Infection Control Policy and Procedure Manual ... - Mission Health

Infection ControlInfection Control Policy Number : 714Policy and Procedure ManualSubject: Hand Washing/Hand Hygiene Page: 1 of 2 pagesEffective Date: May 2003 Revised Date: March 3, 2008Approved:Approved:Signed by Dale Fell, M.D. 3/3/08Signed by James Whitehouse, M.D. 3/3/08Original filed in IC DepartmentChief Medical OfficerChairperson, Infection Control CommitteeApproved:Signed by Ramona Whichello, R.N. 3/3/08Vice President, Nurse ExecutivePurpose: Hand washing/hand hygiene is the single most important measure in preventing thetransmission of infectious agents from the source to other patients, personnel, and the inanimateenvironment. Gloves should never replace hand washing.Policy: Hand hygiene is a critical component of patient safety in the hospital. CDC recommends acomprehensive evidence based approach in the hospital that consists of hand washing with soap andwater when the goal is to remove visible debris; alcohol hand rub for reducing microbial counts; andgloving when people have contact with blood and other body fluids in accordance with standardprecautions. This policy of Mission Health, Inc. (“Mission”) is applicable to Mission Hospitals andother locations where services of the hospital are being provided.Procedure:1. When hands are visibly dirty or contaminated with proteinaceous material or are visiblysoiled with blood or other body fluids, wash hands with either a non-antimicrobial soap andwater or an antimicrobial soap and water.-Wet hands with warm water, apply soap to hands and rub hands together for 15seconds covering all surfaces of hands and fingers. Rinse hands with warm waterand dry thoroughly with a disposable towel. Use disposable towel to turn off waterfaucets. Avoid using hot water, because repeated exposure to hot water may increasethe risk of dermatitis.2. For routinely decontaminating hands when not visibly soiled, use an alcohol based waterlesshand rub for 15 seconds.-Apply the product to the palm of one hand and rub hands together covering allsurfaces of hands and fingers until hands are dry. If an adequate volume of alcoholbased hand rub is used it should take 15-25 seconds for hands to dry.

Infection Control Policy #714 – Hand Washing/Hand Hygiene 2-Decontaminate hands not visibly soiled with alcohol hand rub or alternately with anantimicrobial soap and water:a. when entering a patient’s room,b. before donning sterile gloves wheninserting a central intravascular catheter,c. before inserting urinary catheter, peripheral vascular cathetersor other invasive device,d. after contact with patient’s intact skin (taking a pulse or blood pressure,or lifting a patient),e. after contact with body fluids or excretions, mucus membranes, nonintactskin or wound dressings as long as hands not visibly soiled,f. if moving from a contaminated body site to clean site during patientcare,g. after contact with inanimate objects in immediate vicinity ofthe patient,h. after removing glovesi. when leaving a patient’s room.3. Wash hands for 15 seconds with soap (non-antimicrobial or antimicrobial) and waterbefore eating and after using a restroom.4. Wash hands with non-antimicrobial or antimicrobial soap and water if exposure toClostridium difficile, Norovirus or Bacillus anthracis is suspected or proven. Thephysical action of washing and rinsing hands under such circumstances is recommendedbecause alcohols, chlorhexidine, iodophors, and other antiseptic agents have poor activityagainst spores and some viruses.5. Do not wear artificial fingernails or extenders (i.e. acrylic nails, tips, wraps made of silk,linen, fiberglass, gels, glues and mixture of these products) when having direct contactwith patients. Keep natural fingernail tips less than 1/4 inch long.6. Wear gloves when it can be reasonably anticipated that contact with blood or mucusmembranes, other potentially infectious material and non-intact skin will occur.7. Remove gloves after caring for a patient - do not wear the same pair of gloves for care ofmore than one patient, and do not wash gloves between patients. (Hands to be thoroughlydried before donning gloves.)8. Use hospital approved water based hand lotion in order to minimize hand irritation thatmay be associated with hand washing or hand antisepsis.9. When performing surgical procedure use either the specific alcohol based hand rub orantimicrobial soap for surgical hand antisepsis before donning sterile gloves. When usingan alcohol based hand rub, hands and forearms are to be prewashed with a nonantimicrobialsoap and water and dried completely. Decontaminate hands using a spongeto minimize skin damage. Refer to OR Department specific policies for details onsurgical hand scrub.