Pre‐procedure

ActionRationale

1. 1.Show
   Remove wristwatch, any rings and/or bracelets and roll up sleeves. Note: it is good practice to remove all hand and wrist jewellery and roll up sleeves before entering any clinical area, and the Department of Health has instructed NHS trusts to implement a ‘bare below the elbows’ dress code.
   Jewellery inhibits good hand washing. Dirt and bacteria can remain beneath jewellery after hand washing. Long sleeves prevent washing of wrists and will easily become contaminated and so a route of transmission of micro‐organisms (DH [23], C; WHO [124], C).

   Many organizations’ dress codes allow staff to wear wedding rings while providing care. Although it can be argued that a smooth ring is less likely to retain dirt and bacteria than one with a stone or engraving, there is no evidence to suggest that wedding rings inhibit hand decontamination any less than other rings. E
2. 2.Show
   Cover cuts and abrasions on hands with waterproof dressings.
   Cuts and abrasions can become contaminated with bacteria and cannot be easily cleaned. Repeated hand washing can worsen an injury (WHO [124], C). Breaks in the skin will allow the entry of potential pathogens. E
3. 3.Show
   Remove nail varnish and artificial nails (most uniform policies and dress codes prohibit these). Nails must also be short and clean.
   Long and false nails and imperfections in nail polish harbour dirt and bacteria that are not effectively removed by hand washing (WHO [124], C).

Procedure

1. 4.Show
   Turn on the taps and where possible direct the water flow away from the plughole. Run the water at a flow rate that prevents splashing.
   The plughole and the associated waste are often contaminated with micro‐organisms, which could be transferred to the environment or the user if splashing occurs (Aranega‐Bou et al. [4], R; Garvey et al. [43], C).
2. 5.Show
   Run the water to a comfortable temperature.
   Warm water is more pleasant to wash with than cold so hand washing is more likely to be carried out effectively. E

   Water that is too hot could cause scalding (DH [33], C).
3. 6.Show
   Wet the surface of the hands and wrists.
   Soap applied directly onto dry hands may damage the skin. The water will also quickly mix with the soap to speed up hand washing. E
4. 7.Show
   Apply liquid soap and water to all surfaces of the hands.
   Liquid soap is very effective in removing dirt, organic material and any loosely adherent transient flora. Tablets of soap can become contaminated, potentially transferring micro‐organisms from one user to another, but may be used if liquid soap is unavailable (WHO [124], C).

   To ensure all surfaces of the hands are cleaned. E
5. 8.Show
   Rub hands together for a minimum of 10–15 seconds, paying particular attention to between the fingers and the tips of the fingers and thumbs (Action figure 4.11). The areas that are most frequently missed through poor hand hygiene technique are shown in Figure 4.7.
   To ensure all surfaces of the hands are cleaned. Areas that are missed can be a source of cross‐infection (Fraise and Bradley [41], E).
6. 9.Show
   Rinse soap off hands thoroughly.
   Soap residue can lead to irritation and damage to the skin. Damaged skin does not provide a barrier to infection for the healthcare worker and can become colonized with potentially pathogenic bacteria, leading to cross‐infection (DH [33], C).
7. 10.Show
   Turn off the taps using a wrist or elbow. If the taps are not lever‐type, turn them off using a paper hand towel to prevent contact.
   To avoid recontaminating hands. E

Post‐procedure

1. 11.Show
   Dry hands thoroughly with a disposable paper towel from a towel dispenser.
   Damp hands encourage the multiplication of bacteria and can become sore (DH [33], C).
2. 12.Show
   Dispose of used paper towels in a black bag in a foot‐operated waste bin.
   Paper towels used to dry the hands are normally non‐hazardous and can be disposed of via the domestic waste stream (DH [25], C).

   Using a foot‐operated waste bin prevents contamination of the hands. E

   Electric hand dryers are generally not recommended for use in clinical areas (Best et al. [6], E).