Hand Hygiene Policy and Procedure (an element of Standard Infection Control Precautions)
Date of issue: September 2009 Date of review: February 2011

1. Introduction
Hands are the most common way in which microorganisms, particularly bacteria, might be transported and subsequently cause infection, especially to those who are most susceptible to infection. In order to prevent the spread of microorganisms to those who might develop serious infections by this route while receiving care, hand hygiene must be performed adequately. This is considered to be the single most important practice in reducing the transmission of infectious agents, including Healthcare Associated Infections (HAI), during delivery of care.

The hand hygiene procedure being undertaken should consider the potential/actual hazards that have or might be encountered, the subsequent potential/actual contamination of hands, and any risks that may present as a result. The nature of the work - patient/client interaction will often determine this along with the vulnerability of individuals.

It must however, always be assumed that every person encountered could be carrying potentially harmful microorganisms that might be transmitted and cause harm to others. For this reason, hand hygiene is one precaution which must be applied as standard. Hand hygiene is one of the ten elements of Standard Infection Control Precautions (SICPs).

Everyone has an important part to play in improving patient/client safety. Undertaking SICPs is an essential element to ensure everyone’s safety
All of the steps detailed in this policy aid the process of ensuring hands are free from contamination and are therefore not a factor in causing infection.

The term hand hygiene used in this document refers to all of the processes, including hand washing and hand decontamination achieved using other solutions, e.g. alcohol based hand rub.
2. What are the underpinning elements to ensure adequate hand
hygiene?

Responsibilities

All staff – (providing direct care in a health or social care setting including a patient’s/client’s own home) must:

Apply the principles of SICPs. All staff have a responsibility to ensure that they undertake adequate hand hygiene and encourage others delivering care to do so

Ensure all other staff/agencies apply the principles of SICPs

Offer reassurance to patients/clients and visitors/carers on precautions being taken

Advise the patients/clients, carers or visitors of any infection control requirements such as hand hygiene

Ensure supplies of hand hygiene solutions and other materials, such as paper towels are readily available for all to use, including visitors

Ensure posters featuring when to perform hand hygiene and the steps included in the hand hygiene process etc. are displayed in relevant, prominent areas to support
infection control.

Report to line managers any deficits in knowledge or other factors in relation to SICPs and 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 the patient/client/others. If in any doubt consult with your manager, General Practitioner, Occupational Health Department or the local Infection Control/Health Protection Team

Consider the elements of SICPs such as hand hygiene as an objective within your CPD

Managers must:

Ensure that all staff have had instruction/education on the principles of hand hygiene and SICPs

Ensure that adequate resources are in place to allow for the recommended infection control measures such as hand hygiene to be implemented. This includes liaison with the estates/maintenance staff in relation to hand hygiene facilities such as sinks

Ensure areas participate in surveillance and audit programmes at a national or local level including auditing as part of the National Hand Hygiene Campaign
(www.washyourhandsofthem.com) and active support for presentation and improvement of hand hygiene compliance results

Undertake a risk assessment to optimise patient/client and staff safety, consulting expert infection control guidance if/as required

Support staff in any corrective action or interventions if an incident occurs that may have resulted in cross transmission

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 to the relevant person e.g., General Practitioner or Occupational Health
Ensure that hand hygiene posters are displayed in relevant prominent areas

Ensure that all staff are aware of hand hygiene campaigns

Staff with infection control/health protection responsibilities must:

Provide education for staff and management on this policy

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, including for the National Hand Hygiene Campaign, both at local and national level

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 good practice:

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 and any risks of slips, falls or ingestion of products by particular patient/client 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

Hand hygiene is an important part of respiratory hygiene/cough etiquette. Advice can also be given on this:

o Cover nose and mouth with disposable single-use tissues when sneezing, coughing, wiping and blowing noses
o Dispose of used tissues in the nearest waste bin
o Wash hands after coughing, sneezing, using tissues, or after contact with respiratory secretions and contaminated objects
o 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 offered hand hygiene facilities

