Hand hygiene is the most important measure a healthcare worker can take to prevent the spread of pathogens and reduce healthcare-associated infections (HAIs). These infections pose a significant risk to patients. The choice of cleaning agent depends entirely on the condition of the hands and the potential exposure. The primary rule is clear: hands that are visibly dirty require mechanical removal of the soil using plain soap and water, not an alcohol-based rub.
When Visible Soil Demands Soap and Water
The presence of visible dirt, blood, or other organic bodily fluids on a healthcare worker’s hands immediately invalidates the use of alcohol-based hand rubs. Alcohol is a chemical disinfectant, and its efficacy is significantly hampered by organic matter. Physical debris can coat the microbes, creating a barrier that prevents the alcohol solution from making direct contact with and inactivating the microorganisms.
The standard procedure in this scenario is a thorough hand wash using liquid soap and water. Soap works by creating an emulsion, lifting the physical debris and microorganisms from the skin surface. The friction generated from rubbing the hands together, combined with the rinsing action of the water, physically flushes the contaminants down the drain. This mechanical action is necessary to remove the physical soil.
The Preferred Standard: Alcohol-Based Hand Rubs
For routine hand hygiene when hands are not visibly soiled, the standard of care is the use of an alcohol-based hand rub (ABHR). These products are the preferred method for quick hand antisepsis due to their superior speed and broad-spectrum germicidal activity. The typical formulations contain 60% to 95% alcohol, usually ethanol or isopropanol, which rapidly denatures the proteins of bacteria, viruses, and fungi.
Alcohol-based hand rubs are faster to apply and less irritating to the skin than frequent washing with soap and water, which contributes to better compliance among staff. Healthcare workers should use ABHR immediately before and after touching a patient, before performing a clean or aseptic procedure, and after contact with the patient’s surroundings. This method is highly effective for eliminating non-spore-forming organisms commonly transmitted in healthcare settings.
Pathogen-Specific Requirements for Handwashing
While alcohol rubs are excellent for routine care, certain pathogens require the mechanical action of soap and water, even if the hands appear clean. This is primarily true for spore-forming bacteria, most notably Clostridioides difficile (C. diff). The alcohol in hand rubs is not sporicidal, meaning it does not kill the protective spores that C. diff produces.
When caring for a patient with known or suspected C. diff infection, the only reliable way to decontaminate the hands is through washing with soap and water. The friction and rinsing action physically removes the spores from the skin surface, preventing their transfer to other patients or areas. Soap and water washing is also mandated after using the restroom or before eating, regardless of patient contact.
Ensuring Efficacy: The Proper Technique
Regardless of the agent used, the effectiveness of hand hygiene relies heavily on the proper technique and duration. When washing with soap and water, the entire process should take at least 15 to 20 seconds of active scrubbing. This time allows the soap to emulsify the debris and for friction to work across all surfaces of the hands.
The technique requires rubbing palms together, interlacing fingers, rubbing the back of each hand, and paying close attention to the thumbs, fingertips, and area underneath the nails. For alcohol-based hand rubs, the technique involves applying enough product to cover all surfaces of the hands completely. The hands must be rubbed together until the solution has fully dried, which typically takes around 20 to 30 seconds.