Hand Hygiene in the Home Setting: Technique Matters

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The importance of performing hand hygiene is constantly reinforced by home care and hospice management, from the time of initial orientation to supervisory visits and ongoing competence assessment activities. Over the years, home care and hospice clinicians' compliance with hand-hygiene activities has improved, but there are still areas for improvement. This column will focus on hand-hygiene technique and how it can be improved.
Hand washing technique is most commonly taught based on the Centers for Disease Control and Prevention's (CDC) hand-hygiene guidelines to include:
If using an alcohol-based hand rub product, the CDC's hand-hygiene guidelines instructions include:
When washing the hands with soap and water, it is important to note the CDC's hand-hygiene guidelines recommend vigorous hand rubbing for at least 15 seconds. Home care and hospice clinicians often perform this important step in a much shorter period of time. Hand hygiene can be continued to 20 seconds or beyond, but minimally should be 15 seconds. The term “vigorous” is also important as it is through this activity that the transient microorganisms present on the hands (that can contribute to a home care-onset healthcare-associated infection) are lifted and then removed during hand rinsing under the water and hand drying. When performing hand hygiene using an alcohol-based hand rub product, if the hands are dry in less than 20 seconds, a sufficient quantity may not have been applied to the hands, and it is during this time that the alcohol is killing the microorganisms (not spores) present on the skin. Performing hand hygiene using an alcohol-based hand sanitizer is the most effective way to reduce the number of microorganisms on the hands. It is also acceptable (and preferred) to use an alcohol-based hand rub product routinely for performing hand hygiene throughout the home visit except for when the hands are visibly soiled (CDC, 2002), or when the home care or hospice clinician is caring for a patient known or suspected to have a Clostridium difficile infection (McGoldrick, 2015).
One randomized controlled study compared the hand-hygiene technique recommended by the CDC with the hand-hygiene technique recommended by the World Health Organization (WHO) by observing physicians and nurses using an alcohol-based hand rub after delivering patient care. The researchers found the hand-hygiene technique recommended by the WHO to be microbiologically more effective for reducing the median bacterial count (3.28 CFU/mL to 2.58 CFU/mL) compared with the CDC's method (3.08 CFU/mL to 2.88 CFU/mL) on healthcare workers' hands. However, the study also identified that the WHO's hand-hygiene technique took 15% more time to complete (42.50 seconds vs. 35 seconds), and anecdotally only 65% of the healthcare workers completed the entire hand-hygiene process—despite having instructions on the technique in front of them and being directly observed (Reilly et al., 2016). One of the positive elements of the WHO's hand-hygiene technique is that it specifically includes the thumbs, fingertips, and between the fingers on the hands, which have been identified by Widmer and Dangel (2004) as the most often missed locations during hand hygiene.
Hand hygiene using the WHO's recommended technique is the same whether applying an alcohol-based hand rub or soap, and involves rubbing the hands together to include rotational hand rubbing on both hand palms and backs, and interlacing and interlocking the fingers to cover all surfaces (WHO, 2009). The WHO's hand-hygiene technique for both hand washing and using an alcohol-based hand rub can be viewed and downloaded from the WHO's website at http://www.who.int/gpsc/5may/resources/posters/en/.
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