SH CP 12

Hand Hygiene Procedure

(Infection Prevention and Control Policy: Appendix 6)
This Hand Hygiene Appendix must be read in conjunction with the

Infection Prevention and Control Policy.

Version: 4

Summary: This Hand Hygiene Appendix advises staff of the actions they
must take in order to prevent cross infection via contaminated
hands.

Target Audience: All staff of all disciplines, Non-Executive Directors,

Volunteers, Governors and Contractors

Next Review Date: November 2022

Approved by: IP&C & Decontamination Date of meeting:

Group 13.11.18

Date issued: November 2018

Author: Michelle Cook

Lead Nurse Infection Prevention and Control

Accountable Executive Lead: Paula Hull, Director of Nursing and Allied Health Professions

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Version Control

Change Record
Date Author Version Page Reason for Change
05.10.12 Theresa Lewis 2 Throughout Acquisition of Ridgeway to Southern Health NHS
(Lead Nurse Foundation Trust.
Infection
Prevention and
Control)
04.11.14 Theresa Lewis 3 Throughout Policy review

Oct Michelle Cook 4 Policy review

2018

Reviewers/contributors
Name Position Version Reviewed &
Date

Angela Roberts IP&C Team

Jacky Hunt As above
Louise Piper As above
IP&C Group Members All Divisions Represented V3 21.10.14
IP&C Consultation Group V3 21.10.14

Jacky Hunt V4 Nov 2018

Louise Piper As above
Joanne Williams As above
IP&C Group members All Divisions represented As above

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 Contents

Page

1. Introduction 4

2. Definitions 4

3. Process 5
 Hand care
 Bare below the elbow
 Facilities required
 When to perform hand hygiene
 How to perform hand hygiene
 Choice of cleansing agent

4. Training 11

5. Audit 11

6. References 11

Appendices
 6.1 Hand hygiene outside of the healthcare environment 13
 6.2 WHO 5 moments for hand hygiene 14
 6.3 Hand washing technique 15
 6.4 Hand hygiene poster’s 16
 6.5 Hand hygiene technique for alcohol hand sanitiser use 18

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 Hand Hygiene Procedure

1. Introduction:

1.1 Hand hygiene is a term that incorporates the decontamination of the hands by methods
including routine hand washing, surgical hand washing and the use of alcohol hand sanitiser
(Uniform and Workwear Guidance, DH 2010). Contaminated or dirty hands are closely
associated with the transmission of Healthcare Associated Infections. This contamination can
be as a result of an occupational exposure to micro-organisms but importantly it should be
understood that a significant amount of hand contamination is from the individual themselves
e.g. touching own face or sneezing into own hand.

1.2 Hand hygiene is the most important measures to protect patients, healthcare workers and the
environment from microbial contamination (WHO 2009). Failure to perform appropriate hand
hygiene is considered the leading cause of healthcare associated infections (HCAI) and
spread of multi-resistant organisms, and has been recognised as a significant contributor of
outbreaks (WHO 2009).

1.3 This Hand Hygiene Appendix advises staff of the actions they must take in order to prevent
cross infection via contaminated hands. This does not cover surgical hand preparation as
this is covered in LNFH Theatre Policy.

2. Definitions:

Alcohol hand sanitiser - A sanitising gel/foam containing approx. 60% isopropanol alcohol
and emollients (skin softeners). Dispensed in a measured dose from a wall mounted /stand-
alone dispenser or carried by staff. The alcohol hand sanitiser disinfects / sanitises physically
clean hands. These agents have disinfectant activity, and destroy most transient micro-
organisms. If applied for an extended length of time, they will also destroy some resident
flora. Alcohol hand sanitiser does not contain soap and is therefore ineffective in the
presence of physical soiling. Please note alcohol hand sanitiser is not suitable for
environmental cleaning.

Bare Below the Elbow – The term used to describe the removal of all jewellery, (except a
plain wedding ring), watches, nail varnish and false nails. Where sleeves are worn, these
must be rolled up when having close contact with patients and remained rolled up until an
appropriate hand washing technique has been performed.

