VA Hospital
Hines, Illinois 60141
Policy Memorandum 578-03-011-066
Change 1
February 7, 2006

HANDWASHING

PURPOSE:

• This change is to inform all services of the following changes in paragraph 4c regarding the duration of the scrub increasing to "15 seconds" in accordance with the CDC Guidelines and to provide additional guidance regarding the length of time for handwashing for both handwashing methods, i.e. soap and water and waterless cleaner (alcohol-based gel). Instructions were also added about the different circumstances in which to use soap and water handwashing versus) waterless cleaner (alcohol-based gel) handwashing. The new paragraph reads a s follows:

• Soap and water:  If hands are visibly soiled and after using the toilet, soap and water should be used for handwashing. Routine handwashing with soap and water is performed using running water, appropriate soap, a 15-second friction hand rub and paper towels.  At the completion of handwashing, a dry paper towel should be used to turn off the faucet handles.
• Waterless cleaner (alcohol-based gel):  Waterless cleaner (alcohol-based gel) can be used except when hands are visibly soiled.  Apply the product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry.

Education will be provided on all units regarding changes to the handwashing techniques. by the Infection Control Staff.In addition, the Infection Control Practitioners will provide posters to educate all staff regarding changes to the handwashing techniques.

RESCISSION: None.

VA Hospital
Hines, Illinois 60141
Policy Memorandum 578-03-011-066
April 11, 2003

HANDWASHING

PURPOSE: To prevent transmission of microorganisms by establishing hospital policy regarding personnel handwashing.

RESPONSIBILITES:

• Hospital administration will provide adequate handwashing facilities in all personnel bathrooms and work areas.
• Facilities Management Service will maintain a constant supply of regular or anti-microbial soap, a waterless handwashing product, and paper towels. These will be distributed as directed by the Chief Infection Control Section and the Infection Control Committee.
• Central Supply will maintain a supply of a portable waterless hand cleanser and distribute this to patient care areas as an adjunct to soap and water.This product will be maintained on medication and treatment carts on patient units, and near computer stations in all patient care areas.This product is also available for use as an emergency back-up in the event of an interruption in the water supply.
• In situations where an employee is required to wear gloves to be in compliance with the OSHA Bloodborne Pathogen Standard but there is not ready access to running water, the employee's Service will provide a waterless hand cleaner.
• The Infection Control Section will include a section on handwashing in their presentation during the orientation program for all new employees.
• Each employee is responsible for performing appropriate handwashing as outlined in this memorandum and in their service or section infection control policies and procedures.

• Facilities Management Service will provide on a regular schedule an easily dispensed, non-irritating soap product for general use and an anti-microbial soap product to those areas where its routine use is specified by the Infection Control Committee.
• Upon notification by the Infection Control Section, Facilities Management Service will provide an anti-microbial soap product in the dispensers in those areas where a specific nosocomial infection problem has been identified.This product will be provided according to the usually established schedule until notification by the Infection Control Section that the regular product can be resumed.
• Routine handwashing is performed using running water, appropriate soap, a 10-second friction hand rub and paper towels. At the completion of handwashing, a dry paper towel should be used to turn off the faucet handles.
• In the absence of a true emergency, personnel should always wash their hands:
  • before performing invasive procedures;
  • before taking care of a particularly susceptible patient, such as one who is severely immunocompromised;
  • before donning gloves to touch wounds, whether surgical, traumatic, or associated with an invasive device;
  • after removal of gloves;
  • after hands have inadvertently come in contact with mucous membranes, blood or body fluids, secretions or excretions, or with surfaces contaminated with these substances;
  • before eating, drinking, smoking or applying cosmetics, and after using bathroom facilities.
• Handwashing before surgery or before procedures such as chest tube insertion, laparoscopy, culdoscopy, peritoneal catheter insertion or insertion of central catheters for parenteral nutrition, central venous and capillary wedge pressure monitoring, cardiac pacemaker insertion or angiography requires anti-microbial soap and a duration as specified by Surgical Service Line or procedure policy.
• In the event of a scheduled interruption of the water supply, Facilities Management Service will notify Central Supply of the patient care areas affected.Upon such notification, Central Supply will distribute to the affected areas a supply of portable waterless hand cleanser to be used by personnel on duty until a safe water supply is available.
• In the event of an unscheduled interruption of the water supply, the affected patient care areas will notify Central Supply.Upon such notification, Central Supply will distribute to the affected areas a supply of portable waterless hand cleanser to be used by personnel on duty until a safe water supply is available.

• Garner, JS and Favero, MS.Guideline for Handwashing and Hospital Environmental
• Control, 1985, Centers for Disease Control
• Occupational Exposure to Bloodborne Pathogens, OSHA Final Rule 29 CFR Part 1910.1030, December 2, 1991.
• CDC draft guidelines for Hand Hygiene in Healthcare Settings, http://www.cdc.gov/ncidod/hip/hhguide.htm

RESCISSION: Policy Memorandum 11-66 (R-3) dated August 31, 1999.

RECERTIFICATION: This Policy Memorandum will be recertified on or before April 11, 2006.

FOLLOW-UP RESPONSIBILITY: Infection Control Committee

Jack G. Hetrick, FACHE
Hospital Director
Distribution:Hines Intranet Website and Service Chiefs and
Service Line Managers via e-mail