1. WHO hand-hygiene guidelines and the Five Moments for Hand Hygiene
2. Your hospital’s EHO/Environmental Health Officer policy
3. Environmental health and occupational safety rules

In-Service Education Outline: Hand Hygiene

1. Introduction

• Transient flora: Acquired through contact with patients, body fluids, equipment, and environmental surfaces. These organisms are the main source of cross-transmission in health care and are usually removable by good hand hygiene.
• Resident flora: Organisms that normally live in deeper layers of skin. They are harder to remove but are reduced by surgical hand antisepsis.

2. Learning Objectives

1. Define hand hygiene, medical handwashing, and surgical hand preparation.
2. Explain why hand hygiene prevents health care-associated infection.
3. State the WHO Five Moments for Hand Hygiene.
4. Differentiate when to use alcohol-based hand rub and soap-and-water handwashing.
5. Demonstrate the correct medical handwashing and alcohol hand-rub techniques.
6. Demonstrate or describe the steps of surgical hand preparation.
7. Follow EHO and institutional infection-prevention requirements for hand hygiene.
8. Identify common barriers to compliance and methods to improve practice.

3. Required Teaching Materials

• Clean sink with running water
• Liquid soap dispenser
• Alcohol-based hand rub, preferably 60% to 95% alcohol as per institutional product
• Disposable paper towels
• Foot-operated or elbow-operated waste bin
• Posters showing WHO handwashing and hand-rub steps
• Surgical scrub solution or alcohol-based surgical hand rub
• Sterile towels and sterile gloves for demonstration
• UV hand-hygiene training lotion/light box, if available
• Attendance register, pre-test and post-test forms

4. Key Definitions

5. Why Hand Hygiene Matters

• From one patient to another
• From contaminated equipment or the environment to a patient
• From body fluids to themselves or colleagues
• From hands to invasive devices, wounds, intravenous lines, urinary catheters, and surgical sites

Important points

• Even apparently clean patient-care activities can contaminate hands.
• Gloves do not replace hand hygiene.
• Hand hygiene is required before putting on gloves and immediately after removing gloves.
• Poor compliance is associated with workload, inadequate staffing, lack of supplies, skin irritation, and missed opportunities.

6. WHO Five Moments for Hand Hygiene

1. Before touching a patient
   Example: Before checking pulse, assisting with feeding, moving the patient, or taking vital signs.
2. Before a clean or aseptic procedure
   Example: Before injections, IV cannulation, wound dressing, catheter insertion, preparing medication, or handling invasive devices.
3. After body-fluid exposure risk
   Example: After handling blood, secretions, excreta, wound drainage, specimens, or after glove removal.
4. After touching a patient
   Example: After examination, repositioning, or providing personal care.
5. After touching the patient’s surroundings
   Example: After touching bed rails, bedside tables, monitors, curtains, infusion pumps, or other nearby equipment.

7. Medical Hand Hygiene

A. When to Use Alcohol-Based Hand Rub

Indications

• Before and after routine patient contact
• Before aseptic procedures, when hands are visibly clean
• After touching patient surroundings
• Before putting on gloves
• After removing gloves
• Between patients
• Before preparing or administering medicines, if hands are not visibly soiled

Duration

B. When to Wash with Soap and Water

• Hands are visibly dirty or visibly contaminated
• Hands are contaminated with blood or body fluids
• After using the toilet
• Before eating or handling food
• After caring for a patient with suspected or confirmed spore-forming organisms, such as Clostridioides difficile
• During outbreaks when the infection-control team directs soap-and-water use
• After exposure to chemicals or substances for which alcohol rub is unsuitable

Duration

8. Medical Handwashing Technique: Soap and Water

Steps

1. Remove rings, wristwatch, and bracelets where required by policy.
2. Wet hands with clean running water.
3. Apply enough liquid soap to cover all hand surfaces.
4. Rub palm to palm.
5. Rub right palm over left dorsum with fingers interlaced, then reverse.
6. Rub palm to palm with fingers interlaced.
7. Rub backs of fingers against opposing palms with fingers interlocked.
8. Rotationally rub each thumb.
9. Rotationally rub fingertips and nails in the opposite palm.
10. Rub wrists.
11. Rinse thoroughly under running water.
12. Dry completely with a single-use disposable towel.
13. Use the towel to turn off the tap if the tap is not hands-free.
14. Dispose of towel in the designated bin.

