s

RECOMMENDED PRACTICES

Implementing AORNRecommended Practicefor Hand HygieneMARCIA PATRICK, MSN, RN, CIC;SHARON A. VAN WICKLIN, MSN, RN, CNOR, CRNFA, CPSN, PLNC

www.aorn.org/CE

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ABSTRACT

This article focuses on implementing the revised AORN “Recommendedfor hand hygiene in the perioperative setting.” The content of the documenexpanded and reorganized from the previous iteration and now includactivity statements about water temperature, water and soap dispensing cotype of dispensers to use, paper towel dispenser requirements, placement orub dispensers, and regulatory requirements for products and recommendhand hygiene practices. A successful hand hygiene program allows end usinput into the selection and evaluation of products and should includepersonnel about proper hand hygiene, product composition and safety, anwhen to use specific products. Measures for competency evaluation and cmonitoring include observations, quizzes, skills labs, electronic monitorinhandheld device applications, and data collection forms. AORN J 95 (A492-504. © AORN, Inc, 2012. doi: 10.1016/j.aorn.2012.01.019

Key words: AORN recommended practices, hand hygiene, surgical hand a

endeperi

publiandar

9 and sub-

of the book.

ended prac-

guidance for

invasive

even recom-

ve RNs iden-

optimal and

he periopera-

can be

gical and

contacrn thewingletingationhours

The revised AORN “Recommtices for hand hygiene in thetive setting” document was

online in AORN’s Perioperative St

indicates that continuing educationhours are available for this activity. Eatact hours by reading this article, reviepurpose/goal and objectives, and componline Examination and Learner Evaluhttp://www.aorn.org/CE. The contact

this article expire April 30, 2015.

492 AORN Journal ● April 2012 Vol 95 N

d prac-opera-shedds and

Recommended Practices in July 200

sequently in the 2010 print edition

The purpose of the revised recomm

tices (RP) document is to “provide

hand hygiene for surgical and other

procedures.”1(p73) The RP includes s

mendations that will help perioperati

tify specific practices representing an

achievable level of hand hygiene in t

tive setting. These recommendations

adapted to various settings where sur

tcon-

thetheatfor

other invasive procedures are performed.

doi: 10.1016/j.aorn.2012.01.019

o 4 © AORN, Inc, 2012

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RP IMPLEMENTATION GUIDE: HAND HYGIENE www.aornjournal.org

WHAT’S NEWThe 2009 “Recommended practices fgiene in the perioperative setting”1 su2005 document, “Recommended pracgical hand antisepsis/hand scrubs.”2 Tchanges do not relate as much to cosion as they do to expansion and reof the content. Procedures for handhave been separated from procedurecal hand antisepsis, and each is nowof a distinct recommendation. Instrsurgical hand antisepsis using an ansurgical scrub agent and surgical hasis using an alcohol-based antiseptibeen combined into a single recommrather than remaining two separatedations as they were previously.

Several new activity statements haadded to address various aspects of hhygiene,1(p76) including the need for

� water temperature at the faucet totained between 105° F and 120° F48.9° C),

� hands-free water and soap dispenin new or remodeled facilities,

� paper towel dispensers designed ithat prevents recontamination of twhen removing towels, and

� proper placement of alcohol-basedseptic product dispensers in areassurgical and other invasive procedare performed.

Hand antiseptic product dispensersflammable antiseptics may be a fire heas where oxygen and ignition sourcent; therefore, an activity statement waddress the importance of dispensersstalled in accordance with the Nationtection Association Life Safety Codestate and local regulations.

The previous RP document containrecommendation for developing polic

cedures that also discussed the need for ed

nd hy-des thefor sur-rimaryt revi-izationingsurgi-topics forrobial

ntisep-have

ationmen-

en

ain-6° C to

ontrols

annernds

d anti-e

containin ar-pres-ded toin-

e Pro-ell as

singled pro-

perioperative personnel regarding surantisepsis. The current RP documentthree separate recommendations relattion and competency validation, policdure development, and quality managgrams. The current RP document alsotable that compares the activity of haagents and various considerations thataken into account when selecting the

RATIONALEMore than 150 years ago, Ignaz SemOliver Wendell Holmes independentlthat the hands of health care providetransmit infection to patients. They estrated that the use of an antiseptic sreduced the risk of infection,3 but itfor hand hygiene to achieve widespretance as a valuable infection preventi

Infections acquired during treatmecal or surgical conditions are knowncare-associated infections (HAIs).4 Hassociated infections can occur in allsettings and are associated with a varcauses (eg, medical devices such asand ventilators, overuse of antibiotision between patients and health caers).4 Health care-associated infectiarise from a wide variety of commocommon bacteria, viruses, and fung2007, the greatest percentage of HAnary tract infections (34%), followecal site infections (17%), bloodstreations (14%), and pneumonia (13%)

A significant cause of morbidityity, HAIs have been estimated to acapproximately 1.7 million infectiondeaths in the United States each yestays for methicillin-resistant Staphaureus (MRSA) infections have incmost 10-fold since 1995 and have mtripled since 2000.6

Prevention of HAIs must be a prio

ucating health care personnel, regardless of their work

AORN Journal 493

ieneHAInismestim

ne pr50%.7

ed had, evid hygy red

that are incters f

plemeimbuciatedreportand thry re

(ie, an interogre

e persarm.”the c

thogetatioquire

s developingn the pro-monitoringthe responsi-e RN to en-

patientscedures in

hand care,proper usehand hygieneemployeea good way

tion—theser hand hy-roduct safety

l safety datasure thatthe requisiterform theand to helpmportant torioperative

policiesuipment,

ollow estab-aintaining

d fingernail

egarding the

elry in the

tting.”1(p73)

rsonnel must

to properlynds totation and tofrom patho-. Personnelse productsashes orirritation.

