Primary Care and Mental Health Partnership Trusts
GUIDELINES FOR HAND HYGIENE
(updated November 2009)
GUIDELINES FOR HAND HYGIENE
Hand hygiene is the single most important means of stopping the spread of infection.
Infection Control Nurses’ Association (2002).
The World Health Organisation (2009) recognises that thousands of people die every day around
the world from infections acquired while receiving health care. Hands are the main pathways of
germ transmission during health care and hand hygiene is therefore the most important measure to
avoid this transmission of harmful germs and prevent health care-associated infections.
Infections can occur because micro-organisms on the hand are introduced directly into a susceptible
site, e.g. catheters, cannulas and wounds or because they colonise the patient’s skin and can cause
infection (Pratt
et al 2001).
The aim of these guidelines is to provide advice on
why,
when, with
which product and
how hand
hygiene should be carried out. Information is also provided relating to skin care. An audit tool is
available from the Infection Prevention and Control team which sets evidence based standards for
facilities and practices, alternatively a hand hygiene observation tool (2007) can also be requested.
MICROBIOLOGY OF THE HANDS
By definition micro-organisms are invisible to the naked eye. Micro-organisms on the hand are
either resident or transient flora.
Resident micro-organisms are commonly termed normal flora or commensals.
They are usually of a low virulence and rarely cause infections except when
introduced into the body through exposure prone procedures such as surgery or
the introduction of a urinary catheter.
Transient micro-organisms are located on the surface of the skin. They are
termed “transient” because direct contact with other people, equipment or other
body sites all result in the transfer of these micro-organisms to and from hands.
They may consist of many different pathogenic micro-organisms. They are not
firmly attached to the skin and are removed quickly and effectively with routine
hand washing using soap and water or if no visible soiling present alcohol based
hand rub/gel (hygienic hand rub).
The ability of transient micro-organisms to transfer to and from hands with ease results in hands
being extremely efficient transmitters of infection. Unlike resident flora, transient micro-organisms
are easily removed with hand washing and the risk of cross infection is immediately reduced.
WHY CLEANSE YOUR HANDS?
Any healthcare worker, member of staff working in healthcare settings, care giver or person
involved in direct or indirect patient care needs to be concerned about hand hygiene and should be
able to perform it correctly and at the right time. The object is to render hands physically clean,
remove micro-organisms picked up during activities and to minimise the risk of cross infection.
The spread of infection via hands is well established (Larson 1981, Ayliffe et al 1990). Hand
washing is one of the most important procedures for preventing the spread of disease. Hands are
the principal route by which cross infection occurs (Elliott 1992).
The current spread of antibiotic resistant infection can be attributed, at least in part to a failure by
health care professionals to wash their hands either as often or as efficiently as the situation
requires, (Heenan 1996).
Hand washing is an infection control practice with a clearly demonstrated efficacy and must remain
the cornerstone of efforts to reduce the spread of infection.
Section B 1 - Hand Hygiene
1 November 2009
EXAMPLES OF ACTIVITIES SHOWN TO TRANSFER MICROBES TO THE HANDS
INCLUDE:-
• Touching, lifting, washing a patient. Casewell & Philips (1997)
• Changing babies nappies. Samadi
et al (1983)
• Bed Making, handling curtains. Sanderson & Weisler (1992)
• Dressing a Wound. Thomlinson (1997)
• Respiratory Care. Pittet (1999)
• Catheter Care. Crow
et al (1988).
Hands have also been implicated in the spread of both enteric and respiratory viral infections, either
directly from one person to another or via contaminated surfaces. The ability of transient micro-
organisms to transfer to and from hands with ease results in hands being an easy mechanism by
which infection can spread.
FACILITIES REQUIRED TO PERFORM HAND HYGIENE
• Access to appropriate hand hygiene facilities, and associated supplies, is essential to ensure
adequate hand hygiene can be performed. This not only includes the type and number of
facilities but also where they are situated in relation to where work/care is carried out.
• In new build and refurbishment projects the use of ‘hands free sensor’ tap systems should be
considered at designated clinical wash hand basins. An alternative is the use of wrist, elbow or
foot operated taps. Elbow taps are currently most commonly used in clinical or communal care
areas and, if used properly (e.g. turning taps off utilising the elbows) are adequate.
• The design of taps must be able to withstand decontamination.
• There should be no plugs fitted in clinical hand wash basins.
• Mixer taps or thermostatic mixer valves are preferred to provide the correct temperature of
water for performing hand hygiene.
• Availability of supplies for hand hygiene is essential, including hand hygiene solutions (soap,
antiseptic hand wash solution and alcohol based hand rub/gel (hygienic hand rub), preferably
wall mounted in easy to use, and easy to clean holder systems that contain single use,
disposable cartridge sets, particularly in clinical or communal care areas.
• Nozzles of solution bottles/containers should always be clean and free of any congealed
product
(bottles should not be reused or ‘topped up’).
• Soft, user friendly disposable paper towels for hand drying, preferably stored in a wall
mounted, easy to use and clean dispenser.
• Hands free, i.e. pedal operated, waste receptacles located at point of waste generation e.g.
adjacent to sink.
• Community staff should carry their own hand hygiene solutions and hand towels as facilities
may not be adequate when visiting non-NHS premises.
• Supplies of paper towels and other hand hygiene supplies should always be stored in a clean
dry area prior to use.
