ENDORSED BY

ASSOCIATION OF HEALTHCARE PROVIDERS (INDIA)

HAND WASH
&
HAND HYGIENE

AUTHORED BY
DR. ASHTO MATHUR (CONSULTANT OBSTETRICIAN & GYNAECOLOGIST)

EDITED BY
DR. SUNIL KHETARPAL (DIRECTOR AHPI)
 ENDORSED BY

ASSOCIATION OF HEALTHCARE PROVIDERS (INDIA)

HAND WASH
&
HAND HYGIENE

AUTHORED BY
DR. ASHTO MATHUR (CONSULTANT OBSTETRICIAN & GYNAECOLOGIST)

EDITED BY
DR. SUNIL KHETARPAL (DIRECTOR AHPI)
ABOUT THE AUTHOR

Ashto Mathur , is a highly motivated and hard working medical

consultant. She began her career in Mumbai as a Medical Officer in
Mumbai Municipal Corporation.

During her career she worked in different capacities in many reputed

hospitals on Clinical as well as Hospital Management and
Administration issues. She has had extensive experience in all topics
of infection control in hospitals and other clinical settings.

She worked as a visiting faculty at different institute, e.g. SNDT

Polytechnic, Gurunanak Hospital Nursing College, All India Institute
of Local Self Government, Mumbai Marine Institute, teaching medical
& Health care Management with a specific brief to enhance efficiency
and service levels.

As a Medical Director with Family Planning Association of India, she

guided, advised, and monitored the maintaining of Quality of Care
Standards in a chain of 40 Clinics all over India.

This manual is the outcome of her many months of full time effort
with the aim to promote awareness about the importance of infection
prevention and control measures in health care workers and co-
workers, patients and visitors and to make it part of their daily
practice.
 TABLE OF CONTENT

Introduction 1
Hand Washing 2
Hand Flora 3
Level of Hand Decontamination 4
Indications for Social Hand Washing 5
Indications for Hygiene Hand Washing 6
Indications for Surgical Hand Washing 7
Alcohol Based Hand Rub and Hand Wash 8
Recommendations 9
Hand Hygiene Facilities 10
Steps to Increase Chances of Success for Hand Washing 11
Myths 12
Summary 13
Action Plan 14
Monitoring 15
Auditing 16
Training & Education 17
Tips & Warnings 18
1. INTRODUCTION
“Prevention is better than cure”. No other situation fits as aptly to
this popular phrase as hospital / health care associated infection.

Hand washing is the act of cleaning one’s hands with the use of
any liquid with or without soap for the purpose of removing dirt
or microorganisms. It is the most effective measure in reducing the
risk of transmitting infectious diseases.

It cannot be said too often that hand washing is the most important
and most basic technique in preventing and controlling infections. It
is the single most effective infection control measure.

Hand washing is under the umbrella of hand hygiene. Hand hygiene

is defined by the World Health Organization as a general term that
applies to hand washing, antiseptic hand wash, antiseptic hand
rub or surgical hand antisepsis.

Good hand hygiene of all members of the staff is one of the most
crucial interventions to prevent cross-infection in health care
facilities.

Hands become easily contaminated with microorganisms. Frequent

hand washing can reduce the spread of infection from the hands of
health workers and others. By persuading people, especially young
children, to wash their hands with soap and clean water after going to
the toilet, or after handling or changing a dirty baby, or doing other
tasks that potentially contaminate hands (cleaning vegetables, fresh
meat or fish) can reduce diarrheal diseases.

When you need to wash your hands:

Hands normally carry lots of germs and should be washed:

After visiting the toilet,

Before handling food,
When visibly dirty,
After coughing or sneezing into your hands.
2. HAND WASHING
Hand washing is defined as a vigorous, brief rubbing together of all
surfaces of lathered hands, followed by rinsing under a stream of
water. The detergent or soap in the hand washing solution
dissociates the microorganisms from the skin by reducing the
surface tension. This is also facilitated by the mechanical rubbing
together of the hands. The subsequent rinsing with a stream of water
removes these microorganisms.

Washing hands properly is one of the most important things to help

prevent and control the spread of many illnesses. It is the most
effective method for preventing the transfer of bacteria between
personnel and patients within the hospital.

The detergent or soap in the hand washing solution dissociates the

microorganisms from the skin by reducing the surface tension. This
is also facilitated by the mechanical rubbing together of the hands.
The subsequent rinsing with a stream of water removes these
microorganism.

