Hand Hygiene

A high impact SSI prevention aspect.

Why hand hygiene is a separate aspect in SSI prevention

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“The purpose of routine hand hygiene in patient care is to remove dirt, organic material and reduce microbial contamination from transient flora.” (WHO)1
GuidelineRecommendationCategory (if mentioned)

“Equipped hand hygiene stations should be available at the entrance and exit of the sterile services department or decontamination area.”1

“If hands are visibly soiled, the guidelines recommend to washhands and remove debris from underneath fingernails using a nail cleaner (sinks should be designed to reduce the risk of splashes).”1

“Wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids or after using the toilet.”2
Category IB
“If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks ofClostridium difficile, hand washing with soap and water is the preferred means.”2Category II

Category IB
“Use an alcohol-based handrub as the preferred means for routine hand antisepsis in all other clinical situations…, if hands are notvisibly soiled. If alcohol-based handrub is not obtainable, wash hands with soap and water.”2

Category IA
Category IB
Situations in which hand hygiene should be performed are listed below in the grey box.
“Before handling medication or preparing food perform hand hygiene using an alcohol-based handrub or wash hands with either plain or antimicrobial soap and water.”2Category IB
“Soap and alcohol-based handrub should not be used concomitantly.”2Category II
NICE3“The operating team should wash their hands prior to the first operation on the list using an aqueous antiseptic surgical solution, with a single-use brush or pick for the nails and ensure that hands and nails are visibly clean.“-
CDC4“Clean underneath each fingernail prior to performing the first surgical scrub of the day.”
Category II
“Do not wear hand or arm jewelry.”Category II
KRINKO5All persons who wish to enter the operating department should, among other things, carry out hygienic hand disinfection.
Category II
If the MNS has been removed, it is replaced with a new MNS. Then carry out a hygienic hand disinfection.Category IB
OR personnel, regardless of the surgical team (e.g. stand-ins), should avoid contamination of their hands with potentially contaminated materials or liquids by wearing protective gloves and, in the event of accidental soiling, carry out hygienic hand disinfection, followed by hand washing if necessary.Category IA
After touching contaminated objects (e.g. manipulation of the MNS) as well as before all measures on the patient, hygienic hand disinfection must be carried out.Category IA
Hands must be washed after using the toilet... Hygienic hand disinfection must be carried out before resuming work.Category IB


Denise Leistenschneider, Senior Clinical Consultant
"The hands of the surgical team are the most valuable asset, regardless of the task, but at the same time they also carry a high risk of endangering the patient - not only in terms of postoperative wound infections."

Process & instructions


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Perform hand hygiene:
a. before and after touching the patient
b. before handling an invasive device for patient care, regardless of whether or not gloves are used
c. after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings
d. if moving from a contaminated body site to another bodysite during care of the same patient
e. after contact with inanimate surfaces and objects (including medical equipment) in the immediate vicinity of the patient
f. after removing sterile or non-sterile gloves


Icon of hand washing
  • Apply a palmful of alcohol-based handrub and cover all surfaces of the hands. Rub hands until dry.

  • When washing hands with soap and water, wet hands with water and apply the amount of product necessary to cover all surfaces. Rinse hands with water and dry thoroughly with a single-use towel. Use clean, running water whenever possible. Avoid using hot water, as repeated exposure to hot water may increase the risk of dermatitis.
    Use towel to turn off tap/faucet. Dry hands thoroughly using a method that does not recontaminate hands. Make sure towels are not used multiple times or by multiple people.


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  • To protect the patient against harmful germs carried on your hands

  • To protect the patient against harmful germs, including the patient's own, from entering his/her body

  • To protect yourself and the health-care environment from harmful patient germs.


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Any person entering the operating area.5

Other aspects2

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  • “Do not wear artificial fingernails or extenders when having direct contact with patients

  • Keep natural nails short (tips less than 0.5 cm long or approximately ¼ inch).”

  • No jewelry (watches, rings).

Relevance of hand hygiene

  • Average hand hygiene compliance in German hospitals between 41-55%6

  • Reduction of HAIs by 6% by improving hand hygiene compliance by 10%7

"My 5 moments for hand hygiene"2

Illustration of a hand with instructions for hand hygiene listed

Improving HH compliance by optimising workflow practices8

A prospective tri-phase study evaluated the effect of an intervention consisting of:

  • Training on HH
  • Individual with direct feedbacks
  • Development and implementation of SOPs
  • Compilation of flowcharts for patient admission
Graphic illustration of overall HHC before and after intervention

Advantages of high-alcohol hand rubs

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Lower consumption
Evaluation of data from more than 250 approved hand rubs* revealed: with decreasing alcohol content, the application volume (in ml) needed to meet the requirements of EN 1500 increases.

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1/3 Cost reduction
Products with low alcohol content are less economical – due to the higher application volumes –than products with high alcohol content.

Table of a data comparison high alcohol versus low alchol
* VAH-listed9 ** Determined from prices of three online stores
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1. WHO (2016) Global guidelines for the prevention of surgical site infection. World Health Organization 2016.
2. WHO (2009) WHO Guidelines on Hand Hygiene in Health Care. World Health Organization 2009.
3. NICE (2019) Surgical site infections: prevention and treatment. NICE guidelines. Published 11 April 2019. www.nice.org.uk/guidance/ng125.
4. KRINKO (2018) Prävention postoperativer Wundinfektionen. Empfehlungen der Kommission für Krankenhaushygiene und Infektionsprävention (KRINKO)
beim Robert Koch-Institut. Bundesgesundheitsbl 61: 448–473.
5. CDC (1999) Guideline for Prevention of Surgical Site Infection. Infection Control and Hospital Epidemiology 20(4): 247–278.
6. Baier C, et al. (2022) Compliance with hand disinfection in the surgical area of an orthopedic university clinic: results of an observational study. Antimicrob
Resist Infect Control 11(1): 22.
7. Tomsic I, et al. (2021) Determinants of orthopedic physicians’ self-reported compliance with surgical site infection prevention: results of the WACH-trial’s
pilot survey on COM-B factors in a German university hospital. Antimicrob Resist Infect Control 10: 67.
8. Scheithauer S et al. (2013) Improving hand hygiene compliance in the emergency department: getting to the point. BMC Infect Dis 13: 367.
9. Verbund für Angewandte Hygiene, Desinfektionsmibel-Liste des VAH: hbps://vah-liste.mhp-verlag.de (accessed on 29.11.2023).

In focus

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Our periodically published DISINFACTS offers well-founded and practical information on special topics related to hygiene and infection protection.

Look here for current issues…