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Trust Hand Washing Policy 
This document emphasises the role of effective hand decontamination programmes and 
protocols in the management of infection.   
Document Number and Version: 
EDC004         Version 3 
Authorised by: 
Governance and Performance Board 
Date authorised: 
Next review date: 
Document Author: 
Infection Prevention Team 

Pennine Acute Hospitals NHS Trust                                                                            Hand Washing Policy   Version: 3 
Pennine Acute Hospitals NHS Trust 

Trust Hand Washing Policy 
Main Revisions from previous issue 
Name of Previous Document:  

Trust Hand washing Policy 
Document Number: 
EDC 004  
Version Number: 

Reason for Revision: 
More in depth information provided on 
risk assessment, of hand 
decontamination technique and skin 
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Purpose         4 

The Role of Hand Washing in Preventing  
Skin Care 
10.2 Education and Training 
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Hands are the principal route by which cross-infection occurs. 
This policy sets out clear guidance and procedures to prevent the transmission of infection 
by hand. It emphasizes the Trust’s commitment to infection control and details the 
accountabilities for implementing and supporting the policy. 
2. Scope of This Policy 

This document emphasises the role of effective hand decontamination programmes and 
protocols in the management of infection. It sets out the standard for hand hygiene and 
decontamination for all healthcare personnel, including Trust employees, contractors, 
students and agency staff. 
This standard will enable all staff to comply with the requirement to carry out hand hygiene at 
appropriate times during patient care. 
3. Roles and Responsibilities 

Each individual has a clinical and ethical responsibility to carry out effective hand hygiene 
and to act in a way, which minimises risk to the patient. 
Divisional Managers/ clinical leads must ensure that resources are available for health care 
workers to undertake effective hand hygiene. 
Divisional Managers / clinical leads should ensure that all patients and visitors in the hospital 
setting have access to products and facilities to perform effective hand hygiene (e.g. alcohol 
gel suitably placed on entry/exit to wards/clinics with appropriate notices). Patients and 
visitors to wards should be actively encouraged to undertake effective hand hygiene. 
Senior staff must act as excellent role models for junior grade staff. Line managers must 
ensure that appropriate staff has had hand hygiene training and regular updates. 
The working environment must support excellent hand decontamination through the 
provision of conveniently located and designed sinks, supplies of liquid soap, conveniently 
sized alcohol gel dispensers, paper towels and “hands free” waste bins. 
Each clinical area should display appropriate posters/education material to promote good 
hand hygiene practice for both healthcare staff and patients/visitors for ward areas 
4. Background 
Many clinical activities carried out during healthcare exposes patients to an increased risk of 
infection. Studies in the UK suggest that between 6% (Glenister et al 1992) and 8% 
(Plowman et al 1999) of patients acquire an infection during their stay in hospital and at any 
one time 9 in every 100 patients is likely to have a hospital acquired infection (Emerson et al 
Since hands are frequently implicated in transmitting infection from patient to patient, 
effective hand hygiene is of key importance to infection control. 
4.1. Costs of Hospital Acquired Infection 
The acquisition of health care associated infection (HCAI) increases the cost of care by three 
times due to increased length of stay in hospital, drug therapy, tests and specialist care 
(Plowman et al 1999). This study estimated that HCAI cost the NHS nearly one billion 
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pounds annually. An infection also has an intangible cost to the patient and their family. It 
may affect the patient physically and emotionally, delay their return to health and increase 
the burden of care to other family members. 
It has been estimated that 10% of patients who acquire an infection in hospitals will die as a 
result and for many others the infection is a major contributory factor in their death (Haley 
5. The role of handwashing in preventing Health Care Associated      