• Poorly maintained hand hygiene facilities, e.g. chipped/cracked enamel should be
reported/repaired.
WHEN SHOULD YOU DECONTAMINATE YOUR HANDS?
Hands must be decontaminated immediately before each and every episode of direct patient/service
user contact/care and after any activity or contact that potentially results in hands becoming
contaminated. This includes between different patients/service users or between different care
activities for the same patient/service user. For convenience and efficacy an alcohol based hand
rub/gel (hygienic hand rub) is preferable unless hands are visibly soiled. EPIC (2007).
Section B 1 - Hand Hygiene
2 November 2009
There is no set frequency for hand washing, it is determined by actions – those completed and those
intended to be performed but must be carried out if hands are visibly dirty. Routine hand washing
removes most transient micro-organisms from soiled hands. It is essential to wash hands after they
may have become contaminated with micro-organisms and before contact with any susceptible site
on a patient/service user.
Decontaminate Hands…
BEFORE…
AFTER…
Starting work
Handling patients with known infection
Direct patient contact
Removing gloves
Donning sterile gloves
Bed-making
Leaving isolation rooms
Handling patients
Preparing, handling/serving and eating food
Handling contaminated waste/laundry
Handling wounds, urethral catheters and
When visibly soiled
intravenous lines
Handling wounds, urethral catheters and
Emptying urine drainage bags
intravenous lines
Caring for susceptible patients
Administering medication
Administering medication
Undertaking decontamination/cleaning of
surfaces/equipment
Blowing your nose, covering a sneeze
Using the toilet
Key points to consider include:
• Even if gloves have been worn (see Personal Protective Equipment Policy) hand hygiene must
be performed as hands may still be contaminated beneath gloves or become so during their
removal. It must also be noted that hand hygiene may have to be performed between dirty and
clean tasks on the same patient/service user.
• If hands have touched a patient/service user before or during a procedure, but are not soiled with
any body fluids and do not require re-hand washing with soap, alcohol based hand rub/gel
(hygienic hand rub) can be used, (see Appendix 2).
• Any visible soiling or organic matter can inactivate the activity of alcohol and therefore hand
washing is essential as a primary response in these circumstances.
• Where infection with a spore forming organism e.g.
Clostridium difficile is suspected/proven it is
recommended that hand hygiene is carried out initially with liquid soap and water although it can
be followed by alcohol based hand rub/gel (hygienic hand rub).
• In clinical and communal care settings in particular, it is recommended that solutions be stored
within a wall mounted dispenser that can be easily cleaned, have single use, disposable cartridge
sets within the dispenser, and have easy-to-use dispensing systems.
• Solutions used may vary but the physical actions of performing hand hygiene, however, should
always be the same and are essential in ensuring hands are adequately decontaminated.
The World Health Organisation (2009) identify 5 moments of hand hygiene. These are based on
the need for hands to be cleansed at a range of times. This is to minimise the risk of cross
contamination or cross infection. The times indicated are fundamental times during care delivery
and daily routines. When caring for the sick and vulnerable the '5 moments of Hand Hygiene'
should be followed (see page 4).
Section B 1 - Hand Hygiene
3 November 2009
Your 5 moments for hand hygiene
at the point of care*
*Adapted from the WHO Alliance for Patient Safety 2006
1. Before touching a patient
WHY? To protect the patient/service user against colonization and exogenous (cross) infection by
harmful germs carried on your hands.
WHEN? Clean your hands before touching a patient when you are approaching them.
Situations when Moment 1 applies:
• Before shaking hands, before stroking a child’s forehead
• Before assisting a patient in personal care activities e.g. to move, take a bath, eat, get dressed
• Before delivering care and other non-invasive treatment e.g. applying oxygen mask, giving a
massage
• Before performing a physical non-invasive examination e.g. taking pulse, blood pressure, chest
auscultation, recording ECG
2. Before clean/aseptic procedure
WHY? To protect the patient against infection with harmful germs, including his/her own germs,
entering his/her body
WHEN? Clean your hands immediately before accessing a critical site with infectious risk for the
patient (e.g. a mucous membrane, non-intact skin, an invasive medical device)
Situations when Moment 2 applies:
• Before brushing the patient’s teeth, instilling eye drops, performing a digital rectal examination,
examining mouth, nose, ear with or without an instrument, inserting a suppository/pessary,
suctioning mucous
• Before dressing a wound with or without instrument, applying ointment on vesicle, making a
percutaneous injection/puncture
• Before inserting an invasive medical device (nasal cannula, nasogastric tube, endotracheal tube,
urinary probe, percutaneous catheter, drainage), disrupting / opening any circuit of an invasive
medical device (for food, medication, draining, suctioning, monitoring purposes)
• Before preparing food, medications, pharmaceutical products, sterile material
Section B 1 - Hand Hygiene
4 November 2009
3. After body fluid exposure risk
WHY? To protect you from colonization or infection with a patient’s harmful germs and to protect
the health-care environment from germ spread
WHEN? Clean your hands as soon as the task involving an exposure risk to body fluids has ended
(and after glove removal)*
Situations when Moment 3 applies:
• When the contact with a mucous membrane and with non-intact skin ends
• After a percutaneous injection or puncture; after inserting an invasive medical device (vascular
access, catheter, tube, drain); after disrupting and opening an invasive circuit
• After removing an invasive medical device
• After removing any form of material offering protection (e.g. napkin, dressing, gauze, sanitary
towel)
• After handling a sample containing organic matter, after clearing excreta and any other body
fluid, after cleaning any contaminated surface and soiled material (e.g. soiled bed linen, dentures,
instruments, urinal, bedpan, lavatories)
4. After touching a patient
WHY? To protect you from colonization with patient germs and to protect the health-care
environment from germ spread
WHEN? Clean your hands when leaving the patient’s side, after having touched the patient
Situations when Moment 4 applies, if they correspond to the last contact with the patient before
leaving him/her:
• After shaking hands, stroking a child’s forehead
• After you have assisted the patient in personal care activities e.g. to move, bath, eat, dress
• After delivering care and other non-invasive treatment e.g. changing bed linen with the patient in
the bed, applying oxygen mask, giving a massage
• After performing a physical non-invasive examination e.g. taking pulse, blood pressure, chest
auscultation, recording ECG
5. After touching patient surroundings
WHY? To protect you from colonization with patient germs that may be present on surfaces or
objects in patient surroundings and to protect the health-care environment against germ spread
WHEN? Clean your hands after touching any object or furniture when leaving the patient
surroundings, without having touched the patient
Moment 5 applies in the following situations if they correspond to the last contact with the patient
surroundings, without having touched the patient:
• After an activity involving physical contact with the patient’s immediate environment e.g.
