17.2 Hand Hygiene (WHO 5 Moments), Sharps Safety & Waste Segregation

Hand Hygiene, Sharps Safety & Waste Segregation

Core Safety Standard: In Irish acute and community healthcare settings, cross-transmission of pathogens and occupational exposure to blood-borne viruses are strictly mitigated through three interconnected safety pillars: rigorous adherence to the WHO 5 Moments for Hand Hygiene, compliance with the European Sharps Directive (S.I. No. 135/2014), and precise point-of-generation healthcare waste segregation.

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Hand Hygiene: The Cornerstone of Patient Safety

Transient microbial flora acquired on healthcare workers' hands during routine patient contact or environmental touching is responsible for over 80% of hospital cross-infections. While resident flora colonise deeper epidermal layers and are non-pathogenic, transient organisms (such as MRSA, E. coli, and respiratory viruses) survive on superficial skin layers and are readily transferred unless removed.

The WHO / HSE 5 Moments for Hand Hygiene

The World Health Organization (WHO) and HSE AMRIC framework establishes five distinct clinical moments where hand hygiene is mandatory:

+-----------------------------------------------------------------------------+
|                     THE WHO 5 MOMENTS FOR HAND HYGIENE                      |
+---+-----------------------------+-------------------------------------------+
| # | CLINICAL MOMENT             | OBJECTIVE / RATIONALE                     |
+---+-----------------------------+-------------------------------------------+
| 1 | BEFORE touching a patient   | Protects patient from colonisation by     |
|   |                             | exogenous flora carried on staff hands    |
+---+-----------------------------+-------------------------------------------+
| 2 | BEFORE a clean / aseptic    | Protects patient's sterile body sites     |
|   | procedure                   | from microbial inoculation (IV, catheter) |
+---+-----------------------------+-------------------------------------------+
| 3 | AFTER body fluid exposure   | Protects staff member and healthcare      |
|   | risk (after glove removal)  | environment from heavy pathogen burdens   |
+---+-----------------------------+-------------------------------------------+
| 4 | AFTER touching a patient    | Protects staff and subsequent patients    |
|   |                             | from acquired transient microorganisms    |
+---+-----------------------------+-------------------------------------------+
| 5 | AFTER touching patient      | Protects staff and environment from       |
|   | surroundings (fomites)      | fomites (bed rails, pumps, charts)        |
+---+-----------------------------+-------------------------------------------+

Alcohol-Based Hand Rub (ABHR) vs Soap & Water

The 6-Step Hand Hygiene Technique

Whether using alcohol rub or soap and water, all anatomical surfaces must receive vigorous friction across six sequential steps:

1. Palm to palm.
2. Right palm over left dorsum with interlaced fingers, and vice versa.
3. Palm to palm with fingers interlaced.
4. Backs of fingers to opposing palms with fingers interlocked.
5. Rotational rubbing of left thumb clasped in right palm, and vice versa.
6. Rotational rubbing backwards and forwards with clasped fingertips of right hand in left palm, and vice versa.

The Irish "Bare Below the Elbows" Policy

To ensure hand hygiene technique is physically unhindered and sleeves do not transmit pathogens between beds, all clinical staff in Irish hospitals must comply with the National Bare Below the Elbows policy:

• Sleeves must be short or rolled up securely above the elbow.
• Wristwatches, fitness trackers, and bracelets are strictly prohibited.
• Only a single, plain, smooth wedding band is permitted (must be rotated during hand hygiene).
• Fingernails must be short, clean, and trimmed (<0.5 cm).
• Artificial nails, acrylics, gel coatings, nail jewellery, and nail polish are strictly forbidden (chipped polish and artificial nails harbour Gram-negative bacilli and fungi).

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Sharps Safety & The European Sharps Directive

Occupational exposure to blood-borne viruses (Human Immunodeficiency Virus [HIV], Hepatitis B Virus [HBV], and Hepatitis C Virus [HCV]) represents a severe hazard to healthcare staff. In Ireland, the European Union (Prevention of Sharps Injuries in the Healthcare Sector) Regulations 2014 (S.I. No. 135/2014), transposing Council Directive 2010/32/EU, establishes statutory obligations to protect workers.

