Hand Hygiene Policy
Document Version number: 1.0
Date Written: September 2007
Updated: Not applicable
Authors: Dee May and Helen Evans
Job Title: Infection Control Advisors
Email Address: email@example.com
Contact Number: 0208 812 7643
Date Approved by Infection Control Committee: September 2007
Next Review Date: September 2009
This policy can only be considered valid when viewed via the Wandsworth PCT website.
If this document is printed into hard copy or saved to another location, you must check
that the version number on your copy matches that of the one online.
This Policy is valid on: 19 June 2012
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Hand Hygiene Policy
1.1. Effective hand hygiene is the single most important measure in reducing the risk
of transmission of micro-organisms from one person to another or from one site to
another on the same person. Decontaminating hands as promptly and as
thoroughly as possible between patient contacts and after contact with blood,
body fluids, secretions, excretions and contaminated equipment / articles is
essential in order to minimise the risk of cross-infection.
1.2. Hands are contaminated with transient and resident flora.
1.2.1. Transient flora are those micro-organisms that are not resident on the skin
but are acquired by day-to-day activity including direct contact with patients,
contaminated equipment and environmental surfaces. It is these micro-
organisms that are responsible for the majority of episodes of cross infection.
Transient flora includes the vast majority of bacteria, viruses and other
pathogenic micro-organisms that our hands come into contact with during the
course of daily living. This includes organisms such as Staphylococcus
aureus, Clostridium difficile, gram negative bacilli and noroviruses. Transient
flora are readily removed by the mechanical action of washing, rinsing and
drying hands using soap and water. They can also be readily removed by the
application of alcohol gel / rub etc.
1.2.2. Resident flora are those micro-organisms that live on the skin and provide
a protective function. In the vast majority of instances these flora do not
cause cross-infection and it is unnecessary to eradicate them from hands
during most healthcare activities. However, in certain circumstances resident
flora can pose a risk to susceptible individuals. They are a particular risk
during surgery and the insertion of invasive devices such as IV cannulae etc.
Resident flora are not easily removed by mechanical methods and require the
application of skin antiseptics e.g. chlorhexidine or povidone iodine to reduce
their numbers to acceptable levels. Thus the use of skin antiseptics is
standard practice prior to surgical procedures and the insertion of invasive
2. ROLES AND RESPONSIBILITIES
The Director of Provider Services has over-arching responsibility for all Infection Control
issues at Wandsworth tPCT. The tPCT has an Infection Control team who are available
to advise on any issues on 0208 812 7643. The Infection Control Team also provide the
Infection Control Training.
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3. WHEN HANDS MUST BE DECONTAMINATED
3.1. Health care workers must decontaminate their hands before and after all patient
contact and whenever hands are visibly soiled. It is best to think of this in terms
What activity has just been undertaken?
What activity is about to be undertaken?
Hands should thus be decontaminated after an activity that may result in
contamination or soiling and before any activity on another patient or another
activity on the same patient that could result in contamination if hands are not
The following provides guidance on general activities which require hand
decontamination but healthcare workers should also undertake a risk assessment
to ensure that specific risks are identified before each and every episode of care.
Eating, drinking or handling food
Performing a clinical procedure
Before performing an aseptic technique
Providing care to a vulnerable patient / site
Direct contact with any blood and / or body fluids
Using the toilet, blowing their nose, coughing or sneezing
Giving personal care
Removing protective clothing
Performing a clinical procedure
Any cleaning of the environment or equipment
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3.2. ASK YOURSELF:
What have I just done? What could have contaminated my hands?
What am I about to do? Is this patient vulnerable or is this a vulnerable
site that I could contaminate?
4. TYPES OF HAND HYGIENE / DECONTAMINATION
Current research advocates a variety of processes to ensure effective hand hygiene
and these are described below. The most appropriate of these must be used by the
health care worker depending on the work that is being undertaken.
4.1. Basic Hand Care
To keep hands in good condition and to perform effective hand hygiene, staff should
perform some basic hand care.
Use an emollient hand-cream twice a day. Use before and after shifts to help
replace the skin’s oils that can be lost through frequent hand hygiene.
Observe the hands for any signs of damage to the skin as this can provide a portal
for micro-organisms to enter the body. Cover with a waterproof plaster or dressing
before the shift begins and replace if necessary. If cracks or breaks do not heal,
then occupational health advice should be sought. Dermatitis can be caused by
sensitivity to ingredients in hand cleansers. Always seek guidance from
Occupational Health if skin problems on hands do not clear.
Hand jewellery, apart from a wedding band, must be removed before attempting
hand hygiene to reduce the risk of inadequate decontamination. Also, long sleeves
must be rolled up and watches removed.