3. Performing hand hygiene

3.1 General information

Hand hygiene is considered the single most important infection control activity and can help reduce the spread of healthcare associated infections

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 microorganisms are not a factor in the spread of infectious agents

The times that hand hygiene should be performed have been summarised into the “Your 5 Moments for Hand Hygiene” as these are considered the most fundamental times for the levels of hand hygiene to be undertaken during care delivery and daily routines

Even if gloves have been worn (see Personal Protective Equipment Policy), hand hygiene must be performed as per recommendations above as hands may still be contaminated beneath gloves, or upon removal of these and, therefore, may pose a risk for transmitting microorganisms

It should also be noted that hand hygiene may have to be performed between tasks on the same patient

If hands have touched a patient/client before or during a procedure, but are not soiled with any body fluids and, therefore, do not require re-hand washing with soap or an antiseptic hand cleanser, alcohol based hand rub can be used, using the same technique/duration
(see Performing hand hygiene using alcohol based hand rub)

Any soilage/organic matter can inactivate the activity of alcohol and, therefore, re-hand washing in these circumstances is essential

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 although it can be followed by alcohol based hand rub

Where infection with a viral gastroenteritis e.g. norovirus is suspected/proven it is important that hand hygiene is carried out with liquid soap and water although it can be followed by alcohol based 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 (e.g. a large lever)

Bar soap should not be used in a clinical setting. Those working in areas such as patient’s/client’s own home may have to carry their own supplies of solutions and hand towels

Solutions used may vary in local settings. The physical actions of performing hand hygiene, however, should always be the same and are essential in ensuring hands are adequately decontaminated

‘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 The use of antimicrobial impregnated wipes has been considered for use in the hand hygiene process, however, it has been shown that such wipes are not as effective as hand washing or the use of alcohol based hand rub, therefore these are not considered a substitute. For further advise contact local infection control teams/health protection teams


3.2 Types of hand hygiene

3.2.1 Social Hand Hygiene

Why should Social Hand Hygiene be performed?
Social hand hygiene is performed to render the hands physically clean and to remove
microorganisms picked up during activities considered ‘social’ activities (transient
microorganisms1)

When should social hand hygiene be performed?

BEFORE
AFTER
starting/leaving work
touching a patient/client
using computer keyboard (in a clinical area)
hands becoming visibly soiled
eating/handling of food/drinks (whether own or patient/clients)
visiting the toilet
preparing/giving medications
handling equipment/waste
touching a patient/client
using computer keyboard (in a clinical area)
entering/leaving clinical areas
blowing/wiping/touching nose

touching inanimate objects (e.g. equipment, items around the patient/client) and the
patient/client environment

removing gloves


What solution should be used for performing social hand hygiene?
Plain or antimicrobial soap, preferably liquid soap
Alcohol based hand rub can also be used for social hand hygiene (where hands have not been soiled) for ease of use where appropriate
How long should it take to perform social hand hygiene?
It should take at least 15 seconds to perform social hand hygiene, however washing your hands for excessive lengths of time is not recommended as this may damage the skin leading to increased shedding of skin scales or increased harbouring of microorganisms

1 Transient microorganisms include different potentially pathogenic microorganisms, primarily bacteria. Hands acquire microorganisms from other sites on an individual’s body, from other people and from the environment. Transient organisms do not normally survive for long periods on individuals’ hands and so either die or are passed to objects or others through touch contact. The ease with which these organisms can be passed to and from the hands makes them extremely efficient vectors for infection (AAHB Control of Infection Manual, 4th Edition).
Why should hygienic hand hygiene be performed?
To remove or destroy transient microorganisms. In addition to provide residual effect during times when hygiene is particularly important in protecting yourself and others (reduces resident microorganisms)

When should hygienic hand hygiene be performed?
BEFORE AFTER
Clean/aseptic procedures
Contact with immunocompromised patients/clients
Touching patients/clients (or their surroundings) being cared for in isolation or having additional (Transmission
Based) precautions applied due to the potential for spread of infection to others
Being in wards/departments/ units during outbreaks of infection
Blood/body fluid contamination
Surgical/invasive procedures