Emollient - A non-perfumed hand cream / skin moisturising agent that must be compatible
with the soap and alcohol hand sanitiser in use. Emollient should be applied when hands are
at rest i.e. during coffee break, lunch break or at the end of the working day.

Hand soap – A non-perfumed gentle liquid soap that does not contain anti-bacterial agents.
Dispensed from a well maintained, wall mounted or stand-alone dispenser in a measured
dose.

Handwashing – Washing hands with plain / antimicrobial soap and warm water

Point of Care - The place where the healthcare worker provides care or treatment to the
patient.

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 Resident Flora - Normal flora or ‘commensal organisms’, forming part of the body’s normal
defence mechanisms, and protecting the skin from invasion by more harmful micro-
organisms. They rarely cause disease and are of minor significance in routine clinical
situations. However, during surgery or other invasive procedures, resident flora may enter
deep tissues and establish infections. Removal of these organisms is essential in these
situations, by following the surgical scrub technique (please refer to the LNFH policy)

Transient Flora - Microorganisms that colonise the superficial layers of the skin. They are
also acquired by touch e.g. from the environment, touching patients, laundry, equipment etc.
Transient flora are readily transmitted to the next thing touched, and is responsible for the
majority of healthcare–associated infections. They are easily removed by hand
decontamination.

Visibly Soiled Hands - Hands on which dirt or body fluids are readily visible.

3. Process:

3.1 Hand Care:

The frequent use of hand hygiene agents may cause damage to the skin and alter normal
hand flora. Excoriated hands are associated with increased colonisation of potentially
pathogenic microorganisms such as Meticillin-resistant Staphylococcus Aureus (MRSA), and
increase the risk of infection. In order to achieve effective hand hygiene, it is therefore
important to look after the skin and fingernails. Continuing damage to the skin may result in
cracking and weeping, exposing the care worker to increased infection risk, and can lead to
sick leave.

Cover cuts and abrasions with a water-impermeable dressing, prior to contact with service
users. Staff with skin lesions on their hands eg eczema or psoriasis, that cannot be
adequately covered (wearing gloves to protect open lesions on hands is not acceptable) must
not work until they have received advice from the Occupational Health Department.

Skin damage and dryness often results from frequent use of harsh soap products, application
of soap to dry hands, or inadequate rinsing of soap from the hands. It is therefore essential
that only approved liquid soap products are used, and that staff carefully follow correct hand
hygiene techniques. Emollient creams alone e.g. Diprobase, are insufficient to provide
clinical hand hygiene. Please contact the Occupational Health Dept if you need further
advice.

All care areas should ensure adequate supplies of moisturiser (wall mounted where
appropriate) are available for staff use, as this is more cost-effective than sickness-absence
due to damaged skin. Several controlled trials have shown that regular use of such products
can help prevent and treat irritant contact dermatitis caused by hand hygiene products (WHO
2009). Moisturiser available from the NHS Supply Chain is free from perfumes to reduce the
risk of reaction with other products. Therefore ideally only moisturisers purchased via the
NHS Supply Chain should be used. Staff should regularly use moisturiser to maintain skin
patency when hands are at rest. Communal tubs of moisturiser are not recommended

Natural fingernails harbour micro-organisms (Larson 1995). Fingernails should be kept short,
clean and free from nail varnish.

3.2 Bare Below the Elbows

The Trust has adopted the Department of Health ‘Bare Below the Elbows’ Strategy. This
includes:

