Hand Hygiene: Why, How & When?

WHY? HOW?
Thousands of people die every day Clean your hands by rubbing them
around the world from infections with an alcohol-based formulation,
acquired while receiving health care. as the preferred mean for routine
hygienic hand antisepsis if hands
Hands are the main pathways of are not visibly soiled. It is faster,
germ transmission during health care. more effective, and better tolerated
by your hands than washing with
Hand hygiene is therefore the most
soap and water.
important measure to avoid the
transmission of harmful germs Wash your hands with soap and
and prevent health care-associated water when hands are visibly dirty or
infections. visibly soiled with blood or other body
fluids
This brochure explains how and
or after using the toilet.
when to practice hand hygiene.
If exposure to potential spore-forming
pathogens is strongly suspected
WHO? or proven, including outbreaks of
Clostridium difficile, hand washing with
Any health-care worker, caregiver
soap and water is the preferred means.
or person involved in direct or
indirect patient care needs to be
concerned about hand hygiene and
should be able to perform it
correctly and at
the right time.

PAGE 1 OF 7
Revised August 2009
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members
of the Infection Control Programme, for their active participation in developing this material.
All reasonable precautions have been taken by the World Health Organization to
verify the information contained in this document.
However, the published material is being distributed without warranty of any kind, either
expressed or implied. The responsibility for the interpretation and use of the material lies
with the reader. In no event shall the World Health Organization be liable for damages
arising from its use.
HAND HYGIENE: WHY, HOW &
WHEN?

HOW TO HANDRUB?

RUB HANDS FOR HAND HYGIENE! WASH HANDS WHEN VISIBLY SOILED
Duration of the entire procedure: 20-30 seconds

1a 1b 2

Apply a palmful of the product in a cupped hand, covering all surfaces; Rub hands palm to palm;

3 4 5

Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing
interlaced fingers and vice versa; palms with fingers interlocked;

6 7 8

Rotational rubbing of left thumb Rotational rubbing, backwards and Once dry, your hands are safe.
clasped in right palm and vice versa; forwards with clasped fingers of right
hand in left palm and vice versa;

PAGE 2 OF
7
WHO acknowledges the Hôpitaux Universitaires de Genève (HUG), in particular the members All reasonable precautions have been taken by the World Health Organization to verify
of the Infection Control Programme, for their active participation in developing this material. the information contained in this document.
However, the published material is being distributed without warranty of any kind, either
expressed or implied. The responsibility for the interpretation and use of the material lies with
the reader. In no event shall the World Health Organization be liable for damages arising from its
use.
HOW TO HANDWASH?

WASH HANDS WHEN VISIBLY SOILED! OTHERWISE, USE HANDRUB

Duration of the entire procedure: 40-60 seconds

0 1 2

Wet hands with water; Apply enough soap to Rub hands palm to palm;
cover all hand surfaces;

3 4 5

Right palm over left dorsum with Palm to palm with fingers interlaced; Backs of fingers to opposing
interlaced fingers and vice versa; palms with fingers interlocked;

6 7 8

Rotational rubbing of left thumb Rotational rubbing, backwards and Rinse hands with water;
clasped in right palm and vice versa; forwards with clasped fingers of right
hand in left palm and vice versa;

9 10 11

Dry hands thoroughly Use towel to turn off faucet; Your hands are now safe.
with a single use towel;

Hand care
dry completely before putting on gloves.
hand cream or lotion, at least daily.

before or after using an alcohol-based handrub.

Please remember

or extenders when
in direct contact
with patients.
WHEN?

YOUR 5 MOMENTS
FOR HAND HYGIENE*

CRITICAL SITE WITH

INFECTIOUS RISK
FOR THE PATIENT

1 4
BEFORE AFTER
TOUCHING TOUCHING
A PATIENT A PATIENT

CRITICAL SITE
WITH BODY FLUID
EXPOSURE RISK

5
AFTER
TOUCHING PATIENT
SURROUNDINGS

*NOTE: Hand hygiene must be performed in all indications

described regardless of whether gloves are used or not.
 1 Before touching a patient 4 After touching a patient
WHY? To protect the patient against colonization and, in some WHY? To protect you from colonization with patient germs
cases, against exogenous infection, by harmful germs carried on your and to protect the health-care environment from germ spread
hands
WHEN? Clean your hands when leaving the patient’s side,
WHEN? Clean your hands before touching a patient when after having touched the patient *
approaching him/her*

Situations when Moment 1 applies: Situations when Moment 4 applies, if they correspond to the
a) Before shaking hands, before stroking a child’s last contact with the patient before leaving him / her:

forehead b) Before assisting a patient in personal care a) After shaking hands, stroking a child’s forehead

activities: b) After you have assisted the patient in personal care activities:
to move, to take a bath, to eat, to get dressed, etc to move, to bath, to eat, to dress, etc

c) Before delivering care and other non-invasive treatment: c) After delivering care and other non-invasive treatment: changing bed
applying oxygen mask, giving a massage linen as the patient is in, applying oxygen mask, giving a massage

c) Before performing a physical non-invasive examination: d) After performing a physical non-invasive examination:
taking pulse, blood pressure, chest auscultation, recording ECG taking pulse, blood pressure, chest auscultation, recording ECG

2 Before clean / aseptic procedure 5 After touching patient surroundings

WHY? To protect the patient against infection with harmful WHY? To protect you from colonization with patient germs that may
germs, including his/her own germs, entering his/her body be present on surfaces / objects in patient surroundings and to protect
the health-care environment against germ spread
WHEN? Clean your hands immediately before accessing a
critical site with infectious risk for the patient (e.g. a mucous WHEN? Clean your hands after touching any object or furniture when
membrane, non-intact skin, an invasive medical device)* living the patient surroundings, without having touched the patient*

