Hand Hygiene Protocol

Hand hygiene is the single most effective measure to prevent the spread of healthcare-associated infections.

The WHO 5 Moments

Perform hand hygiene at these five moments:

Before touching a patient
Before a clean / aseptic procedure
After body-fluid exposure risk
After touching a patient
After touching patient surroundings

Alcohol-based hand rub (ABHR) — preferred default

Use ABHR for routine decontamination when hands are not visibly soiled. Apply enough to cover all surfaces; rub until dry (~20 seconds).

Effective against most bacteria, enveloped viruses (influenza, RSV, SARS-CoV-2), and Candida auris.

Soap and water — required when

Hands are visibly soiled with dirt, blood, or body fluids.
Caring for a patient with Clostridioides difficile (alcohol does not kill spores).
Caring for a patient with norovirus (alcohol has limited activity against non-enveloped viruses).
After using the restroom.

Wash for at least 20 seconds. Cover all surfaces, including under nails and between fingers.

Glove use does not replace hand hygiene

Always perform hand hygiene before donning and after removing gloves.

Audit and feedback

Direct observation remains the gold standard for compliance audits. Aim for at least 100 observations per ward per quarter; share results with frontline staff.