Policies,Clinical,UW Health Clinical,Infection Control

Hand Hygiene (4.1.13)

Hand Hygiene (4.1.13) - Policies, Clinical, UW Health Clinical, Infection Control


Policy Title: Hand Hygiene
Policy Number: 4.1.13
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: July 17, 2017


To prevent the spread of healthcare-associated pathogens by removing dirt, debris and transient microbes
from the hands.


Diligent hand hygiene is important for patient and personnel safety and is essential to good hygiene and
cleanliness. Proper hand hygiene reduces the number of transient pathogens on the hands and reduces
incidence of healthcare-associated infections. Frequency of hand hygiene is determined by the nature of
one's activities, length of procedure, and materials handled. Hand hygiene may be necessary multiple times
during the care of an individual patient.

The Centers for Disease Control and Prevention recommends the use of waterless, alcohol-based hand
rubs as the preferred method for routine decontamination of hands when hands are not obviously soiled.
Advantages include improved effectiveness and diminished drying of skin. Additionally, alcohol hand rubs
require less time and do not require the use of a sink.


Hand hygiene: A general term that applies to either hand washing with bland or antiseptic-containing
soaps, use of an alcohol hand rub, or surgical hand antisepsis.

Artificial fingernails: Any nail other than the natural nail is considered an artificial nail. This includes acrylic
nails which are adhered to the underlying natural nail, extensions, tips, gel overlays, resin wraps, and

A. Hand hygiene shall be performed upon entry to a patient room, exam room, or procedure room, and when
exiting these locations.
B. Hand hygiene shall be performed in the following situations:
i. Before and after touching a patient.
ii. Before clean/aseptic procedures, such as a central line site care or oral care.
iii. After body fluid exposure contamination, using either a non-antimicrobial soap and water or an
antimicrobial soap and water.
iv. After touching a patient’s surroundings.
v. When coming on duty, before going off duty and before eating.
vi. Between "dirty" and "clean" patient care activities performed on the same patient: (e.g., hand
hygiene is mandatory after a dirty procedure such as changing a wound dressing or toileting a
patient, before performing a clean procedure such as central line site care or oral care on the same
vii. Before gloving regardless if the gloving is for patient cares or required for contact isolation.
C. Artificial nails or nail extensions of any type are prohibited among healthcare workers who have direct
patient care responsibilities, perform or assist with surgical procedures, staff that compound sterile drugs,
and foodservice workers. Nail polish has not been shown to pose an infection risk, but should be maintained
without chips or cracks.
D. A surgical hand scrub should be completed prior to donning sterile gloves for surgical procedures
designated to be performed in an operating room or equivalent environment (i.e. Operating Room, Hybrid
OR, Cardiac Cath Lab, Interventional Radiology).
E. Surgical hand scrubs which utilize water and an antimicrobial cleansing product are performed for a
minimum of three to five minutes. The surgical hand antiseptic agent should:
i. Significantly reduce microorganisms on intact skin.
ii. Contain a non-irritating antimicrobial preparation.

Policy Title: Hand Hygiene
Policy Number: 4.1.13

iii. Be broad spectrum.
iv. Be fast acting.
v. Have a persistent effect.
F. Cuticles, hands, and forearms should be free of open lesions and breaks in skin integrity. Cuts, abrasions,
exudates, lesions, and hang nails may harbor pathogens which could increase risk to the patient, and may
also pose a risk of exposure to the employee in the event of contact with a patient’s body fluids.. Employees
with open draining lesions, rashes and breaks on cuticles, hands, forearm skin should be referred to
Employee Health prior to scrubbing or providing direct patient care.
G. Because of the unique vulnerability of the neonatal patient population, a modified surgical hand scrub is
practiced in the Neonatal Intensive Care Unit (NICU). All healthcare personnel who provide patient care or
enter patient rooms are required to perform this NICU Hand Scrub prior to unit entry. Refer to Nursing
Patient Care policy #14.36P, Neonatal Intensive Care Unit (NICU) Visitation and Infection Control
(Pediatric), for more details.

