Hand Hygiene and Standard Precautions

Germs travel on hands more than on anything else. Clean hands at the right moments do more to stop infection than any other single step, whether you are helping a patient, changing a diaper or cleaning a restroom. Standard precautions are the basic protections you use every time, because you cannot tell who is carrying an infection by looking at them.

What You Will Be Able to Do

• Name the moments when your hands must be cleaned.
• Choose between hand rub and soap and water, and use each one correctly.
• Explain what standard precautions are and who they apply to.
• Decide which protective equipment a task needs.
• Put on and take off gloves and other protective equipment without contaminating yourself.

Why Hands Matter So Much

Your hands touch people, door handles, phones, tools and your own face all day. Each touch can pick up germs or drop them off. Most of those germs are invisible, and clean-looking hands can still carry them. Good hand hygiene protects two groups of people. Cleaning before contact protects the person you are about to touch. Cleaning after contact protects you, your coworkers and the next person you help. That is why doing only one or the other is not enough.

The Moments That Count

The World Health Organization describes five moments for hand hygiene in patient care:

1. Before touching a patient.
2. Before a clean or aseptic procedure, meaning any task where germs must be kept out of the body.
3. After a risk of contact with body fluids.
4. After touching a patient.
5. After touching the patient's surroundings, such as the bed rail, table or call button.

Outside a hospital, the same thinking applies. Clean your hands when you arrive at work or at a client's home, before and after each care task, before you leave and any time they are soiled. Also clean them:

• After using the toilet or helping someone use it.
• After changing a diaper or handling soiled laundry.
• Before preparing or serving food and before eating.
• After coughing, sneezing or blowing your nose.
• After touching garbage, cleaning chemicals or used cleaning tools.
• After taking off gloves.

Hand Rub or Soap and Water

Alcohol-based hand rub is the usual choice in most clinical care because it is fast and kills most germs. It needs at least 60 percent alcohol to work. Some situations call for soap and water instead.

Hand rub has two limits you need to remember. Dirt, grease and body fluid form a barrier that keeps the alcohol from reaching the germs underneath, so it works poorly on soiled hands. Alcohol also does not kill C. difficile spores. Washing works on them by lifting them off the skin and rinsing them away.

Using Hand Rub

1. Put enough product in a cupped palm to cover all surfaces of both hands.
2. Rub palms, backs of hands, between fingers, fingertips and thumbs.
3. Keep rubbing until your hands are completely dry, which takes about 20 seconds.

If your hands are dry in less than 20 seconds, you probably used too little. Do not wipe it off or wave your hands to speed it up.

Washing With Soap and Water

1. Wet your hands with clean running water and apply soap.
2. Lather and scrub all surfaces for at least 20 seconds, including backs of hands, between fingers, under nails and thumbs.
3. Rinse well under running water with fingers pointing down.
4. Dry completely with a clean paper towel.
5. Use the towel to turn off the faucet and open the door if the handle is dirty.

Keeping Your Hands Ready

Keep nails short and clean. Artificial nails and chipped polish hold germs, and many employers do not allow them for hands-on care. Rings and watches make it harder to clean the skin underneath. Cracked skin holds germs and hurts, so use the lotion your employer approves, and report skin problems instead of skipping hand hygiene.

What Standard Precautions Are

Standard precautions are the minimum protections used with every person, every time, whatever their diagnosis and whether or not anyone knows they have an infection. You treat all blood, body fluids (except sweat), broken skin and mucous membranes, such as the inside of the mouth or nose, as if they could be infectious.

They include:

• Hand hygiene.
• Protective equipment chosen for the task.
• Covering coughs and sneezes.
• Safe handling of needles and other sharps.
• Cleaning and disinfecting shared equipment and surfaces.
• Careful handling of soiled laundry and waste.

Choosing Protective Equipment

Decide by asking one question: what could I touch, or what could splash on me, during this task?

Gloves come with four rules:

1. Clean your hands before you put them on and after you take them off. Gloves can have tiny holes, and hands get contaminated during removal.
2. Change gloves between people. Never wear the same pair from one person to the next, and never wash gloves to reuse them.
3. Change gloves between a dirty task and a clean task on the same person, such as moving from toileting to touching the face.
4. Do not touch doorknobs, phones or your face with used gloves.

Warning: Gloves are not a replacement for hand hygiene. Used gloves spread germs to everything they touch.

Putting On and Taking Off Equipment

The order matters. It keeps the dirtiest items away from your skin and clothes. When you wear several items, follow this order unless your employer's procedure differs.

Putting on:

1. Clean your hands.
2. Gown.
3. Mask or respirator.
4. Eye protection.
5. Gloves, last, pulled over the gown cuffs.

Taking off:

1. Gloves first, because they are the most contaminated item.
2. Eye protection, handled by the band or earpieces.
3. Gown, rolled inside out and away from your body.
4. Mask or respirator, handled by the ties or straps.
5. Clean your hands right away.

To remove gloves safely, pinch the outside of one glove at the wrist and peel it off inside out. Hold it in your other gloved hand. Slide a bare finger under the cuff of the second glove, touching only the inside, and peel it off over the first one. Drop both in the trash. Never leave used protective equipment on a counter, chair or floor, where other people can touch it.

Coughs, Linens, Surfaces and Waste

• Coughs and sneezes: Cover with a tissue or your elbow, throw the tissue away and clean your hands. Offer a mask to someone with a cough if your workplace provides them.
• Soiled laundry: Wear gloves. Do not shake it, and hold it away from your clothing. Put it straight into a laundry bag or hamper where you are working, and do not sort it there. If it could leak, use a leak-proof bag.
• Shared equipment: Clean and disinfect shared items, such as thermometers, changing tables and blood pressure cuffs, between people, following the product label.
• Waste: Put used gloves and soiled supplies in the bag or container your employer or the local rules require. Keep sharps out of regular trash.

Common Mistakes

Check Your Understanding

1. You just helped someone clean up after a bout of diarrhea. Your hands look clean after you take off your gloves. Is hand rub enough?

No. After diarrhea, wash with soap and water, because the cause could be C. difficile or norovirus, and hand rub does not reliably remove those germs.

2. You finish changing a dressing on one resident and the next resident's room is across the hall. What do you do with your gloves?

Take them off, clean your hands and put on a new pair only if the next task calls for gloves. Gloves are never worn from one person to the next.

3. A person you are helping has no known infection. Do standard precautions still apply?

Yes. They apply to everyone, because you cannot tell who is infectious by looking at them or by reading a chart.

4. You are wearing a gown, mask, goggles and gloves. Which comes off first?

The gloves. They are the most contaminated item. Finish by removing your mask and cleaning your hands.

Key Takeaways

• Hand hygiene is the most effective single way to stop the spread of infection.
• Rub until dry, about 20 seconds, or wash for at least 20 seconds.
• Use soap and water when hands are soiled and after contact with C. difficile or norovirus.
• Standard precautions apply to every person, every time.
• Change gloves between people and between dirty and clean tasks, and clean your hands afterward.
• Put gloves on last and take them off first.