hand hygiene policy€¦ · in line with the clean. your. hands campaign patients are encouraged to...

Hand Hygiene Policy

Reader information

Reference CLIN/POL/2009197

Directorate NURSING AND GOVERNANCE

Document purpose To ensure adherence to best practice.

Version 1

Title Clinical Policy for Hand Hygiene

Author/Nominated Lead

(Title plus contact details)

Revised by Sheila Smith Infection Prevention & Control Nurse Nottinghamshire Community Health Ransom Hall Ransom Wood Business Park Rainworth Nottinghamshire NG21 0ER Tel 01623 414114 [email protected] Original Authors: Julie Wright and Sally Bird Commissioning Matrons Infection Prevention & Control

Approval Date March 2009

Approving Committee Governance Committee

Review Date March 2012

Groups/staff Consulted Nottinghamshire Community Health Infection Prevention and Control Group

Target audience All staff employed by Nottinghamshire Community Health

Circulation list All staff employed by Nottinghamshire Community Health

Associated documents See Reference List

Superseded documents Hand Hygiene Policy - IPC01

Sponsoring Assistant

Director

Michelle Bateman Assistant Director of Nursing and Governance

mailto:[email protected]

Contents

Page Number

1. Introduction 3

2. Equality and Diversity Statement 3

3. Evidence Base 3

4. Risk Management 3

5. Equipment List 5

6. Describing the Care Required 5

7. User Involvement 6

8. Education/Training Programme 6

9. Dissemination and Implementation Plans 7

10. Review and Revision Arrangements 7

11. Monitoring Compliance and the Effectiveness of Policy 7

12. . Key Performance Indicators 7 13. References 8

Appendix 1a 9

Appendix 1a 10

Appendix 2 11

Hand Hygiene Policy CLIN/POL/2009/197 March 2009 2

Hand Hygiene Policy

1. Introduction

Under the terms of The Health and Social Care Act (DH 2008) Nottinghamshire Community Health (NCH) has a duty to ensure that the risk of healthcare associated infection (HCAI) is kept as low as possible. The National Patient Safety Agency (NPSA) recognises that improving the hand hygiene of healthcare staff at the point of patient care will reduce the risk of HCAI. Not all infections are preventable but evidence shows that improving hand hygiene contributes significantly to the reduction of HCAI (NPSA 08) The importance of Hand Hygiene is reinforced in The Winning Ways report which states that ‘hand washing by healthcare staff is vitally important in the control of infection’ and that ‘each clinical team should demonstrate consistently high levels of compliance with hand washing and hand disinfection protocols.’(DH 2003) This policy has been written for all healthcare staff within NCH in order to:

Promote the optimal techniques for decontaminating hands. Help staff to understand the precise moments when they need to clean their

hands and why Protect patients and staff from cross infection and therefore reduce incidents

of HCAI 2. Equality and Diversity Statement

NCH is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on the basis of their ethnic origin, physical or mental abilities, gender, age, religious beliefs or sexual orientation

3. Evidence Base See source documents and refer to reference list.

4. Risk Management Indications All healthcare staff have an individual responsibility to assess the need for hand hygiene in their daily practice. The point of care refers to the patient’s immediate environment in which staff to patient contact or treatment is taking place (NPSA 2008) There are 5 recognised crucial points of care for hand hygiene, representing the time and place at which there is the highest likelihood of transmission of infection via the hands of healthcare staff (World Health Organisation 2006)

Before patient contact Before an aseptic task After body fluid exposure risk After patient contact After contact with patient surroundings

Refer to Appendices 1a and 1b


Contraindications There should be no contraindications preventing staff from carrying out effective hand hygiene practice within NCH facilities. All clinical environments should provide adequate hand hygiene facilities, with designated hand washbasins, as well as liquid soap, paper towels, alcohol hand rub and hand cream. However, this policy acknowledges the fact that some facilities outside of NCH premises, e.g. a patient’s home, may not be conducive to effective hand hygiene practice. All staff on domiciliary visits should be supplied with liquid soap, paper towels, alcohol hand rub & hand cream. Where a practitioner assesses that hand washing facilities and supplies are inadequate, e. g in a patient’s home, hands should be decontaminated using alcohol hand rub. If necessary, the practitioner should then, as soon as is reasonably practicable, decontaminate their hands using soap and water.