Hands are considered to play a major role in the transmission of infection between patients 
(Reybrouck, 1983). Infections may occur because micro-organisms on the hands are 
introduced directly into a susceptible site such as a wound or vascular catheter, or they 
colonise the patients’ skin and subsequently cause infection. Handwashing is the single 
most important measure for preventing the transmission of infection.  
On admission to the Trust, Patients and their relatives are given written information in the 
Trust welcome literature highlighting the importance and necessity of hand hygiene for staff, 
visitors and patients. Hand Hygiene posters are distributed to every clinical area of the Trust 
and alcohol gel is by every bed, hand wash basin and ward entrance. 
5.1. Why we don’t wash our hands 
Many studies have shown that healthcare workers frequently do not wash their hands after 
contact with patients’ even after dirty procedures (Ward  
et al 1997, Pittet et al 1999). Several factors have been found to discourage handwashing 
such as poor staffing levels, inadequate sinks, lack of soap, hand towels or water 
temperature controls (Wilson 2001). Healthcare workers seem to have a poor understanding 
of the risks to patients of not washing their hands. Changing both their understanding and 
behaviour is essential to ensure that handwashing becomes of part of a routine high 
standard of care for all healthcare workers. (Hand Hygiene Liaison Group 1999). 
5.2. The microbiology of hands 
Micro-organisms are invisible to the naked eye. This may result in the failure of healthcare 
workers to recognise that their hands can be responsible for cross infection (Horton, 1995). 
The microbial flora of the skin consists of resident and transient micro-organisms. 
5.2.1 Resident skin flora (e.g. coagulase-negative staphylococci, diphtheroids, micrococci) 
survive and multiply in the superficial skin layers. Resident micro-organisms are low grade 
pathogens and are not easily dislodged. Therefore, they are not usually implicated in 
infections. However, during surgery or other invasive procedures they may enter deep 
tissues and establish an infection (Garner and Favoro, 1986) 
5.2.2 Transient skin flora represents recent contaminants, which usually survive only for a 
limited period of time. They can be pathogens (e.g. E.coli, S. aureus) acquired from 
colonised or infected patients or the inanimate hospital environment and may cause 
nosocomial infection. The ability of transient micro-organisms to transfer to and from hands 
with ease results in hands being extremely efficient vectors of infection. Transient micro-
organisms can easily be removed with handwashing and the risk from cross infection 
immediately reduced. 
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Before Handwashing 
After Handwashing 
6. The aims of hand decontamination 

Hand decontamination has a dual role to protect both the patient and the healthcare worker 
from acquiring micro-organisms which may cause them harm. 
Hands may be contaminated by direct contact with patients, indirectly by handling equipment 
or through contact with the general environment. Patients with invasive devices or 
undergoing invasive procedures are particularly vulnerable to infection from micro-organisms 
transferred on hands. 
Expert consensus groups agree that effective hand decontamination results in significant 
reduction in the carriage of potential pathogens on hands (Rotter et al 1986, Larson et al 
1987, Ehrenkranz and Alfonso 1991, Doebbeling et al 1992). 
6.1 When to decontaminate your hands 
To prevent the transfer of micro-organisms it is essential to decontaminate hands before 
contact with any susceptible patient or site on a patient and after hands may have become 
contaminated with micro-organisms. 
There is not a set frequency for hand decontamination as it is determined by clinical actions; 
those completed and those intended to be performed. 
A risk assessment of the activity intended or performed will determine the appropriate 
decontamination process and the choice of agent e.g. soap, alcohol or antiseptic 

