Some basics about standard hand-hygiene in wound care

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Figure 1  The WHO Guidelines on Hand Hygiene in Health Care is a comprehensive guide. If you are interested in reading more about hand hygiene, we strongly suggest reading this. It also takes into consideration low resource situations. What do you do when your facility does not have single-use paper towels? How can you cheaply make your own hand disinfectant? Click on the image above to get to this pdf.

Sensible hand hygiene is one of the most important measures to prevent the spread of infectious microorganisms.

In some situations, we use handwashing with soap and water followed by disinfection with alcohol.  In other situations, we only need to disinfect our hands with alcohol.  We will take a closer look at which situations need which procedure.  

Remember that healthcare personnel working with patients should not wear rings, jewelry, watches, or nail polish at work.  This applies to wound care and all aspects of healthcare in general. 

Figure 2 Even though most healthcare workers are aware that there is no place for jewelry and watches when in direct contact with patients, we still see situations like in the image above!  We have to be particularly focused on hygiene when working in wound care as there often are high concentrations of different bacterial strains to be found in these wounds and in used dressings.

When should we perform hand hygiene?

  • Before we start a "clean" procedure

  • Before we go to fetch clean, disinfected, or sterilized equipment

  • Before we handle food

  • Before and after we have had physical contact with a patient

  • Between two procedures on the same patient

  • Before we put on single-use gloves / sterile gloves

  • Before and after, we have washed the patient or taken care of them in other ways.  Before and after, we have made the patient's bed. 

  • After we have been to the toilet or blown our nose.  

  • After we have touched contaminated equipment such as bedpans or thermometers.  

  • After you have used gloves ( be it single-use or sterile gloves).  Sometimes, there can be tiny holes in gloves, and your hands can get contaminated without you noticing.  Besides, gloves do not protect you against contamination of the lower end of the arms where the gloves' cuffs stop.   

 

This list is by no means complete, but it gives you an idea of how many times we have to perform hand hygiene during a day at work.  We differentiate between the cleansing of the hands with soap and water and hand disinfection using alcohol-based products.  The latter is mainly used before and after most procedures, but if there is visible dirt on the hands and after visiting the toilet, handwashing with soap and water is necessary.  

How to wash your hands correctly with soap and water

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Figure 3  We wash our hands with soap and water when we start the day at work, when we have visible dirt on our hands, when we have been to the toilet or blown our nose and when we are unsure if we can have touched something unclean. 

  • Washing the hands with soap and water intends to remove visible dirt from our hands. Thorough washing of the hands can reduce the bacterial load of the hands by 99%.  

 

  • Moisten the hands with water and add soap 

 

  • Spread the soap over all areas of the hands just up to past the wrists of the hand, working up a good lather.

 

  • Ensure that the thumbs, fingertips, and the areas between the fingers are also covered with soap.  

  • Rub your hands for at least 30 seconds, preferably 60 seconds. Again, make sure to rub the area between the fingers with the lather.

  • Rinse all soap residues off under running, preferably warm water.

  • Dry your skin thoroughly but gently with preferably single-use tissues. If your facility cannot afford single-use tissues, you should have a pile of clean mini towels available that have been washed at 90 degrees. Use a fresh mini towel for each handwash session. 

 

  • Close the tap with the used tissue ( or mini towel) or use your elbow if you have a modern tap. This will prevent you from contaminating your hands from the tap and is an essential part of the procedure which is often overlooked.  

  • If you are going to a patient after you have washed your hands with soap and water, you should use an alcohol-based disinfectant after this. 

When should we use alcohol-based hand disinfection?

Video 1  This video provided by the NHS UK shows the internationally recommended method for washing hands with soap and water in healthcare settings.  

Figure 4 Alcohol-based hand disinfection is the most common form of hand hygiene in healthcare.  The products are often quite gentle as they usually contain substances to make them more skin-friendly.  Some health care personnel will, however, develop contact dermatitis, especially with prolonged use, and it is useful to know that there are alternatives on the market.   Handdesinfectants without alcohol are widely available now- they often contain PHMB, for example.  

  • Hand disinfection with alcohol-based products is the primary form of hand disinfection, and it should be carried out between each patient contact and before each clean procedure. Note- a debridement of a wound is a clean procedure even though the wound itself is far from sterile.   We want to avoid transferring new ( our) bacterial strains into the patient's wound. 

  • The South African Health Products Regulatory Authority (SAHPRA), with international guidelines set by the World Health Organisation (WHO), recommends the following for alcohol-based hand sanitizers: ​

    • A minimum of 70% alcohol content (if alcohol like ethanol, isopropanol, or n-propanol is the main ingredient)

    • 60% alcohol content if there are other active ingredients

 

  • The hands must be dry and have no visible dirt residues before applying the disinfectant. 

 

  • Use sufficient quantities of the disinfectant - all skin surfaces on the hands must be well covered with alcohol. The minimum amount required is at least 3 milliliters.  

 

  • Rub your hands until they are dry again ( at least 20 seconds, preferably 30 seconds). If you are completely dry already after just 10 seconds, you have used too little amounts of disinfectant.  

