Infection Prevention & Control (IPC)
Hand Hygiene
Health & Safety


Hand hygiene is the most effective way of preventing the transmission of healthcare-associated infection (HAI) to patients, staff, and visitors in all healthcare settings. Hand hygiene (hand cleaning) is universally accepted as the single most important method for infection prevention and control.


This policy applies to staff, contracted services, volunteers, and students in clinical settings who will perform hand hygiene before and after touching any patient and/or touching any object that comes in contact with the patient. The expectation is that all staff will be in compliance 100% of the time in non-emergency situations.


Patients, Visitors and staff in Trimetrics Physiotherapy facilities will be actively encouraged to remind one another to perform hand hygiene.

  1. Staff, Patients and Visitors are 100% accountable for their own behavior – When it comes to hand hygiene, we are our own best auditors. Be accountable to yourself 100% of the time.
  2. 100% accountable for the behavior of others – Sometimes, we need to act as an unofficial “auditor” of someone else. That means when we see a co-worker not properly cleaning their hands, we need to remind them, respectfully, that they need to perform hand hygiene. If someone reminds us that we haven’t cleaned our hands in those vital times (before and after contact with the patient and patient environment), we need to clean our hands again in front of them…even if we had already done it.

Hand Hygiene Education and Training

All Trimetrics Physiotherapy workers at a minimum, upon initial orientation and on an annual basis receive education and training on Trimetrics Physiotherapy’s Infection and Control program training on hand hygiene and the Hand Hygiene Policy and Procedure.


All employees must ensure that their hand hygiene routine practices are compliant with this policy. All employees must perform hand hygiene:

  1. Before contact with a patient or patient environment including but not limited to: putting on personal protective equipment, providing patient care and /or entering a patient’s room.
  2. After exposure (or a risk of exposure) to blood and/or body fluid, including but not limited to, when hands are visibly soiled or following the removal of gloves.
  3. After contact with patient’s environment, including but not limited to, removing personal protective equipment, after handling patient care equipment, and or leaving a patient’s room.

The use of gloves is not a substitute for performing hand hygiene. Hand hygiene must be performed before putting on gloves and after removing gloves.

Best Practice Hand Hygiene – the single most important step in preventing infections
√  Before and after every patient/patient environment contact.

√  Perform hand hygiene using alcohol-based hand rub (ABHR) or soap and water

√  Use ABHR for hand hygiene unless hands are visibly soiled

√  Use plain soap and water when:

– hands are visibly soiled

– caring for clients with diarrhea and/or vomiting

√  Keep finger nails natural, clean, healthy and short.

√  Perform hand hygiene:

– before obtaining clean linen or supplies

– before and after glove use

– before entering a professional bag or glove box

– before/after contact with a patient or patient’s environment

– before a clean or aseptic procedure

– after exposure or risk of exposure to blood or body fluids

√  Prior to using computers and other electronic devices.

√  Educate/show patients, family members and visitors on hand hygiene

√  If sink is excessively soiled or clean sinks are inaccessible:

– Use ABHR if hands are not visibly soiled

– If hands are visibly soiled, use a pre-moistened towelette. Discard and follow with ABHR.

√  Carry personal-size ABHR bottle. Never leave unattended.

√  Never use client’s bar soap. Carry personal-size hand hygiene soap and lotion.

√  Never use client’s towels. Carry paper towels.