changing bed linen with the patient out of the bed, holding a bed rail, clearing a bedside table
• After a care activity e.g. adjusting perfusion speed, clearing a monitoring alarm
• After other contacts with surfaces or inanimate objects (ideally try to avoid these unnecessary
contacts) e,g. leaning against a bed, leaning against a night table / bedside table
Hand hygiene as an important part of respiratory hygiene/cough etiquette should be
promoted at all times:
• Cover nose and mouth with disposable single-use tissues when sneezing, coughing, wiping and
blowing noses
• Dispose of used tissues in the nearest waste bin
• Wash hands after coughing, sneezing, using tissues, or after contact with respiratory secretions
and contaminated objects
Section B 1 - Hand Hygiene
5 November 2009
• Keep hands away from the mucous membranes of the eyes and nose. Certain patient/clients (e.g.
the elderly, children) may need assistance with containment of respiratory secretions. Those
who are immobile will need a receptacle (e.g. a plastic bag) readily at hand for the immediate
disposal of used tissues and will need to be offered hand hygiene facilities
GLOVED HANDS
The use of gloves does not replace the need for cleaning your hands.
• Gloves give added protection when performing nursing, medical and cleansing tasks.
• Gloves should be worn as indicated by safe working practices guidance in section B1.
• Hands can become contaminated from leaks/punctures in gloves or when removing gloves
therefore
always wash hands up on removal of gloves.
• Gloves are a single use item and must be changed in between patients and between clean and
dirty tasks. Hands should be socially washed or if physically clean alcohol based hand rub/gel
(hygienic hand rub) can be used up on removal of gloves.
• Remove gloves to perform hand hygiene when an indication for hand hygiene occurs while
wearing gloves.
• Prior to donning surgical gloves appropriate hand hygiene must be carried out.
• Gloved hands must not be washed with alcohol based hand rub/gel (hygienic hand rub) or wipes.
Hand hygiene must be performed when appropriate regardless of the indications for glove use.
LEVELS OF HAND HYGIENE:-
Social Hand Hygiene
This is undertaken to render the hands physically clean and to remove micro-organisms picked up
during activities considered ‘social’ activities (transient micro-organisms). It should be undertaken
before starting/leaving work, using computer keyboard (in a clinical area), eating/handling of
food/drinks (whether own or for a patient/service user), preparing/giving medications, touching a
patient/service user, entering/leaving clinical areas. After touching a patient/service user, hands
becoming visibly soiled, visiting the toilet, using computer keyboard (in a clinical area), handling
laundry/equipment/waste, blowing/wiping/touching nose, touching inanimate objects (e.g.
equipment, items around the patient/service user or their immediate environment). It is performed
using soap and warm running water for a duration of 10 –15 seconds. It is used when hands are
visibly soiled, before and after a work shift, before and after patient contact, after contact with
blood/body fluids and soiled linen/equipment, before handling food and after using the toilet. It
must be noted that if hands are visibly clean, alcohol based hand rub/gel (hygienic hand rub) can be
used for social hand hygiene for ease of use where appropriate
Hygienic Hand Hygiene
The aim of this is to remove or destroy transient micro-organisms. Additionally it is to provide
residual effect during times when hygiene is particularly important in protecting yourself and others
by potential reduction of resident micro-organisms. It should take at least 15 seconds to perform
hygienic hand hygiene, however washing your hands for excessive lengths of time is not
recommended as this may damage the skin. Hygienic Hand Hygiene should be undertaken before
clean/aseptic procedures, prior to and following contact with those who are immuno-compromised,
require isolation or during outbreak situations, before and after blood/body fluid contamination,
invasive procedures, wound management. It is performed as for social hand washing but involves
using an alcohol based hand rub/gel (hygienic hand rub) solution after drying hands. Please note
that alcohol based hand rub/gel (hygienic hand rub) can also be used as the sole agent when hands
are visibly clean.
