KEIT Day Hospital protocols

Hand hygiene, sterile barrier and skin preparation protocol

Official Manual of Clinical, Care and Organizational Protocols

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Hand Hygiene, Sterile Barriers and Skin Preparation Hospital Infection Control
KEIT DAY HOSPITAL

Hand hygiene, sterile barrier and skin preparation protocol

Official Manual of Clinical, Care and Organizational Protocols
Document CodeKEIT-SOP-04Version2.0
Revision02StatusOfficial
Issue Date28/03/2026Next Review28/03/2027
Prepared byMedical Directorate / QualityApproved by
Signature and DateDistributionControlled - Internal Use
Purpose of the document. To officially define the scope, responsibilities, operating procedure, KEIT standards, records and protocol review criteria.

1. Document Control Information

ApplicationAll clinical, nursing, technical and organizational personnel involved in the described process.
ArchivingKEIT internal document management system and controlled copy in the relevant areas.
ReviewAt least annually or earlier in the event of regulatory, organizational or technological updates.

2. Scope of Application

Applicable to all surgical activities, invasive dressings and every procedure requiring sterile technique.

3. Responsibilities

  • All healthcare professionals: hand hygiene and compliance with sterile technique.
  • Scrub nurse and operating room nurse: verification of the correct preparation of the instrument table and sterile field.
  • Operating surgeon: supervision of compliance with aseptic conditions.

4. Operating Procedure

  • Perform hand hygiene using the appropriate technique and at the times specified by the protocol.
  • Correctly wear a surgical cap, mask, sterile gown and single-use sterile gloves.
  • Prepare the surgical field using sterile, waterproof, single-use kits and dedicated materials.
  • Perform the patient’s skin preparation according to the procedure, with careful antisepsis and compliance with the contact time of the product used.
  • Repeat skin preparation when required by the procedural protocol and in the event of contamination.
  • Immediately replace gloves or sterile materials in the event of breakage, contamination or suspected contamination.
  • Document any deviations from the protocol and implement corrective measures.

5. KEIT Operational Standards

  • In the KEIT operating theatre, the patient’s skin is thoroughly disinfected according to the surgical team’s operating protocol; for implant procedures, the protocol requires maximum attention to timing, asepsis and continuity of the sterile field.
  • For procedures involving breast implants, the team requires a change of sterile gloves before the final placement of the implant.
  • Surgical hand antisepsis is performed before sterile gowning by all personnel involved in the sterile phase.

6. Records and Documentation

  • Operating room preoperative checklist.
  • Sterile technique non-conformity register.
  • Staff training records.

7. Review and Updates

Periodic updates based on operating room audits, training and reviews of IPC procedures.

Implementation Note
This document is an internal operational draft. Before final adoption, review by the Medical Directorate, Clinical Directorate, Legal Advisor and the relevant department managers is recommended.

8. Related Attachments and Forms

  • Operational checklists, recording forms, audit sheets and maintenance registers applicable to this protocol.
  • Any department-specific or equipment-specific technical attachments are referenced in the relevant local operating instructions.

9. Final Approval

PositionName and SignatureDate
Medical Directorate

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