Hand Hygiene Policy

Policy Register No: 04072 Status: Public

Developed in response to: NHSLA Risk Mgt Standards

Best Practice Contributes to HCC Core Standard number: C4

Consulted With Individual/Body Date Infection Prevention

Team September 2008

Grant Crawshaw Dep Dir of IP&C September 2008 Professionally Approved By:

Dr L Teare September 2008

Version Number 5.1 Issuing Directorate Governance Ratified by Document Ratification Group Ratified on 20th November 2008 Trust Executive Board Date December 2008 Next Review Date August 2010 Author/Contact for Information Infection Prevention Team Policy to be followed by (target staff) All Trust Staff including temporary

staff, contractors, patients, visitors and volunteers.

Distribution Method Intranet & Website Related Trust Policies (to be read in conjunction with)

Infection Prevention Assurance Framework Mandatory Training Policy (including Training Needs Analysis)

Document Review History Review No. Reviewed by Review Date 1.0 2.0 3.0 Chris Craven September 2008 4.0 Grant Crawshaw November 2008 Staff Reading this policy are required to ensure that they have the most up to date copy. This will always be the version on the intranet

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Index 1. The purpose of this policy 2. The aims of Hand Decontamination 3. When to decontaminate your hands 4. Hand Decontamination Technique 5. Preparation of hands prior to decontamination 6. Types of hand decontamination 7. Choice of cleansing agents 8. Soap and water 9. Alcohol- based preparations 10. Routine hand decontamination using soap and water 11. Routine hand decontamination using alcohol products 12. Surgical hand decontamination 13. Hand drying 14. Training 16. Audit 17. References 18. Infection Prevention Team Contact Numbers Appendix 1 Infection Control Accountability, Responsibility and Role Link Clarification Appendix 2 Alcohol Hand Audit Appendix 3 Hand Hygiene Observation Audit Tool Appendix 4 The Trust Hand Hygiene Statement

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1. The Purpose of this Policy

1.1 The purpose of this policy is to describe the Trust process for ensuring that all MEHT staff on entering, leaving and between patient care are compliant with ensuring that they decontaminate their hands to reduce the risk of cross infection and Healthcare acquired infection. All staff have a duty to ensure that hand hygiene is compliant in line with the MEHT Pledge.

2. The Aims of Hand Decontamination

2.1 Hand decontamination has a dual role to protect both the patient and the healthcare worker (HCW) from acquiring micro-organisms, which may cause them harm.

2.2 Hands may be contaminated by direct contact with patients, indirectly by handling equipment or through contact with the general environment. Patients with invasive devices or undergoing invasive procedures are particularly vulnerable to infection from micro-organisms transferred on hands.

2.3 Expert consensus groups agree that effective hand decontamination results in significant reduction in the carriage of potential pathogens on hands.

2.4 The efficacy of hand decontamination is improved if the principles in 5.0 are adhered to:

3. When to Decontaminate your Hands

3.1 To prevent the transfer of micro-organisms it is essential to decontaminate hands Before direct patient contact and After this contact as hands may have become contaminated with micro-organisms.

3.2 A risk assessment of the activity intended or performed will determine the appropriate decontamination process and the choice of agent e.g. soap, alcohol or antiseptic preparation.

3.3 The 5 moments of hand hygiene are set in the NPSA Clean your hands campaign Show the key moments during patient care when hands must be decontaminated.

3.4 The National Patient Safety Agency 5 moments are identified as:

• Before patient contact • Before and after aseptic task • After exposure to any bodily fluids. • After patient contact • After contact with patient surroundings.

3.5 The Trust promotes the use of alcohol rub by patients, staff and visitors and provides alcohol gel throughout the hospital.

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4. Hand Decontamination Technique

A good technique covering all surfaces of the hands at the right time is more important than the agent used or the length of time taken to perform it. The ideal technique should be quick, reduce hand contamination to the lowest possible level and be free from notable side effects to the skin.

5. Preparation of Hands Prior to Decontamination 5.1 The efficacy of hand decontamination is improved if the following principles

are adhered to: 5.2 Keep nails short and pay attention to them when washing hands – most

microbes on the hands come from beneath the finger nails. 5.2 Do not wear rings with ridges or stones – total bacterial counts are higher

when rings are worn. 5.4 Do not wear artificial nails or nail polish as they discourage vigorous hand

washing. Nail polish can flake and itself become a source of contamination. 5.5 Remove wrist watches, bracelets and roll-up long sleeves or remove long

sleeved clothing prior to hand washing. 6. Types of hand decontamination

6.1 Routine hand decontamination

The aim of routine hand decontamination is to remove transient micro-organisms acquired on the hands before they can be transferred. This activity is sometimes called ‘social’ hand decontamination when soap is used or ‘hygienic’ hand decontamination if an antiseptic or alcohol-based preparation is used.