ƒ  Do you need to decontaminate your hands before this 
     activity /contact? 
ƒ  Do you need to decontaminate your hands after this activity/contact? 
ƒ  Are your hands visibly soiled? 
ƒ  Is this a high risk procedure or a vulnerable patient? 
In the majority of clinical situations, soap and water or alcohol hand rub will 
Higher level disinfection using a surgical scrub is required prior to all surgical 
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6.2 Types of decontamination 
6.2.1 Routine hand decontamination 
The aim of routine hand decontamination is to remove transient micro-organisms acquired 
on the hands before they can be transferred. This activity is sometimes called “social” hand 
decontamination when soap is used or “hygienic” hand decontamination if an antiseptic or 
alcohol based preparation is used. Hands that are visibly soiled with dirt or organic material, 
or potentially contaminated with micro-organisms should be washed using liquid soap and 
water. Antiseptic hand cleansing solutions are not usually recommended for routine hand 
decontamination. However, if hands are visibly clean they can be decontaminated using an 
alcohol hand rub. 
6.2.2 Surgical hand decontamination 
Surgical hand decontamination is used prior to surgical or other highly invasive procedures 
where extra care must be taken to prevent micro-organisms being introduced into tissues 
should gloves be damaged. Surgical hand decontamination aims to substantially reduce 
resident micro-organisms and remove or destroy transient micro-organisms. This process 
is achieved by using an antiseptic hand cleansing preparation. 
7. Choice of cleaning agents 
There are ranges of cleaning products available for hand decontamination and the selection 
of the correct agent will depend on whether the removal of transient or resident micro-
organisms is required 
7.1 Soap and water 
For most routine daily activities handwashing with plain liquid soap and water is sufficient 
(Russell et al 2000).  Handwashing with soap suspends transient micro-organisms in 
solution and allows them to be rinsed off; this process is referred to as mechanical removal 
of micro-organisms. 
Liquid soap dispensers are the preferred option for use in clinical settings. The soap 
dispenser should be wall mounted, maintained regularly and operated by elbow, wrist or 
foot. The dispensers should have individual replacement cartridges that are discarded when 
empty. This will reduce the chance of accidental contamination of the soap (Ayliffe et al 
7.2 Alcohol –based preparations 
Alcohol hand rub offers a practical and acceptable alternative to handwashing in most 
situations, provided hands are not dirty (Pratt et al 2001). Alcohol is not a cleansing agent 
and visible contaminants must be removed with soap and water. In addition, build up of 
emollients means that hands need to be washed with soap and water after 2 – 3 applications 
of alcohol hand rub. 
7.3 Aqueous antiseptic solutions 
Antiseptic handwash solutions used with water will both remove and destroy micro-
organisms on the hands. This process is referred to as chemical removal of micro-
organisms (Garner and Favero 1985). 
Hand disinfection will reduce counts of colonizing resident flora as well as removing or 
destroying transient micro-organisms contaminating the hands. Some antiseptic agents have 
a residual activity so provide continual anti-microbial activity (Larson 1995). This on-going 
activity is of benefit during surgical procedures and helps to minimize the risk of 
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contaminating the surgical field if glove punctures occur. The antiseptic of choice in this 
Trust is Chlorhexidene gluconate (Hibiscrub). 
8. Hand decontamination technique 
A good technique covering all surfaces of the hands at the right time is more important than 
