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

This is a controlled copy when approved. Printed copies are uncontrolled; check the version against the document register before use.

Contents

Abbreviations

Purpose

To prevent transmission of micro-organisms between staff, patients and the care environment by cleaning hands at the moments of care where contamination is most likely. Hand hygiene is the most important single measure for reducing healthcare-associated infection [1][2]. This procedure defines what must be done, by whom, how it is checked, and what happens when it is not done.

Scope

Definitions

Policy statement

The facility requires hand hygiene at the five moments for every person in scope. Stations are provided and maintained by the facility. Staff perform hand hygiene and report any gap in stations, products or equipment. Leaders provide the stations, products, training and audit, and act on the results. No member of staff is penalised for reporting an empty station or a product problem.

Background and evidence

Contaminated hands are a major route by which micro-organisms move between patients, and between patients and staff [1][3]. Transmission can occur when hands look clean, and through gloves that are torn or not changed between tasks. Improving hand hygiene compliance has been shown to reduce healthcare-associated infection in a hospital-wide programme that combined availability of products, training, observation and feedback [2]. Guidance from the WHO and the US Centers for Disease Control and Prevention (CDC) sets out the evidence base, the five-moments model and the techniques used in this procedure [1][3].

Roles and responsibilities

Key: R = performs; A = accountable for the outcome; C = consulted; I = informed. Accountability for the audit result rests with the unit manager and the IPC lead jointly.

Materials and equipment

Safety and product control

• Use only facility-approved products. Check the expiry date and batch before use. Do not decant products into unlabelled containers.
• Store handrub away from heat and naked flame. Keep stock in the store, with only the amount needed for each station on the unit.
• Report dermatitis, itching or product intolerance to occupational health on the same day. Do not stop hand hygiene because of skin symptoms; request an approved alternative.
• Where organism-specific precautions apply, follow them. For example, for suspected or confirmed Clostridioides difficile infection, soap and water are used in preference to handrub [3].
• If no station is available, use the nearest sink or stop the task and call for help. Record the event in the incident system.

Procedure

9.1 The five moments for hand hygiene

The five moments are the basis of the WHO approach to hand hygiene [1].

9.2 Choose the method

• Alcohol-based handrub is the preferred method when hands are not visibly soiled [1].
• Soap and water is used when hands are visibly soiled or contaminated with blood or body fluid, after using the toilet, and where an organism-specific protocol requires it [1][3].
• If soap and water has been used, hands must be completely dry before handrub is applied, or handrub is not used at that moment.

9.3 Alcohol-based handrub technique (20 to 30 seconds)

1. Apply enough product to cover all hand surfaces (about 3 ml).
2. Rub palm to palm.
3. Right palm over the back of the left hand, with fingers interlaced; then the reverse.
4. Palm to palm, with fingers interlaced.
5. Backs of fingers against opposing palms, with fingers interlocked.
6. Rotational rubbing of each thumb, held in the opposite hand.
7. Rotational rubbing, backwards and forwards, of the fingertips in the opposite palm.
8. Rub until hands are completely dry. Do not rinse or wipe off the product before it dries [1].

9.4 Handwashing technique (40 to 60 seconds)

1. Wet hands with water and apply enough soap to cover all surfaces.
2. Follow steps 2 to 7 of section 9.3, rinsing under running water.
3. Rinse thoroughly so that no soap is left on the skin.
4. Dry hands thoroughly with a single-use paper towel.
5. Use the towel to turn off a manually operated tap, then dispose of it in the waste bin [1].

9.5 Start of each shift

• Check that the station in your area has handrub and paper towels, and that the product is in date.
• If a station is empty or a product is missing, refill it from the supply store, or report the gap to the ward manager at once.
• Record any station still empty one hour after it was reported, with the time of the report.

9.6 Hands, nails and jewellery

• Keep nails short and natural. Artificial nails and chipped nail polish are not permitted in clinical areas unless local policy allows them [1].
• Remove rings and bracelets that prevent the hand hygiene technique from reaching all surfaces. Plain bands may be worn if local policy allows [1].
• Keep hands moisturised with the approved product, particularly after repeated washing.

9.7 Gloves

• Perform hand hygiene before putting on gloves, and again immediately after removing them [1].
• Change gloves between patients, and between a contaminated task and a clean task on the same patient.
• Do not wash or disinfect disposable gloves for reuse.
• If a glove tears, remove it, perform hand hygiene and put on a new glove before continuing.

Decision points

Special situations

Escalation

Monitoring and compliance

Compliance is measured by direct observation of staff during patient care, using the WHO observation method as adapted in the Hand Hygiene Observation Audit Tool (HH-FRM-001) [1][2]. Each area is observed for at least 20 opportunities per month. Observers record each opportunity by moment, and record whether the action was performed.

Compliance rate (%) = actions performed ÷ opportunities observed × 100 [2].

The targets above are proposed for approval by each facility. They are not universal requirements; the governance group sets the final targets.

Feedback. Results are shown to the team each month, with the best and worst areas named. Unit results are reported to the governance group each quarter.

Records

Training and competence

• Induction: before independent work. Covers the five moments, both techniques, glove rules and the location of stations.
• Annual competency: direct observation of technique, and a short knowledge check.
• Refresher: after any audit result below target, and after any change to this procedure.

Related documents

References

1. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care: First Global Patient Safety Challenge Clean Care is Safer Care. Geneva: WHO; 2009. Available from: https://www.who.int/publications-detail-redirect/9789241597906
2. Pittet D, Hugonnet S, Harbarth S, Mourouga P, Sauvan V, Touveneau S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. Lancet. 2000;356(9238):1307–12. PubMed: https://pubmed.ncbi.nlm.nih.gov/11073019/
3. Boyce JM, Pittet D; Healthcare Infection Control Practices Advisory Committee; HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. Guideline for hand hygiene in health-care settings. MMWR Recomm Rep. 2002;51(RR-16):1–45. Available from: https://www.cdc.gov/mmwr/PDF/rr/rr5116.pdf

Change history

Approval

Annex A. Audit record

Use this record for each observation session (HH-FRM-001). Record one line per opportunity. Enter the moment (1 to 5) and whether the action was performed (Y or N).

Annex B. The five moments

The five moments summarise section 9.1 in a single view. Hand hygiene is required at each moment, as described in section 9.1 and based on the WHO guideline [1].