Hand Hygiene:

Hand Hygiene is a means of achieving a reduction in or removal of

visible soiling, transient or resident organisms and/or other
hazardous toxic substances while maintaining the integrity of the
skin.

Pathogenic organisms from colonized and infected patients (and

sometimes from the environment) transiently contaminate the
hands of Healthcare delivery team comprising broadly eight
categories namely; doctors (allopathic, alternative medicine);
nursing and midwifery professionals; pharmacists; dentists;
paramedical workers; grass-root workers and support staff during
normal clinical activities and can then be transferred to other
patients.

Hand Hygiene is a means of achieving a reduction in or removal of

visible soiling, transient or resident organisms and/or other
hazardous toxic substances while maintaining the integrity of the
skin.
3. HAND FLORA
There are two groups of micro-organisms on the hands i.e. Transient
micro-organisms and Resident micro-organisms.

Transient micro-organisms are carried temporarily on the surface

of the skin and acquired on the hands through contact with other
sites on the same individual, from other people, or from the
environment. These microorganisms do not survive on the skin for
more than a few hours due to antibacterial properties of the skin
but can readily be transferred to other people or objects. These
microorganisms are derived from a health care environment thus
they are more likely to be of pathogenic potential. Removal of These
organisms is achieved by hand washing with soap and water.

Resident micro-organisms are deeply seated and live within the

epidermis under the finger nails and in the deeper layers of skin (hair
follicles, sweat glands and sebaceous glands). They are also known
as “normal” flora and are not readily transferred to other people
or surfaces.

Though these organisms are usually harmless and in most situations,

there is a risk that they may enter the epidermis (skin) during
invasive procedures, e g. surgery and cause surgical site infections.

4. LEVELS OF HAND DECONTAMINATION

Hand washing
Hygiene hand washing
Surgical hand washing

Social Hand Washing is the mechanical displacement of

microorganisms. It is normally done using plain soap and water.
This will remove most transient micro-organisms from
moderately soiled hands e.g. when first attending to a patient and
between patients.

Hygienic Hand Washing or Antiseptic Hand rub inhibits and kills

both transient and resident flora on the hands. It is a procedure
where antiseptic detergent preparation and waterless alcohol-based
hand rub products are used for washing or disinfection of hands (for
at least a minimum of 15-30 seconds).
Surgical Hand Washing/ antisepsis is an extension of hygienic hand
washing. It is performed before donning sterile attire preoperatively.
The aim is to both reduce the number of resident and transient flora
to a minimum and also to inhibit their re-growth for as long as
possible, on the hands, the wrists and forearms.

5. INDICATIONS FOR SOCIAL HAND WASHING

At the start of a shift a 2-minute scrub is essential.
After any direct contact with patient or patient equipment.
Between procedures on the same patient.
Before contact with the next patient.
Before and after nursing the patient (e.g. bathing, bed making).
Before caring for patients in ICU, nurseries and
immunocompromised patients.
Before and after direct physical contact with a client/patient.
Before putting on sterile or high-level disinfected surgical gloves
or examination gloves and after removing gloves and protective
clothing.
Before performing invasive procedures.
Before and after touching wounds, mucous membranes, blood,
body fluids, secretions or excretions (except sweat).
After handling contaminated items objects, including used
instruments such as dressings, bedpans, waste, urinals and urine
drainage bags, commodes, toilet seats etc.
During an outbreak of infection.
When hands are visibly dirty.

Points to remember before the Hand Washing procedure and

preparation:

The effectiveness of decontamination is increased by certain

important parameters. Remember to:
 Keep nails short, Clean and Polish Free.
Avoid wearing wrist watches and jewellery, Specially Rings with
ridges or Stone and Bracelets.
Not to wear artificial Nails
Cover cuts and abrasions with the water proof Dressings.
Roll up long sleeves before washing your hand and wrists.

Basic Hand Washing Area

Illustration: Basic Hand Washing Area

Indications for Hand Washing:

Before preparing or serving food.

Before eating, drinking or handling food.
After visiting the toilet, blowing your nose or covering a
sneeze/cough.
Before and after each work shift or work break.
Before and after smoking.
Whenever hands become visibly soiled
Before and after patient contact
After touching a contaminated environment

Hand Washing Technique

Hands should be wet by putting them under running water and

avoiding splashing of water to surrounding areas. Liquid/bar soap
should be applied to cover all hand surfaces. (In places where
running tap water is not available, a drum with a drain spout could be
elevated to serve as running water. Alternatively, a clean bowl of
water can be used. Water should be replaced between each use.)