Key practice points

• Keep nails short, clean, and natural.
• Avoid artificial nails and nail extensions in clinical areas.
• Avoid chipped nail polish.
• Do not use shared cloth towels.
• Avoid very hot water because it may contribute to dermatitis.
• Cover cuts or abrasions with a waterproof dressing.

9. Alcohol-Based Hand-Rub Technique

Steps

1. Apply a palmful of ABHR sufficient to cover all hand surfaces.
2. Rub palm to palm.
3. Right palm over left dorsum with fingers interlaced, then reverse.
4. Palm to palm with fingers interlaced.
5. Backs of fingers to opposing palms.
6. Rotational rubbing of thumbs.
7. Rotational rubbing of fingertips and nails in opposite palm.
8. Continue rubbing until hands are completely dry.

Important points

• Do not wipe hands dry after applying ABHR.
• Hands must remain wet with the product for the entire rubbing process.
• Never apply ABHR to visibly soiled hands without cleaning them first.
• ABHR is flammable. Store and use according to fire-safety procedures.

10. Surgical Hand Preparation

Purpose

• Remove debris and transient microorganisms
• Reduce resident skin flora
• Maintain antimicrobial activity throughout the procedure
• Reduce the risk of surgical-site infection

Indications

• Before every operative procedure
• Before donning sterile gown and gloves
• Before procedures that require sterile surgical technique, according to institutional policy

Preparation Before Surgical Hand Antisepsis

1. Wear clean theatre attire.
2. Remove rings, wristwatch, bracelets, and other hand jewellery.
3. Keep fingernails short and natural.
4. Artificial nails are prohibited for surgical hand preparation.
5. Ensure hands and forearms are free from cuts, lesions, or contamination.
6. Cover cuts with an appropriate waterproof dressing as permitted by policy.
7. Clean under fingernails using a disposable nail cleaner under running water if required.
8. Do not use nail brushes routinely because they can damage skin.

11. Methods of Surgical Hand Preparation

Method A: Antimicrobial Surgical Scrub With Water

Steps

1. Open the sterile scrub pack or prepare required supplies.
2. Turn on water without contaminating hands.
3. Wet hands and forearms.
4. Clean under fingernails using a single-use nail cleaner.
5. Apply antimicrobial scrub solution.
6. Scrub fingers, hands, and forearms systematically, keeping hands higher than elbows.
7. Work from fingertips toward elbows. Do not return from elbows to hands.
8. Scrub for the manufacturer-recommended time, commonly 2-6 minutes.
9. Rinse from fingertips to elbows, allowing water to flow from cleanest to less clean areas.
10. Keep hands elevated and away from clothing or the sink.
11. Enter theatre while maintaining hands above waist level.
12. Dry with a sterile towel, using one end for one hand and the other end for the opposite hand.
13. Don sterile gown and gloves.

Method B: Alcohol-Based Surgical Hand Rub

Steps

1. If hands are visibly soiled, wash first with plain soap and water.
2. Clean under nails if needed and dry hands thoroughly.
3. Apply the surgical hand rub in the amount and sequence specified by the manufacturer.
4. Cover fingertips, fingers, palms, backs of hands, wrists, and forearms.
5. Keep hands and forearms wet with product throughout the timed application.
6. Allow hands and forearms to dry completely.
7. Do not touch non-sterile surfaces after preparation.
8. Don sterile gown and gloves.

12. Medical Hand Hygiene vs Surgical Hand Preparation

13. EHO / Environmental Health and Occupational Safety Requirements

A. Personal Hygiene Requirements

• Keep nails short, clean, and natural.
• No artificial nails in clinical or surgical areas.
• Avoid rings, watches, bracelets, and hand jewellery, especially for surgical procedures.
• Keep sleeves above the wrist during patient care where required.
• Cover cuts and dermatitis with waterproof dressings and report significant skin problems.
• Use hospital-approved hand lotion compatible with gloves and hand-hygiene products.

B. Hand-Hygiene Facility Requirements

• Ensure an adequate number of accessible handwashing sinks.
• Maintain a reliable supply of clean running water.
• Provide liquid soap in closed dispensers.
• Provide ABHR at point of care, entrances, treatment rooms, and procedure areas.
• Provide disposable towels and hands-free waste bins.
• Maintain handwash stations in clean working condition.
• Refill dispensers safely. Do not “top up” partially empty dispensers unless the local policy allows a validated process.
• Keep handwash sinks free from equipment storage and waste disposal.
• Ensure surgical scrub sinks minimize splashing and contamination.