Situations when Moment 2 applies: This Moment 5 applies in the following situations if they correspond
to the last contact with the patient surroundings, without having
a) Before brushing the patient’s teeth, instilling eye drops, performing a
touched the patient:
digital vaginal or rectal examination, examining mouth, nose, ear with or
without an instrument, inserting a suppository / pessary, suctioning a) After an activity involving physical contact with the patients immediate
mucous environment: changing bed linen with the patient out of the bed,
holding a bed trail, clearing a bedside table
b) Before dressing a wound with or without instrument, applying ointment
on vesicle, making a percutaneous injection / puncture b) After a care activity: adjusting perfusion speed, clearing a monitoring alarm

c) Before inserting an invasive medical device (nasal cannula, nasogastric c) After other contacts with surfaces or inanimate objects (note – ideally
tube, endotracheal tube, urinary probe, percutaneous catheter, try to avoid these unnecessary activities): leaning against a bed,
drainage), disrupting / opening any circuit of an invasive medical device leaning against a night table / bedside table
(for food, medication, draining, suctioning, monitoring purposes)
d) Before preparing food, medications, pharmaceutical products,
sterile material

3 After body fluid exposure risk

WHY? To protect you from colonization or infection
with patient’s harmful germs and to protect the health-
care environment from germ spread

WHEN? Clean your hands as soon as the task involving an

exposure risk to body fluids has ended (and after glove
removal)*

Situations when Moment 3 applies: c) After removing an invasive medical device

a) When the contact with a mucous membrane and with non-intact skin d) After removing any form of material offering protection
(napkin, dressing, gauze, sanitary towel, etc)
ends b) After a percutaneous injection or puncture; after inserting an
e) After handling a sample containing organic matter, after clearing excreta
invasive
and any other body fluid, after cleaning any contaminated surface and
medical device (vascular access, catheter, tube, drain, etc);
soiled material (soiled bed linen, dentures, instruments, urinal, bedpan,
after disrupting and opening an invasive circuit
lavatories, etc)
*NOTE: Hand hygiene must be performed in all
indications described regardless of whether gloves
are used or not.
HAND HYGIENE AND MEDICAL GLOVE USE The Glove Pyramid – to aid decision making
on when to wear (and not wear) gloves
your hands.
Gloves must be worn according to STANDARD and CONTACT
PRECAUTIONS. The pyramid details some clinical examples in which
of the indications for glove use. gloves are not indicated, and others in which clean or sterile gloves are
indicated. Hand hygiene should be performed when appropriate
regardless of indications for glove use.
occurs while wearing gloves.

gloves may carry germs.

Contact Precautions (see examples in the pyramid below) –

otherwise they become a major risk for germ transmission.

STERILE
GLOVES
INDICATED
Any surgical procedure;
vaginal delivery; invasive
radiological procedures;
performing vascular access
and procedures (central lines);
preparing total parental nutrition
and chemotherapeutic agents.

EXAMINATION GLOVES INDICATED

IN CLINICAL SITUATIONS
Potential for touching blood, body fluids, secretions,
excretions and items visibly soiled by body fluids.
DIRECT PATIENT EXPOSURE: Contact with blood; contact with
mucous membrane and with non-intact skin; potential presence of
highly infectious and dangerous organism; epidemic or emergency
situations; IV insertion and removal; drawing blood; discontinuation
of venous line; pelvic and vaginal examination; suctioning non-closed
systems of endotrcheal tubes.
INDIRECT PATIENT EXPOSURE: Emptying emesis basins;
handling/cleaning instruments; handling waste; cleaning up spills of body
fluids.

GLOVES NOT INDICATED (except for CONTACT precautions)

No potential for exposure to blood or body fluids, or contaminated environment
DIRECT PATIENT EXPOSURE: Taking blood pressure, temperature and pulse; performing SC
and IM injections; bathing and dressing the patient; transporting patient; caring for eyes and
ears (without secretions); any vascular line manipulation in absence of blood leakage.
INDIRECT PATIENT EXPOSURE: Using the telephone; writing in the patient chart; giving oral medications;
distributing or collecting patinet dietary trays; removing and replacing linen for patient bed; placing non-
invasive ventilation equipment and oxygen cannula; moving patient furniture.
Glossary

Alcohol-based formulation An alcohol-containing preparation (liquid, gel or foam) designed for

application to the hands for hygienic hand antisepsis.

Body fluids Blood; excretions like urine, faeces, vomit; meconium; lochia;
secretions like saliva, tears, sperm, colostrum, milk, mucous secretions,
wax, vernix; exudates and transudates like lymphatic, pleural fluid
cerebrospinal fluid, ascitis fluid, articular fluid, pus (except sweat);
organic samples like tissues, cells, organ, bone marrow, placenta.

Clean / aseptic procedure Any care activity that implies a direct or indirect contact with a mucous

procedure no germs should be transmitted.

Critical site Critical sites are associated with risk of infection. They either correspond
to body sites or medical devices that have to be protected against
harmful germs (called critical sites with risk of infection for the patient),
or body sites or medical devices that potentially lead to hand exposure
to body fluids and bloodborne pathogens (called critical sites with body
fluid exposure risk).

Hand care Actions to prevent skin irritation.

Hand hygiene Any action of hygienic hand antisepsis in order to reduce transient
microbial flora (generally performed either by handrubbing with an
alcohol-based formulation or handwashing with plain or antimicrobial
soap and water).

Indication for hand hygiene Moment during health care when hand hygiene must be performed
to prevent harmful germ transmission and/or infection.

Invasive medical device Any medical device that enters the body either through a body opening
or through a skin or mucous membrane breaking.