  1. Hand Hygiene Product Recommendations
  2. Alcohol Based Hand Rub(ABHR) an alcohol gel that contains 60% to 95% ethanol or isopropanol alcohol) is the Infection Prevention and Control recommended product of choice for performing hand hygiene except:
  3. a) When hands are visibly soiled with food, dirt or blood and body fluids,
  4. b) During food preparation
  5. c) Following glove removal when providing care for patients
  6. d) In service divisions where employees may have limited access to soap and water, employees are encouraged to carry a portable waterless alcohol based hand rub.
  7. Plain soap and water recommended:
  8. a) When hands are visibly soiled with food, dirt or blood and body fluids,
  9. b) During food preparation
  10. c) Following glove removal when providing care for patients
  1. Procedure for Use of Alcohol Based Hand Rub
  • Ensure hands are not visibly soiled and are dry before use
  • Remove rings and watches
  • Apply enough alcohol based hand rub product to the palm of one hand to coverall hand surface (e.g. two- three pumps)
  • Vigorously rub product over all the surfaces of the hands and wrists, including palms, spaces between fingers, back of hands and wrists, fingers, fingertips and thumbs
  • Hands must remain wet with the product for a minimum of 15 seconds
  • Continue rubbing alcohol-based hand rub product over hands until hands are completely dry
  • The use of hand lotion is recommended to prevent skin dryness and dermatitis, which may occur as a result of frequent hand hygiene and glove use
  1. Procedure for Use of Plain/ Antimicrobial Soap and Water
  • Remove rings and watches
  • Wet hands with warm water and apply enough soap to ensure all hand surfaces are lathered thoroughly (e.g. two- three pumps).
  • Vigorously rub soap over all the surfaces of the hands and wrists, including palms, spaces between fingers, back of hands and wrists, fingers, fingertips and thumbs for a minimum of 15 seconds
  • Rinse hands under warm running water.
  • Pat hands dry with disposable paper towels
  • Use paper towels to turn off faucets and to open door.
  • Discard towels
  • If using antimicrobial soap, the hand lotion selected for use should be compatible with the antimicrobial product, particularly if chlorhexidine gluconate (CHG) is used for hand hygiene. Regular (anionic) lotions have been shown to decrease the activity of CHG. In addition, the lotion should be compatible with gloves; lotions containing petroleum products can reduce the integrity of gloves.
  1. Pre-moistened Towelettes
  • Staff should not routinely use pre-moistened towelettes for hand hygiene
  • Pre-moistened towelettes are alternate products for removing visible soil from hands and should only be used under exceptional circumstances when sinks and running water are not available
  • ABHR must be used following the removal of visible soil with pre-moistened towelettes
  1. Skin Health/Integrity
  2. ABHR

– Rub until dry. Skin left wet will breakdown and crack.

  1. Liquid Soap and Water

– To prevent skin irritation, rinse hands thoroughly to remove all soap

– Pat, rather than rub, hands dry

– Apply hand lotions at regular intervals

For concerns about skin integrity or suspected hand hygiene product sensitivities, check with your manager.

  1. Storage and Placement and Dispensing of Hand Hygiene Products
  • Hand hygiene products will be placed as close as possible to the point of care.
  • Products used for hand hygiene can become contaminated and support the growth of microorganisms. To decrease this risk, both plain soap and antimicrobial soap should be purchased in disposable, closed system containers that do not allow for refilling or backflow into the container.
  • Lotions can also become reservoirs for microbial growth and should be dispensed from small, individual use containers or non-refillable dispensers.
  • Hand lotions are recommended to maintain skin integrity and reduce the occurrence of contact irritant dermatitis. Hand lotions selected by the staff member must be compatible with antimicrobial soaps and must not reduce the integrity of latex gloves. Petroleum-based lotions are not permitted because they degrade glove integrity.
  • To prevent cross contamination, lotion bottles and jars should not be shared between staff members.
  1. Factors that Reduce Hand Hygiene Effectiveness – The fingernails are the area of greatest contamination. Short nails are easier to clean and are less likely to tear gloves. Natural nails should be no more than 1/4 inch in length. Medical devices (splints), jewellery (rings, watches, etc.) increase the number of microorganisms present on hands. Long nails and rings can increase the risk of tears in gloves.
  1. Expiration Dates – Check expiration dates and do not use hand hygiene products beyond expiration date.


  1. Health Canada Hand washing, cleaning, disinfection and sterilization in health care. An infection control guideline. CCDR 2002: 28S1.
  2. Best Practices for Hand Hygiene in all Healthcare Settings ʹ 4th Edition. Provincial Infectious Diseases

Advisory Committee (PIDAC), Ontario; (2010).


  1. Guidelines for Hand Hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/IDSA Hand Hygiene Task Force MMWR October 25, 2002/vol. 51/No. RR-16.
  2. Hand Hygiene Fact Sheet for Health Care Settings, Provincial Infectious Diseases Advisory Committee, Ontario
  3. World Health Organization (2009) Guidelines on Hand Hygiene in Healthcare
  4. College of Physicians & Surgeons of Alberta. 2016. General Infection Prevention & Control Assessment
  5. Alberta Health Services Infection Prevention & Control. 2011. Hand Hygiene Procedure PS-02-01.
  1. Canadian Patient Safety Institute. 2015. Your 4 Moments of Hand Hygiene.
  1. College of Physicians & Surgeons of Alberta. 2016. General Infection Prevention & Control Assessment
  3. Public Health Agency of Canada. 2012. Hand hygiene practices in healthcare settings.