C. Occupational Safety Requirements

• Use gloves according to standard precautions and task risk assessment.
• Remove gloves immediately after the task and perform hand hygiene.
• Manage sharps safely. Hand hygiene does not replace safe injection or sharps practice.
• Report dermatitis, allergy, skin injury, or adverse reaction to hand-hygiene products.
• Follow fire safety requirements for storage and handling of alcohol-based products.
• Follow local procedures after exposure to blood or body fluids.

D. Monitoring and Quality Improvement

• Observe compliance using the WHO Five Moments.
• Monitor availability of soap, water, towels, and ABHR.
• Use direct observation, feedback, audits, reminders, and education.
• Display posters at sinks and points of care.
• Encourage staff to remind one another respectfully.
• Report monthly compliance data to the infection-control committee.

14. Common Errors to Discuss

• Wearing rings, watches, bracelets, artificial nails, or chipped polish
• Using ABHR on visibly dirty hands
• Missing thumbs, fingertips, nail beds, and spaces between fingers
• Wearing gloves instead of performing hand hygiene
• Failing to clean hands after glove removal
• Touching phone, face, hair, uniform, or environmental surfaces after hand hygiene
• Turning off a tap with clean bare hands
• Reusing towels
• Inadequate drying before donning gloves
• Recontaminating hands after surgical preparation
• Skipping hand hygiene due to emergencies or workload

15. Teaching Plan

16. Return-Demonstration Checklist

17. Post-Test Questions

1. List the WHO Five Moments for Hand Hygiene.
2. When should soap and water be used instead of alcohol-based hand rub?
3. Do gloves replace hand hygiene?
4. Why are artificial nails not acceptable for surgical hand preparation?
5. What areas of the hands are commonly missed during hand hygiene?
6. What should be done after removing gloves?
7. What is the purpose of surgical hand preparation?
8. Why should hands be kept above elbows after a surgical scrub?

Answer Key

1. Before touching a patient; before a clean/aseptic procedure; after body-fluid exposure risk; after touching a patient; after touching patient surroundings.
2. When hands are visibly soiled, contaminated with blood/body fluids, after toilet use, and when spore-forming organisms such as C. difficile are a concern.
3. No. Hand hygiene is required before donning and after removing gloves.
4. They can harbour microorganisms and interfere with effective hand antisepsis.
5. Thumbs, fingertips, nail beds, between fingers, backs of hands, and wrists.
6. Remove gloves and perform hand hygiene immediately.
7. To reduce transient flora and suppress resident flora before sterile procedures.
8. To prevent contaminated water from flowing from forearms back onto hands.

18. Closing Messages

• Clean hands save lives.
• The right product must be used at the right time.
• Alcohol hand rub is preferred for routine care when hands are visibly clean.
• Soap and water are essential when hands are visibly soiled or spore contamination is suspected.
• Gloves do not replace hand hygiene.
• Good surgical hand preparation protects patients from surgical-site infection.
• Follow WHO guidance plus your local EHO, infection-control, theatre, and occupational-safety policies.

Bibliography

Books

1. Barash PG, Cullen BF, Stoelting RK, et al. Barash, Cullen, and Stoelting’s Clinical Anesthesia. 9th ed. Philadelphia: Wolters Kluwer; 2023. Hand hygiene, pp. 554-556.
2. Greenfield LJ, Mulholland MW, Oldham KT, Zelenock GB, Lillemoe KD, editors. Mulholland and Greenfield’s Surgery: Scientific Principles and Practice. 7th ed. Philadelphia: Wolters Kluwer; 2022. Surgical hand antisepsis, p. 504.
3. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO; 2009.
4. Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. Latest available edition. St. Louis: Elsevier. Chapter on infection prevention and control.

Journal Articles

1. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports. 2002;51(RR-16):1-45.
2. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet. 2000;356(9238):1307-1312.
3. Afework AA, Tamene AA. Uncovering the obstacles: a comprehensive analysis of barriers to hand hygiene adherence among healthcare providers: a systematic review. BMC Infectious Diseases. 2025. PMID: 40211179.
4. Allegranzi B, Pittet D. Role of hand hygiene in healthcare-associated infection prevention. Journal of Hospital Infection. 2009;73(4):305-315.

