Hand Hygiene
"last update: 28 Oct 2024"
- Recommendations
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Serial |
Recommendations |
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1 |
Indications for hand hygiene a. Wash hands with soap and water when: 1. Visibly dirty or visibly soiled with blood or other body fluids or after using the toilet (Strong recommendation, High grade evidence) 2. If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of Clostridium difficile (Strong recommendation, Moderate grade evidence) b. Use an alcohol-based handrub as the preferred means for hand antisepsis in all other clinical situations, if hands are not visibly soiled (Strong recommendation, High grade evidence) c. Perform hand hygiene 1. before and after touching the patient (Strong recommendation, Moderate grade evidence) 2. before handling an invasive device for patient care, regardless of whether or not gloves are used (Strong recommendation, Moderate grade evidence) 3. after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (Strong recommendation, High grade evidence) 4. if moving from a contaminated body site to another body site during care of the same patient (Strong recommendation, Moderate grade evidence) 5. after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient after removing sterile or non-sterile gloves (Strong recommendation, Moderate grade evidence) d. Before handling medication or preparing food perform hand hygiene using an alcohol-based handrub or wash hands with soap and water. (Strong recommendation, Moderate grade evidence) |
Remarks
When to Perform Hand Hygiene
The 5 moments of hand hygiene developed by the WHO to provide safe healthcare services for both people receiving and workers providing healthcare services from acquiring infectious microorganisms. (Annex 1).
Table (3): Methods for Hand Hygiene
Alcohol-Based Hand Rub/ Wash with soap and water |
Wash with soap and water |
Immediately before touching a patient |
When hands are visibly soiled |
Before performing an aseptic task (e.g., placing an indwelling device) or handling invasive medical devices |
After caring for a person with known or suspected infectious diarrhea |
Before moving from work on a soiled body site to a clean body site on the same patient |
After known or suspected exposure to spores (e.g. B. anthracis, C difficile outbreaks) |
After touching a patient or the patient’s immediate environment |
After contact with blood, body fluids or contaminated surfaces |
Immediately after glove removal |
- Before start and leaving work
- Before eating or handling food
- Before and after use of computer keyboards, tablets, mobiles or devices surrounding the patient.
- Before and after visiting the toilet
- Before wearing gloves not to contaminate them
- After removing gloves to decontaminate hands from splash while taking off gloves
- Handling laundry, waste or equipment
- Blowing/wiping/touching nose and mouth
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Serial |
Recommendations |
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2 |
Hand hygiene technique a. Apply a palm-full of alcohol-based handrub and cover all surfaces of the hands. Rub hands until dry. (Strong recommendation, Moderate grade evidence) b. When washing hands with soap and water, wet hands with water and apply the amount of product necessary to cover all surfaces. Rinse hands with water and dry thoroughly with a single-use towel. Use clean, running water whenever possible. Make sure towels are not used multiple times or by multiple people. (Strong recommendation, Moderate grade evidence) |
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Serial |
Recommendations |
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3 |
Surgical hand preparation a. Remove rings, wrist-watch, and bracelets before beginning surgical hand preparation. (Good practice statement) Artificial nails are prohibited. (Strong recommendation, Moderate grade evidence) b. If hands are visibly soiled, wash hands with plain soap before surgical hand preparation. (Conditional recommendation, Moderate grade evidence) c. Remove debris from underneath fingernails using a nail cleaner, preferably under running water. (Good practice statement) d. Sinks should be designed to reduce the risk of splashes (Good practice statement) e. Brushes are not recommended for surgical hand preparation. (Conditional recommendation, Moderate grade evidence) f. Surgical hand antisepsis should be performed using either a suitable antimicrobial soap or suitable alcohol-based handrub, preferably with a product ensuring sustained activity, before donning sterile gloves. (Strong recommendation, Moderate grade evidence) g. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, typically 2–5 minutes. Long scrub times (e.g. 10 minutes) are not necessary. (Strong recommendation, Moderate grade evidence) h.When using an alcohol-based surgical handrub product with sustained activity, follow the manufacturer’s instructions for application times. Apply the product to dry hands only and allow hands and forearms to dry thoroughly before donning sterile gloves. (Strong recommendation, Moderate grade evidence) |
Hand Hygiene for Surgery
- Surgical hand antisepsis
▪️ Performing surgical hand antisepsis using either an antimicrobial soap or an alcohol-based hand sanitizer with persistent activity is recommended before donning sterile gloves when performing surgical procedures.
▪️ When using an alcohol-based surgical hand-scrub product with persistent activity, follow the manufacturer’s instructions.
▪️ Before applying the alcohol solution, prewash hands and forearms with a non-antimicrobial soap and dry hands and forearms completely
▪️ After application of the alcohol-based product as recommended, allow hands and forearms to dry thoroughly before donning sterile gloves.
