INFECTION CONTROL

PACU—Why Hand Washing Is Vital!

William Clayton Petty, MD, Guest Columnist

Hand washing is one of the oldest methods of reducing infections. Recent

evidence based research has re-confirmed the efficacy of proper hand hy-
giene and recommendations for hand hygiene by the CDC and WHO are
outlined. The PACU is a unique environment; patients are in a ‘‘cross-
road of infection;’’ many patients are exposed to infections coming from
various wards brought to the PACU through the OR. The PACU nurse is
not only responsible for observing and monitoring the patient’s vital signs
but is also responsible for making sure patients are not exposed to an addi-
tional risk, e.g. a hand-transmitted infection.
Keywords: hand washing, hand hygeine, preventing infections, MRSA, im-
proving hand-hygeine compliance.
Ó 2009 by American Society of PeriAnesthesia Nurses

IF YOU WERE pregnant, poor, carrying an illegitimate
baby, or were having birth complications in Vienna in
1845 or before, you went to the Vienna General Hospital.
Before 1846 you had a good chance of dying while in the
hospital and most women stayed at home to deliver. You
could improve your chance of living by being admitted to
the Second Obstetrical Clinic operated by midwives,
where the mortality rate was only 2.03%. If you went to
the First Obstetrical Clinic, staffed by medical students
and obstetricians, you raised your risk of dying to
13.10%. But if you went to the First Obstetrical Clinic in
June 1847, your risk of dying had been reduced to
2.38%.1,2 What made the big difference?
In 1846, Dr Ignaz Semmelweis’s best friend cut himself
with a scalpel while performing an autopsy; he died and
his autopsy showed signs similar to mothers who died of
puerperal fever or childbirth fever (a bacterial infection
of the female genital tract after childbirth) after delivery.
After a thorough investigation, Dr Semmelweis found
that medical students and obstetricians were going di-
rectly from the autopsy room to the First Obstetrical Clinic
and examining women vaginally without properly wash-
William Clayton Petty is a Former Professor of Anesthesiology, De-
partment of Anesthesiology, University of Utah, Salt Lake City, UT.
The author reports no conflict of interest.
Address correspondence to Dr Clayton Petty, P.O. Box 716, Cedar
City, UT 84721; e-mail address: williamcpetty@yahoo.com.
Ó 2009 by American Society of PeriAnesthesia Nurses
1089-9472/09/2404-0009$36.00/0
doi:10.1016/j.jopan.2009.05.101
ing their hands. He ordered the medical students, with
some resistance at first, to wash their hands with chlori-
nated lime before examining patients. The result was a re-
duction in the maternal death rate from 13.10% to 1% in 2
years; in the first month, the mortality rate fell to 2.38%.
When Dr Semmelweis moved to another hospital and
had full authority over the maternity suites, he was able
to reduce the mortality rate to 0.82%, a miracle consider-
ing germ theory had not yet been discovered.1,2
Today Dr Semmelweis is considered by some to be the
‘‘Defender of Motherhood’’ for his heroic contribution
to medicine. Why then is it that we have to be continually
reminded of the simple practice of hand washing to
reduce infections? Is it complacency, thinking that
antibiotics can cure any infection? If this is true, why is
methicillin-resistant Staphylococcus aureus (MRSA) so
prevalent and killing so many?
Health care workers have been found to have 3.9 3 104 to
4.6 3 106 aerobic bacteria colony-forming units on their
hands. Despite this known fact of contamination, the
average duration of hand washing by health care workers
declined from 24 seconds in 1989 to 4.7–5.3 seconds in
1997.3 Hand washing for health care workers should be
a reflex and not a chore. Yet, many health care workers
in areas where infection is easily transmitted from one pa-
tient to another on contaminated hands, eg, in the PACU,
do not wash their hands repeatedly during the day. Many
excuses such as ‘‘hand washing is low on my priority list
because I am busy taking care of patients’’; ‘‘since I wear
gloves for ‘dirty jobs’ in the PACU, I do not need to wash

