Healthcare associated infections (HCAI) are the most frequent adverse event during care delivery and are a global problem for patient safety. The prevention and management of the risk of HCAIs is an essential part of maintaining patient safety and fundamental in any healthcare setting (World Health Organisation (WHO), 2011).
The transfer of organisms between humans can occur directly via hands, or indirectly via an environmental source (e.g. clinical equipment, toys or sinks) (Loveday et al, 2014). It is universally acknowledged that the hands are the principal route by which cross-infection occurs and that hand hygiene is the single most important factor in the control of infection (Weston, 2013). However, studies on hand hygiene compliance among healthcare workers have repeatedly shown poor compliance with hand hygiene (Damani, 2012).
The Trust is committed to increasing and maintaining hand hygiene compliance and is actively promoting education programmes on hand hygiene. Hand hygiene compliance is audited trust wide on a monthly basis.
Parents and children/young people should be taught the importance of good hand hygiene in the home environment as well as in hospital.
Types of hand hygiene procedures
Routine/social hand wash
Why should a routine/social hand wash be performed?
A routine/social hand wash is performed to remove transient microorganisms and to render the hands socially clean. This level of decontamination is sufficient for general social contact and most clinical care activities (Rationale 1) (Loveday et al, 2014).
When should a routine/social hand wash be performed?
The occasions when hand hygiene should be performed have been summarised into the ‘5 Moments for Hand Hygiene' document, as these are considered the most fundamental times for hand hygiene to be undertaken during care delivery and daily routines (National Patient Safety Agency, 2009).
Examples of when to perform a routine/social hand wash
- the beginning of the shift
- entering clinical areas
- entering patient rooms/bed spaces
- any patient contact
- donning gloves
- clean/aseptic procedures
- preparing/giving medications
- preparing, handling and eating food
- using a computer keyboard in a clinical area
- any patient contact
- removal of gloves
- exposure to blood and/or body fluids
- the administration of medications
- bed making
- leaving patient rooms/bed spaces
- contact with patient surroundings
- handling laundry or waste
- leaving clinical areas
- hands become visibly soiled
- visiting the toilet
- using a computer keyboard in a clinical area
- the end of a shift
What solution should be used for performing a routine/social hand wash?
Liquid soap (plain or antimicrobial)
- The soap is supplied in disposable cartridges to fit in the wall-mounted dispensers. Cartridges must not be re-used or 'topped-up' (Rationale 2).
- Bar soap should not be used in clinical areas (Rationale 2).
How should a routine/social hand wash be performed?
Routine/social hand washing should take 40-60 seconds:
- Wet hands under running warm water.
- Dispense one dose of soap into cupped hands.
- Rub hands palm to palm.
- Right palm over the back of the other hand with interlaced fingers and vice versa.
- Palm to palm with fingers interlaced.
- Back of fingers to opposing palms with fingers interlocked.
- Rotational rubbing of left thumb clasped in right palm and vice versa.
- Rotational rubbing, backwards and forwards with clasped fingers of right hand in left palm and vice versa.
- Rinse hands with warm water.
- Dry thoroughly with a paper towel (Rationale 3). Cloth towels must not be used (Rationale 4). Jet air and warm air dryers may only be used in non-clinical areas (Rationale 5).
- Turn off taps using a ‘hands-free’ technique (e.g. elbows). Where this is not possible, the paper towel used to dry the hands can be used to turn off the tap (Rationale 6).
- Dispose of the paper towel without re-contaminating hands. Do not touch bin lid with hands (Rationale 7).
Alcohol hand rub (alcohol gel or foam)
Alcohol hand rub can be used on visibly clean hands as an alternative to a routine/social hand wash and is the preferred means for routine hand antisepsis (WHO, 2009).
Alcohol hand rub:
- Will not remove dirt and organic matter and can therefore only be used on hands that are not visibly soiled.
- Is NOT effective against Clostridium difficile and Norovirus. When caring for a patient with either of these organisms, hands must be washed with soap and water.
- Soap and alcohol-based hand rub should not be used concomitantly (Rationale 8).
- Should not be used prior to handling medical gas cylinders because of the risk of ignition.
- When applying alcohol hand rub leave to dry naturally on the skin.
- Hands should be washed with soap and water after several consecutive applications of hand rub (Rationale 9).
Hygienic hand wash
Why should a hygienic hand wash be performed?
To remove or destroy transient microorganisms and to substantially reduce resident microorganisms during times when aseptic procedures are performed (Rationale 10).