April 2012 Vol 95 No 4 PATRICK—VAN WICKLIN

setting. Lack of appropriate hand hygconsidered to be the leading cause ofthe spread of multidrug-resistant orgaassociated outbreaks,3 yet it has beenthat adherence to optimal hand hygieby health care providers is less thanthough the definitive effect of improvgiene on HAIs has not been identifiesupports the theory that effective hanhealth care providers can substantiallinfection rates.3

As a result of HAIs, it is estimatedhealth care costs in the United States aby $28 billion to $33 billion.8 The CenMedicare & Medicaid Services has imfinancial disincentives by refusing to rehealth care organizations for costs asso“hospital acquired infections.”9 Publicinfections is now required in 31 statestrict of Columbia, one state has voluntaand five other states have a study lawfloated before the legislature without apass it at that time or in that form) in p

DISCUSSIONEffective hand hygiene by health carsupports the maxim of “first, do no hhygiene is currently considered to bestone for preventing the spread of paorganisms. To be effective, implemenadvances in practices and products re

AORN Resources� Confidence-Based Learning m

Perioperative Setting. http://wwCurriculum/Confidence_Basedthe_Perioperative_Setting_CB

� Periop 101: A Core CurriculumEducation/Curriculum/Periop1

� AORN Clinical Answers: handClinical_Practice/Clinical_Ans

Web site access verified Decembe

494 AORN Journal

iss ands andated

acticesAl-nd hy-denceiene by

uce

nnualreasedorntedrsewith

ing ofe Dis-

porting,lawnt toss.10

onnelHand

orner-nicn ofs a

programmatic approach. This includeand implementing policies that govercesses and products used, as well ascompliance with these policies. It isbility of the professional perioperativsure safe, high-quality nursing care toundergoing surgical and invasive proall settings.

Educating health care providers onhand antisepsis, and the purpose andof products is critical for a facility’sprogram. Education begins with neworientation. Orientation checklists areto keep track of new employee educashould include the elements of propegiene as well as elements related to p(eg, flammability, chemicals, materiasheets). A solid orientation helps ennew perioperative employees haveknowledge and skills to properly petasks associated with their positionprevent future problems. It is also iprovide ongoing education to all peemployees as a reminder of existingand as changes arise in products, eqprocesses, and procedures.

Recommendation I“All health care personnel should flished hand hygiene practices for m

healthy skin an

condition and r

wearing of jew

perioperative sePerioperative pe

understand howcare for their haprevent skin irriprotect patientsgenic organismswill likely not uthat give them rcause other skin

: Hand Hygiene in thern.org/Education/ning/Hand_Hygiene_in_

x.http://www.aorn.org/riop_101.aspx.

iene. http://www.aorn.org//Clinical_Answers.aspx.

2011.

odulew.ao

_LearL.asp

™.01/Pehyg

wers

r 19,

The use of alcohol-based

helption f

can

ion w

nsmit

and a

ansm

ng th

ene p

nd he

wettinashin

the C3 reco

e pra

the h

easie

disp

velop

ationalso ce difUsin

sing o

ature

20° F

prov

erma

loose

tip of the

ing resinrylic over-14

acceptable asr crazed.15,16

or wrists.eria.3,13,15,17

e with bothe prod-giene prod-and approved

the author-ions.

m the periop-threat toviders whormatitis, or

ould notthe skin

mmendation,be educatedcts. Educa-n, how toc functione at the fa-am is not a

for this

755-

ation

x.

RP IMPLEMENTATION GUIDE: HAND HYGIENE www.aornjournal.org

hand rubs containing emollients mayduce skin damage, dryness, and irrita

antiseptic preparations.3 Irritated skin

rough and broken, allowing colonizat

pathogenic organisms that can be tra

patients or the patient’s environment

creasing the potential for acquiring tr

infections from the patient.11 Followi

ufacturer’s instructions for hand hygi

use increases product effectiveness amaintain skin integrity.

A good example is the need forhands before applying soap when w

Most hand soap manufacturers and

for Disease Control and Prevention

mend this, but it is a skin-protectiv

that sometimes is ignored. Wetting

loosens transient soil and makes it

move. Wetting the hands also helps

product more evenly and aids in de

lather that may enhance skin penetrtoo much or too little of a producta problem. Too much product can bto rinse off, causing skin irritation.

little can result in inadequate clean

infection of the skin. Water temper

be maintained between 105° F to 1

cause a comfortable temperature im

acceptance and aids in preventing d

Thorough drying helps remove soilduring hand washing, andblotting rather than rubbingcan decrease skin irritation.

Health care providersshould adhere to the follow-ing practices:

� Keep fingernails short, notto exceed 1/4 inch.13 Aneasy and effective way toensure that nails are theproper length is to holdthe hand vertically and

R�

�

�

W

look at the palmar side;

to re-rom

become

ith

ted to

lso in-

issible

e man-

roduct

lps to

gg.

enters

m-

ctice

ands

r to re-

erse the

ing a

. Usingan beficultg too

r dis-

should

be-

es user

titis.12

ned

nails should not extend beyond thefinger (Figure 1).

� Do not wear artificial nails, includbonding, extensions, tips, gels, aclays, resin wraps, or acrylic nails.

� Maintain nail polish. Nail polish islong as it is not chipped, cracked, o

� Do not wear jewelry on the handsHand and wrist jewelry traps bact

� Use hand lotion that is compatiblgloves and antiseptic hand hygienucts.3,18,19 As with other hand hyucts, lotions should be evaluatedby an interdisciplinary group withity to evaluate and select hand lot

� Exclude health care providers froerative environment if they pose apatient safety (eg, health care prohave cuts, abrasions, weeping defresh tattoos on exposed skin shprovide direct patient care untilis healed).