A. Examine hands for breaks in the skin, cuts or infection. Open areas on the skin may be a portal of entry for
microbes and should be protected and treated. Serious skin breakdown, especially if there is oozing or
bleeding, must be reported to Employee Health Service.
B. Alcohol hand rub is the preferred method of hand hygiene when the hands are not visibly soiled.
i. When decontaminating hands with an alcohol-based hand rub, apply the product to the palm of one
hand and rub the hands together, covering all surfaces of the hands and fingers, until hands are
ii. Follow the manufacturer's recommendations regarding the volume of product used. As a general
rule, sufficient volume of the alcohol based hand rub should be used to ensure at least 15 - 20
seconds of contact time before the product evaporates.
iii. Because alcohol lacks activity against bacterial endospores, alcohol hand rub should not be used
when Clostridium difficile enterocolitis is suspected or confirmed. The Enhanced Contact isolation
sign, used for this agent, stipulates the need for soap and water hand hygiene.
C. Soap and water hand washing is an acceptable hand hygiene option in any situation. Chlorhexidine-based
antimicrobial hand soaps are routinely stocked in clinical areas. .
i. Open water faucet(s), adjust temperature and flow rate of water. Paper towels should be used to
open the faucet(s) if hands are grossly contaminated; however, all sinks and faucets are
considered contaminated.
ii. Wet and lather the hands and wrists thoroughly. Use friction on the entire area including the
surfaces between fingers and around nails for at least 15-30 seconds. Clean nails, if indicated.
Hands and wrists are held below the elbows during procedure so that forearms remain clean.
iii. Rinse hands and wrists under running water.
iv. Dry hands with a paper towel.
v. Use the paper towel to turn off hand-controlled faucet(s), then discard paper towel.
D. The hospital-approved hand lotion, Cavilon™ (CHG compatible) is recommended to prevent irritation and
abrasion of the skin from frequent hand washing; micro-cracks in the skin may provide a portal of entry for
microorganisms. It is available through Central Supply, order number 4010091. Dry, irritated skin may also
increase the degree of shedding of microbes from the skin of the healthcare worker. Because the scheduled
use of hand creams is proven to be effective, individuals prone to skin irritation should apply the hospital-
approved agent at least four times per shift, to prevent integument breakdown.
i. Only the hand lotion provided by the hospital should be used. Some commercially available hand
care products can nullify the antimicrobial effect of chlorhexidine, the hospital's preferred
antimicrobial hand washing agent. In addition, some hand care products contain ingredients which
can degrade latex gloves.
A. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-
intact skin could occur.
B. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one
patient. Exam gloves should never be rinsed or washed.

Policy Title: Hand Hygiene
Policy Number: 4.1.13

C. Change gloves during patient care if moving from a contaminated body site to a clean body site.
D. Hand hygiene must be performed before and after glove use.

