A coalition of epidemiology and infection control groups, including the Centers for Disease Control and Prevention (CDC, have issued a comprehensive update of hand hygiene recommendations that emphasizes care of hands and fingernails.
“Promote the maintenance of healthy hand skin and fingernails,” the guidelines state.1 “Include fingernail care in facility-specific policies related to hand hygiene. Healthcare personnel (HCP) should maintain short natural fingernails, not extending past the fingertip. HCP who work in high-risk areas (intensive care unit, perioperative) should not wear artificial fingernail extenders.”
With skin concerns a known risk factor for noncompliance, the guidelines recommend making hand lotion easily available and taking measures to prevent dermatitis, including providing cotton glove liners to reduce irritation.
Although the lead author is the CDC, the recommendations are published in Infection Control & Hospital Epidemiology, the journal of the Society for Healthcare Epidemiology of America (SHEA). Also credited in the collaboration are the Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), the American Hospital Association (AHA), and the Joint Commission. The document updates a similar 2014 compendium.
Successful hand hygiene programs require several structural components and leadership support, the authors emphasize. Critically, infection preventionists must have the training and resources to direct the program. An adequate number of personnel for observations is needed for programs that go this route, and there must be support for data analysis to facilitate feedback.
Key Recommendations
In addition to those mentioned earlier, other key recommendations include:
• Perform hand hygiene consistent with the CDC recommendation or the World Health Organization Five Moments.
• Promote the preferential use alcohol-based hand sanitizers (ABHS) in most clinical situations.
• Policies regarding the use of fingernail polish and gel shellac are at the discretion of the infection prevention program, except among HCP who scrub for surgical procedures, for whom fingernail polish and gel shellac should be prohibited.
• ABHS dispensers should be placed in plain sight within the workflow of HCP.
• Facilities that are seeking ABHS with ingredients that may enhance efficacy against organisms anticipated to be less susceptible to biocides should consider manufacturers’ product-specific data.
To the third point, there are problem pathogens that resist removal from the hands and the environment. These include Clostridium difficile, norovirus, and Candida auris. The compendium document recommends washing hands with soap and water during outbreaks of C. difficile and norovirus but specifies that ABHS should not be prohibited in these instances.
“A study examining germicidal activity of hand-sanitizing preparations against C. auris demonstrated that a 70% ethanol-based hand sanitizer resulted in a 4-log reduction,” the authors state.2 “Surgical hand scrubs containing chlorhexidine resulted in < 2.0 log reduction and were less efficacious when alcohol was not included in the formulation.”
Glove Use
“HCP should receive competency-based training to ensure knowledge and skill in avoiding contamination during doffing,” the guidelines state. “Routine double-gloving is not recommended, except when specifically recommended for certain job roles or in response to certain high-consequence pathogens.”
Indiscriminate glove use or failure to change gloves at the appropriate intervals can lead to environmental contamination. “In an observational study, the patient care items most frequently touched by soiled gloves included disinfectant wipes or packaging of patient-care items, patient skin, patient clothing, and durable medical equipment,” the authors note.3
Other recommendations regarding glove use include:
• Use gloves for all contact with the patient and environment as indicated by standard and contact precautions during care of individuals with organisms confirmed to be less susceptible to biocides (e.g., C. difficile or norovirus).
• HCP caring for preterm neonate with central lines should perform hand hygiene before donning nonsterile gloves prior to patient and vascular device contact.
• Educate HCP about the potential for self-contamination and environmental contamination when gloves are worn. Whenever hand hygiene is indicated during episodes of care, HCP should doff gloves and perform hand hygiene.
• Clean hands immediately following glove removal. If handwashing is indicated and sinks are not immediately available, use ABHS and then wash hands as soon as possible.
• Educate and confirm the ability of HCP to doff gloves in a manner that avoids contamination. Consider using fluorescent indicators applied to gloves during demonstrations of doffing to help HCP visualize how contamination may occur.
Why Is Compliance So Difficult?
Hand hygiene has long been a bedrock principal of infection prevention, yet it is honored as much in the breach as in the observance. Shot-staffed healthcare teams may forget to wash their hands before a patient encounter and, just like that, a multidrug-resistant pathogen from a prior patient is on the bedrail of the next one.
“Hand hygiene has long been a foundational component of infection prevention in all healthcare settings,” the guidelines state. “However, adherence by HCP to hand hygiene protocols has been an ongoing challenge, complicated by the lack of a national standard for measurement and increasingly complex care environments.”
With the disruptions of the pandemic and the continuing rise of drug-resistant organisms, hand hygiene is probably as important as it has ever been. Yet there always has been a struggle for compliance, and the guidelines cite the pros and cons of various methods to track hand hygiene.
These include direct observation, covert observation, remote video observation, measuring product use, and conducting audits of the accessibility and functionality of equipment and supplies. All have their strength and weaknesses. (See Table 1 at bit.ly/3jRzkof)
“The goal of measuring hand hygiene is to provide timely, meaningful, and actionable feedback to guide HCP improvement,” the authors state. “Routine measurement should be performed to establish a performance baseline, to support improvement efforts, and to identify barriers and facilitators of adherence.”
Feedback is most effective when it is tied to clear targets and action plans, provided by a supervisor or colleague, and given verbally and in writing.
“A facility that aimed to improve adherence among physicians provided regular reports to chiefs of service. Comparative rankings of service varied initially but rose to > 90% each month, with sustained improvement over a two-year period,” the guidelines state.4
- Glowicz JB, Landon E, Sickbert-Bennett EE, et al. SHEA/IDSA/APIC Practice Recommendation: Strategies to prevent healthcare-associated infections through hand hygiene: 2022 update. Infect Control Hosp Epidemiol 2023; Feb 8:1-22. doi:10.1017/ice.2022.304. [Online ahead of print].
- Fu L, Le T, Liu Z, et al. Different efficacies of common disinfection methods against Candida auris and other Candida species. J Infect Public Health 2020;13:730-736.
- Burdsall DP, Gardner SE, Cox T, et al. Exploring inappropriate certified nursing assistant glove use in long-term care. Am J Infect Control 2017;45:940-945.
- Reich JA, Goodstein ME, Callahan SE, et al. Physician report cards and rankings yield long-lasting hand hygiene compliance exceeding 90%. Crit Care 2015;19:292.
