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3 Hand Hygiene and Non-Sterile Gloves – Clinical Procedures for Safer Patient Care

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CLINICAL PROCEDURES FOR SAFER PATIENT CARE

CONTENTS

Chapter 1. Infection Control

1.3 Hand Hygiene and Non-Sterile Gloves

Hand Hygiene

Hand hygiene is the most important part of practice for health care workers and is the single most
effective way to stop the spread of infections; failure to properly perform hand hygiene is the
leading cause of HAIs and the spread of multi-drug-resistant organisms (MDROs) (BC Centre for
Disease Control, 2014; WHO, 2009a). Hand hygiene is a general term used to describe any ac-
tion of hand cleaning and refers to the removal or destruction of soil, oil, or organic material, as
well as the removal of microbial contamination acquired by contact with patients or the environ-
ment. Hand hygiene may be performed using an alcohol-based hand rub (ABHR) or soap and wa-
ter. A surgical hand scrub is also a method of hand hygiene (WHO, 2009a).

To break the chain of infection, there are five key moments at which to perform hand hygiene
when working
Previous: in healthPrevention
1.2 Infection care, as and
outlined inPractices
Control Checklist 2 and illustrated in Figure 1.1.

Next: 1.4 Additional Precautions and Personal Protective Equipment (PPE)

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CHECKLIST 2: FIVE KEY MOMENTS IN HAND HYGIENE

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Safety considerations:

If contact dermatitis occurs, use soap and water for hand hygiene.

Instruct patients and family on the importance of hand hygiene, proper technique, and
ways to incorporate routines into everyday practice.

Certain practices can increase the risk of skin irritation and should be avoided. For
example, washing hands regularly with soap and water immediately before or after using
an alcohol-based product is not only unnecessary but may lead to dermatitis.
Always wash hands whenever in doubt.

KEY MOMENTS ADDITIONAL INFORMATION

1. Before initial contact with Before touching a patient (e.g., feeding, toileting,
patient/client/resident or environment contact or personal care)

Before touching the patient’s environment

Before adjusting an IV rate

Before taking a pulse or blood pressure

2. Before any clean (routine) or aseptic (sterile) Before applying clean or sterile gloves
procedure
Before performing a sterile dressing change

Before feeding a patient

Before performing oral/dental care

Before inserting eye drops

Before inserting Foley catheter

Previous: 1.2 Infection Prevention and Control PracticesBefore preparing medication

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3. After blood or body fluid risk/exposure After contact with body secretions, mucous
membranes, or non-intact skin

After glove removal (clean or sterile gloves)

After handling waste (urine, drainage, wound

care)

After wound care or a sterile procedure

When moving from a contaminated area on

the body to a non-contaminated area

4. After contact/touching the After taking a blood pressure or pulse, touching a

patient/client/resident urinary catheter, or feeding or dressing a patient

5. After contact with the After touching a bed table or bathroom light
patient’s/client’s/resident’s environment
After touching personal toiletries

After touching walkers or wheelchairs

After touching electronic IV devices

After taking blood pressure or pulse

After changing bed linen

Data source: Kampf & Loffler, 2003; WHO, 2009a, 2009b

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Figure 1.1 Five moments in hand hygiene

SAFETY ALERT: FACTORS THAT REDUCE HAND HYGIENE EFFECTIVENESS

Jewellery: Rings and bracelets increase microbial count on hands. Rings also increase the
risk of torn or pierced gloves. Jewellery should not be worn during patient care (Longtin,
Sax, Allegranzi, Schneider, & Pittet, 2011). All jewellery must be removed. In an instance
where a bracelet may not be removed due to religious reasons, the bracelet may be pushed as
Previous:
high as1.2 Infectionabove
possible Prevention and Control
the wrist beforePractices
performing hand hygiene.
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Skin integrity: The condition of the hands can influence the effectiveness of hand hygiene,
and proper skin care is essential for infection control (Bissett, 2007). Skin cracks, dermatitis,
or cuts can trap bacteria and may place patients at an increased risk (CDC, 2007). Inspect
hands for cuts and open sores, and cuticles for tears. Open cuts, sores, or abrasions should be
covered prior to starting work. Use barrier creams and lotion after patient care to keep skin
healthy and hydrated.