What solution should be used for performing hygienic hand hygiene?
An approved antiseptic hand cleanser, e.g. 2-4% chlorhexidine, 5-7.5% povodine iodine, 1% triclosan, or antimicrobial soap from a dispenser
Alcohol based hand rub can also be used following hand washing or when hands are physically clean, for example when performing aseptic techniques, to provide further cleansing and residual effect

How long should it take to perform hygienic hand hygiene?
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 leading to increased shedding of skin scales or increased harbouring of microorganisms

Why should surgical scrub be performed?
To remove or destroy transient microorganisms and to substantially reduce those microorganisms which normally live on the skin (resident microorganisms2) during times when surgical procedures are being carried out

When should surgical scrub be performed?
BEFORE
surgical/invasive procedures
NB Specific policies and procedures on surgical preparation should be available at local level

What solution should be used for performing surgical scrub?
An approved antiseptic hand cleanser, e.g. 2-4% chlorhexidine, 5-7.5% povodine iodine, 1% triclosan from a dispenser Persons sensitive to antiseptic cleansers can wash with an approved non-medicated liquid soap
followed by two applications of alcohol based hand rub.

How long should it take to perform surgical scrub
Carry out surgical scrub process for 2-3 minutes, ensuring all areas of hands and forearms are
covered

2 Resident microorganisms are generally harmless and form part of normal skin flora. They are not readily
transferred to other people or surfaces. Infection may sometimes result in patients undergoing surgery or other
invasive procedures or those who are immunocompromised.


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5. 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

• It has been shown that inadequate facilities will lead to poor hand hygiene performance. 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

• Specific information relating to these aspects in healthcare premises is available at a local level and is supported by guidance for the built environment, e.g. from NHS Health Facilities Scotland (HFS)

• The use of ‘hands free’ tap systems is crucial in preventing re-contamination of hands following hand hygiene performance at a sink and should be available as far as possible, particularly where personal care is delivered in clinical or communal settings. These can include:
o 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 acceptable
o Motion sensor controlled taps (e.g. those that turn on and off when hands are waved in front of a sensor light area, no touching of the sink/tap system required). It is essential, however, that these systems provide users with adequate time to wet their hands prior to performing hand hygiene and that users are not put off by any delay in water delivery.
The design of these taps must be able to withstand decontamination

• There should be no plugs in hand wash basins in order to avoid the filling of sinks with water as this is not an adequate way to perform hand hygiene, particularly in clinical or communal care areas

• Mixer taps or thermostatic mixer valves are preferred to provide the correct temperature of water for performing hand hygiene as this is an important step in the process

• The tap should not directly expel/drain water straight down the drain. It should be sited appropriately to ensure water hits the sink basin as it flows out, otherwise aerosol from the drainage system can splash back on to the user

• Hand wash basins should not have an overflow

• Availability of supplies for hand hygiene is essential, including:
o hand hygiene solutions (soap, antiseptic hand wash solution and alcohol based 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’)
o soft, user friendly disposable paper towels for hand drying, preferably stored in wall mounted, easy to use and clean holders
o hands free, i.e. pedal operated, waste receptacles, close at hand (see Safe Disposal of Waste Policy)

• 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 bereported/repaired. Hand wash basins must conform to standards as damaged surfaces may harbour microorganisms


6. The procedure for performing hand hygiene (hand washing)
Preparation:
Gather all relevant equipment. Ensure all that is needed to perform hand hygiene is at hand
Ensure the sink area is free from extraneous items, e.g. cups, utensils
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
Hands should be wet before applying the chosen solution
Apply solution
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
A good lather should be evident for undertaking the steps to perform adequate hand hygiene
All areas of the hands should be covered in these steps (see Appendix 1). The steps should take at least 15 seconds
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 microorganisms
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 hands