When should a hygienic hand wash be performed?
Before all aseptic procedures (e.g. lumbar punctures, biopsies) on the ward.
What should be used for performing a hygienic hand wash?
An approved antiseptic detergent (e.g. 4% Chlorhexidine gluconate or 7.5% Povidone iodine).
How should a hygienic hand wash be performed?
See above instructions on ‘How should a routine/social hand wash be performed?’
Surgical hand wash
Why should a surgical hand wash be performed?
To remove or destroy transient microorganisms and to substantially reduce resident microorganisms during times when surgical procedures are performed (Rationale 10).
To prevent the re-growth of microorganisms on hands, wrists and forearms from contaminating the surgical wound and/or from being introduced into tissues in the event of gloves becoming damaged during the procedure.
When should a surgical hand wash be performed?
Before all surgical/invasive procedures.
What should be used for performing a surgical hand wash?
- An approved antiseptic detergent (e.g. 4% Chlorhexidine gluconate or 7.5% Povidone iodine).
- How should a surgical hand wash be performed?
- When performing a surgical hand wash, the level of the hands should always remain above the elbows (Rationale 11).
- Always use elbow operated taps (Rationale 12).
- Apply antiseptic detergent to the hands and wrists and wash for at least one minute up to the elbow.
- A sterile brush may be used for the first application of the day, but continual use is not advisable (Rationale 13).
- Using a pre-packed sterile brush and clean under and around the nails only of both hands.
- Rinse thoroughly.
- The initial scrub procedure should last 5 minutes and a clock should be provided for timing the scrub procedure.
- Apply a second application of antiseptic detergent and wash hands and two thirds of the forearms with either Povidone iodine for at least one minute, or Chlorhexidine gluconate for at least two minutes.
- Rinse thoroughly.
- One sterile towel should be used to blot dry the first hand and arm and another sterile towel for the second hand and arm (Rationale 12).
- If the scrub practitioners hands or arms accidentally touch the taps, sink or other unsterile object during any phase of the scrub cycle they are considered contaminated and the scrub cycle must begin again.
The use of gloves
- The use of gloves does not replace the need for hand hygiene by either hand washing or using alcohol hand rub (WHO, 2009)
- Gloves must be worn for invasive procedures, contact with sterile sites and non-intact skin/mucous membranes, and all activities that have been assessed as carrying a risk of exposure to blood, body fluids, secretions or excretions, or sharp or contaminated instruments. Some procedures not normally requiring gloves may require gloves when infection is present e.g. eye care (Loveday et al, 2014).
- Gloves can have pores that may allow microorganisms to pass through and hands should be cleaned before and after wearing gloves (Loveday et al, 2014).
- Gloves should be single-use and changed between dirty and clean procedures and between patients (Rationale 12) (Loveday et al, 2014).
- Gloved hands should not be washed or cleaned with alcohol hand rubs or sanitising wipes (Rationale 14) (Damani, 2012).
- Sensitivity to natural rubber latex in patients, carers and healthcare workers must be documented and alternatives to natural rubber latex gloves must be available (Loveday et al, 2014).
Other aspects of hand hygiene
- Artificial fingernails or extenders should not be worn when having direct contact with patients (Rationale 15).
- Natural nails should be kept short (tips less than 0.5cm long) (Rationale 15).
- The wearing of rings and wrist jewellery (including watches and fit tracker bracelets) during health care is strongly discouraged. If religious or cultural influences strongly condition the health care worker’s attitude, the wearing of a simple wedding ring (band) during routine care may be acceptable, but in high-risk settings, such as the operating theatre, all rings and other jewellery should be removed (WHO, 2009).
- Cuts and abrasions must be covered with waterproof dressings (Rationale 17).
- Bare below the elbows - in order to ensure that hands can be easily decontaminated, only clothing that does not go past the elbow should be worn. Suit jackets, long sleeves, wrist watches, bracelets and rings (other than a plain wedding band) should not be worn.
- Download the poster:
- 'Bare below the elbows' applies to all clinical staff wearing a uniform, anyone entering a patient's bed space, room or out-patient consultation room, when having clinical patient contact and anyone entering PICU, NICU or CICU.
- 'Bare below the elbows' is not required for anyone visiting a ward (with the exception of PICU, NICU or CICU) that does not enter a patient's bed space or room.
