The Foundation of Infection Control

The benefits of handwashing and hand hygiene have been stressed for generations. In 1822, a French pharmacist published an article on handwashing with an antiseptic solution.¹ He asserted that physicians and others who attended patients with contagious illnesses would benefit from washing their hands with a disinfectant.¹ The Centers for Disease Control and Prevention (CDC) state that handwashing is the single most critical means of preventing cross contamination and disease transmission.¹

Although studies have not been conducted on the efficacy of handwashing and hand hygiene among dental hygiene professionals, research evaluating hand hygiene practices in hospitals and other health care facilities estimates that fewer than 50% of that specific practice group comply with standard recommendations for handwashing.² Additional studies report that the amount of time a health care worker (HCW) spends hand washing ranges from 6.6 to 30 seconds and that HCWs often do not wash all surfaces of their hands.³

With the risks so great for both practitioner and patient, it’s curious why noncompliance is an issue. The literature suggests that a lack of training, lack of hand hygiene products and stations, misconceptions about products, confusion about terminology, and lack of time all seem to contribute to poor hand hygiene.

Technique

Handwashing is a critical component in the prevention of disease transmission, yet little time and effort are spent performing a thorough handwashing procedure.³ For nonsurgical procedures, such as those performed by a dental hygienist, a routine handwash is acceptable. Washing hands with soap and water should begin with an appropriate amount of soap dispensed into the palm of one hand. The amount of soap should create a substantial lather. The clinician should vigorously rub all surfaces of the hands for a minimum of 15 seconds. Each finger and thumb should be individually rubbed with one hand and repeated on the fingers and thumb of the other hand. The back of the hands and the palms should be rubbed over one another in a circular motion. Singing the “happy birthday song” while rubbing provides an adequate timeframe for washing. Areas most commonly missed include the thumb, fingertips, and the “Y” area between the thumb and index finger.⁴ Hands should then be rinsed with cool or tepid water and thoroughly dried with a paper towel prior to donning gloves. The use of cool or tepid water helps prevent chapping, which can lead to breaks in the skin, resulting in a portal of entry for infectious disease. If using hand faucets, turning the faucets off with a paper towel to prevent contaminating clean hands is also recommended. Another option is to install foot controls or an automatic sensor for water control.

Soap

The use of antimicrobial soap versus plain soap as the most effective agent for hand hygiene is a much debated topic. Some studies suggest that antimicrobial soap is overkill as it may create a larger population of resistant microorganisms. For this reason, consumer publications have gone so far as to recommend not using antimicrobial soap in the home. The CDC recommends either plain soap or antimicrobial soap as an effective agent for routine handwashing. However, if the HCW is performing a hand antisepsis prior to surgery, then the CDC recommends an antimicrobial soap containing chlorhexidine, iodine, iodophors, chloroxylenol, or triclosan. If water and plain soap are used, then the hand antisepsis needs to be followed by an alcohol-based surgical hand scrub product. The surgical antisepsis procedure should take approximately 2-6 minutes. Regardless of the type of soap, the product should be in a liquid form with hands-free dispensing controls. Bar soap is strictly contraindicated.

Antiseptic Hand Gels/Rubs

The 2003 CDC Guidelines recommend an antibacterial hand gel for hand hygiene, which is one of the most significant changes involving hand hygiene in years. Hopefully with the addition of alcohol-based antiseptic, hand gel compliance will improve in the future.

However, rules do apply when using the alcohol-based gels. The gels should only be used when hands are not visibly soiled. The dime size amount of gel or one pump of the gel should be dispensed and rubbed using a handwashing technique for at least 15 seconds until the gel has evaporated and hands are dry. There is no need to dry hands with a paper towel. If it takes longer than approximately 15 seconds for hands to dry, then too much gel is being dispensed. If the gel dries sooner than 15 seconds, then the clinician is not using an appropriate amount of gel. When the hands are soiled, they must be washed with plain or antimicrobial soap and water. Gels can be used between patients and during a boil water advisory (when the community is notified by the public health department that tap water should be boiled before drinking).

Advantages of using hand gels include: no need for a sink, a shortened hand hygiene time, and less irritation of the skin.⁵ Other studies have concluded that alcohol-based rubs are more effective than hand washing with antimicrobial soap and water because the clinician is required to rub the hands together until the gel has dried.⁶ Additionally, alcohol-based gels are more efficient when it comes to killing microorganisms and the potential risk from faucet contamination is eliminated.²

Hand Gels

The ideal scenario for nonsurgical procedures is to start and end each day with a handwash using plain or antimicrobial soap and water. Using hand gel in between patients is all that is necessary unless hands are visibly soiled.⁷ Often when using the gel, the hands become covered with a film or feel gritty from powdered gloves. When this occurs, washing with plain or antimicrobial soap and water is appropriate.

