This is an HTML version of an attachment to the Freedom of Information request 'Hand Hygiene'.


 
 
 
 
 
 
 
 
 
 
 
Hand Hygiene 
Policy 

 
 
 
 
 
 
 
 
Produced by: Swindon & Marlborough Infection Control 
Team for Swindon Intermediate Care Centre 
 
Adopted as Trust Policy: 01/03/1992 
 
Version Number:
 4.3 
 
Review Date:
 01/05/2011 
 
Policy to be Reviewed by: Swindon PCT Infection 
Control Committee 
 
Approved by: Swindon PCT Infection Control Committee 
May 2009 
 
 
 
 
 

Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
Table of Contents 
 
1.
 
Document Definition .................................................................................................................... 2 
1.1 Revision 
History........................................................................................................................ 2 
1.2 Review 
and 
Approval History ................................................................................................... 2 
1.3 References ............................................................................................................................... 2 
1.4 Glossary/Definitions.................................................................................................................. 3 
1.5 Purpose .................................................................................................................................... 3 
1.6 Scope........................................................................................................................................ 3 
1.7 Regulatory Position................................................................................................................... 3 
1.8 Special Cases........................................................................................................................... 3 
1.9 Comments ................................................................................................................................ 3 
2. 
Policy Details ................................................................................................................................ 4 
 
1. Document 
Definition 
1.1 Revision 
History 
Version  Status 
Reason for change 
Date 
Author 
1.0 
Issued 
New Policy 
March 1997 
Ruth Lockwood 
2.0 
Issued 
Following review 
August 2000 
Sue Thompson 
3.0 
Issued 
Following review  
July 2003 
Helen Forrest 
3.1 
Draft 
Review 
Nov 2005 
Jenny Wright 
4.0 
Final 
 
March 2006 
Jenny Wright 
4.1 
Final 
Added Bear Below the Elbow 
November 2007 
Tina McCready 
4.2 
Final 
Added training under ‘Responsibilities’ 
December 2007 
Tina McCready 
4.3 
Final 
2-yearly review 
Aug 2008 
Tina McCready 
4.4 
Final 
PCT review 
April 2009 
Sharren Pells 
 
1.2 
Review and Approval History 
Version 
Reviewer/Approver 
R/A
Scope 
Date 
3.0 
Jenny Wright 

Context, completeness and accuracy 
Nov 2005 
3.1 
ICC, OH, HR, SNM/MMs, 

Current and compliant 
March 2006 
H&S, ICLNs 
4.1 
ICC 

 
12 Nov 2007
4.3 
ICC 

Current and compliant 
Aug 2008 
4.3 
Tina McCready 

Context, completeness and accuracy 
Aug 2008 
4.4 
Sharren Pells 

Context, completeness and accuracy 
April 2009 
 
1.3 References 
Clean, safe care: reducing infections and saving lives.  DH (2008) 
The Health and Social Care Act 2008.  Code of Practice for the NHS on the Prevention and Control of 
Healthcare Associated Infections and Related Guidance.  DH (revised 2008) 
Swindon & Marlborough NHS Trust Dress & Personal Appearance Code.  July 2007 
Swindon & Marlborough NHS Trust Occupational Health latex policy 
Swindon & Marlborough NHS Trust Occupational Health Skin care protocol 
NPSA cleanyourhands campaign  - www.npsa.uk/cleanyourhands  
RCA Good Practice in Infection Control ‘Wipe it out’ campaign.  
http://www.rcn.org.uk/__data/assets/pdf_file/0003/78654/002741.pdf 
Note: This document is electronically controlled. The master copy is maintained by the owner department.  
If this document is printed it becomes uncontrolled. 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
ICNA Hand Decontamination Guidelines (2002) - ICNA. 
Infection Control, Standard Infection Control Precautions policy.  
Taylor LJ (1978) An evaluation of hand washing techniques.  Nursing Times 74: 108-10. 
 