Artificial nails and nail extenders: Artificial nails and nail extenders increase the viral load of
bacteria up to nine times compared with bacteria found on hands. Extenders or artificial nails
are not recommended for health care workers (Kennedy, 2013).
Nail length: Nails should be a maximum of 1/4-inch long and should not extend past the end
of the finger (Patrick & Van Wicklin, 2012). Most microbes on hands come from under the
fingernails. Subungual areas (under the fingernails) can harbour higher concentrations of
microorganisms (Kennedy, 2013). In addition, long nails are harder to clean and may lead
to more frequent puncture in gloves from the thumb and forefinger (Patrick & Van Wicklin,
2012).

Nail polish: Nail polish should be freshly applied and be free from chips or cracks. Studies
have shown that chipped nail polish and polish older than four days can harbour microorgan-
isms (Patrick & Van Wicklin, 2012).

Water temperature and products: Warm water removes less protective oils than hot water,
whereas hot water increases the likelihood of skin damage (WHO, 2009a). To prevent con-
tamination, products must be dispensed in a disposable pump container that is not topped
up. An adequate amount of soap is required to dissolve fatty materials and oils from hands as
water alone is not sufficient to clean soiled hands (WHO, 2009a).

HOW TO WASH HANDS: TYPES OF HAND HYGIENE

Two types of hand hygiene are commonly used in the health care setting: hand hygiene with an
alcohol-based hand rub (see Figure 1.2) and hand hygiene with soap and water.

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Figure 1.2 Alcohol-

based hand rub

Alcohol-based hand rub (ABHR) is a product containing 60% to 90% alcohol concentration and
is recommended for hand hygiene in health care settings (CDC, 2012). ABHR is the preferred
method of hand hygiene and is more effective than washing hands with soap and water (WHO,
2009a). ABHRs:

Kill the majority of germs (including viruses) from hands

Require less time to use than soap and water (20 to 30 seconds)

Are easy to use and have high levels of availability at the point of care

Provide better skin tolerability

See Checklist 3 for the steps to take when washing hands with ABHR.

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CHECKLIST 3: HAND HYGIENE WITH ABHR

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Safety considerations:

Do not use in combination with soap and water. This practice may increase skin irritation.
Use ABHR that contains emollients (oils) to help reduce skin irritation and overdrying.

Allow hands to dry completely before initiating tasks or applying clean or sterile gloves.
ABHR may be used for all five moments in hand hygiene (see Checklist 2) as long as
hands are not contaminated or visibly soiled.

DO NOT use ABHR if patient is suspected to have or confirmed with Clostridium

difficile, norovirus, or Bacillus anthracis. ABHR will not kill spore-forming pathogens.

STEPS ADDITIONAL INFORMATION

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1. Remove all jewellery on hands. Apply 1 to 2

pumps of product into palm of dry hands.

Remove jewellery

Product should not be applied to wet hands, as

this will dilute the product.

Enough product should be applied to thor-

oughly wet hands and fingers for the entire
procedure of 20 to 30 seconds.

Apply ABHR onto hands

Always follow the manufacturer’s guidelines.

2. Rub hands together, palm to palm. Rubbing hands together ensures palm surfaces are
covered by the product.

Rub alcohol over entire

surface of palms

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3. Rub the back of the hands. Rubbing the back of the hands allows all surfaces
of the fingers to be exposed to the product.

Rub back of hands

4. Rub the alcohol between all the fingers to Rubbing between the fingers allows all surfaces
cover all the fingers. of the hands to be exposed to the product.

Rub between the fingers

5. Press fingertips into the palm of opposing hand Pressing fingertips into opposing palms and
and rub back and forth. rubbing ensures fingertips and nails are exposed
to the cleaning product. Nails harbour more
bacteria than do hands.

Clean with ABHR under

the fingernails

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6. Rub each thumb in a circle in the palm of the Rubbing each thumb provides complete coverage
opposite hand. of the product on the thumb.

Clean the surface of

thumb

7. Rub hands together until they are dry. Do not Rubbing hands together provides adequate time
use a paper towel to dry hands. for the alcohol to dry. The minimum time
required for proper rubbing technique when using
ABHR is 20 to 30 seconds.

