Hand Hygiene Policy

1. Policy Statement

It is the policy of this organization that hand hygiene shall be performed routinely during all patient care activities by all clinical personnel. Hand hygiene remains the single most effective measure for preventing healthcare-associated infections and reducing transmission of microorganisms between patients, healthcare workers, and the clinical environment. All personnel shall adhere to these standards without exception, regardless of care setting.

2. Purpose

This policy exists to:

• Establish unambiguous standards for when, how, and with what products hand hygiene must be performed across all care settings.
• Define fingernail and jewelry standards that directly affect hand hygiene effectiveness.
• Specify organizational responsibilities for ensuring product accessibility, compliance monitoring, and sustained education.
• Provide the foundation for patient and family engagement in hand hygiene as an infection prevention strategy.

3. Scope

This policy applies to:

• All clinical and non-clinical personnel with direct or indirect patient contact in any care setting, including inpatient, ambulatory, home care, and long-term care.
• All supervisors and organizational leadership responsible for ensuring compliance with hand hygiene standards.
• Patients, family members, and caregivers who receive education under this policy.

4. Policy Requirements

4.1 Foundational Standard

4.1.1 Hand hygiene shall be performed routinely during all patient care activities. It remains the single most effective measure for preventing healthcare-associated infections and reducing transmission of microorganisms between patients, healthcare workers, and the clinical environment.

4.2 Indications for Hand Hygiene

4.2.1 Clinical personnel must perform hand hygiene at critical moments throughout patient care to interrupt pathogen transmission pathways. The following circumstances require hand hygiene without exception:

• Before patient contact: Hand hygiene must occur prior to entering a patient room and before donning gloves for any procedure. This protects the patient from organisms the clinician may be carrying from previous interactions or environmental contact.

• After patient contact: Hands must be cleaned following any direct interaction with the patient, including wound dressing removal, physical examination, or any touching of intact or non-intact skin. Hand hygiene must also occur immediately after removing gloves, as glove integrity cannot be guaranteed and microbial contamination of hands during glove removal is common.

• Following potential body fluid exposure: Clinicians must perform hand hygiene after any contact with blood, secretions, excretions, or mucous membranes. This applies even when gloves were worn during the exposure, as contamination during doffing frequently occurs.

• After environmental contact: Hand hygiene is required after touching any surfaces in the patient’s immediate surroundings, including medical devices, monitoring equipment, bed rails, and furniture. These surfaces serve as reservoirs for pathogens and facilitate indirect transmission.

• During aseptic procedures: Hand hygiene must be performed before, during as required, and after any clinical procedure utilizing Aseptic Non Touch Technique (ANTT). This encompasses insertion and removal of vascular access devices and other indwelling medical devices, ongoing manipulation and management of established devices, and all infusion administration activities.

• Personal hygiene occasions: Hand cleaning is required before and after eating and following restroom use.

• When moving between body sites: Hands must be cleaned before transitioning from a contaminated or soiled body site to a clean body site on the same patient, preventing cross-contamination of anatomical regions.

4.3 Hand Hygiene Products and Techniques

4.3.1 Alcohol-Based Hand Rub (ABHR)

Alcohol-based hand rubs containing a minimum of 60% ethanol or 70% isopropyl alcohol serve as the preferred method for routine hand hygiene in most clinical situations (WHO, 2009; Glowicz et al., 2023). Evidence demonstrates superior compliance with ABHR compared to soap and water, attributed to greater convenience, reduced skin irritation, and effectiveness without sink access (Australian Commission on Safety and Quality in Healthcare, 2019).

The recommended application duration is a minimum of 15 seconds, or as specified by the product manufacturer (Price et al., 2022). A systematic technique shall be employed that covers all hand surfaces, including palms, dorsum, interdigital spaces, fingertips, thumbs, and wrists.

In settings with high viral load, ethanol-based preparations at concentrations between 70% and 95% may provide enhanced efficacy against viral pathogens (Kampf, 2018).

Contraindications to ABHR use include visibly soiled hands, suspected or confirmed patient infection with spore-forming organisms such as Clostridioides difficile, norovirus or rotavirus gastroenteritis during outbreak conditions, and immediately following handling of hazardous drugs. In these situations, soap and water must be used instead.

4.3.2 Soap and Water

Washing with either nonantimicrobial or antimicrobial soap and water for a minimum of 15 seconds is required in the following circumstances:

• When hands are visibly contaminated with blood, body fluids, or other organic matter, mechanical removal through washing is essential as alcohol cannot penetrate or displace visible contamination.
• After providing care to patients with suspected or confirmed norovirus, rotavirus, or infection with spore-forming pathogens during outbreak conditions, soap and water must be used because alcohol-based products lack sporicidal activity (CDC, 2011; Loveday et al., 2014).
• Following exposure to hazardous drugs, hands must first be washed with soap and water before any ABHR application to prevent cutaneous absorption of chemotherapeutic or other hazardous agents.

4.3.3 Chlorhexidine Gluconate

Chlorhexidine gluconate products shall be used with caution for routine hand hygiene due to potential for skin sensitization and contact dermatitis with repeated use (Baraldi et al., 2019). Chlorhexidine may be appropriate for surgical hand preparation but is not recommended as a standard agent for routine clinical hand hygiene.