Further Reading 
Ayliffe G, et al  (2000) Control of Infection.  A practical handbook.  4th Ed.  Chapman & Hall, London. 
Boyce J (2000) Rubs Vs Scrubs- Study of the compatibility of hand disinfectants.   Infection Control in 
focus, issue 4. Spring 2003: 6-8 
Damani N.N (2003) Manual of Infection Control Procedures. 2nd edition.  Greenwich Medical Media Ltd 
Emmerson AM, Enstone JE, Griffin M et al (1996) The second national prevalence survey of infection in 
hospitals - overview of the results.  J Hosp Infect 32: 175-190. 
Glenister HM, Taylor LJ, Cooke EM et al (1992) A study of surveillance methods for detecting hospital 
infection, PHLS, London. 
Heenan ALJ (1996) Handwashing solutions.  Professional Nurse  1 (9) pp 615-622 
Plowman R, Graves N, Griffin M et al (1994) The socio-economic burden of hospital-acquired infection.  
PHLS, London. 
Pratt RJ, Pellowe C, Loveday HP et al (2001) Standard principles for preventing hospital-acquired 
infection.  J Hosp Infect, 47 (Suppl): 531-537 
Russell AD, Hugo WB, Ayliffe GAJ (2000) Disinfection, Preservation and Sterilisation.  3rd Edn. Blackwell 
Science, Oxford. 
http://www.healthcarea2z.org/index.aspx 
1.4 Glossary/Definitions 
Hand decontamination is defined as the removal, or killing, of micro-organisms acquired on the hands 
before they can be transferred. 
 
The following acronyms are used within the document  
 
CHC 
Carillion Health Care 
CVC 
Central Venous Catheter 
HCAI 
Health Care Associated Infection 
NPSA 
National Patient Safety Agency 
PCT 
Primary Care Trust 
SLA 
Service Level Agreement 
 
1.5 Purpose 
To provide clear guidelines on hand decontamination in order to reduce the risks of transmission of 
infection within the healthcare setting. 
 
1.6 Scope 
Implementation within all wards/departments and health care settings within Swindon and 
Marlborough NHS Trust and in-patient areas of other Trusts were SLAs are in place e.g. Swindon 
PCT, Avon & Wiltshire Mental Health Partnership NHS Trust. 
 
1.7 Regulatory 
Position 
 
Winning Ways (DOH 2003) 
 
Saving lives   (DOH 2005) 
 NPSA 
cleanyourhands campaign (NPSA 2004) 
 
The Health Act 2006.  Code of Practice for the Prevention and Control of Healthcare 
Associated Infections.  DH (revised 2008) 
 
1.8 Special 
Cases 
None 
 
1.9 Comments 
Any comments on this document should, in the first instance, be addressed to the PCT Infection 
Prevention and Control Team. 
 
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If this document is printed it becomes uncontrolled. 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
2. Policy 
Details 
 
Why decontaminate your hands? 
 
It is universally accepted that hand decontamination is the single most important measure for 
preventing the transmission of infection. 
 
Many clinical activities expose patients to an increased risk of infection, which can occur 
when micro-organisms on the hands are introduced directly into a susceptible site such as a 
wound or vascular catheter, or they colonise the patient’s skin and subsequently cause 
infection.  Therefore hand decontamination has a dual role to protect both the patient and 
the health care worker from acquiring micro-organisms. 
 
Healthcare associated infection (HCAI) has a direct effect on the quality of patient care and 
is therefore a major issue in the context of clinical governance, with studies in the UK 
suggesting that 9-10% of patients acquire an infection during their stay in hospital. 
 
 
It is essential therefore that: 
 
Hands are decontaminated immediately: 
•  before each and every episode of direct patient care/contact  
and  
•  after any activity that would potentially result in hands becoming 
contaminated  
and  

•  on entry and exit to wards/departments 
 
 
Preparation of hands prior to decontamination: 
 
To ensure the efficacy of hand decontamination the following principles must be observed. 
 
Bare below the elbow 
•  The wearing of stoned rings; wristwatches and bracelets is not permitted as they prevent 
effective hand decontamination and provide opportunities for bacterial colonisation, as 
total bacteria counts, particularly of gram negative bacteria, are higher when rings are 
worn.  One plain wedding band poses the highest acceptable risk and may be worn.  
Long sleeves must not be worn or be securely rolled up 
 
 
 
•  Nail varnish, artificial nails or nail extensions must not be worn as this prevents effective 
hand decontamination.  Nails should be kept short.  Pay attention to nails when washing 
hands as most microbes on the hands come from beneath the fingernails. 
 
 
When to decontaminate your hands: 
 
Risk Assessment 
 
There is no set frequency for hand decontamination as it is determined by clinical activity.  A 
risk assessment of the activity intended or performed will determine the appropriate 
decontamination process and the choice of agent eg alcohol, soap or antiseptic preparation.  
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
Patients are put at risk of developing an HCAI when a health care practitioner caring for 
them has contaminated hands. 
 
In deciding when it is necessary to decontaminate hands, four key risk factors need to be 
considered: 
 
•  The level of the anticipated contact with patients or objects. 
 
•  The extent of the contamination that may occur with that contact. 
 
