Hand Hygiene

Purpose: To outline the proper hand washing and hand antisepsis technique
Scope: All colleagues

Policy: The two approved methods of hand hygiene are washing with soap and water and using an approved alcohol-based hand sanitizer.

Situations that require proper hand hygiene are:

• Before entering an exam or procedural room
• Before donning gloves
• Before meals
• After direct patient contact
• After contact of medical equipment and items in the immediate area of the patient
• After removing gloves
• After leaving the exam or procedural room

In all the situations listed above, approved alcohol-based hand sanitizers may be used when hands are not visibly soiled.

Soap and water must be used when:

• hands are visibly soiled with blood, bodily fluids, and/or secretions
• After caring for patients with enteric precautions
• After using the restroom

Procedure:

1. Applying an alcohol-based hand sanitizer
   • The dispenser will automatically dispense the correct amount of product. The entire amount must be captured in your hand for proper hand hygiene.
   • Rub the solution vigorously over entire hands, under and around fingernails until hands are completely dry.
   • Hands should be completely dry before touching patients, medical equipment, and other objects.
   • If a buildup of hand sanitizer occurs, soap and water should be used to remove the residue.
2. Hand washing with soap and water
   • Wet hands with water before applying soap to hands.
   • Apply the recommended amount of soap to hands.
   • Rub hands vigorously for at least 15 seconds covering all surfaces of hands, fingers, and nails.
   • Thoroughly rinse hands with warm water. You should avoid repeated use of hot warm due to the increased risk of dermatitis.
   • Dry hands with disposable towel.
   • Turn off faucet with disposable towel.

Other aspects related to hand hygiene

1. The manager, or designee, is responsible for ensuring that proper hand hygiene is being adhered to. Colleagues should be provided with feedback regarding their observed hand hygiene practices.
2. Casts, ace warps, and other medical devices may prevent proper hand hygiene compliance. Colleagues should be evaluated prior to providing direct patient care.
3. If colleagues notice that a soap dispenser or hand sanitizer is out, expired, or not functioning properly, the colleague will bring it to a manager’s attention to have it addressed promptly.
4. Artificial nails are not acceptable for colleagues that have direct patient care.
5. A maximum fingernail length of ¼ inch above the tip of the finger is allowed.

Definitions:
References: IC.01.04.01