Hand Hygiene Policy

Key points:

Hand hygiene will occur at each of the ‘five moments’ of patient contact:


1. Before touching a patient

2. Before clean/aseptic procedure

3. After body fluid exposure risk

4. After touching a patient

5. After touching patient surroundings


NOTE: Gloves are not a substitute for hand hygiene.



1. Hand hygiene: Cleansing hands by either hand antisepsis or hand washing

2. Hand washing: Cleansing hands with soap and water

3. Hand antisepsis: Cleansing hands using an alcohol-based hand rub product



All OHSU Healthcare Workforce Members: Have responsibility for compliance for hand hygiene at each of the defined ‘five moments’ of patient contact.


1. Hand hygiene by either hand washing or hand antisepsis shall be performed:

a. Before patient contact including when wearing gloves during patient care

b. Before donning sterile gloves

c. Before clean/aseptic task (i.e. inserting/handling invasive devices in patient care)

d. After patient contact

e. After body fluid exposure risk (i.e. contact with body fluids or excretions, mucous membranes, nonintact skin or wound dressings)

f. Moving from a contaminated body site to another body site

g. After contact with inanimate objects and surfaces in the immediate vicinity of the patient

h. After removing gloves

2. Hand hygiene with soap and water instead of alcohol-based hand rub shall be performed:

a. Anytime hands are visibly dirty or soiled with blood or other body fluids

b. Before eating

c. After using a restroom

d. When caring for a patient on Modified Contact Precautions

3. Procedure for hand hygiene using alcohol-based hand rub:

a. Hands should be free of any visible debris

b. Apply amount of hand sanitizer recommended by manufacturer in palm of one hand

c. Rub hands together, covering all surfaces of hands and fingers until dry (should take about 15 seconds)

4. Procedure for hand hygiene using soap and water:

a. Thoroughly wet hands under running water (warm or cool, not hot water)

b. Apply enough soap to cover all hand surfaces

c. Vigorously lather hands and rub together to create friction for at least 15 seconds, covering all surfaces of the hands and fingers. Give special attention to areas between fingers, around and under rings and under fingernails. Keep fingertips point downward during cleaning.

d. Rinse hands, wrists, and forearms thoroughly under the running water to remove soap residue.

e. Pat hands dry with paper towels. Do not touch water faucets with clean hands; use a clean dry towel toturn off faucets.

f. Discard paper towels in proper receptacle.

5. Fingernails

a. Artificial nails or extenders will not be worn by anyone having direct patient contact.

b. Natural nail tips will be kept less than ¼ inches long.

6. Skin Care

a. Regardless of type of soap used, frequent hand washing will cause increased skin dryness.

b. In order to prevent irritation to the hands, hospital approved and provided lotions compatible with antimicrobial soaps should be used liberally while at work. Personal lotions should be used while away from work.

c. If hands continue to remain dry, especially if skin integrity is affected, the employee should consult Employee Health as soon as skin breakdown is noticed. Poor skin integrity might increase the employee’s risk of exposure to infectious pathogens.

Supplemental Information for all Neonatal Intensive Care Unit (DNCC) healthcare providers

1. Before examining or handling a patient:

a. Remove all rings (including wedding bands), bracelets, and wristwatches, and then perform hand hygiene.

b. Sleeves (including lab coat sleeves) are to be rolled up above the elbows.

c. Although an initial three minute surgical scrub is not required, the entire OHSU Hand Hygiene policy is to be followed at all times.

d. Routine or “universal” glove and/or gown use for examining patients is not recommended, unless following isolation precautions which require gloves and gown (e.g. contact precautions).


 This policy is based on the recommendations from the Centers for Disease Control and Prevention. 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 2002; 51 (No. RR-16).

Educational efforts at OHSU are based on the 'My 5 moments for Hand Hygiene', URL: http://www.who.int/gpsc/5may/background/5moments/en/index.html © World Health Organization 2009. Allrights reserved.


This reflects policy in MCN HC-NPSG_104-POL as of 11/2012.