September 6, 2018

Are Your Hands Clean? – Exploring the Importance of Hand Hygiene in ASCs

By: Donna Label, MSN, RN, NEA-BC, CNOR

Are Your Hands Clean? – Exploring the Importance of Hand Hygiene in ASCs

by Donna Label, MSN, RN, NEA-BC, CNOR, Consultant


Taylor, thank you so much for asking me to do this post for the new ASC blog with OR Manger. As this is my first entry, I felt it would be important to address an issue that is very near and dear to my heart and something we all need to do not just for us but for our patients, our families, and ourselves, Hand Hygiene. You would think that we would not need to continue to work on this, but unfortunately it is still an issue. Thousands of people die every day around the world from infections acquired while receiving healthcare.

Hands are the main pathways of disease transmission, and hand hygiene is the most important action we can take as healthcare providers to prevent the transmission of microorganisms and prevent healthcare associated infections.

Microorganisms that are capable of causing infectious diseases are all around us. They can even be found on furniture and equipment and in areas we think are the cleanest. If our immune systems or our patients’ immune systems are weakened, these pathogens may enter our systems and cause serious illnesses. However, transmission of these harmful microbes can be prevented through handwashing.

There are 5 basic instances in which hand hygiene should be performed and 5 steps for proper handwashing:

The 5 basic instances for hand hygiene are:

  • Before touching a patient
  • Before clean/aseptic procedures
  • After body fluid exposure/risk
  • After touching a patient
  • After touching a patient’s surroundings

The 5 steps for proper hand washing are:

  • Wet your hands with clean water — warm, if available — and apply soap.
  • Lather by rubbing hands together; be sure to cover all surfaces.
  • Continue rubbing hands together for 15 to 20 seconds — sing “Happy Birthday” twice in your head.
  • Thoroughly rinse hands under running water to ensure removal of residual microorganisms.
  • Use paper towels or an air dryer to dry hands and then, if possible, use a paper towel to turn off the faucet.

When I went into Nursing School I was one of those young “dewy eyed” students who was going to “save the world.” I always knew that I was going to be a nurse. Growing up in a small town in the Central Valley of California there was not a lot to do, so we did a lot to entertain ourselves. My sisters and I always found something to do.

Although we were not rich in wealth, we were rich in love. My Mother was a great seamstress and always made all of our clothes. Everyone always thought my sister and I were twins because we were only a year apart and always had matching dresses and played together.

There were 5 of us girls, and my mother was a stay at home mom.  She also volunteered for the auxiliary of our local 20 bed rural community hospital. Her job with the auxiliary was to make patient gowns, surgeon gowns, masks, and hats for the hospital. I can remember many times playing with our dolls on the floor next to the sewing machine while mom sewed. In 1959, Santa brought Barbie’s with a full hospital wardrobe for my sister and me. We went “bonkers” and had many happy hours playing hospital with those dolls. Mom told us that we have choices in life and doing good and helping others is important.

My mother died a few years ago from a hospital acquired infection (HAI). This infection was Clostridium difficile, which led to colitis and sepsis. When she was hospitalized, a health care worker spread the bacteria to her. Most likely it was because their hands were contaminated, and adequate proper hand hygiene had not been done. My interest in surgery came from those early days of play, when I was always the nurse and my sister was the patient. I love taking care of patients and their families. I love how we scrub and ensure our hands are clean prior to surgery.

When I went to nursing school we learned about hand hygiene and asepsis. We also learned that the founder of modern nursing was Florence Nightingale. Nightingale was a handwashing champion. In 1860, Nightingale published “Notes on Nursing,” which laid the foundation for nursing. She stated the following: “Every nurse ought to be careful and wash her hands very frequently during the day.” Her observations during the Crimean war help to develop the foundation on which we practice. At a time when most people believed that infections were caused by foul odors called miasmas, Florence Nightingale, implemented handwashing and other hygiene practices in the war hospital where she worked. While the target of these practices was to fight the miasmas, Nightingale’s handwashing practices achieved a reduction in infections.

Ignaz Semmelweis, a Hungarian physician, is known as the father of hand hygiene. In 1846, before Nightingale published her “Notes on Nursing,” he noticed that women giving birth in the medical student/physician-run maternity ward in his hospital were much more likely to develop a fever and die compared to the women giving birth in the adjacent midwife-run maternity ward.

Sadly, hand hygiene in areas other than the operating room (OR) lost its momentum for over a century. Fortunately, in the 1980s, the United States Centers for Disease Control and Prevention identified hand hygiene as an important way to prevent the spread of infection. In doing so, they heralded the first nationally endorsed hand hygiene guidelines, and the World Health Organization has followed. Collaborations in the Global Handwashing Partnership are focused on making hand hygiene global. Handwashing is a cost-effective, essential tool for preventing infections.

I have had the opportunity for the past several years to travel and work around the country as an interim leader for perioperative services, and I have found that nurses and physicians are still struggling with proper hand hygiene. The CDC recommends that “healthcare providers do not wear artificial fingernails or extensions when having direct contact with patients at high risk (e., those in the intensive care units or operating rooms).” However, in the OR, I see staff scrubbing with jewelry and artificial gel fingernails on and a lack of hand hygiene after removing gloves.

I don’t get it. Does this happen because we, as leaders, are not holding the staff accountable? Am I over critical of the gel nail system? Isn’t it considered artificial? Do we need to do more education? How do we change this behavior? I look forward to reading the ideas of my colleagues.

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