1.Wetting the hands 2.Applying the foam 3.Leathering the soap

with water soap and scrubbing both
hands palm to palm

All surfaces of the hands should be rubbed vigorously for at least

a minimum of 10-15 seconds paying particular attention to the
tips of the fingers, the thumbs and the areas between the fingers.

4.Scrubbing back of 5.Scrubbing finger 6.Scrubbing each

each hand with tips of each hand in thumb in
palm of other hand palm of opposite hand opposite hand
A nailbrush should only be used if the nails are dirty – it should
not be used on the skin.

Hands should be rinsed thoroughly under clean running water

from a tap or a bucket. Dipping hands into a basin containing
standing water should be avoided because microorganisms can
survive and multiply in this water even if an antiseptic agent is
added .A bucket with tap or a bucket with a pitcher can be used if
running water is not available from the tap and splashing of water
in the surrounding area should be avoided.

7.Scrubbing each 8.Washing thoroughly

wrist Under running water

There should be no visible trace of detergent remaining on the

hands.

Hands should be dried with personal dry clean towel, disposable

paper towel (by patting rather than rubbing) or air dried.

Used paper towels should be disposed of according to the local

waste disposal policy.

The whole procedure usually takes about 40-60 seconds.

If bar soap is used, it should be kept in a receptacle (soap

container/box) which facilitates its drying. Wet bar soaps can be a
source of infection
 9.Drying (patting) 10.Turning off water
hands with paper towel with same towel

Liquid soap dispenser should be thoroughly cleansed and dried

before refilling.

Topping up liquid soap should not be practiced.

6. INDICATIONS FOR HYGIENE HAND WASHING

Hands should have been washed previously with soap and water
and should be visibly clean and dried from fingertip to elbow.

Antiseptic soap containing an antiseptic agent (often

chlorhexidine, iodophors, or triclosan) instead of plain soap
should be applied on each hand to cover all hand surfaces and
scrubbed using a rotator movement from finger tips to elbow for
at least 20 seconds before rinsing under running water.

Any breaks in the skin should be securely covered by a

waterproof dressing.

During hand washing, care should be taken that the arms are not
passed back and forth but held flexed under running water so
that the water drips from hands to the elbow and not vice versa.
 The water should be turned off using either the elbow or foot
depending on the taps. If the taps do not operate this way, leave
the water running until drying of the hands is complete, when the
taps can be turned off using a clean paper towel.

7. INDICATIONS FOR SURGICAL HAND WASH

Before donning sterile attire preoperatively.

Before all surgical procedures.

To be performed preoperatively by the surgical team to prevent

the risk of wound contamination in case gloves become damaged.

Before handling dressings or touching open wounds, inserting

urinary catheter etc.

Before contact with invasive devices.

Before performing any invasive procedures such as placement of

an intravascular device.

Before contact with immunocompromised patients.

Before caring for highly susceptible patients in high-risk areas:

ICU, OR, Burn Unit, Dialysis, and Intensive Care Nurseries.

Surgical Hand Washing Technique

All jewellery should be removed as jewellery harbours micro-

organisms and is difficult to clean.

Debris from under nails should be removed using a nail pick. Nail
brushes should not be used as it is difficult to keep them clean.

Hands and arms up to the elbow should be wet under running

water.

Hands and arms should be washed with an antimicrobial solution

or plain soap under running water right up to the level of the
elbows for at least one more minute using an extra squirt of
washing liquid/ plain soap.
1.Wet hands with 2.Take soap in the 3.Cleaning below the
water hands nails

Water should flow from the area of least contamination to the

area of most contamination. Soap can kill some micro-organisms.

4.Hand washing 2.Scrubbing the 3.Rinsing the hands

hands and elbow

Hands should be washed with soap by :

1. Rubbing the back of each hand with the front of the other
2. Rubbing the palms against each other with the fingers
between each other
3. Rubbing the back of each hand with the front of the other with
the fingers between each other.
4. moving from fingertips to the elbows of one hand and the
same procedure should be repeated with the other hand.

All surfaces of hands, fingers and forearms should be vigorously

rubbed for at least 2 minutes.

Each arm should be rinsed separately, fingertips first, holding

hands above the level of elbows at all times.
Rinse water should not flow over clean areas.

Splashing water over the whole surgical attire should be avoided.

Hands should be kept up and away from the body and any surface
or article should not be touched.

