Handwashing practices in the patient care setting began in the early 19th century. The practice evolved over the years with evidential proof of its vast importance and coupled with other hand-hygienic practices, decreased pathogens responsible for nosocomial or hospital-acquired infections (HAI). 
Contaminated hands of healthcare providers are a primary source of pathogenic spread. Proper hand hygiene decreases the proliferation of microorganisms, thus reducing infection risk and overall healthcare costs, length of stays, and ultimately, reimbursement.
According to the Centers for Disease Control and Prevention (CDC), hand hygiene is the single most important practice in the reduction of the transmission of infection in the healthcare setting. Despite this evidence, studies have repeatedly shown that the importance of hygiene has not been adequately recognized amongst healthcare professionals and compliance remains low .
According to the CDC, understanding the importance of hand hygiene and its impact on the pathogenic spread of microorganisms is best understood when one understands the anatomy of the skin. The skin serves as a protective barrier against water loss, heat loss, microorganisms, and other environmental hazards.
Structurally, the skin is made up of an outer, superficial layer known as the stratum corneum, the epidermis, dermis, and the hypodermis. Healthy skin is colonized with resident flora that are microorganisms that reside below the stratum corneum and the skin's surface . This flora has two main functions: microbial antagonism and competing for nutrients within the ecosystem. Generally, these bacteria are not pathogenic on intact skin but may cause infections in other areas of the body such as nonintact skin, the eyes, or sterile body cavities .
Transient microorganisms are often acquired by healthcare workers through direct, close contact with patients or contaminated inanimate objects or environmental surfaces. Transient flora colonizes the superficial skin layers . It can be removed by routine handwashing more easily than resident flora. These organisms vary in number depending upon body location. Healthcare-associated infections are a result of these transient organisms.
According to the CDC, hand hygiene encompasses the cleansing of your hands with soap and water, antiseptic hand washes, antiseptic hand rubs such as alcohol-based hand sanitizers, foams or gels, or surgical hand antisepsis. Indications for handwashing include when hands are visibly soiled, contaminated with blood or other bodily fluids, before eating, and after restroom use. Hands should be washed if potential there was potential exposure to Clostridium difficile, Norovirus, or Bacillus anthracis.
In 2009, the World Health Organization (WHO) highlighted preset guidelines known as the "Five Moments for Hand Hygiene." 
Alcohol-based hand sanitizers are the recommended product for hand hygiene when hands are not visibly soiled. Apply alcohol-based products per manufacturer guidelines on dispensing of the product. Typically, 3 mL to 5 mL in the palm, rubbing vigorously, ensuring all surfaces on both hands get covered, about 20 seconds is required for all surfaces to dry completely .
Patient and facility healthcare professionals are monitored for hand-washing practices, and they are conforming to hand-hygiene practices. This practice is becoming increasingly popular as healthcare professionals strive for a safer environment.
Artificial nails and nail extensions contain pathogens in the subungual spaces; thus posing a threat to microorganism transmission in the healthcare arena. Therefore, it is recommended that healthcare professionals do not use them. Well-manicured nails and adherence to artificial nail policies outlined in facility-specific guidelines are vital to hand hygiene practices. The WHO guidelines recommend that nails should be kept less than 0.5cm long .
Hand rubbing with an alcohol-based rub should not be performed when the hands are visibly soiled. In this case, the CDC and WHO guidelines recommend that handwashing with soap and water .
Handwashing is the act of washing hands with soap, either antimicrobial or nonantimicrobial, and water for at least 15 to 20 seconds with a vigorous motion to cause friction making sure to include all surfaces of the hands and fingers.
It requires a specific skill set to ensure proper technique.
Handwashing Technique: 
Healthcare professionals caring for high-risk patients that are immunocompromised must take great care in performing proper hand hygiene as this patient population is at high risk for opportunistic infections . Handwashing with soap and water will remove nearly all transient gram-negative bacilli in 10 seconds while chlorhexidine may be more appropriate than soap and water for the removal of transient gram-positive bacteria .
Handwashing is a requirement if potential there was potential exposure to Clostridium difficile, Norovirus, or Bacillus anthracis. Clostridium difficile and Bacillus anthracis contain spores, and none of the agents used in antiseptic handwash or hand-rub preparations are reliably sporicidal. In these cases, vigorous handwashing with soap will assist in the removal of the spores from the skin.
According to the CDC, established guidelines recommend that agents used for surgical hand scrubs should reduce microorganisms on intact skin in a substantial manner, contain a nonirritating antimicrobial preparation, have broad-spectrum activity, and be fast-acting and persistent. Studies have demonstrated that formulations containing 60% to 95% alcohol alone or 50% to 95% in combination with other products lower bacterial counts on the skin immediately post-scrub more effectively than other agents .
Surgical hand antiseptic practices began in the late 1800s and remain vital to the prevention of infection today. Surgical hand antisepsis or hand hygiene for surgery requires a different set of skills than regular handwashing techniques . The inadvertent transfer of microorganisms to a patient's surgical site can result in a surgical site infection, these are one of the most common forms of hospital-associated infections for surgical patients . Carrying out the correct hand hygiene steps prior to surgery can help reduce the risk of surgical site infections.
According to the CDC, "Hand Hygiene in the Healthcare Settings," hand hygiene for surgery follows specific vital steps using either an antimicrobial soap or an alcohol-based hand sanitizer before donning sterile gloves for surgical procedures. In contrast to hygienic handwashing, surgical hand preparation must remove the transient flora and reduce the presence of resident flora .
Hand hygiene practices are paramount in reducing cross-transmission of microorganisms, hospital-acquired infections and the risk of occupational exposure to infectious diseases.
Mortality and morbidity increase in the presence of hospital-acquired infections, thus diligent hand hygiene is essential to providing safe, cost-efficient, quality care to our patients.
Educational programs for patients and healthcare providers, ergonomics, and staffing ratios all play a role in hand hygiene compliance.
All healthcare workers should regularly wash hands as this is the most cost-effective way to prevent transmission of infections. While compliance with handwashing is high among healthcare workers, the same is not true of the public. Thus, the nurse, pharmacist and physician should educate the patient on the benefits of handwashing at every clinic visit. 
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