This document provides a history and overview of hand hygiene guidelines and practices in healthcare settings. It discusses how recommendations have evolved over time, from Semmelweis' work in 1846 demonstrating the importance of handwashing in reducing maternal mortality, to the WHO's 2009 guidelines recommending alcohol-based hand rubs when hands are not visibly soiled. The document outlines the five moments for hand hygiene according to WHO, reviews different hand hygiene products and techniques, including for surgical hand preparation, and discusses barriers to adherence and ways to promote a culture of hand hygiene compliance.

1. HAND HYGIENE
RUVY TAN DE GUZMAN, RN MGM
SAN LAZARO HOSPITAL

2. OBJECTIVES

3. OUTLINE

4. HISTORY OF HANDWASHING
A French Pharmacist
demonstrated that solutions
containing chloride of lime or soda
could eradicate the foul odor
associated with human corpses
and be used as disinfectants and
antiseptics
1822

5. HISTORY OF HANDWASHING
Ignaz Philipp Semmelweis insisted
that physicians cleanse their hands
with chlorine solution between
patients. Thereafter, the maternal
mortality rate in the First Clinic
dropped dramatically.
(CDC, 2002)
1846

6. HISTORY OF HANDWASHING
The U.S. Public Health Service
recommendations directed personnel to
wash their hands with soap and water for
1 to 2 minutes before and after patient
contact. Rinsing hands with an antiseptic agent
was believed to be less effective than hand
washing with plain soap and
was recommended only in emergencies or in
areas where sinks were not available.
1961

7. HISTORY OF HANDWASHING
Guidelines on hand washing practices in
hospitals were published by CDC. They recommended
hand washing with plain soap between patients and
washing with antimicrobial products
before and after performing invasive procedures.
Waterless antiseptic agents such as alcohol-based
solutions were recommended only in situations
where sinks were not available.
1975 & 1985

8. HISTORY OF HANDWASHING
Guidelines similar to those of the CDC were
published by the Association for
Professionals in Infection Control (APIC,
2010). The 1995 APIC guidelines included
discussion of alcohol-based hand rubs and
supported their use in more clinical settings
than had been recommended earlier.
1988 & 1995

9. HISTORY OF HANDWASHING
Healthcare Infection Control Practices Advisory
Committee (HICPAC) recommended that upon
leaving the rooms of patients with multi-drug
resistant pathogens such as methicillin-resistant
Staphylococcus aureus (MRSA), caregivers use
either antimicrobial soap or a waterless
antiseptic agent to cleanse their hands. These
guidelines also recommended hand washing and
hand antisepsis for routine patient care.
1995 & 1996

10. HISTORY OF HANDWASHING
Guideline for Hand Hygiene in Health-Care
Settings was published as the
recommendations of the Healthcare
Infection Control Practices Advisory
Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force. In 2010, the 2002 Guideline
continued to be available on the CDC
website (CDC, 2002).
2002

11. HISTORY OF HANDWASHING
World Health Organization (WHO) reaffirmed
the recommendation to wash hands with soap and
water when visibly dirty, soiled with blood or other
body fluids, or exposed to potential spore-forming
pathogens, such as Clostridium difficile.
When hands are not visibly soiled, the WHO
recommended the use of alcohol-based hand rubs
as the preferred means for routine
hand antisepsis
2009 (WHO, 2009)

12. HISTORY OF HANDWASHING
Although the guidelines of all these healthcare
organizations have been adopted by the majority
of hospitals, adherence by healthcare providers to
recommended hand washing protocols remains
low. For this reason, various professional groups
have undertaken studies to identify factors that
improve adherence to hand hygiene protocols.
2011

13. Categories of skin flora
Resident Flora Transient Flora
Deep seated Superficial
Difficult to
remove
Transferred with
ease to and from
hands
Part of the
body’s natural
defense
mechanism
Deactivated
through Hygienic
hand disinfection

14. SOURCES &TRANSMISSION OF PATHOGENS

15. SOURCES &TRANSMISSION OF PATHOGENS
Inanimate ObjectsPatient

16. SOURCES &TRANSMISSION OF PATHOGENS

17. HAND HYGIENE PRODUCTS

18. HAND HYGIENE PRODUCTS
IODINE AND
IODOPHORS
Iodine and iodophors have bactericidal activity against
gram-positive, gram-negative, and certain spore-forming
bacteria (e.g., clostridia, Bacillus spp.) and are active
against mycobacteria, viruses, and fungi. However, in
concentrations used in antiseptics, iodophors are not
usually sporicidal. The majority of iodophor preparations
used for hand hygiene contain 7.5%–10% povidone-
iodine.
QUATERNARY
AMMONIUM
COMPOUNDS
are primarily bacteriostatic and fungistatic, although at
high concentrations they are microbicidal against certain
organisms; they are more active against gram-positive
bacilli than gram-negative bacilli. Quaternary ammonium
compounds have relatively weak activity against
mycobacteria and fungi and have greater activity against
lipophilic viruses.