6.2 Hands that are visibly soiled with dirt or organic material, should be washed using liquid soap and water. Antiseptic hand cleansing solutions are not usually recommended for routine hand decontamination. However, if hands are potentially contaminated, but visibly clean they can be decontaminated using an alcohol-based preparation.

Use of an alcohol–based preparation is the most practical method of hand decontamination.

6.2 Surgical Hand Decontamination

Surgical hand decontamination is used prior to surgical or other highly invasive procedures where extra care must be taken to prevent micro-organisms on the hands being introduced into tissues should gloves be damaged. Surgical hand decontamination aims to substantially reduce resident micro-organisms. This process is achieved by using an antiseptic hand cleansing preparation.

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7. Choice of Cleansing Agents

There are a range of cleansing products available for hand decontamination and the selection of the correct agent will depend on whether the removal of transient or resident micro-organisms is required. It is also important that the product does not cause adverse reactions to the skin. Local disinfection and/or hand decontamination policies should provide healthcare workers with a choice of products from which to make individual ward/department decisions based on risk assessment.

8. Soap and Water 8.1 For most routine daily activities hand washing with plain soap and water is

sufficient. Hand washing with soap suspends transient micro-organisms in solution and allows them to be rinsed off; this process is referred to as mechanical removal of micro-organisms.

8.2 Soap and water is not suitable for hand decontamination where a higher level

of skin disinfection is required i.e. prior to surgery or other highly invasive procedures.

8.3 Liquid soap dispensers are the preferred option for use in clinical settings.

The soap dispenser should be wall mounted, maintained regularly and operated by hands, elbow wrist or foot as appropriate. The dispenser should have individual replacement cartridges that are discarded when empty. This will reduce the chance of accidental contamination of the soap.

8.4 Advantages of soap and water

• Cheap and readily available

• Effectively removes transient micro-organisms 8.5 Disadvantages of soap and water

• Time consuming

• Requires facilities for washing and drying

• Can damage skin 9. Alcohol-based Preparation 9.1 Alcohol hand rubs and gels offer a practical and acceptable alternative to

hand washing in most situations, provided hands are not dirty. Alcohol is not a cleansing agent and visible contaminants must be removed with soap and water. In addition, repeated applications of the alcoholic hand rub will produce a build-up of emollient on the skin, which produces a tacky feeling and at this stage, hands should be washed with soap and water.

In addition, alcohol hand rubs and gels can be used when a higher level of

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skin disinfection is required i.e. prior to surgery or other highly invasive procedures.

9.2 Advantages of alcohol

• Active immediately against a wide range of micro-organisms

• Requires no facilities

• Kinder to the skin due to added emollients

• Can be packaged into bag/pocket sized containers

• Useful for rapid bedside hand decontamination between patients or procedures

• Useful for community-based HCW's where access to adequate hand washing facilities may be lacking

9.3 Disadvantages of alcohol

• Not a cleansing agent

• Astringent, making hands sting if minor skin abrasions are present

• Flammable – requires correct storage

• Emollients build up on the skin after several applications

• Limited activity against bacterial spores and some viruses i.e. Clostridium difficile and SRSV (in these cases soap and water must be used to decontaminate hands)

• Does not have any residual activity 10. Routine Hand Decontamination using Soap and Water 10.1 Hand washing is generally defined as a vigorous, brief rubbing together of all

surfaces of lathered hands, followed by rinsing under running water.

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1. Palm to palm 2. Back of hands 3. Interdigital spaces 4. Fingertips 5. Thumbs and wrists 6. Nails 10.3 During hand washing, particular attention should be paid to those areas of

hands which are most frequently missed. (Figure 2). 11. Routine Hand Decontamination using Alcohol Products 11.1 Apply alcohol to visibly clean, dry hands. Rub hands together covering all

surfaces until hands are dry. This takes about 15 seconds. Follow manufacturer’s recommendations on the volume of product to be used.

