Disinfecting Those Digits is Critical

Disinfecting Those Digits is Critical

By Nancy B. Bjerke, BSN, RN, MPH, CIC

While Ingaz Semmelweis is credited with being the father of handwashing,¹ the most predominant teacher was our mothers. Those familiar words, "Go wash your hands," ring loud and clear, filled with the ultimate authority of "I know what is best for you." Much later in our education did the fundamental knowledge crystallize with increasing facts, rationale and emphasis.

RESERVOIR AND TRANSMISSION

Known as the 10 dirty digits, our hands are valuable assets to daily functioning as healthcare personnel and in our ability to care for a myriad of patients. However, these helpful hands have gained some notoriety as culprits in serious infections. Hands, especially under the fingernails, are reservoirs for microorganisms. Unless cleaning under the nails occurs daily, debris accumulates and can be easily transferred to other animate or inanimate sources.

A sign of healthy fingernails is well-manicured nails -- clean, short, with jagged nail tips smoothed away and with surrounding skin intact. Paronychia-free fingernails are evidence that healthcare personnel are conscious of the danger their fingers have for being implicated in outbreaks.² Well-manicured nails exclude the adornment of artificial nails, assorted nail applications and piercing jewelry. Microbes have an affinity for moist, dark areas to establish their habitat and artificial nail applications contribute to this reservoir. Proliferation is natural and rapid for transient organisms.

The most noted link of these adornments and their accompanying nail extension to a major Pseudomonas aeruginosa outbreak was published by the Centers for Disease Control and Prevention (CDC) in February 2000, where the causal links to 16 neonate deaths were a nurse with long natural nails and a nurse with long artificial nails.³

In the healthcare arena, dress codes require conformity for hygiene, safety and identification reasons; yet individuality is obvious in noncompliant personnel who add adornments. A word about nail polish: although it has been written in healthcare guidance that clear nail polish is acceptable⁴, has anyone informed the microbes to avoid it? Nail polish deteriorates, chips and breaks off the nail surface. The time it takes varies based on the age of the polish, its adherence characteristics, health of the nail and the wearer's activity. Polish fragments are foreign bodies that can potentially cause reaction when deposited in wounds through glove tears. Dermatologists report reactions to nail hardeners and lacquers cause onycholysis and secondary Pseudomonas and Candida infections.⁵

The workflow principle is basic to hand cleansing activities and is the separation of dirty, clean, cleaner and cleanest. The workflow pattern is often the guiding premise in reprocessing fomites and maintaining sterile fields. For hand cleansing, the removal of dirt and debris, transient and resident bioburden, and natural skin substances is basic. This is frequently referred to as routine handwashing. Requirements include the physical equipment of a draining sink with warm running water, a liquid non-antimicrobial soap, paper towels and wastebasket. Ideally, operational sensor activated water and soap distribution limit the person's spread of contamination.

If lotion is used in the healthcare arena, compatibility with soap, antiseptics and gloves is essential to avert negating its benefits. Lotion dispensed from a disposable container and disposed of when empty is recommended.⁶

Indications for routine hand cleansing include, but are not limited to: when visibly soiled; in between patient contact; after handling contaminated fomites; before glove placement; after glove removal as mandated by OSHA;⁷ after bodily functions (i.e., toileting, sneezing, coughing, handling body secretions, touching the face, etc.); after smoking; before and after eating. When in doubt, just do it!

The progression to cleaner hands connotes a further decline in surface organisms with a more potent agent, namely an antiseptic. The Food and Drug Administration (FDA) defines a healthcare antiseptic as a product applied topically to the skin to help prevent infection or cross contamination; being frequently used; reducing the number of transient microorganisms on intact skin; having a broad spectrum and being fast acting and persistent.⁸ These antiseptics must meet the testing requirements of FDA before being cleared for market distribution. The familiar comparative list from healthcare guidance includes alcohol, iodine/iodophors, chlorhexidine gluconate, triclosan and para-chloro-meta-xylenol (PCMX).⁹ The physical requirements for routine handwashing apply here with the upgrade from soap to an antiseptic detergent product, requiring a single dose amount specified by the manufacturer's label instructions to be effective.

When the spectrum of care elevates to surgical invasion, handwashing is even more stringent. Known as the surgical hand scrub, the physical requirements generally include some type of hands-free mechanism to initiate a warm stream of water. The FDA-cleared surgical hand scrub is dispensed in an impregnated disposable sponge-brush or is triggered by a no-hands system. The common surgical scrub agents are iodophors, chlorhexidine gluconate, tricolsan, and PCMX formulations.¹⁰ Once again, dosage is product dependent; however, more is not necessarily better or more effective. The sequential steps to scrubbing commence by washing hands and forearms before cleaning under the sublingual areas under running water with a nail pick or file to remove debris accumulation. The steps for the scrub include a count or a timed method which is a local written policy in surgical suites. The anatomical area is expanded from fingertips to two inches above the elbow. The sequent steps for cleansing the skin surface remain the same to maintain skin integrity. The time duration has narrowed from 10 minutes to two minutes based on published research.¹¹ Although this surface is protected with sterile attire, body fluids can still seep through the barrier and contact the skin. Cross transmission can occur between patient and surgical team member and vice versa. The newest tendency is to eliminate the scrub brush due to research indicating this amount of friction increases skin shedding.

Realize that you are responsible to break the chain of infection and handwashing is the most effective, economical, reliable and timely method. 

Nancy B. Bjerke, BSN, RN, MPH, CIC, is an infection control consultant for Infection Control Associates in San Antonio.