Section B 1 - Hand Hygiene
6 November 2009
Surgical Hand Hygiene
The aim of this is to remove or destroy transient micro-organisms and to substantially reduce those
micro-organisms which normally live on the skin (resident micro-organisms) during times when
surgical procedures are being carried out. A hand forearm wash using an aqueous antiseptic
solution, e.g. Chlorhexidine or Povidone iodine in skin contact for 2-3 minutes. It is essential that
this is carried out before all surgical or invasive procedures. The first surgical hand wash must be
carried out with an antiseptic detergent however on subsequent occasions if hands are dry and
visibly clean an alcohol based hand rub/gel (hygienic hand rub) can be used. Two successive
applications of alcohol based hand rub/gel (hygienic hand rub) are necessary and should be applied
to the hands and wrist using a standardised technique and rubbed until completely dry for 2–3
minutes. All applications/washing should be undertaken in a systematic manner ensuring that all
aspects of the hands/wrist/lower arms are included as required.
CHOICE OF CLEANING AGENT
Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material must
be washed with liquid soap and water, (EPIC 2007).
The use of safe, effective and acceptable hand washing solutions must be considered in all health
care settings. This includes the effect of the agent on the health or skin of staff, patients/ service
users and relatives. To minimise the risk of sensitisation to liquid soaps or surgical scrub solutions
hands should be rinsed prior to and after the process of hand washing.
• An effective hand washing technique involves three stages:
preparation, washing and rinsing, and drying. Preparation requires
wetting hands under tepid running water before applying the
recommended amount of liquid soap or an antimicrobial
preparation. The hand wash solution must come into contact with
all of the surfaces of the hand. The hands must be rubbed
together vigorously for a minimum of 10-15 seconds, paying
particular attention to the tips of the fingers, the thumbs and the
areas between the fingers. Hands should be rinsed thoroughly
prior to drying with good quality paper towels, EPIC (2007).
Poster DH (2006).
•
Social/Hygienic Hand Washing: In most care settings hand washing with liquid soap and
warm water is adequate. Liquid soap dispensers with disposable cartridges should be used to
reduce the risk of contamination occurring. Preferably these should be wall mounted. Although
it is not recommended for use, if only refillable containers are available these need to be cleaned
and dried thoroughly before replenishing. If only bar soap is available care should be taken to
ensure that it is not left in a pool of water.
•
Hand washing using aqueous antiseptic solutions (Surgical Hand washing only): Aqueous
Antiseptic solutions that can be used differ in their properties. Therefore during one session of
use it is essential that the same solution is used. Prior to use, it should be checked that solutions
are within their expiry date. Where possible solutions used should contain a 70% alcohol
solution to ensure a broader anti microbial action. Containers and plungers should be visibly
clean. (Plungers need to be cleaned and dried in between re-use.) Containers in use should have
a plunger fitted to allow dispensing of an accurate dose of solution and to minimise potential for
cross contamination. Paper towel used to dry hands should be sterile if used with a surgical hand
wash technique.
Staff may wish to consider the use of alcohol based hand rub/gel (hygienic hand rub) - (see page 8)
as a sole agent if hands are physically clean or soap and water wipes if hands are visibly soiled.
Section B 1 - Hand Hygiene
7 November 2009
HAND DRYING
• Hand drying has been shown to be a critical factor in the hand hygiene process, in particular
removing any remaining residual moisture that may facilitate transmission of micro-organisms
(Hoffman and Wilson 1994). The methods of hand drying is also important in the maintenance
of effective hand drying.
• Hands that are not dried properly can become dry and cracked, leading to an increased risk of
harbouring micro-organisms on the hands that might be transmitted to others.
• Once the taps have been turned off using a ‘hands-free’ technique, use clean, preferably
disposable paper towels to dry each area of the hand thoroughly. This should be done by patting
dry each part of the hand remembering all of the steps included in the hand washing process.
• The use of soft, user-friendly, disposable paper towels is preferable to encourage compliance
with the hand hygiene process. Drying following surgical scrub is recommended using a motion
from the hands to the elbow.
• Disposable paper towels should be placed immediately into appropriate waste receptacles,
avoiding recontamination of hands, e.g. foot-operated bins not flip top or lids which require
lifting.
• Recontamination of hands immediately following the hand hygiene process must be avoided, e.g.
by not touching any contaminated areas in the environment or touching own hair or face.
• Disposable paper towels should always be used in clinical settings.
• The use of air dryers are not recommended in clinical areas unless it can be proven that they do
not cause aerosols of pathogens and can dry hands as quickly as paper towels.
• Communal Hand Towels should be avoided wherever possible. If use is required in domiciliary
settings where towels are visibly clean and paper hand towels are not available then use can be
considered if alternatives such as alcohol based hand rub/gel (hygienic hand rub) or skin
cleansing are not available/appropriate.
ALCOHOL BASED HAND GEL/RUB (HYGIENIC HAND RUB)
Alcohol based hand rub/gel (hygienic hand rub) is a skin antiseptic which does not require the use of
water or a towel to achieve hand hygiene. It is quick and easy to use and should be available in all
health care facilities (wards, clinical departments). It should be dispensed either from a pump
dispenser or community sized containers which are flip top.
Use of Alcohol Based Hand Rub/Gel (Hygienic Hand Rub)
• Alcohol based hand rub/gel (hygienic hand rub)with a concentration of 70% e.g. isopropanol,
ethanol or npropanol or a combination of two of these are generally used as they are effective,
cause less skin drying dermatitis and are less costly. Products that contain emollients can be used
to ensure the drying effects of alcohol based hand rub/gel (hygienic hand rub) are minimised.
