World Hand Hygiene Day is coming up. It’s a good reminder to make sure the organization’s infection control and hand hygiene rules and practices are up to date.

  • Follow the World Health Organization’s six-step hand hygiene technique.
  • Operating room staff should avoid all artificial nails and extenders and keep natural nail tips short.
  • While some guidelines permit fresh nail polish, many surveyors will not approve.

Take May 5 — World Hand Hygiene Day — to make sure infection control and hand hygiene rules and practices are up to date, incorporating both regulatory and advisory guidelines. Hand hygiene is the most important action to prevent healthcare-acquired infections, and, yet, it also is poorly performed, according to the World Health Organization (WHO) and others.1

Last year, WHO released guidance and a video, recommending a six-step hand hygiene technique.

The CDC created a Clean Hands Count campaign, using the hashtag #CleanHandsCount. The CDC’s recommendation for hand hygiene for surgery involves surgical hand antisepsis, including removing debris from underneath fingernails, using a nail cleaner under running water. The CDC also addresses fingernail care, stating that germs can live under artificial fingernails both before and after using an alcohol-based hand sanitizer and handwashing. The CDC joins other organizations in recommending that healthcare providers do not wear artificial fingernails or extensions when directly contacting patients at high risk, including in operating rooms. Also, the guidelines suggest keeping natural nail tips less than one-quarter of an inch long.

That advice is a little less strict than what some associations recommend, says Sandy Berreth, RN, MS, CASC, administrator of Foothills Surgery Center at Sansum Clinic in Santa Barbara, CA.

For example, the Association for Professionals in Infection Control and Epidemiology (APIC) says freshly applied nail polish does not increase germs. APIC also says that chipped nail polish may harbor bacteria, and people with artificial nails are more likely to harbor higher bacterial counts, so artificial nails should not be worn.

A surveyor exploring an ASC might note any fingernail color on direct patient caregivers, including scrub nurses, RNs, and medical assistants, Berreth says.

“That is considered a breach, although some understand the rules better and will say that if you have fingernail polish that is well-maintained and short fingernails, it is OK,” she says. “Every surveyor looks at it differently, with some that are very strict.”

The Association of periOperative Registered Nurses’ (AORN) answer sheet that addresses nail polish in the operating room contains an analysis that says a multidisciplinary team that includes perioperative RNs, physicians, and infection preventionists should make the determination of whether fingernail polish is worn. AORN states that further research is needed to determine whether nail polish affects hand contamination or patient outcomes. The organization has a similar answer for whether ultraviolet-cured nail polish and enhancements may be worn.

AORN says artificial nails should not be worn in the perioperative environment, and this includes any substance or device added to natural nails.

As ASCs revisit hand hygiene policies, they will need to back up policies with evidence from associations and literature.

“We have to realize that people want to follow a policy, but in order for a policy to be carried out, you have to show the evidence — have every policy backed by a standard,” Berreth says. “I like to make sure when I develop a policy that I have someone much greater than I who says, ‘This is how we should do it to protect our patients.’”


  1. World Health Organization (WHO) Five Moments Hand Hygiene. Jackson Health System and Public Health Trust (slide presentation); 2016. Available at: http://bit.ly/2jFSJX8.