Health care–associated infections (HAIs) are infections that clients acquire while receiving care and that were not present or incubating on admission. The main device- and procedure-related HAIs are central line–associated bloodstream infection (CLABSI), catheter-associated urinary tract infection (CAUTI), surgical site infection (SSI), ventilator-associated or hospital-acquired pneumonia, and C. difficile infection. In recent US point-prevalence surveys, pneumonia has been the most common HAI, followed by gastrointestinal infection (mostly C. difficile) and SSI; urinary tract infections have fallen as catheter use declined. Older textbooks listing UTI as the most common HAI reflect earlier data.
Contaminated hands of health care workers are the most common route of transmission. Hand hygiene is therefore the single most important measure to prevent HAIs.
Two kinds of asepsis
| Medical asepsis (clean technique) | Surgical asepsis (sterile technique) |
|---|
| Goal | Reduce the number of microorganisms and prevent their spread from person to person or place to place | Eliminate all microorganisms from an area and keep objects and areas sterile |
| When | Routine care: hygiene, oral medications, vital signs, handling linens, isolation precautions, cough etiquette | Entering sterile body cavities or tissue, or breaking the skin: surgery, urinary catheter insertion, central line insertion and dressing, sterile dressing changes, suctioning the lower airway; injections and IV insertion — keep the needle, syringe tip and plunger, and medication sterile (aseptic non-touch technique; clean gloves are acceptable) |
| Items | Clean | Sterile |
| Hands | Hand hygiene; clean gloves as needed | Hand hygiene (surgical hand antisepsis in the OR); sterile gloves |
- Client risk factors for infection: extremes of age, immunosuppression (chemotherapy, steroids, neutropenia), diabetes, malnutrition, invasive devices, surgery, broken skin, prolonged hospital stay, antibiotic exposure
- Local signs of infection: redness, warmth, swelling, pain, purulent drainage, loss of function
- Systemic signs: fever, tachycardia, rising white blood cell count; older adults may show only confusion or functional decline
- Assess the environment and equipment for sterility breaks: wet or torn packages, items below waist level, reaching over the field
- Cultures (wound, blood, urine, sputum) before antibiotics when possible
- White blood cell count with differential; C-reactive protein and procalcitonin in selected cases
- Hand hygiene compliance monitoring (direct observation, electronic systems) and HAI surveillance rates used as quality indicators
Hand hygiene methods
| Method | When | Technique |
|---|
| Alcohol-based hand rub (ABHR) — preferred for most situations | Hands not visibly soiled | Enough product to cover all surfaces; rub palms, backs, between fingers, thumbs, fingertips, wrists until dry, about 20–30 seconds |
| Soap and water | Hands visibly soiled with blood or body fluids; after caring for clients with C. difficile or norovirus (alcohol does not kill C. difficile spores and is less effective against nonenveloped norovirus); before eating and after using the restroom | Wet hands, apply soap, rub all surfaces at least 20 seconds (whole procedure about 40–60 seconds), rinse, dry with disposable towel, turn off the faucet with the towel |
| Surgical hand antisepsis | Before donning sterile gown and gloves for surgery | Antimicrobial soap scrub or surgical ABHR per product (commonly 2–5 minutes); remove jewelry; fingertips to elbows, keeping hands above the elbows so water runs from clean to less clean; dry with a sterile towel from fingertips toward the elbow, using a separate part of the towel for each arm |
Surgical hand antisepsis aims to reduce resident flora as much as possible and keep them suppressed during the procedure, because glove microperforations occur.
WHO "My 5 Moments for Hand Hygiene"
- Before touching a patient
- Before a clean/aseptic procedure
- After body fluid exposure risk
- After touching a patient
- After touching patient surroundings (bed rails, bedside table, monitors) — even without touching the client
Hand care rules
- Keep natural nails short (commonly under about 0.6 cm / 1/4 inch); no artificial nails or extenders for staff with direct client contact or in high-risk areas
- Remove rings and wrist jewelry per policy for surgical hand antisepsis
- Use facility-approved lotions to prevent dermatitis — damaged skin harbors more bacteria
- Gloves do not replace hand hygiene: perform hand hygiene before putting on and after removing gloves, and change gloves between clients and when moving from a dirty to a clean body site
Listed in priority order.
