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CASE STUDY - Subject: Infection Prevention and Control

Topics: Hand Hygiene

Baby Isaac had been doing well with the care provided. He is stable, with all vital signs in normal range. He is Day of life 8. Two nurses are doing hand over at the end of a night shift in one of the NCU room where babies in incubators (incubator room) are cared. The good thing about this room is that at the top of each incubator there is a bottle filled with alcohol 70% for hand rub. Isaac is sleeping inside incubator A; the day duty Nurse opens the portholes of incubator A. She/he asks the mother and the night duty nurse about Isaac feeding and examines his abdomen. The abdomen shape and skin are normal, the cord had completely dried and off, the abdomen is soft on palpation and no organomegaly observed. After completing the abdomen assessment, she/he went back at the entrance of the room, washes her/his hands in the sink with soap and water and wait them to dry on air. She/ he makes notes in the Isaac’s file/chart and then passes to the next incubator B for next baby handover.

Please answer:

Question 1: Was the day duty Nurse compliant with good hand hygiene practice?

Explain your answer.

Question 2: Which of “the World Health Organization (WHO) Five Moments for Hand

Hygiene” did she/he miss?

Question 3: Was the soap and water the most appropriate method of hand hygiene?

Question 4: What would you do, if you were the night duty nurse?

Question 5: In your Neonatology setting, what are measures in place to improve/ maintain the hand hygiene compliance?

*Please answer and discuss in the comments below:
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Q1:The nurse on the day duty do not respect aspsie because he/she examine the baby without washing their hand.

Q2: she/he the steps of washing hand before touching the patient

Q3:Yes.The hand washing on soap and water is the best hand hygiene method.

Q4:to reminder the day duty nurse wash first their hand before opening the incubator and start examination.

Q5: the area of washing hands are available, for each incubator or radiant warmer the bottle of alcohol are present, the practice of separation of newborn baby born outside of institution with those how born in the hospital.Every cleaning of incubator,


Apr 11

1.Missed hand hygiene before touching the baby

2.Before touching the patient-

3. No

4.Alert my colleague to wash his hands before touching the baby

5.Items for hand hygiene are made available,posters are kept at visible locations,mothers are educated and encouraged to wash their hand before and after caring for their babies and constant IPC training sessions for staffs.


  1. No, as it wasn't said that she sanitized her hands before and after touching Baby Isaac

  2. She did not sanitize before and after touching Baby Isaac

  3. No, as washing in between babies might not be very realistic and that's the essence of hand rub that is being placed at the top of every incubator

  4. Remind the day nurse to make use of the hand rub before touch the babies

  5. There are the WHO 5step posters on entering the unit for everyone to remind us all of hand hygiene protocols. Also, hand rub is made available by the side of all babies to ensure it's usage before and after touch.


  1. No, the day nurse should have used the alcohol hand rub before touching the incubator and Isaac

  2. Before touching the patient

  3. Well, am not sure because it's not clear how many other patients the day nurse had touched while using the hand rub. After 5 patients, hands feel sticky and some guidelines say you wash hands after 5 hand rubs. If Isaac was the first, then she should have used the hand rub

  4. Remind my colleague to use the hand rub by handing it to her

  5. Have hand rubs at each bed and at all entrances and exits. Have functional sinks in each room with soap, running water and hand towels when possible

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