Core Engineering & Work Practice Controls

1. Elimination of Unnecessary Sharps: Replacing sharp instruments with needleless vascular access connectors and blunt plastic drawing-up cannulae.
2. Safety-Engineered Devices (SEDs): Mandatory implementation of medical devices incorporating active or passive safety shielding mechanisms (e.g., retractable hypodermic needles, automatically sheathing peripheral IV cannulae, safety butterflies).
3. Prohibition of Re-sheathing: MANUAL RE-SHEATHING / RE-CAPPING OF USED NEEDLES IS STRICTLY FORBIDDEN BY LAW. The two-handed re-capping technique is the single most common cause of avoidable puncture wounds.
4. Point-of-Use Disposal: Yellow sharps containers must be placed immediately adjacent to the clinical activity (e.g., on the procedure phlebotomy tray or dressing trolley) so sharps are discarded in one continuous motion without walking across the room.

Safe Sharps Container Protocol

• Assembly: Assemble the rigid polypropylene bin securely; ensure the lid clicks permanently into place; sign and date the label upon opening.
• Positioning: Locate bins at a comfortable, safe height (between waist and shoulder height); never place sharps bins directly on the floor where pediatric patients or visitors can reach them, and never position them above eye level.
• Temporary Closure: Use the temporary closure flap whenever the bin is unattended or during transit to prevent accidental spillage if knocked over.
• The Fill Line: NEVER fill beyond the manufacturer fill line (two-thirds to three-quarters full). Overfilled bins create severe puncture hazards for the next user.
• Final Closure: Engage the irreversible final locking mechanism; sign and date the closure label; transfer to the secure locked clinical waste holding area. Never shake, press down, or retrieve items from a sharps bin.

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Needle-Stick / Inoculation Injury Protocol

When a percutaneous puncture, sharps laceration, or mucosal splash involving blood or bodily fluids occurs, every second counts. Registered nurses must follow the national HSE emergency protocol:

+-----------------------------------------------------------------------------+
|                  EMERGENCY INOCULATION INJURY PROTOCOL                      |
+-----------------------------------------------------------------------------+
| 1. IMMEDIATE FIRST AID                                                      |
|    - Encourage gentle spontaneous bleeding under cool running tap water     |
|    - Wash thoroughly with warm water and liquid soap (DO NOT scrub)         |
|    - DO NOT suck the wound; DO NOT squeeze or press aggressively            |
|    - Mucosal splash (eye/mouth): Irrigate copiously with water / saline     |
|    - Dry site gently and cover with a sterile waterproof dressing           |
+-----------------------------------------------------------------------------+
                                      v
| 2. IMMEDIATE CLINICAL ESCALATION                                            |
|    - Report immediately to Clinical Nurse Manager (CNM) / Ward Sister       |
|    - Attend Occupational Health Department or Emergency Department (ED)     |
|    - Complete within 1 to 2 hours of exposure                              |
+-----------------------------------------------------------------------------+
                                      v
| 3. RISK STRATIFICATION & SOURCE TESTING                                     |
|    - Obtain informed consent from source patient for urgent serology        |
|    - Test source for: HIV antibody/antigen, HBsAg, HCV antibody            |
|    - Source testing performed by independent clinician (not exposed nurse)  |
+-----------------------------------------------------------------------------+
                                      v
| 4. POST-EXPOSURE PROPHYLAXIS (PEP) & MONITORING                             |
|    - HIV PEP: Initiate within 2 hours (effective up to 72 hours maximum)    |
|    - Hepatitis B: If nurse unvaccinated/non-responder and source HBsAg+ --> |
|      Administer Hepatitis B Immunoglobulin (HBIG) + vaccine booster         |
|    - Draw baseline serum for storage; complete NIMS incident report         |
+-----------------------------------------------------------------------------+

Pharmacological Post-Exposure Prophylaxis (PEP)

• HIV Post-Exposure Prophylaxis: A 28-day regimen of three antiretroviral agents (e.g., Emtricitabine / Tenofovir disoproxil plus Raltegravir or Dolutegravir). Most effective when initiated within 2 hours of exposure; negligible clinical benefit if delayed beyond 72 hours.
• Hepatitis B Virus (HBV):
  • If the exposed worker has documented anti-HBs titre $\ge 10\text{ mIU/mL}$, they are immune; no booster is required.
  • If anti-HBs titre is $< 10\text{ mIU/mL}$ or unknown, administer an immediate HBV vaccine booster.
  • If the source is known HBsAg-positive and the healthcare worker is a non-responder or unvaccinated, administer Hepatitis B Immunoglobulin (HBIG) within 48 hours (maximum 7 days) alongside a full vaccination course.
• Hepatitis C Virus (HCV): There is currently no approved active or passive post-exposure prophylaxis for HCV. Baseline serology is drawn, with follow-up HCV RNA PCR testing at 4–6 weeks and HCV antibody testing at 12–24 weeks. Highly effective direct-acting antiviral (DAA) therapy is commenced if seroconversion occurs.

