Hand Hygiene (Home Health Care) - CE - Elsevier
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Hand Hygiene (Home Health Care) - CE
ALERT
Carry alcohol-based hand rubbing solutions, small containers of liquid soap, and
disposable paper towels to every home visit. Never use the patient’s personal bar or
liquid soap or cloth towels because these may be contaminated.
Avoid using water in homes with potentially contaminated water sources.
Wearing gloves does not replace the need to perform hand hygiene.
Avoid acrylic nails and excessive jewelry; these may retain infectious organisms.
OVERVIEW
Research indicates that for hand hygiene to be effective, it must be performed at the times
and places where transmission of organisms is most likely to occur—the point of care.5
Hand hygiene, properly performed at the appropriate point of care, is recognized as one
of the most effective ways to prevent the spread of infection. The Centers for Disease
Control and Prevention (CDC),1 the World Health Organization (WHO),7 and The Joint
Commission4 have embraced hand hygiene as a standard of practice and critical
component in infection control across health care settings, including the home setting.
Hand hygiene is a general term that refers to handwashing (with plain soap and water),
antiseptic handwashing (with soap containing an antiseptic agent and water), antiseptic
hand rubbing (rubbing an antiseptic agent, usually alcohol, on all surfaces of the hand), or
surgical hand antisepsis (washing or rubbing with an antiseptic agent preoperatively).1
The purpose of hand hygiene is to remove dirt, materials, and microbial organisms picked
up by contact with other people or the environment. Merely rinsing hands under water or
quickly rubbing them with alcohol is not sufficient to prevent the spread of infection.
Proper hand hygiene requires using the right agent for the circumstances (soap, water,
and a disposable towel, or an alcohol-based rub) and mechanical rubbing of all surfaces
for a sufficient length of time.8 Although both methods of hand decontamination are
effective if performed properly, a few smaller studies show rubbing with alcohol-based
agents keeps microorganisms from returning to the skin for a slightly longer time.8 The
key is to choose the right method for the right circumstance and to perform hand hygiene
correctly whenever it is indicated. Antimicrobial agents or plain soap and water should be
used in the following situations:7
• When hands are visibly dirty or soiled with blood or other body fluids
• After using the bathroom
• After exposure or suspected exposure to spore-forming pathogens (e.g., Clostridium
difficile)
When not contraindicated, alcohol-based products are considered the gold standard when
performing routine patient care because they reduce bacterial counts more effectively
than soap and water. An alcohol-based hand rub should be used for routinely
decontaminating hands in situations other than those previously listed.7
Copyright © 2020, Elsevier, Inc. All rights reserved. Page 1 of 6Hand Hygiene (Home Health Care) - CE
There is an increase in the number of bacteria colonized under jewelry such as rings
and watches. Long fingernails, artificial nails, and chipped nail polish also harbor
bacteria. Therefore, health care personnel should refrain from wearing rings and
other jewelry when providing care and should keep fingernails well-trimmed, natural
(no artificial nails or extenders), and polish free. If jewelry is worn, it must be
removed before performing hand hygiene.7
Regardless of the health care setting or the method used, hand hygiene is a requisite skill
that every health care professional must perform at key times. These include before and
after patient contact, after contact with blood or body fluids, after contact with
contaminated surfaces, and before donning and after removing gloves. In the home
setting, the patient and caregivers need to perform hand hygiene and ensure the home
health nurse does the same.2
EDUCATION
• Teach the patient, family, and caregivers proper hand hygiene techniques.
• Teach the patient, family, and caregivers the reason for hand hygiene.
• Teach the patient, family, and caregivers situations in which hand hygiene is
required.
• Provide developmentally and culturally appropriate education based on the desire
for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Educate the patient, family, and caregivers about the risks for infection with
improper hand hygiene.
• Teach the patient, family, and caregivers to ensure that the home health nurse
performs hand hygiene.
• Encourage questions and answer them as they arise.
