Download Ambulatory Clinic Policy and Procedure

Ambulatory Clinic Policy and Procedure
Title:
Hand Hygiene
Policy Number:
Version Number
Regulation Reference:
CDC, APIC
Effective Date:
Original Approval:
7.03
3
12/2015
8/2007
POLICY STATEMENT:
It is the policy of the Texas Tech University Health Sciences Center (TTUHSC) ambulatory clinics to follow the
Centers for Disease Control (CDC) guidelines for hand hygiene in healthcare settings.
SCOPE:
This policy applies to all TTUHSC ambulatory clinics operated through its schools.
PROCEDURE:
1. Basic Hand Washing (soap and water):
a. When soap and water should be used:
1) Hands are visibly soiled (dirty).
2) Hands are visibly contaminated with blood or body fluids.
3) After removing gloves.
4) Before and after eating.
5) After using restroom.
b. How to wash hands effectively with soap and water
1) Dispense your paper towel,
2) Wet hands first with warm (avoid HOT) water,
3) Apply 3 to 5 ml (about the size of a quarter) of soap to hands,
4) Rub hands together for 15 seconds,
5) Cover all surfaces of the hand and fingers (palms, back of hands, between fingers and wrists)
with soap using friction,
6) Rinse hands with water and dry thoroughly, and
7) Use paper towels after drying hand to turn off faucet.
2. When alcohol based hand rubs should be used:
a. Alcohol base hand wash should be available in every patient care area of each clinic and used
whenever soap and water wash is impractical.
1) Before having direct contact with a patient,
2) After having direct contact with a patient’s skin,
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3) After having direct contact with body fluids, wounds or broken skin,
4) After touching equipment or furniture near the patient,
b. How to affectively use alcohol based hand rubs:
1) Apply 1.5 to 3 ml (about the size of quarter) of alcohol rub to the palm of the hand and rub
together or follow manufacturer’s instructions.
2) Cover all surfaces of your hands and fingers including areas around/under fingernails.
3) Rub hands together until alcohol dries (15 to 25 seconds). Make sure hands are completely dry
prior to putting on gloves.
4) Wash hands with soap and water when you feel a “build up” of emollients on your hands.
*NOTE: The use of hand sanitizers is not in lieu of hand washing with soap and warm,
running water. Hand sterilizers containing 60-80 ethanol alcohol or isopropanol with
equivalent sanitizing strength may be used in addition to proper hand washing.
**Alcohol-based rubs are not effecting in killing Clostridium difficile.
For more information on proper hand hygiene, see TTUHSC Safety Services Employee Refresher Training,
Infectious Disease Exposure video.
APPROVAL AUTHORITY:
This policy shall be recommended for approval by the Joint Ambulatory Policy Committee to the Council of Deans.
RESPONSIBILITY AND REVISIONS:
It is the responsibility of the Joint Ambulatory Policy Committee to review and initiate necessary revisions based
on collaboration and input by and through Quality Improvement/Performance Improvement, Risk Management
and the Office of Institutional Compliance.
CERTIFICATION:
This policy was approved by the Council of Deans on December 3, 2015.
REFERENCES
Centers for Disease Control and Prevention. (2002). Guideline for Hand Hygiene in Health-Care Settings:
Recommendation of the Healthcare Infection Control Practices Advisory Committee and the HICPAAC/SHEA/
APIC/IDSA Hand Hygiene Task Force. MMWR 51(16): 1-46. Retrieved October 2, 2014 from CDC: www.cdc.gov/
mmwr/pdf/rr/rr5116.pdf.
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