Websites

1. The WHO hand-hygiene guideline provides the full evidence-based recommendations, including medical and surgical hand hygiene.
2. The CDC hand-hygiene guideline gives detailed indications, technique, product selection, and surgical-hand-antisepsis guidance.
3. The WHO Five Moments resource can be used for posters and staff education.

In-Service Education: Hand Washing

Medical Hand Washing and Surgical Hand Washing

1. Introduction

• Medical hand washing with soap and water
• Alcohol-based hand rubbing
• Antiseptic hand washing
• Surgical hand washing or surgical hand preparation

2. General Objective

3. Specific Objectives

1. Define medical and surgical hand washing.
2. Explain the importance of hand hygiene in preventing cross-infection.
3. State the WHO Five Moments for Hand Hygiene.
4. Identify indications for medical hand washing.
5. Demonstrate the correct medical handwashing technique.
6. Differentiate between soap-and-water washing and alcohol-based hand rubbing.
7. Identify indications for surgical hand washing.
8. Describe and demonstrate surgical handwashing steps.
9. Follow hand and nail care requirements in clinical and surgical areas.
10. Explain why gloves do not replace hand hygiene.

4. Definitions

A. Medical Hand Washing

B. Surgical Hand Washing

C. Alcohol-Based Hand Rub

5. Importance of Hand Washing

• Prevents transmission of microorganisms between patients.
• Reduces health care-associated infections.
• Protects patients, staff, visitors, and families.
• Prevents contamination of wounds, invasive devices, and surgical sites.
• Reduces the risk of transmission after contact with blood and body fluids.
• Supports standard precautions and infection-prevention policies.
• Helps reduce antimicrobial-resistant organism transmission.

6. WHO Five Moments for Hand Hygiene

1. Before touching a patient
   Example: Before checking temperature, pulse, blood pressure, or assisting the patient.
2. Before a clean or aseptic procedure
   Example: Before injection, IV cannulation, wound dressing, catheterization, suctioning, or medication preparation.
3. After body-fluid exposure or risk of exposure
   Example: After contact with blood, urine, stool, sputum, wound drainage, or specimens.
4. After touching a patient
   Example: After physical examination, repositioning, or personal care.
5. After touching the patient’s surroundings
   Example: After touching bed rails, bedside tables, curtains, monitors, pumps, or patient files near the bed.

7. Medical Hand Washing

A. Indications for Medical Hand Washing With Soap and Water

• When hands are visibly dirty.
• When hands are contaminated with blood or body fluids.
• Before eating or handling food.
• After using the toilet.
• Before and after patient care when hands are visibly soiled.
• Before and after handling wounds or invasive devices.
• After removing gloves, if hands are visibly contaminated.
• After caring for a patient with suspected or confirmed spore-forming infection, such as Clostridioides difficile.
• During outbreaks, if directed by the infection-control team.

B. Equipment Needed

• Clean running water
• Liquid soap
• Disposable paper towel
• Hands-free waste bin

C. Duration

• Medical hand washing with soap and water: 40-60 seconds
• Follow hospital policy if a specific time is prescribed.

D. Procedure: Medical Hand Washing

1. Remove jewellery, including rings, watch, and bracelets, according to local policy.
2. Roll sleeves above the wrist.
3. Wet hands under clean running water.
4. Apply sufficient liquid soap to cover all surfaces of the hands.
5. Rub palms together.
6. Rub right palm over left dorsum with fingers interlaced, then repeat on the opposite side.
7. Rub palm to palm with fingers interlaced.
8. Rub backs of fingers against opposing palms with fingers interlocked.
9. Rub each thumb using a rotational movement.
10. Rub fingertips and nails in the opposite palm using a rotational movement.
11. Rub wrists.
12. Rinse thoroughly under running water, keeping fingers pointing downwards.
13. Dry hands completely with a single-use paper towel.
14. Use the paper towel to turn off the tap, if the tap is not hands-free.
15. Discard the towel in the designated waste bin.

E. Points to Remember

• Do not touch the sink after washing.
• Do not use bar soap in shared clinical areas unless approved by the institution.
• Do not use shared cloth towels.
• Avoid very hot water, as it can cause skin dryness and dermatitis.
• Keep nails short, clean, and free from chipped nail polish.
• Cover cuts or abrasions with waterproof dressings.
• Perform hand hygiene before putting on gloves and immediately after removing gloves.