PROCEDURE
1. Remove hand hygiene supplies from the outer pocket of the nursing bag.
2. Remove rings or other jewelry and place them in a secure area. Do not leave jewelry
on the patient’s sink, counters, or tables.
If rings are replaced after hand hygiene, perform hand hygiene
again.
3. Inspect all surfaces of the hands for breaks or cuts in the skin or cuticles.
4. Cover any skin lesions before providing patient care.
5. Push long sleeves up above the wrists.
Hand Hygiene Using a Waterless Alcohol-Based Antiseptic Rub
1. Dispense an ample amount of alcohol-based product into the palm of one hand.
Rationale: An adequate amount of product is needed to thoroughly
cover the hands.
2. Rub the hands together, covering all surfaces of hands and fingers with antiseptic rub.
Rub the palms of the hands together.
Copyright © 2020, Elsevier, Inc. All rights reserved. Page 2 of 6Hand Hygiene (Home Health Care) - CE
3. Rub the fingers of one hand over the dorsum of the other hand and interlace the
fingers. Repeat with the other hand.
4. Rub the fingers of each hand over the palmer surface of the other hand and interlace
the fingers.
5. Rub the backs of fingers across the palms of each hand alternately.
6. Decontaminate the fingertips by rubbing them in the palm of the other hand. Repeat
with the other hand.
Rationale: Many microorganisms on the hands come from the
subungual region (beneath the fingernails).
7. Clasp each thumb in the palm of the opposite hand and twist.
8. Rub the hands together until the alcohol is dry. Allow the hands to completely dry
before donning gloves.
Rationale: Rub hands until they are dry to ensure maximum efficacy.
If hands dry completely in less than 20 seconds, insufficient product
probably was applied.6
Hand Hygiene Using Plain or Antimicrobial Soap, Water, and Disposable
Paper Towel
1. If using soap and water, ask the patient, family member, or caregiver where the sink or
water source for sanitizing hands is located; take the hand hygiene supplies to this
location.
2. Stand in front of the sink, keeping the hands and clothing away from the sink surfaces.
Rationale: Sink surfaces may be contaminated; contact with surfaces may
transfer contaminates to skin or clothing.
If the hands touch the sink during handwashing, repeat
handwashing.
3. Turn on the faucets to begin the flow of water.
4. Avoid splashing water on clothing.
Rationale: Microorganisms travel and grow in moisture.
5. Regulate the flow of water so that the temperature is warm.
Rationale: Warm water removes less of the protective oils on hands
than hot water.
6. Wet the hands and wrists thoroughly under the running water. Keep the hands and
forearms lower than the elbows during washing.
Copyright © 2020, Elsevier, Inc. All rights reserved. Page 3 of 6Hand Hygiene (Home Health Care) - CE
Rationale: Hands are the most contaminated parts to wash. Water
should flow from the least to the most contaminated area, rinsing
microorganisms into the sink.
7. Apply an adequate amount of soap in the palm of one hand and rub the hands together
to work up a lather.
8. Use a rotating frictional motion, applying friction to all surfaces of the hands and
wrists, including the balls of hands, between fingers, and around and under the nails.
Interlace the fingers and rub up and down. Continue washing for at least 20 seconds.
Hum the “Happy Birthday” song from beginning to end twice as a timer.3
Rationale: Soap cleanses by emulsifying fat and oil and lowering
surface tension. Friction and rubbing mechanically loosen and remove
dirt and transient bacteria. Interlacing the fingers and thumbs ensures
that all surfaces are cleansed.
9. Rinse the hands and wrists thoroughly, keeping the hands down and elbows up.
Rationale: Rinsing mechanically washes away dirt and microorganisms.
10. Dry the hands thoroughly with a paper towel.
11. Discard the paper towel in a trash can.
12. Turn off the faucet with a clean, dry paper towel. Avoid touching the handles with the
hands.
13. Apply lotion to the hands if needed at the end of the visit. Avoid petroleum-based
lotions.