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12. Surgical Hand Decontamination 12.1 There are a number of alternative methods for preparing the hands, nails and

forearms prior to undertaking a surgical procedure:

• Wash hands with an aqueous antiseptic solution for 3 to 5 minutes

• Wash hands with an aqueous antiseptic solution for 3 minutes followed by an alcohol based product

12.1 Since the number of bacteria on the skin gradually increase over time hand

washing with antiseptic solution or alcohol should be repeated every few hours.

12.3 Surgical hand decontamination has traditionally included scrubbing with a

brush or sponge to further decrease bacterial counts on the hands. However, it has been suggested that this is not necessary, especially when alcohol-based products are used.

13. Hand Drying 13.1 Effective drying of hands after washing is important because wet surfaces

transfer micro-organisms more effectively than dry ones and inadequately dried hands are prone to skin damage. The method of hand drying is important in the maintenance of hand hygiene, as hands that have been washed can be re-contaminated by incorrect drying. Cloth towels are not suitable for use in healthcare facilities for this reason.

13.2 Paper disposable hand towels are quicker and more thorough than existing

warm air dryers. It has been suggested that paper towels not only dry the skin but also rub away transient micro-organisms and dead skin cells loosely attached to the surface of the hands. Paper towels should be conveniently placed in relation to hand washing facilities, preferably in a wall-mounted dispenser, where they will not be contaminated by splashing water. Foot operated bins should be used because contact with the bin lid may cause hands to become re-contaminated.

13.3 Hand drying after surgical hand decontamination must be undertaken using

sterile towels whilst maintaining strict asepsis. 14. Training 14.1 Hand Hygiene training is provided for all new staff as part of the corporate

induction process by the Infection Prevention Team. 14.2 Further training is delivered and monitored in line with the Trust Training

Needs Analysis (Mandatory Training Policy). It is the responsibility of Line Managers to identify a mandatory training schedule, including Hand Hygiene training, for staff members. Learning and Development co-ordinators will take

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bookings from designated persons, maintain records of attendance and notify managers of non attendance on booked sessions so that corrective action can be taken. Further details are available in the Mandatory Training Policy.

14.3 Staff are informed and have access to all patient information leaflets. 15. Audit 15.1 Weekly audit of hand hygiene practices are completed in all areas by Infection

Prevention link or Leads. The frequency of depend on the audit score. If compliance falls below 95% then daily audits are performed for one week until compliance is 95% or over. Results are displayed for public information. Hand Hygiene posters are in all departments at the point of care. Audit tools are included in appendices 2 and 3.

15.2 The effectiveness of the policy is monitored and performance managed at the

monthly Divisional bilateral meetings. 15.3 Any planned actions required are taken forward by the Divisional Leads and

Matrons. 15.4 The process to monitoring compliance with the requirement for all staff to

complete mandatory hand hygiene training in accordance with the Training Needs Analysis is described in the Mandatory Training Policy.

15.5 Alcohol use outside clinical areas is no longer audited or monitored but

alcohol units will be left in situ to heighten staff and public awareness to ward cleanliness.

16. References EPIC2 : National Evidence- based Guidelines for Preventing Healthcare

associated Infections in NHS hospitals in England, Journal of Hospital Infection (65S),pp s1-s64. Pratt R J et al (2007).

www.npsa.nhs.uk/cleanyourhands Clean your Hands campaign (2006).

Guideline for Hand hygiene in Health- care Settings. (Recommendations of e Infection Control Practices. Advisory committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force) Morbidity and Mortality Weekly Report: Vol 51: No. RR-16: October 25th 2002.

17. Infection Prevention Team Contact Numbers

For information on issues not covered in the policy please contact the infection control team. Infection Prevention Team – Telephone Extn: 6398/6579 Grant Crawshaw Consultant Nurse Deputy Director of Infection Prevention Galbraith House Broomfield Hospital Pager: #6400 587 Mob 0770701246

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Angela Hyman - Infection Prevention Nurse Broomfield Court Annex, Broomfield Hospital Pager. #6555 2227 Mob 07983338419

Elaine Finn Davies – Infection Prevention Nurse Galbraith House, Broomfield Hospital Pager: #6555 2220 Mob 07747036718 Chris Craven – Infection Prevention Matron Galbraith House, Broomfield Hospital Pager: #6400 836 Mob 07500950847

Consultant Microbiologists

Dr L Teare – Director of Infection Prevention and Control Microbiology Department, West Wing 2 Broomfield Hospital Extn: 6311

Dr D Marossy – Consultant Microbiologist Microbiology Department, West Wing 2, Broomfield Hospital Extn: 6312

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Appendix 1 Infection Control Accountability, Responsibility and Role Link Clarification

me Accountability and Responsibilities ief Executive Accountable to: Secretary of State and Trust Chairman.

