Hand Hygiene

Purpose

This document provides perioperative team members with evidence-based practice guidance for performing hand hygiene and surgical hand antisepsis to promote patient and personnel safety and reduce the risk for health care–associated infections, especially surgical site infections (SSIs). Hand hygiene is widely recognized as a primary method to prevent health care–associated infections and the transmission of pathogens in the health care setting.¹  Health care–associated infections can result in untoward patient outcomes, such as morbidity and mortality, pain and suffering, longer lengths of hospital stay, delayed wound healing, increased use of antibiotics, and higher costs of care.²  Thus, the prevention of health care–associated infections is a priority for all health care personnel. Hand hygiene and surgical hand antisepsis are effective and cost-efficient ways to prevent and control infections in the perioperative setting.³ 

Normal skin flora on the hands includes transient and resident microorganisms. Transient microorganisms colonize the superficial layers of the skin. These microorganisms are transmitted to perioperative team members while they are caring for patients and when they come in contact with contaminated environmental surfaces. Moderate-quality evidence has confirmed intraoperative transmission of Staphylococcus aureus from the hands of anesthesia providers,⁴  surgical attendings, surgical assistants, and circulating nurses⁵  to patients and environmental surfaces. Transient microorganisms are easier to remove by performing hand hygiene than are resident microorganisms, which are seated in the deeper layers of the skin. Skin and nail condition and the presence of jewelry contribute to the number of transient microorganisms on the hands. In a review of 10 hospital outbreaks caused by gram-negative bacteria in which health care workers were thought to be the source of the outbreak, Ulrich et al⁶  found that the main reservoir of transmission in seven of the outbreaks was the hands of health care personnel with nail fungus, artificial nails, or jewelry.

Surgical hand antisepsis aims to remove soil and transient microorganisms from the hands of perioperative team members and suppress the growth of resident microorganisms for the duration of the surgical procedure to reduce the risk that the patient will develop an SSI.⁷  Safe and effective surgical hand antiseptics rapidly and persistently remove transient microorganisms and suppress the growth of resident microorganisms with minimal skin and tissue irritation.¹ 

The perioperative registered nurse (RN) plays a crucial role in developing and implementing protocols for hand hygiene and surgical hand antisepsis in the perioperative setting. This includes involvement in the selection of surgical hand antiseptics and hand hygiene products and the development of procedures inclusive of health care workers’ religious and cultural beliefs (eg, some individuals have restrictions about showing bare skin below the elbows in the presence of others).^8,9 

Topics outside the scope of this document include hand hygiene in health care settings other than the perioperative setting and glove use (See the Guideline for Transmission-Based Precautions).¹⁰ 

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from March 2016 through February 2021. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until September 2021. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included 2-propanol, acrylic nails, alcohol, alcohol based hand sanitizer, alcohol based hand scrub, alcohol prohibition, allergic contact dermatitis, allergy, Alphadine, ambulatory surgery center, anesthesiologists, artificial nails, Asepsol, Avaguard, audits, bare below the elbows, betadine, Betaisodona, benzalkonium chloride, Birnbach, *contamination, cardiac catheterization laboratory, chaplains, chloroxylenol, clergy, clerics, compatible products, compliance, contact dermatitis, contact eczema, contact irritant dermatitis, contact sensitivity, cross contaminat*, cross infect*, deacons, dermatitis, dermatitis (allergic contact), dermatitis (contact), dermatitis (irritant), Disadine, Drapolene, eczema flare, electric eye faucets, endoscopy suite, exanthema, exudates and transudates, fingernails, gel nail overlay, gel nail polish, Germex, gloves, guideline adherence, hand antisep*, hand disinfect*, hand hygiene, hand sanitiz*, hand wash*, handwashing, henna, hexachlorophane, hypersensitivity, imams, infection, infection control, inflamed skin, interventional radiology, intraoperative period, iodine, irritant dermatitis, Islam, Isodine, isopropanol, isopropyl alcohol, pastors, perioperative care, perioperative nursing, perioperative period, perioperative setting, petrolatum, petroleum, petroleum jelly, policy compliance, povidone iodine, pre-operative hand antisepsis, pre-operative hand preparation, pre-operative rub, pre-operative scrub, pre-operative wash, pre-surgical hand antisepsis, pre-surgical hand preparation, pre-surgical rub, pre-surgical scrub, pre-surgical wash, preoperative hand antisepsis, preoperative hand preparation, preoperative rub, preoperative scrub, preoperative wash, preoperative period, presurgical, presurgical hand antisepsis, presurgical hand preparation, presurgical rub, presurgical scrub, presurgical wash, priests, procedural areas, protocol compliance, PVP-I, PVP-iodine, rabbis, radiology (interventional), rash, religious compliance, religious practices, rings, rubbing alcohol, scrub brush, scrub sink, self tanning products, skin cream, skin inflammation, skin irritation, skin lotion, skin rash, skin sloughing, squames, super shedder, surgical hand antisepsis, surgical hand preparation, surgical nursing, surgical rub, surgical scrub, surgical scrubbing, surgical suite, surgical wash, surgicenters, UV-cured nail polish, waterless hand sanitizer, wearable dispensers, wedding band, wedding ring, wood alcohol, and Zephiran.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. Low-quality evidence was excluded when higher-quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1. Flow Diagram of Literature Search Results

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and two evidence appraisers. The lead author divided the search results into topics and assigned members of the team to review and critically appraise each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

Note: The evidence summary table is available at http://www.aorn.org/evidencetables/.