4.Hand washing

Hands and forearms should be dried thoroughly with sterile

paper hand towel for each hand, rotating down hands to elbows
before discarding.

5.Drying of finger
tips

Hot air hand dryers are forbidden in healthcare facilities.

While donning sterile gloves and gown, hands should be held

above the level of the waist without touching anything. The area
below the level of the waist is considered contaminated.
8. ALCOHOL BASED HAND RUB AND HAND WASH

Alcohol Based Hand Rub contains a minimum of 60% alcohol

and can be used in all clinical situations except when hands are
visibly dirty.

Alcohol based hand wash Alcohol rub is applied in five strokes

rubbing backwards and forwards and by rubbing palm to palm
with fingers interlaced.

Alcohol should evaporate before donning sterile or high-level

disinfected surgical gloves to avoid the risk of dermatitis. The
product usually dries within 15-20 seconds.

Alcohol based rubbing palm Rubbing palm to Back of Fingers to

hand rub in to palm over palm fingers opposite palms
palm from left dorsum interlaced with fingers
bottle interlaced

9. RECOMMENDATIONS

To encourage hand hygiene practices, it is recommended that hand

hygiene facilities should be provided which are easily too accessible
and with reminders to do so.
10. HAND HYGIENE FACILITIES

Access to appropriate hand hygiene facilities should be there:

Adequate supplies for hand hygiene products.

Availability of hand-free tap system.
Mixed taps are preferred to provide correct temperature of water
for performing hand hygiene.
Hand washing poster, indicating the correct hand washing
technique should be placed at all the hand washing areas.
Signs explaining the importance of hand hygiene should be
visible on all important entry to all health care facilities especially
on entry and exit from health care facilities.
Soap and a bowl of water or hand cleansing wipes should be
offered to patients who are unable to access hand washing
facilities.
Alternative options like waterless alcohol-based hand rubs
should be made available to improve the compliance with hand
washing.
Disposal of body fluids at the clinical hand wash-hand-basin
should not be done.
Hand wash basin should not be used for storing used equipment
awaiting decontamination.
After contact with inanimate surfaces and objects (Including
medical equipment) in the immediate vicinity of the patient.
Hand rub solution should be kept at the bedside and replaced as
soon as possible

11. STEPS TO INCREASE THE CHANCES OF

SUCCESS FOR HAND WASHING

Educate healthcare providers about the need and methods of

hand hygiene.
 Healthcare providers should reduce the frequency of hand
hygiene required, by minimizing unnecessary direct contact with
patients, their immediate environment and actions such as
leaning on bedrails.

If the patient bathroom is used for hand hygiene, contamination

of hands with potentially contaminated surfaces and objects
should be avoided.

Patients and visitors should be instructed on proper hand

hygiene e.g. Patient should perform hand hygiene before eating
(with assistance, if necessary), after personal use of the toilet, and
when soiled.

Current guidelines for hand hygiene practices should be widely

disseminated with the evidence supporting their effectiveness in
preventing disease and the need for health providers to adhere to
the guidelines.

Wall dispensers, education, brochures, buttons, posters should be

made available.

12. MYTHS

Hand Washing

Between every patient encounter is unnecessary as it does not

affect clinical outcome.

Is unnecessary when gloves are worn.

Is unnecessary as routine or frequent hand washing interrupts

efficient patient care

Frequent hand washing damages skin and causes cracking,

dryness, irritation and dermatitis.

Damages nails and nail polish.

Facilities are not conveniently placed or well designed.

Is not always convenient and takes too much time.

Mistakes

Use of a bar soap

Use of warm water

Not washing hands after toilet

Not rinsing and scrubbing and rinsing for long enough (20-30
seconds)

Use of warm water

Use of air dryer

Use of one hand towel for the whole family

13. SUMMARY

Hand hygiene is the most important precaution that prevents the

spread of infection. It is the single most important procedure for
preventing the transmission of diseases and infection. After washing,
hands should be dried carefully. If soap and clean water are not
available, an alcohol-based product should be used to clean hands.
Washing hands properly can help prevent the spread of the germs
(like bacteria and viruses) picked up from out surfaces that cause
serious complications, especially for young children and the elderly
people. Proper hand washing can protect you and others from a
range of diseases.

14. ACTION PLAN

The Hospital Administrator under the advice of Infection Control

Team should ensure that:

Current guidelines for hand hygiene practices is widely

disseminated with the evidence supporting its effectiveness in
preventing disease and the need for health providers to adhere to
the guidelines.
 Should be involved in promoting and enforcing the guidelines by
convincing them of the cost benefits of hand washing and other
hand hygiene practices.

