Bare Below the Elbows Version: 7. Date Adopted: 21 November Name of responsible Committee: Date issued for publication: Review date: May 2019

Transcription

1 Hand Hygiene Policy (Including Bare Below the Elbows) This policy describes the Processes and Procedures for Hand Hygiene for all staff working within Leicestershire Partnership NHS Trust. Key Words: Infection Prevention and Control Hand Hygiene Bare Below the Elbows Version: 7 Adopted by: Quality Assurance Committee Date Adopted: 21 November 2017 Name of Author: Name of responsible Committee: Date issued for publication: Antonia Garfoot Senior Infection Prevention Control Nurse Infection Prevention and Control Committee November 2017 Review date: May 2019 Expiry date: 1 November 2019 Target audience: All LPT staff Type of Policy Clinical Non Clinical Which Relevant CQC Fundamental Standards? 1

2 Contents Version Control...3 Equality Statement...3 Due Regard...3 Definitions that apply to this policy...4 THE POLICY 1.0 Purpose of the Policy Summary of the Policy Introduction Hand hygiene Duties within the Organisation Training Needs Monitoring Compliance and Effectiveness Standards/Performance Indicators References and Bibliography...13 REFERENCES AND ASSOCIATED DOCUMENTATION Appendix 1 Policy Training Requirements...14 Appendix 2 NHS Constitution Checklist...15 Appendix 3 Appendix 4 Appendix 5 Stakeholder and Consultation...16 Due Regard Screening Template Statement Failure of formally assessed hand hygiene Appendix 6 / 7 Hand Hygiene techniques /20 Appendix 8 Bare Below Elbow flowchart / Standards and rationale

3 Version Control and Summary of Changes Version Date Comments number (description change and amendments) Version 1.0 August 2007 Review of national guidelines relevant to policy Version 2 September Replaces K027 V1 and K028 Version Version 3 October 2009 Reviewed by A. Howell. Changed from guidelines to policy and incorporated associated CQC requirement changes and requirements from the NHS LA standards Version 4 August 2011 Harmonised in line with LCRCHS, LCCHS, LPT (Historical organisations) Version 5 December Reviewed in line with policy review date Version 6 June 2015 Review of policy against current legislation Version 7 October 2017 Further review of policy by Antonia Garfoot encompassing Bare Below the Elbows Flow chart, standards and rationale For further information contact: Infection Prevention and Control Team Equality Statement Leicestershire Partnership NHS Trust (LPT) aims to design and implement policy documents that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. It takes into account the provisions of the Equality Act 2010 and promotes equal opportunities for all. This document has been assessed to ensure that no one receives less favourable treatment on the protected characteristics of their age, disability, sex (gender), gender reassignment, sexual orientation, marriage and civil partnership, race, religion or belief, pregnancy and maternity. In carrying out its functions, LPT must have due regard to the different needs of different protected equality groups in their area. This applies to all the activities for which LPT is responsible, including policy development and review. Due Regard LPT must have due regard to the aims of eliminating discrimination and promoting equality when policies are being developed. Information about due regard can be found on the Equality page on e-source and/or by contacting the LPT Equalities Team. 3

4 The Due regard assessment template is Appendix 4 of this document Definitions that apply to this Policy Organisms Infections Disinfection Decontamination LPT NHS BBE Defined as any living thing, in medical terms we refer to bacteria and viruses as organisms An organism which is present at a site and causes an inflammatory response or where the organism is present in a normally sterile site. A process used to remove harmful organisms with alcohol/or other chemical Process of cleaning to remove contamination Leicestershire Partnership Trust National Health Service Bare Below the Elbows Definitions that apply to this policy 4