Most important, gloves do not replace the need for hand hygiene. Gloves only reduce the potential for hand carriage contamination by 70% to 80%.⁶ It is critical to gel or wash hands prior to donning gloves and immediately after removing gloves (See Table 1).

Fingernails and Artificial Nails

Fingernail length has not been directly related to the spread of infection. However, studies suggest that short nails are less likely to exhibit a positive bacterial growth as opposed to long nails.⁸ But nail length may be unimportant since most microorganisms live within the proximal 1 mm of the nail next to the soft tissue.⁹ Nevertheless, it is good practice to maintain short, filed nails with smooth edges to prevent glove tears. Looking at the fingertips from the palm side of the hand provides a guide to nail length. The nail should not extend beyond 1 mm to 2 mm from the tip of the finger. Nail health is promoted by keeping nails well manicured to prevent hang nails since a break in a cuticle can serve as an entry way for infectious microorganisms.⁴ While the CDC does not specify an appropriate nail length, the recommendation is to maintain a length that is short enough to clean under and prevent glove tears.

Click to View Table [ PDF Format | JPG Format ]

While most of the research regarding the risk of artificial nails has been conducted with small numbers of employees in hospital intensive care units and operating rooms, much can be gleaned from these studies. A prime example is the documented outbreak of Pseudomonas aeruginosa in a neonatal intensive care unit. This study revealed that the risk of bacterial transmission was great from those HCWs who wore artificial fingernails. Diseases that occurred in affected infants in the neonatal study included conjunctivitis, skin infections, bloodstream infections, meningitis, pneumonia, diarrhea, and necrotizing enterocolitis. Hand cultures from the HCWs that came in contact with the infants confirmed the transmission. Artificial nails were confirmed to be risk factors for colonization. Once the artificial nails were removed, the amount of microorganisms found in the hand cultures significantly decreased.¹⁰

Other studies have confirmed that artificial nails contribute to the proliferation of gram-negative bacilli and yeast. Three cases of Candida albicans occurred in a hospital operating room. Skin and mucous membrane samples from the surgical personnel were obtained and one operating room technician was clearly implicated as the source of infection. As a result, the hospital developed policies preventing operating room personnel from wearing artificial nails.⁹ This study demonstrated that artificial nails are a contributing factor in disease transmission. In addition to the flora accumulation, artificial nails make donning gloves difficult and can result in glove tears thereby compromising the integrity of the gloves. While the researchers suggest that more studies are needed on the hand carriage of microorganisms when wearing artificial nails, the CDC and the Association of Operating Room Nurses (AORN) have policies stating artificial nails should not be worn in the operating room. Consequently, the CDC Guidelines in the Dental Health-Care Setting strongly recommend that artificial nails not be worn by dental personnel.

Nail Polish

Cracked or chipped fingernail polish contributes to the collection of high concentrations of bacteria. Strains include staphylococci, gram-negative rods, and yeasts.¹¹ When compared to unpolished nails or freshly applied nail polish, chipped or cracked polish has the ability to harbor an increased number of bacteria regardless of the handwashing technique.¹² While this aspect of infection control practices may permit the transmission of health care associated infections, the CDC does not address nail polish in the guidelines.

Jewelry

Jewelry has also been cited as an infection control hazard. Studies have demonstrated that skin under rings has a higher concentration of bacteria when compared to skin without rings.¹³ One study of intensive care nurses reported rings were the only risk factor for carriage of gram-negative bacterial colonies. Yet other studies have not shown a significant difference in bacterial colony counts of skin with or without rings.^14,15 However, the primary issue with jewelry is related to glove integrity. Jewelry can tear and/or puncture gloves. Hence, the CDC recommends not wearing hand or nail jewelry if it may compromise the integrity of the gloves.

Hand Lotions

Hand lotions pose another problem for HCWs. Because hands are washed frequently, the skin becomes damaged resulting in more frequent colonization of bacteria. Damaged skin needs to be repaired with emollients because the skin flora is altered, resulting in a higher concentration of staphylococci and gram-negative colonies.^16,17 However, petroleum-based emollients compromise the integrity of latex gloves, thus increasing permeability.⁵ While the CDC recommends the use of hand lotions to prevent skin dryness, HCWs should obtain information from the manufacturer about lotion and glove interaction.