A. A surgical hand scrub instructional video is available for reference. (Surgical Hand Scrub Video )
B. Preparing to Scrub
i. Determine that all hair is covered by the cap and that the mask fits securely over the nose and
mouth. Hospital supplied scrubs and caps are changed at a minimum of every day. Refer to UW
Health clinical policy #2.3.12, Scrub Attire for details.
ii. Remove wristwatch, rings, and bracelets. Jewelry harbors bacteria and prevents adequate
cleansing of skin beneath.
iii. Trim fingernails short and remove all chipped nail polish. Artificial nails may not be worn. Nail polish
may be worn if no chips are present.
C. Surgical Hand Scrub – Soap and Water Method
i. For the first scrub of the day or if your hands are visibly soiled follow these steps prior to beginning
the timed scrub
a. Wash hands and arms with antimicrobial soap up to 2 inches above elbow.
b. Open scrub sponge wrapper and set the sponge in the wrapper on the sink.
c. Under running water, clean fingernails with nail cleaner and discard.
d. Rinse hands and forearms under running water, keeping hands higher than elbows.
ii. Remove the disposable brush (sponge) from the wrapper, wet the brush and apply soap
(Povidone-iodine or Chlorhexidine soaps).
iii. Scrub fingers, hands and arms to two inches above the elbow. A 3 – 5 minute scrub should be
timed to allow adequate product contact with skin.
iv. Holding brush in one hand, start scrubbing fingertips and progress up. Visualize each finger, hand,
and arm as having 4 sides and wash all sides effectively keeping the hand elevated. Repeat the
process on the opposite fingers, hand, and arm.
v. Rinse the hands and arms thoroughly, moving in the direction of fingertips to the elbow, in a single
pass, keeping the hands higher than the elbows at all times. Avoid splashing water on scrub attire
because moisture may contaminate the sterile gown.
vi. Keeping hands above the elbows and in front of body proceed to designated operating room. Avoid
contamination of the hands and arms before gowning and gloving.
vii. Drying the Hands and Arms
a. Pick up a sterile towel from the table. Be careful not to drop water on the gown beneath it.
b. Using a rotating motion, securely hold the top half of the towel in one hand and blot dry
the other hand and arm.
1. Do not allow the towel to contact the scrub suit.
c. Once the arm is dried, bring the dry hand to the opposite end of the towel and repeat the
process for the other hand and arm.
d. Discard the towel in the linen hamper
1. Keep your hands above your elbows at all times.
D. Surgical Hand Scrub – Waterless, brushless alcohol-based surgical hand scrub/rub product (ex. Avagard)
Follow manufacturer’s written instruction, including, but not be limited to, the following:
i. For the first scrub of the day or if your hands are visibly soiled follow these steps prior to applying
the waterless product
a. Wash hands and arms with antimicrobial soap up to 2 inches above elbow
b. Open scrub sponge wrapper and set the sponge in the wrapper on the sink
c. Under running water, clean fingernails with nail cleaner and discard
d. Rinse hands and forearms under running water, keeping hands higher than elbows
e. Dry hands and forearms thoroughly with a paper towel.
ii. Apply waterless product to clean, dry hands and nails.
iii. Dispense one pump (2 ml) into the palm of one hand.
iv. Dip the fingertips of the opposite hand into the lotion and work it under the nails.
v. Spread the remaining lotion over the hand and up to just above the elbow.
vi. Using another 2 ml of lotion, repeat with the other hand.
vii. Dispense another 2 ml of lotion into the other hand and reapply to all aspects of both hands up to
the wrists.

Policy Title: Hand Hygiene
Policy Number: 4.1.13

viii. Allow to dry before donning gloves. To facilitate drying, continue rubbing hand prep into hands until
dry. When using an alcohol-based surgical hand scrub/rub, never wipe hands and arms dry with a


Author: Infection Control Practitioner
Senior Management Sponsor: SVP/Chief Nurse Executive
Reviewers: Hospital Epidemiologist
Approval committees: Infection Control Committee, UW Health Clinical Policy Committee, Medical Board
UW Health Clinical Policy Committee Approval: May 15, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

14.36 P – Neonatal Intensive Care Unit Visitation and Infection Control (Pediatric)

CDC Guideline for Hand Hygiene in Health-Care Settings, Recommendations of the healthcare infection
control practices advisory committee and the HICPAC/SHEA/APIC/IDSA hand hygiene task force. MMWR
2002;51(RR-16)1-45 (http://www.cdc.gov/handhygiene/)

WHO Guidelines on Hand Hygiene in Health Care, 2009.

-McCormick RD, Buchman TL, Maki DG, Double-blind, randomized trial of scheduled use of a novel barrier
cream and an oil-containing lotion for protecting the hands of health care workers. Am J Infect Control 2000;
28(4): 302-10
-World Health Organization WHO Guidelines on Hand Hygiene in Health Care First Global Patient Safety
Challenge Clean Care is Safer Care, 2009.
- AORN Standards of Recommended Practices and Guidelines 2014
- Surgical Hand Scrub Instructional Video, UConnect
hygiene/videos/surgical-hand/ )

Version: Revision
Last Full Review: July 17, 2017
Next Revision Due: July 2020
Formerly Known as: UWHC policy #13.08, MF Hand Hygiene