- Hand hygiene at every one of the 5 moments; model and remind others
- Principles of surgical asepsis
- A sterile object stays sterile only when touched by another sterile object
- Only sterile items are placed on a sterile field
- A sterile object or field out of sight, or below waist level, is contaminated; never turn your back on a sterile field
- The outer 2.5 cm (1 inch) border of a sterile field is considered nonsterile
- A sterile field becomes contaminated by prolonged exposure to air — open it just before use; avoid talking, coughing, sneezing, or reaching over it
- Moisture passing through a sterile barrier contaminates it (strike-through by capillary action)
- Fluid flows with gravity — keep forceps tips down; hold hands above the elbows after scrubbing
- Skin cannot be sterilized; nonsterile hands must not touch sterile items
- If in doubt, consider it contaminated
- Opening a sterile package and setting up a field
- Place the package on a clean, dry surface at or above waist level
- Open the first (top) flap away from your body, then the side flaps, and the last flap toward you — so you never reach over the sterile interior
- Drop items onto the field from a small height without touching the border; pour sterile solutions from a small height without splashing, label side up
- Sterile gloving (open method)
- Hand hygiene; open the glove package on a clean surface
- With the nondominant hand, pick up the dominant glove by the folded cuff (inside) and slide it on
- Slip the gloved fingers under the cuff of the second glove (touching only the sterile outside) and pull it on
- Keep gloved hands in front, above the waist, within sight
- If a glove touches anything nonsterile (including your skin) — remove it and put on a new sterile glove
- Sterile gown and closed gloving (operating room)
- The gown is considered sterile in front from chest to the level of the sterile field and on the sleeves from about 5 cm (2 inches) above the elbow to the cuff; the back, neck, shoulders, and underarms are not sterile
- In closed gloving the hands stay inside the gown sleeves; the glove cuff is pulled over the gown's knit cuff, so no skin is exposed
- Keep hands between chest and waist; do not fold arms with hands in the axillae
- A scrubbed person who leaves the sterile area, or whose gown or gloves become contaminated, replaces the gown and gloves (and repeats hand antisepsis if they leave the room)
- Medical asepsis in daily care: clean from cleanest to dirtiest area; hold soiled linen away from the uniform and never shake it; do not place items on the floor; clean shared equipment between clients
- Report breaks in technique immediately — correcting a break matters more than finishing the procedure on time
- Clients and visitors should perform hand hygiene when entering and leaving the room, before eating, and after toileting
- Clients may ask staff whether they have cleaned their hands — this is encouraged
- Cover coughs and sneezes; do not touch wounds, dressings, IV sites, or catheters
- Report redness, drainage, fever, or pain at a wound or device site
- Home technique: wash hands for at least 20 seconds; use hand sanitizer with at least 60% alcohol when soap is not available
| Problem | What to watch for |
|---|
| Surgical site infection | Wound redness, warmth, drainage, fever, usually within 30 days (90 days with implants) |
| CLABSI | Unexplained fever, chills, hypotension in a client with a central line |
| CAUTI | Fever, suprapubic pain, delirium in a catheterized client |
| C. difficile | Three or more unformed stools in 24 hours after antibiotics |
| Hand dermatitis in staff | Cracked skin → poor hand hygiene and more colonization |
| Unrecognized sterility breaks | Surgical outbreaks, clusters of device infections |
- Hand hygiene is the most important measure to prevent HAIs
- ABHR for routine hand hygiene (20–30 seconds until dry); soap and water when visibly soiled and for C. difficile or norovirus
- WHO 5 Moments: before patient, before aseptic task, after body fluid risk, after patient, after patient surroundings
- Medical asepsis = reduce and contain microbes (clean); surgical asepsis = eliminate microbes (sterile) — urinary catheter insertion is sterile
- Sterile field: 1-inch border nonsterile; below waist or out of sight = contaminated; wet = contaminated
- Open sterile package: first flap away from you, last flap toward you
- Surgical scrub: hands above elbows; dry fingertips to elbows with sterile towel
- Closed gloving: glove cuff covers the gown cuff
- Sterile glove touches skin or anything nonsterile → replace
- Gloves do not replace hand hygiene; no artificial nails in direct care
- Pneumonia is currently the most common HAI in US surveys; CAUTI, CLABSI, SSI are key device/procedure HAIs
Country Notes
United States
- CDC's Clean Hands Count campaign and The Joint Commission National Patient Safety Goal on infection prevention require hospitals to follow CDC or WHO hand hygiene guidelines and monitor compliance.
- HAIs such as CLABSI, CAUTI, SSI, MRSA bacteremia, and C. difficile are reported to CDC's National Healthcare Safety Network (NHSN) and tied to CMS quality programs.
Philippines
- Hospitals commonly follow the WHO multimodal hand hygiene strategy and the WHO 5 Moments.
- Where running water or ABHR supply is limited, plan hand hygiene stations at the point of care and teach watchers (family members) hand hygiene before helping with feeding or care.