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Serial |
Recommendations |
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4 |
Use of gloves a. The use of gloves does not replace the need for hand hygiene by either hand rubbing or handwashing. (Strong recommendation, Moderate grade evidence) |
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5 |
Selection and handling of hand hygiene agents a. Provide HCWs with efficacious hand hygiene products that have low irritancy potential. (Strong recommendation, Moderate grade evidence) b.To maximize acceptance of hand hygiene products by HCWs, solicit their input regarding the skin tolerance feel, and fragrance of any products under consideration. (Strong recommendation, Moderate grade evidence) c. When selecting hand hygiene products: 1. determine any known interaction between products used to clean hands, skin care products, and the types of gloves used in the institution. (Good practice statement) 2. solicit information from manufacturers about the risk of product contamination. (Strong recommendation, Moderate grade evidence) 3. ensure that dispensers are accessible at the point of care. (Strong recommendation, Moderate grade evidence) 4. ensure that dispenser function adequately and reliably and deliver an appropriate volume of the product. (Good practice statement) 5. ensure that the dispenser system for alcohol-based handrubs is approved for flammable materials. (Conditional recommendation, low grade evidence) 6. solicit and evaluate information from manufacturers regarding any effect that hand lotions, creams, or alcohol-based handrubs may have on the effects of antimicrobial soaps being used in the institution. (Strong recommendation, Moderate grade evidence) d. Do not add soap to a partially empty soap dispenser. If soap dispensers are reused, follow recommended procedures for cleansing. (Strong recommendation, Moderate grade evidence) |
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6 |
Educational and motivational programs for health-care workers 1. In hand hygiene promotion programs for HCWs, focus specifically on factors currently found to have a significant influence on behaviour, and not solely on the type of hand hygiene products. The strategy should be multifaceted and multimodal and include education and senior executive support for implementation. (Strong recommendation, High grade evidence) 2. Educate HCWs about the type of patient-care activities that can result in hand contamination and about the advantages and disadvantages of various methods used to clean their hands. (Good practice statement) 3. Monitor HCWs’ adherence to recommended hand hygiene practices and provide them with performance feedback. (Strong recommendation, High grade evidence) 4. Encourage partnerships between patients, their families, and HCWs to promote hand hygiene in health care settings. (Good practice statement) |
1.1.1.1 Washing hands with soap and water is required if hands are visibly soiled while either product can be used if hands are visibly clean.
1.1.1.2 Minimize physical contact with patient surroundings.
1.1.1.3 Whenever there is shortage in hand soap, drying paper or hand rub this must be brought up to the responsible in the department and IPC specialist
1.1.1.4 Wearing jewelry, watches, rings, artificial fingernails, or nail polish by healthcare workers can compromise performance of optimal hand hygiene.
1.1.1.5 Intact skin is a natural defense against infection. Cuts, abrasions, fingernail or hand skin disease can reduce the effectiveness of hand hygiene practices and can be sources of infectious microorganisms. So, it is advised to cover those areas with waterproof dressings.
1.1.1.6 Fingernails should therefore be kept short (the length of the finger pad) and clean, and artificial fingernails should not be worn. Nail polish/varnish should not be used; particularly as chipped nail polish may support the growth of microorganisms on the fingernail.
1.1.1.7 It is better not use crude 70% alcohol to perform hand hygiene practices as it does not achieve the proper contact time required during hand rub and its repeated use leads to excessive dryness and inflammation e.g. contact dermatitis can take place leading to diseased skin.
1.1.1.8 Appropriate use of hand lotion or moisturizers added to hand hygiene preparations is an important factor in maintaining skin integrity, encouraging adherence to hand hygiene practices and assuring the health and safety of healthcare workers.
1.1.1.9 Healthcare workers should be educated about the risk of irritant contact dermatitis and in case of allergy from a hand hygiene disinfectant or soap, and in case it is encountered it should be discussed with the manager and IPC specialist to find a proper substitute.
1.1.1.10 Extending awareness on hand hygiene practices to general population individuals who attend healthcare settings: visitors or users of services to receive medical and health services is also important in reducing significantly rates of healthcare associated infection, spread of communicable diseases and spread of multidrug resistant bacteria whether in the medical settings or in the general community.
1.1.1.11 It is important to ensure effectiveness by choosing an appropriate product (as per standards noted above) using a sufficient amount of product which allows complete coverage of the hands and allowing the hands to remain wet for the recommended amount of time, as per manufacturer instructions Alcohol-based hand rub should be readily available in work areas and near patients to increase accessibility unless the ease of access to alcohol poses a specific risk to individual patients. The following alcohol-based hand rub features are important in influencing acceptability:
▪️ Appealing fragrance is not mandatory while it is necessary to use emollient agents to prevent skin drying and irritant skin reactions, but not leave a sticky residue on hands. All hand hygiene products should be chemically compatible. It is advisable that hand hygiene and hand care products are from a range made by a single manufacturer as this can reduce risk of incompatibility between the products.