Hazards NCH endorses the ‘Bare Below the Elbows’ initiative for all staff working within a clinical area. Staff must have short sleeves and wear no hand or wrist jewellery other than a plain wedding band. Nails should be clean, short and free from polish. The hand hygiene technique will be compromised by failing to adhere to this initiative. There are hazards associated with hand hygiene such as dry, sore or irritated skin, which may be due to a variety of reasons, including:-

Poor hand hygiene technique Poor hand drying technique Sensitivity to hand hygiene products Existing allergies and skin conditions, e.g. eczema and psoriasis. These

conditions may be exacerbated by some products and poor technique. If this occurs then staff should seek advice from one of the Occupational Health Departments:

Queens Medical Centre – 0115 9249924 / 970962 extension 44342 Nottingham City Hospital – 0115 9691169 / 9627657 extension 46657 Mansfield Community Hospital 01623 785135 (ext 5135) Risks associated with alcohol hand rub All alcohol based hand hygiene products purchased and supplied to staff by NCH must comply with the European Committee for Standardisation (CEN 1997) standard EN1500. Placement of alcohol at sites other than the point of care should be at the discretion of the locality managers and based on a risk assessment. The NPSA (2008) suggest that the following factors should be taken into consideration when undertaking the risk assessment;

Accessibility to alcohol hand rub by high risk patient/client groups e.g. children, patients at risk of deliberate self harm and patients with alcohol use disorders

Accidental splashes to the eyes Storage considerations Fire Risk


5. Equipment List Access to hand washbasin and running water Liquid soap Paper towels Alcohol Hand Rub Hand cream Anti microbial agent for pre surgical hand washing Sterile towel for pre surgical hand washing

Soap and Alcohol Hand Rub in healthcare settings should be provided in a wall-mounted dispenser using single use cartridge systems. Hand washbasins in clinical areas should be compliant with HTM64 and be designated for hand hygiene purposes only. (DH 2006)

6. Describing the Care Required Micro-organisms Micro-organisms on the skin can be classified into two groups – resident and transient. Resident micro-organisms are part of the normal human flora and live deep-

seated within the epidermis. They protect the skin from invasion by more harmful organisms. They do not easily cause infections and are not easily removed.

Transient micro-organisms are located on the surface of the skin. They are described as ‘transient’ because they are easily transferred to other people, equipment and the environment, via the hands following direct contact. They have the potential to cause infections and can be easily removed or destroyed by good hand hygiene techniques.

Routine Hand Hygiene - This is achieved using liquid soap and running water following the NPSA hand washing technique (Refer to Appendix 2) This method is sufficient to remove visible dirt and most transient micro-organisms. Visibly clean hands can be decontaminated with an application of alcohol hand rub following the NPSA recommended technique (Refer to appendix 2) Aseptic hand washing- should be carried out prior to undertaking any procedure requiring an aseptic technique. It is achieved by washing with soap and water prior to preparation of equipment, following the NPSA recommended technique (refer to appendix 2) Subsequent hand decontamination, during the procedure, can then be achieved by the application of alcohol hand rub, using the NPSA recommended technique (refer to appendix 2) Pre surgical hand hygiene- Surgical hand washing is intended to remove or destroy transient micro-organisms and to significantly reduce the level of detachable resident micro-organisms. It is essential to the maintenance of asepsis within the theatre environment. It is achieved by using an antimicrobial solution, which should be applied for two minutes using the hand hygiene technique included in this policy and should also include washing and rinsing up to the elbows. A sterile, disposable nail brush can be used for the first surgical hand wash of the day, but it is not advisable to use on consecutive hand washes as damage to the skin may occur, leading to an


increased likelihood of microbial colonisation. A sterile towel should be used for drying. Alcohol Hand Rub Alcohol hand rub should be used only on visibly clean hands It is not recommended for use when patients are known to have Clostridium difficile, norovirus, or are experiencing diarrhoea and/or vomiting. Hand Drying Hands should be dried thoroughly using disposable paper towels. If a hand towel is provided by the patient for the use of community staff, then the staff member should ensure that it is clean and dry and intended only for use by the healthcare worker. Poorly dried hands can more easily transfer micro-organisms to other surfaces than dry hands (Gould 2000), the damper the hands, the greater the number of micro-organisms (Taylor et al. 2000) Skin Care Excoriated hands are associated with increased colonisation of potentially pathogenic micro organisms and therefore increase the risk of infection. (Pratt et al, 2001; Boyce and Pittet, 2002) The appropriate use of hand cream is an important factor in maintaining skin integrity and staff are advised to use an emollient hand cream regularly, e. g after washing hands, before a break or when going off duty to maintain the integrity of the skin (Pratt et al, 2001)

7. User Involvement In order to comply with the Health and Social Care Act (DH 2008) healthcare workers should encourage the involvement of patients and the public in Infection Prevention and Control. Hand Hygiene notices and posters should be displayed in areas that are visible to patients and hand hygiene information leaflets should be made available to all patients and visitors to healthcare facilities Facilities should be made available in all NCH environments for patients and visitors to carry out relevant hand hygiene. Patients should be encouraged and, where necessary, assisted to carry out hand hygiene In line with the Cleanyourhands Campaign patients are encouraged to ask staff if they have cleaned their hands prior to any clinical contact. NCH and the Infection Prevention and Control Team will support all patients in challenging poor practice in relation to hand hygiene.