Rationale: Lotion helps minimize skin dryness.
EXPECTED OUTCOMES
• Complete cleansing of hands, including under fingernails, achieved
• No skin irritation from use of soap or alcohol-based product
• No transmission of organisms
UNEXPECTED OUTCOMES
• Skin irritation or dermatitis due to repeated use of harsh soaps or alcohol-based
products
• Incomplete decontamination of hands or areas under fingernails, leading to
transmission of organisms
DOCUMENTATION
• Patient, family, and caregiver’s learning and ability to verbalize or demonstrate
topics taught
• Education
• Unexpected outcomes and related interventions
Copyright © 2020, Elsevier, Inc. All rights reserved. Page 4 of 6Hand Hygiene (Home Health Care) - CE
OLDER ADULT CONSIDERATIONS
• Older adult patients may have an increased susceptibility to infections.
• Older adult patients may have an increased incidence of dry skin and skin
breakdown.
REFERENCES
1. Boyce, J.M. and others. (2002). Guideline for hand hygiene in health-care settings.
Recommendations of the Healthcare Infection Control Practices Advisory Committee and
the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR, 51(RR-16), 1-45.
(Classic Reference)* (Level VII)
2. Centers for Disease Control and Prevention (CDC). (2017). Hand hygiene in
healthcare settings. Retrieved March 13, 2020, from
3. Centers for Disease Control and Prevention (CDC). (2016). Handwashing: Clean hands
save lives: When and how to wash your hands. Retrieved March 13, 2020, from
https://www.cdc.gov/handwashing/when-how-handwashing.html
4. Joint Commission, The. (2009). Measuring hand hygiene adherence: Overcoming the
challenges. Retrieved March 13, 2020, from
https://www.jointcommission.org/assets/1/18/hh_monograph.pdf
(classic reference)* (Level VII)
5. Kirk, J., Kendall, A., Marx, J. & others. (2016). Point of care hand hygiene—where's
the rub? A survey of US and Canadian health care workers' knowledge, attitudes, and
practices. American Journal of Infection Control, 44(10), pp. 1095-1101.
doi:10.1016/j.ajic.2016.03.005. Retrieved March 13, 2020 from
(https://www.sciencedirect.com/science/article/pii/S0196655316002285)
6. Longtin, Y. and others. (2011). Videos in clinical medicine: Hand hygiene. New
England Journal of Medicine, 364(13), e24. doi:10.1056/NEJMvcm0903599 (classic
reference)*
7. World Health Organization (WHO). (2009). WHO guidelines on hand hygiene in
health care. Retrieved March 13, 2020, from
https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf?sequenc
e=1 (classic reference)* (Level VII)
8. World Health Organization (WHO). (2012). Hand hygiene in outpatient care, home-
based care and long-term care facilities. Retrieved March 13, 2020, from
https://apps.who.int/iris/bitstream/10665/78060/1/9789241503372_eng.pdf?ua=1 (Level
VII)
*In these skills, a “classic” reference is a widely cited, standard work of established
excellence that significantly affects current practice and may also represent the
foundational research for practice.
Elsevier Skills Levels of Evidence
• Level I - Systematic review of all relevant randomized controlled trials
• Level II - At least one well-designed randomized controlled trial
• Level III - Well-designed controlled trials without randomization
• Level IV - Well-designed case-controlled or cohort studies
Copyright © 2020, Elsevier, Inc. All rights reserved. Page 5 of 6Hand Hygiene (Home Health Care) - CE • Level V - Descriptive or qualitative studies • Level VI - Single descriptive or qualitative study • Level VII - Authority opinion or expert committee reports Supplies • Small bottle of alcohol-based waterless antiseptic containing emollients • Small bottle of liquid antimicrobial or regular soap • Paper towels Clinical Review: Martha Beck, MA, BSN, RN, CNOR Published: April 2020 Copyright © 2020, Elsevier, Inc. All rights reserved. Page 6 of 6
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