the agent used or the length of time taken to perform it (Ayliffe et al 2000). 
The ideal technique should be quick, reduce hand contamination to the lowest possible level 
and be free from notable side-effects to the skin (Pittet and Boyce 2001). 
8.1 Preparation of hands prior to decontamination 
The efficacy of hand decontamination is improved if the following principles are adhered to: 
ƒ  Keep nails short and pay attention to them when washing hands – most microbes on 
the hands come from beneath the finger nails (Larson 1989). 
ƒ  Do not wear rings with ridges or stones - total bacterial counts, particularly of Gram 
negative bacteria, are higher when rings are worn (Larson 1985, Jacobson et al 
ƒ  Do not wear artificial nails or nail polish as they discourage vigorous hand washing 
(Larson 1989). Nail polish can flake and itself become a source of contamination. 
ƒ  Remove wrist watches, bracelets and roll up long sleeves prior to handwashing 
(Gould 1994) 
ƒ  Cuts and abrasions must be covered with waterproof dressings. 
8.2 Routine hand decontamination using soap and water 
The correct technique for routine hand washing involves: 
ƒ  Wetting the hands under running water 
ƒ  Applying the liquid soap and covering all surfaces of the hands. 
ƒ  Vigorously rubbing all surfaces of lathered hands for 10 – 15 seconds 
ƒ  Rinsing hands under running water to remove residual soap 
ƒ  Thoroughly drying hands 
Ayliffe et al (1978) devised a “six step technique” for handwashing that can be used to 
ensure that all parts of the hands are covered. Each step consists of five strokes forward 
and five strokes backwards. 
S I X   S T A G E   H A N D W A S H I N G   T E C H N I Q U E
1     p a lm   t o   p a lm
4     f in g e r t i p s
b a c k s   o f   h a n d s
5     t h u m b s   a n d   w r is t s
in t e r d ig it a l  s p a c e s
6     n a i ls
R e p r o d u c e d   w i t h   k i n d   p e r m i s s i o n   o f   t h e   N u r s i n g   S t a n d a r d
C h r i s t i e   H o s p i t a l   T r u s t
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During handwashing, particular attention should be paid to those areas of the hands that 
are most frequently missed (Taylor 1978). 
eas M
 M ost
st Frequent
 Frequently M
 M issed
HAHS © 1999
Reference: Taylor L. (1978)
Christie Hospital Trust
8.3 Routine hand decontamination using alcohol hand gel 
ƒ  When decontaminating hands using an alcohol hand rub, hands should be free of dirt 
and organic material. The handrub solution must come into contact with all surfaces 
of the hand. The hands must be rubbed together vigorously using the 6 stage 
technique, paying particular attention to the tips of the fingers, the thumbs and the 
areas between the fingers, and until the solution has evaporated and the hands are 
ƒ  Alcohol is an effective alternative when there is no water or towels readily available 
and there is need for rapid hand disinfection. 
8.4 Surgical hand decontamination 
There are a number of alternative methods for preparing the hands, nails and forearms prior 
to undertaking a surgical procedure: 
1.  Wash hands with an aqueous antiseptic solution for 3 to 5 minutes (Rotter 1999, 
Larson 1995). 
2.  Apply an alcohol - based product to clean hands for 3 minutes (Rotter et al 1998). 
3.  Wash hands with an aqueous antiseptic solution for 3 minutes, followed by an 
alcohol based product for 4 to 5 minutes (Rotter and Koller 1990). 
Since the number of bacteria on the skin gradually increase over time handwashing with 
antiseptic solution or alcohol should be repeated every few hours. 
Surgical hand decontamination has traditionally included scrubbing with a brush or sponge 
to further decrease bacterial counts on the hands. However, it has been suggested that this 
is not necessary, especially when alcohol based products are used (Hand Hygiene Task 
Force 2001). 
8.5 Hand drying 
Wet surfaces transfer micro-organisms more effectively than dry ones (Hoffman & Wilson 