4.4 Fingernail Standards

4.4.1 Nails must be kept clean and trimmed short, with nail length not extending beyond the fingertip. Studies demonstrate that longer nails harbor significantly higher bacterial counts and interfere with effective hand hygiene technique.

4.4.2 Artificial fingernails, nail extenders, and nail enhancements of any type are prohibited for healthcare workers providing direct or indirect care in high-acuity settings including intensive care units and perioperative areas. Research consistently demonstrates association between artificial nails and elevated colonization with Gram-negative bacilli and Candida species compared to natural nails (Hewlett et al., 2018; Cimon & Featherstone, 2017).

4.4.3 Policies regarding standard fingernail polish and gel or shellac applications are determined by individual facility infection prevention programs. Personnel who perform surgical scrubs and interact with critical aseptic fields during operative procedures must not wear any fingernail polish or gel coatings.

4.5 Jewelry Considerations

4.5.1 Wrist jewelry must be removed for all surgical aseptic procedures. Policies regarding finger jewelry, including rings, during routine patient care activities are established at the facility level based on institutional infection prevention risk assessment.

4.6 Patient and Family Education

4.6.1 Education of patients, family members, and caregivers regarding hand hygiene represents an important component of comprehensive infection prevention strategy. Instruction shall address when hand hygiene is indicated, proper technique for effective hand cleaning, and empowerment to request clinician hand hygiene if not observed prior to direct patient contact (Görig et al., 2019; Choong et al., 2021; Biswal et al., 2020).

4.6.2 A systematic, structured, multistep technique that can be readily taught and replicated shall be employed for educational purposes.

4.7 Organizational Compliance Strategies

4.7.1 Multimodal approaches demonstrate the greatest effectiveness and shall incorporate system change through ensuring readily accessible supplies, education and training programs, evaluation and feedback mechanisms, workplace reminders, and institutional safety culture development (Grayson et al., 2018; Aghdassi et al., 2020).

4.7.2 Compliance monitoring shall be implemented through direct observation audits, with consideration of electronic monitoring systems to enhance objectivity and enable real-time feedback (Wang et al., 2021; Strauch et al., 2020).

4.7.3 Performance feedback shall occur regularly, with results shared during staff meetings and integrated into quality improvement processes. Activities demonstrating contamination visualization, leadership engagement, knowledge assessment, and ongoing performance data sharing all contribute to sustained compliance improvement (Kaveh et al., 2021; Iversen et al., 2021).

4.8 Product Accessibility and Clinician Involvement

4.8.1 Hand hygiene supplies, including ABHR dispensers, soap, water access, and paper towels, must be readily available at all points of care to remove barriers to compliance.

4.8.2 Clinical staff shall participate in evaluation of hand hygiene products, assessing characteristics including product feel, fragrance, and potential for skin irritation. Alternative products must be available for clinicians with sensitivity to standard formulations. Skin care products such as gloves, lotions, and moisturizers shall be assessed for compatibility with hand antisepsis agents to ensure they do not reduce product efficacy or increase skin irritation (Glowicz et al., 2023; Stadler & Tschudin-Sutter, 2020).

5. Compliance

5.1 Monitoring. Compliance shall be monitored through direct observation audits, electronic monitoring system data where available, product consumption tracking, and results shared transparently with clinical teams on a regular basis.

5.2 Key Performance Indicators.

• Hand hygiene compliance rate by unit and discipline (target: ≥85% at all observation points).
• ABHR and soap consumption rates tracked monthly as a proxy indicator.
• Compliance rates stratified by the five WHO indications for hand hygiene.
• Healthcare-associated infection rates correlated with hand hygiene compliance trends.

5.3 Enforcement. Observed non-compliance with hand hygiene standards shall be addressed through real-time coaching by peers, supervisors, or designated compliance observers. Repeated non-compliance shall be documented and escalated according to the organization’s human resources and performance management policies. Fingernail standard violations in prohibited settings shall result in immediate corrective action.

6. Exceptions

6.1 ABHR may be contraindicated in individual clinical scenarios as described in Section 4.3.1. In such cases, soap and water shall be substituted without exception.

6.2 Clinical emergencies requiring immediate intervention may result in momentary delay of hand hygiene; however, hand hygiene must be performed as soon as the patient’s condition permits.

6.3 No exception shall be granted to the prohibition on artificial nails in high-acuity settings.

7. Related Documents

• Standard Precautions Policy (this collection)
• ANTT® Policy (this collection)
• Transmission-Based Precautions Policy (this collection)
• POL-007: Competency and Competency Validation in Vascular Access
• POL-006: Interprofessional Safety and Care Transitions
• POL-003: Evidence-Based Selection and Clinical Monitoring Standards
• Organizational Infection Prevention and Control Policy
• WHO Guidelines on Hand Hygiene in Health Care (2009)
• SHEA/IDSA/APIC Practice Recommendation: Strategies to Prevent Healthcare-Associated Infections Through Hand Hygiene, 2022 Update

8. Revision History