8. Alcohol-Based Hand Rub

A. When to Use It

• Before touching a patient
• Before aseptic procedures
• After touching a patient
• After touching the patient’s surroundings
• Before putting on gloves
• After removing gloves
• Between patients
• Before preparing medicines, if hands are visibly clean

B. Duration

• Rub hands for 20-30 seconds or until completely dry.

C. Technique

1. Apply a palmful of alcohol-based hand rub.
2. Rub palm to palm.
3. Rub right palm over left dorsum with fingers interlaced, then reverse.
4. Rub palm to palm with fingers interlaced.
5. Rub backs of fingers against opposing palms.
6. Rub thumbs using rotational movements.
7. Rub fingertips and nails in opposite palm.
8. Continue rubbing until hands are fully dry.

D. Do Not Use Alcohol Hand Rub

• Hands are visibly soiled.
• Hands are contaminated with blood or body fluids.
• After using the toilet.
• After exposure to suspected or known spore-forming organisms.
• Hands are wet.
• The local infection-control policy requires soap and water.

9. Surgical Hand Washing

A. Purpose

• Remove transient microorganisms.
• Reduce resident skin flora.
• Decrease bacterial growth beneath surgical gloves.
• Prevent contamination of the surgical wound.
• Reduce the risk of surgical-site infection.

B. Indications

• Before all operations.
• Before sterile surgical procedures.
• Before wearing sterile gown and sterile gloves.
• Before assisting in surgery.
• Before procedures requiring surgical asepsis, according to institutional policy.

C. Preparation Before Surgical Hand Washing

1. Wear clean theatre attire.
2. Remove rings, watches, bracelets, and hand jewellery.
3. Ensure nails are short, clean, and natural.
4. Do not wear artificial nails or nail extensions.
5. Avoid chipped nail polish.
6. Cover cuts or lesions with a waterproof dressing, if permitted by policy.
7. Clean under fingernails with a disposable nail cleaner under running water.
8. Do not use brushes routinely, as they may cause skin damage.
9. Keep hands higher than elbows during the procedure.

10. Surgical Handwashing With Antimicrobial Soap and Water

Equipment

• Surgical scrub sink
• Running water
• Antimicrobial surgical scrub solution, according to hospital policy
• Disposable nail cleaner
• Sterile towel
• Sterile gown and gloves

Duration

• Follow the product manufacturer’s instructions and local OT policy.
• The usual scrub duration is 2-6 minutes.
• A 10-minute scrub is not required and may cause skin irritation.

Procedure

1. Remove jewellery and ensure nails are short and clean.
2. Turn on water without contaminating hands.
3. Wet hands and forearms.
4. Clean under nails with a disposable nail cleaner under running water.
5. Apply antimicrobial scrub solution.
6. Clean each finger, including web spaces and nail areas.
7. Scrub palms, backs of hands, thumbs, wrists, and forearms.
8. Work from fingertips toward the elbows.
9. Keep hands above elbow level throughout the scrub.
10. Do not return from the elbow area to the hands.
11. Rinse from fingertips to elbows, allowing water to run away from hands.
12. Avoid touching the sink, taps, uniform, or other non-sterile surfaces.
13. Enter the operating room with hands held above waist level and away from the body.
14. Dry hands and forearms using a sterile towel. Use one side of the towel for one hand and forearm, and the other side for the other hand and forearm.
15. Don sterile gown and sterile gloves.

11. Surgical Hand Preparation With Alcohol-Based Surgical Hand Rub

Procedure

1. If hands are visibly soiled, first wash with plain soap and water.
2. Clean under fingernails if necessary.
3. Dry hands and forearms thoroughly.
4. Apply the surgical alcohol hand rub in the volume recommended by the manufacturer.
5. Cover fingers, thumbs, palms, backs of hands, wrists, and forearms.
6. Keep hands and forearms wet with the product throughout the recommended application period.
7. Rub until hands and forearms are completely dry.
8. Do not touch any non-sterile surface after preparation.
9. Don sterile gown and gloves.