5 1.0. Purpose of the Policy Hand hygiene is a term that incorporates the decontamination of the hands by methods including routine hand washing, surgical hand washing and the use of alcohol hand sanitisers (Hand Hygiene Task Force 2002). This policy has been developed to give clear guidance to staff in relation to the procedures for hand hygiene set by LPT. Direction is given on: Indications for hand hygiene Types of cleansing agents and indications for use Hand hygiene technique Promoting hand hygiene Healthcare workers with patient contact Bare Below the Elbows Failure in regard to formally assessed hand hygiene ( Appendix 1) Further guidance for healthcare workers and other staff who work in prisons and places of detention can be found in Prevention of infection & communicable disease control in prisons & places of detention A manual for healthcare workers and staff Summary and Key Points Hand Hygiene is considered the single most important means of preventing the spread of infection. It is an essential practice for patient safety. Staff compliance with guidance for hand hygiene is often poor (Hand Hygiene Liaison Group 1999, Pittet et al 2000). The reasons why staff do not wash their hands include lack of available hand hygiene products, lack of time and the personal belief that they will not spread infection. The National Patient Safety Agency chose hand hygiene as their first national priority for action and implemented a national programme to improve staff hand hygiene compliance in 2004, 2008 (NPSA 2008) In September 2008 the NPSA issued a patient safety alert and launched the Cleanyourhands campaign nationally in England and Wales. ( The World Health Organisation (WHO) First global Patient Safety Challenge Clean Care is Safer Care has expanded on the tools originally developed for this strategy and the concept of MY five moments for hand hygiene was developed (Sax et al 2007) Infection is most commonly spread by contaminated hands. Some bacteria will inhabit and multiply on the skin; these are known as resident flora or commensals. Other bacteria will be picked up by contact and passed on by contact; these are known as transient flora. 5

6 Resident flora Normal flora or commensal organisms which form part of the body s normal defense mechanism, and protecting the skin from invasion by more harmful micro-organisms. They rarely cause disease and are of minor significance in routine clinical situations. However during surgery or other invasive procedures, resident flora may enter deep tissues and establish infections. Removal of these organisms is desirable in these situations, by following the surgical scrub technique. Transient flora Are loosely attached to the skin surface and are easily transferred by direct contact, easily removed with routine hand washing and most abundant around finger tips. Important source of cross - infection 5 Moments of Hand Hygiene Good hand hygiene at the point of care has been shown to reduce the spread of healthcare associated infections. The Five Moments of hand Hygiene show the key times during patient care when cleaning your hands is crucial Introduction The purpose of this policy is to provide all staff employed by LPT with a clear and robust process for hand hygiene. This policy applies to all permanent employees including medical staff who work for LPT including those on bank, agency or honorary contracts within LPT. All health professionals should ensure they work within the scope of their professional code of conduct. Hand hygiene is one of the simplest, most cost efficient ways of reducing healthcare acquired infections and reducing the risk of cross infection from person to person. It 6

7 is a mandatory requirement that all staff are aware of the hand hygiene policy and adhere to correct management of hand hygiene at all times. Hand hygiene forms part of the mandatory training requirements for all clinical staff and should be updated every two years. This policy supports that training. 4.0 Hand hygiene 4.1 Indications for hand hygiene Hands must be decontaminated immediately before each and every episode of patient contact/care and after any activity or contact that potentially results in hands becoming contaminated. (The following list is not exhaustive) Before: 7 Starting work Assisting patients with meals Administering medications Assisting with personal care Performing invasive procedures (catheter insertion, insertion of intravenous devices) Undertaking wound dressings and ANTT Entering an area where a patient is receiving source isolation precautions Donning PPE Entering a patient environment to perform a clinical activity, this includes a patient home. After Completing a shift Assisting patients with meals Administering medications Assisting with personal care Performing invasive procedures Undertaking wound dressings Removal of personal protective equipment (PPE) When visibly soiled or contaminated After using the toilet Leaving an area where a patient is receiving source isolation Contact with bodily fluids or blood Contact with soiled linen Contact with waste and equipment Where there is contact with a patient who is receiving source isolation precautions hands must be decontaminated first with liquid soap and water followed by alcohol sanitiser. Alcohol sanitizer is not effective against clostridium difficile spores.