•  The patient care actively being performed. 
 
•  The susceptibility of the patient 
 
Levels of hand decontamination: 
 
There are three main levels of hand decontamination:  Routine, Disinfection and Surgical.  
The level of decontamination is determined according to the risk (see chart in Appendix 1). 
 
Routine hand decontamination: 
 
The aim of routine hand decontamination is to remove transient micro-organisms and can be 
achieved by: 
 
•  Rubbing socially clean hands systematically with Purell alcohol hand rub or equivalent, 
covering all surfaces until the solution dries (approximately 15 seconds). 
 
•  Washing hands systematically with soap and warm water for 10-15 seconds, covering all 
surfaces. 
 
NB  Routine hand decontamination is sufficient for most regular daily activities. 
 
Must precede hand disinfection  - ie you cannot disinfect dirty hands
 
Hand Disinfection: 
 
The need for a higher level of decontamination is required in some clinical situations, ie hand 
disinfection (eg using antiseptic solutions).  Hands that are visibly soiled or potentially 
grossly contaminated with dirt or organic material must always be washed with liquid soap 
and warm water, prior to hand disinfection. 
 
For example, caring for patients with severe neutropenia, before insertion of an indwelling 
urinary catheter and prior to aseptic technique. (See appendix 1 for further details) 
 
Hand disinfection can be achieved by: 
 
•  Washing hands systematically with soap and warm water, drying hands, followed by an 
application of Purell alcohol hand rub or equivalent (most commonly used method). 
 
•  Washing hands systematically with antiseptic solution eg Hibiscrub. 
 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
Surgical hand decontamination: 
 
Surgical hand decontamination is used prior to surgical or other highly invasive procedures 
(eg insertion of CVC) where extra care must be taken to prevent micro-organisms on the 
hands being introduced into tissues should gloves be damaged. 
 
Surgical hand decontamination aims to substantially reduce resident micro-organisms and 
to remove or destroy transient micro-organisms.  This process is achieved by using an 
antiseptic hand cleansing preparation. 
 
NB   Persons undertaking any surgical intervention should follow the theatre policy for 
surgical scrubbing. 
 
Preparations available: 
 
Purell Alcohol Hand Rubs or equivalent:   
 
Alcohol based hand rub is now considered to be one of the most effective hand 
decontamination agents for routine hand decontamination, on hands that are not visibly dirty.  
Using the alcohol hand rub on hands will kill the transient organisms acquired from contact 
with patients. 
Alcohol hand rub is convenient for rapid bedside use and between patients and procedures.  
(See appendix 2 for decontamination technique
 
It must be remembered, however, that alcohol hand rub is not a cleaning agent and is 
not effective in the presence of physical dirt or organic material ie blood/body fluids, 
some viruses and Clostridium difficile
 spores.  
 
Liquid Soap:
   
 
Soap assists in the physical removal of transient micro-organisms from the skin.  These 
organisms are acquired through direct contact with other people or equipment and are 
readily transferred to and from the hands. (See appendix 3 for technique
 
NB
   Ward/Department supplies are available through CHC  -  contact the helpdesk if 
sufficient supplies of soap and hand towels are not available. 
 
Antiseptic Soaps:
   
 
These are soap solutions with an antiseptic added (for example Hibiscrub).  They will reduce 
the number of resident micro-organisms that normally live on the skin as well as the removal 
of transient ones.  Antiseptic soaps may be inactivated if used in conjunction with ordinary 
hand soaps.   
 
Responsibilities for hand decontamination: 
 
•  All new starters will undergo hand hygiene training as part of the Trust Induction.  All 
trust staff will have a mandatory annual update for hand hygiene.  This will be provided 
by an ICLN, a member of the IP&C Team or other appropriate person and can be 
accessed within scheduled clinical skills courses, ICLN workshops, via the intranet, 
ward/department training sessions and ad hoc presentations.  The appraisal process is 
used to follow up staff who fail to receive education. 
 
•  It is the ward/department manager’s and CHC’s responsibility to ensure adequate 
supplies of the preparations listed above are always available and replenished. 
 
•  All staff are asked to remind all visitors to their ward/department that hands must be 
decontaminated on entry and exit and that the appropriate method is used in isolation 
rooms. 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
How to wash your hands: 
 
Handwashing, when performed correctly, is an infection control practice with clearly 
demonstrated efficacy.  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.  
If using soap and water, hands should be dried thoroughly using disposable paper towels.  
Particular attention should be given to the finger webs.  The towels should be sterile if used 
prior to a surgical procedure. (For technique see appendix 3)  
 
Gloves: 
 
Gloves are not always a complete impermeable barrier, however they do reduce the transfer 
of micro-organisms to and from the wearers hands.   
 