To effectively implement this recoperioperative personnel will need toabout appropriate practices and prodution should cover product compositioproperly use products, and the specifiand application of each product in uscility. For example, alcohol-based fosurgical scrub and should not be used

ources for ImplementationRN Nurse Consult Line. (800) 755-2676 or (303)0, option 3.Nurse Link. http://www.aorn.org/ORNurseLink.

ioperative Job Descriptions and Competency Evaluols [CD-ROM]. http://www.aorn.org/Books_and_blications/AORN_Publications/Perioperative_Job_scriptions_and_Competency_Evaluations_Tools.asp

te access verified December 19, 2011.

esAO630ORPerToPuDe

eb si

AORN Journal 495

o use

,” the

and

conten

m. U

hand

toring

ative

in th

spec

ho f

re add

in su

prov

wards

res ch

ashi

and w

d cor

d, wrist, and

er must wash

d leaving

ith a patient

ing or re-

g or using

sibility that

other poten-

, and when

need for

ved, hands

nd rub

d water for at

effective in

e Centers for

mends the use

f soap and

d.3

or hand

ld take the

nd the

April 2012 Vol 95 No 4 PATRICK—VAN WICKLIN

purpose. If a facility’s policy states t

ucts “per manufacturer’s instructions

current instructions must be available

members should be educated on the

the instructions and where to find the

personal calendar that indicates when

giene educational activities and moni

occur can be very useful for perioper

overseeing hand hygiene compliance

facility.

Education should be tailored to the

personnel. For example, individuals w

in the role of scrub person will requi

education and competency validation

hand antisepsis. Education should be

initial hire and at least annually after

well as any time products or procedu

Recommendation II“A standardized procedure for hand w

should be followed.”1(p75) A proper h

includes using the correct product an

Figure 1. Nails should not extend beyo

amount of product; applying it for the requ

496 AORN Journal

prod-

most

team

ts of

sing a

hy-

should

RNs

e

ific

unction

itional

rgical

ided on

, as

ange.

ng

ash

rect

amount of time; and covering all han

finger surfaces.

A perioperative health care provid

his or her hands when coming on an

duty, before and after each contact w

or the patient’s environment, on donn

moving gloves, before and after eatin

the restroom, any time there is a pos

there has been contact with blood or

tially infectious materials or surfaces

hands are visibly soiled.3,20

Wearing gloves does not replace the

hand hygiene.21 When gloves are remo

must be washed or an alcohol-based ha

used.22,23 Washing hands with soap an

least 15 seconds has been shown to be

removing pathogenic organisms.3,20 Th

Disease Control and Prevention recom

of an alcohol-based hand rub instead o

water when hands are not visibly soile

To perform the proper procedure f

washing,3 health care providers shou

tips of the fingers.

ired following steps:

recom

wristnd pa

thedispo

aucetvent

onvecordiGuid

th Cace for

oulders cogenshou

towelshou

from the topome con-els that are

n a counterreason.

alcohol-ensing thef productuntil theions for us-s include

contain atlth care set-ol-free prod-

lth care use.3

Association-based hand

feet apart;, corridors,ot be placedtlet or

ons may be

s should be

hand

RP IMPLEMENTATION GUIDE: HAND HYGIENE www.aornjournal.org

� Remove hand and wrist jewelry.� Use warm water to wet hands.� Apply soap per the manufacturer’s

dations.� Scrub all skin surfaces, including

of hands, fingertips, inner webs, aat least 15 seconds.

� Rinse thoroughly to remove all of� Dry with nonabrasive, absorbent,

paper towels.� Use paper towels to turn off the f

open the door, if necessary, to pretamination of hands.

Hand washing stations should be clocated throughout the facility and aclocal and state building codes.12 Thefor Design and Construction of Healcilities, 201024 is an excellent resourplacement requirements.

Cartridge-type soap dispensers shused because refillable soap containcome contaminated and spread pathusers’ hands.25 Paper towel holderslow the user to pull down a singleout touching the dispenser. Towels

Figure 2. Application of alcohol-based

dispensed from the bottom of the dispen

men-

s, backslms for

soap.sable

s and torecon-

nientlyng toelinesre Fa-sink

bean be-s to theld al-with-

ld be

In-counter containers that dispenseare not acceptable because they bectaminated easily.26 Use of paper towstacked on top of the dispenser or oshould be discouraged for the same

If hands are not visibly soiled, anbased hand rub may be used3 by dispmanufacturer-recommended amount oand briskly rubbing all skin surfacesproduct is dry (Figure 2). Considerating alcohol-based hand rub dispenserthe following:

� An alcohol-based hand rub mustleast 60% alcohol for use in a heating. Currently, there are no alcohucts that meet the criteria for hea

� The 2004 National Fire ProtectionLife Safety Code requires alcoholrub dispensers be placed at least 4hold no more than 1.2 L in roomsand areas open to corridors; and nwithin 6 inches of an electrical ouswitch.20,27 State or local regulatimore stringent.

� Alcohol-based hand rub container

rub.

ser. disposable and never refilled from another

AORN Journal 497

placimmmem

equenrtanthat p

indire coto into pto e

trol dnd lo

facili, soapub diof croave tks, sdisp

ed toconst

sibiliRNs

elinggieneRNs solicesleagurativehealtnd whandnd hye faciss m

gramperfo

persomilia

for alcohol-fire? Cann instructionsproducts andrvations arecompliancean individu-nd for a sin-lements ineing per-d hygiene ofnother op-

g whichugh a stationThis pro-one withere are alsose when thehe patientactivatesrub dis-

d badges atspent; videotain compli-e compli-

facility, but.29-33

performedonning ster-vasive pro-robial sur-rgical hand

ntiseptic sur-persistentmet USFDA) regu-hand anti-

rubs must bergical handll skin sur-

April 2012 Vol 95 No 4 PATRICK—VAN WICKLIN

container.28 Some facilities havealcohol-based hand rub containersoutside each OR and require teamto “gel/foam in, gel/foam out.” Frconsistent use is particularly impoto multidrug-resistant organisms tmay or may not be aware of in anpatient. Dispenser locations that anient and easily spotted are likelycompliance.3 Other areas in whichalcohol-based hand rub dispensersage hand hygiene include the connursing station, anesthesia carts, abreak rooms.

� New construction and remodeledshould include hands-free faucetspensers, and alcohol-based hand rers because these reduce the riskcontamination. It is important to hmember input on placement of sinalcohol-based hand rub and towelor any other critical element relathygiene in any OR renovation orproject.