8 4.2 Types of cleansing agents and indications for use Liquid soap and water For hand washing, liquid soap and running water must be used. Soaps must not be decanted from one container to another. 8 Before and after contact with a patient. When hands are visibly soiled. After dealing with a patient who has a known or suspected infection. Alcohol sanitiser Alcohol hand products can be used when hands are visibly clean. It must not be used when hands are visibly dirty or when dealing with patients with diarrhoea. It is ineffective against Clostridium difficile spores and associated diarrhoeal type illnesses. Alcohol sanitiser can be used after hand washing as a secondary measure. Alcohol sanitiser products are especially useful in situations where hand washing and drying facilities are unavailable or inadequate, or where there is a frequent need for hands to be cleaned i.e. in-between bed making, during the drug round, in patient s own homes. Following contact with a patient and their environment who is being nursed in source isolation, hands should be washed with liquid soap and water within the patients room or area, or as soon as possible if the environment does not have a hand wash basin available and followed by hand decontamination using alcohol hand products outside the patient s environment. Surgical soaps ( scrubs) are used in situations where a reduction in the resident flora is necessary, for example when preparing for surgery, but should not be used for routine social hand washing unless agreed by the Infection prevention and control Team, Microbiologist or Consultant in Communicable Disease Control. Staff who experience skin problems when using any hand hygiene products should be assessed by Occupational Health. They can be referred by their manager or through self- referral. All staff must undergo an annual skin integrity check. 4.3 Hand hygiene technique A good technique at the correct time, which covers all surfaces of the hands, is more important than the cleanser used or the length of time of hand washing (see Appendix 2). The duration of washing needs to be as long as required to ensure all areas of hands have been covered. Hands should be systemically rubbed, ensuring all part of the hands and wrists are included, taking particular care to include the areas of the hand which are most frequently missed.

9 Hands must be washed under running water using a sink with elbow or wrist operated taps Hands must be wet before applying liquid soap (soap applied to dry hand will potentially be more drying to the skin surface and the majority of the soap will be washed off as soon as the hands are put under running water. Thoroughly wash all hand surfaces and beneath wedding ring (if applicable) Rinse thoroughly (this helps to reduce sensitivity to cleaning products) Dry hands thoroughly with single use paper towels discard after use (wet hands are more likely to become damaged and also harbour more micro-organisms) Bar soap must not be used as it poses a cross infection risk Areas frequently missed during hand washing Taylor L (1978) 4.4 Promoting hand hygiene Adequate facilities should be provided in a healthcare environment, to encourage staff to clean their hands appropriately when indicated. This includes: 9 Dedicated hand wash basins that are clean and accessible Liquid soap in wall mounted easy to use and easy to clean holder systems that contain singe use disposable cartridge sets Wall mounted disposable paper towel dispensers containing soft absorbent disposable paper towels Plugs must not be used in hand wash basins Nail brushes must not be used All hand wash basins in healthcare settings should be fitted with elbow operated or

