HAND HYGIENE POLICY
Version
10
Name of responsible (ratifying) committee
Infection Prevention Management Committee
Date ratified
02 October 2014
Document Manager (job title)
Consultant in Infection Prevention
Date issued
04 December 2014
Review date
03 December 2016
Electronic location
Infection Control Policies
Related Procedural Documents
Infection Control Policy Essential Training Policy.
Key Words (to aid with searching)
Hand hygiene; hand soap; alcohol hand gel/rub; 5 key
moments for hand hygiene; Contamination; Dirty
hands; Hygiene; Cross infection; Hospital acquired
infection; Infection control; Clinical hand washing;
Religious beliefs; Occupational health and safety;
Clinical guidelines
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
10
October 2014
Minor revision and review
IPCT
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 1 of 13
CONTENTS
QUICK REFERENCE GUIDE .............................................................................................................3
1. INTRODUCTION..........................................................................................................................4
2. PURPOSE ...................................................................................................................................4
3. SCOPE ........................................................................................................................................4
4. DEFINITIONS ..............................................................................................................................4
5. DUTIES AND RESPONSIBILITIES ..............................................................................................4
6. PROCESS ...................................................................................................................................5
7. TRAINING REQUIREMENTS ......................................................................................................9
8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................9
9. EQUALITY IMPACT STATEMENT ............................................................................................. 11
10. MONITORING COMPLIANCE ................................................................................................... 12
APPENDIX A .................................................................................................................................... 13
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 2 of 13
QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy.
1. Hands must be decontaminated when the hands are visibly dirty / contaminated and at the 5
key moments and immediately after the removal of gloves (Pgs 5/6):
2. All staff must be ‘naked below the elbow’ before entering a clinical area and for the duration of
their work (Pg 8).
Compliant
Non-Compliant
3. The two main products for hand decontamination are; alcohol-based hand rub for clean hands
or liquid soap and water for visibly dirty hands or when caring for patients with vomiting or
diarrhoeal illness (Pg 6).
4. All clinical staff must use a seven-step technique to systematically decontaminate hands (Pg 7).
5. Aseptic hand hygiene must be performed prior to invasive procedures e.g. central line insertion,
dressing etc (Pg 6).
6. Staff should follow recommended hand hygiene techniques to prevent damage or cracking to
hands and regularly use emollient hand cream to maintain skin patency when hands are at rest
(Pgs 7/8).
7.
All clinical staff are responsible for completing, and remaining up to date with annual hand
hygiene training (pg 9).
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 3 of 13
1. INTRODUCTION
The decontamination of hands is shown to significantly reduce the carriage of potential
pathogens and decrease the risk and occurrence of Healthcare Associated Infections1,2. The
purpose of this Policy is to reduce the risk of cross-infection to staff, patients and the general
public3.
2. PURPOSE
The purpose of this policy is to provide staff with clear guidelines on the actions they must take in
order to prevent cross-infection due to contamination of their own hands
3. SCOPE
This Policy applies to all staff employed by Portsmouth Hospitals NHS Trust (the Trust), and also
to all visiting staff including staff from external agencies (e.g. CCG or other Trusts), tutors,
students, agency/locum staff and contractors.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises that
it may not be possible to adhere to all aspects of this document. In such circumstances, staff
should take advice from their manager and all possible action must be taken to maintain
ongoing patient and staff safety’
4. DEFINITIONS
Alcohol Hand Rub: A sanitising gel containing alcohol and emollients which sanitizes physically
clean hands and destroys transient micro-organisms. If applied for an extended length of time,
they will also destroy some resident flora. Alcohol Hand Rub does not contain surfactant or soap
so does not have any cleaning properties
Hand Decontamination or Hygiene: The use of soap and water or an antiseptic solution to
reduce the number of microorganisms on the hands
Hand soap: a non-perfumed gentle liquid or foaming soap that contains surfactants to remove
organic matter but no anti-bacterial agents
Organic matter: Any derivative of a living or once-living organism
Resident (hand) flora: Microorganisms that live in the deeper crevices of skin and hair follicles.
These form part of the normal flora of the body and are not readily transferred to other people or
objects, or removed by the mechanical action of soap and water. They can be reduced in number
with the use of antiseptic soap.
Transient (hand) flora: Microorganisms acquired on the skin through contact with surfaces. The
hostile environment of skin means that they can usually only survive for a short time, but they are
readily transferred to other surfaces touched. Can be removed by washing with soap and water,
and most are destroyed by alcohol-based hand rubs.
5. DUTIES AND RESPONSIBILITIES
Infection Prevention and Control Team (IPCT) is responsible for:
 Providing expert proactive and reactive information and advice to all staff, patient, relatives
and carers in respect of healthcare associated infections and hand hygiene
 Ensuring the effective auditing of infection prevention practices, including hand hygiene
 The production and review of the hand hygiene policy; in line with national guidelines