19. When to perform hand hygiene?

20. FIVE MOMENTS FOR HAND HYGIENE
WHO, 2012

21. • Webs of fingers
• Thumbs
• Palms
• Nails
• Backs of fingers &
hands
• Wrists
Missed Spots in Washing Hands

22. Running Water Soap
Towel
Paper TowelLiquid
Soap Sanitizer
WASTE BIN
Sink
Palm to palm Back of hands Between fingers Back of fingers
Base of thumbs Fingernails Wrists Rinse & wipe dry
1 2 3 4
5 6 7 8

23.  1. Remove hand /wrist
jewelries, watch
 2. Keep your
nails short
X 3. Avoid nail polish
and artificial nails

24. HAND HYGIENE PROCEDURE

25. HAND HYGIENE PROCEDURE

26. 1) PALM TO PALM

27. 2) Right Palm over dorsum
and vice versa

28. 3) Palm to palm, fingers
interlaced

29. 4) Back of fingers to opposing
Palms, fingers interlocked

30. 5) Rotational rubbing of right thumb
clasped in left palm and vice versa

31. 6) Rotational rubbing, backwards
and forwards with clasped fingers
of right hand in left palm & vice versa

37. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
The hand rubbing technique for surgical hand preparation
must be performed on perfectly clean, dry hands.
On arrival in operating room and after having donned
OR clothing (cap/bonnet and mask), hands must be wash
with soap and water.
After the operation, when removing gloves, hands must be
rubbed with an alcohol-based formulation or washed with
soap and water if any residual talc or biological fluids are
present.

38. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Put approximately 5ml (3 doses) of
alcohol-based handrub in the palm
of left hand, using the elbow of
your other arm to operate the
dispenser.
Dip the fingertips of your right
hand in the handrub to
decontaminate under the nails
(5 seconds)

39. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Image 3-7: Smear the handrub on
the right forearm up to the
elbow. Ensure that the whole
skin area is covered by using
circular movements around the
forearm until the handrub have
fully evaporated (10-15 seconds)

40. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Put approximately 5ml (3 doses) of
alcohol-based handrub in the palm
of right hand, using the elbow of
your other arm to operate the
dispenser.
Dip the fingertips of your left
hand in the handrub to
decontaminate under the nails
(5 seconds)

41. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Smear the handrub on the left forearm up to the elbow.
Ensure that the whole skin area is covered by using circular
movements around the forearm until the handrub have fully
evaporated (10-15 seconds)

42. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Put approximately 5ml (3 doses) of alcohol-based handrub in the
palm of left hand, using the elbow of your other arm to operate
the dispenser. Rub both hands at same time up to the wrist, and
ensure that all the steps represented in images 12-17 are
followed (20-30 seconds)

43. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Cover the whole
surface of the hands
up to the wrist with
alcohol-based
handrub, rubbing palm
against palm with a
rotating movement.
Rub the back of the
left hand, including
the wrist, moving
the right palm back
and forth and vice-
versa
Rub palm against
palm back and
forth with fingers
interlinked

44. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB
Rub the back of the
fingers by holding
them in the plm of the
other hand with a
sideways back and
forth movement.
Rub the thumb of
the left hand by
rotaing it in clasped
palm of the right
hand and vice-versa
When the hands
are dry, sterile
surgical clothing
and gloves can be
donned.
Repeat the illustrated sequence (average duration-60sec.) according to the
number of times corresponding to the total duration recommended by the
manufacturer for surgical hand preparation with an alcohol- based handrub.

45. SURGICAL HAND PREPARATION TECHNIQUE
WITH AN ALCOHOL-BASED HANDRUB

46. BARRIERS TO HAND HYGIENE
• Inaccessible hand hygiene supplies
• Skin irritation caused by hand hygiene agents
• Hand washing and hygiene products thought to be harmful to the
skin
• Priority of care (the patient’s need takes priority over hand
hygiene)
• Lack of knowledge of the guidelines
• Lack of feedback to encourage compliance
• Insufficient time for hand hygiene
• Forgetfulness
• High workload and understaffing
• Lack of scientific information about healthcare-related infection
rates

47. CULTURE OF CARE TO PRACTICE HAND HYGIENE
• Provide written guidelines for all healthcare
providers
• Introduce and demonstrate hand hygiene protocols
to all caregivers
• Encourage leaders to model and support antiseptic
hand hygiene practice
• Monitor and give feedback to all healthcare
providers, including physicians, nursing care
providers, food service personnel, laboratory
technicians, pharmacists, and therapists

49. REFERENCES