1994).  Consequently, the methods of hand drying is also important in the maintenance of 
hand hygiene (Blackmore, 1987).  
Drying with paper towels is quicker and more thorough – 7-9 seconds compared with 25.4 
seconds with dryers (Redway et al. 1994). It has been suggested that paper towels operate 
effectively by two mechanisms. They rub away transient organisms and old, dead skin cells 
loosely attached to the surface of the hands. Paper towels should be conveniently placed in 
relation to handwashing facilities, preferably in a wall-mounted dispenser, where they will not 
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be contaminated by splashing water (Garner and Favero 1985).  Care should be taken when 
disposing of paper towels.  
The foot operated pedals on bins must be used rather than using the hands to open and 
close bins as the bin lid may cause hands to become recontaminated (Gidley, 1987). 
9. Skin Care 
9.1 Caring for your skin 
People in occupations such as healthcare, where frequent handwashing is required, are 
susceptible to long-term changes in the skin. These can result in chronic damage, irritant 
contact dermatitis and eczema as well as changes in the bacterial flora of the skin. The 
prevalence of irritant contact dermatitis in healthcare professionals has been shown to be 
10-45% (Larson 2001) 
Moreover, washing damaged skin may cause skin shedding or greater numbers of micro-
organisms and washing is less effective at removing them (Larson 2001). Failure to remove 
jewellery may predispose to skin problems, and eczema can begin under a ring and spread 
over the hand (Field 1994). Damaged skin caused by harsh handwashing agents, has been 
cited as a reason why staff fail to decontaminate their hands (Gould and Ream 1994). 
9.2 Prevention of skin damage 
Skin damage is generally associated with the detergent base and/or poor handwashing 
technique (Pratt et al 2001). To minimize the risk hands should always be wetted under 
running water before applying any soap or detergent. After washing, hands should be 
thoroughly rinsed to remove residual soap and then dried carefully, paying particular 
attention to drying the area between the finger webs (Field 1994, Larson 1995). If a 
particular hand hygiene preparation causes skin irritation, advice should be sought from 
Occupational Health. When the hands are not visibly soiled, alcohol gel can be used instead 
of soap and water as it is associated with less skin damage (Pittet and Boyce 2001, Pittet et 
al 2000, Girard et al 2001). 
9.3 Hand creams 
Hand cream should be applied regularly to the hands to protect the skin from the drying 
effects of regular hand decontamination (Pratt et al 2001). Communal jars of hand cream are 
not to be used as the contents may become contaminated and subsequently become a 
source of cross infection (Gould 1994). Hand creams with a non-ionic base are 
recommended (Larson 1995). The use of emulsions for hand care has been documented 
(Kolari et al 1989) and found to improve the conditions of the hands. 
9.4 Gloves 
Increased awareness of the need to wear gloves as part of standard precautions has 
resulted in a significant increase in their use. Natural rubber latex (NRL) remains the material 
of choice for user protection against blood- borne viruses because of its resealable 
properties, flexibility and barrier protection. Risks relating to the wearing of NRL gloves have 
become increasingly apparent and range from immunological responses, Type I and Type IV 
sensitivity, to an irritant response. These responses can range in severity from chapped, 
itchy hands to anaphylaxis. Appropriate synthetic gloves must be available for use by staff 
that are known to be sensitized to NRL proteins (Infection Control Nurses Association 2002). 
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Important points to note 