250 Journal of PeriAnesthesia Nursing, Vol 24, No 4 (August), 2009: pp 250-253

WHY HAND WASHING IS VITAL IN THE PACU
my hands’’; ‘‘it is too inconvenient for me to wash my
hands’’; I forget’’; ‘‘I don’t have time’’; ‘‘there is no place
for me to wash my hands’’; or ‘‘hand washing makes my
skin dry and irritated.’’ These are poor excuses for any
nurse, nursing tech, or physician working in the PACU!
Recently there have been two articles substantiating the ef-
fect of hand washing on reducing in-hospital infections.
The first was an effort to improve compliance in hand wash-
ing in nine hospitals and seven partnerships of the Novant
Health system in North and South Carolina.4 The second
was an effort to improve hand hygiene with the use of
a belt-attached alcohol dispenser worn by anesthesia pro-
viders in the OR.5 In one of the facilities of Novant Health
in 2004, there was a death of a child from an outbreak of
MRSA. The pursuant investigation found, among other
things, that health care workers were noncompliant to in-
place standards for hand hygiene put forth by the Centers
for Disease Control and Prevention (CD).4 Because hand hy-
giene has been proven repeatedly to be highly effective in
reducing morbidity and mortality, the best and simplest ap-
proach was to institute a ‘‘comprehensive system-wide pro-
gram’’ stressing hand hygiene, supported by education,
marketing, clinical improvement, and clinical care depart-
ments. Hand hygiene compliance was adopted as a 3 year
corporate goal, thus giving needed support from adminis-
tration to the program.4
Novant Health established a Hand Hygiene Committee
composed of key clinical and administrative leaders
from all units and was made responsible for ‘‘collecting,
analyzing, and disseminating the data reports to the orga-
nization’’ to reach a corporate goal of 90% compliance.4
After reviewing CDC recommendations for hand hygiene
practices already in place, Novant Health instituted
a corporate-wide awareness campaign of (1) traditional
nursing and physician memos and poster board communi-
cations; (2) hard-hitting posters that implied the staff
could harm a patient by poor compliance, eg, ‘‘You could
kill him with your bare hands,’’ and ‘‘What you can’t see is
killing them’’; (3) hand hygiene fairs; (4) a ‘‘Gel in, Gel out’’
button; (5) visitor education programs; and (6) an internal
marketing campaign, with life-sized cartoon cut-outs, em-
phasizing hand hygiene at visitor centers and lobbies. All
components were designed to make hand hygiene an au-
tomatic compliance, like fastening your seat belt, for all
health care workers. A culture was created ‘‘where non-
compliance was unacceptable and where patient safety
became an individual employee responsibility.’’
Hand hygiene compliance in Novent Health facilities was
greater than 90% after November 2006 and has been
maintained at this level since the introduction of the
campaign. The MRSA hospital-acquired infection rate
was decreased from 0.52 to 0.24 per 1000 patient days,
‘‘representing a 54% reduction associated with improved
compliance.’’ The reduction in MRSA infections meant
251
there were an estimated 105 fewer MRSA hospital-
acquired infections in the Novant Health system,
eg, 234 infected patients in 2005 reduced to 129 patients
at year’s end in 2008.4 The intense campaign was success-
ful in reducing MRSA infections and changing the
behavior of health care workers.
Novant Health has made available, at no cost to health
care organizations, all posters, stickers, ads, banners,
and other marketing treatments on their website
(http://www.washinghandssaveslives.org). As of April
2009, 859 US organizations and 41 foreign organizations
have accessed the materials.4
A clinical research group at Dartmouth-Hitchcock
Medical Center in Lebanon, New Hampshire recently re-
ported a reduction in the rate of contamination of periph-
eral intravenous (IV) stopcocks by anesthesia providers in
the OR from 17.2% to 3.8% by the use of an alcohol-
dispenser worn by anesthesia providers.5 Each time the
Sprixx GJ Personal Dispenser (Harbor Medical, Inc, Rye
Beach, NH) is pressed it expresses 0.75 mL of a fluid gel
alcohol-based hand cleaner.6
The study data for the clinical research was obtained
over a 2 month period and involved 111 patients
(58 control, 53 treatment). The 46 anesthesia providers
in the control group used standard hand hygiene methods
in place, ie, a wall-mounted alcohol-based gel dispenser
located only three steps from the OR anesthesia worksta-
tion and a 70% ethanol liquid dispenser on the anesthesia
cart. The 97 anesthesia providers in the treatment group