Hand Care Product Storage and Dispensing

With the myriad of products available for hand hygiene and care, HCWs must ensure that products are compatible with each other and the gloves that are worn, as well as knowing how to correctly store and dispense the product. The manufacturers of lotions and gels should be contacted to determine compatibility. Products can become contaminated if not stored or dispensed appropriately.¹⁸ Soap dispensers should not be topped off as this practice may lead to bacterial contamination. Instead, soap should be dispensed from a disposable container or one that has been cleaned and dried.¹⁹ All liquid products should be stored in tightly closed containers prior to dispensing.

Dental hygienists should be meticulous regarding hand care and hand hygiene. Dental personnel need to be certain they are washing hands thoroughly and following the CDC recommendations for fingernails and jewelry. Evidence-based research and epidemiologic studies drive the guidelines that are designed to protect all health care workers and patients. It is our obligation—as health care professionals—to put safety above the latest fashion trends.

Acknowledgement

Thank you to Janelle Schierling, RDH, EdD, for her editorial assistance.

References

1. Boyce JM, Pittet D, Healthcare Infection Control Practices Advisory Committee, HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Society for Healthcare Epidemiology of America/Association for Professionals in Infection Control/Infectious Diseases Society of America. MMWR Recomm Rep . 2005;51(RR-16):1.
2. Walling AD. Alcohol rub vs. antiseptic soap to reduce contamination. Family Physician . 2003;67(2):393.
3. Crawford JJ. Clinical Asepsis In Dentistry . Mesquite, Tex: Oral Medicine Press; 1987.
4. Cooper MD, Wiechmann L. Essentials of Dental Hygiene . Upper Saddle River, NJ: Pearson Prentice Hall; 2005.
5. Larson E, Anderson JK, Baxendale L, Bob L. Effects of a protective foam on scrubbing and gloving. Am J Infect Control . 1993;21:297-301.
6. Centers for Disease Control and Prevention. Hand-washing guidelines allow alcohol-based rubs: new rules is a departure for the CDC. Hospital Home Health . 2003;20(5):2.
7. US Department of Labor, Occupational Safety and Health Administration. Hazard Communication. Available at: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=FEDERAL_REGISTER&p_id=13373. Accessed November 21, 2005.
8. Moolenaar RL, Crutcher JM, San Joaquin VH. A prolonged outbreak of pseudomonas aeruginosa in a neonatal intensive care unit: did staff fingernails play a role in disease transmission? Infect Control Hosp Epidemiol . 2000;21:80-85.
9. Parry MF, Grant B, Yukna M, et al. Candida osteomyelitis and diskitis after spinal surgery: an outbreak that implicates artificial nail use. Clin Infect Dis . 2001;32:352-357.
10. Foca M, Jakob K, Whittier S. Endemic Pseudomonas aeruginosa infection in a neonatal intensive care unit. N Engl J Med. 2000;343:695-700.
11. CDC’s hand washing guidelines. Health Care Food Nutr Focus . 2003;20:1, 3-7.
12. Parini S, Myers F. Keeping up with hand hygiene recommendations. Nursing . 2003;33:17.
13. Trick WE, Vernon MO, Hayes RA. Impact of ring wearing on hand contamination and comparison of hand hygiene agents in a hospital. Clin Infect Dis . 2003;36: 1383-1390.
14. Jacobson G, Thiele JE, McCune JH, Farrell LD. Handwashing: ring-wearing and number of microorganisms. Nurs Res . 1985;34:186-188.
15. Salisbury DM, Hutfilz P, Treen LM, Bollin GE, Gautum S. The effect of rings on microbial load of heathcare workers’ hands. Am J Infect Control . 1997;25:24-27.
16. Ojajarvi J, Makela P, Rantasalo I. Failure of hand disinfection with frequent handwashing: a need for prolonged field studies. J Hyg (Lond) . 1977;79:107-119.
17. Larson EL, Hughes CA, Pyrek JD, Sparks SM, Cagatay EU, Bartkus JM. Changes in bacterial flora associated with skin damage on hands of healthcare personnel. Am J Infect Control . 1998;26:513-521.
18. Larson EL. APIC guidelines for handwashing and hand antisepsis in healthcare settings. Am J Infect Control . 1995;23:251-269.
19. Grohskopf LA, Roth VR, Feikin DR, et al. Serratia liquefaciens blood-stream infections from contamination of epoetin alfa at a hemodialysis center. N Engl J Med . 2001;344:1491-1497.

From Dimensions of Dental Hygiene. January 2006;4(1):18-20.