3.2. General / Clinical Hand Wash
This involves the use of liquid soap products, warm running water and disposable
paper towels. This activity mechanically removes transient micro-organisms from
the hands and is perfectly acceptable for the vast majority of healthcare
Alternatively, an alcohol-based product can be used for general hand
decontamination in the place of a hand-wash but only if hands are visibly clean and
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See section 7.3 for technique
3.3. Surgical Hand Scrub
An antiseptic detergent containing either chlorhexidine gluconate (Hibiscrub) or
povidone iodine (Betadine) is used prior to surgery and the insertion of invasive
devices to remove and destroy transient micro-organisms and reduce levels of
resident micro-organisms. An alcoholic hand gel may also be used after
decontamination with a liquid soap. Current research suggests that a nailbrush
should not be used as repeated scrubbing can damage skin. If the nail bed requires
cleaning, a disposable nail pick may be used. Surgical hand scrub should take a
minimum of 2 minutes to perform and hands should be cleaned up to the elbows and
dried with sterile towels.
4. TRAINING REQUIREMENTS
4.1 Hand Hygiene techniques and training are covered at Infection Control Training.
Infection Control Training is mandatory for all staff as identified in the Training Needs
Analysis. Non-clinical staff are required to attend Infection Control training at
Corporate Induction at commencement of employment. Clinical Staff are required to
attend a full day Infection Control training at commencement of employment and
thereafter update training annually. Training is provided by the Infection Control
4.2 Non-attendance at Infection Control Training is monitored through the Training
and Development Department.
5 TYPES OF HAND DECONTAMINATION PRODUCTS
5.1. Liquid soap products
These products are used for the vast majority of hand decontamination
interventions that require the removal of transient micro-organisms. Products
should be purchased from a supplier of medical products e.g. NHS PASA as
these products have been independently evaluated and economies of scale will
be achieved with regards to cost. Bar soap should not be used in clinical areas
as it can harbour micro-organisms.
5.2 Alcohol Hand Rub / Gel (with or without antibacterial additives)
The decontamination of clean hands before and after undertaking clinical
procedures – including asepsis - may be carried out using a recommended 70%
alcohol product plus emollient. Alcohol hand gel can also be used between other
patient related tasks and between patients and is useful where adequate facilities
are not available and for staff visiting patients in their own home. Alcohol is
inactivated in the presence of organic matter i.e. body fluids etc. and therefore is
not to be used on soiled, grubby hands. Alcohol products build up on the skin
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and hands will need to be washed with soap and water after a maximum of 5 – 6
applications of alcohol products to remove residues.
Alcohol-based products should be purchased from a supplier of medical products
e.g. NHS PASA thus ensuring that an appropriate product suitable for
healthcare activities is supplied. Alcohol products should be used from wall-
mounted dispensers (see below) or can be provided for individual staff use in
bottles that can be attached to uniforms thus ensuring that the product is
available at the point of care.
5.3 Antiseptic Detergents (e.g. Chlorhexidine)
These products should be supplied in elbow / wrist operated pump dispensers
that should be wall-mounted. Products should be purchased from a medical
supply company e.g. NHS PASA to ensure that appropriate medical grade
products are used and for economies of scale. These products should not be
used routinely for hand decontamination as they are unnecessary and costly.
5.4. Soap / alcohol / antiseptic containers
All hand washing and disinfection agents should be dispensed from a sealed
container, which delivers a measured amount of soap / alcohol l /antiseptic
detergent. The nozzle must be cleaned regularly to prevent clogging and
contamination. Open containers and refillable containers must not be used as they
can become contaminated with micro-organisms.
Ideally, containers should be wall mounted with a pump-action and operated with
heel of hand or wrist, not fingers.
6 EQUIPMENT REQUIRED FOR EFFECTIVE HAND HYGIENE IN CLINICAL
All hand wash basins and taps in clinical areas must conform to the requirements
of HTM 64 (2006) which outlines the minimum requirements for such equipment.
This includes the need for:
Elbow / wrist / automatically operated lever taps
Mixer taps ensuring that water is delivered at an appropriate temperature
Basins without plugs or overflows
Taps that are situated so that water does not flow directly into the waste
outlet but are off-set
It is a requirement of the Healthcare Commission (during the registration /
inspection process) that when facilities are built or are refurbished then all hand
wash equipment will comply with HTM 64.
