• Standard precautions in hospitals
• Contact precautions in hospitals
• Environmental measures for the prevention and management of multi-drug resistant organisms
• Prevention of ventilator-associated pneumonia
• Prevention of surgical site infections
• Prevention of bloodstream infections
• Prevention of catheter-associated urinary tract infections

Level of evidence ranking (I – V) and strength of recommendation ranking (A – D, Unresolved issue [UI], No recommendation) definitions are presented at the end of "Major Recommendations" field.

Hand Hygiene Recommendations

1. Indications for handwashing and hand antisepsis
   1. When hands are visibly dirty or contaminated with proteinaceous material or are visibly soiled with blood or other body fluids, wash hands with either a non-antimicrobial soap and water or an antimicrobial soap and water. A-IV*
   2. If hands are not visibly soiled, an alcohol-based hand rub is preferred for routinely decontaminating hands in all other clinical situations described in items below because it significantly reduces the number of microorganisms on the skin and is easy to use. A-I (Girou et al., 2002; Lucet et al., 2002; Parienti et al., 2002; Kac et al., 2005; Larson et al., 2005; Sickbert-Bennett et al., 2005; Macdonald et al., 2006). Alternatively, wash hands with an antimicrobial soap and water in all clinical situations described in items below (C-J) A-II*
   3. Decontaminate hands before having direct contact with patients. A-II*
   4. Decontaminate hands before donning sterile gloves when inserting a central intravascular catheter. A-II*
   5. Decontaminate hands before inserting indwelling urinary catheters, peripheral vascular catheters, or other invasive devices that do not require a surgical procedure. It is unknown whether more intensive hand hygiene is required for prolonged non-surgical procedures and therefore current Centers for Disease Control and Prevention (CDC) hand hygiene guidelines should be followed in the interim. A-II (Chambers et al., 2006).
   6. Decontaminate hands after contact with a patient's intact skin (e.g., when taking a pulse or blood pressure, and lifting a patient). A-II*
   7. Decontaminate hands after contact with body fluids or excretions, mucous membranes, non-intact skin, and wound dressings if hands are not visibly soiled. A-II*
   8. Decontaminate hands if moving from a contaminated-body site to a clean-body site during patient care. A-III*
   9. Decontaminate hands after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. A-III*
   10. Decontaminate hands after removing gloves. A-II*
   11. Before eating and after using a restroom, wash hands with a non-antimicrobial soap and water or with an antimicrobial soap and water. A-II*
   12. Antimicrobial-impregnated wipes (i.e., towelettes) may be considered as an alternative to washing hands with non-antimicrobial soap and water. Because they are not as effective as alcohol-based hand rubs or washing hands with an antimicrobial soap and water for reducing bacterial counts on the hands of healthcare workers (HCWs), they are not a substitute for using an alcohol-based hand rub or antimicrobial soap. B-II*
   13. Based on in vitro data, alcohol is not effective at killing spores of organisms such as Clostridium difficile or Bacillus anthracis. (III) Although no direct comparison studies have been conducted, washing hands with water and soap physically removes spores from the skin and therefore may be more effective in this clinical setting. (IV) B-V (Bettin et al., 1994; King, 2004; Gordin et al., 2005; Boyce et al., 2006; Cherifi et al., 2006). In the setting of an outbreak of a spore-forming organism such as Clostridium difficile, washing hands with soap and water is recommended. B-IV (Bettin et al., 1994; King, 2004; Gordin et al., 2005; Boyce et al., 2006; Cherifi et al., 2006).
   14. No recommendation can be made regarding the routine use of nonalcohol-based hand rubs for hand hygiene in health-care settings. Unresolved issue. B-IV*

       For surgical antisepsis recommendations, please refer to Hand/forearm antisepsis for surgical team members in the NGC summary of the Massachusetts Department of Public Health guideline Prevention of Surgical Site Infections (SSI).

Hand-Hygiene Technique

2. When decontaminating hands with an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Follow the manufacturer's recommendations regarding the volume of product to use. A-II*
3. When washing hands with soap and water, wet hands first with water, apply an amount of product recommended by the manufacturer to hands, and rub hands together vigorously for at least 15 seconds, covering all surfaces of the hands and fingers. Rinse hands with water and dry thoroughly with a disposable towel. Use towel to turn off the faucet. A-II* Avoid using hot water, because repeated exposure to hot water may increase the risk of dermatitis. A-II*
4. Liquid, bar, leaflet or powdered forms of plain soap are acceptable when washing hands with a non-antimicrobial soap and water. When bar soap is used, soap racks that facilitate drainage and small bars of soap should be used. B-III*
5. Multiple-use cloth towels of the hanging or roll type are not recommended for use in health-care settings. A-IV*
6. Standard hand hygiene practices apply to neonatal intensive care units (ICUs); surgical scrubs are not routinely required. A-III (Sharek et al., 2002; Won et al., 2004)

Selection of Hand-Hygiene Agents

7. Provide personnel with efficacious hand-hygiene products that have low irritancy potential, particularly when these products are used multiple times per shift. This recommendation applies to products used for hand antisepsis before and after patient care in clinical areas and to products used for surgical hand antisepsis by surgical personnel. If hands are not visibly soiled, alcohol-based hand rubs (ABHRs) are preferred because ABHRs have a lower irritancy potential for skin. B-II (Kramer, Bernig, & Kampf, 2002; Pedersen et al., 2005; Houben, De Paepe, & Rogiers, 2006; Kampf, Wigger-Alberti, & Wilhelm, 2006).
8. To maximize acceptance of hand-hygiene products by healthcare workers, solicit input from these employees regarding the feel, fragrance, and skin tolerance of any products under consideration. The cost of hand-hygiene products should not be the primary factor influencing product selection. B-II*
9. When selecting non-antimicrobial soaps, antimicrobial soaps, or alcohol-based hand rubs, solicit information from manufacturers regarding any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution. B-IV*
10. Before making purchasing decisions, evaluate the dispenser systems of various product manufacturers or distributors to ensure that dispensers function adequately and deliver an appropriate volume of product. B-III*
11. Do not add soap to a partially empty soap dispenser. This practice of "topping off" dispensers can lead to bacterial contamination of soap. A-II*