8. Education and Training Program The Health and Social Care Act (DH 2008) stipulates that infection prevention and

control training is included for all staff at induction. Hand hygiene training is included in the induction programme; this ensures compliance with the National Health Service Litigation Authority requirements. Hand hygiene training is also included in all mandatory infection prevention and control update sessions. All members of staff have an individual responsibility to ensure that they access mandatory training. The training sessions can be accessed through Learning and Development at The Firs Learning Centre, Ransom Hall Tel: 01623 414114 extensions 4402/3 or via the intranet. Glow and Tell machines, which are used to demonstrate the effectiveness of hand hygiene techniques, are available for loan from the IPC team, for the use of staff who wish to carry out hand hygiene training within their own teams/departments.

9. Plans for Implementation and Dissemination


The policy will be placed on the intranet and hard copies will be made available upon request.

The policy will be circulated to all service managers to distribute to all staff. who should then sign a signature form to say that they have read and understand the contents

Infection Control Link Professionals will be informed of the availability of the policy and asked to cascade the information to their teams and colleagues.

Reference to the policy will be made at all Infection Prevention & Control training sessions.

10. Review and Revision arrangements

This Policy shall be reviewed every 3 years by the Infection Prevention and Control Team or sooner if the base of evidence indicates an earlier review.

11. Process for Monitoring Compliance and Effectiveness

Compliance with this policy will be monitored by the IPC team as part of the IPC audit programme and will include observations of hand hygiene practice and audit of hand hygiene facilities within NCH environments.

Staff should self audit hand hygiene compliance using the Essential Steps assessment tool (DH 2007)

All audit results and action plans should be forwarded to the IPC team who will be responsible for feeding back the information to the IPC Group

Frequency of audit/ monitoring should be variable, according to the results and on advice from the IPC Team

12. Key Performance Indicators

Hands are decontaminated at the appropriate time i.e. in line with the WHO five moments for hand hygiene

The product used is appropriate to the situation i.e. soap and water or alcohol hand rub.

Hands are decontaminated following the NPSA recommended technique. The healthcare worker is ‘bare below the elbows’.


13. References

Boyce, J M, Pittet, D. (2002). Guidelines for Hand Hygiene in Healthcare Settings. Recommendations of the Healthcare Infection Control Practice Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hygiene Task Force Department of Health. (2003). Winning Ways Working Together to reduce Healthcare Associated Infection in England. Department of Health. London Department of Health. (2006). Health Technical Memorandum 64: Sanitary assemblies Department of Health. London Department of Health. (2007). Essential Steps to Safe, clean care. Department of Health. London Department of Health. (2008). The Health and Social Care Act 2008:Code of Practice for the NHS on the Prevention and Control of HCAI and related guidance. Department of Health. London Gould, D. (2000). Innovations in hand hygiene: manual from SSL International. British Journal of Nursing. 9. (20). 2175-80 National Patient Safety Agency. (2008). Clean Hands Save Lives Patient Safety Alert. Second Edition. September 2008 Pratt, R, J, et al (2001). The Epic Project. Developing National Evidence-based Guidelines for Preventing Healthcare associated Infections Phase 1: Guidelines for preventing Hospital-acquired Infections. Journal of Hospital Infection; 47 (supplement). S1-S82 Standardization ECF. Chemical disinfectants and antiseptics-hygienic handrub-test method and requirements: European Committee for Standardization Brussels 1997 Taylor, J.H. et al (2000). A microbiological evaluation of warm air hand driers with respect to hand hygiene and the washroom environment. Journal of Applied Microbiology. 89(6). 910-19 World Health Organisation. (2006). WHO Guidelines on Hand Hygiene in Health Care (Advance Draft). 2006


Appendix 1a


Appendix 1b


Appendix 2

Employee Record of Having Read the Policy and Clinical/Non Clinical Procedure Title of Policy and Clinical/Non Clinical Procedure: I have read and understand the principles contained in the named policy/clinical/non clinical procedural document. PRINT FULL NAME

SIGNATURE

DATE

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