Clinical SOP • Infection Prevention
Hand Hygiene
Reduce the spread of infection by performing hand hygiene at the correct times, using the correct method, and maintaining clean hands throughout every patient interaction and clinical task.
Purpose
Hand hygiene is one of the most important actions employees can take to reduce the spread of infectious organisms within the clinic.
Every employee is responsible for performing hand hygiene consistently, regardless of job title or whether gloves are worn. Hand hygiene must be completed before clean tasks, after contaminated tasks, after glove removal, and whenever hands may have contacted infectious material or contaminated surfaces.
When Hand Hygiene Is Required
Before Patient Contact
Clean hands before touching the patient, assisting with mobility, obtaining vital signs, or beginning an examination.
Before a Clean or Aseptic Task
Clean hands before injections, wound care, specimen handling, medication preparation, or touching clean supplies.
After Exposure Risk
Clean hands after contact with blood, body fluids, mucous membranes, non-intact skin, contaminated items, or potentially infectious material.
After Patient Contact
Clean hands after touching the patient, even when gloves were worn.
After Contact With Patient Surroundings
Clean hands after touching examination tables, equipment, chairs, door handles, mobility devices, or other items near the patient.
After Removing Gloves
Gloves are not a substitute for hand hygiene. Clean hands immediately after glove removal.
Between Different Tasks
Clean hands when moving from a contaminated body site or task to a clean body site or task on the same patient.
Before Handling Medications or Supplies
Clean hands before preparing medication, opening sterile supplies, stocking clean areas, or handling patient-use items.
Choose the Correct Method
Alcohol-Based Hand Rub
Use when hands are not visibly dirty. Apply enough product to cover all hand surfaces and rub until completely dry.
Soap and Water
Use when hands are visibly soiled, after restroom use, before eating, or when directed by infection-control precautions.
Alcohol-Based Hand Rub Procedure
Apply Product
Place enough hand rub in one palm to cover all surfaces of both hands.
Rub Palms Together
Spread the product across both palms using firm, continuous friction.
Clean the Backs of Hands
Rub each palm over the back of the opposite hand, including between the fingers.
Clean Between Fingers
Interlace fingers and rub thoroughly between each finger.
Clean Fingertips and Nails
Rub fingertips in the opposite palm and clean around the nail beds.
Clean Thumbs
Rotate each thumb inside the opposite palm.
Continue Until Dry
Continue rubbing all surfaces until the product has fully dried.
Soap and Water Procedure
Wet Hands
Wet hands with clean running water before applying soap.
Apply Soap
Apply enough soap to cover all surfaces of both hands.
Lather Thoroughly
Rub palms, backs of hands, between fingers, fingertips, thumbs, wrists, and around the nail beds.
Scrub for at Least 20 Seconds
Maintain friction across all hand surfaces for at least 20 seconds.
Rinse Thoroughly
Rinse hands under clean running water while keeping fingertips pointed downward when possible.
Dry Hands
Dry hands completely with a clean disposable towel.
Turn Off the Faucet
Use the disposable towel to turn off manually operated faucets and avoid recontaminating clean hands.
Glove Use and Hand Hygiene
Gloves provide a barrier but do not replace hand hygiene. Hands may become contaminated during glove removal or through small defects in the glove.
Nails, Jewelry, and Skin Care
Natural Nails
Keep nails clean and maintained at a length that does not interfere with gloves, hand hygiene, or patient care.
Artificial Nails
Follow clinic policy and role-specific restrictions for artificial nails, extensions, wraps, or similar products.
Jewelry
Limit hand and wrist jewelry when it interferes with effective hand hygiene, glove use, or patient safety.
Skin Integrity
Cover cuts or open areas with an appropriate protective dressing. Report significant dermatitis or skin breakdown that may affect safe patient care.
Hand Lotion
Use only clinic-approved products that are compatible with gloves, soaps, and hand sanitizers.
Hand Hygiene Supplies
Report empty, damaged, expired, or malfunctioning dispensers immediately so supplies can be replaced.
High-Risk Situations
Visible Soil or Body Fluid
Use soap and water when hands are visibly dirty or contaminated.
Contact With Non-Intact Skin
Remove gloves safely and clean hands immediately after the task.
Specimen or Laboratory Handling
Perform hand hygiene before preparation and after handling specimens, containers, bags, or contaminated surfaces.
Medication Preparation
Clean hands before accessing medication supplies, preparing injections, or handling medication containers.
Patient Isolation Precautions
Follow all posted or communicated precautions, including any required soap-and-water instructions.
Hand Hygiene Supply Failure
Notify leadership immediately when required supplies are unavailable and use an approved alternate station.
Do and Do Not
Always Do
- Clean hands before and after patient contact.
- Clean hands before clean or aseptic tasks.
- Clean hands after glove removal.
- Cover all hand and finger surfaces.
- Use soap and water when hands are visibly dirty.
- Allow alcohol-based hand rub to dry fully.
- Keep nails and skin clean and maintained.
- Report empty or damaged dispensers promptly.
Never Do
- Use gloves as a substitute for hand hygiene.
- Skip hand hygiene because contact was brief.
- Touch clean supplies with contaminated gloves.
- Reuse disposable gloves.
- Wipe off hand sanitizer before it dries.
- Touch your phone during a clean procedure.
- Continue care with visibly contaminated hands.
- Ignore damaged skin that affects safe care.
Environmental and Workflow Expectations
Hand hygiene products must be readily accessible in patient-care areas, procedure areas, medication-preparation areas, laboratory spaces, and other locations where staff move between clean and contaminated tasks.
Employee Competency
The employee should demonstrate each skill during onboarding or competency validation.