Ranking system for evidence

The consensus recommendations listed below (Part II, Sections 1–9) are categorized according to the CDC/HICPAC system, adapted as follows:

1. Indications for hand hygiene

1. Wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids (IB) or after using the toilet (II).^{179,248,249,287,339,899,1001–1005}
2. If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of Clostridium difficile, hand washing with soap and water is the preferred means (IB).^{419–421,432}
3. Use an alcohol-based handrub as the preferred means for routine hand antisepsis in all other clinical situations described in items D(a) to D(f) listed below, if hands are not visibly soiled (IA).^{60,221,329,333,484–487,665} If alcohol-based handrub is not obtainable, wash hands with soap and water (IB).^60,195,196
4. Perform hand hygiene:
   1. before and after touching the patient (IB);^{50,52,73,88,110,114, 121,125,126,1006}
   2. before handling an invasive device for patient care, regardless of whether or not gloves are used (IB); ¹⁰⁰⁷
   3. after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (IA);^{50,125,127,179}
   4. if moving from a contaminated body site to another body site during care of the same patient (IB);^{73,88,125–127}
   5. after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient (IB);^{73,111,112,114,125–127,129,130}
   6. after removing sterile (II) or non-sterile gloves (IB).^{73,123,139,520,1008}
5. Before handling medication or preparing food perform hand hygiene using an alcohol-based handrub or wash hands with either plain or antimicrobial soap and water (IB).^1001–1004
6. Soap and alcohol-based handrub should not be used concomitantly (II).^617,1009

2. Hand hygiene technique

1. Apply a palmful of alcohol-based handrub and cover all surfaces of the hands. Rub hands until dry (IB).^201,814 (The technique for handrubbing is illustrated in Figure II.1)
2. When washing hands with soap and water, wet hands with water and apply the amount of product necessary to cover all surfaces. Rinse hands with water and dry thoroughly with a single-use towel. Use clean, running water whenever possible. Avoid using hot water, as repeated exposure to hot water may increase the risk of dermatitis (IB).^255,586,587 Use towel to turn off tap/faucet (IB).^{151,220,222,1010,1011} Dry hands thoroughly using a method that does not recontaminate hands. Make sure towels are not used multiple times or by multiple people (IB).^{75,115,257,671} (The technique for handwashing is illustrated in Figure II.2).
3. Liquid, bar, leaf or powdered forms of soap are acceptable. When bar soap is used, small bars of soap in racks that facilitate drainage should be used to allow the bars to dry (II).^{265,266,640,1012–1015}

Figure II.1

How to handrub.

Figure II.2

How to handwash.

3. Recommendations for surgical hand preparation

1. Remove rings, wrist-watch, and bracelets before beginning surgical hand preparation (II).^{962,965,966,968,1016} Artificial nails are prohibited (IB).^{154,167,534,974,977}
2. Sinks should be designed to reduce the risk of splashes (II).^235,552
3. If hands are visibly soiled, wash hands with plain soap before surgical hand preparation (II). Remove debris from underneath fingernails using a nail cleaner, preferably under running water (II).⁶³
4. Brushes are not recommended for surgical hand preparation (IB).^{247,261,463,511,545–547}
5. Surgical hand antisepsis should be performed using either a suitable antimicrobial soap or suitable alcohol-based handrub, preferably with a product ensuring sustained activity, before donning sterile gloves (IB).^{162,227,282,336,463,482,524,525}
6. If quality of water is not assured (as described in Table I.11.3) in the operating theatre, surgical hand antisepsis using an alcohol-based handrub is recommended before donning sterile gloves when performing surgical procedures (II).^{250,282,463,482}
7. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, typically 2–5 minutes. Long scrub times (e.g. 10 minutes) are not necessary (IB).^{284,378,380,460,511,512,525,541,542}
8. When using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to dry hands only (IB).^562,564 Do not combine surgical hand scrub and surgical handrub with alcohol-based products sequentially (II).⁶¹⁷
9. When using an alcohol-based handrub, use sufficient product to keep hands and forearms wet with the handrub throughout the surgical hand preparation procedure (IB).^328,557,568 (The technique for surgical hand preparation using alcohol-based handrubs is illustrated in Figure I.13.1.)
10. After application of the alcohol-based handrub as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves (IB).^463,482