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  Clothing - Remove long sleeved clothing or roll up long sleeves before undertaking any
direct ‘hands on’ care. Long sleeves prevent thorough hand hygiene procedures and are
more likely to become contaminated during work activities
 Nails - Fingernails should be short, clean and free from false nails or nail polish when
having direct contact with services users at work (EPIC 3, 2014). Artificial nails and nail
extensions harbour higher levels of micro-organisms than natural fingernails, and these
micro-organisms are not removed easily during hand hygiene (DH 2010). Artificial
fingernails can also fall off when caring for patients. Long nails can puncture gloves and
are harder to keep clean
 Jewellery - Remove rings (except wedding band), wristwatches, bracelets and all other
wrist and hand jewellery when having any contact with patients (EPIC 3, 2014). Rings,
wristwatches and other jewellery worn on the hands and wrists become contaminated
during work activities and in addition skin underneath rings is more heavily colonised with
microorganisms in comparison to other areas where rings are not worn (WHO 2009). In
addition they prevent thorough hand hygiene procedures
 Non-Clinical Roles - Staff who work in certain non-clinical roles e.g. cleaning staff,
catering or food handling staff will need to comply with being Bare Below the Elbows to
facilitate effective hand hygiene
 Social Care - In social care settings staff should be bare below the elbows when
undertaking physical care activities

Staff who are unable to comply with the ‘Bare Below the Elbow’ strategy may wear
disposable over sleeves/gauntlets. These are single use items and must be changed
between each different procedure on the same patient and between patients. They are to be
removed after patient contact and before hand hygiene is performed. Disposable over
sleeves should be disposed of as clinical waste and are not to be worn outside of the care
area. Please contact a member of the IP&C team for further advice if required.

3.3 Facilities Required:

Adequate facilities must be provided to enable staff to wash and dry their hands regularly and
appropriately, to use alcohol hand sanitiser if applicable, to use Clinell wipes if applicable and
to protect their skin using moisturiser.

Each inpatient and non-domestic area must have the following equipment near to the patient,
to ensure adequate hand washing:

 Dedicated hand wash basin*, that is easily accessible (separate to a dedicated sink for
cleaning equipment or body fluid discharge)
 Ideally should have elbow operated mixer taps – if elbow taps are not available disposable
paper towels can be used to turn off the taps
 Well maintained liquid soap dispenser, with adequate supply of liquid soap
 Disposable paper towels
 Hand hygiene posters (laminated) indicating correct technique
 New builds should include hand washing sinks which conform to national standards eg
they must not have a plug or overflow (HBN 00-10 DH 2013).
 Well maintained moisturiser dispenser with adequate supply of emollient – these are
usually placed in staff rest areas

*Requirements for a clinical hand wash basin (HBN 00-09 DH 2012)

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  The dimensions of the clinical hand wash basin should be large enough to contain most
splashes and therefore enable the correct hand wash technique to be performed without
excessive splashing of the user
 Clinical hand wash basins should be wall mounted using concealed brackets and fixings.
They should be sealed to a waterproof splash-back to allow effective cleaning of all
surfaces
 They should not have a plug or a recess capable of taking a plug.
 Clinical hand wash basins should not have overflows as these are difficult to clean and
become contaminated
 Clinical hand wash basins should be accessible eg not situated behind curtain rails
 Taps should be elbow operated or sensor and be fitted with a thermostatic mixing valve
 Taps should not be aligned to run directly into the drain aperture as contamination from
the waste outlet could be mobilised
 Clinical hand wash basins should not be used for other purposes eg cleaning patient
equipment

Each area must also have (where it is deemed safe to use following Risk Assessment) easily
accessible alcohol hand sanitisers (with emollients). Suggested locations include:

 At every ward/unit entrance in a wall dispenser;

 At the entrance to service user bays in a wall dispenser;
 On all healthcare record trolleys and drugs trolleys and outside isolation rooms
 By every patient’s bed / at the point of care, except in certain areas such as Child Health
and Mental Health
 If on risk assessment alcohol hand sanitiser is deemed unsafe to be located at the point of
care, staff should be provided with pocket sized containers of alcohol hand sanitiser which
is carried on a short clip or retractable cord

Community Staff: Mobile community staff should be provided with appropriately sized
containers of alcohol hand sanitiser. When hand washing is required and mobile staff have
no access to soap and water, hand wipes e.g. Clinell sanitising wipes can be used however
these wipes should only be used as a last resort, when there is no alternative and hands
should be washed with soap and water at the first available opportunity.

