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Clean hands are the single most important way to stop infections spreading to someone whose immunity is low. Staff clean their hands at five set moments around every patient, usually with alcohol rub, and with soap and water when hands are dirty or when there is diarrhoea such as C. difficile. Patients, families and visitors should clean their hands too, and ask staff to if they have not.
The WHO 2009 guideline (CDC/HICPAC categories) is the international standard, and NICE CG139 the UK one for community care. Alcohol-based handrub is the preferred means of routine hand antisepsis when hands are not visibly soiled (WHO IA; NICE 'preferably with a handrub'); wash with soap and water when hands are visibly dirty or soiled with body fluids (IB), after the toilet (II), and when spore-forming organisms such as Clostridioides difficile are suspected or proven (IB). WHO's five moments: before touching a patient, before a clean or aseptic procedure (including handling an invasive device such as a central line, whether or not gloves are worn, IB), after body fluid exposure risk (IA), after touching a patient (IB) and after touching the patient's surroundings (IB); also after removing gloves. Gloves do not replace hand hygiene (IB). Handrub takes 20 to 30 seconds and handwashing 40 to 60 seconds (WHO); NICE asks for vigorous rubbing for at least 10 to 15 seconds when washing. Staff do not wear artificial nails with direct patient contact (WHO IA) and are bare below the elbows (NICE). Programmes should be multimodal with monitoring and feedback (IA). For families, the Dutch paediatric oncology guideline makes hand hygiene by patients, carers and staff a strong good practice statement; NICE asks that patients and carers are taught hand decontamination before discharge; the HCT guideline asks all visitors to clean hands before and after visits.
Why: Alcohol rub kills more germs, faster, than soap and water, and is quicker to use at the bedside.
“Use an alcohol-based handrub as the preferred means for routine hand antisepsis in all other clinical situations described in items D(a) to D(f) listed below, if hands are not visibly soiled (IA).”
Why: Alcohol does not cut through dirt or body fluids; washing removes them.
“Wash hands with soap and water when visibly dirty or visibly soiled with blood or other body fluids (IB) or after using the toilet (II).”
World Health Organization 2009 · IB (soiled); II (after the toilet)
Why: Alcohol does not kill the spores of C. difficile; washing removes them from the hands.
“If exposure to potential spore-forming pathogens is strongly suspected or proven, including outbreaks of Clostridium difficile, hand washing with soap and water is the preferred means (IB).”
Why: This stops germs passing from staff to patient, and from one patient to the next.
“before and after touching the patient (IB);”
Why: Most line and procedure infections come from the patient's own skin germs or the last surface touched; gloves alone may not prevent contamination.
“For some tasks on clean sites (lumbar puncture, surgical procedures, tracheal suctioning, etc.), the use of gloves is standard procedure. In this case, hand hygiene is required before donning gloves because gloves alone may not entirely prevent contamination”
Why: Hands can pick up germs from body fluids even without visible soiling, and carry them to a clean body site or to the next surface.
“after contact with body fluids or excretions, mucous membranes, non-intact skin, or wound dressings (IA);”
Why: Bed rails, pumps and tables near the patient carry their germs; gloves can have tiny holes and hands are contaminated when they come off.
“immediately after any other activity or contact with a patient's surroundings that could potentially result in hands becoming contaminated”
Why: Gloves reduce but do not stop contamination of the hands.
“The use of gloves does not replace the need for hand hygiene by either handrubbing or handwashing (IB).”
Why: Missed areas, such as fingertips and thumbs, and wet hands are where germs survive.
“Apply a palmful of alcohol-based handrub and cover all surfaces of the hands. Rub hands until dry (IB).”
Why: Nails, jewellery and sleeves stop the hands and wrists being cleaned properly and harbour germs.
“being bare below the elbow when delivering direct patient care (for the purposes of this guideline, bare below the elbow means: not wearing false nails, nail polish, a wristwatch or stoned rings; wearing short-sleeved garments or being able to roll or push up sleeves)”
Why: Most cancer treatment is given as an outpatient, so families do much of the care, including line care, at home.
“Patients and carers should be educated about and trained in techniques of hand decontamination, insertion of intermittent catheters where applicable, and catheter management before discharge from hospital.”
Why: Visitors can bring germs that are harmless to them and serious to someone with low immunity.
“All visitors should perform hand hygiene before and after visits.”
CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009
Why: Products alone do not change behaviour; education, leadership, reminders and feedback do.
“Monitor HCWs’ adherence to recommended hand hygiene practices and provide them with performance feedback (IA).”
How care is usually carried out, read from the guidelines and standards cited. Your own team's protocol and their judgement come first; this page is for understanding it, not for doing it yourself.
The WHO 2009 guideline, with its five moments, alcohol handrub as the default (IA) and soap and water for visible soiling (IB) or spore-forming organisms such as C. difficile (IB), is the international standard and is reflected in NICE CG139 for the UK. The two differ only in detail: WHO grades each recommendation with CDC/HICPAC categories and gives 20 to 30 seconds for handrub and 40 to 60 seconds for handwashing; NICE does not grade, describes five equivalent circumstances, asks for at least 10 to 15 seconds of vigorous rubbing when washing, and adds bare below the elbows. For families of children with cancer, the Dutch guideline (2024, endorsed by the Children's Oncology Group) makes hand hygiene by patients, carers and staff the one strong good practice statement among its daily-life recommendations.
World Health Organization 2009 · NICE 2012 · Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 · CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009
Where it differs: Asks that hands be rubbed together vigorously for a minimum of 10 to 15 seconds during a handwash, against WHO's 40 to 60 seconds for the whole handwashing procedure.
Evidence: NICE does not grade; the wording dates from 2003. WHO gives its durations in the technique figures rather than as graded recommendations.
Where it differs: Some hospitals invite patients and families to remind staff to clean their hands. WHO asks governments to encourage partnerships between patients, families and health-care workers to promote hand hygiene.
Evidence: WHO Category II.
| Recommendation | Grade, as printed | Source |
|---|---|---|
| Alcohol-based handrub preferred for routine hand antisepsis | IA | World Health Organization 2009 |
| Hand hygiene before handling an invasive device, with or without gloves “before handling an invasive device for patient care, regardless of whether or not gloves are used (IB);” | IB | World Health Organization 2009 |
| No artificial fingernails or extenders with direct patient contact “Do not wear artificial fingernails or extenders when having direct contact with patients (IA).” | IA | World Health Organization 2009 |
| Multimodal hand hygiene promotion with education and senior support | IA | World Health Organization 2009 |
| Hand hygiene by patients, caregivers and medical personnel (children with cancer) “Proper hand hygiene should be performed by patients, caregivers, and medical personnel (STRONG recommendation, GOOD PRACTICE STATEMENT).” | STRONG recommendation, GOOD PRACTICE STATEMENT | Dutch Children's Oncology Group (DCOG), Supportive Care in Cancer 2024 |
| Health-care workers and others in contact with HCT recipients follow hand hygiene | AIII | CDC, IDSA, ASBMT and international partners (Biology of Blood and Marrow Transplantation) 2009 |
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