Rub hands until dry

8. Hands are now safe to use.

Clean hands

Data source: CDC, 2012; PIDAC, 2012; PHAC, 2012b; WHO, 2009a, 2009b

HAND HYGIENE WITH SOAP AND WATER

Hand hygiene with water requires soap to dissolve fatty materials and facilitate their subsequent
flushing with water. Soap must be rubbed on all surfaces of both hands followed by thorough
Previous: 1.2 Infection Prevention and Control Practices
rinsing and drying, Water alone is not suitable for cleaning soiled hands (WHO, 2009a). The en-
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tire procedure should last 40 to 60 seconds and should use soap approved by the health
agency. See the steps in Checklist 4.

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CHECKLIST 4: HAND HYGIENE WITH SOAP AND WATER

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Safety considerations:

Always wash hands with soap and water if hands are visibly dirty or soiled.

When working with patients where Clostridium difficile (CDI), norovirus, or Bacillus
anthracis is suspected or confirmed, soap and water must be used. CDI can remain
dormant on surfaces for long periods of time.
Always use soap and water if hands are exposed to blood or body fluids.

Multi-step rubbing techniques using soap and water are required to promote coverage of
all surfaces on hands. Friction and rubbing are required to remove oil and debris from
hands.

STEPS ADDITIONAL INFORMATION

1. Remove all jewellery. Wet hands with warm

water.

Remove jewellery

A comfortable temperature of water should be

used. Hot water may damage skin.

Regulate water
temperature
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2. Apply 1 to 2 pumps of soap. Enough soap should be used to lather the palms,
back of hands, fingers, and thumbs.

Dispense soap

3. Lather soap and rub palms together. Ensure all surfaces of the palms are covered with
soap, using friction to remove debris and oil.

Lather hands with soap and

water

4. Rub in between fingers and around fingers. Ensure all surfaces of the fingers are covered with
soap, using friction to remove debris and oil.

Rub hands to remove

debris and oil

5. Rub the back of each hand with the palm of the Ensure all surfaces on the back of the hands are
opposite hand. covered with soap, using friction to remove debris
and oil.

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Rub the back of the hands
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6. Press and rub fingernails and fingertips into the Ensure all surfaces around the fingertips are
palm of the opposite hand. covered with soap, using friction to remove debris
and oil.

Clean tips of fingers and

underneath nailbeds

7. Rub each thumb in a circle with the palm of the Ensure all surfaces around the thumbs are
opposite hand. covered with soap, using friction to remove debris
and oil.

Clean around the thumb

up to the wrist on both
hands

8. Rinse hands under water by keeping fingers Rinsing in this way allows the oil and debris to be
pointing downward toward the drain. washed off the hands and down the drain.

Rinse soap and water off

hands

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9. Pat hands dry using clean paper towel. Use a gentle action to prevent skin irritation.

Dry hands

10. Using a clean paper towel, turn off faucet. Using a paper towel prevents re-contamination of
hands by touching dirty faucet handles.

Turn off faucet with dry

paper towel

11. Hands are now safe to use.

Clean hands

Data source: Accreditation Canada, 2013; CDC, 2014; PHAC, 2012a; WHO, 2009a

Non-sterile (Clean) Gloves

Both hand hygiene and clean glove use are strategies to prevent transmission of infections
through hand contact. In the context of patient care, it makes sense to think of glove use and hand
hygiene as complementary strategies to prevent transmission of pathogens. Gloves are critical to
prevent the transmission
Previous: of organisms
1.2 Infection Prevention whenPractices
and Control hand hygiene alone is not enough in an outbreak such
as Clostridium difficile or the norovirus, or when a patient has a suspected or known
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pathogen. Studies have shown that gloves reduce transmission of microbes from the hands of
health care workers (PIDAC, 2012).

Non-sterile gloves are single use and should be applied:

Before an aseptic procedure

When anticipating contact with blood or body fluid, non-intact skin, secretions, excretions,
mucous membranes, or equipment/environmental surfaces contaminated with the above
blood or body fluids

When in contact with a patient or patient equipment/environment during additional

precautions

Non-sterile gloves should be removed:

If gloves are damaged and integrity is compromised

When contact with blood, body fluid, non-intact skin, or mucous membranes has ended

When contact with a single patient and that patient’s surrounding or a contaminated body site
on a patient has ended

When there is an indication for hand hygiene

See Checklist 5 for steps on how to apply non-sterile gloves.