12. Difference Between Medical and Surgical Hand Washing

13. Hand Care and Safety Rules

• Keep fingernails short, clean, and natural.
• Do not wear artificial nails in surgical or direct-care areas.
• Avoid rings, watches, bracelets, and hand jewellery.
• Cover cuts with waterproof dressings.
• Report skin allergy, dermatitis, cracks, or broken skin.
• Use institution-approved hand lotion to prevent skin dryness.
• Do not refill or top-up soap dispensers unless the approved facility process allows it.
• Ensure soap, water, paper towels, and alcohol hand rub are available.
• Use gloves based on the task and exposure risk.
• Gloves do not replace proper hand hygiene.
• Alcohol-based hand rub is flammable. Store it according to fire-safety policy.

14. Common Mistakes

• Missing thumbs, fingertips, nail beds, and areas between fingers.
• Wearing rings, bracelets, watches, artificial nails, or chipped nail polish.
• Using alcohol hand rub when hands are visibly dirty.
• Skipping hand hygiene after glove removal.
• Touching taps, phones, uniforms, face, hair, or contaminated surfaces after washing.
• Failing to dry hands completely.
• Reusing towels.
• Allowing water to flow from the elbow back to cleaned hands during surgical washing.
• Touching non-sterile objects after surgical preparation.

15. Demonstration and Return Demonstration

Demonstration

1. Medical handwashing technique.
2. Alcohol-based hand-rub technique.
3. Surgical handwashing technique.
4. Proper drying method after surgical scrub.
5. Correct wearing of sterile gloves after surgical preparation.

Learner Return Demonstration Checklist

16. Evaluation Questions

1. What are the WHO Five Moments for Hand Hygiene?
2. When should soap and water be used instead of alcohol-based hand rub?
3. What is the purpose of surgical hand washing?
4. Why should jewellery be removed before surgical hand preparation?
5. Which areas of the hands are commonly missed during hand washing?
6. Do gloves replace hand hygiene?
7. Why should hands be held above elbows after surgical washing?
8. What should be done immediately after glove removal?

17. Summary

• Hand hygiene is the simplest and most effective method of infection prevention.
• Use soap and water when hands are visibly soiled, after toilet use, after body-fluid contamination, and where spores are suspected.
• Use alcohol-based hand rub for routine hand hygiene when hands are visibly clean.
• Follow the WHO Five Moments for Hand Hygiene.
• Surgical hand washing is performed before surgery to reduce transient and resident microorganisms.
• Remove jewellery, keep nails short, avoid artificial nails, and maintain skin integrity.
• Gloves do not replace hand hygiene.
• Follow local hospital policy, EHO requirements, infection-control policy, and OT protocol.

Bibliography

Books

1. Barash PG, Cullen BF, Stoelting RK, et al. Barash, Cullen, and Stoelting’s Clinical Anesthesia. 9th ed. Philadelphia: Wolters Kluwer; 2023. pp. 554-556.
2. Mulholland MW, Greenfield LJ, editors. Mulholland and Greenfield’s Surgery: Scientific Principles and Practice. 7th ed. Philadelphia: Wolters Kluwer; 2022. p. 504.
3. Potter PA, Perry AG, Stockert PA, Hall AM. Fundamentals of Nursing. St. Louis: Elsevier. Chapter on infection prevention and control.
4. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO; 2009.

Journal Articles

1. Boyce JM, Pittet D. Guideline for hand hygiene in health-care settings: recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR Recommendations and Reports. 2002;51(RR-16):1-45.
2. Pittet D, Hugonnet S, Harbarth S, et al. Effectiveness of a hospital-wide programme to improve compliance with hand hygiene. The Lancet. 2000;356(9238):1307-1312.
3. Afework AA, Tamene AA. Uncovering the obstacles: a comprehensive analysis of barriers to hand hygiene adherence among healthcare providers: a systematic review. BMC Infectious Diseases. 2025. PMID: 40211179.

Websites

1. The WHO Guidelines on Hand Hygiene provide international recommendations for hand hygiene in health care.
2. The CDC hand-hygiene guideline provides recommendations for clinical hand hygiene and surgical hand antisepsis.
3. The WHO surgical hand-preparation guidance explains the rationale and technique for surgical hand antisepsis.

In-Service Education: Hand Washing

Medical and Surgical Hand Washing

Objectives

1. State the importance of hand washing.
2. Perform medical hand washing correctly.
3. Describe surgical hand washing.
4. Follow the WHO Five Moments of Hand Hygiene.