ƒ  The use of bar soap is discouraged.  
ƒ Gloves 
not be regarded as a substitute for hand washing. A glove is not 
always a complete impermeable barrier (20 -30% of surgical gloves are punctured 
during surgery) but they reduce the transfer of micro-organisms. 
ƒ  In an epidemic situation, hand washing and the use of gloves are important 
protective measures to prevent the transmission of the infectious agents to other 
susceptible patients, or staff, providing the same glove is not worn from one patient 
to another patient, or between dirty and clean procedures on the same patient. 
ƒ Hands 
always be washed after removing gloves, and also before sterile 
gloves are worn. 
10. Implementation  
The Trust will demonstrate that this document has been issued, read and implemented as 
10.2 Dissemination 
12.2.1 A variety of dissemination methods are in place to make sure that all staff are aware 
of, have access to and comply with the Trust’s Controlled Documents. These are: 
• Summary list of all new documents published in the monthly core brief including a brief    
description of the document and its intended core audience 
• Inclusion in the Weekly Bulletin 
• Inclusion in the monthly Medical Director/Nursing Director Bulletin 
• Inclusion in the Document Management System on the Trust’s Intranet, which all staff 
are encouraged to use to gain access to Controlled Documents. 
• Distribution to relevant Ward and Departmental Managers 
10.3 Education and training 
It is the expectation of the Trust that all staff coming into contact with patients, working in 
clinical areas, high risk areas, (such as food preparation), receive hand hygiene training. 
All Health care workers must undertake annual mandatory training provided by the Infection 
Control Team.  Hand hygiene and decontamination is covered on the training programme. 
Divisional Managers /clinical leads must ensure that all newly appointed healthcare workers 
within Christie hospital NHS foundation trust, including students on clinical placements, 
receive hand hygiene education in their induction programme.  It is vital all staff are aware of 
the reasons for hand hygiene and decontamination and the consequences of non-
compliance in terms of adverse patient outcome and professional accountability. 
The Infection Control team is responsible for ensuring that hand hygiene education is 
provided to all Trust staff.  The induction and mandatory training policy describes the 
systems in place to ensure that all staff receive hand hygiene education and that centrally 
held training records are kept up to date. 
It is essential that any volunteers that have patient contact or are in clinical areas attend the 
hand hygiene session of mandatory training. (If this is not feasible then the ICT will deliver 
session’s particular to that group) 
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Patients and/or carers are increasingly encouraged to play active roles in their own 
treatment/care plans. In such cases, the health care worker must ensure that the care plan 
indicates appropriate hand hygiene education for the carer/patient to minimise any risk of 
cross infection. 
10.4 Monitoring Systems 
Monitoring the compliance with this policy forms part of the annual audit programme of 
infection prevention and control and key findings are reported to the Trust Infection Control 
Committee and within the Trust annual report for infection prevention and control
The ‘Saving Lives’ High Impact Intervention audits, patient survey results and 
‘CleanYourHands’ campaign observational audits will also form part of the monitoring 
process for compliance with this policy. 
Each Ward and department has a hand Hygiene Champion that ensures hand hygiene 
facilities, posters and education needs are continuously reviewed. 
Monitoring of attendance at infection control training is undertaken by the Learning and 
Development Unit in line with the arrangements described in the induction and mandatory 
training policy. 
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11. References 
Ayliffe GAJ, Babb JR and Quoraishi AH (1978) A test for hygienic hand disinfection. Journal 
of Clinical Pathology 31; 923 
Ayliffe GAJ, Fraise AP, Geddes AM, Mitchell K (2000) Control of Hospital Infection - a 
practical handbook 4th edition Arnold 
Blackmore, M.A. (1987), “Hand Drying Methods”. Nursing Times- Journal of Infection Control 
Nursing, Vol. 83 (37), pp 71-74. 
Field EA (1994) Hand hygiene, hand care and hand protection for clinical dental practice. 
British Dental Journal 176; 129-134  
Garner J.S., Favero M.S. (1986), CDC guidelines for the prevention and control of 
nosocomial infections: Guideline for handwashing and hospital environmental control. 
American Journal of Infection Control. Vol. 14 (3), pp 110-129. 
Garner JS, Favaro MS (1985) CDC Guidelines for handwashing and hospital environmental 
control. US Department of Health and Human Services, Public Health Service, Atlanta, USA 
Gidley, C. (1987), Now wash your hands, Nursing Times, Vol. 83 (29), pp 40-42. 
Girard R, Amazian K and Fabry J (2001) Better compliance and better tolerance in relation 
to a well-conducted introduction to rub-in hand disinfection. Journal of Hospital Infection 47
Glenister HM, Taylor LJ, Cooke EM et al (1992) A study of surveillance methods for 
detection hospital infections, PHLS, London. 
Gould, D. (1992), Making sense of hand hygiene. Nursing Times- The Journal of Infection 
Control Nursing. Vol.90 (47). Pp 63-64. 
Gould D and Ream E (1994) Nurses’ views of infection control: an interview study. Journal of 
Advanced Nursing 19; 1121-1131 
Haley RW (1986) Managing hospital infection control for cost effectiveness. A strategy for 
reducing infectious complications. America Hospital Publishing, Chicago. 
Hand Hygiene Task Force (2001) Draft guideline for hand hygiene in health care settings 
Hospital Infection Control Practices Advisory Committee (HICPAC) Centres for Disease 
Control and Prevention (CDC) Atlanta USA 
Handwashing Liaising Group (1999) Handwashing. A modest measure – with big effects. 
Brit. Med. J. 318: 686 
Hoffman, P.N., Wilson, J. (1994). Hands, hygiene and hospitals. PHLS Microbiology Digest. 
Vol. 11(4), pp 211-261. 
Horton, R., (1995), Handwashing: the fundamental infection control principle. British Journal 
of Nursing. Vol. 4 (16), pp 926-933. 
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