 

  • Ensure that all areas of the thumb, fingertips, and interspaces between the fingers and the back of your hands are well covered in the disinfectant. 

  • Even though modern hand disinfectants are quite gentle on the skin, many caregivers will experience dry skin when using alcohol-based products for extended periods. Make sure to routinely use hand cream/ lotion after finishing your work shift. 

Video 2  This film is provided by John Hopkins Medicine and shows how to disinfect the hands with alcohol-based products using the WHO technique.

Alternatives to alcohol-based hand sanitizers: HOCL-based products

Using alcohol-based hand sanitizers over extended periods will dry out the skin, and some healthcare workers develop rashes or allergic reactions. There are alcohol-free alternatives available that are more gentle on the skin. Especially hand sanitizers based on hypochlorous acid (HOCL) are a well-documented alternative to alcohol-based sanitizers. The term "hypochlorous acid" sounds like an aggressive chemical product - in suitable concentrations, however, it will usually cause fewer skin irritations than alcohol-based products. Hypochlorous acid is also called Hypochlorous anolyte or simply anolyte water.

Hydrochlorous acid hand sanitizers offer many advantages over alcohol-based products. Besides being more skin-friendly, they are straightforward to produce, cheap, non-toxic, and there is an unlimited supply. Many healthcare workers are not aware that this alternative exists. In fact, we are surprised that it took so long before the world discovered that there was an excellent alternative to alcohol-based sanitizers. Due to the Covid-19 epidemic, there was a sudden lack of alcohol-based products, which gave HOCL- based products the attention they deserve. Many African companies have started to produce HOCL- based disinfection products available in small dispensers and bulk. We have noted considerable price differences, so do some market research before purchasing larger quantities. Be aware that there are different strengths available. For hand disinfecting, concentrations of 100-200 ppm HOCL are recommended. Incidentally, HOCL is also an excellent antibacterial solution for irrigating wounds. Refer to our chapter on wound irrigation to read more about this. 

Note that HOCL disinfectants intended for surface disinfection are much stronger ( usually between 300-500 ppm) and are not recommended for hand hygiene. 

Did you know that it is straightforward to make HOCL- hand sanitizer yourself? Small appliances that resemble an electric water boiler and can produce HOCL up to concentrations of 200ppm are cheaply available. Working at an off-the-grid clinic, you can easily become self-sufficient concerning your need for sanitizer, surface disinfectant, and wound irrigation fluid! We have written a separate chapter on this under "Tools."

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Figure 5 Spurred by the lack of alcohol-based hand sanitizers, many African companies have started to produce sanitizers based on hypochlorous acid (HOCL).  These products are not only very cheap to produce but also highly skin-friendly and non-toxic.  They are not flammable either.  HOCL- based sanitizers are steadily making their way into health care today and have already replaced alcohol-based sanitizers in many institutions. 

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Figure 6 The above document is an application for the inclusion of HOCL in the 2021 WHO Essential Medicines list, submitted by Briontech Inc. It provides a good overview of HOCL products. Click on the image above to get to the pdf file. 

Hand sanitizers which are dangerous

The massive demand for hand sanitizers during the Covid-19 epidemic led to a lack of alcohol-based products. Looking for quick profits, some companies on the African continent ( and elsewhere) started producing hand sanitizers containing other spirits like acetone, methanol, or methylated spirits. Not only can these be highly irritating to the skin, but they can be absorbed through the skin, causing toxicity. Furthermore, there have been alarming fatalities in Africa from ingesting, especially acetone- and methanol-based hand sanitizers. Many African countries have accordingly banned sanitizers containing these chemicals. 

Make sure always to buy hand sanitizers from reputable companies. Read the labels carefully. The South African Bureau of Standards (SABS) has recently ( 2021) made a list of requirements for producers/ distributors of hand sanitizers to ensure the quality and safety of the products for the consumers. All other African countries should quickly adopt these requirements. The following list of information is the minimum requirement:

  • Expiry date

  • Mandatory warnings (flammable, do not ingest, store below specific temperature)

  • Type of sanitizer (liquid or gel)

  • Mass or volume (generally ml)

  • Percentage of alcohol

  • A statement that it is a "disinfectant alcohol rub."

  • Registration number and address of the manufacturer

  • Ingredients and type of alcohol

  • Batch number and manufacture date

  • Instructions for use

Please buy your hand sanitizer from a reputable producer, as we mentioned earlier. Even if the product's labeling is in concordance with the requirements, this does not mean that the product contains what is stated on the label! The Covid-19 epidemic has unfortunately produced many black sheep amongst producers of hand sanitizers. Regulatory authorities did not have the resources to check all products that suddenly emerged during that time. 

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Figure 6 The sudden high demand for hand sanitizers during the Covid-19 epidemic has seen many fake sanitizers emerging on the market. Others contained substances like acetone, methanol, or methylated spirits, which have caused toxic side effects and even fatalities. South Africa was one of the first countries to recognize this and introduce stricter regulatory requirements for producers and distributors. Click on the image above to read the entire article from The Conversation, published October 20, 2020.