Proper handwashing technique: a restaurant observation

Jasminka Criley, MD, FACP, FHM

Jasminka Criley, MD, FACP, FHM

President and CEO, Indelible Learning
Associate Clinical Professor of Medicine, UCLA School of Medicine

Hands rinsing under running water

People just do not know proper handwashing technique.

Or do they?

When I tell people that we have been creating an app to improve people’s handwashing technique, and upgrade their health habits, I often hear: “I always wash my hands,” or “I always use hand sanitizer to wash my hands.” Implying: “I already do it.”

But does doing it mean doing it well?

The only way to wash your hands well is by doing it properly.

Doing it properly means more than washing for 20 seconds as often recommended. Doing it well means being aware of things you touch around you that are potentially contaminated, and washing your hands, well, mindfully.

Are you aware of how you wash your hands? At all times?

If you touch poop, you would probably be aware that you need to wash your hands well. But what if you are distracted? Or if you touch a handle that someone else with poop on their hands touched? You would not know that you got poop on your hands too. If you do not wash your hands thoroughly, you might still have some “poop remnants” on your hands. And if that poop came from person with infectious diarrhea, theoretically, you might get it too.

During and/or after the pandemic, I made a number of personal observations while visiting restaurants or hotels that confirmed my suspicion: even with good will, and good intentions to wash their hands, people often do not do it well.

Here is only one example (from a restaurant) that illustrates my point:

A woman comes out of the restroom. She is beautifully groomed with a long hair, impeccable makeup, and fashionable outfit. As she comes out after using the toilet, this is what she does:

  1. First, she holds her mobile phone in her hand (which she was using while on the toilet) and puts it on the counter.
  2. Then, she looks at herself in the mirror, checking her hair and her makeup. She touches her right eye to fix her artificial eyelashes.
  3. She opens the water using the faucet handle, and washes her hands, rubbing palms while continued to look at herself in the mirror. And somewhat, rubbing the back of her hands. She has beautiful long nails with flawless nail polish.
  4. She turns off the faucet.
  5. She dries her hands.
  6. She picks up her phone and looks at it.
  7. She again inspects her face and her makeup.
  8. Then, she opens the bathroom doors and exits.

How did she do?

Let’s analyze her steps:

  1. She used her cellphone while on the toilet.
    1. Where did she hold her phone if she needed to wipe herself? On the floor? In her hand?
    2. Did some of the “stuff” get on her phone?
  2. She came out and placed her phone on the bathroom counter.
    1. How clean is her phone now, I wonder?
    2. Will she clean it before picking it up again?
    3. How clean was the counter in the publicly shared bathroom?
    4. If the counter is not clean, is she adding to the number of germs on her phone?
    5. If she got some germs on her phone while using the toilet, did she let some of those germs spread on the counter?
    6. If someone comes after her and touches the same counter, will they pick up some of these germs, too?
  3. She touched her eye before she washed her hands.
    1. Did she spread some of the germs she potentially had on her hands, before washing them, onto her eye? If she did, does it matter?
  4. She turned on the faucet with her hands after using the toilet.
    1. Were those hands dirty and did she spread some germs on that faucet handle too?
    2. Will the next person that touches the faucet handle get those germs on their hands?
  5. Handwashing duration:
    1. She washed her hands for about 20 seconds. According to CDC guidelines, that is sufficient for handwashing. Unfortunately, the duration of handwashing does not determine (and is not correlated with) the quality of handwashing.
    2. Let’s look closer at how she washed her hands.
  6. Handwashing technique: she was washing her hands automatically, without even thinking about it.
    1. She washed her palms thoroughly.
    2. She washed the back of her hands, somewhat.
    3. She did not wash in between her fingers.
    4. She did not wash her fingertips.
    5. She did not wash the area around her nails (which were long).
    6. She did not wash her thumbs.
    7. She had jewelry on her wrists and did not wash her wrists either.
  7. She rinsed her hands.
  8. She turned off the faucet with her clean hands.
    1. Did she get additional germs from the faucet handle on her hands?
  9. She dried her hands which was good, but then threw the paper away too soon.
  10. She picked up her phone from the counter (with clean hands).
    1. How clean are her hands now?
  11. She touched her eyes and face again (did she transmit some germs onto her face?).
  12. She opened the restroom doors touching the restroom door handle with her bare hands.
    1. How clean was that handle?
    2. Did her potentially newly contaminated hands (from faucet handle and/or her dirty phone) transmit additional germs to the door handle?

She went out to the real world, hugging, touching her friends, eating, drinking, and living her life.

What was her Handwashing Score?

Turn on clean running water 1
Wet hands under water 1
Apply soap 1
Scrub PALMS 1
Scrub BACK of left hand 1
Scrub BACK of right hand 1
Scrub BETWEEN fingers 0
Scrub THUMB of left hand 0
Scrub THUMB of right hand 0
Scrub NAILS of left hand 0
Scrub NAILS of right hand 0
Scrub FINGERTIPS of left hand 0
Scrub FINGERTIPS of right hand 0
Scrub WRIST of left hand 0
Scrub WRIST of right hand 0
Rinse 1
Dry hands with a clean towel 1
Turn off water with a towel 0
Handwashing score 8

She did 8 out of 18 total steps.

In relation to the 12-handwashing scrubbing steps she did only 3 out of 12 steps (she washed her palms and backs of her hands only).

It is easy to see how even well-meaning people do not do a good enough job washing their hands. In our example, she had good intentions. If asked, she would honestly say that she washed her hands.

But she missed so many steps. That might potentially contribute to spreading germs to others. Especially if, let’s say, she had diarrhea. Some pathogens that we transmit via diarrhea and dirty hands include: E. coli, the notorious norovirus that continues to be a problem, salmonella and shigella. Dirty hands can also transmit germs from a upper respiratory infection, like the common cold, the flu or RSV.

Any of these germs could have been spread this way from incompletely washed hands. Even clean hands that touch something dirty can undo the best of hand hygiene efforts.

While advising people to wash their hands for 20 seconds might have been a good initial public health strategy, more could be done.

We need to teach people healthy habits including how to wash their hands properly. Ideally, we would start instruction at an early age. That includes practicing all handwashing steps, especially handwashing scrub steps. Adults might need a refresher and reminder too. People are capable of learning more. Let’s not underestimate them.

What are your observations about how people wash their hands at home, work, in hotels, restaurants, or other public places? Are they doing it well? What could they do even better?

 

Jasminka Vukanovic-Criley is an award-winning physician internist, hospitalist, mentor, educator, speaker and can be reached on Twitter @criley_md.