The Importance of Hand Hygiene in Ambulatory Care Settings

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Tiny menaces, known as germs, lurk on skin and surfaces, awaiting the opportunity to grow into serious infections and spread to unsuspecting health care providers and patients. Luckily, in the 19th century, the concept of handwashing during patient care emerged by outlining the strategy of hand hygiene as a tool to combat the spread of deadly infections. More than 100 years ago, in an Austrian hospital, Ignaz Semmelweis demonstrated the power of hand hygiene in patient care by implementing hand hygiene measures for students assisting with deliveries in the maternal ward.¹ It is from Semmelweis’ study that explains an effective action plan and years of credible evidence of infection reduction from various researchers around the globe that hand hygiene is cited as the “single most effective way to prevent the transmission of disease.”¹ It is essential for health care providers who have direct contact with patients to exercise their ability to combat the spread of germs through the simple and inexpensive act of performing hand hygiene.

Hand hygiene was not a standard method of defense in Semmelweis’s era. Still, hand hygiene is unquestionably the most essential tool in the health care provider’s arsenal for preventing infections today. It has been said that Semmelweis’ study marks the beginning of infection control.¹ According to the former head of the CDC and world-renowned public health and biosecurity expert Julie Gerberdin, MD, MPH,¹ “It was a landmark achievement not just in health care settings but in public health in general because today the value of handwashing in preventing disease is recognized in the community, in schools, in child care settings, and in eating establishments.”¹

Ambulatory Care Settings

Typically, acute care facilities receive the most recognition for their ability to mitigate the risk of spreading health care–associated infections. However, ambulatory care settings (eg, clinics, urgent care centers, ambulatory surgical centers, imaging centers, dialysis centers, physical therapy centers, rehabilitation centers, and alternative medicine clinics) work just as hard to protect the millions of patients seen each year. They must rely heavily on the simple and inexpensive measure of hand hygiene to safeguard against potentially fatal infections from spreading from patient to patient, patient to health care worker, and vice versa. The increasing demand for outpatient care is associated with a higher risk of infection transmission in these settings. The CDC published the Guide to Infection Prevention for Outpatient Settings: Minimum Expectations for Safe Care to ensure that outpatient facilities have efficient guidelines on standard precautions, including hand hygiene.² Also, the World Health Organization (WHO) provides “5 Moments for Hand Hygiene in Outpatient Settings,” which outlines a consistent routine for infection prevention through hand hygiene.³

Corresponding with data from the hospital setting, health care workers in ambulatory settings perceive their hand hygiene performance as proficient or even optimal while justifying any observed noncompliance as a lack of time or the patient’s undocumented infection status. This phenomenon lends to the common misconception that the risk of infection in the ambulatory care setting is low, but this stems from the lack of data to substantiate any infections related to the care received in an ambulatory care setting, given the patient’s short stay in the facility. The patient’s length of stay also makes it challenging to determine community-acquired infections and health care–associated infections in ambulatory care settings. This reason alone substantiates the need for meticulous hand hygiene in ambulatory care settings.

Hand Hygiene Approach

The primary methods of hand hygiene in ambulatory care settings are alcohol-based hand rubs/sanitizers and soap and water. Some might find it surprising that the CDC cites alcohol-based hand rubs/sanitizers as the primary method of hand hygiene in health care settings.⁴ Hand sanitizer is preferred over soap and water in most clinical situations due to evidence of better compliance compared with that of soap and water. Soap and water are the only preferred methods for hand hygiene when hands are visibly soiled. Washing hands with soap and water may be the best technique to remove germs. Still, if soap and water are not readily available, using hand sanitizer with at least 60% alcohol can kill many germs that can cause harmful infections.

No matter where you are or what you are doing, performing hand hygiene is an imperative step in germ protection. The hand hygiene recommendations from the CDC vary depending on the setting. The CDC recommends using alcohol-based hand sanitizer for health care settings unless hands are visibly dirty. Switching between sanitizer and handwashing is helpful for health care providers who wash their hands multiple times a day.⁵ Washing hands frequently with soap and water may result in dry, cracked skin, leading to increased discomfort and skin infections. Currently, the CDC recommends handwashing whenever circumstances allow. Hand sanitizer may have the ability to kill bacteria and most viruses precisely, but handwashing can effectively remove all dirt, microbes, and chemicals on the hands.

Hand Hygiene Basics

All elements of handwashing are key: friction for removing debris; soap to emulsify dirt, chemicals, and microbes; and running water to remove the debris.⁵ Here are 5 steps to wash hands appropriately⁶:

1. Wet the hands with clean running water, either warm or cold, and apply soap.
2. Lather the hands by rubbing them together with the soap. Lather the backs of the hands, between the fingers, and under the nails.
3. Scrub the hands for at least
   20 seconds.
4. Rinse the hands under clean running water.
5. Dry the hands with a clean towel or air-dry them.

The WHO defined 5 moments of hand hygiene to explain when a health care worker should perform hand hygiene to maintain the utmost health and safety for everyone in their facility³:

1. Before touching a patient
2. Before clean/aseptic procedures
3. After bodily fluid exposure/risk
4. After touching a patient
5. After touching patient surroundings

Effectiveness

Hand sanitizer and handwashing offer adequate protection against the spread of infectious pathogens, but both methods will only work effectively if they are used correctly. The 20 seconds recommended to scrub hands with clean running water and soap during handwashing is not arbitrary because this allows adequate time for the soap to dissolve potential viruses and bacteria.⁶ Also, hand sanitizer should be rubbed for at least 20 seconds or until hands are thoroughly dry. A common mistake is using too little sanitizer to cover both hands, with dispensers often releasing less than the recommended quantity in a single pump. Ultimately, hand hygiene promotion must encourage appropriate performance moments and thorough techniques.

Culture

The infection prevention and control culture, including hand hygiene, should be among the highest priorities in outpatient care settings worldwide. Ambulatory health care facilities must regularly revisit their current procedures to ensure that hand hygiene protocols are continuously maintained to the highest standard. Also, patients should be motivated to contribute to creating a safe patient climate. The growing number of patients accessing outpatient settings is more reason to provide patient education on the importance of appropriate hand hygiene practices by health care workers and the patient’s role in preventing infection transmission. Fundamentally, hand hygiene is everyone’s responsibility because hand hygiene benefits everyone’s health.

REFERENCES

1. Why is handwashing important? News release. CDC. March 6, 2000. Accessed November 20, 2023. https://www.cdc.gov/media/pressrel/r2k0306c.htm

2. Guide to infection prevention for outpatient settings: minimum expectations for safe care. CDC. Updated September 9, 2014. Accessed November 20, 2023. https://www.cdc.gov/hai/settings/outpatient/outpatient-care-guidelines.html

3. Hand Hygiene in Outpatient and Home-Based Care and Long-Term Care Facilities. World Health Organization. May 5, 2012. Accessed November 20, 2023. https://iris.who.int/bitstream/handle/10665/78060/9789241503372_eng.pdf?sequence=1

4. Hand hygiene guidance. CDC. Updated January 30, 2020. Accessed November 20, 2023. https://www.cdc.gov/handhygiene/providers/guideline.html

5. Murcia J. Handwashing vs hand sanitizer -what’s the difference? UCLA Health. March 10, 2020. Accessed November 20, 2023. https://www.uclahealth.org/news/handwashing-vs-hand-sanitizer-whats-the-difference

6. Frequent questions about hand hygiene. CDC. Updated November 4, 2022. Accessed November 20, 2023. https://www.cdc.gov/handwashing/faqs.html