used the same hand hygiene methods in place but also
wore a Sprixx GP Personal Dispenser. The outcome
data of the effectiveness of wearing a dispenser for hand
hygiene was derived by measuring the extent of contam-
ination of peripheral IV stopcocks and analysis of
hospital-associated infections measured in the 30-day pe-
riod after surgery. The results are summarized in Table 1.5
Ten of 58 (17%) patients in the control group developed
hospital-acquired infections that included ventilator-
associated pneumonia, wound infection, bloodstream
infection, and urinary tract infection.
The authors of the anesthesia research study concluded
that ‘‘a simple cost-effective device containing an
Table 1. Contamination and Infections
Sprixx GP
Control Personal Dispenser
Group n 5 58 Group n 5 53
Stopcock positive 32.8% 7.5%
Nosocomial infection 17.2% 3.8%
Death 3.4% 0
252
for the PACU have been combined here for the sake of
brevity:
d Indications for hand washing and hand antisepsis:
B When hands are visibly dirty or contaminated with
Figure 1. Sprixx GJ Personal Dispenser. Reprinted with
permission by Sprixx. This figure is available in color online at
www.jopan.org.
alcohol-based solution significantly reduces intraopera-
tive transmission of potentially pathogenic bacterial or-
ganisms.’’ Would hospital-acquired infections have been
further reduced if nurses in the PACU, ICU, and wards
had used a personal dispenser device?
In May 2009, the World Health Organization (WHO)
released the extensive 270-page WHO Guidelines on
Hand Hygiene in Health Care.7 The report is a sentinel
effort of the WHO and is a logical outgrowth of the theme
‘‘Save Lives: Clean Your Hands’’ of the First Global Patient
Safety Challenge. More than 117 countries have pledged
support for WHO hand hygiene efforts. The WHO guide-
lines are more extensive than those found in the CDC’s
45-page document Guideline for Hand Hygiene in
Health-Care Settings3 published in 2002. Both sets of
guidelines use a similar grading system, have a similar lay-
out and discussion of issues, and review evidence exten-
B If hands are not visibly soiled, use an alcohol-based
sively. The CDC guidelines are intended primarily for
the United States and the WHO guidelines ‘‘were
conceived in a more global perspective.’’
The ‘‘My Five Moments for Hand Hygiene’’ program
included in the WHO guidelines document deserves em-
phasis because of its success rate in 400 hospitals world-
wide in 2006 to 2008. The evidence-based program is easy
to follow and reminds the health care worker to practice
good hand hygiene:
1. before touching a patient
2. before a clean/aseptic procedure
3. after body fluid exposure risk
4. after touching a patient
5. after touching patient surroundings
All five steps are ‘‘strongly recommended for imple-
mentation and supported by some experimental, clini-
cal, or epidemiological studies and a strong theoretical
rationale.’’
Because the CDC and WHO hand hygiene recommenda-
tions are very similar, some of them especially applicable
WILLIAM CLAYTON PETTY
proteinaceous material or are visibly soiled with
blood or other body fluids, wash hands with either
a nonantimicrobial soap and water or an antimicro-
bial soap and water.
- Proper hand washing technique is essential
for best results:
d Wet hands with water
d Apply enough soap to cover all surfaces
d Rub hands palm to palm
d Right palm over left dorsum with interlaced
finger and vice versa
d Palm to palm with fingers interlaced
d Backs of fingers to opposing palms with
fingers interlocked
d Rotational rubbing of left thumb clasped in
right palm and vice versa
d Rotational rubbing, backwards and for-
wards with clasped fingers of right hand in
left palm and vice versa
d Rinse hands with water
d Dry thoroughly with a single-use towel
d Use towel to turn off faucet/tap
d Duration of entire procedure: 40 to
60 sec and your hands are safe.
- Paper towels, warm air dryers, and cloth
towels were no different in the efficiency to
dry wet hands.
- When using towels, pat dry instead of rubbing
dry to avoid cracking.
hand rub for routinely decontaminating hands or
wash hands with an antimicrobial soap and water.
- Proper hand rubbing with alcohol-based hand
rub is:
d Apply a palm full of the product in a cupped
hand and cover all surfaces
d Rub hands palm to palm
d Right palm over left dorsum with interlaced
finger and vice versa
d Palm to palm with fingers interlaced
d Backs of fingers to opposing palms with fin-
gers interlocked
d Rotational rubbing of left thumb clasped in
right palm and vice versa
d Rotational rubbing, backwards and for-
wards with clasped fingers of right hand in
