National Public Health Service Hand Hygiene Audit
HAND HYGIENE
Quality improvement toolkit for
Infection Prevention & Control in
General Practice
Author: Primary Care Quality & Information Service
Date: October 2008 Version: Final
Intended Audience: Public (Internet) / NHS Wales (Intranet) / NPHS
(Intranet) / LHB /General Practice
Purpose and Summary of Document:
This simple hand hygiene audit is for use by all staff working in general
practice that have patient or specimen contact .The purpose of this
observational audit is to support practices in assessing the quality of hand
hygiene technique performed by staff and in working with staff to improve
their hand hygiene technique.
Completion of this audit would constitute a suitable piece of Continuing
Professional Development that could be included within the GP appraisal
process or Personal Practice Development.
This straight forward audit is designed to prompt reflection
Publication and Distribution: Publication in NPHS Document Database
(Consultant infection control nurse)
Link from NPHS e-Bulletin
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Preface
Quality improvement toolkits
The Primary Care Quality and Information Service (PCQIS) have developed quality improvement
toolkits to assist practices in collating and auditing information.
The quality improvement toolkits produced support the specification requirements of the latest
evidence based practice. They should be seen as good practice and cover areas that some or
even all practices may not be achieving at this stage. It is not expected that all the criteria within
this audit will be achieved in year one therefore the PCQIS suggests that the toolkits should be
used to aid development within the practice.
You can access other quality improvement toolkits that support enhanced services and National
Service Frameworks from the National Public Health Service (NPHS) website:
Intranet [Link]
Internet [Link]
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CONTENTS
Page
Preface 2
1 Introduction and background 4
2 Aim of the quality improvement toolkit 4
3 Methodology 5
4 Data entry template 6
Appendix 1 - 10 steps to effective hand hygiene 7
Appendix 2 - Effective hand hygiene information 9
Appendix 3- Quality improvement toolkit evaluation form 11
Appendix 4- Summary collection sheet 12
Appendix 5- WHO Five moments for hand hygiene 15
References 16
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1 Introduction and background
4
“Hand hygiene is the entrance door to better infection control and safer patient care”
Health care-associated infections (HCAIs) remain a major cause of morbidity, mortality, and
excess health care cost despite concerted infection control efforts over nearly a half-century.
Patients in Wales should expect to receive care and treatment in a way that does not pose a
3
greater risk to their health
A key objective of the Healthcare Associated Infections Community strategy for Wales - (2007) is
to introduce a clean culture throughout the healthcare system and to ensure that hygiene and
infection prevention and control are embedded in the management agenda and the accountability
3
of all staff. The importance of hand hygiene in the healthcare environment is considered a priority
7
and the need for its emphasis in the primary care setting is recognised .
Hand hygiene is the most effective measure to prevent transmission of microorganisms. Adequate
hand hygiene can be achieved by hand washing with soap and water--or by the use of an alcohol-
based hand-rub solution9. It is an infection control practice with a clearly demonstrated efficacy,
4,8
and remains the cornerstone of efforts to reduce the spread of infection . Technique is of
12
crucial importance in all hand hygiene .
All Primary care staff Involvement
It is important that all staff develop awareness and knowledge of infection control processes and
procedures. The practice could undertake a baseline audit to identify if practice staff have
received training in hand hygiene procedures. This simple audit will help gain a baseline
understanding of whether staffs are performing effective hand hygiene techniques. The audit will
also provide an opportunity for staff to reflect on their own hand hygiene practices, improving their
technique where required.
Nominated lead for infection control
The practice must nominate a lead for Infection Prevention and Control, someone who must have
received training in infection prevention and control to achieve competence. Central to the role of
the nominated lead will be to ensure compliance with standard infection control precautions
(SICP’s), direct an ongoing audit programme and guarantee that improvements in practice, where
identified are implemented. The nominated lead will be a role model who can influence the culture
in their workplace to encourage behaviour change in the prevention and control of infection
2 Aim
To identify effective hand preparation and hand decontamination of all staff within General
Practice to minimise the risk of transmission of infection.