(The use of Purell products are promoted in areas where this soap /moisturiser is contained in
pump dispensers).
• These products can be useful for performing hand hygiene when sinks are not readily available
for hand washing or when hands may be contaminated but no visible soiling is present e.g.
entering or leaving a ward/clinical/patient area.
• Alcohol based hand rub/gel (hygienic hand rub) can also be used following hand washing, e.g.
when performing aseptic techniques, to provide a further cleansing and residual effect.
Where infection with a spore forming organism e.g.
Clostridium difficile is suspected/proven it is
•
recommended that hand hygiene is carried out with liquid soap and water (or a skin cleansing
wipe) although it can be followed by alcohol based hand rub/gel (hygienic hand rub).
Section B 1 - Hand Hygiene
8 November 2009
How to Use Alcohol Based Hand Rub/Gel (Hygienic Hand Rub)
• The amount/volume used to provide adequate coverage of the hands should be indicated in the
manufacturers’ instructions. This is normally around 3 ml (one pump).
• The steps to perform hand hygiene using alcohol based hand rub/gel (hygienic hand rub) are the
same as when performing hand washing.
• The time taken to perform hand hygiene using alcohol based hand rub/gel (hygienic hand rub) is
at least 20 seconds (20-30 seconds is adequate). Manufacturers’ instructions should be followed
(a number of these recommend rubbing for 30 seconds).
• If the solution has not dried by the end of this process allow hands to dry fully before any
procedures are undertaken (do not use towels to do this).
It can be used:-
• As an alternative to hand washing if hands are visibly clean
• An addition to hand washing to achieve a hygienic hand wash
• As a rapid decontaminate on visibly clean hands:
o On ward rounds, between each patient
o After bed making
o Before handling medication
o When carrying out aseptic procedures if hands become contaminated mid procedure.
• Where hand washing facilities are unavailable or not fit for use (this may include
domiciliary/community settings)
• On subsequent surgical hand washes using an appropriate technique for application
Good Practice Points
• No scientific evidence is currently available to advise as to the maximum number of applications
of alcohol based hand rub/gel (hygienic hand rub) before hand washing is then required (i.e.
when hands have not been soiled). Individuals are, therefore, required to use their own judgment
or follow local guidance or manufacturers’ instructions (particularly regarding build up of
products on hands). Hands should be washed after repeated applications of gel when they feel
tacky.
• Topping up of bottles that contain solutions should never occur as the inside of bottles, even
those containing antiseptic solutions, can become a breeding ground for bacteria over time.
• Caution must be taken when using alcohol based hand rub/gel (hygienic hand rub) in relation to
flammability and ingestion. Local risk assessments should be undertaken to address each of these
issues.
• Caution should be taken to avoid drips or spills of solutions for health and safety reasons (e.g.
slips or falls).
• Those working in domiciliary settings such as homes should carry personal issue alcohol based
hand rub/gel (hygienic hand rub)
HAND HYGIENE – CORRECT TECHNIQUE FOR WASHING OR APPLYING
ALCOHOL BASED HAND RUB/GEL (HYGIENIC HAND RUB)
Hand cleansing with a good technique covering all surfaces of the hands at the right time is the most
important aspect of hand hygiene. See page 10 and Appendix 1 for examples of technique. By
following all steps included within the hand hygiene process, e.g. preparation for hand hygiene
(care of nails and jewellery), hand drying and hand care you will ensure potentially harmful micro-
organisms are not a factor in the spread of infectious agents. The procedure for performing hand
hygiene (hand washing) is detailed below.
Preparation:
• Gather all relevant equipment. Ensure all that is needed to perform hand hygiene is accessible.
• Ensure the sink area is free from extraneous items, e.g. cups, utensils.
Section B 1 - Hand Hygiene
9 November 2009
• Ensure jackets/coats are removed, and wrists and forearms are exposed.
• Jewellery should be removed.
• Ensure nails are short (False nails must not be worn).
Procedure:
• The tap should first be turned on and the temperature of the water checked. Water should be
warm (a comfortable temperature).
• Hands should be wet before applying the chosen solution.
• Apply solution, the manufacturers’ instructions for the solution being used should give
guidance as to the volume of solution to be applied. This is usually in the region of 3 ml (one
pump from dispenser).
• A good lather should be evident for undertaking the steps to perform adequate hand hygiene
• All areas of the hands should be covered systematically in these steps (see below and also
Appendix 1). The steps should take at least 15 seconds and staff should consider areas they are
likely to miss.
• For surgical scrub, an additional step of cleaning the forearms is required.
• Hands (and forearms where applicable) should be rinsed well under the running water.
• The physical action of washing and rinsing hands is essential as different solutions will have
different activity against micro-organisms.
• Hands should be adequately dried (without rubbing).
• Taps should be turned off using a ‘hands-free’ technique, e.g. elbows. Where ‘handsfree’ tap
systems are not in place, paper towels used to dry hands can be used for this.
• Dispose of the paper towels without re-contaminating your hands e.g. use the foot pedal. Do
not touch bin lids with your hands.
EFFECTIVE HAND HYGIENE (Ayliffe et al etc)
The application of alcohol based hand rub/gel (hygienic hand rub) when applied to hands should be
undertaken using the above technique (also refer to Appendix 2).