left palm and vice versa
d Duration of the entire procedure: 20 to
30 sec and, once dry, your hands are
safe
- Alcohols are rapidly germicidal and work by
denaturing proteins; 60% to 70% alcohol will
WHY HAND WASHING IS VITAL IN THE PACU
kill bacteria, mycobacteria, fungi, herpes
simplex virus, HIV, influenza virus, hepatitis
B virus, and probably hepatitis C virus.
B Decontaminate hands before having direct con-
tact with patients
B Decontaminate hands before donning sterile
gloves
B Decontaminate hands after removing gloves
B Before eating and after using a restroom, wash
hands with a nonantimicrobial soap or antimicro-
bial soap and water
B Use an alcohol-based hand rub as the preferred
means of routine hand antisepsis in all the above
listed items
B Soap and alcohol-based hand rub should not be
used concomitantly
d Selection of hand hygiene agents:
B Provide personnel with efficacious hand hygiene
products that have low irritancy potential
B Do not add soap to a partially empty soap dis-
penser; this practice of ‘‘topping off’’ dispensers
can lead to bacterial contamination of soap
d Skin care:
B Provide health care workers with hand lotions or
creams to minimize the occurrence of irritant
contact dermatitis
d General considerations:
B Do not wear artificial fingernails or extenders
when having direct contact with patients at
high risk
B Keep natural nail tips less than 4
1
⁄ -inch long
B Wear gloves when contact with blood or other
potentially infectious materials, mucous mem-
branes, and nonintact skin could occur
B Remove gloves after caring for a patient
B Potable water combined with a detergent will re-
move dirt and dissolve fatty materials
References
1. Thom R. Semmelweis: Defender of Motherhood. CDC Online,
reprinted with permission from Pfizer, Inc. Available at: www.cdc.gov/
ncidod/eid/vol7no2/cover.htm. Accessed April 1, 2009.
2. NNDB (Notable Names Database). Ignaz Semmelweis. Available at:
www.nndb.com/people/601/000091328. Accessed April 1, 2009.
3. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Set-
tings. Recommendations of the Healthcare Infection Control Practices
Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene
Task Force. MMWR Morb Mortal Wkly Rep. 2002;51:1-45.
4. Lederer JW Jr, Best D, Hendrix V. A comprehensive hand hygiene
approach to reducing MRSA health care-associated infections.
Jt Comm J Qual Patient Saf. 2009;35:180-184.
253
B Proper hand washing technique is essential for
best results
d Irritant contact dermatitis ranges from 25% to 55%
B Alcohols are less irritating than soap and water
B Putting on gloves with wet hands increases skin
irritation
B Washing hands regularly with soap and water
immediately before or after using an alcohol-
based product is not only unnecessary, but may
lead to dermatitis
d Use of sterile gloves:
B The National Institute for Occupational Safety
and Health mandates the use of gloves during
‘‘all patient-care activities involving exposure to
blood or body fluids that may be contaminated
with blood’’
B Reduces the risk of contaminating your hands
- Reduces the risk of germ dissemination to the
environment and of transmission to patients
Proper hand hygiene by health care workers is one of the
simplest, most effective means of decreasing morbidity
and mortality in patients in health care settings. Hand
hygiene removes dirt and organic material as well as micro-
bial contamination acquired by contact with patients and
the environment. The leading cause of health care–
associated infection and spread of multiresistant organisms
is the failure to practice proper hand hygiene. There is a def-
inite link between ‘‘improved hand hygiene practices and
reduced infection and cross-transmission rates.’’
The PACU nurse is a key link in the care of surgical
patients and plays a major role in reducing or increasing
cross contamination and direct contamination of patients
recovering from anesthesia and surgery. Efforts should be
made in every PACU to make hand hygiene an ‘‘automatic
compliance’’ and give PACU personnel ‘‘ownership’’ in
patient safety.
5. Koff MD, Loftus RW, Burchman CC, et al. Reduction in intrao-
perative bacterial contamination of peripheral intravenous tubing
through the use of a novel device. Anesthesiology. 2009;110:
978-985.
6. Harbor Medical Inc. Sprixx GJ Personal Dispenser Kit. Material
Safety Data Sheet. Revision date 16 May 2007. Available at: http://sprixx.
com. Accessed April 1, 2009.
7. World Health Organization. Guidelines on Hand Hygiene in Health
Care, May 2009. Available at: http://whqlibdoc.who.int/publications/
2009/9789241597906_eng.pdf. Accessed June 5, 2009.