Hand Hygiene Protocol for UTMB Hospitals and Clinics

The goal of the hand hygiene protocol is to increase compliance with hand hygiene in UTMB Hospitals and Clinics. Hand hygiene is the single most important means to prevent transmission of infectious agents.

All employees of UTMB Hospitals and Clinics, contract workers, volunteers and students will follow the hand hygiene protocol. Visitors will also be encouraged to perform hand hygiene.
Hand Hygiene shall be performed:

• Before and after patient contact
• Before entering room and after exiting room
• Before putting on gloves and after glove removal
• Before and after procedures

UTMB Hand Hygiene Policy

The hand hygiene protocol is based on the Center for Disease Control and Prevention’s Guideline for Hand Hygiene in Healthcare Settings.

Preparations Used for Hand Hygiene:

• Plain soap (Non-Antimicrobial)
• Chlorhexidine gluconate (antimicrobial soap)
• Triclosan (antimicrobial soap)
• Alcohols
• Surgical Hand Antisepsis
• 3M Avagard
• 4% Chlorhexidene Gluconate or Betadine (10% povidone iodine)

Monitoring - Healthcare workers will be monitored regarding their adherence to recommended hand hygiene practices and provided information regarding their performance.

• Any person who is observed to have a hand hygiene opportunity and who goes to the sink and runs the water with the apparent intent to wash their hands will be counted as completing the hand hygiene activity.
• Any person who is observed to have a hand hygiene opportunity and applies alcohol gel will be counted as completing the hand hygiene activity.
• Hand hygiene surveillance and artificial nail surveillance with observations ongoing (see policy).

Related HCE Policies