Responsible for: strengthening, preventing and controlling communicable disease, and monitoring the effectiveness of existing infection control processes across the Trust. Reviewing arrangements for the control of infection within the trust through the Patient Safety Committee (IP annual report).

ector of Nursing and Workforce velopment

Accountable to: Chief Executive Responsible for: delegated executive responsibility for strengthening, preventing and controlling communicable disease, and monitoring the effectiveness of existing infection control processes across the Trust. Reviewing arrangements for the control of infection within the trust through the Patient Safety Committee (IP annual report),

ector of Infection Prevention and ntrol, Consultant Microbiologist

Accountable to: Chief Executive Responsible for: Clinical lead for overseeing, providing advice on and implementation of infection control practices across trust. Providing regular reports to the Patient Safety Committee and Trust Executive Board / Trust Board Formulating Infection Prevention Annual Report.

nsultant Nurse Deputy Director of ction Prevention and Control

Accountable to: Director of Infection Prevention and Control Responsible for: in conjunction with the DIPC, leading the prevention monitoring, investigating and controlling of infection across all Mid Essex Hospital Services NHS Trust sites, in accordance with Trust Policies, Procedures and protocols. Manage and ensure a 24- hour responsive Infection Control Service. Provide effective feedback of surveillance data to clinicians and managers. Manage and co-ordinate the infection control nursing team to ensure the highest possible standards of practice, particularly with regard to the safety of patients and staff against all hazards associated with infection and cross infection. Provide quarterly reports to the Infection Prevention and Control Group.

tron for Infection Prevention and ntrol

Accountable to: the Deputy DPC Responsible for: preventing, monitoring, investigating and controlling infection across all Mid Essex Hospital Services NHS Trust sites, in accordance with Trust Policies, Procedures and Protocols. Line management of Infection Prevention Nurses.

ction Prevention Nurses ension: 6398/6579 ail: ction.coxxxxx.xxxxxx@xxxx.xxx.u

Accountable to: Deputy Director of Infection Prevention and Control Responsible for: Supporting the Matron in preventing, monitoring, investigating and controlling infection across all Mid Essex Hospital Services NHS Trust sites, in accordance with Trust Policies, Procedures and Protocols. Deputise for the Matron as appropriate. Take lead responsibility for surveillance of hospital acquired infections. Deliver mandatory training on Infection Prevention.

SO 3 Microbiology Accountable to: Laboratory Director Responsible for: To manage specified sections of the

laboratory on behalf of the Laboratory Manager and to provide a microbiological service that is of a high quality and cost effective for clinical, research and training purposes.

Infection Control Link Nurses(Special interest staff in each ward and department)

Accountable to: Directorate General Manager Responsible for: supporting the Infection control team in ensuring good infection control practices are adopted and maintained within all clinical areas within Mid Essex Hospital Trust

Infection Control Link Nurses (Special interest staff in each ward and department)

Accountable to: Directorate General Manager Responsible for: supporting the Infection control team in ensuring good infection control practices are adopted and maintained within all clinical areas within Mid Essex Hospital Trust

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Appendix 2 INFECTION CONTROL DEPARMENT

Alcohol Hand Rub Audit Y = Yes N = No N/A = Not Applicable

Name: Ward or Department: Date:

AREA e.g. Cubicle, consulting room, bed space

Is there alcohol hand rub available in this area

Are the dispenser nozzles clean?

INFECTION CONTROL DEPARMENT Alcohol Hand Rub Audit

Y = Yes N = No N/A = Not Applicable Name: . . . . . . . . . . . . . . . . . . . . . . . . . Ward or Department:. . . . . . . . . . . . . . . . . . . . . . . . . Date. . . . . . . . . . . . . . . . . . . . . Is Alcohol Hand Rub available for use as you enter the ward?

Is the dispenser visible to all individuals entering the ward?

Are posters in place to explain the reasons for use?

Is there alcohol hand rub available in these areas? (Answers in first row) Are the dispenser nozzles clean? (Answers in second row) Bay 1 Beds 1-6 Bay 2 Beds 1- 6 Bay 3 Beds 1 – 6 Bay 4 Beds 1 – 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6 1 2 3 4 5 6

Side Rooms - Is alcohol hand rub available inside and outside the room? (Answers in first row) Are the dispenser nozzles clean? (Answers in second row).

