Wednesday, May 1, 2013

Recommendations regarding hand hygiene for Primary Health Care

Clean Hands

Recommendations regarding hand hygiene for Primary Health Care Personnel  and Health Care Centers in Spain
Jesús Palacioa, Mª Dolores Martínb, Carlos Aibarc, Rosa Marecac and the SEMFYC Patient Safety Working Group*
1.- Introduction
The WHO’s Clean Care is Safer Care campaign gives special attention to hand hygiene. These recommendations are guidelines for Primary Health Care doctors and nursing personnel, as regards when and how we should wash our hands and put on gloves, in order to prevent transmission of diseases to our patients. 
It is up to health care services to provide the resources so that professionals in this field, as well as in others, may offer quality service.

2. Hand hygiene - procedures
-          With liquid soap and water. Useful for eliminating visible dirt. The reduction in the amount of microorganisms depends on the time spent in washing and the soap’s antiseptic content. Antiseptic soaps are more harmful to the skin than regular soaps, and more time is needed to adequately wash when using them. Regular soap eliminates transient or contaminating flora without affecting resident flora. Washing with soap and water can be finished in 40 seconds.
-          With alcohol-based formulations. Handrubbing with alcohol-based formulations is faster, less irritating since these formulations contain an emollient, and has an antiseptic capacity similar to that of washing with antimicrobial soaps. Washing for twenty seconds is sufficient time for adequate antisepsis, equivalent to the time allowed for alcohol volatility.
3. When should we wash our hands and put on gloves?
The recommendations of the Guidelines for Hand Hygiene published in 2002 by the Centers for Disease Control (CDC) serve as the basis for the majority of the guidelines prepared since then. There are no current studies carried out in PHC that show consistent and applicable evidence at this level. With reference to application of the abovementioned recommendations at the Primary Health care level, hand washing is recommended at the following times and under the following circumstances:
3.1 Hand washing:
-          At the start of and after the appointment. It is recommended that hands be washed with soap and water or with an alcohol-based formulation, in case hands are already visibly clean.
-          Before and after carrying out certain exams that involve direct and continual contact with the patient’s skin and mucus:  Respiratory and genital exams

-          Before and after putting on sterile gloves in order to perform interventions that require them, such as minor surgery, treatment of injuries, urinary catheter insertion. The method of choice of PHC is handrubbing with alcohol-based formulations.
-          When there exists risk of exposure to body liquids, such as contact with bodily fluids, secretions or excretions, mucous membranes, broken skin or other objects that show visible evidence of contamination by such liquids.  Also after having been exposed to these risks while wearing gloves, after having taken them off.
-          Between patient consultations, depending on the kind of direct contact that has been occurred between the health professional and the patient, as well as on the patient’s pathology. For instance, it is beneficial to wash hands after auscultating a patient, if there is a chance of contamination. Under these circumstances, the importance of this measure will be related to the risk assessment, in other words, to the type of pathology. The health care professional must adapt this recommendation according to his circumstances, since the risk of hand contamination greatly varies, for instance, if an administrative procedure is performed, such as a patient report or discharge confirmation, or if a patient has been visited that is suffering from a serious disease that is easily transmitted by hand contact.
Some common primary health care exams present low risks, such as checking the pulse, blood pressure, and temperature, performing an ECG or auscultating patients that do not present a contagious pathology. Therefore it is not strictly necessary to take either pre- or post-exam preventive measures either before or after these exams, except in special cases, such as suspected contamination by drops or by contact with microorganisms transmitted by hand contact.
3.2 Use of gloves:
Gloves are a common protective measure for health care personnel and patients. However, by no means does the use of gloves eliminate the necessity of hand washing.
Their use should be limited to the time of their application, being taken off immediately afterwards and specifically not being utilized while attending to different patients, using the telephone, or computer, or writing by hand.
Use of sterile gloves is required for:
-          Handling of skin areas with solution of continuity
-          Treatments and minor surgery
-          Any type of catheterization
The use of clean non-sterile gloves is restricted to:
-          Emergency attention
-          Pelvic and rectal exams
-          Oropharyngeal exam
-          Handling of bodily fluids and contaminated material
-          Blood sample extraction

In any case, hand washing or handrubbing with alcohol-based solutions is indicated, before and after putting on sterile gloves, avoiding the wearing of excessively long nails.
The infectious capacity and the seriousness of potentially transmissible diseases will be kept in mind in order to decide on the required level of hygiene and precautions in particular cases, as with all cases.
4. Recommendations for public health centers
It is the responsibility of the health care management officials, and of the primary health care centers, to supply the necessary resources in order to perform adequate hand hygiene.
Every consulting room should be supplied with:
-          A sink and running water
-          Regular liquid soap with dispenser
-          Disposable towels
-          Alcohol-based formulation with wall dispenser
-          Alcohol-based formulation in small containers of 100 cc, for home visits
-          Moisturizing cream with dispenser
-          Sterile gloves
-          Non-sterile gloves
aFamily practitioner, Centro de Salud Muñoz Fernández-Ruiseñores, Zaragoza, Spain
bSpecialist in Family and Community Medicine, Quality Control Department, Fundación Pública Urxencias Sanitarias de Galicia-061
cSpecialist in Preventive Medicine and Public Health, Patient Safety Department, Servicio Aragonés de Salud (SALUD)
*SEMFYC Patient Safety Improvement Group: Fernando Palacio (coordinator), Carlos Aibar, María Pilar Astier, Rafael Bravo, Maria José Gómez, Marian López, José Ángel Maderuelo, Mª Pilar Marco, Mª Dolores Martín, Sergio Minué, Guadalupe Olivera, Jesús Palacio, Marisa Torijano.
Correspondence: Jesús Palacio, Centro de Salud Muñoz Fernández-Ruiseñores, Pº de Sagasta, 52, 5006, Zaragoza, Spain Email:

Spanish Society of Family and Community Medicine

See also: 

SEMFYC adapts the WHO recommendations on hand hygiene for Primary Care. Aten Primaria 2010; 42(8): 401-402 (Spanish)