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3 Methodology
• Observational audit
• Compile a list of all staff trained and untrained in effective safe hand hygiene procedures
• Identify a practice lead for infection prevention and control to carry out an observational audit
or encourage staff to ‘buddy’ with another colleague to perform the audit
• Observe one staff member at a time,
• Collect relevant data for each individual staff and record using the data collection sheet
provided ( page 6)
• Feedback the results immediately to the staff member
• Where 100% is not achieved by an individual they should be advised/encouraged to reflect on
their practice. The audit should be repeated at an agreed time until 100% is achieved
• Aggregate data from completed audits for analysis using the summary sheet (Page 12)
• The Audit Lead / Team should reflect on the overall results of the audit, review themes
identified from the analysis and recommend any changes to practice considered appropriate
• A repeat of the overall audit within the practice should be undertaken as part of the practices’
infection control audit programme
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4 Hand hygiene Quality Improvement Audit for Primary Care
Individual staff data entry template checklist
Staff Name……………………….. Date…………………………………
Practice Infection control lead…………………….
The practice lead is an individual who /is undertaking or has completed the healthcare associated
infection (HCAI) champion E-learning programme and who should be the person observing hand
hygiene technique.
Criteria – All criteria are essential Achieved Not achieved
Hand washing
Hand Preparation
Hands and wrists are free from watches and jewellery (non stoned wedding
rings are acceptable)
Nails are short and without nail extensions and varnish
Sleeves are short or rolled up during hand washing
Cuts are covered with a waterproof dressing
Hand washing technique
CCCC1. Hands are wet under continuously running water
2. Warm Water is used to wash hands
3. Dispensed liquid soap is used
4. Liquid soap is applied to wet hands
5. Hands are rubbed to create a lather
6..A copy of the 10 steps to effective hand hygiene wall chart is
prominently displayed at each wash basin (See appendix 1)
[Link] lather is rubbed over all surfaces of the hands for 10-15 seconds,
including the thumbs, between the fingers, fingertips and the wrist
(demonstrating the 10 steps to effective hand hygiene technique
(See appendix 1)
8. Hand are rinsed thoroughly under running water
Drying of Hands
[Link] are turned off using wrist/elbow levers or using a clean paper towel
10. Hands are dried using paper towels
Alternative
Hand Hygiene using Alcohol based hand rubs/
Hand Preparation
Hands and wrists are free from watches and jewellery (non stoned wedding
rings are acceptable)
Nails are short and without nail extensions and varnish
Sleeves are short or rolled up during hand hygiene
Cuts are covered with a waterproof dressing
Hands are visibly clean
Alcohol based hand rub is dispensed onto the hands
Alcohol hand rub is rubbed onto the hands ensuring all surfaces are
covered by the alcohol
Hands are rubbed until the alcohol has evaporated
Definition of Achieved: criteria met in full: Not Achieved: criteria not met
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Appendix 1
The following guide has been adapted from the RCN and Kimberly-Clark hand washing Guide (RCN Good Practice in Infection Prevention and
Control 2005)
10 steps to effective hand hygiene
To ensure that all parts of the hands are cleaned properly the following technique should be followed. The same principles can be applied when
using alcohol hand rubs
1 2 3 4
Wet hands and forearms Soap up and rubbing palm to palm Rub with fingers interlaced Massage between fingers. Right
palm over back of Left hand, left
palm over back of right hand
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5 6 7
Scrub with fingers locked Rub rotationally with thumb Rinse thoroughly
Including finger tips locked
8 9 10
Dry palms using paper towels Work towel between fingers Dry around and under nails
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Appendix 2
Effective hand hygiene Information
Importance of Hand Hygiene
Hand hygiene is considered to be one of the most common ways that transmission of
infection occurs. Effective, timely hand hygiene can contribute significantly to reducing the
risks of transmission.
The hand washing technique adopted must ensure that all areas of the hands are covered.
Particular attention should be paid to the finger tips, between the fingers and to the outside
and back area of the thumbs, which are often missed.
Once rinsed thoroughly, hand should be dried carefully with paper towels.
The use of moisturisers can prevent the skin becoming dry and sore
Healthcare staffs have the greatest potential to spread micro-organisms that can cause
infection. Hands can
• transfer the patients own micro-organisms into sterile areas of the patients own body
during care or treatment
• transfer micro-organisms from one patient to other patients
• transfer micro-organisms from the environment and equipment to a patient
• Acquire micro-organisms as a result of their contact with patients which place healthcare
staff at risk of infection.