Contact dermatitis caused by frequent exposure to soaps and cleaners is the most common form of work-related skin disease in nurses and other healthcare professionals (Health and Safety Executive, 2007)
Hand care advice:
- Always wet hands thoroughly before washing (Rationale 18).
- Ensure water is warm (neither hot nor cold).
- Do not use more soap product than recommended by the manufacturer ('One squirt is enough').
- During hand washing, thoroughly rinse off residual soap.
- Dry hands completely by carefully patting rather than rubbing with a paper towel.
- Donning gloves while hands are still wet from either washing or applying alcohol hand rub increases the risk of skin irritation.
- Use emollient creams regularly, especially before breaks and after finishing work. Ensure all parts of the hand are covered.
- Check your skin for early signs of dermatitis and report concerns to Occupational Health (Rationale 19). Early detection can help prevent more serious dermatitis from developing. (Loveday et al, 2014)
Rationale 1: Transient microorganisms often acquired by health care personnel during direct contact with patients or contaminated environmental surfaces. Transient microorganisms are most frequently associated with health care-associated infections and are more amenable to removal by routine hand washing than resident flora.
Rationale 2: This increases the risk of contamination.
Rationale 3: To remove remaining microorganisms through friction and wick away moisture to minimise chapping of hands.
Rationale 4: To avoid cross-contamination.
Rationale 5: The use of jet air and warm air dryers results in an increased bacterial aerosolisation and facilitates microbial cross-contamination via airborne dissemination to the users and the environment (Best et al, 2014).
Rationale 6: To avoid re-contaminating the hands.
Rationale 7: To prevent re-contamination of hands if the lid is touched.
Rationale 8: Washing hands with soap and water immediately before or after using an alcohol-based product is not only unnecessary, but may lead to dermatitis (Kampf and Loeffler, 2003).
Rationale 9: Some alcohol-based hand rubs become less effective following ten consecutive hand hygiene episodes (Sickbert-Bennett et al, 2005).
Rationale 10: Resident flora are species of microorganisms that are always present on or in the body and are not easily removed by mechanical friction.
Rationale 11: To prevent contaminated water from the arms running onto the hands.
Rationale 12: To avoid cross-contamination.
Rationale 13: To minimise irritation
Rationale 14: This may spoil the integrity of the glove material and organisms may adhere to the material (National Association of Theatre Nurses, 1998)
Rationale 15: HCWs who wear artificial nails are more likely to harbor Gram-negative pathogens on their fingertips than those who have natural nails, both before and after hand washing or the use of alcohol gel (WHO, 2009).
Rationale 16: Long sharp fingernails, either natural or artificial, can puncture gloves easily. They may also limit the HCWs performance in hand hygiene practices (WHO, 2009).
Rationale 17: To prevent microorganisms from entering or leaving the wound.
Rationale 18: To minimise irritation.
Rationale 19: To monitor possible side effects of hospital antiseptics/detergents. To provide the individual with alternative cleansing agents.
World Health Organisation (WHO) (2011) Report on the burden of endemic health care-associated infection worldwide. [Accessed on 16.02.16]
Loveday HP, Wilson JA, Pratt RJ, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, Wilcox M. (2014) epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014) S1–S70
Weston D (2013) Fundamentals of Infection Prevention and Control (2nd Edition) Oxford: Wiley Blackwell
Damani N (2012) Manual of Infection Prevention and Control (3rd Edition) Oxford: University Press
National Patient Safety Agency (2009) Your 5 Moments for Hand Hygiene. [Accessed on 16.02.16)
World Health Organisation (2009) WHO guidelines in hand hygiene in health care. France, World Health Organisation
Health and Safety Executive (2007) Preventing contact dermatitis at work. London, HSE
Best EL, Parnell P, Wilcox MH (2014) Microbiological comparison of hand-drying methods: the potential for contamination of the environment, user and bystander. Journal of Hospital Infection 88(4): 199-206
Kampf G, Loeffler H (2003) Dermatological aspects of a successful introduction and continuation of alcohol-based hand rubs for hygienic hand disinfection. Journal of Hospital Infection 2003; 55:1-7
Sickbert-Bennett EE, Weber DJ, Gergen-Teague MF, Sobsey MD, Samsa GP, Rutala WA (2005) Comparative efficacy of hand hygiene agents in the reduction of bacteria and viruses. Am J Infect Control 33 (2): 67-77.
National Association of Theatre Nurses (1998) Principles of safe practice in the peri-operative environment. Harrogate, National Association of Theatre Nurses