Guidelines for the use of Alcohol-Based Hand Rubs

Introduction
Improving hand hygiene among healthcare workers (HCW) is currently the single most effective
intervention to reduce the risk of hospital-acquired infections in hospitals. One way in which
HCWs improve their hand hygiene practices is through the regular use of alcohol-based hand
rubs at the point-of-care. There are a number of risks to patients and staff associated with the
use of alcohol hand rub, however the benefits in terms of its use far outweigh the risks.
Purpose
1. To reduce the risk of infection by making it easy for personnel to access alcohol-based
hand rubs.
2. To minimize or eliminate the risk of fire from flammable hand rubs.

Policy
1. Location of the hand rub
1.1 Products must be
1.1.1 Located where they are needed
1.1.2 Available in appropriate numbers
1.1.3 Clearly visible
1.1.4 Within reasonable reach
1.1.5 Unobstructed
1.1.6 Fully stocked
1.1.7 Fully functional
1.1.8 Cleaned regularly

2. Placement
2.1 At-the- point of care (within arm’s reach or within 3 feet of the care). Point-of-care is
when three elements are present at the same time (the patient, the health care
provider and care involving contact).
2.2 At least one ABHR is located by each bed in multi-bed rooms.
2.3 Hand rubs should be in clear view upon room entrance.
 3. Installation
1.1 Dispenser will be spaced a minimum of 48” apart,
1.2 Wall - mounted dispensers must be installed with the nozzle 37-47 inches (94-
120cm) from the floor.
1.3 See Figure 1.
4. Safety
4.1 Hand rub dispensers should not be placed above or close to potential sources of
ignition, such as light switches and electrical outlets, or next to oxygen or other
medical gas outlets, due to the increased risk of vapours igniting.
4.2 There will be at least 6 inches clearance between a dispenser and any ignition
source. Ignition sources include;
4.2.1 Outlets and light switches
4.2.2 Electrical cover plates
4.2.3 Phones and intercoms
4.2.4 Lights of any kind
4.2.5 Electrical beds (motors)
4.2.6 Mobile electrical equipment
4.3 There will be no ignition source directly below a dispenser or the dispenser’s
horizontal clearance area.
4.4 Consideration should be given to the risks associated with spillage onto floor
coverings, including the risk of pedestrian slips.

5. Refilling and Maintaining Dispensers

5.1 Responsible for refilling and maintaining the dispensers is the head unit of the floor
and also the ICN for monitoring.
5.2 Hand rub dispenser should be clean from dust.

Figure 1. No alcohol-based hand rub dispenser is permitted within 6 inches of ignition

source
 6 inches 6 inches
6 inches 6 inches

48 inches
minimum

No ignition in this area No ignition in this area

(light switches, (light switches,
outlets, etc.) outlets, etc.)

References:
who.int/gpsc/tools/faqs/abhr2/en
Canadian Patient Safety Institute. (2010). Hand Hygiene Human Factors Toolkit.
Retrieved from www.handhygiene.ca