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n October 25, 2002, the Centers for Disease Control and Prevention (CDC) released the Guideline for Hand Hygiene in Health-Care Settings, recommendations of the Healthcare Infection Control Practices Advisory Committee (HICPAC) and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. In my view, this is, without doubt, the most significant document for wound care to be released since the 1992 and 1994 pressure ulcer guidelines from the AHCPR.
       All wound care practitioners should become familiar with the scientific data that supports the Guideline and with its 44 specific recommendations for practice. Copies of the document can be downloaded with or without the 423-citation reference list from the following website: http://www.cdc.gov/handhygiene/. The website also contains other information, including a Fact Sheet (suitable for posting) that summarizes the key points in the Guideline and a Press Kit. Educational support materials are promised for January 2003.

Anatomy of the Document
       A special interdisciplinary Hand Hygiene Task Force chaired by John M. Boyce, MD, Hospital of Saint Raphael, New Haven, Connecticut, and including physicians, nurses, and researchers, compiled the Guideline.
       The first section (pages 1-31) contains a thorough Review of the Scientific Data Regarding Hand Hygiene, from the pioneering work of Ignaz Semmelweis (who in 1846 demonstrated a dramatic reduction in puerperal fever on the obstetrics ward in Vienna by instituting hand washing with a chlorine solution) to today's evidence for the efficacy of alcohol-based hand rubs. The second section of the guideline (pages 31-34) contains recommendations for practice that apply to all healthcare settings. The third section (page 34) lists four Performance Indicators that can be used for measuring outcomes. The Guideline concludes with an extensive 423-citation reference list.

Major Findings and Recommendations
       The Guideline panel makes an important distinction between hand washing and the decontamination of hands, both of which are part of hand hygiene. Here are some critical definitions of terms:
       Hand hygiene. A general term that applies to either handwashing, antiseptic handwash, antiseptic hand rub, or surgical hand antisepsis.
       Handwashing. Washing hands with plain (i.e., nonantimicrobial) soap and water.
       Decontaminate hands. Reducing bacterial counts on hands by performing antiseptic hand rub or antiseptic handwash.
       Antiseptic handwash. Washing hands with water and soap or other detergents containing an antiseptic agent.
       Antiseptic hand rub. Applying an antiseptic hand-rub product to all surfaces of the hands to reduce the number of microorganisms present.
       For most healthcare facilities in the United States today, the practical impact of the recommendations in the Guideline will be to dramatically increase the use of antiseptic hand rubs throughout the facility.
       The Guideline rating system and Hand Hygiene Recommendations are reproduced below for your reference.

Part II. Recommendations
       Categories. These recommendations are designed to improve hand-hygiene practices of healthcare workers (HCWs) and to reduce transmission of pathogenic microorganisms to patients and personnel in healthcare settings. This guideline and its recommendations are not intended for use in food processing or food-service establishments and are not meant to replace guidance provided by the Food and Drug Administration (FDA) Model Food Code.
       As in previous CDC/HICPAC guidelines, each recommendation is categorized on the basis of existing scientific data, theoretical rationale, applicability, and economic impact. The CDC/HICPAC system for categorizing recommendations is as follows:
       Category IA. Strongly recommended for implementation and strongly supported by well-designed experimental, clinical, or epidemiologic studies.
       Category IB. Strongly recommended for implementation and supported by certain experimental, clinical, or epidemiologic studies and a strong theoretical rationale.
       Category IC. Required for implementation, as mandated by federal or state regulation or standard.
       Category II. Suggested for implementation and supported by suggestive clinical or epidemiologic studies or a theoretical rationale.
       No recommendation. Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exist.