10 hands free mixer taps, wherever possible. Contact time and friction appear to be more important than the temperature of water, though for staff comfort, water should be warm. Foot operated lidded pedal bins if appropriate to area in healthcare environments must also be positioned near the wash basin. In areas where facilities are either unavailable or inappropriate (such as patients own home) then alternative provisions should be made/sought. Healthcare professionals working within the primary care environment should be provided by the organisation with a personal supply of liquid soap, alcohol hand sanitiser, and hand cream with a supply of disposable paper towels/kitchen towels for hand drying, where it is demonstrated that provisions are not routinely available. 4.5 Healthcare workers with direct patient care contact Bare below the elbows and hand hygiene The Department of Health has confirmed its commitment to the implementation of Bare Below the Elbows (BBE) by all NHS Trusts (Johnson 2007). This is based on research that hand and wrists jewellery can harbour microorganisms and reduce compliance with hand hygiene. BBE is a Department of Health led initiative to improve patient safety using effective hand hygiene to reduce the risk of infections to patients. All staff must comply with BBE when entering the patient environment. Therefore staff must be BBE whenever they are in a clinical area (a clinical area is any location in LPT premises or off site which includes the patient s own home, where face to face consultations take place and/or direct hands on care is undertaken by staff. Leicestershire Partnership NHS Trust supports BBE and requires that short sleeves be worn, hands cannot be thoroughly and effectively washed if restricted by the wearing long sleeves. Sleeves can easily become contaminated and are likely to come into contact with patients. Wrist watches must not be worn in clinical areas as they hinder the thorough and effective washing of hands. Non clinical staff who have no contact at all with patients or the patient environment do not need to be BBE. (See appendix 4) Finger nails Finger nails must be kept clean, short, smooth and natural. When hands are viewed from palm side, no nail should be visible beyond the fingertip. Nail varnish, false nails, gel or infills should never be worn. False nails encourage the growth of bacteria and fungi around the nail bed. This is 10

11 because they can limit the effectiveness of hand washing. The nail bed is often scuffed to facilitate attachment of the false nail and the fixative can sometimes give rise to nail bed damage. These issues may result in infection, particularly fungal infection, for the wearer and will certainly present a risk of cross infection for the patient Hand and wrist Jewellery Stoned rings, (including engagement rings and stoned wedding and eternity rings), wristwatches, bangles, friendship bands, Fitness trackers, and charity bracelets must not be worn when working in the clinical environment or undertaking clinical activity. One wedding ring or steel Kara bracelet is permitted. Staff who need to wear an alert bracelet should ensure their manager is aware as is Occupational Health and a non-fabric bracelet is worn. For religious requirements some staff may wish to cover their forearms, in this instance disposable sleeves from elbow to wrist should be available and changed and discarded as per gloves. Skin care Hands should be maintained in good condition to discourage the accumulation of micro-organisms. This includes the regular application of hand moisturiser, which should be perfume free, preferably water-based and contain an effective preservative and provided by the organisation. Staff should not provide their own moisturisers and it is unacceptable to use brands used for personal use. Moisturisers should be dispensed from sealed units, and should not be re-filled. If hand moisturiser is supplied via occupational health due to staff health and therefore is not dispensed from a sealed unit it should be clearly identified for individual staff use. Any member of staff who is unable to use the available hand hygiene products due to the development of, or existing skin condition / allergy, must seek advice from Occupational Health and/or their general practitioner and report to their line manager. Hand/Skin integrity checks must be performed during the organisations hand hygiene audits and/or for Managers to undertake on an annual basis and documented Cuts and abrasions must be covered with an occlusive, waterproof dressing which should be changed as frequently as necessary (soiled or damaged) 4.6 Hand hygiene for patients and their visitors Hand hygiene for patients is also important. Whilst in a health care setting a patients health may become compromised for a number of reasons. This is an ideal opportunity for staff to educate patients in the importance of hand hygiene and to encourage good hand hygiene practice. Appropriate hand hygiene facilities must be provided for use by patients. Patients should be encouraged to wash their hands, especially at the following times:- After using the toilet/bedpan/commode 11