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The following basic principles also apply:
A separate designated hand washing basin i.e. not used to wash
instruments/cups etc, should be available wherever clinical activity takes
Each hand washing basin must be equipped with warm running water from
a mixer tap
Hand washing basins in clinical areas should be equipped with lever (wrist
or elbow-operated) taps
Disposable paper hand towels and liquid hand soap in wall mounted
dispensers must be available at each hand washing basin
A foot operated pedal bin should be available at each hand washing basin
for the hygienic disposal of paper hand towels. (Used towels do not need to
be disposed of as clinical waste unless contaminated by blood or body
A hand washing poster demonstrating an effective hand washing technique
should be displayed near hand washing basins in each clinical area
Alcoholic hand gel should also be available in wall-mounted dispensers and
as an individual container for each staff member.
7 HAND HYGIENE FACILITIES IN THE PATIENT’S HOME
Hand hygiene practices in the patient’s own home should follow the same general
principles outlined previously. However, it is accepted that hand wash facilities may
not be of an acceptable standard in the patients own home. To minimise risks, the
following principles should apply:
All health care workers must have access to adequate equipment that allows them
to decontaminate their hands when required. It is the responsibility of managers to
ensure this is available. Hand decontamination undertaken in the patient’s own
home must be delivered to the same high standards as in healthcare facilities. It
should not be presumed that appropriate resources will be available from the
Hand washing should be undertaken using a liquid soap in a sink that is clean and
free from articles. Liquid soap should be provided for staff to ensure that it is
always available. Staff should not have to rely on patients providing soap which
may not be adequate or appropriate. Bar soap provided by the patient and in a
suitable condition i.e. dry and without cracks / visible dirt may be a suitable
alternative for basic patient care but not prior to invasive procedures or wound
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When drying hands, paper towels should be used in preference, otherwise a clean
freshly laundered towel can be used. Staff should be provided with a supply of
paper towels to ensure that they always have access to appropriate products.
Health care workers should be encouraged to take alcohol hand gel with them on
visits to ensure adequate decontamination between tasks. However, alcohol
products must not be seen as a direct substitute for hand washing and should be
provided in addition to, not instead of soap, water and paper towels.
8 HAND HYGIENE METHODS
To ensure all surfaces of the hands are adequately decontaminated, it is helpful to
use a standardised technique. To wash all surfaces thoroughly should take 10-15
Some areas of the hands are more frequently missed than the others during hand
decontamination. It is important to pay attention to all areas of the hands, whilst
washing, but paying particular attention to the finger tips and nail area. These are
the areas most in contact with the patient and can be heavily contaminated with
8.1. Application of alcohol gel / rub etc.
Ensure hands are not soiled – if necessary wash with soap and water beforehand
Dispense a measured dose of the gel / rub into the palm of one hand
Rub vigorously into all surfaces of the hand up to the wrist using the hand washing
technique pictured until the product has dried.
8.2 Application of liquid soap or aqueous hand antiseptic
Wet hands under running water, then apply the recommended amount of hand
cleanser, rub hands together vigorously to make a lather using following technique
Palm to palm (including wrists);
Right palm over left dorsum & left palm over right dorsum;
Palm to palm with fingers interlaced;
Backs of fingers to opposing palms with fingers interlaced;
Rotational rubbing of thumbs with thumbs clasped in opposite palms;
Rotational rubbing of finger tips in palms;
REPEAT EACH STEP 5 TIMES.
Rinse hands thoroughly under running water;
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Turn off taps using elbows or clean paper towels to prevent recontamination, and
dry hands thoroughly with clean paper towels. Pat the hands to dry them rather
than rub them dry.
If in patient’s home, dry hands first and turn taps off using paper towels or towel.
Dispose of paper towel into a foot operated pedal bin. Do not lift up the lid of the
bin with hands as this will re-contaminate them. If necessary, use hand towels to
If in patient’s home, dispose of towels into domestic waste.
9 MONITORING AND REVIEW
9.1 The effectiveness of this policy will be monitored through the Infection Control
Committee from the Team Tool audit results. Infection Control will be monitored
via the Team Tool annually.
9.2 The effectiveness of this policy will also be monitored through infection control
audits carried out by the infection Control Advisor. The audit programme will be
monitored at the Infection Control committee. Where there are any areas of
concern, a detailed action plan will be devised to ensure improvements in
9.3 Uptake of hand hygiene training (Infection Control training) will be monitored by
the Training and Development department. This will also be reported to the
Infection Control Committee.
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Figure 1 below show areas of the hands most frequently missed.
AREAS MISSED DURING
Reference: Taylor L. (1978)
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SIX STAGE HANDWASHING TECHNIQUE
1 2 3
4 5 6
1 palm to palm 4 fingertips
2 backs of hands 5 thumbs and wrists
3 interdigital spaces 6 nails
Reproduced with kind permission of the Nursing Standard
Figure 2: DIAGRAM OF AN EFFECTIVE HAND WASHING TECHNIQUE
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