Your staff might profess to know the basics of hand washing, but do they know enough to wet their hands before applying soap? Take a quick poll. Ask if it's an acceptable practice to apply soap to dry hands before routine hand washing. It isn't, of course. You should only apply soap or antiseptic cleansing agents after you've wet your hands, according to hand hygiene guidelines. When applied to dry hands, soap embeds in the pores, which prevents water from really penetrating the pores and leaves residue that cracks skin, providing an opening for bioburden and microbes in large numbers.

What about water temperature for hand washing? Tepid water temperature is generally more effective and compatible with hand-washing agents. (Manufacturers' labels should indicate the temperature at which the hand agent will activate to more effectively remove bioburden.) When the water is too hot or too cold, your OR team tends not to use enough friction or wash for the suggested period of time. This also abbreviates the rinsing step, and diminishes the benefits of hand washing.

We could write the fundamentals of hand washing on an index card: Wet both hands from fingertips to elbows, then apply soap and lather up with friction for about 15 seconds before thoroughly rinsing the cleansed area with tepid water. There's so much more, of course. Let's take a look at some of the do's, don'ts and suggested best practices.

Take time for drying
After routine washing, drying hands thoroughly before gowning and gloving seems like common sense, but it's not always done. Putting gloves on wet hands requires additional force and may ultimately take more time in the end. But most importantly, the extra force needed to slip gloves over still-wet skin can also create holes or tears that further expose surgeons, the surgical team and patients to bacteria.

et hands dry until gloves can be easily slipped on. This should take less than 1 minute, but may be influenced by the user's skin integrity and/or the temperature of the OR. Begin to dry the cleansed area from the fingers to the hands to the forearm, using a dry towel. Then repeat on the other arm. I suggest patting as opposed to rubbing.

Nix the nail polish

AORN recommendations for best hand hygiene practices — largely considered the gold standard — prohibit artificial fingernails in the perioperative environment. You can wear clear nail polish on fingernails for up to 4 days after its original application. But I'd advise against permitting nail polish of any type or color to be worn, in any amount or for any duration. For one, it's difficult to enforce the "4-day rule." But more importantly, chipped fingernail polish — and believe me, it can begin to chip almost immediately after application — becomes a foreign body when it enters the patient's wound, usually through a tear in a glove's finger. A foreign body in the wound can create complications. As a condition of hiring, prohibit OR staff from wearing nail polish for the safety of patients, and make enforcing the policy the responsibility of supervisors, surgeons and co-workers in the OR.

Natural fingernail length should be about one-quarter of an inch (or less), and should never be longer than the fingertips. Keeping nails at this length prevents tears in the fingertips of gloves, which is where glove failures often occur. Monitor compliance on a random basis, correct infractions on the spot, and document process improvement activities.

Rubs between cases
In my experience, compliance with hand washing before the day's first case isn't a huge issue in most facilities. Rather, it's between cases — when staffers feel rushed and preoccupied with prepping for the next case — that hand hygiene practices can start to slip.

Using an alcohol-based hand rub for hand antisepsis between patients is usually sufficient, so long as hands aren't bloody or visibly soiled, or haven't come in contact with dressing or bodily fluids. While alcohol-based products kill bacteria, they fail to eliminate organic materials and contaminants like dirt, blood and other fluids. In cases of visible soiling or even suspected contamination, thoroughly wash hands with an antibacterial agent and running water. Some manufacturers also recommend soap-and-water hand washing after 8 to 10 consecutive uses of an alcohol-based rub.

When using an alcohol-based sanitizer, use a formulation with at least 60% alcohol. Alcohol-based hand rubs denature proteins, are most effective at 60% to 95%, and less potent at higher concentrations because proteins aren't easily denatured in the absence of water. Using a dose recommended by the manufacturer, rub the product from fingertips to elbow until the skin is adequately dry, which usually takes 1 to 3 minutes. Thorough drying becomes especially critical when using alcohol-based rubs, given the fire hazard that alcohol fumes can create in the OR.

Nix the hand lotion
If your staff is adhering to best practices, they're frequently washing and scrubbing their hands: upon entering the perioperative area, between cases, before and after donning gloves, and before and after using the restroom. All that hand washing can result in cracked and irritated skin (especially true in cold-weather areas.) Using hand lotions seems like an ideal solution, but it's preferable that you don't use them in the perioperative area.

Most facilities approve and provide certain hand lotions that, biologically speaking, are compatible with the hand hygiene products their staff uses. Some lotions, however, contain substances and ions that counter the formulation of these cleansing agents, actually inhibit their efficacy, and compromise the integrity of latex gloves.

I urge OR teams to leave the hand lotion at home, and use it before going to bed at night, which is the longest period when hand hygiene isn't performed. This is a recommended practice for infection control purposes, and should also be more beneficial in healing cracked skin in comparison to using it right after washing hands and moving on to the next case.

Too little or too much soap
We tend to assume that soap dispensers are always working properly and doling out an adequate dose of cleaning agent (as determined by the manufacturer's instructions) each time. Not necessarily. When dispensers aren't cleaned on a regular basis, soap or cleaning agents tends to stick in the lumen of the dispenser, which naturally decreases the volume of the agent reaching the hand. Depending on the type of dispenser, manufacturer's cleaning directions and frequency of use, using hot water to rinse the lumen is usually an effective way to keep dispensers functioning correctly.

On the flip side, too much soap isn't a good thing, either. If the dispenser's spigot is wide open and dispensing the proper amount, that amount applied to a wet hand should be enough for an initial wash. Some staff members have a tendency to subscribe to the "more is better" theory in terms of how much soap to use. But in addition to wasting supplies, using a "double dose" of soap can actually increase residue on the hands and hinder the cleaning process by adding to the time necessary to properly rinse it off.

If additional hand washing is necessary — due to gross contamination, presence of blood or visible soiling — use a 2-step approach rather than using a double dose once. The first wash, using the usual amount of soap, should reduce the gross amount of bioburden present on the skin, and the second dose should eliminate whatever residual bacteria remains behind. Washing hands twice using the proper amount of soap each time is much more effective at removing bioburden and maximizes the efficacy of the cleaning agent.