12 Before eating or handling food When caring for their urinary catheter etc, When participating in dressings or other clinical activity (to support self-care or discharge) Hand wipes and alcohol sanitisers can provide an alternative (if applicable) when patients/clients experience difficulties gaining access to hand wash basins. Soap and water should be used after using the toilet/bedpan and commode where possible. Visitors are encouraged to support the practice of hand hygiene and use the alcohol sanitisers provided on entering and leaving the ward, All visitors attending a patient who is undergoing source isolation precautions or when entering or leaving an area with a diarrheal increased incident must be instructed to use liquid soap and water to wash their hands, on entering the area and when leaving the patient Duties within the Organisation 5.1 The Trust Board has a legal responsibility for Trust policies and for ensuring that they are carried out effectively. 5.2 Trust Board Sub-committees have the responsibility for ratifying policies and protocols Training needs There is a need for training identified within this policy. In accordance with the classification of training outlined in the Trust Learning and Development Strategy this training has been identified as mandatory training / role development training. The course directory e-source link below will identify who the training applies to, delivery method, the update frequency, learning outcomes and a list of available dates to access the training. A record of the event will be recorded on ulearn. The governance group responsible for monitoring the training is Infection Prevention and Control Committee and Quality Assurance Committee Monitoring Compliance and Effectiveness Ref Hand Hygiene and Bare Below the Elbow Minimum Requirement s Health and Social Care Act CQC Outcome 8 Evidence for Selfassessment Audit, training records Process for Monitoring Activity training reports and audit reports Responsible Individual / Group IPCC Frequency of monitoring As part of annual report and monthly hand hygiene audit 12

13 8.0. Standards/Performance Indicators TARGET/STANDARDS Monthly audit in all areas Staff to access ulearn hand hygiene training KEY PERFORMANCE INDICATOR 96% or above for compliance 90% or above for compliance 9.0. References and Bibliography Central and Northwest London NHS Foundation Trust Hand Hygiene Policy (February 2017) Centre for disease Control and Prevention. Guidelines on hand hygiene in Health Care Settings; Recommendations of the healthcare infection control practices advisory committee and the ICPA/SHEA/APIC/IDSA Hand hygiene task force, MMWR 202;51 Hand Hygiene Liaison Group 1999 Pittet et al (2000) Infection prevention and control Nurses Association, Hand Decontamination Guidelines, April (2002). Johnson A (2007) Johnson outlines new measures to tackle hospital bugs, London, Department of Health National Institute for Clinical Excellence: Infection prevention and control: Prevention of healthcare-associated infection in primary and community care. June (2012). National Patient Safety Agency (2008) Clean Hands Save Lives, Patient Safety Alert Second Edition 2 September 2008 National Patient Safety Agency Pittet D, et al (2000) Effectiveness of a hospital wide programme to improve compliance with hand hygiene. The Lancet 356:12 Public Health England: // The World Health Organisation (WHO) My five moments for hand hygiene ( Sax et al 2007) 13

14 Appendix 1 Training Requirements Training Needs Analysis Training topic: Type of training: (see study leave policy) Division(s) to which the training is applicable: Staff groups who require the training: Regularity of Update requirement: Who is responsible for delivery of this training? Have resources been identified? Has a training plan been agreed? Hand hygiene Mandatory (must be on mandatory training register) Role specific Personal development Adult Mental Health & Learning Disability Services Community Health Services Enabling Services Families Young People Children Hosted Services All Clinical staff have to complete every 2 years. All other staff have to complete every 3 years. All Clinical staff have to complete every 2 years. All other staff have to complete every 3 years. ulearn Yes Yes Where will completion of this training be recorded? ULearn Other (please specify) How is this training going to be monitored? Training and Development will formulate a report. (Bi-monthly) 14

15 Appendix 2 The NHS Constitution The NHS will provide a universal service for all based on clinical need, not ability to pay. The NHS will provide a comprehensive range of services Shape its services around the needs and preferences of individual patients, their families and their carers Respond to different needs of different sectors of the population Work continuously to improve quality services and to minimise errors Support and value its staff Work together with others to ensure a seamless service for patients Help keep people healthy and work to reduce health inequalities Respect the confidentiality of individual patients and provide open access to information about services, treatment and performance 15

