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Can Hastanesi

Our Hand Hygiene Policy

Hand hygiene is the most important and simplest infection control measure for preventing healthcare-associated infections. Our hospital’s hand hygiene definitions, goals, responsibilities and continuous improvement strategy.

This translation is provided for information only; the Turkish version is legally binding.

5
indications

Before and after patient contact, before an aseptic procedure, after body fluid exposure, after contact with patient surroundings

75%
compliance target

The target value set for our hospital’s hand hygiene compliance rate

6 months
training interval

Hand hygiene training for all hospital staff every six months

3 months
sharing of results

Observation analyses are shared with all staff every three months

Institutional policy document

1Definition and General Scope of Hand Hygiene

  • 1.1Hand Hygiene: A general term used for any act of hand cleansing. Hand hygiene covers handwashing, antiseptic handwashing, hand rubbing with an alcohol-based hand antiseptic, surgical hand antisepsis, antisepsis/decontamination/degerming, hand care, hand cleansing, hand disinfection, hygienic hand antisepsis and hygienic handwashing. Disinfection is used for inanimate surfaces; however, although not in this guideline, hand disinfection is frequently used in the literature with the same meaning as hand antisepsis.
  • 1.2Handwashing: Washing hands with plain or antimicrobial soap and water.
  • 1.3Hand Cleansing: Performing hand hygiene for the purpose of physically or mechanically removing dirt, organic material or microorganisms from the hands.
  • 1.4Hygienic Handwashing: Washing hands with soap containing an antiseptic agent to remove transient microbial flora without affecting the resident skin flora. Although broad-spectrum, it is generally less effective and acts more slowly than a hygienic hand rub.
  • 1.5Antiseptic Hand Rubbing (or hand rubbing): Applying an antiseptic hand rub to reduce or inhibit the growth of microorganisms without the need for an exogenous source of water or rinsing, or drying with towels or other devices.
  • 1.6Hand Care: Actions taken to reduce the risk of skin irritation.
  • 1.7Hand Antisepsis: A term widely used in some parts of the world, referring to antiseptic handwashing, antiseptic hand rubbing, hand antisepsis/decontamination/degerming, handwashing with antimicrobial soap and water, hygienic hand antisepsis or hygienic hand rubbing.
  • 1.8Hygienic Hand Antisepsis: Treating the hands with an antiseptic hand rub or antiseptic handwashing to remove transient microbial flora without affecting the resident skin flora. The preparations used are broad-spectrum and fast-acting, and persistent activity is not necessary.
  • 1.9Surgical Hand Antisepsis/Surgical Hand Preparation: Antiseptic handwashing or antiseptic hand rubbing performed preoperatively by the surgical team to eliminate transient flora and reduce resident skin flora. These antiseptics often have persistent antimicrobial activity. The term surgical hand scrub/presurgical scrub refers to preparing the hands for surgery with antimicrobial soap and water. Surgical hand rub refers to surgical hand preparation with a waterless, alcohol-based hand rub.

2Importance of Hand Hygiene for the Hospital

Hand hygiene is the most important and simplest infection control measure for preventing healthcare-associated infections and the spread of antimicrobial-resistant pathogens. Ensuring adequate hand hygiene is foremost among the measures to prevent these infections, which cause high morbidity, mortality and treatment costs. Healthcare-associated infections are one of the major problems related to patient safety. They lead to prolonged hospital stays, patients being kept away from normal life for long periods, increased antimicrobial resistance in microorganisms, increased costs and death. Preventing hospital infections is a priority goal of our hospital.