1 2 3 4 5 6 7 8 9 10 11 12 Is there alcohol hand rub available in these areas? (Answers in first row) Are the dispenser nozzles clean? (Answers in second row)

Notes Trolley

Drugs Trolley

Sinks on the ward

Has every patient on ward received a clean your hands campaign leaflet? Is the current clean your hands poster on display?

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Appendix 3

INFECTION CONTROL DEPARTMENT

HAND HYGIENE OBSERVATION TOOL

Background Approximately 8% of hospitalised patients acquire an infection during their hospital stay It is estimated that the additional costs for each patient ranges from £1300 - £5300 and that patients remain in hospital for a further 10 days on average. The cost to the NHS is approximately £1 billion per year. It is estimated that hospital acquired infections (HAI) cause more than 5000 deaths each year. It is recognised that HAI could be significantly reduced if Healthcare workers complied with hand hygiene guidance. Reference: Pratt RJ, Pellowe C, Loveday HP et al 2001. The epic Project: developing national Evidence-based (Guidelines for preventing Healthcare Associated Infections Journal of Hospital Infection 47 supplement.

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INFECTION CONTROL DEPARTMENT

HAND HYGIENE OBSERVATION TOOL

This tool has been developed to measure hand hygiene compliance in healthcare workers. It is based on previous work, by Pittet et al (2000) and Faulkener (Meengs et al 1994). The underlying principle is that in healthcare there are ‘hand hygiene opportunities'. These are identifiable episodes when hand hygiene should take place e.g. before doing a sterile procedure, after handling body substances, before and after patient contact. The observational tool compares hand hygiene opportunities with observed hand hygiene. Compliance can then be expressed as a percentage i.e. Observed hand hygiene Hand hygiene opportunities X 100 = compliance Pittet et al 2000 Effectiveness of hospital wide programme to improve compliance with hand hygiene. Lancet 356: 1307-12 Meengs et al 1994 Hand washing frequency in an emergency department. Annals of Emergency medicine 23 (6)1307-12 Instructions 1. You can do this alone but it is better with a partner. 2. Identify an observable part of the clinical area. 3. Position yourself so that you do not cause an obstruction but can still see what is happening. 4. Observe for 20-minute periods. 5. Using the observation sheet mark a '1' for a hand hygiene opportunity and a '0' for an observation of hand hygiene actually taking place. 6. When you have completed 20 minutes observation, do give feedback to the staff - a feedback form is included in this pack. When you give verbal feedback try to stress positive findings first and if you give negative feedback give examples and suggestions for improvement. 7. While you are observing you may identify issues which are barriers to hand hygiene e.g. no soap, obstructed sinks - include this in your feed back. The results should be shared with the Matron for your clinical area and key actions incorporated into your Directorate Infection Control action plan. A copy of the completed audit should be filed in the clinical area. Results should be forwarded to the Infection Control Team. Expected compliance 100%

Hand Hygiene Observation sheet

Key: 1 = hand hygiene opportunity 0 = observation of hand hygiene Observers Names: Date: Time: Location:

Hand Hygiene Opportunities Nurses Doctors HCA’s Others

Before direct contact with a patient

After direct contact with a patient

In between patients when doing observations

In between making beds During bed making, visiting linen trolley

Before serving meals After removing gloves and aprons

Before an aseptic technique i.e. Wound care, IV line care, enteral feeding

After an aseptic technique

After toileting a patient

When hands are visibly soiled

After leaving an isolation room

Before and after emptying a drainage bag

In between tasks for the same patient i.e. mouth care, catheter care

In between patients on ward rounds

Before commencing a drug round

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Barriers to Hand Hygiene

The above generic list can be altered, extended to reflect the clinical area you work in. Please ring the Infection Control Nurses for support or advice on extension 6518

INFECTION CONTORL DEPARTMENT

HANID HYGIENE OBSERVATION TOOL- FEEDBACK FORM

DATE………………. TIME....................... LOCATION:............………. OBSERVERS NAMES:......................................................... SCORE (observed hand hygiene / hand hygiene opportunities X 100) SPECIFIC FEEDBACK FEEDBACK GIVEN TO............................. Further action required

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Appendix 4

Mid Essex NHS Hospitals Trust Hand Hygiene Statement

The Trust and its employees pledge to patients that health care workers will only touch them with CLEAN hands.

All health care workers will decontaminate their hands before and after each patient contact.