As patient advocates with a responensure safe patient care, perioperativetake an active role in following, modpromoting best practices for hand hymuch as it is possible, perioperativeactively monitor that hand hygiene pprocedures are being followed by colteam members. Additionally, periopeshould support and participate in theorganization’s educational activities aensure that engineering controls (eg,ing stations) are provided and that hais easy and convenient throughout th

Competency and compliance proceevaluations for the hand hygiene proaccomplished through observation ofand verbal quizzing of perioperativeelements of the program—are they fa

the products, indications, contraindications

498 AORN Journal

edediatelyberst andrelative

ersonnelvidualnve-creaselacencour-esk, theunge or

tiesdis-

spens-ss-eamoap,ensers,handruction

ty tomust

, and. In sohouldand

es andRNs

h careork towash-giene

lity.easurecan bermancennel onr with

proper use and the special precautionsbased products to reduce the risk ofthey locate the manufacturers’ writteand recommendations for use of thethe material safety data sheets? Obseanother excellent tool for measuringwith hand hygiene. One can observeal’s performance from beginning to egle procedure, checking that all the ethe competency evaluation tool are bformed correctly or by observing hanall personnel at the start of the day. Ation is to implement skills labs, durineach employee is required to go throand correctly perform a skill or task.vides an opportunity to work one-on-anyone who is having a problem. Thelectronic monitors available that senhealth care provider is approaching tand whether the health care providereither the soap or alcohol-based handpenser. Other monitoring systems reasinks and record the amount of timemonitoring can also be used to ascerance. These electronic systems providance reports by individual, unit, andthey are expensive to acquire and use

Recommendation IIIA surgical hand scrub should beby health care providers before dile gloves for surgical or other incedures. Use of either an antimicgical scrub agent intended for suantisepsis or an alcohol-based agical hand rub with documentedand cumulative activity that hasFood and Drug Administration (latory requirements for surgicalsepsis is acceptable.1(p77)

All products used as surgical hand scFDA approved for this purpose.34 Suantisepsis will only be successful if a

, and faces are exposed to the mechanical cleaning and

ryingrsiste

ical hrovid:

and

asks srub s

ey ar

posab3).unnin

ly wi

menduct a

cordions.

dry.

s, don aloves in the

-water prod-ioperative

ete the fol-

and other

asks shouldrub sink

soap and

il pick under

unning

ial scrubritten

using a soft,

ally scrubr three

RP IMPLEMENTATION GUIDE: HAND HYGIENE www.aornjournal.org

chemical antisepsis process. A fast-dand chlorhexidine product that has peresidual effect is preferred.3

When using an alcohol-based surgantiseptic, perioperative health care pshould complete the following steps3

� Remove rings, watches, bracelets,hand jewelry.

� Don a surgical mask—surgical mbe worn by all personnel at the scduring hand scrub activity.

� Prewash hands and forearms if thbly soiled.

� Clean under fingernails with a dispick under running water (Figure

� Rinse hands and forearms under rwater.

� Dry hands and forearms thoroughposable paper towels.

� Dispense the manufacturer-recomamount of surgical antisepsis prodapply it to hands and forearms acthe manufacturer’s recommendati

� Repeat application as directed.� Rub thoroughly until completely

Figure 3. Cleaning the areas under fingernai

alcoholnce and

anders

other

houldink

e visi-

le nail

g

th dis-

edndng to

� For surgical or invasive proceduresterile surgical gown and sterile gOR or procedure room.

When using a traditional scrub-withuct for surgical hand antisepsis, perhealth care providers should compllowing steps15:

� Remove rings, watches, bracelets,hand jewelry.

� Don a surgical mask—surgical mbe worn by all personnel at the scduring hand scrub activity.

� Prewash hands and forearms withwater if they are visibly soiled.

� Clean under fingernails with a narunning water.

� Rinse hands and forearms under rwater.

� Dispense the approved antimicrobproduct per the manufacturer’s winstructions.

� Apply to wet forearms and handsnonabrasive sponge.13,35

� Keeping hands elevated, methodicall skin surfaces with a sponge fo

ls during surgical hand scrub.

AORN Journal 499

rer’s

he fau

contds ander r

sterilown

hygiis ron vals beompmbers asw toplica

it and re-.36 Addi-llectionfor Health-l kit.37

ld be selectedctiveness,ptance.”1(p78)

the collabora-the multidis-rol committeeize producthygieneection and, and skinat are notterrent toation criteriae following:

April 2012 Vol 95 No 4 PATRICK—VAN WICKLIN

to five minutes, per the manufactuinstructions.

� For water conservation, turn off twhen it is not in use, if possible.

� Avoid splashing surgical attire.� Discard sponges in an appropriate� Keeping hands elevated, rinse han

arms from fingertips to elbows unwater (Figure 4).

� In the OR, dry thoroughly with acal towel before donning sterile ggloves.

One strategy for improving handcompliance in health care facilitiesobservation and feedback. It is ofteable to have different team membersible for monitoring hand hygiene cat various times. Assigned team meshould be provided with instructionspecific activities to observe and hoobservations. There are software ap

Figure 4. Rinsing from fingertips to elbows d

500 AORN Journal

cet

ainer.d fore-

unning

e surgi-and

eneutineu-respon-liancesto therecord

tions

that can be tailored to a specific unsults entered into a handheld devicetionally, sample compliance data coforms are available in the Institutecare Improvement hand hygiene too

Recommendation IVSurgical hand hygiene products shoufollowing an analysis of product effeapplication requirements, and user accePerioperative RNs can participate intive evaluation process as members ofciplinary infection prevention and contand as individual end users. To maximacceptance, end users of surgical handproducts should have input into the selevaluation regarding the feel, fragrancetolerance of such products. Products thwell accepted by end users can be a defrequent hand hygiene.20 Written evalushould include, but not be limited to, th

uring surgical hand scrub.

utcom

rds, F

lectioost alwillsmalbe s

iple pprovinneler ofve seirrit

es noa sheeachle proshouluctsto be

alson an

identie ind

lved

and hl threpeten

assura

practice rec-ive initialcy validationting new

affords anate compe-

AORN’sdevelopedtions andsist perioper-tency evalua-

developed,essary, andg. New orpresent anith nurses

s in the facil-cies and pro-d practices.mplates, 2ndample poli-on AORN’snded Prac-jects are nec-ensure safe,ee practicee RP docu-fer to the full

RIOcare unit athelpingn Mr P, whoS sees

ring forwashing his

take?iling to per-s puttingy personnelaction for

RP IMPLEMENTATION GUIDE: HAND HYGIENE www.aornjournal.org

� safety,� purpose and use,� ease of use,� skin comfort and reaction,� fragrance,� consistency,� color,� compatibility with other products,� patient and health care provider o� efficacy,� regulatory control (eg, fire standa

approval), and� cost.

