This policy and procedure applies to all employees of the Royal Victoria Regional Health Centre (RVH) as well as professional staff with RVH privileges (i.e., medical, dental, midwifery, and extended class nursing staff), volunteers, students, and contractors. These individuals shall be referred to collectively as workers herein. The requirements apply whether working on RVH property or working on behalf of or representing RVH elsewhere.
This policy describes the process that is implemented to help workers overcome the barriers to proper hand hygiene and improve compliance with hand hygiene best practices.
This policy and procedure serves to provide clear expectations regarding appropriate methods and practices for hand hygiene for all RVH workers. This will:
1. Decrease the risk of transfer of infectious organisms from one person to another, one area to another, and into the community.
2. Decrease the risk of worker illness/injury.
Alcohol-based Hand Rub (ABHR): A liquid, gel or foam formulation of alcohol (e.g. ethanol, isopropanol) used to decrease the number of microorganisms on hands in clinical situations when the hands are not visibly soiled.
Hand Hygiene: Refers to any action of hand cleaning and relates to the removal or killing of transient microorganisms and removal of visible soil from the hands. Hand hygiene includes the use of soap and running water or ABHR. Hand hygiene includes surgical hand antisepsis.
Plain Soap: Detergents that contain very low or no concentrations of antimicrobial agents.
Point-of-Care: A concept that refers to a hand hygiene product which is easily accessible to staff, as close as possible to where patient contact is taking place. Three elements occur together: the patient, the health care provider and care or treatment involving patient contact. The products should be accessible without the provider leaving the patient environment.
1. Health Care and Residential Facilities, Ontario Regulation 67/93
2. Occupational Health and Safety Act, R.S.O. 1990, CHAPTER O.1
It is the policy of the RVH to:
1. Provide an effective multidisciplinary Hand Hygiene program with ongoing initiatives, surveillance and public reporting of hand hygiene compliance rates.
2. Provide education and visual reminders regarding indications for hand hygiene and proper hand hygiene techniques to all workers, patients and visitors through use of written and visual information and/or educational sessions.
3. Provide adequate supplies for workers, patients, and visitors to perform proper hand hygiene that includes the placement of ABHR, sinks, and appropriate supplies.
It is the policy of the RVH to:
Term Care for Public Reporting of hand hygiene compliance rates pre and post patient contact.
RVH – Corporate Dress Code Policy
Infection Prevention and Control Manual Additional Tools:
3.2.1 Your 4 Moments for Hand Hygiene
3.2.2 When and How to Perform Hand Hygiene
3.2.3 Factors that Reduce Effectiveness of Hand Hygiene and Hand Care
Public Health Ontario. Just clean your hands campaign. Retrieved March 3, 2014 from http://www.publichealthontario.ca/
Ministry of Health and Longterm Care. Best Practices For Hand Hygiene In All Health Care Settings Reviewed and Revised April 2014 –. Retrieved May 5, 2014 from:
World Health Organization. WHO guidelines on hand hygiene in health care. Retrieved March 3, 2014 from http://whqlibdoc.who.int/