Effective hand hygiene removes all transient micro-organisms and most resident micro-
2,3,4,5,6,7,8
organisms from soiled hands
When to Wash Your Hands
The point of care is the crucial moment for hand hygiene as this represents the time and
place at which there is the highest likelihood of transmission of infection via the hands of
healthcare staff.
The World Health Organisation (WHO) five moments for Hand Hygiene should be used to
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guide staff in understanding when hand hygiene is required .
1 Before patient contact
2 Before aseptic techniques
3 After body fluid exposure risk
4 After patient contact
5 After contact with the patient’s surroundings
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Hand Care.
• Fingernails should be kept short.
• Nail varnish and/or false nails should NOT be worn by those working in clinical areas.
Remove all wrist and hand jewellery (except non stoned wedding rings) prior to performing a
hand decontamination technique.
Any breaks anywhere on the skin should be covered with a waterproof dressing, as damaged
areas of skin are more prone to colonisation with micro-organisms, increasing the risk of
7
cross infection .
Method
Wash hands using soap and running water for 10-15 seconds. The same time applies for
washing with aqueous antiseptics solutions or when using alcohol hand rubs or gels 3,5
6,7
Hand washing technique
An effective hand washing technique involves the following three stages: Preparation,
Washing and Rinsing, and Drying.
Preparation
This requires wetting of hands with tepid running water before applying liquid soap or an
antimicrobial preparation. The hand wash solution must come into contact with all of the
surfaces of the hand.
Washing
The hands must be rubbed together vigorously for a minimum of 10–15 seconds, paying
particular attention to the tips of the fingers, the thumbs and the areas between the fingers.
Rinsing
Hands should be rinsed thoroughly before drying with good quality paper towels.
Alcohol based hand rubs/gels can be used in place of soap and water except when
hands are visibly soiled or after contact with patients who have diarrhoea and or
vomiting 10. Recent studies have demonstrated that the use of an alcohol based hand rub
between each patient contact has reduced the rate of associated infections11. They are
especially useful in situations where hand washing and drying facilities are not in the
2, 6
immediate vicinity.
Application
The hands must be rubbed together vigorously for a minimum of 10–15 seconds, paying
particular attention to the tips of the fingers, the thumbs and the areas between the fingers13
When using alcohol hand rub, time must be allowed for the hands to dry completely for
evaporation of the alcohol to take place.
Foot operated bins should be used for the disposal of towels as contact with the bin lid may
cause the hands to become re-contaminated. Cloth towels should not be used in
healthcare premises as they have the potential to become contaminated with micro-
organisms which will subsequently be transferred to the hands.
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Appendix 3
Practice review
A. What lessons did the practice discover from carrying out this observational audit?
B. What changes, if any have the practice agreed to implement as a result of this audit?
C. What support would enable the practice to enhance the service it provides to patients?
This audit was compiled by;
Name(s) ______________________________________________________
Signature(s) ________________________________________________________
Practice (name and address)
___________________________________________________________________
__________________________________________________________________
Date ______________________________________
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Summary Collection Sheet
Appendix 4
Action Action Action Action
Criteria
Staff 1 Plan Staff 2 Plan Staff 3 Plan Staff 4 plan
All criteria are essential
Name Review Name Review Name Review Name Review
Hand washing
date date date date
Not Not Not Not
Hand preparation Achieved
achieved
Achieved
achieved
Achieved
achieved
Achieved
achieved
Hands and wrists are free
from watches and
jewellery (Non stoned
wedding rings are
acceptable)
Nails are short and
without nail extension and
varnish
Sleeves are short or rolled
up during hand washing
Cuts are covered with a
waterproof dressing
Hand washing
technique
1. Hands are wet under
continuously running
water
[Link] water used to
wash hands
3. Dispensed liquid soap
is used
[Link] soap is applied to
wet hands
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Action Action Action Action
Staff 1 Plan Staff 2 Plan Staff 3 Plan Staff 4 plan
Name Review Name Review Name Review Name Review
date date date date
Not Not Not Not
Achieved Achieved Achieved Achieved
achieved achieved achieved achieved
5. Hands are rubbed to
create a lather
6.A copy of the 10 steps
to effective hand hygiene
wall chart is prominently
displayed at each wash
basin (See appendix 1)
7. The lather is rubbed
over all surfaces of the
hand for 10-15 seconds,
including the thumbs,
between fingers, fingertips
and the wrist.
