the hands (see step 3).
  3. Rub the hands briskly together making sure that the backs of the hands, between the fingers, the palms, the fingernails and fingertips, the thumbs, and the wrists are thoroughly washed. This should take at least 15-20 s (Loveday et al. 2014, WHO 2009).
    Rationale – The entire procedure should take 40–60 s (WHO 2009). Many research studies have shown that hand-washing techniques are not always effective. Areas of the hands that are commonly missed are the thumbs, fingernails, fingertips, palms, backs of the hands and the wrists. Scrubbing the skin with a brush is not recommended, as it causes micro abrasions. Only if the fingernails are visibly dirty should a nailbrush be used.
  4. Rinse hand and wrists thoroughly until all traces of the cleansing agent are removed.
    Rationale – Thorough rinsing reduces the risk of skin irritation, especially when using antiseptic soap solutions.
  5. Turn off the taps with your elbow and allow the water to run off with your hands pointing upwards.
    Rationale – Using your elbows avoids touching the ‘dirty’ taps with your clean hands. Keeping the hands pointing upwards means that water from the unwashed arms will not run down over your clean hands.
  6. Dry your hands, using disposable paper towels, working from your fingertips towards the wrists.
    Rationale – Thorough drying is essential to minimise the growth of micro-organisms and more organisms are probably removed by the paper towel. Thorough drying also prevents the hands becoming sore.
  7. Use a foot-operated bin to discard the used paper towels according to local policy.
    Rationale – It is important not to contaminate your hands by touching the bin with your clean hands. Some organisations treat used hand towels as clinical waste (orange bin) whereas others require them to be discarded into the household waste (black bin). Check your local policy.

Ongoing care, monitoring and support

  • Research has shown that some healthcare staff do not wash their hands at all after contact with patients, even after dirty procedures, and commonly believe that they wash their hands far more frequently than they do (Loveday et al. 2014).
  • Frequent hand washing, especially with antiseptic soap solutions, depletes skin lipids and damages the skin barrier. Regular use of hand cream may help prevent skin damage but communal use creams should be avoided as they may become a potential source of infection (Health Protection Scotland 2015).

Documentation and reporting

  • Hand hygiene practices are not usually documented.
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