NB It is recommended that nailbrushes are not used to perform social or hygienic hand hygiene as scrubbing can break the skin, leading to increased risk of harbouring microorganisms or dispersing skin scales that may cause harm to others. Where nailbrushes are used for surgical scrub they should be fit for purpose and single use

NB Where running water is not available, for example during water failure or in non-NHS settings, the use of other products such as alcohol based hand rub should be used. Local infection control/health protection teams should be contacted for advice

7. 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 microorganisms
Hands that are not dried properly can become dry and cracked, leading to an increased risk of harbouring microorganisms 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 (see Safe Disposal of Waste Policy). 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
Communal towels for hand drying should be avoided in the clinical setting. If used in non-clinical settings (e.g. patient’s/client’s own home) they should be easily identifiable for the purpose of hand drying only and washed daily or in between times if heavily contaminated
The use of air dryers are not recommended in clinical areas unless it can be proven that they do not cause aerosolisation of pathogens and can dry hands as quickly as paper towels

8. Use of alcohol based hand rub

8.1 General Information
Alcohol based hand rubs 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 also contain emollients can be used to ensure the drying effects of alcohol based hand rubs are minimised
It has been shown that alcohol based hand rub used for the hand hygiene process can inhibit microorganisms on hands by filling the crevices in hands and evaporating as it spreads over all areas
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 soilage is present
e.g. entering or leaving a ward/clinical/patient area
Alcohol based 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 although it can be followed by alcohol based hand rub
Where infection with a viral gastroenteritis e.g. norovirus is suspected/proven it is important that hand hygiene is carried out with liquid soap and water although it can be followed by alcohol based hand rub

8.2 How to use alcohol based 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
The steps to perform hand hygiene using alcohol based hand rub are the same as when performing hand washing (see Appendix 2)
The time taken to perform hand hygiene using alcohol based 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 patient/client procedures are undertaken (do not use towels to do this)

8.3 Good Practice Points
No scientific evidence is currently available to advise as to the maximum number of applications of alcohol based 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)
Caution must be taken when using alcohol based 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 areas such as patients’/clients’ own homes should carry their own supplies of solutions

NB. The use of antimicrobial impregnated wipes has been considered for use in the hand hygiene process, however, it has been shown that such wipes are not as effective as hand washing or the use of alcohol based hand rub, therefore these are not considered a substitute.

9. 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 microorganisms, which could then be transmitted to those who are receiving care
• Nails must be natural, kept short and clean
• Nail polish should not be worn
• Artificial fingernails/extensions should not be worn when providing care
• Nail brushes should not be used
• The steps included in the hand hygiene process must be followed in order to ensure nail areas are cleaned properly (see Appendix 1)

10. Hand hygiene and jewellery
11. Hand hygiene and work clothing
It has been shown that jewellery, particularly rings with stones and/or jewellery of intricate detail, can be contaminated with microorganisms, which could then spread via touch contact and potentially cause infection.
Wrist and hand jewellery should be removed before care is provided. Where there will be close personal contact with patients/clients 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, however, these must be moved/removed when hand hygiene is being performed in order to reach the bacteria which can harbour underneath them
In order to ensure hands can be easily decontaminated it is helpful to wear work clothing that does not go past the elbow. Jackets and coats should be removed and long sleeves if worn rolled up, allowing for wrists and forearms to be exposed

12. Hand care
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
Hand creams can be applied to care for the skin on hands, however, only individual tubes of hand cream should be used or hand cream from wall mounted dispensers
Creams used should not affect the action of hand cleaning solutions being used or the integrity of gloves
Communal tubs, in particular, should be avoided as these may contain bacteria over time
Perfumed soaps, or other solutions, might cause skin problems for some if used frequently, therefore, this should be discussed with Occupational Health services and alternatives sought and made available
Report any skin problems to your Manager, Occupational Health or General Practitioner in order that appropriate skin care can be undertaken and the risks


Appendix 1

How to Hand Wash - step by step images
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Appendix 2



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