1.     Indications for hand washing and hand antisepsis

1. Wash hands with soap and water when visibly dirty or contaminated with proteinaceous material, or visibly soiled with blood or other body fluids, or if exposure to potential spore-forming organisms is strongly suspected or proven?or after using the restroom .
   
   
2. Preferably use an alcohol-based hand rub for routine hand antisepsis in all other clinical situations described in items 3a to 3f listed below if hands are not visibly soiled. Alternatively, wash hands with soap and water.
   
   
3. Perform hand hygiene:
   
   
   1. before and after having direct contact with patients;
   2. after removing gloves;
   3. before handling an invasive device (regardless of whether or not gloves are used) for patient care;
   4. after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings;
   5. if moving from a contaminated body site to a clean body site during patient care;
   6. after contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient;
   7. Wash hands with either plain or antimicrobial soap and water or rub hands with an alcohol-based formulation before handling medication and preparing food.
   8. When alcohol-based hand rub is already used, do not use antimicrobial soap concurrently.

2.     Hand hygiene technique

1. Apply a palmful of the product and cover all surfaces of the hands. Rub hands until hands are dry.
   
   
2. When washing hands with soap and water, wet hands with water and apply the amount of product necessary to cover all surfaces. Vigorously perform rotational hand rubbing on both palms and interlace fingers to cover all surfaces. Rinse hands with water and dry thoroughly with a single use towel. Use running and clean water whenever possible. Use towel to turn off faucet.
   
   
3. Make sure hands are dry. Use a method that does not re-contaminate hands. Make sure towels are not used multiple times or by multiple people. Avoid using hot water, as repeated exposure to hot water may increase the risk of dermatitis.
   
   
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, small bars of soap in racks that facilitate drainage should be used.

3.     Recommendations for surgical hand preparation

1. If hands are visibly soiled, wash hands with a plain soap before surgical hand preparation. Remove debris from underneath fingernails using a nail cleaner, preferably under running water.
   
   
2. Sinks should be designed to decrease the risk of splashes.
   
   
3. Remove rings, watches, and bracelets before beginning surgical hand preparation. Artificial nails are prohibited.
   
   
4. Surgical hand antisepsis should be performed using either an antimicrobial soap or an alcohol-based hand rub, preferably with sustained activity, before donning sterile gloves.
   
   
5. If quality of water is not assured in the operating theatre, surgical hand antisepsis using an alcohol-based hand rub is recommended before donning sterile gloves when performing surgical procedures.
   
   
6. When performing surgical hand antisepsis using an antimicrobial soap, scrub hands and forearms for the length of time recommended by the manufacturer, i.e. 2 to 5 min. Long scrub times (e.g. 10 min) are not necessary .
   
   
7. When using an alcohol-based surgical hand rub product with sustained activity, follow the manufacturer's instructions. Apply the product on dry hands only. Do not combine surgical hand scrub and surgical hand rub with alcohol-based products.
   
   
8. When using an alcohol-based product, use sufficient product to keep hands and forearms wet with the hand rub throughout the procedure.
   
   
9. After application of the alcohol-based product, allow hands and forearms to dry thoroughly before donning sterile gloves.

4.     Selection and handling of hand hygiene agents

1. Provide health-care workers with efficacious hand hygiene products that have low irritancy potential.
   
   
2. To maximize acceptance of hand hygiene products by health-care workers, solicit their input regarding the feel, fragrance, and skin tolerance of any products under consideration. In some settings, cost may be a primary factor.
   
   
3. When selecting hand hygiene products:
   
   
1. determine any known interactions between products used to clean hands, skin care products, and the types of gloves used in the institution;
2. solicit information from manufacturers about risk of contamination (pre-marketing and in-use);
3. ensure that dispensers are accessible at the point of care;
4. ensure that dispensers function adequately and reliably, and deliver an appropriate volume of the product;
5. ensure that the dispenser system for alcohol-based formulations is approved for flammable materials;
6. solicit information from manufacturers regarding any effects that hand lotions, creams, or alcohol-based hand rubs may have on the effects of antimicrobial soaps being used in the institution.
7. Do not add soap to a partially empty soap dispenser. If soap dispensers are reused, follow recommended procedures for cleansing.

5.     Skin care

1. Include information regarding hand care practices designed to reduce the risk of irritant contact dermatitis and other skin damage in health-care workers?education programmes.
   
   
2. Provide alternative hand hygiene products for health-care workers with allergies or adverse reactions to standard products used in the health-care setting.
   
   
3. When needed to minimize the occurrence of irritant contact dermatitis associated with hand antisepsis or hand washing, provide health-care workers with hand lotions or creams.

6.     Use of gloves

1. The use of gloves does not replace the need for hand cleansing by either hand rubbing or hand washing.
   
   
2. Wear gloves when it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, and non-intact skin will occur.
   
   
3. Remove gloves after caring for a patient. Do not wear the same pair of gloves for the care of more than one patient.
   
   
4. When wearing gloves, change or remove gloves during patient care if moving from a contaminated body site to a clean body site within the same patient or to the environment.
   
   
5. Gloves are single-use devices and should never be re-used.

7.     Other aspects of hand hygiene

1. Do not wear artificial fingernails or extenders when having direct contact with patients.
   
   
2. Keep natural nails short (tips less than 0.5 cm long).