*Please note this order code is accurate as at Oct 2018

Social Care: Staff working within supported living environments, where possible, should
have access to dedicated hand hygiene facilities. Where liquid soap, water and disposable
paper towels are not available, bottles of alcohol hand sanitiser and disposable hand wipes
should be made available for staff use. It is not appropriate for staff to use communal bars of
soap or to share a communal hand towel.

Moisturising cream should also be freely available to maintain skin integrity. Where
appropriate this should be supplied in wall-mounted dispensers, located in suitable positions
eg staff rest room. Alternatively individual pocket sized containers can be used.

Please see Appendix 6.1 for further guidance on performing hand hygiene outside of the
healthcare environment.

3.4 When to Perform Hand Hygiene:

Hands must be decontaminated before each episode of direct patient contact or care
including clean or aseptic procedures (EPIC 3 2014).

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 Both the decision to decontaminate hands and what type of cleaning agent to be used should
be based on a risk assessment. This must include the likelihood that micro-organisms have
been acquired or may be transmitted, whether the hands are visibly soiled or not, and what
procedure is about to take place.

Hands must be decontaminated:-

Before and after each episode of patient contact / care – NB hand hygiene is only
required once between each patient contact e.g.:

 Changing dressings
 Handling invasive devices
 Administrating medications or in between administrations (when assisting the service
user) during a drug round.
 Handling food
 Contact with urethral catheters
 Bed making or in between bed making if making multiple beds
 Assisting service users with personal hygiene

Before e.g.:

 Direct close contact with a service user

 Before performing a clean or aseptic technique
 Leaving source isolation
 Leaving the care area
 Before eating or serving food
 Commencing work

After e.g.:

 Direct close contact with a patient

 Close contact with the patient’s environment
 Removing personal protective clothing
 Sluice room activities
 After any exposure to body fluids
 After the removal of personal protective equipment e.g. gloves and aprons
 Personal contamination e.g. coughing or sneezing
 Handling surfaces that are likely to be contaminated e.g. specimen pots, suction
equipment
 After contact with waste
 Using the toilet
 After handling soiled laundry

The World Health Organisation (WHO) 5 moments for hand hygiene is a useful tool which
can be used for guidance as to when hand hygiene could be performed. See Appendix 6.2

3.5 Choice of Cleansing Agent

The following types of cleansing agent can be used to remove micro-organisms from hands:

Liquid Soap - Washing the hands with plain liquid soap and tepid water* is adequate for
most routine activities. Hand washing with soap lifts transient micro-organisms from the
surface of the skin and allows them to be rinsed off. An effective hand wash technique
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 involves three stages; preparation, washing and rinsing, and drying. In preparation for hand
washing, staff must be bare below the elbows see section 3.2.

*Apart from the issue of skin tolerance and level of comfort, water temperature does not
appear to be a critical factor for microbial removal from hands being washed. However
warmer temperatures have been shown to be very significantly associated with skin irritation
and therefore the use of very hot water for hand washing should be avoided as it increases
the likelihood of skin damage. (WHO 2009). The use of cold water alone may deter some
from washing their hands during cold winter conditions (HSE 2014).

Bars of soap should not be used for hand hygiene.

Technique
Routine hand washing – use liquid soap and tepid water, and follow this procedure:

 Wet hands under running water

 Dispense one dose of liquid soap into the cupped hand
 Wash hands vigorously – cover all surfaces as per 6-step hand hygiene poster
 Hands must be rubbed together vigorously for a minimum of 15-20 seconds, paying
particular attention to the tips of fingers, the thumbs and areas between the fingers
 Rinse hands thoroughly under running water
 Turn off taps using elbows (or a paper towel if taps are not elbow operated)
 Pat hands dry with a disposable paper towel and discard without touching a dirty surface
e.g. bin lid

Please see appendix 6.3 for Hand Washing Technique Poster and Appendix 6.4 for generic
Hand Hygiene posters

Hand drying
Because wet hands can more readily acquire and spread microorganisms, the proper drying
of hands is an integral part of routine handwashing. Hands must be patted dry and not
rubbed. Care must be taken to avoid recontamination of washed and dried hands. Reusing
or sharing towels should be avoided because of the risk of cross-infection (WHO 2009).