 Reviewing, in collaboration with other, the status of the environment including facilities for
promoting and supporting effective hand hygiene
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 4 of 13
 Facilitating link staff, ensuring they are empowered to continually raise the standards of
infection prevention and control, including hand hygiene
Infection Prevention Link Advisors are responsible for:
 Continually raising the standards of infection prevention and control, including hand hygiene
 Providing infection prevention and control training (including hand hygiene) to colleagues on
an ad-hoc basis and at regular ward meetings
 Ensuring monthly hand hygiene audits naked below the elbow compliance and bi-monthly
Infection Prevention and Control audits are undertaken
 Ensuring that results of all audits are fed back to the IPCT and to Matrons, through the CSC
structure
 Developing action plans, in conjunction with the IPCT and Matrons; to rectify any deficiencies
highlighted by the audits
Matrons / Ward Managers:
 Must establish a culture of compliance with infection prevention guidelines across their units
 Promote good practice and challenge poor practice
 Undertake peer review audits to support the Trust monitoring hand hygiene and act on audit
results in their own areas
All Healthcare Staff:
 Must be familiar with and adhere to the relevant infection prevention policies to reduce the risk
of cross infection of patients
 Must adhere to the full terms and conditions documented in this policy
 Report to their managers and/or Infection Prevention Team if they are unable to follow this
policy
 Report to their managers and occupational health if any condition (allergy, dermatitis, eczema
etc) prevents them adequately decontaminating their hands
6. PROCESS
6.1.
Hand Hygiene
Hand hygiene must be performed when the hands are visibly dirty or contaminated, at the 5 key
moments (figure 1) 1,4 and immediately after removing gloves4,5.
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 5 of 13
Figure 1: The Five Moments of Hand Hygiene1
6.1.1. Other appropriate occasions for hand decontamination include:
 Before applying and after removing personal protective equipment
 Before preparing, handling or eating food
 After visiting the toilet
 Before and after administration of medicine
 Before and after leaving an isolation cubicle
 Before and after emptying urinary drainage bags
 After bed-making or in between bed making if making multiple beds
 After handling contaminated laundry and waste, including sluice room activities
 Before commencing and after finishing work
 Personal contamination e.g. blowing your nose, sneezing into your hand, after smoking
This includes the use of alcohol gel where appropriate
6.2.
Cleansing Agents
Hands may be decontaminated using:
Alcohol hand rub
 This may be used if hands are visibly clean
 Alcohol hand rub will remove transient flora from the hands and will substantially reduce
resident hand flora4
 Hand decontamination with Alcohol hand rub should take 20-30 seconds1
 Alcohol hand rub is not effective against spore-forming bacteria like Clostridium difficile and
some viruses (e.g. Norovirus) so hands must be washed using soap and water when caring
for these patients4
 After five consecutive uses of the Alcohol hand rub hands must be washed with soap and
water to remove the protein build up on the skin
Liquid soap and water
 Washing hands with liquid soap and water is adequate for most routine clinical activities
where removal of transient hand flora is required4
 Hand washing should take 40–60 seconds1
 Soap is provided in disposable containers and should never be re-used or re-filled. Bar soap
should never be used in clinical areas4
 Soap and water hand hygiene must always be used when caring for patients with suspected
or confirmed Clostridium difficile or diarrhoea of unknown origin4
Aseptic hand hygiene
 Aseptic hand hygiene must be performed prior to invasive procedures4 e.g. central line
insertion, dressing etc. to remove resident hand flora
 This must be used before any aseptic procedure and involves the use of aqueous antiseptic
solutions (e.g. chlorhexidine gluconate, povidone-iodine)
 Alternatively a hand wash with soap and water followed by an application of alcohol gel as per
policy is acceptable
6.3.
Hand Decontamination Technique
Hands should be decontaminated using a systematic technique to ensure exposure of the hands
and wrists to the cleaning agent4. This technique should be used for washing with liquid soap
and water or the application of alcohol hand rub (figure 2)
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 6 of 13
Figure 2: Hand decontamination technique
6.4. Hand Care
Skin damage due to hand hygiene is generally associated with the detergent base, poor hand
washing technique and frequency5. Staff should follow recommended hand hygiene techniques
to prevent damage or cracking to hands and maintain skin patency when hands are at rest: This
includes:
 always wetting hands under tepid running water before applying the recommended amount of
liquid soap (usually a single shot)
 always rinsing soap off hands thoroughly and drying hand completely
 ensuring that Alcohol hand rub is completed rubbed into the hands and not left to air dry
 using a good quality personal emollient hand cream during breaks and at home5. Multi-person
use emollient hand cream is not provided due to the risk of contamination. Pump dispensed
emollient hand cream should not be available in clinical areas
Staff with acute or chronic skin lesions/conditions/reactions on their hands (e.g. figure 3) which
prevent effective hand decontamination should not perform clinical duties and should seek
advice from the Occupational Health Department
Hand Hygiene Policy:
Eczema
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Dermatitis
Page 7 of 13
Figure 3: Eczema and dermatitis preventing adequate hand decontamination
All cuts and abrasions must be covered with a water-impermeable dressing, prior to clinical
contact4,5.
Staff requiring hand splints should not undertake direct clinical care and should seek advice from
the Occupational Health Department. Hand splints which cover any key hand parts (wrists,
thumbs, fingers, palms or backs) prevent adequate hand hygiene and become easily
contaminated.
6.5. Naked Below the Elbow
To achieve adequate hand decontamination, hands and wrists need to be fully exposed to the
hand hygiene product and therefore should be free from jewellery and long-sleeved clothing4,5.
