Effective Date: 
Thu, 01/01/2004
Fri, 06/18/2021
Fri, 06/18/2021

PURPOSE:    To decrease the risk of transmission of infection by appropriate hand hygiene.

POLICY:       Handwashing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections.  Antiseptics control or kill microorganisms contaminating skin and other superficial tissues and are sometimes composed of the same chemicals that are used for disinfection of inanimate objects.  Although antiseptics and other handwashing/hand hygiene agents do not sterilize the skin, they can reduce microbial contamination depending on the type and the amount of contamination, the agent used, the presence of residual activity and the handwashing/hand hygiene technique followed.

1. All personnel and medical staff comply with the recommended hand washing and hand-hygiene guidelines.

2. Hand hygiene stations are conveniently located throughout the patient care areas and are kept well-stocked. Alcohol-based hand cleaner containers are located throughout the SHC in clinical as well as public access areas to encourage all staff as well as patients and visitors to clean their hands often.

3. The health care worker practices hand hygiene at their discretion as well as in the following guideline:

In the absence of a true emergency, personnel and medical staff members should always wash their hands or practice hand-hygiene;

a)  Before/after work;

b)  Before/after contact with a patient;

c)  Before and after performing procedures;

d)  After potential microbial contamination of hands is likely, especially those involving contact with mucous membranes, blood or body fluids, secretions, or excretions;

e)  After touching inanimate sources that are likely to be contaminated with infectious waste (e.g., urine specimen containers, pathology samples, etc);

f)  Before and after eating;

g)  Before and after handling used equipment;

h)  Before and after using the restroom;

i)   As soon as possible after removal of gloves or other personal protective equipment;

Additional Notes

  • In the absence of particulate matter the health care worker at the SHC may choose whether they use soap and water or the alcohol-based gel for the purpose of hand hygiene.
  • Fingernails should be short, clean and well groomed.  This decreases accumulation of bacteria under and around nails.

1.      HANDWASHING   

When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, and in case of a patient with a spore-forming organism (e.g., C. difficile), or with suspected norovirus, after going to the restroom, and before eating, perform hand hygiene with either a non-antimicrobial soap and water or an antimicrobial soap and water.

  1. Turn on water.
  2. Moisten hands with soap and water and make a heavy lather.
  3. Wash well under running water for a minimum of 40 seconds, using a rotary motion and friction.
  4. Rinse hands well under running water.
  5. Dry hands with a clean paper towel. Use the paper towel to turn off the faucet, then discard.


If hands are not visibly soiled, use an alcohol-based hand rub for routinely decontaminating hands in all clinical situations other than those listed under “Handwashing” above.

  1. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry.
  2. Follow the manufacturer’s recommendations regarding the volume of product to use.


Key Points: 

Even in the absence of particulate matter on the hands, hand washing is imperative after 10 uses of the alcohol-based gel as a build-up of emollients, humectants, or thickening agents hinders the gel’s effectiveness.