It should be remembered that gloves are used in addition to hand decontamination, 
not instead of. 
 
•  The right glove should be used for the procedure to be carried out (see Glove Selection 
Guidelines and Chart within the Swindon PCT Latex Policy).  Refer to standard 
precautions policy for when to use gloves. 
 
•  Gloved hands should not be washed or cleaned with alcohol hand rubs, gels or wipes. 
 
General Hand Care: 
 
It is important to take particular care of your hands and nails at all times.  Ensure your nails 
are natural, clean and short and cover any cuts in your skin with a waterproof dressing.   
You should ensure your skin is well moisturised.  Hand Medic skin conditioner is provided in 
ward/department areas.  This protects particularly vulnerable areas like nail beds.  
Communal hand creams should not be used.  (For further advice refer to Occupational 
Health’s skin information.) 
 
Any health care worker who suffers any allergic reactions due to hand decontamination or 
has any areas of broken skin eg rashes, eczema, psoriasis on their hands or forearms 
should report to the Occupational Health Department where further advice may be obtained. 
 
Audit 
 
Observation and audit of compliance with the policy is the joint responsibility of all relevant 
clinical teams and the IP&C Team.  A weekly audit will be undertaken within both Forest and 
Orchard Wards, with compliance scores and comments placed onto a dashboard reporting 
system for the PCT Board Meetings and Clinical Governance and Patient Safety Forum. 
 
 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
Appendix 1 
 
Hand Decontamination Process 
 
 
Risk Group 
Routine clean 
Disinfection 
Surgical 
Method 
ie high level 
disinfection 
 
 
 
 
 
High Risk 
Surgical hand decontamination 
•  All surgical procedures 
•  Full surgical scrubbing  
•  Insertion of CVC  
 
 
 
 
 
 
Medium Risk 
Hand disinfection 
•  Before donning sterile gloves, prior to 
 
manipulation of an IV or CVC. 
•  Washing hands with soap and warm water, 
•  Prior to peripheral venous cannulation 
followed by application of alcohol hand rub 
•  Before caring for patients with severe 
 
neutropenia 
•  Washing hands with antiseptic cleansing solution 
•  After providing care to a patient with a 
eg Hibiscrub 
highly transmissible organism 
•  When removing or changing a wound 
dressing 
•  Before insertion of urinary catheter. 
 
 
 
 
 
 
Low Risk 
Routine hand decontamination 
•  Taking routine observations  - TPR 
•  Application of alcohol hand gel to visibly clean 
• Bed making 
hands 
•  On entry or exit of ward/department 
•  Routine hand washing with soap and warm water 
 
 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
Appendix 2 
 
Hand decontamination with alcohol hand gel 
 
An effective technique must be learned, practised and always used in clinical 
practice for the use of alcohol hand rub.   
 
1 2  3 4 
 
 
 
Palm to palm. 
Palm to palm, fingers 
Right palm over left 
Back of fingers to 
interlaced 
dorsum.  Left palm over 
opposing palms with 
right dorsum 
fingers interlaced 
 
 
 
 
5 6  7  
Finally, clasp left 
 
hand around right 
 
wrist and vice versa 
 
Rotational rubbing back-
Rotational rubbing of 
NB Diagrams demonstrating an effective hand 
wards and forwards with 
right thumb clasped in 
decontamination technique should be widely posted 
fingers of right hand in 
left palm and vice-
in all wards/departments 
palm of left, and vice-
versa 
versa. 
 
 
It is important to pay particular attention to the areas most commonly missed eg thumbs, nails, 
cuticles and finger webs. 
Areas most commonly missed during hand decontamination 
 
 
Most frequently 
 
missed 
 
 
 
 
Less frequently 
 
missed 
 
 
 
 
Not missed 
 
 
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Hand Hygiene Policy 
Number: 2IPC-POL-001 
Version: 4.3 
Status Final 
Dated: 14/05/2008 
 
 
Appendix 3 
 
Hand decontamination technique for soap and water 
 
An effective technique must be learned, practised and always used in clinical 
practice for the use of soap and water.    
 
 Wet hands    
 
 
 
2  Apply soap 
     
 
 
 
 
 
 
 
 
 
 
 
 
 
3  
Lather hands using the 6-step technique plus wrists. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Rinse hands well  
 
 
 
 Pat dry hands thoroughly 
 
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