WHO Guidelines on Hand Hygiene in Health Care - Safe Care ...

PART I. REVIEW OF SCIENTIFIC DATA RELATED TO HAND HYGIENE
simple and practical solution allowing effective hand hygiene is
for HCWs to wear their ring(s) around their neck on a chain as a
pendant.
23.4 Fingernails and artificial nails
Numerous studies have documented that subungual areas
of the hand harbour high concentrations of bacteria, most
frequently coagulase-negative staphylococci, Gram-negative
rods (including Pseudomonas spp.), Corynebacteria, and
yeasts. 63,534,970 Freshly applied nail polish does not increase
the number of bacteria recovered from periungual skin, but
chipped nail polish may support the growth of larger numbers
of organisms on fingernails. 971,972 Even after careful handwashing
or surgical scrubs, HCWs often harbour substantial numbers
of potential pathogens in the subungual spaces. 154,973,974 In
particular, the presence of fingernail disease may reduce
the efficacy of hand hygiene and result in the transmission
of pathogens. A cluster of P. aeruginosa SSIs resulted from
colonization of a cardiac surgeon’s onychomycotic nail. 523
A growing body of evidence suggests that wearing artificial
nails may contribute to the transmission of certain health
care-associated pathogens. HCWs who wear artificial nails
are more likely to harbour Gram-negative pathogens on their
fingertips than those who have natural nails, both before and
after handwashing 154,534,974,975 or handrub with an alcohol-based
gel. 154 It is not clear if the length of natural or artificial nails is
an important risk factor, since most bacterial growth occurs
along the proximal 1 mm of the nail, adjacent to subungal
skin. 154,972,974 An outbreak of P. aeruginosa in a neonatal ICU
was attributed to two nurses (one with long natural nails and
one with long artificial nails) who carried the implicated strains
of Pseudomonas spp. on their hands. 976 Case patients were
significantly more likely than controls to have been cared for
by the two nurses during the exposure period, suggesting that
colonization of long or artificial nails with Pseudomonas spp.
may have played a role in causing the outbreak. HCWs wearing
artificial nails have also been epidemiologically implicated in
several other outbreaks of infection caused by Gram-negative
bacilli or yeast. 159,167,977 In a recent study, multiple logistic
regression analysis showed the association of an outbreak of
extended-spectrum beta-lactamase-producing K. pneumoniae
in a neonatal ICU resulting from exposure to an HCW wearing
artificial fingernails. 155 A cluster of five cases of S. marcescens
bacteraemia in haemodialysis was associated with a nurse who
used an artificial fingernail to open a vial of heparin that was
mixed to make a flush solution. The strains isolated from the five
patients and the nurse were indistinguishable. 856 Allergic contact
dermatitis resulting in months of sick leave has been reported in
an office worker with artificial nails. 978
Long, sharp fingernails, either natural or artificial, can puncture
gloves easily. 123 They may also limit HCWs’ performance in
hand hygiene practices. In a recent survey among neonatal ICU
HCWs, 8% wore artificial fingernails at work, and knowledge
among them about the relationship between Gram-negative
bacterial hand contamination and long or artificial fingernails
was limited. 960
Jeanes & Green 979 reviewed other forms of nail art and
technology in the context of hand hygiene in health care,
including: applying artificial material to the nails for extensions;
nail sculpturing; protecting nails by covering them with a
protective layer of artificial material; and nail jewellery, where
decorations such as stones may be applied to the nails or
the nails are pierced. In addition to possible limitations of
care practice, there may be many potential health problems,
including local infection for individuals who have undergone
some form of nail technology. 979
Each health-care facility should develop policies on the wearing
of jewellery, artificial fingernails or nail polish by HCWs. These
policies should take into account the risks of transmission of
infection to patients and HCWs, rather than cultural preferences.
Consensus recommendations are that HCWs do not wear
artificial fingernails or extenders when having direct contact with
patients and natural nails should be kept short ( 0.5 cm long or
approximately ¼ inch long).
23.5 Infrastructure required for optimal hand hygiene
Compliance with hand hygiene is only possible if the healthcare
setting ensures the adequate infrastructure and a reliable
supply of hand hygiene products at the right time and at the
right location in alignment with the concept of “My five moments
for hand hygiene” (Part I, Section 21.4). 1 An important cause
of poor compliance may be the lack of user-friendliness of
hand hygiene equipment, as well as poor logistics leading
to limited procurement and replenishment of consumables.
The latter is one of the most commonly cited obstacles to
hand hygiene improvement in developing countries (reports
of workshops hosted by the <strong>WHO</strong> Regional Offices for Africa
(AFRO) and South-East Asia (SEARO) in 2007, see http://
www.who.int/gpsc/in/). As an example, very low overall hand
hygiene compliance (8%) was shown in a university hospital
in Mali where, at the same time, a survey on infrastructure for
hand hygiene demonstrated that no alcohol-based handrub
was available. Only 14.3% of patient rooms were equipped
with sinks, and soap and towels were available at only 47.4% of
sinks. 980 In developed countries, Suresh & Cahill 981 described
several deficiencies in the structural layout of hand hygiene
resources that hinder their usage: poor visibility, difficulty of
access, placement at undesirable height, and wide spatial
separation of resources that are used sequentially.
Other parts of these <strong>Guidelines</strong> have already described the
need for clean water for handwashing and have elaborated on
the advantages of handrubs over handwashing, namely, the
freedom from the requirement of sinks and the possibility to
clean hands at the point of care. While describing the overall
infrastructure necessary, this section is particularly focused on
soap and handrub dispensers.
23.5.1 General guidelines
All health-care settings should have written guidelines
describing the appropriate placement of sinks and soap and
handrub dispensers. Furthermore, the delegated responsibility
with regards to supply of hand hygiene products, replenishment
of consumables, and maintenance of the dispensers should be
clearly described and communicated.
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