Section B 1 - Hand Hygiene
10 November 2009
Care should be taken to include areas that are most frequently missed, (Taylor 1978).
SKIN CARE - LOOK AFTER YOUR HANDS
Bacterial counts increase when the skin is damaged. It is important to protect the skin on hands
from drying and cracking where bacteria in particular may harbour, and to protect broken areas
from becoming contaminated, particularly when exposed to blood and body fluids.
• Cover all cuts and abrasions with a waterproof dressing, taking care to maintain intact skin as
much as possible.
• Hand creams can be applied to care for the skin on hands. However, only individual tubes or
hand cream from wall mounted dispensers should be used.
• Always wear disposable vinyl/latex/nitrile gloves when handling blood/body fluids. Gloves
must be powder free and hand hygiene must occur following their removal.
• Creams used should not affect the action of hand cleaning solutions being used or the integrity of
gloves. Oil based emollients should be avoided. Please note that hand creams containing an
anionic emulsifying agent reduce the residual antibacterial effect of Chlorhexidine solutions.
Communal tubs should be avoided as these may contain bacteria overtime.
• Hands should be wet prior to washing and thorough rinsing and drying is necessary. Drying is
especially important during winter months when the hands have a tendency to become chapped.
• Report any skin problems to your Manager, Occupational Health or General Practitioner in order
that appropriate skin care can be undertaken and the risks of harbouring micro-organisms while
providing care for others can be avoided.
NAIL CARE
• It has been shown that nails, including chipped nail polish, can harbour potentially harmful
bacteria. Caring for nails helps prevent the harbouring of micro-organisms, which could then be
transmitted to those who are receiving care.
• Nails must be natural, kept short and clean.
Section B 1 - Hand Hygiene
11 November 2009
• Nail polish must not be worn by staff undertaking healthcare activities/consultations or staff
working within healthcare settings who undertake hand hygiene within their role e.g.
housekeeping staff.
• Artificial fingernails/extensions should not be worn when providing care.
• Nail brushes should not be used with the exception of surgical scrub and in this instance must be
single use disposable. If required in other settings it is imperative that these are single use.
• The steps included in the hand hygiene process must be followed in order to ensure nail areas are
cleaned properly
HAND HYGIENE AND JEWELLERY
It has been shown that jewellery, particularly rings with stones and/or jewellery of intricate detail,
can be contaminated with micro-organisms, which could then spread via touch contact and
potentially cause infection. Wrist and hand jewellery should be removed before care is provided.
When direct care is provided or hand hygiene is required as part of the individual’s job this is
essential. Most staff providing care must, therefore, remove these at the start of the working day. It
is acceptable to wear plain bands, for example wedding bands.
HAND HYGIENE AND WORK CLOTHING
In order to ensure hands can be easily decontaminated it is helpful to wear work clothing that does
not go past the elbow (Bare below the Elbows). Jackets and coats should be removed and long
sleeves if worn rolled up, allowing for wrists and forearms to be exposed, this is essential for any
staff in healthcare settings who are required to undertake hand hygiene (healthcare staff, medical
staff, housekeeping staff, therapy staff).
Remove wrist watches, bracelets, hand jewellery and roll up long sleeves or remove long sleeved
clothing. Wrists should also be included when washing hands, it may also be necessary to wash the
forearms if they are likely to have been contaminated.
CLEAN
YOURHANDS
CAMPAIGN (National Patient Safety Agency 2004)
The National Patient Safety Agency’s (NPSA) clean
yourhands campaign has been implemented in
in Mental Health settings, PCT Provider Services and also GP practice settings within
Worcestershire. The campaign aims to support efforts to improve hygiene generally across acute,
community and mental health settings in hospitals, ambulances, clinics, health centres, general
practices and people’s homes, in a bid to reduce infections. This is based on national and
international evidence on what works in hand hygiene improvement.
The campaign builds on existing practices and aims to improve compliance with hand hygiene
guidelines and help to make is as easy as possible for staff to clean their hands at the right time and
for the right task. This includes:
• Improving the quality of care delivered through improving compliance with national and local
hand hygiene guidelines
• Decreasing the overall cost to the healthcare economy over the longer term by reducing the
number of patients catching infections
• Increasing the behaviour and personal responsibility of healthcare workers in observing hand
hygiene standards
• Sharing learning and best practice to enhance service user safety and confidence in healthcare
• Patient/Service User and Public involvement including challenging whether hand hygiene has
occurred
Section B 1 - Hand Hygiene
12 November 2009
The core message of the campaign is simple, clean
yourhands. The impact of the campaign will be
measured through observing staff hand hygiene behaviour, monitoring usage of the alcohol based
hand rub/gel (hygienic hand rub) and routine surveillance of infections over time. Implementation
of the campaign also assists achievement of NHSLA risk management standards.
Patient and Visitors Involvement All staff must ensure that relatives/visitors/patients/service users are encouraged to decontaminate
their hands when appropriate to do so e.g. when entering/leaving a ward during an outbreak.
Patients/Service Users must also be offered the opportunity to cleanse their hands after toileting,
before consumption of food or drink and before and after contact with susceptible sites, (eg wounds,
PEG sites, urinary catheters, administering insulin). Promotion of hand hygiene should also be
considered in community clinic settings e.g. for when parents are involved in nappy changing and
facilities to enable this must be accessible.