Cost is listed last because product seshould not be made on the basis of c

It is unlikely that a single productfor everyone. There will always be aber of health care providers who willto any given product, so often multare needed to serve all health careThis can frustrate purchasing persoto standardize and reduce the numbproducts; however, it is better to haacceptable products and reduce skinissues than a single product that dofor everyone. A material safety datbe on file and readily available forused in the facility, including samp

Facility policies and proceduresclearly delineate hand hygiene prodsoaps, antiseptics, lotions) that arethe facility. Policies and proceduresinclude written criteria for evaluatiotion of hand hygiene products anddesignated approving body and thosals, including end users, to be invoevaluation process.

The Final ThreeIn the “Recommended practices for hin the perioperative setting,”1 the finaommendations discuss education/compolicies and procedures, and quality

performance improvement. These topics ar

es,

DA

none.workl num-ensitiveroducts

ders.who trylikeveralationt worket mustproductducts.

d(eg,used inshould

d selec-fy theividu-

in the

ygienee rec-cy,nce/

gral to the implementation of AORNommendations. Personnel should receand ongoing education and competenas applicable to their roles. Implemenand updated recommended practicesexcellent opportunity to create or updtency materials and validation tools.perioperative competencies team hasthe AORN Perioperative Job DescripCompetency Evaluation Tools38 to asative personnel in developing competion tools and position descriptions.

Policies and procedures should bereviewed periodically, revised as necreadily available in the practice settinupdated recommended practices mayopportunity for collaborative efforts wand personnel from other departmentity to develop organization-wide policedures that support the recommendeThe AORN Policy and Procedure Teedition,39 provides a collection of 15 scies and customizable templates basedPerioperative Standards and Recommetices. Regular quality improvement proessary to improve patient safety and toquality care. For details on the final thrrecommendations that are specific to thment discussed in this article, please retext of the RP document.

AMBULATORY PATIENT SCENANurse S works in the postanesthesiaan orthopedic surgical facility. AfterNurse T perform a dressing change ounderwent a knee arthroscopy, NurseNurse T enter a cubicle and begin caanother postoperative patient withouthands. What actions should Nurse S

Nurse S must recognize that by faform proper hand hygiene, Nurse T ihimself, his patients, and other facilitat risk for infection. The appropriate

e inte- Nurse S would be to respectfully remind Nurse T

AORN Journal 501

d hygt. Nurd prooperth cae pots. N

ns to

ve RNmunite foscru

rub hat these of

en quates ton hertherive ase thesterileshou

alth cy mactioncrubot alake athe prto hist beitionn infeupatifessiog a dploye

gram canwith hande patient

hat are ac-ations andocated inns and en-rsonnel set

hand hy-cial re-goals. Fund-and hygieneto suc-

lan or bud-ptable handrmancehygiene.y over timeutcomes and

iene in thee StandardsCO: AORN,

nd antisepsis/ed Practices,c; 2005:377-

re settings. Rec-Control Prac-C/SHEA/APIC/. 2002;51(RR-r/rr5116.pdf.

-Associatedf Health & Hu-itiatives/hai/

2.Jr, et al. Esti-and deaths in2007;122(2):

methicillin-) in US hospi-tilization Projecthcup-us.ahrqd January 3,

April 2012 Vol 95 No 4 PATRICK—VAN WICKLIN

about the need to perform proper hanbefore and after every patient contaccould refer to the facility policy anand emphasize the importance of prhygiene by all members of the healin preventing HAIs and reducing thfor acquiring transmissible infectionalso may want to report her concernurse manager.

HOSPITAL PATIENT SCENARIONurse R is employed as a perioperativascular surgery department at a compital. He has been assigned to circularoscopic cholecystectomy with a newson. As the scrub person begins to schands at the sink, Nurse R notices thperson appears to have a moderate caing dermatitis on her right wrist. Whtioned about this, the scrub person stwas embarrassed and afraid to mentition for fear of losing her job. She futhat the procedure is minimally invasdoes not think it really matters becaufected skin will be covered with herand two pair of gloves. What actionsNurse R take?

Nurse R should understand that hepersonnel with breaks in skin integritrisk for acquiring or transmitting infeR should express his concern to the sthat she is putting herself at risk by nthe affected area to heal. He should tensure that she does not scrub in onand immediately report his concernsmanager. The scrub person should noto have patient contact until the condhealed and she has been cleared by apreventionist, employee health or occhealth nurse, or other health care prowith specialized knowledge in makinnation regarding the safety of the em

turning to work in the perioperative setting

502 AORN Journal

ienese Scedurehand

re teamentialurse Sher

in thety hos-r a lapa-b per-erscrubweep-

es-hat sher condi-states

nd sheaf-gown

ld

arey be ats. Nursepersonlowingction toocedurenurse

allowedisction

onalnaletermi-e re-

CONCLUSIONA comprehensive hand hygiene proimprove team member compliancehygiene measures and help to ensursafety. Products for hand hygiene tceptable for users, hand washing stalcohol-based hand rub dispensers lstrategic areas, and clear expectatioforced policies for perioperative pethe stage for uniform compliance.

A critical element in an effectivegiene program is the need for finansources to accomplish the programing to accomplish the goals of the hprogram is essential for the programceed. The organization’s financial pget should include funding for accehygiene products, systems for perfomonitoring, and education on handReducing infections will save moneand will lead to improved patient ohealth care provider satisfaction.

References1. Recommended practices for hand hyg

perioperative setting. In: Perioperativand Recommended Practices. Denver,Inc; 2012:73-86.