Introduction

WHO Five Moments of Hand Hygiene

1. Before touching a patient
2. Before a clean or aseptic procedure
3. After body-fluid exposure
4. After touching a patient
5. After touching patient surroundings

Medical Hand Washing

Purpose

• Removes dirt and transient microorganisms
• Prevents cross-infection
• Protects patients and health-care workers

When to Wash With Soap and Water

• Hands are visibly dirty
• After contact with blood or body fluids
• After using the toilet
• Before eating
• After caring for a patient with C. difficile or suspected spore infection

Procedure: Medical Hand Washing

1. Remove jewellery and roll sleeves above wrist.
2. Wet hands under running water.
3. Apply liquid soap.
4. Rub palms together.
5. Rub backs of hands and between fingers.
6. Rub backs of fingers, thumbs, fingertips, nails, and wrists.
7. Rinse thoroughly.
8. Dry with a disposable towel.
9. Use towel to turn off tap.

Alcohol-Based Hand Rub

Surgical Hand Washing

Purpose

Before Starting

• Remove rings, watch, and bracelets
• Keep nails short and clean
• Artificial nails are not allowed
• Cover cuts with waterproof dressing
• Clean under nails with a disposable nail cleaner
• Do not use brushes routinely

Procedure: Surgical Hand Washing

1. Wet hands and forearms.
2. Apply antimicrobial surgical scrub solution.
3. Clean nails, fingers, palms, back of hands, wrists, and forearms.
4. Start from fingertips and move towards elbows.
5. Keep hands above elbows throughout.
6. Rinse from fingertips to elbows.
7. Do not touch sink, taps, uniform, or other surfaces.
8. Dry with sterile towel, from hands to elbows.
9. Wear sterile gown and gloves.

Difference Between Medical and Surgical Hand Washing

Important Rules

• Gloves do not replace hand washing.
• Wash hands before wearing gloves and after removing them.
• Keep nails short and clean.
• Avoid rings, watches, bracelets, and artificial nails.
• Do not use alcohol rub when hands are visibly dirty.
• Follow hospital infection-control and OT policies.

Conclusion

References

1. World Health Organization. WHO Guidelines on Hand Hygiene in Health Care. Geneva: WHO; 2009.
2. Boyce JM, Pittet D. Guideline for Hand Hygiene in Health-Care Settings. MMWR Recommendations and Reports. 2002;51(RR-16):1-45.
3. Barash, Cullen, and Stoelting’s Clinical Anesthesia, 9th ed., pp. 554-556.
4. Mulholland and Greenfield’s Surgery: Scientific Principles and Practice, 7th ed., p. 504.

Medical Hand Washing Procedure

1. Remove rings, watch, bangles, and roll sleeves above the wrist.
2. Wet hands under running water.
3. Apply enough soap to cover both hands.
4. Rub palms together.
5. Rub the back of each hand with the opposite palm, fingers interlaced.
6. Rub palms together with fingers interlaced.
7. Rub backs of fingers against opposite palms.
8. Rub each thumb with the opposite hand using a rotational movement.
9. Rub fingertips and nails in the opposite palm.
10. Rub each wrist.
11. Rinse hands well under running water.
12. Dry with a clean disposable towel.
13. Use the towel or elbow to close the tap.
14. Discard the towel properly.

Surgical Hand Washing Procedure

1. Remove rings, watch, bangles, and other jewellery.
2. Ensure nails are short, clean, and without nail polish or artificial nails.
3. Wear cap and mask before beginning the surgical scrub.
4. Open the sterile scrub pack and turn on water without contaminating hands.
5. Wet hands and forearms under running water.
6. Clean under the nails with a nail cleaner under running water.
7. Apply antimicrobial surgical scrub solution.
8. Scrub each finger, including the sides, web spaces, and nail area.
9. Scrub palms, dorsum of hands, thumbs, and wrists.
10. Scrub forearms from wrist towards elbow.
11. Keep hands higher than elbows throughout the procedure.
12. Rinse from fingertips towards elbows. Do not allow water to run from elbows back to hands.
13. Do not touch the sink, tap, uniform, or any unsterile object.
14. Enter the operation room with hands held above waist level.
15. Dry hands and forearms with a sterile towel, moving from fingers to elbows.
16. Wear sterile gown and gloves.

One-line Difference

• Medical hand washing: Done during routine patient care to remove transient microorganisms.
• Surgical hand washing: Done before surgery to remove transient microorganisms and reduce resident flora on hands and forearms.