3General Hospital Goals for Hand Hygiene

  • 3.1To prevent hospital infections, the aim is for hand hygiene to be performed according to the 5 indications principle. The 5 indications cover before patient contact, after patient contact, before aseptic procedures, after contact with body fluids and after contact with patient surroundings.
  • 3.2At our hospital, announced hand hygiene observations are carried out by the Infection Control Nurse on the basis of the 5 indications, by occupational group and by department; analyses are performed, the results are shared with all staff every three months, and the aim is to reach the target value.
  • 3.3Every year, our hospital carries out a “Hand hygiene belief scale and practice inventory” study; the results are shared with staff, and corrective work is carried out based on the results.
  • 3.4At our hospital, hand hygiene training is provided to all hospital staff every six months.
  • 3.5The target value for our hospital’s hand hygiene compliance rate has been set at 75%

4Key Responsibilities of Managers and Staff Regarding Hand Hygiene

  • 4.1Healthcare workers
    • 4.1.1They must perform hand hygiene by determining the method appropriate to the patient and the procedure.
    • 4.1.2They must act in accordance with the hand hygiene instructions established by the hospital.
    • 4.1.3They must attend the training provided.
    • 4.1.4They must report to management any shortages of materials and equipment they identify in the field.
  • 4.2Managers
    • 4.2.1They must create conditions that promote hand hygiene strategies and a patient safety culture.
    • 4.2.2Healthcare workers must be given access to sinks with a safe and continuous water supply for handwashing.
    • 4.2.3Alcohol-based hand hygiene products that healthcare workers can easily access in the setting where they provide patient care must be provided.
    • 4.2.4Hand hygiene compliance must be made an institutional priority, and the necessary leadership, financial and administrative support must be provided for hand hygiene and other activities aimed at preventing and controlling infection.
    • 4.2.5Hand hygiene training and infection control training must be planned.
    • 4.2.6The production and storage of alcohol-based hand hygiene products must comply with national safety instructions and local legal regulations.
    • 4.2.7Hand hygiene compliance analyses must be carried out, and improvement activities must be initiated for the deficiencies identified.

5Continuous Improvement Strategy

Identifying and implementing effective strategies to improve hand hygiene compliance is very important.

Strategies used by our hospital:

  • 5.1Education and Training: By providing training on hand hygiene indications, the aim is to eliminate confusion about handwashing indications and raise the level of awareness. The scope and duration of the training are determined specifically for the target audience. Distributing hand hygiene brochures, group work and activities are among the other educational activities that increase hand hygiene rates.
  • 5.2Audit and Feedback: Measures taken in response to non-conformities identified through field audits and feedback are important for ensuring the continuity of hand hygiene.
  • 5.3Use of Reminders: Routine monitoring, feedback on hand hygiene compliance and the use of visual and audio systems (reminders) that prompt handwashing behaviour in the workplace are highly effective in improving hand hygiene rates. Examples of reminder systems include posters, e-mail messages and voice messages.
  • 5.4Measures to Increase Hand Hygiene Compliance: Making hand hygiene practice easy and convenient, administrative sanctions, rewards, ensuring active participation at individual and institutional level, creating an environment of institutional trust, strengthening individual and institutional competence, and preventing staff shortages and heavy workloads increase hand hygiene compliance.
  • 5.5Evaluation of Hand Hygiene Compliance:
    • 5.5.1Setting targets: The hospital sets a target value for hand hygiene compliance and works to achieve it. (The target value for our hospital is 75%.)
    • 5.5.2Measuring performance: The hand hygiene compliance rate in all units and all specialties of the hospital is measured through observation according to the 5 indications rule using the hand hygiene evaluation form.
    • 5.5.3Evaluating results: Measurements are analysed by the 5 indications, by unit and by specialty. The causes of shortcomings are determined according to sub-indicators.
    • 5.5.4Improvement: Improvement activities are planned and implemented for the shortcomings identified. Continuous improvement is pursued by evaluating the short- and long-term effects of the interventions implemented.

6Hand Hygiene Coordinator

In line with the established policies, the chair of the infection control committee has been appointed by the hospital management as hand hygiene coordinator in order to determine hand hygiene strategies and to monitor and improve practices. The coordinator works within the Infection Control Committee, which meets at regular intervals.

7Related Documents

  • Hand Hygiene and Glove Use Instruction
  • Procedure for the Control and Prevention of Infections
  • Isolation Precautions Procedure
  • Hand Hygiene Observation Form
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