2. Recommended practices for surgical hahand scrubs. In: Standards, Recommendand Guidelines. Denver, CO: AORN, In385.

3. Guideline for hand hygiene in health-caommendations of the Healthcare Infectiontices Advisory Committee and the HICPAIDSA Hand Hygiene Task Force. MMWR16):1-2. http://www.cdc.gov/mmwr/PDF/rAccessed December 16, 2011.

4. HHS Action Plan to Prevent HealthcareInfections. June 2009. US Department oman Services. http://www.hhs.gov/ash/ininfection.html. Accessed January 3, 201

5. Klevens RM, Edwards JR, Richards CLmating health care-associated infectionsUS hospitals, 2002. Public Health Rep.160-166.

6. Elixhauser A, Steiner C. Infections withresistant Staphylococcus aureus (MRSAtals, 1993-2005. Healthcare Cost and UStatistical Brief. July 2007. http://www..gov/reports/statbriefs/sb35.pdf. Accesse

. 2012.

is themic ev):171-1of Heand theDisea

ov/HAary 3,s) &dicareCsAnd

tes thaalthcarofessioc. http:p.gif. U011.JA, edlogy. Wn Infec51-22.th, Facign anhingto

antiselin. 20

, Kaufbial sotion of. Clin

ealthWorld

/patienk/en/.

terialJ. 199

llin Gbial loContr

ent proorne pration.w_doc

essed J

hospitmoistu4.APICashingn Con

EN, H

xposure to2003;31(2):97-

mann T,sh and dryingnfluence the? BMC Micro-

er A. Effect offficacy of con-standard alco-nviron Health.

of Health Careuideline Insti-

/2010guidelines

er N, Michaelsd the potentialAm J Infect

haels B. Bacte-tential associ-Infect Control.

cilities. Quincy,n; 2005.tal cleaning in

ive StandardsO: AORN, Inc;

m/products/.

u. http://wwwon-controlbCTlmA. Ac-

lenz.com/12.med. http://ands/higeia/sed January 16,

washing compli-deo/21461/sed January 16,

re antiseptic41-31452 (codi-

ani AK. Com-rub solutions

esurgical anti-pital. J Hosp

es Preview.ite/

3, 2012.e. A Guide fore Workers.

RP IMPLEMENTATION GUIDE: HAND HYGIENE www.aornjournal.org

7. Suresh G, Cahill J. How “user friendly”for practicing hand hygiene? An ergonoJt Comm J Qual Patient Saf. 2007;33(3

8. Scott RD II. The Direct Medical CostsAssociated Infections in US Hospitals aof Prevention. Atlanta, GA: Centers forand Prevention; 2009. http://www.cdc.ghai/Scott_CostPaper.pdf. Accessed Janu

9. Overview. Conditions for coverage (CfCof participations (CoPs). Centers for Meicaid Services. https://www.cms.gov/CFAccessed December 19, 2011.

10. HAI reporting laws and regulations: staenacted laws relating to reporting of heassociated infections. Association for PrInfection Control and Epidemiology, In.apic.org/downloads/legislation/HAI_maJuly 6, 2011. Accessed December 19, 2

11. Dental services. In: Molinari JA, HarteText of Infection Control and Epidemioton, DC: Association for Professionals iControl and Epidemiology; 2005: 51-1–

12. AIA Academy of Architecture for HealGuidelines Institute. Guidelines for Desstruction of Health Care Facilities. WasAmerican Institute of Architects; 2006.

13. Graves PB, Twomey CL. Surgical handevidence-based review. Perioper Nurs C235-246.

14. McNeil SA, Foster CL, Hedderwick SAEffect of hand cleansing with antimicroalcohol-based gel on microbial colonizafingernails worn by health care workersDis. 2001;32(3):367-372.

15. WHO Guidelines on Hand Hygiene in H(Advanced Draft). Geneva, Switzerland:Organization; 2006. http://www.who.intinformation_centre/ghhad_download_linJanuary 3, 2012.

16. Wynd CA, Samstag DE, Lapp AM. Bacon the fingernails of OR nurses. AORN799-805.

17. Salisbury DM, Hutfilz P, Treen LM, BoGautam S. The effect of rings on microhealth care workers’ hands. Am J Infect25(1):24-27.

18. CPL 02-02-069–CPL 2-2.69: Enforcemfor the occupational exposure to bloodbOccupational Safety & Health Administwww.osha.gov/pls/oshaweb/owadisp.shotable�DIRECTIVES&p_id�2570. Acc2012.

19. Marino C, Cohen M. Washington State2000: gloves, handwashing agents, andAm J Infect Control. 2001;29(6):422-42

20. Hand hygiene. In: Underwood MA, ed.Infection Control and Epidemiology. WAssociation for Professionals in InfectioEpidemiology; 2005:19-1–19-7.

21. Kim PW, Roghmann MC, Perencevich

Rates of hand disinfection associated with glo

hospitalaluation.79.lthcare-Benefits

se ControlI/pdfs/2012.conditions& Med-CoPs/.

t havee-nals in//wwwpdated

s. APICashing-tion

ilitiesd Con-n, DC:

psis: an06;1(3):

fman CA.ap orartificial

Infect

CareHealth

tsafety/Accessed

carriage4;60(5):

E,ad ofol. 1997;

ceduresathogens.http://ument?p_anuary 3,

al surveyrizers.

Text ofton, DC:trol and

arris AD.

patient isolation, and changes between evarious body sites. Am J Infect Control.103.

22. Hubner NO, Kampf G, Kamp P, KohlKramer A. Does a preceding hand watime after surgical hand disinfection iefficacy of a propanol-based hand rubbiol. 2006;6:57.

23. Hubner NO, Kampf G, Loffler H, Krama 1 min hand wash on the bactericidal esecutive surgical hand disinfection withhols and on skin hydration. Int J Hyg E2006;209(3):285-291.

24. Guidelines for Design and ConstructionFacilities, 2010. Dallas, TX: Facilities Gtute; 2010. http://www.fgiguidelines.org.html. Accessed January 3, 2012.

25. Griffith CJ, Malik R, Cooper RA, LookB. Environmental surface cleanliness anfor contamination during handwashing.Control. 2003;31(2):93-96.