Alcohol hand sanitisers (with emollients). These may be used in place of soap and water
if hands are visibly clean. They are especially useful if hand washing and drying facilities
are inadequate, or where there is a need for rapid or frequent hand washing. These agents
have disinfectant activity, and destroy transient micro-organisms. If applied for an extended
length of time, they will also destroy some resident flora.

In some religions, alcohol use is prohibited or considered an offence. As a result the adoption
of alcohol-based formulations for hand hygiene may be unsuitable or inappropriate for some
HCW’s either because of their reluctance to have contact with alcohol, or because of their
concern about alcohol ingestion or absorption via the skin. WHO (2009) state that in general,
those religions with an alcohol prohibition in everyday life demonstrate a pragmatic vision in
the perspective of optimal patient-care delivery and do not object to the use of alcohol-based
products for environmental cleaning, disinfection or hand hygiene.

When NOT to use alcohol sanitiser:

Visibly clean hands can be decontaminated with alcohol hand sanitiser for all activities with
the following two exceptions when liquid soap and water must be used instead.

 When hands are visibly soiled or potentially contaminated with body fluids

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  When caring for a patient with diarrhoea and/or vomiting e.g. norovirus or clostridium
difficile

Technique
 Enough alcohol hand sanitiser should be dispensed to ensure all surface areas of the skin
are covered.
 Hands must be rubbed together vigorously, paying particular attention to the tips of the
fingers, the thumbs and the areas between the fingers until the solution has evaporated
and the hands are dry.

Please see Appendix 6.5 for poster on Hand Hygiene Technique with alcohol hand sanitiser

Sanitising Hand Wipes. If hands are visibly dirty and soap and water is not available, a
Clinell sanitising wipe can be used. Care must be taken to ensure the wipe covers all
surfaces of the hands.

Common Examples:

If your hands are visibly soiled or covered with body fluids:

 Use soap and water followed by drying with a disposable paper towel. If no access to
soap and water use a Clinell sanitising wipe or similar.

If exposure to potential spores e.g. Clostridium difficile and viral diarrhoea & vomiting
in suspected outbreaks of norovirus

 Use soap and water followed by drying with a disposable paper towel. If there is no
access to soap and water antiviral gel can be used in suspected outbreaks of viral
diarrhoea and vomiting. Antiviral gel differs from the normal alcohol gel used as this has
been proven to be effective against viruses such as norovirus. Standard alcohol hand
sanitiser is not effective against viruses.

If you are about to, or have had, contact with a patient and your hands are visibly
clean:

 You can use either alcohol hand sanitiser/ soap and water followed by drying with a
disposable paper towel. Clinell sanitising wipes can be used as a last resort if no other
method is available.

If you are about to perform an aseptic technique:

 Use soap and water followed by drying with a disposable paper towel if hands are visibly
dirty
OR
 Use alcohol hand sanitiser if hands are visibly clean.

3.6 Hand Hygiene and patients

Patients and relatives should be provided with information about the need for hand hygiene
and how to keep their own hands clean.

Patients should be offered the opportunity to clean their hands before meals, after using the
toilet, commode or bedpan and at other times as appropriate (EPIC 3, 2014).

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 Products available should be tailored to the needs of the patients and may include alcohol
hand sanitisers, hand wipes and access to handwash basins.

HCW’s should educate patient and carers about their role in maintaining standards of
healthcare workers’ hand decontamination. (NICE 2012).

4 Training

Training in hand hygiene is included as part of IP&C essential training at induction and as
part of ongoing training.

Practical training in hand hygiene using the light box is carried out by our IP&C Link Advisors
or by a member of the IP&C team if hand hygiene audit scores drop or during outbreak if this
is required.

Refer to TNA in IP&C Policy.

5 Audit

Hand hygiene is audited regularly as part of the IP&C Annual Audit plan. Results from audits
are reported via the IP&C Group and through Divisional Governance systems.

