Bare below the elbows

Hand hygiene remains one of the most important measures in prevention of hospital acquired infections.Bare Below the Elbows is an initiative that aims to improve the effectiveness of hand hygiene performed by health care workers. Bare Below the Elbows is achieved when sleeves are above the elbow, hands and forearms are free of jewelry, skin is intact, and nails are natural, short, and unvarnished.

Research suggests that wearing of rings is associated with higher median skin organism counts, contamination with Staphylococcus aureus, gram-negative bacilli, or Candida species. There is also an increased risk of contamination with any transient organism as the number of rings worn by a person increases.

The World Health Organization (WHO) recommends that long sleeves be avoided. Long sleeves have been found to be contaminated with pathogens and can hinder effective hand hygiene.

Research conducted on healthcare worker white coats demonstrated contamination with S. aureus, including MRSA following hand hygiene. The study recognised the difficulty of performing effective hand hygiene with soap and water without getting the cuffs of the sleeves wet when they are long. Other studies also outlined that clothing may be an important vector for patient-to-patient transmission of S. aureus.

Healthcare workers should perform hand hygiene in accordance with the National Hand Hygiene Initiative.

The Bare Below the Elbows initiative

A Bare Below the Elbows approach enables healthcare workers to decontaminate their hands and improves the effectiveness of hand hygiene.

All staff having direct contact with patients or a patient’s environment should observe the following

  • Bracelets, wrist watches, and rings should not be worn.
  • A significant ring such as a single flat ring or band, with no stones or ridges may be permitted but should not interfere with effective hand hygiene practice. If working in a high risk setting such as Operating Theatres, wearing of any type of ring is not permitted.
  • Long sleeves are discouraged. If worn, sleeves should be rolled or pushed up above the elbow when giving direct patient care or in the patient environment so as not to interfere with effective hand hygiene.
  • Fingernails should be kept natural, short, and clean, and nail polish or embellishments should not be worn. Artificial nails (acrylic and gel) should not be worn.
  • Any skin integrity breaches (abrasions, cuts, or dermatitis) should be covered with waterproof film dressing. Staff with dermatitis should report for evaluation as per local procedures.
  • Remove protruding piercings and body modification jewelry/items positioned from the elbow to the fingertips as they impede effective hand hygiene (including but not limited to piercings or other body modifications, resulting in non-intact skin from the elbow to the fingertips).
  • Long ties and lanyards are not recommended. Retractable (or similar) ID card holders are recommended in place of lanyards and should be cleaned regularly. If ties are worn, they should be tucked in or secured.
  • Guidance from staff line manager or local infection prevention and control service should be sought for any staff with casts or compression garments below the elbows prior to patient contact.

Audits of staff compliance with Bare Below the Elbows may be undertaken. An audit tool (PDF 145 kB) has been developed for this purpose.

Related documents

Resources for staff

Last updated: 6 June 2024