16 Appendix 3 Stakeholders and Consultation Key individuals involved in developing the document Name Designation Antonia Garfoot Senior Infection Prevention Control Nurse Circulated to the following individuals for comment Name Designation Adrian Childs Chief Nurse Claire Armitage Lead Nurse, Adult Mental Health & LD Community Michelle Churchard Lead Nurse AMH & LD, Inpatients Kathy Feltham Safeguarding Lead Sally Smith Senior Zone Coordinator, Domestic & Cleaning Services Joanne Wilson Lead Nurse FYPC Bernadette Head of Trust Health and Safety Compliance Keavney Kam Palin Occupational Health Nurse Vic Peach Head of Professional Practice and Education Andrew Swann Consultant Microbiologist Helen Walton Property Manager, Emma Wallis Lead Nurse CHS physical health, inpatient Dr.Phillip Monk Consultant Public Health England Liz Compton Senior Matron AMHS ( In Patients) Tejas Khatau Lead Pharmacist Tracy Yole Lead Nurse CHS Jane Martin Senior Nurse Rehabilitation and LDS Katie Willetts Senior Nurse FYPC Amanda Hemsley Senior Nurse Advisor IPAC Andy Knock Infection Prevention and Control Nurse Mel Hutchings Infection Prevention and Control Nurse Annette Powell Infection Prevention and Control Nurse Laura Belshaw Lead Nurse MHSOP 16

17 Appendix 4 Section 1 Due Regard Screening Template Name of activity/proposal Hand Hygiene and Bare Below the Elbow Date Screening commenced October 2017 Directorate / Service carrying out the Infection Prevention and Control assessment Name and role of person undertaking Antonia Garfoot this Due Regard (Equality Analysis) Give an overview of the aims, objectives and purpose of the proposal: AIMS: This policy is designed to enable and to apply and be supported to undertake hand hygiene training which will include bare below the elbow. It is important that individuals accessing training are given support by management and Infection Prevention Control team. OBJECTIVES: This policy outlines the principles and processes that must be followed by all staff employed within LPT. Section 2 Protected Characteristic Age Disability Gender reassignment Marriage & Civil Partnership Pregnancy & Maternity Race Religion and Belief Sex Sexual Orientation Other equality groups? Section 3 If the proposal/s have a positive or negative impact please give brief details In addition to the Trust Equality diversity and human rights policy please refer to Trust Reasonable adjustment policy and Gender reassignment policy which aim to minimise any form of discrimination (direct or otherwise) due to anyone s association with one or more protected characteristics. Does this activity propose major changes in terms of scale or significance for LPT? For example, is there a clear indication that, although the proposal is minor it is likely to have a major affect for people from an equality group/s? Please tick appropriate box below. Yes High risk: Complete a full EIA starting click here to proceed to Part B No Low risk: Go to Section 4. Section 4 If this proposal is low risk please give evidence or justification for how you reached this decision: The decision was reached because all individuals are able to adhere to policy without any impingement on any diverse and / or human rights. Signed by reviewer/assessor Antonia Garfoot Date 23/10/17 Sign off that this proposal is low risk and does not require a full Equality Analysis Head of Service Signed Date 17

18 Appendix 5 Flowchart: Failure of Formally Assessed Hand Hygiene Hand Hygiene (First Occasion) Practitioner responsibility to inform line manager within 24hrs and provide feedback Manager (or designated other) to: Meet with practitioner and explain the seriousness of failure to pass explaining the impact on practice and service Identify support required, exploring below but not inclusive: 1:1 support Practical sessions/assessment at work Supervision agree frequency Review training record Complete performance management plan giving timescale to improve. Timescale for completion of plan is 8 weeks max Where the individual fails on their 2 nd attempt Where the individual fails on their 3rd attempt Where the individual fails on their 4th attempt Consider at Stage 2 of the Performance Management Policy and where appropriate issue a First Written Warning and further improvement plan Refer to Professional Standards 18 Group Consider at Stage 3 of the Performance Management Policy and where appropriate issue a Final Written Warning and further improvement plan Refer to Professional Standards Group Consider at Stage 4 of the Performance Management Policy at a Performance Management Hearing as to whether Dismissal is appropriate Refer to Professional Standards Group 18

19 Appendix 6 19

20 Appendix 7 20

21 Appendix 8 21