26. Harrison WA, Griffith CJ, Ayers T, Micrial transfer and cross-contamination poated with paper-towel dispensing. Am J2003;31(7):387-391.

27. NFPA 99 Standard for Health Care FaMA: National Fire Protection Associatio

28. Recommended practices for environmenthe perioperative setting. In: Perioperatand Recommended Practices. Denver, C2012:237-250.

29. Biovigil. http://www.biovigilsystems.coAccessed January 16, 2012.

30. Ekahau infection control solution. ekaha.ekahau.com/solutions/healthcare/infecti.html?gclid�CL3Kqezd060CFQyb7Qodcessed January 16, 2012.

31. UltraClenz ProGiene. http://www.ultracprogiene.html. Accessed January 16, 20

32. Hand hygiene monitoring system. equipwww.equipmed.com/infection-control/brhand-hygiene-monitoring-system. Acces2012.

33. Duke hand hygiene monitoring � handance boost. http://ondemand.duke.edu/viduke-hand-hygiene-monitoring-h. Acces2012.

34. Tentative final monograph for health-cadrug products. Fed Regist. 1994;59:314fied at 21 CFR §333, 369).

35. Gupta C, Czubatyj AM, Briski LE, Malparison of two alcohol-based surgical scwith an iodine-based scrub brush for prseptic effectiveness in a community hosInfect. 2007;65(1):65-71.

36. iScrub Lite [software application]. iTunhttp://itunes.apple.com/us/app/iscrub-lid329764570?mt�8. Accessed January

37. How-to Guide: Improving Hand HygienImproving Practices Among Health Car

ve use, Cambridge, MA: Institute for Healthcare Improvement;

AORN Journal 503

/www.ne.pdf.

petenORN,

[CD-R

Infectl and PI/001_

sylvanter fo

rmatioicine_

1.st 2011//wwwf. Acce

ealth Care is

h Organization;ns/2009/mber 19, 2011.

the Asso-Control

RN Rec-d and anA. Mshat couldonflict ofticle.

, CNOR,rative nurs-

r, CO. Mstion thatntial con-this article.

racticest. Individu-and refer-

April 2012 Vol 95 No 4 PATRICK—VAN WICKLIN

2011. Last modified July 8, 2011. http:/online.org/Assets/files/IHI_Hand_HygieAccessed January 3, 2012.

38. Perioperative Job Descriptions and Comation Tools [CD-ROM]. Denver, CO: A2012.

39. Policy & Procedure Templates, 2nd edDenver, CO: AORN, Inc; 2010.

Resources1. Guideline for Prevention of Surgical Site

Atlanta, GA: Centers for Disease Controtion; 1999. http://www.cdc.gov/hicpac/SSAccessed December 19, 2011.

2. Health Solutions Lab: University of Pennof Medicine—Partners in Your Care. CenTransformation. http://www.healthtransfouniversity_of_pennsylvania_school_of_medin_your_care. Accessed December 19, 201

3. Surgical site infection (SSI) event. Augufor Disease Control and Prevention. http:nhsn/PDFs/pscManual/9pscSSIcurrent.pdcember 19, 2011.

4. WHO Guidelines on Hand Hygiene in HGlobal Patient Safety Challenge Clean C

This RP Implementation Guide is indocument upon which it is based anals who are developing and updatin

ence the full recommended practices doc

504 AORN Journal

shea-

cy Evalu-Inc;

OM].

ion, 1999.reven-SSI.html.

ia Schoolr Healthn.net/cs/partners_

. Centers.cdc.gov/ssed De-

are. FirstSafer

Care. Geneva, Switzerland: World Healt2009. http://whqlibdoc.who.int/publicatio9789241597906_eng.pdf. Accessed Dece

Marcia Patrick, MSN, RN, CIC, isciation for Professionals in Infectionand Epidemiology liaison to the AOommended Practices Advisory Boarindependent consultant, Tacoma, WPatrick has no declared affiliation tbe perceived as posing a potential cinterest in the publication of this ar

Sharon A. Van Wicklin, MSN, RNCRNFA, CPSN, PLNC, is a periopeing specialist at AORN, Inc, DenveVan Wicklin has no declared affiliacould be perceived as posing a poteflict of interest in the publication of

d to be an adjunct to the complete recommended pot intended to be a replacement for that documenanizational policies and procedures should review

tended is ng org

ument.

.7.aorn.org/CE

EXAMINATION

CONTINUING EDUCATION PROGRAM

2wwwImplementing AORN Recommended

Practices for Hand Hygiene

“Recom-atient and

ted recom-

ces.ioperative

or hand

ur conve-e Exami-

PURPOSE/GOAL

To educate perioperative nurses about how to implement the AORNmended practices for hand hygiene in the perioperative setting” in inpambulatory settings.

OBJECTIVES

1. Describe new activity statements that have been included in the updamended practices document.

2. Identify potential risks involved with insufficient hand hygiene practi3. Discuss AORN’s practice recommendations for hand hygiene in the per

setting.4. Discuss methods for implementing AORN’s practice recommendations f

hygiene.

The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.

re at t

.2° C0.6°48.9°57.2°

s consealthof mutbre

d hygiene pro-providers on

y.

oducts.nd 42, 3, and 4

giene products

g soap.mended by

QUESTIONS

1. For hand washing, water temperatushould be maintained between

a. 75° F and 90° F (23.9° C and 32b. 90° F and 105° F (32.2° C and 4c. 105° F and 120° F (40.6° C andd. 120° F and 135° F (48.9° C and

2. Lack of appropriate hand hygiene ito be the second leading cause of hassociated infections and the spreadresistant organisms and associated o

a. true

b. false

© AORN, Inc, 2012

he faucet

).C).C).C).

ideredcare-ultidrug-aks.

3. Critical elements of a facility’s hangram include educating health care

1. elements related to product safet2. hand care.3. hand antisepsis.4. the purpose and proper use of pr

a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,

4. Examples of proper use of hand hyin the perioperative setting include

1. wetting the hands before applyin2. using more product than is recom

the manufacturer to ensure thorough cleansing.