Where appropriate hand hygiene compliance scores are on display in clinical areas.

6 References:

Department of Health (2010) Uniform and Workwear. Guidance on Uniforms and Workwear
Policies for NHS Employees London HMSO

Department of Health (2010) Saving Lives: a delivery programme to reduce Healthcare

Associated Infections including MRSA. London HMSO

Department of Health (2012) Health Building Note 00-09: Infection Control in the built
environment

Department of Health (2013) Health Building Note 00-10 Part C: Sanitary assemblies

Hand Hygiene Task Force (2007) Guideline for hand hygiene in health-care settings.
Recommendations of the Healthcare Infection Control Practices Advisory Committee and the
HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Morbidity and Mortality Weekly
Report 51(16) 1-48

Health and Safety Executive (2014) A review of the data on efficacy of handcleaning
products in industrial use as alternatives to handwashing

Larson E (1995) APIC guideline for handwashing and hand antisepsis in healthcare settings.
American Journal of Infection Control 23(4), 251-269

Loveday J, Wilson J, Pratt R, Golsorkhi M, Tingle A, Bak A, Browne J, Prieto J, & Wilcox M.
(2014) epic 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated
Infections in NHS Hospitals in England Journal of Hospital Infection 86S1 (S1-S70)

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 National Patient Safety Agency (2004) Clean Your Hands Campaign. NPSA

National Institute for Health and Clinical Excellence (2012) Prevention and control of
healthcare associated infections in primary and community care NICE 2012

Pittet D., Dharan S., Touveneau S., et al (1999) Bacterial contamination of the hands of
hospital staff during routine patient care. Archives of Internal Medicine 159: 821-826

World Health Organisation (2009) WHO Guidelines on Hand Hygiene in Healthcare – First
Global Patient Safety Challenge Clean Care is Safe Care

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Appendix 6.1: Hand Hygiene Outside of the Healthcare Environment

In some circumstances employees working in the community will not have access to the equipment
necessary to carry out hand hygiene such as no running warm water, no access to liquid soap and
no equivalent to disposable hand towels.

Prior to visiting a client in their home the clinician should discuss with the patient what is required
to carry out effective hand hygiene.

This would include providing:

 Plain liquid soap in a dispenser or pump (not a bar of soap) – this does not have to be for the
clinician’s exclusive use.
 Warm running water.
 Clean towel for the clinician’s specific use. Disposable paper towels in the form of a roll of
paper if necessary e.g. kitchen roll

HCWs can obtain supplies of liquid soap and paper towels/roll from their usual supply chain.

There will be certain circumstances when this is not achievable and in those situations the
following alternatives can be used:

ALCOHOL HAND SANITISER

 Before and after providing direct patient care.

 After removal of gloves and before performing further patient care.
 On entering and leaving the patient’s home..

DISINFECTANT WIPES e.g. Clinell (recommended only if soap and water are not available)

 After several applications of alcohol hand sanitiser if hands have become tacky.
 When hands are soiled with organic material such as dirt or body fluids.

MOISTURISERS

 Dispensers can be located at meeting areas, such as GP surgeries, to allow this part of the
hand hygiene policy to be carried out.
 Individual hand moisturisers when used must be purchased through the routine supply chain to
ensure it is compatible with the alcohol hand sanitiser.

This is not an exhaustive list of circumstances. For further advice contact the IP&CT.

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Appendix 6.2: WHO 5 Moments for Hand Hygiene

The World Health Organisation have developed an approach called the 5 moments for hand
hygiene. This supports the national Clean your Hands campaign and helps all health care
professionals to decide when to clean their hands. The Five Moments of hand hygiene is based
around preventing the transfer of micro-organisms between each patient zone e.g. the zone
around a patients bed or chair and lists the important times during our work, where we should stop
to clean our hands. The 5 moments is applicable in all healthcare environments.

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Appendix 6.3: Hand Washing Technique

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Appendix 6.4: Hand Hygiene Posters

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Appendix 6.5: Hand Hygiene Technique with Alcohol-Based Formulations

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