Staff Champions
The importance of staff champions or role models in hand hygiene is critical to ensure local
ownership of the clean
yourhands campaign. Staff champions or leads are available in all areas
where the campaign has been implemented. These staff ideally have a specific interest in hand
hygiene and will promote compliance within their healthcare setting. This can include ensuring
hand hygiene is undertaken appropriately in their area, new colleagues are aware of the campaign,
posters are appropriately displayed and dispensers are working, full and clean (soap, alcohol based
hand rub/gel (hygienic hand rub).
RESPONSIBILITIES
Staff (providing direct care in a health or social care setting including home setting)
must:
• Undertake adequate hand hygiene and encourage others delivering care to do so.
• Ensure all other staff/agencies apply the same principles.
• Offer reassurance to patients/service users and visitors/carers on precautions being taken.
• Advise the patients/service users, carers or visitors of any hand hygiene requirements.
• Ensure supplies of hand hygiene solutions and other materials, such as paper towels are readily
available for all to use.
• Ensure posters featuring when to perform hand hygiene and the steps included in the hand
hygiene process are displayed in relevant prominent areas to support infection control.
• Report to line managers any deficits in knowledge or other factors in relation to hand hygiene in
particular including facilities/equipment or incidents that may have resulted in cross
contamination.
• Attend any mandatory or update infection control education sessions.
• Report any illness, which may be as a result of occupational exposure, to the line manager and
the Occupational Health Department (if applicable).
• Not provide direct patient/client care while infectious as this could cause harm to others. If in
any doubt consult with your manager, General Practitioner, Occupational Health Department or
Infection Prevention and Control Team for advice.
Managers must:
• Ensure that all staff have had instruction/education on the principles of hand hygiene.
• Ensure that adequate resources are in place to allow for the recommended infection control
measures such as hand hygiene to be implemented. This includes items such as sinks/dispensers.
• Ensure areas participate in surveillance and audit programmes at a national or local level
including auditing as required.
Section B 1 - Hand Hygiene
13 November 2009
• Undertake a risk assessment to optimise safety in relation to placement of alcohol based hand
gel/rub (hygienic hand rub), consulting expert infection control guidance if/as required.
• Ensure any staff with health concerns, including any skin irritation related to occupational hand
hygiene, or those who have become ill due to occupational exposure are referred appropriately.
• Promote the use of locking devices on all wall mounted alcohol based hand rub/gel (hygienic
hand rub) dispensers as a matter or routine and on soap dispensers if indicated by risk assessment
(dependent upon area).
Staff with infection prevention and control responsibilities must:
• Provide education for staff and management on hand hygiene practices.
• Act as a resource for guidance and support when advice on hand hygiene is required.
• Provide advice on individual risk assessments for performing hand hygiene.
• Support the monitoring of compliance and present compliance results.
• Provide audit tools on request for local monitoring of standards in addition to the formal rolling
programme of audit.
Incident Reporting:
• Any incidents where failures in hand hygiene have occurred or where there are product/facilities
issues that affect adequate hand hygiene and in turn health and safety should be reported as per
local incident reporting procedures.
General Responsibilities:
• Effective communication between all members of the health and social care team is imperative
for patient safety.
• Health and safety issues, related to staff, patients/clients should also be considered in relation to
products used for hand hygiene, e.g. drips or spillages from alcohol based hand rub/gel (hygienic
hand rub) and any risks of slips, falls or ingestion of products by particular patient/service user
groups. Risk assessments should be carried out locally to highlight/manage relevant issues.
• Control of Substances Hazardous to Health (COSHH) and product data sheets should be referred
to in order to ensure safe use of/exposure to products being used for hand hygiene
• It is up to each and every individual to:
o Continually challenge both their own and their colleagues hand hygiene practices.
o Monitor and change bad practices.
o Access information on infections and control mechanisms to reduce the spread of
infection.
o Devise and initiate creative ways of keeping hand washing to the fore front of health
care workers’ agenda.
Section B 1 - Hand Hygiene
14 November 2009
KEY POINTS (EPIC 2007)
• Hands must be decontaminated immediately before each and every episode of direct
patient/service user contact/care and after any activity or contact that potentially results in hands
becoming contaminated, refer to 5 Moments.
• Hands that are visibly soiled or potentially grossly contaminated with dirt or organic material
must be washed with liquid soap and water.
• Hands should be decontaminated between caring for different patients or between different care
activities for the same patient.
• For convenience and efficacy an alcohol-based hand rub/gel (hygienic hand rub) is preferable
unless hands are visibly soiled or when involved in caring for someone with
Clostridium difficile associated diarrhoea. In some outbreak situations alternative products may be recommended by
the infection prevention and control team.
• Hands should be washed with soap and water after several consecutive applications of alcohol
based hand rub/gel (hygienic hand rub) when they start to feel tacky.
• Before a shift of clinical work begins, all wrist and ideally hand jewellery should be removed.
Cuts and abrasions must be covered with waterproof dressings. Fingernails should be kept short,
clean and free from nail polish. False nails and nail extensions must not be worn by clinical staff.
• An effective hand washing technique involves three stages: preparation, washing and rinsing,
and drying. Preparation requires wetting hands under tepid running water before applying the
recommended amount of liquid soap or an antimicrobial preparation. The handwash solution
must come into contact with all of the surfaces of the hand. The hands must be rubbed together
vigorously for a minimum of 10-15 seconds, paying particular attention to the tips of the fingers,
the thumbs and the areas between the fingers. Hands should be rinsed thoroughly prior to drying
with good quality paper towels.