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CHECKLIST 5: APPLYING NON-STERILE GLOVES

Disclaimer: Always review and follow your hospital policy regarding this specific skill.

Safety considerations:

Hands must be clean and dry before putting on gloves. Gloves do not replace the need for
hand hygiene.

Hand hygiene must be performed every time gloves are removed. Gloves are not
completely free of leaks or 100% tear-proof, and hands may become contaminated when
gloves are removed.

Gloves are for single patient use and must be removed after caring for one patient. Reuse
of gloves has been associated with transmission of antibiotic-resistant organisms.

Change or remove gloves if moving from a contaminated site to a non-contaminated site

on the same person or if touching the environment.

Wear gloves that fit properly. Different sizes are available.

Gloves must be removed immediately and discarded in a waste bin after the activity for
which they were used and before exiting a patient’s environment.

Gloves are not required for health care activities where contact is limited to intact skin,
such as taking blood pressure.
Indiscriminate or improper glove use (e.g., wearing gloves all the time) has been linked to
transmission of pathogens.
Gloves should fit snugly around wrists and hands for use with a gown to provide a better
skin barrier.

STEPS ADDITIONAL INFORMATION

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1. Perform hand hygiene.

Hand hygiene with

ABHR

2. Select the appropriate size of non-sterile

gloves. Remove gloves one at a time out of the
box, touching only the top of the cuff.

Remove gloves from box

3. Put hand through opening and pull up to the

wrist.

Apply first glove

4. Repeat procedure with the second hand.

Apply second glove

5. Adjust gloves to cover wrists or gown as Prevents the contamination of the wrists.
required.

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6. Complete care as required.

Non-sterile gloved hands

HOW TO REMOVE GLOVES

1. Grasp glove on the outside about 1/2 inch

below the cuff (edge of the glove opening). Do
not touch the wrist with the other hand.

Grasp glove on the

outside 1/2 inch below
the cuff

2. Pull down glove, turning it inside out. Hold the

inside-out glove in the gloved hand.

Pull glove off …

… inside out

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3. Gather the inside-out glove in the gloved hand.

Gather inside-out glove

in remaining gloved
hand

4. Insert finger of the bare hand under the cuff of

the gloved hand.

Insert finger under cuff

of gloved hand

5. Pull down the glove until it is inside out,

drawing it over the first glove.

Remove second glove

6. Discard gloves in a garbage container. This step reduces the spread of microorganisms.

Discard used non-sterile

gloves

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7. Perform hand hygiene. This step reduces the spread of microorganisms.

Hand hygiene with

ABHR

Data source: Braswell & Spruce, 2012; PIDAC, 2012; Poutanen, Vearncombe, McGeer, Gardam,
Large, & Simor, 2005; PHAC, 2012a; WHO, 2009a

LATEX ALLERGIES AND NON-STERILE (CLEAN) GLOVE USE

A latex allergy is a reaction to the proteins in natural rubber latex (American Academy of
Allergy, Asthma and Immunology, 2014). When people come in contact with latex, an allergic re-
action may occur. Most reactions are mild (asthma-like symptoms or contact dermatitis), but there
are some rare severe cases (reactions). Many hospitals have moved away from using latex gloves,
but latex is commonly used in many health care products such as IV tubing, urinary catheters, sy-
ringes, dressings, and bandages. People at risk for developing a latex allergy are:

Health care workers and others who frequently wear latex gloves

People who have had many surgeries (10+)

People who are often exposed to natural rubber latex

People with other allergies, such as hay fever (allergic rhinitis), or allergies to certain foods

Note that powdered latex gloves have also been associated with latex allergies. If an allergy to la-
tex exists, the best treatment is to avoid latex and use a medical alert bracelet to inform others of
the allergy (PIDAC, 2012).

Critical Thinking Exercises

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1. Name four factors that decrease the effectiveness of hand hygiene.
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2. What are two ways to reduce or prevent skin irritation with hand hygiene or non-ster-
ile (clean) glove use?

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