Demonstrating the 10
steps to effective hand
hygiene technique (See
appendix 1)
[Link] are rinsed
thoroughly under running
water
Drying of hands
[Link] are turned off
using wrist/elbow levers
or using a clean paper
towel
[Link] are dried using
paper towels
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Action Action Action Action
Staff 1 Plan Staff 2 Plan Staff 3 Plan Staff 4 plan
Name Review Name Review Name Review Name Review
date date date date
Not Not Not Not
Achieved Achieved Achieved Achieved
achieved achieved achieved achieved
Alternative
Hand hygiene using
alcohol based hand
rubs/gels
Hand preparation
Hands and wrists are free
from watches and
jewellery (Non stoned
wedding rings are
acceptable
Nails are short and
without nail extension and
varnish
Sleeves are short or rolled
up during hand washing
Cuts are covered with a
waterproof dressing
Hands are visibly clean
Alcohol based hand rub is
dispensed onto the hands
Alcohol hand rub is
rubbed onto the hands
ensuring all surfaces are
covered by the alcohol
Hands are rubbed until
the alcohol has
evaporated
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Appendix 5
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The WHO five Moments for Hand Hygiene
1 Before patient contact
• When? Clean your hands before touching a patient when approaching him/her
• Why? To protect the patient against harmful germs carried on your hands
2 Before an aseptic task
• When? Clean your hands immediately before any aseptic task
• Why? To protect the patient against harmful germs, including the patient’s own,
from entering his/her body
3 After body fluid exposure risk
• When? Clean your hands immediately after an exposure risk to bodily fluids (And
after glove removal)
• Why? To protect yourself and the healthcare environment from harmful patient
germs
4 After Patient contact
• When? Clean your hands after touching a patient and his/her immediate
surroundings when leaving the patient’s side
• Why? To protect yourself and the healthcare environment from harmful patient
germs
5 After contact with patient surroundings
• When? Clean your hands after touching any object or furniture in the patients
immediate surroundings -even if the patient has not been touched
• Why? To protect yourself and the healthcare environment from harmful patients
germs
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References
1 Ayliffe (2000) Control of Hospital Infection – A Practical Handbook
2 National Patient Safety Agency (NPSA) guidelines “Clean your hands” campaign
3 Healthcare Associated Infections – A Community strategy – Welsh Assembly
Government November 2007[Link]
4 RCN Good Practice in Infection Prevention and Control 2005
[Link]
5 Welsh Healthcare Associated Infections – e learning Champion
Welsh Healthcare Associated Infection Programme (WHAIP) - E-Learning Programme
6 Hand Hygiene and care Bury Primary Care Trust: 2007
7 National Institute for Clinical Excellence (2003) Infection control prevention of
healthcare associated infection in primary and community care
[Link]
8 World Health Organisation (WHO): who guidelines on hand hygiene in health care
summary-clean hands are safe hands.
http:/[Link]/patientsafety/events/05/HH_en.pdf
9 Hugonnet S, Pittet D. 2000. Hand hygiene revisited: Lessons from the past and
present. [Link]; 2(6):484-9.
10 Martin P[ Chief Nursing Officer] 2005, Alcohol based hand rubs and infection control,
Scottish Executive.
11 Ojajarvi J. 2003. Alcohol hand rubs v soap. Finnish experience shows that alcohol
rubs are good for hands. BMJ; 326(7379):50
12 Widmer AE, Dangel M. 2004. Alcohol-based handrub: evaluation of technique and
microbiological efficacy with international infection control professionals.
[Link] [Link]; 25(3): 207-9.
13 Larson EL (1995) APIC guideline for handwashing and hand antisepsis in health care
settings. Am J Infect Control 23 (4): 251-69.
14 National Patient Safety Agency (NPSA) Patient safety alert Second Edition 2
September 2008: The WHO five moments for hand hygiene.
[Link]
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