• When decontaminating hands using an alcohol based hand rub (hygienic hand rub), hands should
be free of dirt and organic material. The hand rub solution must come into contact with all
surfaces of the hand. The hands must be rubbed together vigorously, paying particular attention
to the tips of the fingers, the thumbs and the areas between the fingers, until the solution has
evaporated and the hands are dry.
• Clinical staff should be aware of the potentially damaging effects of hand decontamination
products. They should be encouraged to use an emollient hand cream regularly, for example,
after washing hands before a break or going off duty and when off duty, to maintain skin
integrity.
• If a particular soap, antiseptic hand wash or alcohol based product causes skin irritation, review
method of application and refer to Occupational Health for advice.
• Personal issue alcohol based hand rub/gel (hygienic hand rub) should be available for use by all
clinical staff and appropriate support/facilities staff (e.g. housekeeping staff, porters). This is in
preference to bed side products which are not routinely recommended. The preferred way of
achieving point of care application is via wall mounted dispensers or personal issue supplies.
• Education and training in effective hand hygiene and glove use should form part of all healthcare
workers’ induction and update training, resources should be available within healthcare settings
to promote hand hygiene and a recognised technique.
Section B 1 - Hand Hygiene
15 November 2009
REFERENCES & BIBLIOGRAPHY
ALBERT R.K, F. CONDIE. 1981. Hand washing Patterns in Medical Care Units.
New England
Journal of Medicine. 304(24). 1465 – 1466.
AYLIFFE,G.A.J, J.R. BABB, A.H. QUORAISHI. 1978. A test for hygienic hand disinfection.
Journal of Clinical Pathology. 31. 923.
AYLIFFE, G.A.J, B.J. COLLINS, L.J. TAYLOR. 1990.
Hospital Acquired Infection. Principles
and Prevention. Second Edition. Wright. London.
CASEWELL, M. AND PHILIPS, I. 1997. Hands as a route of transmission for Klevsiella species.
British Medical Journal. 1315 – 1317.
DEPARTMENT OF HEALTH. (2007).
Uniform and workwear: an evidence base for developing
local policy.
ELLIOTT P.R.A. 1992. Hand washing a process of judgement and effective decision making.
Professional Nurse. 2. 292 – 296.
HEENAN A.L.J. 1996. Handwashing solutions.
Professional Nurse. 11(9). 615 – 622.
HOFFMAN P.N, J. WILSON. 1994.
Hands, Hygiene and Hospitals. PHLS Microbiology Digest.
11(4). 211 – 261.
INFECTION CONTROL NURSES ASSOCIATION. 2002.
Guidelines for Hand Hygiene.
Second Edition. ICNA.
LARSON E. 1981. Resistant carriage of gram negative bacteria on hands.
American Journal of
Infection Control. 9. 112 – 119.
NATIONAL PATIENT SAFETY AGENCY (2004) clean
yourhands campaign.
www.npsa.nhs.uk/cleanyourhands
PITTET, D. S. DHARAN, S. TOUVENAU. 1997. Bacterial contamination of the hands of
hospital staff during routine patient care.
Archives of Int. Medicine. 159. 821 – 826.
PRATT R.J, C. PELOW, H.R. LOVEDAY, N. ROBINSON, G.W. SMITH and the EPIC guideline
development team. 2001. National evidence Based Guidelines for preventing Hospital acquired
Infection – Standard principles. Thames Valley University.
PRATT RJ; PELLOWE CM; WILSON JA; LOVEDAY HP; HARPER P; JONES SRLJ;
MCDOUGALL C; WILCOX MH. (2007) Epic 2: National Evidence-Based Guidelines for
Preventing Healthcare-Associated Infections in NHS Hospitals in England.
http://www.epic.tvu.ac.uk/PDF%20Files/epic2/epic2-final.pdf
REYBROUCK G. 1983. Role of Hands in the spread of nosocomial infections.
Journal of
Hospital Infection. 4. 103 – 110.
SAMADI A.R, M.I. HUQ, Q.S. AHMED. 1983. Disinfection of rotavirus in hand washing of
attendants of children with diarrhoea.
British Medical Journal. 286. 188.
SANDERSON P.J, S. WEISLER. 1992. Recovery of coliforms from the hands of nurses and
patients activities leading to contamination.
Journal of Hospital Infection. 21. 85 – 93.
TAYLOR L. 1978. An evaluation of hand washing techniques.
Nursing Times. January 12. 54 –
55.
THOMLINSON, D. 1997. To clean or not to clean.
Nursing Times. 83. 71 – 75.
CROW, R. A. MULHALL, R. CHAPMAN. 1998. Indwelling catheterisation and related nursing
practice.
Journal of advanced nursing. 13. 489 – 495.
Section B 1 - Hand Hygiene
16 November 2009
DEPARTMENT OF HEALTH. (2006). Wet, Soap, Wash, Rinse, Dry
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyandGuidance/dH
_063674
WORLD HEALTH ORGANISATION. (2009) WHO Guidelines on Hand Hygiene in Health
Care.
Section B 1 - Hand Hygiene
17 November 2009
APPENDIX 1
APPENDIX 2
