Guidelines for Hand Hygiene
|Approved by ACP Council||June 23-24, 2016|
Hand hygiene is the most effective way of preventing the transmission of healthcare-associated infection (HAI) to patients, staff, and visitors in all healthcare settings. Effective hand hygiene programs include proper training and education on policies, procedures, and practices that are reviewed on a regular basis.
1. Hand hygiene is performed in accordance with the 4 Moments of Hand Hygiene.
a) Before contact with a patient or patient’s environment (e.g. donning personal protective equipment (PPE), entering an examination room, providing patient care).
b) Before a clean or aseptic procedure (e.g. wound care, handling intravenous devices, handling food, preparing medications).
c) After exposure or risk of exposure to blood and/or body fluids (e.g. hands visibly soiled, after removal of gloves).
d) After contact with a patient or patient’s environment (e.g. doffing PPE, leaving examination room, after handling patient care equipment).
2. Appropriate products are selected and used for hand hygiene.
a) Alcohol-based hand rubs (ABHRs) containing 60-90% alcohol are used for performing hand hygiene, except in situations described in “b”.
b) Plain soap and water are used:
- When hands are visibly soiled with food, dirt, blood, body fluids and/or a buildup of ABHR.
- During food preparation.
- Following glove removal when providing care for patients with diarrhea and/or vomiting. c) Antimicrobial (antiseptic) soap is only used in limited circumstances, such as before aseptic procedures, and is not used for routine hand hygiene.
d) Hand cleaning wipes/towelettes are only used for hand cleaning in exceptional circumstances when sinks and running water are not available; hand hygiene using ABHR must be done following use of hand cleaning wipes/towelettes.
e) If hand lotions are used, they are compatible with hand hygiene products selected.
3. ABHR is used in accordance with the following procedure:
a) Hands are not visibly soiled and are dry before use;
b) Enough ABHR is applied to ensure coverage of all hand surfaces;
c) Product is vigorously rubbed over all surfaces of the hands and wrists, including: palms, space between fingers, back of hands and wrists, fingers, fingertips, and thumbs;
d) Hands remain wet for a minimum of 15 seconds;
e) Hands are rubbed until completely dry.
4. Soap and water are used in accordance with the following procedure:
a) Hands are wet with warm water and enough soap is applied to ensure lathering of all hand surfaces;
b) Hands are vigorously rubbed over all surfaces of the hands and wrists, including: palms, space between fingers, back of hands and wrists, fingers, fingertips, and thumbs;
c) Hands are rubbed for a minimum of 15 seconds;
d) Hands are rinsed under warm, running water;
e) Hands are dried with disposable paper towels;
f) Hands are not re-contaminated after washing (i.e. faucet is turned off and doors are opened with paper towel);
g) Paper towels are discarded in a waste receptacle.
5. Hand hygiene is supported by adequate infrastructure.
a) Hand hygiene products are as close as possible to the point of care.
b) Wall-mounted ABHR dispensers are installed in appropriate designated areas away from sinks and in accordance with the Alberta Fire Code. Areas include, but are not limited to:
- Examination rooms
- Public areas (e.g. building entrance/exits)
- Nursing stations
- Medication carts
- Staff rooms
- Computer stations
- Medical device reprocessing areas
- Clinical and medication preparation areas without sinks
c) Hand hygiene products are not used past expiry. Date of expiration is visible on product containers.
d) Sinks dedicated for hand hygiene are not used for other purposes (e.g. equipment cleaning, waste disposal, food preparation).
e) Hand hygiene products are available for patients and visitors.
6. Employees that cannot perform adequate hand hygiene do not perform tasks that require hand hygiene.
a) Employees that cannot perform adequate hand hygiene include, but is not limited to individuals:
- Wearing casts, dressings, and/or splints.
- Wearing artificial nails, nail enhancements, and/or chipped nail polish.
- Wearing hand jewellery other than a simple ring (i.e. band).
- Experiencing hand sensitivity reactions (e.g. dermatitis).
b) Tasks that require hand hygiene include, but are not limited to:
- Providing patient care.
- Reprocessing or handling surgical linens and/or medical devices.
- Preparing pharmaceuticals or medications.
- Handling food.
7. Hand hygiene training and education is provided to new employees during orientation and ongoing thereafter.
- Alberta Health Services Infection Prevention & Control. 2011. Hand Hygiene Policy PS-02. Available at: http://www.albertahealthservices.ca/info/Page6426.aspx
- Alberta Health Services Infection Prevention & Control. 2011. Hand Hygiene Procedure. PS-02-01. Available at: http://www.albertahealthservices.ca/info/Page6426.aspx
- Canadian Patient Safety Institute. 2015. Your 4 Moments of Hand Hygiene. Available at: http://www.patientsafetyinstitute.ca/en/education/Pages/Hand-Hygiene-Education.aspx
- Public Health Agency of Canada. 2012. Hand Hygiene Practice in Healthcare Settings. Available at: http://publications.gc.ca/site/eng/430135/publication.html
Last updated: June 2016