A hand washing policy should be established and effectively

communicated to all the healthcare providers.

Successful educational techniques including role modelling

(especially by supervisors), mentoring, monitoring and positive
feedback should be used.

To promote compliance performance improvement, approaches

should be targeted to all healthcare providers and not just
physicians and nurses.

Occasional training programmes should be arranged for all the

healthcare providers.

Annual mandatory hand hygiene training should be arranged for

all the staff to maintain their level of competency and knowledge.
All new staff should receive hand hygiene training at general
induction.

Hand washing policy should be established.

All the members of the Infection Control Committee should be

effectively involved in developing and implementing the Hand
Hygiene Policy.

The Hand Hygiene Policy should be effectively communicated to

all healthcare providers in the facility.

Demonstrate hand washing policy through action.

15. MONITORING

Monitoring of healthcare worker hand hygiene performance is

considered a standard in most hospitals. Collection and feedback of
compliance data is used to educate and engage healthcare providers
in hand hygiene improvement campaigns. Data also allows Infection
Preventionists to track the success of interventions or to identify
areas of potential problems. Monitoring can be accomplished using
several different methods, though the gold standard is direct
observation of healthcare provider practices by a trained observer.

Unknown observers should monitor hand hygiene practices on all

the units using standardized definitions and data collection
procedures. Known monitors under direct feedback program should
address, educate, and take the name of staff the moment that they
are observed not performing hand hygiene appropriately. Hand
hygiene compliance should be monitored upon each entry to and exit
from a patient care room or area.

16. AUDITING

A hand hygiene audit is used to assess hand hygiene techniques

being performed within healthcare settings. It aims to prevent the
spread of infection between healthcare providers and patients
through observational inspections. The simplest and most effective
solution for healthcare providers is always to practice proper hand
hygiene techniques while on duty.

Performing a hand hygiene audit of healthcare providers

Before commencing the audit, the hospital administration should

be informed about the period of observation and the purpose of
performing the hand hygiene audit.

Healthcare providers should be informed about the data

documentation method (e.g. photo evidence).

All the areas to be identified where audit is to be taken. The head

nurse, the chief doctor of the unit or the department manager and
other healthcare staff responsible for patient’s safety should be
informed.

Patient privacy must not be compromised during auditing.

Written permission from patients may be required.

Auditing should not be done during extreme situations (e.g.

emergency medical treatment, signs of uncontrolled stress in a
healthcare provider).
A sample Checklist for auditing is provided below:

Activity Location Response Remarks

Soap/scrub soln and clean

water available in all hand
washing areas

Staff wash hands and use

antiseptic solution before
and after each clinical
procedure, after handling
waste or touching body
fluids.

Staff wear sterile disposable

surgical gloves when
performing surgical
procedures or dressings

Staff wear utility gloves

when cleaning or handling
dirty instruments/
equipment and
contaminated surfaces

Routine hand washing is

done before wearing gloves,
after examining or having a
contact with the client and
after removing the gloves
Hand is washed with plain
or antiseptic soap, rinsed
with clean running water,
dried with personal sterile
towel.

Both hands are scrubbed up

to elbow with soap and
water /antiseptic solution
several times for 3 to 5
minutes and kept in upright
position till dried

17. TRAINING & EDUCATION

Healthcare facilities should perform regular hand hygiene audits to

identify training and remind staff of the importance of basic infection
control.

Healthcare providers should receive training frequently

regarding hand hygiene in the facility.
There should be a process to confirm that all health-care
providers complete the training.
All the documents should be easily available to all healthcare
providers.
There should be a professional with adequate skills to serve as
trainer for hand hygiene educational programmes active within
the health-care facility.
There should be a system in place for training and validation of
hand hygiene compliance observers.
There should be a dedicated budget that allows for hand hygiene
training.
18. TIPS & WARNINGS

Hands and arms should be passed slowly under the running

water to allow all the soap to be removed.

If further rinsing is needed to remove soap, entire rinse

process should be repeated again, starting at the fingertips and
not beginning at the elbow. After surgical scrub is complete,
nothing unsterile should be touched.

References

1. WHO Guidelines in Healthcare

2. Kaya Kelp Guidelines
3. Good Practice in Infection and Prevention and Control at
Service

Delivery Points: By Ashto Mathur

PUBLICATION YEAR - 2023