▪️ Other issues as cost issues, availability, convenience and functioning of dispenser and ability to prevent contamination and crusting of material at the dispenser tip. Practical information plain soap and water hand washing refers to the appropriate use of a non-antimicrobial soap and water on the surface of the hands.
▪️ Plain soaps act by mechanical removal of microorganisms and have no antimicrobial activity. They are suitable for performing hand hygiene and are required for cleansing of visibly soiled hands. They are also used for mechanical removal of certain organisms such as C. difficile and norovirus. Liquid soap dispensers are generally preferred to bar soap in healthcare settings. Antimicrobial soaps are sometimes used to decontaminate hands. However, when alcohol-based hand rub is available in the healthcare facility for hand hygiene, the use of antimicrobial soap is not recommended. Alcohol-based hand rubs are also suitable for use in resource limited or remote areas with lack of accessibility to sinks or other facilities for hand hygiene.
1.2 Indicators for Monitoring
1.2.1 Indicators for Monitoring Hand Hygiene in Hospitals
To ensure the effectiveness of hand hygiene practices in hospitals and reduce the risk of healthcare-associated infections (HAIs), specific indicators should be monitored regularly. These indicators provide measurable data to assess compliance, identify areas for improvement, and guide interventions. Here are some key indicators that can be included in hospital policy for monitoring hand hygiene :
1.2.1.1 Hand Hygiene Compliance Rate (Essential)
▪️ Definition: The percentage of observed hand hygiene opportunities where healthcare workers correctly perform hand hygiene according to established guidelines. Can be expressed also per HCW category and per location.
▪️ Calculation:
(Number of hand hygiene actions performed correctly / Total number of observed hand hygiene opportunities) × 100
- Target: Each organization should set its target according to the strength of recommendation and gap analysis.
- Importance: This is a direct measure of how well healthcare workers adhere to hand hygiene protocols, which is critical in preventing HAIs.
*In auxiliary services area that are not in direct contact with patients, we measure compliance rate by number of correct actions/ numbers of required actions.
1.2.1.2 Alcohol-Based Hand Rub (ABHR) Consumption (Optional)
- Definition: The volume of ABHR used per 1,000 patient-days.
- Calculation:
Total volume of ABHR consumed (in liters) / Total patient-days × 1000
- Target: Each organization should set its target according to the strength of recommendation and gap analysis.
- Importance: Monitoring ABHR consumption provides an indirect measure of hand hygiene activity, especially in high-risk areas.
1.2.1.3 Hand Hygiene Infrastructure Availability (For gap analysis)
- Definition: The percentage of patient care areas that have adequate hand hygiene facilities (e.g., sinks, ABHR dispensers) available and accessible.
- Calculation:
(Number of patient care areas with adequate facilities / Total number of patient care areas) × 100
- Target: Each organization should set its target according to the strength of recommendation and gap analysis.
- Importance: Adequate infrastructure is essential for enabling and sustaining high compliance with hand hygiene practices.
1.2.1.4 Hand Hygiene Knowledge and Perception (Orientation and training needs)
- Definition: The percentage of healthcare workers who demonstrate adequate knowledge of hand hygiene guidelines and perceive it as an essential practice.
- Calculation:
Based on survey data (Number of correct responses or positive perceptions / Total number of survey respondents) × 100
- Target: Each organization should set its target according to the strength of recommendation and gap analysis.
- Importance: Knowledge and perception influence behaviour; improving these aspects can enhance compliance.
1.2.1.5 Patient and Visitor Hand Hygiene Promotion (optional/ annual or according to healthcare settings policy)
- Definition: The extent of efforts made to educate patients and visitors about hand hygiene practices, including the availability of ABHR dispensers in public areas.
- Calculation: Based on observational data or surveys
(Number of educational sessions/materials provided / Total patient/visitor population) × 100
- Target: Each organization should set its target according to the strength of recommendation and gap analysis.
- Importance: Engaging patients and visitors in hand hygiene can help reduce the transmission of infections within the hospital.
### Conclusion
Incorporating these indicators into hospital guidelines for monitoring hand hygiene ensures a comprehensive approach to infection prevention. Regular monitoring, combined with effective feedback mechanisms, fosters a culture of continuous improvement in hand hygiene practices, ultimately leading to better patient outcomes and reduced HAIs.
These indicators align with recommendations from the WHO and other healthcare bodies, emphasizing the importance of both direct and indirect measures of hand hygiene performance.
1.3 Plan to Update this National Clinical Guideline
This guideline will be updated whenever there is new evidence.