Recommendations
1. Indications for handwashing and hand antisepsis
A. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a nonantimicrobial soap and water or an antimicrobial soap and water (IA) (66).
B. If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all other clinical situations described in items 1C-J (IA) (74, 93, 166, 169, 283, 294, 312, 398). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items 1C-J (IB) (69-71, 74).
C. Decontaminate hands before having direct contact with patients (IB) (68, 400).
D. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter (IB) (401, 402).
E. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure (IB) (25, 403).
F. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure and lifting a patient) (IB) (25, 45, 48, 68).
G. Decontaminate hands after contact with body fluids or excretions, mucous membranes, nonintact skin, and wound dressings if hands are not visibly soiled (IA) (400).
H. Decontaminate hands if moving from a contaminated body site to a clean body site during patient care (II) (25, 53).
I. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient (II) (46, 53, 54).
J. Decontaminate hands after removing gloves (IB) (50, 58, 321).
K. Before eating and after using a restroom, wash hands with a nonantimicrobial soap and water or with an antimicrobial soap and water (IB) (404-409).
L. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with nonantimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of HCWs, they are not a substitute for using an alcohol-based hand rub or antimicrobial soap (IB) (160, 161).
M. Wash hands with nonantimicrobial soap and water or with antimicrobial soap and water if exposure to Bacillus anthracis is suspected or proven. The physical action of washing and rinsing hands under such circumstances is recommended because alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activity against spores (II) (120, 172, 224, 225).
N. No recommendation can be made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in healthcare settings. Unresolved issue.
2. Hand-hygiene technique
A. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry (IB) (288, 410). Follow the manufacturer's recommendations regarding the volume of product to use.
B. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet (IB) (90-92, 94, 411). Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis (IB) (254, 255).
C. Liquid, bar, leaflet, or powdered forms of plain soap are acceptable when washing hands with a nonantimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used (II) (412-415).
D. Multiple-use cloth towels of the hanging or roll type are not recommended for use in healthcare settings (II) (137, 300).
3. Surgical hand antisepsis
A. Remove rings, watches, and bracelets before beginning the surgical hand scrub (II) (375, 378, 416).
B. Remove debris from underneath fingernails using a nail cleaner under running water (II) (14, 417).
C. Surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand rub with persistent activity is recommended before donning sterile gloves when performing surgical procedures (IB) (115, 159, 232, 234, 237, 418).
D. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, usually 2-6 minutes. Long scrub times (e.g., 10 minutes) are not necessary (IB) (117, 156, 205, 207, 238-241).
E. When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer's instructions. Before applying the alcohol solution, prewash hands and forearms with a nonantimicrobial soap and dry hands and forearms completely. After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves (IB) (159, 237).
4. Selection of hand-hygiene agents
A. Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift (IB) (90, 92, 98, 166, 249). This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel.
B. To maximize acceptance of hand-hygiene products by HCWs, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-hygiene products should not be the primary factor influencing product selection (IB) (92, 93, 166, 274, 276-278).
C. When selecting nonantimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution (II) (174, 372).
D. Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product (II) (286).
E. Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap (IA) (187, 419).
5. Skin care
A. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing (IA) (272, 273).
B. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution (IB) (174, 420, 421).
6. Other aspects of hand hygiene
A. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms) (IA) (350-353).
B. Keep natural nails tips less than 1/4-inch long (II) (350).
C. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and nonintact skin could occur (IC) (356).
D. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients (IB) (50, 58, 321, 373).
E. Change gloves during patient care if moving from a contaminated body site to a clean body site (II) (50, 51, 58).
F. No recommendation can be made regarding wearing rings in healthcare settings. Unresolved issue.
7. Healthcare worker educational and motivational programs
A. As part of an overall program to improve hand-hygiene practices of HCWs, educate personnel regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their hands (II) (74, 292, 295, 299).
B. Monitor HCWs' adherence with recommended hand-hygiene practices and provide personnel with information regarding their performance (IA) (74, 276, 292, 295, 299, 306, 310).
C. Encourage patients and their families to remind HCWs to decontaminate their hands (II) (394, 422).
8. Administrative measures
A. Make improved hand-hygiene adherence an institutional priority and provide appropriate administrative support and financial resources (IB) (74, 75).
B. Implement a multidisciplinary program designed to improve adherence of health personnel to recommended hand-hygiene practices (IB) (74, 75).
C. As part of a multidisciplinary program to improve hand-hygiene adherence, provide HCWs with a readily accessible alcohol-based hand-rub product (IA) (74, 166, 283, 294, 312).
D. To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based hand rub available at the entrance to the patient's room or at the bedside, in other convenient locations, and in individual pocket-sized containers to be carried by HCWs (IA) (11, 74, 166, 283, 284, 312, 318, 423).
E. Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials (IC).