HH-SOP-001: Hand Hygiene at the Point of Care

At a glance

• Clean your hands before touching a patient, and before any clean or aseptic task.
• Clean your hands after any body-fluid exposure, after touching a patient, and after touching the patient’s surroundings.
• Use alcohol-based handrub when hands are not visibly soiled. Use soap and water when they are.
• If the station is empty, stop and tell the ward manager at once.
• Record unit audits on HH-FRM-001.
• Stop and get help straight away if: the hand hygiene product is not available at the point of care, or a station is empty and cannot be restocked during the shift.

Step 1. Check the station before you start.

• Confirm product and paper towels are present.
• If a station is empty, refill it or report it at once.

Key point: A missing station means no hand hygiene at that bed.

Step 2. Clean hands before patient contact (moment 1).

• Clean hands before you touch the patient or their bed.
• Use the station within arm’s reach.

Key point: Clean before you touch, not after.

Step 3. Clean hands before a clean or aseptic task (moment 2).

• Clean hands immediately before an aseptic task, such as a line insertion or a dressing.
• Use gloves in addition, not instead.

Key point: Gloves do not replace hand hygiene.

Step 4. Clean hands after body-fluid exposure (moment 3).

• Clean hands immediately after any exposure to blood or body fluid.
• Remove gloves first, then clean hands.

Key point: Do not wait until the end of the task.

Step 5. Clean hands after patient contact (moment 4).

• Clean hands when you leave the patient.
• Clean again before you go to the next bed.

Key point: Each patient is a new contact.

Step 6. Clean hands after touching the surroundings (moment 5).

• Clean hands after touching bed rails, equipment or the bedside table, if you did not touch the patient.

Key point: The surroundings can carry organisms.