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Hand Hygiene Practices

Introduction

Hand hygiene is crucial in preventing healthcare-associated infections, particularly in surgical environments where contamination risk is high. This policy describes appropriate moments for hand hygiene and provides detailed protocols for handwashing with soap and water as well as with alcohol-based hand rub (ABHR). It complies with 2023 ORNAC standards and World Health Organization (WHO) guidelines.

General Objective

The main objective is to reduce infection transmission through continuous and measurable improvement of hand hygiene practices for both users and healthcare staff, using a multidimensional approach.

1. Defining Hand Hygiene Practice Improvement

Achieve a compliance rate of >80% in hand hygiene practices across all care services within 12 months. This objective covers both clinical and non-clinical areas, integrating user and visitor involvement. This goal aligns with previous assessment results (audits) and current infection control standards.

2. Required Resources:

Managers must allocate the following human, material, and financial resources to support hand hygiene practices:

  • Designation of a team responsible for program implementation, including specialized trainers and observers
  • Implementation of adequate infrastructure: sinks, ABHR dispensers, soap, paper towels, and accessible cleaning products
  • Development and maintenance of a compliance tracking and analysis system (direct observation, audit reports)

3. Developing a Hand Hygiene Quality Improvement Plan:

The plan includes specific activities such as:

  • Ongoing staff and visitor training on proper hand hygiene practices
  • Implementation of visual reminder systems (posters) to encourage handwashing
  • Organization of feedback sessions during team meetings, using dashboards to visualize progress

4. Detailed Hand Hygiene Protocol

a. Scope

This policy applies to all healthcare professionals working in the CREOQ surgical center, including surgeons, nurses, anesthesiologists, and other staff.

b. Responsibilities:

Employer Responsibilities:

  • Provide necessary devices for proper hand hygiene
  • Provide training and reassessment of good hand hygiene practices
  • Establish standards, methods, and measures for hand hygiene by each employee
  • Evaluate the environment to ensure everything is up-to-date for good hand hygiene practice
  • Audit handwashing practices and provide staff updates

Employee Responsibilities:

  • Apply policies and standards as established by the employer
  • Cooperate with the employer to reduce and eliminate microbe spread
  • Complete hand hygiene training provided by the employer

c. General Guidelines:

  • Remove jewelry before performing hand hygiene
  • Keep nails clean and short (<3-4mm from fingertip)
  • Use single-use towels
  • Moisturize hands after each handwashing as needed

d. 5 Key Moments for Hand Hygiene (Based on WHO Guidelines)

  1. Before touching a patient
  2. Before clean/aseptic procedures
  3. After body fluid exposure risk
  4. After touching a patient
  5. After touching patient surroundings

e. Hand Hygiene Protocols

Handwashing with Soap and Water [Detailed 12-step procedure provided in original text]
Duration: At least 40-60 seconds (WHO, 2009)

Hand Hygiene with Alcohol-Based Hand Rub (ABHR) [Detailed 8-step procedure provided in original text]
Duration: At least 20-30 seconds (WHO, 2009)

Conclusion: Hand hygiene practice compliance is essential for reducing infection risk and ensuring patient and staff safety in a surgical center. This protocol establishes a strategic, well-structured, and dynamic approach to ensure continuous and measurable improvement in this crucial area of care quality.

References

Operating Room Nurses Association of Canada (ORNAC). (2023). Standards, Guidelines and Position Statements for Registered Nurses in the Operating Room. ORNAC.

Government of Quebec. (2024, April 22). Hand hygiene.


https://www.quebec.ca/en/health/advice-and-prevention/accidents-injuries-and-diseases-prevention/washing-hands

Infection Prevention and Control Canada. (n.d.). Information about hand hygiene.

https://ipac-canada.org/hand-hygiene#Rationale

Infection Prevention and Control Canada. (n.d.). Infection prevention & control videos.

https://ipac-canada.org/ipac-video

World Health Organization (WHO). (2009). WHO Guidelines on Hand Hygiene in Health Care. WHO.

Public Health Ontario. (2014, April). Best practices for hand hygiene in all health care settings (4th ed.).

https://www.publichealthontario.ca/-/media/documents/b/2014/bp-hand-hygiene.pdf