April 2012 Vol 95 No 4 ● AORN Journal 505

r towetely.ry.nd 32, 3, a

care

an 1/t exte

it is n

mpatine prond 32, 3, a

n forticesrnail

n and

calendies an

l in ale and

nd 32, 3, a

must

with p

th a p

ty.

4, and 6, 3, 4, 5, and 6

competencynd hygiene

anufacturer’s

which eachperform a

ance fromcedure.

k whetherap or alcohol-

personnel on

2, and 42, 3, 4, and 5

al hand anti-health care

hey are visibly

, and other

running water.

giene prod-itten evalua-cts should

s.4, and 6, 3, 4, 5, and 6

with consulta-

e Education.

onflicts of in-

April 2012 Vol 95 No 4 CE EXAMINATION

3. partially drying hands with papeallowing them to air dry comple

4. blotting rather than rubbing to da. 1 and 4 b. 2 ac. 1, 3, and 4 d. 1,

5. In the perioperative setting, healthpractitioners1. should keep fingernails shorter th2. may wear artificial nails but no

or tips.3. may wear nail polish, as long as

chipped, cracked, or crazed.4. should use hand lotion that is co

gloves and antiseptic hand hygiea. 1 and 4 b. 2 ac. 1, 3, and 4 d. 1,

6. To implement the recommendatioing established hand hygiene pracmaintaining healthy skin and fingetion, a facility’s education program1. should cover product compositio

properly use products.2. may include the use of personal

indicate when educational activittoring should occur.

3. should be the same for personne4. should be provided on initial hir

annually afterwards.a. 1 and 4 b. 2 ac. 1, 2, and 4 d. 1,

7. Perioperative health care providerstheir hands1. any time there has been contact

tially infectious materials.2. before eating.3. before and after each contact wi

the patient’s environment.4. after using the restroom.5. when coming on and leaving du

The behavioral objectives and examination fo

tion from Rebecca Holm, MSN, RN, CNOR,

Ms Retzlaff, Ms Holm, and Ms Bakewell hav

terest in the publication of this article.

506 AORN Journal

ls and

nd 4

4 inch.nsions

ot

ble withducts.

nd 4

follow-forcondi-

how to

ars thatd moni-

l roles.at least

nd 4

wash

oten-

atient or

6. on removing gloves.a. 1, 3, and 5 b. 2,c. 1, 2, 4, and 5 d. 1, 2

8. Strategies that might help promoteand compliance with a facility’s haprogram may include1. asking personnel to locate the m

instructions for use of a product.2. implementing skills labs during

employee is required to correctlyskill or task.

3. observing an individual’s performbeginning to end for a single pro

4. using electronic monitors to trachealth care providers activate sobased hand rub dispensers.

5. verbal quizzing of perioperativeelements of the program.a. 3 and 5 b. 1,c. 1, 2, 3, and 4 d. 1,

9. When using an alcohol-based surgicseptic, the first step a perioperativeprovider should complete is toa. don a surgical mask.b. prewash hands and forearms if t

soiled.c. remove rings, watches, bracelets

hand jewelry.d. rinse hands and forearms under

10. To maximize acceptance of hand hyucts in the perioperative setting, wrtion criteria for hand hygiene produinclude1. safety and efficacy.2. cost.3. ease of use.4. skin comfort and reaction.5. fragrance and color.6. compatibility with other product

a. 1, 3, and 5 b. 2,c. 1, 2, 3, and 6 d. 1, 2

program were prepared by Kimberly Retzlaff, editor/team lead,

editor, and Susan Bakewell, MS, RN-BC, director, Perioperativ

eclared affiliations that could be perceived as posing potential c

r this

clinical

e no d

.7.aorn.org/CE

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

2wwwImplementing AORN Recommended

Practices for Hand Hygieneine thon pre item

tives o

t haved prac

Higinsuf

dationting.

ORNne.

ase yo

l objec

tion fr

result ofr question

e? (Select all

team regard-

to change/ure.

eeting withand acceptance

valuate theintervals untilest practice.

e as a resultt all that

t relevant to

teach othersd change.port to make

e verify thecontinuing

This evaluation is used to determto which this continuing educatimet your learning needs. Rate th

described below.

OBJECTIVES

To what extent were the following objeccontinuing education program achieved?1. Describe new activity statements tha

included in the updated recommendedocument. Low 1. 2. 3. 4. 5.

2. Identify potential risks involved withhand hygiene practices.Low 1. 2. 3. 4. 5. High

3. Discuss AORN’s practice recommenhand hygiene in the perioperative setLow 1. 2. 3. 4. 5. High

4. Discuss methods for implementing Atice recommendations for hand hygieLow 1. 2. 3. 4. 5. High

CONTENT

5. To what extent did this article increknowledge of the subject matter?Low 1. 2. 3. 4. 5. High

6. To what extent were your individuamet? Low 1. 2. 3. 4. 5. High

7. Will you be able to use the informa

applicant who successfully completes this program

© AORN, Inc, 2012

e extentogram

s as

f this

beenticeshficient

s for

’s prac-

ur

tives

om this

8. Will you change your practice as areading this article? (If yes, answe#8A. If no, answer question #8B.)

8A. How will you change your practicthat apply)1. I will provide education to my

ing why change is needed.2. I will work with management

implement a policy and proced3. I will plan an informational m

physicians to seek their inputof the need for change.

4. I will implement change and eeffect of the change at regularthe change is incorporated as b

5. Other:8B. If you will not change your practic

of reading this article, why? (Selecapply)1. The content of the article is no

my practice.2. I do not have enough time to

about the purpose of the neede3. I do not have management sup

a change.4. Other:

9. Our accrediting body requires that wtime you needed to complete the 2.7

program:

dentialing Center

eptance of this

ers. Each

article in your work setting? 1. Yes 2. No education contact hour (162-minute)

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.

Event: #12510; Session: #0001; Fee: Members $13.50, Nonmembers $27

The deadline for this program is April 30, 2015.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answ

can immediately print a certificate of completion.

April 2012 Vol 95 No 4 ● AORN Journal 507