Skin Care

12. Provide HCWs with hand lotions or creams to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or handwashing. A-I*
13. Solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand antiseptics may have on the persistent effects of antimicrobial soaps being used in the institution. B-III*

Other Aspects of Hand Hygiene

14. Do not wear artificial fingernails or extenders when having direct contact with patients at high risk (e.g., those in intensive-care units or operating rooms). A-II*

    Do not wear artificial nails in environments that require sterile conditions (e.g., pharmacies or sterile processing departments). A-IV*

15. Keep natural nail tips less than 1/4-inch long. A-IV*
16. Wear gloves when contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin could occur. A-IV*
17. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient, and do not wash gloves between uses with different patients. A-II*
18. Change gloves during patient care if moving from a contaminated body site to a clean body site. A-IV*
19. No recommendation can be made regarding wearing rings in non-surgical healthcare settings. B-V*

Healthcare Worker Educational and Motivational Programs

20. As part of an overall program to improve hand hygiene practices of HCWs, educate personnel regarding the types of patient-care activities that can result in hand contamination and the advantages and disadvantages of various methods used to clean their hands. A-III*
21. Monitor HCWs' adherence with recommended hand hygiene practices with an accepted monitoring approach (refer to section 9 for details) and provide personnel with information regarding their performance. A-II (Berhe et al., 2006; Eckmanns et al., 2006, "Compliance with antiseptic"; Eckmanns et al., 2006, "Hand rub consumption"; Eldridge et al., 2006; Golan et al., 2006; Jenner et al., 2006; McArdle et al., 2006; McGuckin et al., 2006; Randle, Clarke, & Storr, 2006; van de Mortel & Murgo, 2006; Shadowen et al., 2006). Additionally, when outbreaks of infection occur or unusual pathogens are detected, assess the adequacy of healthcare worker hand hygiene and compliance with fingernail recommendations. A-IV (Berhe et al., 2006; Eckmanns et al., 2006, "Compliance with antiseptic"; Eckmanns et al., 2006, "Hand rub consumption"; Eldridge et al., 2006; Golan et al., 2006; Jenner et al., 2006; McArdle et al., 2006; McGuckin et al., 2006; Randle, Clarke, & Storr, 2006; Van de Mortel & Murgo, 2006; Shadowen et al., 2006).
22. Encourage patients and their families to remind HCWs to decontaminate their hands in addition to other efforts to improve compliance with hand hygiene. B-II (McGuckin et al., 2004; McGuckin, 2001; Naikoba & Hayward, 2001).

Administrative Measures

23. Make improved hand hygiene adherence an institutional priority and provide appropriate administrative support and financial resources. A-II*
24. Implement a multidisciplinary program designed to improve adherence of health personnel to recommended hand-hygiene practices. A-II*
25. As part of a multidisciplinary program to improve hand hygiene adherence, provide HCWs with a readily accessible alcohol-based hand-rub product. A-II*
26. To improve hand-hygiene adherence among personnel who work in areas in which high workloads and high intensity of patient care are anticipated, make an alcohol-based hand rub available at the entrance to the patient's room or at the bedside, in other convenient locations, or in individual pocket-sized containers to be carried by HCWs. A-II*
27. Store supplies of alcohol-based hand rubs in cabinets or areas approved for flammable materials. A-IV*

Performance Indicators

Monitoring for adherence to hand hygiene should be done using an accepted approach and that same approach should be used consistently within a single institution. Some approved approaches include performance indicator A or B listed below. A-IV*

1. Periodically monitor and record adherence as the number of hand-hygiene episodes performed by personnel/number of hand-hygiene opportunities by ward or by service. Provide feedback to personnel regarding their performance. B-IV*
2. Monitor the volume of alcohol-based hand rub (or detergent used for handwashing or hand antisepsis) used per 1,000 patient-days. B-IV*

*Identifies evidence from the CDC's updated guidelines without repeating the detailed literature review process.

Definitions:

Level of Evidence Ranking

Level I: Strong evidence from at least one well-designed randomized controlled trial

Level II: Evidence from well-designed non-randomized trials; cohort or case-controlled analytic studies (preferably from >1 center); multiple time-series studies

Level III: Well-designed descriptive studies from more than one center or research group

Level IV: Opinions of authorities (e.g., guidelines), clinical evidence; reports of expert committees

Level V: No quality studies found and no clear guidance from expert committees, authorities or other sources

Strength of Recommendation Ranking

Category A: Strongly recommended

Category B: Recommended for implementation

Category C: Consider for implementation

Category D: Recommended against implementation

Category UI: Unresolved issue

No recommendation: Unresolved issue. Practices for which insufficient evidence or no consensus regarding efficacy exists.

References open in a new window

Electronic copies: Available in Portable Document Format (PDF) from the Massachusetts Department of Public Health Web site.

• Betsy Lehman Center for Patient Safety and Medical Error Reduction, JSI Research and Training Institute, Inc. Prevention and control of healthcare-associated infections in Massachusetts. Part 2: findings from complementary research activities. Boston (MA): Massachusetts Department of Public Health; 2008 Jan 31. 131 p. Available in Portable Document Format (PDF) from the Massachusetts Department of Public Health Web site.
• Handwashing education materials for health care professionals. Available from the Massachusetts Department of Public Health Web site.

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