4. Selection and handling of hand hygiene agents

1. Provide HCWs with efficacious hand hygiene products that have low irritancy potential (IB).^{219,220,262,264,329,548,549,572,607}
2. To maximize acceptance of hand hygiene products by HCWs, solicit their input regarding the skin tolerance, feel, and fragrance of any products under consideration (IB).^{221, 329,488,549,598,608,610,633,1017}
3. When selecting hand hygiene products:
   1. determine any known interaction between products used to clean hands, skin care products, and the types of glove used in the institution (II);^342,946
   2. solicit information from manufacturers about the risk of product contamination (IB);^160,643,644
   3. ensure that dispensers are accessible at the point of care (see Part I.1 for the definition) (IB);^335,486
   4. ensure that dispensers function adequately and reliably and deliver an appropriate volume of the product (II);^60,983
   5. ensure that the dispenser system for alcohol-based handrubs is approved for flammable materials (IC);
   6. solicit and evaluate information from manufacturers regarding any effect that hand lotions, creams, or alcohol-based handrubs may have on the effects of antimicrobial soaps being used in the institution (IB);^342,563,1018
   7. cost comparisons should only be made for products that meet requirements for efficacy, skin tolerance, and acceptability (II).464,488
4. Do not add soap (IA) or alcohol-based formulations (II) to a partially empty soap dispenser. If soap dispensers are reused, follow recommended procedures for cleansing.^161,358

5. Skin care

1. Include information regarding hand-care practices designed to reduce the risk of irritant contact dermatitis and other skin damage in education programmes for HCWs (IB).^618,624
2. Provide alternative hand hygiene products for HCWs with confirmed allergies or adverse reactions to standard products used in the health-care setting (II).
3. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing (IA).^{549,607,623–626}
4. When alcohol-based handrub is available in the health-care facility for hygienic hand antisepsis, the use of antimicrobial soap is not recommended (II).
5. Soap and alcohol-based handrub should not be used concomitantly (II).⁶¹⁷

6. Use of gloves

1. The use of gloves does not replace the need for hand hygiene by either handrubbing or handwashing (IB).^{73,123,139,520,913,914,931}
2. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, or non-intact skin will occur (IC).^{906,1019,1020}
3. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient (IB).^{73,114,123,139,520,941,1021}
4. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to either another body site (including non-intact skin, mucous membrane or medical device) within the same patient or the environment (II).^72,123,139
5. The reuse of gloves is not recommended (IB).⁹⁵⁶ In the case of glove reuse, implement the safest reprocessing method (II).⁹⁵²

7. Other aspects of hand hygiene

1. Do not wear artificial fingernails or extenders when having direct contact with patients (IA).^{154,155,159,856,976,977}
2. Keep natural nails short (tips less than 0.5 cm long or approximately ¼ inch) (II).⁹⁷⁶

8. Educational and motivational programmes for health-care workers

1. In hand hygiene promotion programmes for HCWs, focus specifically on factors currently found to have a significant influence on behaviour, and not solely on the type of hand hygiene products. The strategy should be multifaceted and multimodal and include education and senior executive support for implementation.(IA)^{60,651,657,676,701,708,713,725,732,767,802, 809,813,814,816,820,834,939,1022}
2. Educate HCWs about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean their hands (II).^{60,657,663,666,670,715,716,727,814,939,1022}
3. Monitor HCWs’ adherence to recommended hand hygiene practices and provide them with performance feedback (IA). ^{60,633,651,657,663,666,670,676,686,687,715,939}
4. Encourage partnerships between patients, their families, and HCWs to promote hand hygiene in health care settings (II).^803–805

9. Governmental and institutional responsibilities