All staff must be ‘naked below the elbow’ before entering a clinical area and for the duration of
their work. Clinical areas are defined as any area where patients are being cared for, including:
 Wards
 Departments including outpatient clinics
 Theatres and anaesthetics
Naked below the elbow means (figure 4):
 Wearing short-sleeved tops or rolling long sleeves up above the elbow5. Staff who are unable
to comply with this for religious reasons may wear disposable over sleeves/gauntlets when
performing clinical care and must ensure they wash their hands to the wrist. Over
sleeves/gauntlets are single use items and must be changed between each different
procedure on the same patient and between patients.
 No jewellery (i.e. bracelets, rings, wristwatches): a single, plain, smooth band may be worn
 No artificial nails, nail extensions or nail polish
 Finger nails should be kept short and clean
Compliant
Non-Compliant
Figure 4: compliance with naked below the elbows
6.6. Facilities
Adequate facilities are provided to enable staff to:
 Wash and dry their hands regularly and appropriately
 Use alcohol hand rub at the point of care
Each clinical area will have the following equipment to ensure adequate hand decontamination:
 Dedicated clinical hand wash basin with no plug or overflow that is easily accessible (clinical
hand wash basins are for hand hygiene only – do not dispose of body fluids or washing water
at the clinical hand wash basin and do not wash or store patient equipment at the basin)6
 Elbow operated or automatic mixer taps
 Wall mounted liquid soap dispenser, with adequate supply of liquid soap
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 8 of 13
 Disposable paper towels in wall mounted dispenser
 Easily accessible alcohol hand rub provided at point of care
Clinical hand wash basins that are inaccessible or infrequently used must be reported to the
Carillion Water Safety Team on ext.6261
Mobile, community staff should be provided with appropriately sized containers of alcohol handgel, for use in patient’s homes (see appendix A)
6.7.
Monitoring
Audit
 Monthly Hand Hygiene audits are to be carried out in all clinical areas using the Portsmouth
Hand Hygiene Audit Tool
 Peer review Hand Hygiene audits are to be undertaken 3-monthly by Matrons
 The hand hygiene performance indicators can be found at ‘Hand hygiene Performance
indicators’ on the intranet site
Feedback and Learning
 All monthly hand hygiene audits are to be forwarded to the Infection Prevention Data Manager
who will collate the results and report to the CSC’s and Trust Board monthly, using a
performance dashboard
 The hand hygiene audit trend analysis report will be discussed at every Infection Prevention
Management Committee who will, through the Chair, take any action as identified by the
audits
 The link advisors, in conjunction with the IPCT and the Matrons, will develop and implement
action plans to rectify any deficiencies highlighted by the audits
7. TRAINING REQUIREMENTS
Training forms part of the Trust’s Essential Skills and Training Requirements; as identified in the
Training Needs Analysis. It is included in mandatory Corporate Induction (Setting Direction) and
in local updates
Staff must attend classroom delivered update training every two years, including practical hand
hygiene training, and undertake refresher training via the Electronic Staff Record (ESR) system
in the intervening years
All training (including ad hoc sessions) is recorded on the ESR from which the Learning and
Development Team provide a monthly heat map to each CSC, to enable monitoring of
compliance
Compliance is further monitored through the CSC performance reviews with the Executive Team
8. REFERENCES AND ASSOCIATED DOCUMENTATION
1. World Health Organization. WHO Patient Safety. WHO guidelines on hand hygiene in health
care. Geneva: World Health Organization; 2009.
2. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve
compliance with hand hygiene. Lancet 2000;356:1307–1312.
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 9 of 13
3.Department of Health (2008) The Health and Social Care Act 2008: Code of Practice on the
prevention and control of infections and related guidance. Department of Health, December
2010. London. HMSO
4. Loveday et al (2014). epic3: National Evidence-Based Guidelines for Preventing HealthcareAssociated Infections in NHS Hospitals in England. Journal of Hospital Infection 86S1 (2014)
S1–S70
5. National Clinical Guideline Centre (2012). Infection: prevention and control of healthcareassociated infections in primary and secondary care. NCGC, London (partial update of NICE
CG2)
6. Department of Health (2013) Water systems Health Technical Memorandum 04-01:
Addendum Pseudomonas aeruginosa-advice for augmented care units. DH, London
Associated Documentation:
World Health Organization (2009) Clean Care is Safer Care Campaign.
www.who.int/gpsc/5may/en/
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 10 of 13
9. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects their
individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
All policies must include this standard equality impact statement. However, when sending for
ratification and publication, this must be accompanied by the full equality screening assessment
tool. The assessment tool can be found on the Trust Intranet -> Policies -> Policy Documentation
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviours our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision to
be the best hospital, providing the best care by the best people and ensure that our patients are
at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
No waste
This policy should be read and implemented with the Trust Values in mind at all times.
Hand Hygiene Policy:
Issue Number: 10, Issue Date: 04 December 2014
(Review date: 03 December 2016 (unless requirements change))
Page 11 of 13
10. MONITORING COMPLIANCE
As a minimum the following elements will be monitored to ensure compliance
Minimum requirement
to be monitored
Lead
Tool
Frequency of Reporting
of Compliance
100% of staff following
appropriate hand
hygiene procedures
CSC Matron
Self Assessment
Monthly
100% of staff following
appropriate hand
hygiene procedures
CSC Matron
85% of staff complete
relevant hand hygiene
training – in line with
Trust performance
indicator
Learning and
Development
Business
Manager
Monthly heat map
100% of staff who fail to
attend are followed up
Learning and
Development
Manager
Monthly heat map
Reporting arrangements
Policy audit report to:

Peer Review
Quarterly
Policy audit report to:

Quarterly
Hand Hygiene
Issue 9 07 July 2011
(Review date: June 2013 unless requirements change)
Infection Prevention
Management Committee
Policy audit report to:

Quarterly
Infection Prevention
Management Committee
Infection Prevention & Control
Team
Matron
Infection Prevention Link
Advisors
Infection Prevention & Control
Team
CSC Management Team
Infection Prevention
Management Committee
Policy audit report to:

Lead(s) for acting on
recommendations
Infection Prevention
Management Committee
Page 12 of 13
CSC Management Team
APPENDIX A
COMMUNITY
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 – this does not have to be for the clinician’s exclusive use.
Warm running water.
Clean towel for the clinician’s specific use. The clinician could provide disposable towels
in the form of a roll of paper if necessary
There will be certain circumstances when this is not achievable and in those situations the
following alternatives can be used:
ALCOHOL HAND GEL



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.
DETERGENT WIPES



Hand packs of detergent wipes
After 5 applications of alcohol hand gel or before when the hands have become tacky.
When hands are soiled with organic material such as dirt or body fluids.
SOAP & HAND TOWELS

When running warm water is available the healthcare worker can obtain soap dispenser
and paper hand towels/roll from their usual supply chain.
This is not an exhaustive list of circumstances. For further advice please contact the Infection
Prevention Team, 023 92 286000 Ext 6261
Hand Hygiene
Issue 9 07 July 2011
(Review date: June 2013 unless requirements change)
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