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Hand washing has been shown to reduce nosocomial infection dating back to Semmelweis’ historic research on obstetric infections in the 1800s. Hand washing is now the focus of recommendations and requirements from the Centers for Disease Control and the Joint Commission for Accreditation of Healthcare Organizations. It is also widely felt to be the best measure to prevent the emergence and transmission of drug-resistant nosocomial infections, such as Methicillin Resistant Staphylococcus Aureus (MRSA).

Definitions and Terms

  • ▪  Plain (detergent) soaps: Used for cleansing but lack intrinsic antimicrobial properties.
  • ▪  Antimicrobial soaps Detergent plus an antimicrobial such as alcohol, chlorhexidine, or povidone-iodine.
  • ▪  Alcohol-based hand rub: Contain ethanol or isopropanol and denature proteins when used in water-containing solutions; rapidly active against bacteria, mycobacteria, fungi, and viruses; typically combined with moisturizer to prevent hand chapping.
  • ▪  Chlorhexidine and iodophors: Alternative antiseptic agents with intermediate speed of action and variable activity against infectious agents, chlorhexidine has good persistence (see below).
  • ▪  Visibly soiled hands: Show visible dirt or proteinaceous material, blood, or body fluids.
  • ▪  Persistent (antimicrobial) activity: The property of certain hand-cleansing agents having extended antimicrobial action.


  • ▪  Visibly soiled hands: Wash with soap and water.
  • ▪  Before eating or after using the restroom: Wash with soap and water.
  • ▪  Not visibly soiled hands: Use an alcohol-based hand rub under the following circumstances:
    • —Before direct patient contact
    • —Before donning sterile gloves for a procedure
    • —Before insertion of urinary catheters, intravascular devices, or other invasive devices
    • —After contact with a patient’s skin
    • —After contact with bodily fluids, excretions, or dressings
    • —After contact with inanimate objects in the immediate vicinity of a patient (ie, ventilator, bed rail)
    • —After removing gloves
  • ▪  Remove visible debris from beneath fingernails.
  • ▪  Routine hand washing: Wet hands with water, apply recommended amount of soap, and rub hands together vigorously for at least 15 seconds covering all surfaces of hands and fingers. Dry with disposable paper towel and turn water off with towel.
  • ▪  Decontamination with alcohol-based hand rub: Apply product to palm of one hand and rub hands together covering all surfaces of hands and fingers until hands are dry (Figure 4-1).
  • ▪  Additional recommendations for healthcare workers
    • —Remove rings, watches, and bracelets before hand scrub.
    • —Do not wear artificial fingernails.
    • —Keep natural fingernail length less than 1/4 in long.
    • —Wear gloves when in contact with blood or other infectious agents.
    • —Remove gloves after patient care.
    • —Change gloves when moving from one patient to another.
  • ▪  Recommendations for healthcare institutions
    • —Make improved hand hygiene adherence an institutional priority (Figure 4-2).
    • —Solicit multidisciplinary input in the development of policies pertaining to hand hygiene and product selection.
    • —Ensure ready access to alcohol-based hand rub (Figure 4-3).
    Figure 4-1.

    Hand washing between patient contacts.

    Figure 4-2.

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