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Healthcare Waste Segregation in Irish Hospitals

Waste generated in Irish hospitals is regulated by the Department of Health and Children and the HSE Waste Management Plan. Segregation at the point of generation is legally mandated to protect waste handlers and prevent environmental contamination.

+-----------------------------------------------------------------------------+
|                     HEALTHCARE WASTE SEGREGATION CHART                      |
+---------------------+-------------------+-------------------+---------------+
| WASTE CATEGORY      | RECEPTACLE COLOR  | PERMITTED ITEMS   | DISPOSAL PATH |
+---------------------+-------------------+-------------------+---------------+
| NON-RISK DOMESTIC   | CLEAR or BLACK    | Packaging, paper, | Municipal     |
| WASTE               | plastic bags      | food scraps, hand | landfill /    |
|                     |                   | towels, dry waste | recycling     |
+---------------------+-------------------+-------------------+---------------+
| HEALTHCARE RISK     | YELLOW            | Blood/fluid soiled| Heat disin-   |
| (CLINICAL) WASTE    | heavy-duty bags   | dressings, swabs, | fection or    |
|                     | (UN-approved)     | IV lines, PPE     | high-temp     |
|                     |                   | from isolation    | incineration  |
+---------------------+-------------------+-------------------+---------------+
| CYTOTOXIC /         | PURPLE bags and   | Chemotherapy bags,| High-temp     |
| CYTOSTATIC WASTE    | rigid purple-     | chemo sharps,     | incineration  |
|                     | lidded containers | excreta within 72h| at > 1,000°C  |
+---------------------+-------------------+-------------------+---------------+
| MEDICINAL SHARPS    | YELLOW container  | Needles, syringes | High-temp     |
|                     | with YELLOW lid   | with drug residue,| incineration  |
|                     |                   | glass ampoules    |               |
+---------------------+-------------------+-------------------+---------------+
| CYTOTOXIC SHARPS    | YELLOW container  | Needles & vials   | High-temp     |
|                     | with PURPLE lid   | contaminated with | incineration  |
|                     |                   | cytotoxic drugs   | at > 1,000°C  |
+---------------------+-------------------+-------------------+---------------+
| NON-MEDICINAL       | YELLOW container  | Phlebotomy lancets| Autoclave /   |
| SHARPS              | with ORANGE lid   | suture needles    | heat disin-   |
|                     |                   | without drugs     | fection       |
+---------------------+-------------------+-------------------+---------------+

[!IMPORTANT] Cytotoxic Waste Rule: Any bodily excretion (urine, faeces, vomitus) from a patient who received cytotoxic chemotherapy within the past 48 to 72 hours is classified as cytotoxic hazard. Incontinence pads, catheter bags, and contaminated PPE must be placed in purple bags for high-temperature incineration.

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Clinical Traps & OSCE Safety Pearls

• OSCE Trap 1: Placing Sharps Containers on the Floor. Placing a sharps container on the floor or unstable surfaces during an OSCE station constitutes a critical safety failure. Sharps bins must be mounted securely or placed on the top tier of a clean procedure trolley at point-of-use.
• OSCE Trap 2: Re-capping a Needle. Attempting to re-sheath a needle using two hands after giving a subcutaneous or intramuscular injection is an immediate, non-recoverable fail in practical exams. You must immediately activate the safety shield with one finger or drop the bare sharp directly into the yellow bin.
• OSCE Trap 3: Hand Hygiene Moment Confusion. Performing hand hygiene only after an aseptic procedure but forgetting before touching the sterile syringe is a frequent mistake. Remember: Moment 2 (Before an aseptic procedure) is essential to protect the patient from bloodstream infection.
• OSCE Trap 4: Discarding Non-Soiled Items into Yellow Bags. Disposing of clean cardboard packaging, unused paper towels, or empty saline bottles into yellow clinical waste bags incurs massive financial and environmental penalties. Yellow bags are strictly reserved for items contaminated with biological risk materials.